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Clinical pharmacology and therapeutics > Cardiology 1 and 2 > Flashcards

Cardiology 1 and 2 Flashcards

1
Q

What is acute coronary syndrome?

A

A spectrum of conditions

  • Unstable angina
  • NSTEMI
  • STEMI

Reduction in blood flow through the coronary arteries - usually as a result of atherosclerotic plaque rupture

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2
Q

What is diagnosis of ACS based on?

A

Symptoms
ECG
Bloods

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3
Q

What does an ECG with sustained ST elevation indicate?

A

Full thickness ischaemia and necrosis

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4
Q

List some symptoms of ACS

A 
Heartburn
Chest pain - Radiates to neck or left arm
Sweating
Clammy
Cold
Grey pallor
Nausea
Vomiting
LOC
Arrest 
Anxiety
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5
Q

List the risk factors for ACS

A 
HTN
High cholesterol 
FH
Smoking
Male 
Obesity 
Diabetes
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6
Q

What score is used to predict the risk of death from MI after ACS?

A

GRACE 2 score

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7
Q

List the treatment aims of ACS

A

Reduce cardiac ischaemia
Reduce myocardial O2 demand
Prevent recurrence

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8
Q

How is cardiac ischaemia reduced

A

Revascularisation
Thrombolysis
Medical management

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9
Q

Describe revascularisation

A

Patient to catheter lab
Femoral/radial access
Angiography +/- Angioplasty +/- stenting (bare metal or drug eluting - dual antiplatelet therapy for up to 12 months - premature discontinuation leads to an increased risk of stent thrombosis)

Or coronary artery bypass graft

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10
Q

When is thrombolysis used to treat ACS?

A

Used in a STEMI

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11
Q

Which drugs are used in thrombolysis?

A

Alteplase
Reteplase
Streptokinase
Tenecteplase

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12
Q

When is thrombolysis contraindicated?

A 
Recent bleeding/trauma (<1 month)
Bleeding disorders
Hemorrhagic stroke 
Ischaemic stroke/TIA (<6 months)
On warfarin/DOAC
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13
Q

Describe the immediate management of ACS

A 
Oxygen 
Nitrates
Anti-emetics
Antiplatelet loading
Fondaparinux/LMWH
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14
Q

What long term management and secondary prevention would you expect an ACS patient to be discharged home with?

A 
DAPT - aspirin, clopidogrel/prasugrel/ticagrelor
ACE inhibitors/ARBs
Beta blockers
Statins 
GTN spray 
Lifestyle advice
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15
Q

What is the loading dose of aspirin?

A

300mg

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16
Q

What is the maintenance dose of aspirin?

A

75mg

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17
Q

What must aspirin be taken with?

A

Food

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18
Q

What is the loading dose of clopidogrel?

A

300 or 600mg depending on local guidelines

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19
Q

What is the maintenance dose of clopidogrel?

A

75mg OD

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20
Q

What is the loading dose of ticagrelor?

A

180mg STAT

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21
Q

What is the maintenance dose of ticagrelor?

A

90mg BD

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22
Q

What is the loading dose of prasugrel?

A

60mg STAT

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23
Q

What is the maintenance dose of prasugrel?

A

<60 Kg or >75years old - 5mg OD

>60 Kg 10mg OD

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24
Q

What is a common side effect of ticagrelor?

A

Shortness of breath

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25
Q

What is a common side effect of prasugrel?

A

GI bleeding

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26
Q

Describe the mechanism of action of beta blockers

A

Affect receptors in heart and blood vessels
Slow the SA node which initiates heart beat
Slows heart rate and allows time for the left ventricle to fill completely and lowers heart workload
Dilate arteries
Lower blood pressure

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27
Q

List the contraindications and cautions of beta blockers

A

2nd and 3rd degree heart block
Asthma and obstructive airways disease
Unstable heart failure

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28
Q

What are the side effects of beta blockers?

A 
Fatigue
Cold hands/feet
Nightmares/sleeping disturbances 
Breathing difficulties in asthmatics 
Bradycardia
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29
Q

What can beta blockers mask the symptoms of?

A

Hypoglycaemia

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30
Q

What may happen if a patient suddenly stops taking beta blockers?

A

Rebound tachycardia

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31
Q

Describe the use of ACE inhibitors in ACS

A

Ventricular enlargement causes a poorer prognosis so these patients should have an ACEi 24 hrs post MI
Titrate up every 2 weeks to the maximum tolerated dose
Prevent cardiac remodelling
Continue indefinitely
Monitor renal function and electrolytes

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32
Q

What are common side effects of ACE inhibitors?

A

Dry cough
Loss of taste/appetite
Postural hypotension - advised to take at night time

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33
Q

Describe the mechanism of action of statins

A

HMGCoA reductase inhibitors - prevent the synthesis of cholesterol in the liver
Lowers LDL cholesterol but does not target dietary cholesterol
Stabilises atherosclerotic plaques in coronary blood vessels. Anti inflammatory effect upon blood vessels.

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34
Q

When should simvastatin and pravastatin be taken?

A

At night

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35
Q

How much can statins reduce the risk of another cardiac event by?

A

60%

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36
Q

What is the target total cholesterol?

A

<5

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37
Q

What is the target Non-HDL cholesterol?

A

<4

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38
Q

What is the target LDL cholesterol?

A

<3

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39
Q

What is the target HDL cholesterol?

A

> 1

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40
Q

What is the target triglycerides?

A

<2.3

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41
Q

List the side effects of statins

A 
Muscle pain
Headaches
Nausea
Vomiting
Abdominal pain
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42
Q

What is angina pectoris?

A

Pian, discomfort or pressure typically located in the chest and caused by an insufficient supply of blood to the myocardium

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43
Q

Describe the effects of nitrates in angina pectoris

A

Dilation of veins and collaterals - decreased O2 consumption

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44
Q

Describe the effects of nitrates in heart failure

A

Dilation of conduit arteries and veins - reduced LVEDP, reduced wall stress and reduction of mitral regurgitation

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45
Q

Describe the effects of nitrates in ACS

A

Dilation of conduit arteries, collaterals and antiaggregant effects - increases O2 supply

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46
Q

Give some reasons for nitrate use

A

To relieve or prevent expected chest pain - GTN spray

To prevent regular chest pain (tablets/patches)

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47
Q

What are some side effects of nitrates

A

Flushing
Headache - will reduce over time and become less severe
Dizziness
Postural hypotension

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48
Q

Which drugs interact with nitrates?

A

Sildenafil
Vardenafil
Tadalafil
Cause significant drop in BP

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49
Q

Why must people be careful when driving and taking nitrate?

A

Causes dizziness

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50
Q

Should a person consume alcohol when taking nitrates?

A

No - may cause dizziness - Avoid directly after use

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51
Q

Describe the mechanism of action of nicorandil

A

Nitrate like action and K+ ATP channel opener

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52
Q

What are the side effects of nicorandil?

A

Dizziness
Nausea
Headache

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53
Q

Name the most common arrhythmia

A

Atrial fibrillation

54
Q

Describe atrial fibrillation

A

Rapid atrial rate >300-600 beats per min followed by a rapid and irregular ventricular beat
AV node restricts conduction, giving ventricular rate < 200 bpm

55
Q

List the symptoms of atrial fibrillation

A 
Palpitations
Chest pain 
Fatigue
Dizziness
Dyspnoea 
Syncope
Low exercise tolerance
56
Q

What is persistent AF?

A

> 48hrs after onset but may be cardioverted back to SR using either electrical or pharmacological cardioversion

57
Q

What is paroxysmal AF?

A

Intermittent, self terminating or recurrent arrhythmia combined with normal SR. Main aim of treatment is to maintain SR for as long as possible because cardioversion is ineffective

58
Q

What is permanent AF?

A

Chronic condition which is permanent for >48hrs
Cardioversion is either ineffective or unsuitable.
Aim of treatment is to maintain the HR by controlling the ventricular rate

59
Q

Describe rate control

A

Slow conduction through the AV node

Patient remains in AF but a more controlled/slow rate

60
Q

Describe rhythm control

A

Electrical by cardioversion - immediate or elective

Chemical cardioversion - drug therapy alone or as an adjunct to electrical cardioversion

61
Q

What is ablation?

A

A technique where a small amount of energy is applied directly onto the area responsible for the abnormal electrical circuit within the heart - the energy creates scar tissue which blocks the electrical transmission in these areas

62
Q

List the drug treatments for AF

A

Anticoagulants
Rate control - Beta blockers, rate lowering calcium antagonist (verapamil, diltiazem) and digoxin
Rhythm control - Structural heart disease (beta blocker or amiodarone), No structural heart disease (beta blocker)
Pill in the pocket - Flecainide and propafenone

63
Q

Why is AF dangerous?

A

Most common cardiac disorder leading to stroke and thromboembolism

64
Q

Where do thromboembolisms resulting from AF come from?

A

Left atria

65
Q

What do AF strokes lead to?

A

High mortality and high levels of disability - larger strokes

66
Q

How much does appropriate anticoagulation reduce the risk of stroke by?

67
Q

Which drug class is commonly used to treat AF?

68
Q

Name some DOACS used to treat AF

A

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

69
Q

When do you avoid the use of DOACS

A

If Cr CL is <15ml/min

70
Q

How often would you check U&Es after starting a DOAC?

71
Q

On initiation of DOAC treatment what monitoring must be carried out?

A

Renal function
Patient weight
Liver function
Clotting screen

72
Q

Describe the mechanism of action of warfarin

A

Vitamin K antagonist

Works on clotting cascade factors 2,7,9 and 10

73
Q

What monitoring is needed when a patient is on warfarin?

A

Regular INR checks

74
Q

How is warfarin dosed?

A

According to INR

75
Q

What is warfarin licensed for use in?

A 
AF
PE
DVT
Recurrent DVT and PE 
Mechanical valves
76
Q

Name a scoring system used to estimate the risk of stroke

A

CHA2DS2-VASc Score

77
Q

Name a scoring system used to estimate the bleeding risk

78
Q

List the components on the CHADVASC score

A 
Congestive heart failure (1)
Hypertension (1)
Age >75 (2)
Diabetes mellitus (1)
Previous stroke, TIA or thromboembolism (2) 
Vascular disease (1)
Age 65-74 (1) 
Sex (female = 1)
79
Q

List the components on the HASBLED score

A 
Hypertension (1)
Abnormal renal and liver function (1 point each) 
Stroke (1)
Bleeding (1) 
Labile INRs (1)
Elderly - age >65  (1)
Drugs or alcohol (1 point each)
80
Q

Which drug is used in rhythm control?

81
Q

Describe the mechanism of action of digoxin

A

Increases the force of contraction and reduces conductivity with the AV node

82
Q

What is digoxin only effective for?

A

Controlling ventricular rate at rest

83
Q

Which patient should digoxin be used in?

A

Monotherapy for sedentary patients

84
Q

What should the dose of digoxin be determined by?

A

Ventricular rate at rest

HR should not fall below 60bpm

85
Q

How is digoxin excreted?

86
Q

What monitoring is required with digoxin?

A

The digoxin level

87
Q

What is the ideal digoxin level?

A

0.5-2 micrograms/litre

88
Q

How long after the dose are digoxin levels taken?

89
Q

What can toxic levels of digoxin occur at?

A

> 1.5-3 micrograms/litre

90
Q

What is digoxin toxicity increased by?

A

AKI
Hypokalemia
Hypomagnesaemia
Hypocalcaemia

91
Q

List the signs of digoxin toxicity

A 
Lethargy
Confusion 
Vomiting
Diarrhoea 
Visual changes
92
Q

Are IV and PO digoxin doses equal?

93
Q

Describe the loading dose of digoxin

A

750 micrograms - 1 mg in divided doses over 24 hours (reduce dose if elderly)

94
Q

What is the adult maintenance dose of digoxin?

A

125-250 micrograms OD

95
Q

How much amiodarone is required to load?

96
Q

Describe the loading dose of IV amiodarone

A

5mg/Kg given over 20-120 mins with ECG monitoring

97
Q

Describe the loading dose of infusion amiodarone

A

1.2g/24hrs preferred central administration

98
Q

Describe the loading dose and maintenance dose of oral amiodarone

A

200mg tds for 1 week, then 200 mg BD for 1 week and then maintenance dose of 200mg OD

99
Q

Which bloods would you check if a patient was on amiodarone?

A

TFTs and LFTs

100
Q

List the side effects of amiodarone

A

Cardiac - new/worsened arrythmia
Skin - sensitive to the sun and or blue grey discolouration
Eyes - corneal deposits in the eye - careful with driving
Thyroid - precipitate under active thyroid disease or overactive thyroid disease (blood test before starting and every 6 months)
Liver -rarely causes abnormal liver results (blood test before starting and at 6 months)
Lun - rarely causes inflammation of lining of alveoli
Altered taste and sleep disturbance

101
Q

Name some calcium channel antagonist groups and state their effect

A

Dihydropyridine - antihypertensive effect

Non dihydropyridine - antiarrhythmic effect

102
Q

Which food must patients avoid when taking calcium channel antagonists?

A

Grapefruit

103
Q

Name some dihydropyridine CCBs

A 
Felodipine
Amlodipine 
Nimodipine 
Nifedipine 
Nicardipine
104
Q

Name some non-dihydropyridine CCBs

A

Verapamil

Diltiazem

105
Q

Describe the mechanism of action of monoamine oxidase inhibitors

A

Inhibit calcium ions from entering slow or voltage gated channels seen in vascular smooth muscle and the myocardium - increases myocardium oxygen delivery

106
Q

List the side effects of MAOi

A 
Constipation
Facial flushing
Headaches
Ankle swelling
Fatigue
Dizziness
107
Q

What is heart failure?

A

Clinical syndrome resulting in reduced cardiac output and/or elevated intracardiac pressure at rest or in times of stress

108
Q

What is heart failure caused by?

A

Structural and/or functional abnormality in the heart

109
Q

List the typical symptoms of heart failure

A

Breathlessness
Ankle swelling
Fatigue

110
Q

List the typical signs of heart failure

A

Elevated jugular venous pressure
Pulmonary crackles
Peripheral oedema

111
Q

Describe systolic heart failure

A

Heart failure with reduced ejection fraction - Fraction of blood ejected is <40%

Left ventricle can not contract adequately to eject the blood into the aorta. Lack oxygen rich blood to meet the bodys needs

112
Q

What is systolic heart failure predominately caused by?

A

Coronary artery disease

113
Q

Describe diastolic heart failure

A

Heart failure with a preserved ejection fraction - Fraction of blood ejected >50%

Heart muscles become stiff and do not relax properly resulting in an impaired filling process

114
Q

What is diastolic heart failure predominately caused by?

A

Hypertension

115
Q

Name a class system used to classify heart failure patients

A

New york heart association

116
Q

List some causes of chronic heart failure

A 
IHD
HTN
Valve disease
Myocarditis
Cardiomyopathy 
Arrhythmia 
ACS
117
Q

Describe the treatment of systolic HF

A

ACEi/ARB/ARNi/BB
AA (or MRA)
Manage fluid status

118
Q

Describe the treatment of diastolic HF

A

Manage fluid status

119
Q

What are the goals of HF treatment?

A

Relieve signs and symptoms
Prevent hospital admission
Improve survival

120
Q

Describe the physiological response to heart failure

A

Increase cardiac output
Increase catecholamine release
Activation of renin angiotensin system
Structural changes

121
Q

Describe the compensatory mechanisms in heart failure

A

CO = SV x HR
Starling’s Law
Sympathetic Nervous System
Renin-Angiotensin-Aldosterone System
Endothelin, Nitric oxide and prostaglandins
Vasopressin
Stretch and pressure response (ANP and BNP)

122
Q

What drugs are used to treat HF?

A 
Diuretics
ACEi/ARB (if ACEi not tolerated)
Beta-blockers
Mineralocorticoid receptor antagonists
Ivabradine
Nitrates
Sacubitril/Valsartan
123
Q

Describe the site and mechanism of action of thiazide diuretics

A

Distal convoluted tubule - Inhibition of sodium & water reabsorption.

124
Q

Describe the site and mechanism of action of loop diuretics

A

Ascending loop of henle - Inhibition of sodium & water reabsorption

125
Q

Describe the site and mechanism of action of mineralocorticoid receptor antagonists (aldosterone antagonists)

A

Collecting duct - Inhibition of aldosterone ie allows excretion of sodium & water: potassium retained

126
Q

What is the first line treatment for all left ventricular HF?

A

ACEi and ARBs

127
Q

Describe the dosing of ACE inhibitors and ARBs

A

Start at low dose and titrate upwards every 2 weeks until maximum tolerated dose.

128
Q

When are angiotensin 2 receptor antagonists recommended first line?

A

In patients who can not tolerate ACE inhibitors

129
Q

Name some angiotensin 2 receptor antagonists

A

Candesartan, losartan and valsartan

130
Q

Describe ivabradine

A

Licensed for Chronic HF

5mg BD for 2 weeks then increase to maximum 7.5mg BD (Resting HR >50 bpm)
2.5mg BD if >75 years or unable to tolerate higher dose

NICE recommends it in combination with standard therapy when Beta blockers are not tolerated or contra-indicated

ESC recommends it for EF<35% in SR with resting HR ≥ 70bpm when Beta blockers are not tolerated or contra-indicated

131
Q

List the side effects of ivabradine

A

slow heart rate,
headache,
dizziness,
vision disturbance.

132
Q

List some lifestyle changes used in the treatment of heart failure

A 
Monitor fluid intake
Monitor breathlessness and oedema
Smoking cessation
Optimise BP
Optimise diabetes management
Diet and reduced salt intake
Regular exercise providing condition is stable and doesn’t preclude this
Flu vaccination
Pneumococcal vaccination
Compliance with medication

Clinical pharmacology and therapeutics (27 decks)

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