Cardiology Flashcards
What long term management medication is used for Acute Coronary Syndrome?
- DAPT - Aspirin + Clopidogrel/Prasugrel/Ticagrelor
- ACE-inhibitors/ARB’s
- Beta-blockers
- Statins
- GTN spray
- Lifestyle advice
Aspirin in ACS
COX inhibitor, reduced TXA2 and platelet activation/aggregation.
- 300mg STAT loading dose, then 75mg maintenance OD
- Caution – allergy, asthma, GI ulcer,
- With/after food
reduces the risk of non-fatal reinfarction, vascular death and non-fatal stroke after acute MI
Clopidogrel in ACS
Inhibits ADP binding to PY212 receptor, Requires CYP450 activation, Permanent inhibition,
Some people are resistant due to polymorphs,
Platelet lifespan 7-10 days
- 300mg STAT or 600mg loading dose (not liciscensed ), then 75mg
- Caution – active bleeding (does not inhibit prostaglandins, therefore doesn’t have the same GI side effects of aspirin. GI bleeding is however still a side effect) , planned CABG
can remain on the anti-platelets for yp to a year following a STEMI or NSTEMI
If stented can be for a shorter period
ACE inhibitors/ARB’s in ACS
reduce the production of angiotensin 2/at2 antagonist
- Start low and titrate
- prevents cardiac remodelling
- Caution – renal impairment, hyperkalaemia, first-dose hypotension (take at night initially), postural hypotension, dry cough (ACEi only), anaphylaxis, loss of taste/appetite
Beta-Blockers in ACS
block sympathomimetic activity by binding to beta receptors → slow SA node → slows heart rate allowing the left ventricle to fill
- Start low and titrate,
- Reduces heart rate, reduces BP → lower oxygen demands
- Cardioselective (b1 vs b2 activity), water/lipid-soluble,
- Vasodilating action
- Caution – asthma, PVD, heart block, unstable heart failure, diabetes (mask hypos), interactions (verapamil/diltiazem)
- Contra-indicated in 2nd and 3rd-degree heart block and unstable heart failure
Statins in ACS
HMG Co-A reductase inhibitor reduces the production of cholesterol in the cell
stimulates the production of LDL receptors outside of the cell
decreases secretion VLDL
- Take Simvastatin and Pravastatin at night (shorter half lives, most effect when body produces most cholesterol)
- avoid grapefruit juice and high alcohol intake
- can reduce future risk of cardiac events by 60%
- anti-inflammatory effect on coronary vessels
- Cautions – muscle effects, interactions, liver impairment, headache, N&V and Abdo pain
Lifestyle changes in ACS
Smoking
Excercise
Diet
What is the indication of Prasugrel/Ticagrelor?
Used as an alternative to Clopidogrel - Slightly more potent can be used as first-line txt
- Ticragulor:
- Loading dose: 180mg
- Maintenance dose: 90mg BD
- Duration of treatment: up to 12 months
- Side effects: Shortness of breath
- Contra - indications: active bleeding, history of intracranial haemorrhage
- Prasugrel
- Loading dose: 60mg stat
- Maintenance dose; > 60kg 10mg OD; < 60kg or >75 years 5mg OD
- Duration of treatment: up to 12 months
- Side effects: GI bleeding
- Contra - indications; History of stroke or TIA, active bleeding
What is the sie of action for the following antiplatelets
Aspirin, Clopidogrel/Prasugrel/Ticlopidine, Abiximab/Eptifibatide
Give an example of Beta-blockers and what are their side effects and contraindications
1st Gen: Propranolol, Pindolol → non-selective ore likely to get side effects
2nd Gen: Atenolol. Bisoprolol, Acetubotol → B1 selective, used in individuals with respiratory conditions
3rd Gen: Carvedilol, Labetalol → Non-selective (beta and alpha 1)
3rd Gen: Nebivolol, Betaxolol → selective
-
Contraindications and Cautions
- in history of asthma and obstructive airways disease
- use 2nd gen b-blockers as they are B1 selective
- in 2nd and 3rd degree heart block
- unstable heart failure
- in history of asthma and obstructive airways disease
- Side effects
- Fatigue
- Cold hands / feet
- Nightmares / sleep disturbances
- Breathing difficulties in asthmatics
- Bradycardia
- Masks symptoms of hypoglycaemia (tachycardia won’t show if patient is hypo)
Do not stop taking without a doctor’s advice as you can get rebound tachycardia
What are the use and effects of nitrates?
-
Reasons for use:
- To relieve or prevent expected chest pain (GTN)
- To prevent regular chest pain (Nitrate tablets/ patches)
-
Side effects:
- Flushing, headache, dizziness, postural hypotension
- Headache likely to reduce and become less severe over time (due to rapid vasodilatation)
- Interactions with nitrates : Sildenafil, vardenafil, tadalafil causing significant drop in blood pressure (avoid concomitant use)
-
Driving:
- May cause dizziness: be cautious until your response is known
-
Alcohol:
- May cause dizziness: avoid directly after use
What are the different preparations for nitrates?
how should they be used?
- GTN tablets
- 8 weeks expiry on opening
- Can spit out as soon as pain resolved or if headache occurs
- GTN tablets and spray available over the counter
- Twice daily ISMN: take morning and early afternoon to reduce tolerance risk
- GTN Spray: Spray 1-2 sprays under tongue when you experience chest pain, repeat after 5 min if you still suffer from pain. Call 999 pain is not relieved after 2nd dose.
Nicorandil in ACS
Used as a second-line agent if patients still have angina on nitrates
has nitrate like action → dilates epicardial coronary arteries and vasodilation
acts as a K+ ATP channel opener → dilates peripheral arterioles and dilates coronary microvessels
- side effects: dizziness, headaches, nausea
has to be kept in original container, can’t be put in a blister pack
- Mr MI 56 year old male, No PMH, 95kg
- Smokes 20 per day
- Admitted to hospital with chest pain, diagnosed with STEMI and received 2 x PCI with drug-eluting stents (DES)
What antiplatelet medication would be suitable for Mr MI?
A.Aspirin 75mg OD
B.Aspirin 150mg OD and Clopidogrel 75mg OD
C.Aspirin 75mg OD and Ticagrelor 90mg BD
D.Ticagrelor 90mg BD and Prasugrel 60mg OD
A.Aspirin 75mg OD (needs a second agent)
B.Aspirin 150mg OD and Clopidogrel 75mg OD (wrong dose of Aspirin)
C. Aspirin 75mg OD and Ticagrelor 90mg BD
D.Ticagrelor 90mg BD and Prasugrel 60mg OD (the same site of action)
- Mr MI 56 year old male, No PMH, 95kg
- Smokes 20 per day
- Admitted to hospital with chest pain, diagnosed with STEMI and received 2 x PCI with drug-eluting stents (DES)
What secondary prevention would MR MI be prescribed after receiving antiplatelet treatment?
A.Statin
B.Statin, Ca Channel Antagonist, Beta Blocker
C.Statin, ACE Inhibitor, Beta Blocker
D.Statin, Ca Channel Antagonist, ARB
A.Statin (need additional meds)
B.Statin, Ca Channel Antagonist, Beta Blocker (Ca blockers aren’t first line)
C. Statin, ACE Inhibitor, Beta Blocker
D.Statin, Ca Channel Antagonist, ARB
You are covering night shift as F1, ECG for Mrs CP shows STEMI and the oncall medical registrar has asked you to prescribe loading antiplatelets whilst waiting for angiogram
What antiplatelets would you prescribe Mrs CP?
A.Aspirin 600mg + Clopidogrel 300mg
B.Aspirin 300mg + Clopidogrel 600mg
C.Aspirin 300mg
D.Any of the above options are suitable
A.Aspirin 600mg + Clopidogrel 300mg (does of aspirin is too high)
B.Aspirin 300mg + Clopidogrel 600mg
C.Aspirin 300mg (need two line of antiplatelet)
D.Any of the above options are suitable
Mr SE has been admitted to the hospital with NSTEMI. He has had an angiogram with one DES placed in LAD. He has been known to have a reaction of hives to aspirin.
What would you consider for his long term antiplatelets?
A.Clopidogrel monotherapy
B.Aspirin and antihistamine, with another antiplatelet
C.Clopidogrel and Prasugrel
D.Consider Aspirin desensitisation with another antiplatelet
A. Clopidogrel monotherapy (need dual antiplatelet therapy)
B. Aspirin and antihistamine, with another antiplatelet
C. Clopidogrel and Prasugrel (the same site of action, increasing bleeding risk without increasing antiplatelet cover)
D. Consider Aspirin desensitisation with another antiplatelet (consultant decision)
Mr SE total cholesterol has come back 4.8, with HDL 1.3.
Mr SE has a documented allergy to statins in his medical notes. The documented reaction is muscle pain.
What would you do to manage Mr SE cholesterol?
A.Give lifestyle advice; as his cholesterol is within normal limits
B.Prescribe ezetimibe 10mg OD as an alternative agent
C.Prescribe atorvastatin 80mg OD as per NICE guidelines
D.Find out which statin he had before and trial another statin
A. Give lifestyle advice; as his cholesterol is within normal limits
B. Prescribe ezetimibe 10mg OD as an alternative agent
C. Prescribe atorvastatin 80mg OD as per NICE guidelines
D. Find out which statin he had before and trial another statin (Rosuvastatin is usually well-tolerated, start on a low dose and titrate up)
What are target cholesterol levels?
- Total cholesterol ≤ 5
- Non-HDL cholesterol ≤ 4 (LDL cholesterol levels are often inaccurate)
- LDL Cholesterol ≤ 3
- HDL cholesterol ≥ 1
- Triglycerides ≤ 2.3
What is Heart Failure?
HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. (ESC 2016)
What are the two types of Heart Failure
Systolic Heart failure: reduced ejection fraction
- Left ventricle cannot contract adequately to eject blood into aorta
- Lack O2 rich blood to meet body’s need
- The fraction of blood ejected is ≤40%
- Mainly caused by coronary artery disease
- HF medications and manage fluid status indicated
Diastolic heart failure: preserved ejection fraction
- Heart muscle becomes stiff and does not relax properly → impaired filling
- Fraction of blood ejected ≥50%
- mainly caused by HTN
- HF medication and not as much evidence base to indicate medications, just manage fluid status
What are the New York Heart Association, classes
What are the main goals for managing Heart Failure
Relieve symptoms
prevent hospital admissions
Improve mortality
What drugs are used to treat or manage Heart Failure?
- Diuretics
- ACEi/ARB (if ACEi not tolerated)
- Beta-blockers
- Mineralocorticoid receptor antagonists
- Ivabradine
- Nitrates
- Sacubitril/Valsartan
- Dapagliflozin
What types of diuretics are there including, classes, examples, side effects, monitoring and pertinent information
- give low doses of all three classes of diuretics
- prevents cardiac remodelling
- reduces the rate of hospitalisation of HF
What types of diuretics are there including, classes, examples, side effects, monitoring and ipertinentnformation
Class of drug
Loop Diuretics
Thiazide Like Diuretics
Potassium Sparing Diuretics
Examples
Furosemide/ Bumetanide
Bendroflumethiazide/ Metolazone
Spironolactone/ Eplerenone
Side effects
Fatigue, dizziness, electrolyte imbalance
May exacerbate gout
Hyperkalaemia
gynaecomastia
Monitoring
All diuretics monitor renal function, electrolytes, weight
Useful information
Furosemide 40mg PO = Bumetanide 1mg PO
Maximal affect 1 hour after taking
Metolazone is unlicensed in UK, it has synergistic effect with loop diuretic
Often ineffective if CrCl< 30ml/min
Eplerenone is used in MI patients with EF ≤ 40% - based EPHESUS trial
Spironolactone shows increased blockade of RAAS when combined with ACEi
ACE inhibitors ad ARB in Heart failure
- First line treatment for all left ventricular HF
- Improve signs, symptoms and exercise tolerance
- Reduction in disease progression, hospitalisation and mortality
- Start at a low dose and titrate upwards every 2 weeks until the maximum tolerated dose.
- Angiotensin II receptor antagonists are recommended first-line in those patients intolerant of ACEi
- Candesartan, losartan and valsartan are licensed in UK
Beta-Blockers in Heart Failure
- Used to be contraindicated because of their negative effects on HR and force of contraction. → However, are now recommended first-line with ACEi.
- Improve symptoms and survival.
- Should not be initiated during acute HF due to short term deterioration in LV systole.
- Start slowly and titrate upwards at maximum 2 weekly intervals.
- Patients can experience a temporary decrease in QoL due to lethargy and fluid retention.
- Ensure patients are informed of benefits of treatment to ensure compliance.
When is Ivabradine indicated?
Dose and indication, action, side effects
- K+ channel blocker → slows diastolic depolarisation → lowers HR → ventricle is able to fill presents atrium overloading
- Licensed for Chronic HF
- BNF
- 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 contraindicated
- Sife effects: slow HR, headache, dizziness, vision distubrances
Nitrates in heart failure
ISMN 10mg BD titrated upwards if necessary to total 120mg daily in divided doses.
Used in acute LV HF causing pulmonary oedema
Venous dilators (↓preload) and arterial dilators (↓afterload) and improve coronary blood flow – titrate to BP
When are the below indicated?
Angiotensin II Receptor & Neprilysin inhibitor (ARNi)
Sacubitril Valsartan
- should be started by a heart failure specialist
- Sacubitril valsartan is recommended (NICE 2016) as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only for:
- New York Heart Association (NYHA) class II to IV
- LVEF 35% or less
- already taking a stable dose of ACE inhibitors or ARBs
Explain the action of Sacubtitril Valsartan
- blocks neprilysin allows vasodilation and decreases Na and fluid levels → also maintain the presence of angiotensin II hence given in combination with ARB to counteract the effect
- increased diuretic effect → reduction in diuretic medication patient is taking
- ACEi not given as it causes excessive amounts of bradykinin and angioedema
- must have stopped ace inhibitors > 36hrs before starting
When is Dapagliflozin indicated?
Dose
- adults with and without T2DM with symptomatic chronic heart failure with a reduced EF (≤40%)
- refer to specialists in T2DM patients
- can be used as part of glycaemic control
- can be used in patients with renal impairment, and can be used in addition to standard heart failure txt diuretics
- Dose: 10mg OD
What are cautions for the use of Dapagliflozin in Heart Failure?
- Heart failure with NHYA IV symptoms
- patients at risk of DKA
- Hx of recurrent UTI or candida
- Ptx at risk of necrotising fascitis
- Ptx with eGFR <30
- SBP <95mmHg
- sever hepatic impairment
- cognitive impairment
- may reduce dose diuretic if euvolemic to reduce risk of dehydration
Explain how blood pressure is controlled through the RAAS
- Low blood pressure in the arterioles is identified by the kidney
- Kidney releases renin, which converts angiotensinogen produced in the liver into angiotensin I
- ACE (angiotensin-converting enzyme) released by the lungs helps convert Ang I into Angiotensin II
- Ang II acts on the adrenal gland causing it to release Aldosterone
- Aldosterone causes increased Na+ retention and water retention in the kidneys, increasing blood volume therefore BP
- Ang II also causes vasoconstriction by increased IP3 and decreases the GFR and urine output
- Ang II stimulates the pituitary gland to release ADH
What is the British Hypertension Society guideline flow chart for treatment?
What are NICE guidelines for treating hypertension when diagnosed?
What is the pharmacological treatment pathway for HTN?
What is the management if Statins are contraindicated, not tolerated or not effective?
- Stop, reduce dose or switch statin
- Ezetimibe (± Statin)
- Specialist input
- Bempedoic acid with ezetimibe
- PCSK9 inhibitors - Evolocumab; Alirocumab; Inclisiran
What are the three main types of lipid-lowering drugs and how do they work?
- Statins: inhibit HMG-CoA reductase from converting HMG-CoA to cholesterol → lowering intracellular cholesterol levels
- Ezetimibe: selectively inhibits the absorption of cholesterol and phytosterol from the intestines mainly through inhibiting cholesterol transport protein Niemann-Pick C1-Like 1 (**NPC1L1) (works better in conjunction with statins)
- PCSK9 inhibitors: decreases the breakdown of LDL receptor in the liver therefore more LDL receptors present to remove LDL from the blood
