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Cardiology Flashcards

1
Q

What long term management medication is used for Acute Coronary Syndrome?

A
  • DAPT - Aspirin + Clopidogrel/Prasugrel/Ticagrelor
  • ACE-inhibitors/ARB’s
  • Beta-blockers
  • Statins
  • GTN spray
  • Lifestyle advice
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2
Q

Aspirin in ACS

A

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

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3
Q

Clopidogrel in ACS

A

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

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4
Q

ACE inhibitors/ARB’s in ACS

A

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
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5
Q

Beta-Blockers in ACS

A

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
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6
Q

Statins in ACS

A

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
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7
Q

Lifestyle changes in ACS

A

Smoking

Excercise

Diet

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8
Q

What is the indication of Prasugrel/Ticagrelor?

A

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
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9
Q

What is the sie of action for the following antiplatelets

Aspirin, Clopidogrel/Prasugrel/Ticlopidine, Abiximab/Eptifibatide

A
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10
Q

Give an example of Beta-blockers and what are their side effects and contraindications

A

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
  • 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

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11
Q

What are the use and effects of nitrates?

A
  • 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
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12
Q

What are the different preparations for nitrates?

how should they be used?

A
  • 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.
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13
Q

Nicorandil in ACS

A

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

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14
Q
  • 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

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)

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15
Q
  • 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

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

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16
Q

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

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

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17
Q

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

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)

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18
Q

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

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)

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19
Q

What are target cholesterol levels?

A
  • Total cholesterol ≤ 5
  • Non-HDL cholesterol ≤ 4 (LDL cholesterol levels are often inaccurate)
  • LDL Cholesterol ≤ 3
  • HDL cholesterol ≥ 1
  • Triglycerides ≤ 2.3
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20
Q

What is Heart Failure?

A

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)

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21
Q

What are the two types of Heart Failure

A

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
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22
Q

What are the New York Heart Association, classes

A
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23
Q

What are the main goals for managing Heart Failure

A

Relieve symptoms

prevent hospital admissions

Improve mortality

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24
Q

What drugs are used to treat or manage Heart Failure?

A
  • Diuretics
  • ACEi/ARB (if ACEi not tolerated)
  • Beta-blockers
  • Mineralocorticoid receptor antagonists
  • Ivabradine
  • Nitrates
  • Sacubitril/Valsartan
  • Dapagliflozin
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25
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
26
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
27
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
28
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.
29
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
30
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
31
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
32
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
33
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
34
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
35
What are contra-indications for the use of Dapagliflozin in Heart Failure?
* Type 1 Diabetes * Hx of DKA * Hx of allergy to Dapagliflozin * Severe renal impairment eGFR \<20 or end-stage renal disease or dialysis ptx * Pregnancy or breastfeeding * Ptx on very low calorie/ low carbohydrate diets
36
What are side effects of Dapagliflozin in Heart Failure?
* hypoglycaemia ( with insulin or sulphonylureas ), * dizziness, * rash, * back pain, * UTI, vulvovaginitis /balinitis, * dysuria or polyuria, * initial dip in CrCl, * dyslipidaemia, * haematocrit increased
37
What Lifestyle changes can patients with heart failure do
* 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
38
* **Mr HF 85 year old admitted to hospital with shortness of breath** * **He has been waking up at night feeling like he can’t catch his breath and has recently found it harder to walk up hills.** * **PMHx : AF,** * **SHx: Ex- smoker, moderate alcohol intake** * **DHx: Apixaban 5mg BD** * **Inpatient ECHO showed LV EF 38%** * **BNP was raised at 450pg/ml, U&Es, FBC, LFTS all NAD** * **HR 75, BP 145/98, ECG shows sinus rhythm** **_What medications would you expect to be initiated?_** A.Furosemide 40mg OM, Ramipril 2.5mg OD B.Furosemide 40mg OM, Bisoprolol 2.5mg OD C.Furosemide 40mg OM, Spironolactone 25mg OM, Ramipril 2.5mg OD D.Furosemide 40mg OM with other medications to be started at follow up clinic
**A.****Furosemide 40mg OM, Ramipril 2.5mg OD** B.Furosemide 40mg OM, Bisoprolol 2.5mg OD *(shouldn't be started on Beta blocker when acutely unstable)* C.Furosemide 40mg OM, Spironolactone 25mg OM, Ramipril 2.5mg OD *(BP not high enough to tolerate all three, and all drugs are nephrotoxic)* D.Furosemide 40mg OM with other medications to be started at follow up clinic *(should start some secondary prevention before follow up in clinic to helo with symptoms and improve survival)*
39
What are the receptors associated with the sympathetic regulation of blood pressure?
* Preload alpha-1 receptor * Afterload (arterio-constriction): Afterload alpha-1 receptor * Noradrenaline increases the frequency of and force of contractions by acting on Beta- receptors
40
What is the action of the sympathetic system on the ß1 receptors?
* increase cAMP * increases Ca++ released through ion channels * increases heart rate and force of contractions
41
What receptors does the parasympathetic system act on in the heart and what is its response?
acts on M2 receptors and decrease the cAMP
42
What is the effect of sympathetic activity on total peripheral resistance?
* Increased sympathetic activity * increases peripheral resistances * reduces blood flow * boosts central blood volume
43
What is the sympathetic pathway and the receptor that causes smooth muscle constriction?
* Noradrenaline is released, acts on alpha-1 receptors * stimulates the activation of IP3 * increases Ca++ * causes smooth muscle contraction
44
What is the sympathetic pathway and the receptor that causes smooth muscle relaxation?
* Adrenaline binds to Beta 2 receptors * stimulates adenyl cyclase to form cAMP * cAMP causes smooth muscle relaxation and glycogen breakdown
45
What is the distribution of adrenergic receptor Alpha-1?
* Arterioles: coronary, visceral, cutaneous * veins, * internal sphincters * iris dilator muscle
46
What is the distribution of adrenergic receptor Alpha-2?
* presynaptic membrane * pancreas * veins * adipose tissue * GIT sphincters * salivary glands
47
What is the distribution of adrenergic receptor Beta-1?
* Heart: SA node, atrial muscle, AV node, ventricles * Kidney * Adipose tissue
48
What is the distribution of adrenergic receptor Beta-2?
* muscular Arterioles * veins * bronchi muscles * liver pancreas * uterus * Iris constrictor muscle
49
What is the distribution of adrenergic receptor Beta-3?
* Adipose tissue * Urinary bladder
50
What is the Renin- Angiotensin-aldosterone system?
* Hormone regulatory system that maintains the blood pressure and fluid balance in the body * Regulation is controlled through the kidney
51
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
52
What three factors should be considered when choosing a course of treatment for hypertension?
* Age: \< 55yrs, use ACE inhibitor or Angiotensin receptor blocker, ARB. \> 55yrs calcium channel blocker * Race: ACE inhibitors/beta-blockers may not be as effective, use calcium ion channel blockers in those of Black/African or Black Caribbean backgrounds * Co-existing diseases
53
What are the different types of anti-hypertensive drugs?
* ACE inhibitors and Angiotensin receptor blockers * Calcium channel antagonists * Diuretics * Beta-blockers * Vasodilators
54
What is the British Hypertension Society guideline flow chart for treatment?
55
Give an example of ACE inhibitors
* **Ramipril** * Perindopril * Enalapril
56
What are some side effects and contraindications of ACE inhibitors?
* Dry cough in 10-30% of patients as a result of accumulation in the lungs of bradykinin: switch to ARB instead * First dose hypotension: diuretics or severe hypertension or Na+ depletion * Renal impairment: measure kreatinin output first * Contraindication in bilateral renal artery stenosis * Hypoperfusion in the efferent arteriole in the kidney could be exacerbated * Hyperkalaemia
57
What are ARBs, give an example?
* Angiotensin receptor blockers * Block the action of Ang II on AT1-Receptor * ***Losartan*** * ***Spironolactone***: add on for resistant hypertension, primary aldosteronism
58
Give examples of Ca++ channel antagonists?
* Amlodipine: target L-type Ca++ channels on the smooth muscle of arterioles * Phenylalkylamines (e.g. ***verapamil***) and benzothiazepines (e.g. diltiazem) target L-type channels in the heart and decrease the frequency and force of contraction, less used to treat hypertension.
59
What are the side effects and contraindications of Ca++ channel antagonists
* Peripheral oedema * Flushing and headaches ( meninges of the brain) * Grapefruit juice enhances the action
60
Explain how peripheral oedema is caused by Ca2+ channel antagonists
It increases the hydrostatic pressure across the capillary and reduces fluid reabsorption due to dilation of the precapillary arteriole. The tissue fluid thing
61
Give examples of thiazide diuretics
* Hydrochlorothiazide (HCT) * Bendroflumethiazide * Indapamide.
62
Give examples of thiazide-like diuretics
* Chlorthalidone * Metolazone
63
What is the mechanism of thiazide diuretics?
* Act on the DCT and the collecting duct * Inhibit the sodium/chloride co-transporter * Slow to act, less effective than loop diuretics but longer-acting * Causes vasodilation over time
64
What are the side effects and contraindications for thiazide diuretics?
* Hypokalemia * Increase in urate: wouldn't give to gout patients * Increase in blood glucose: (-like) not good for diabetes patients * Increase in blood lipids
65
What is the action of Indapamide?
* a thiazide diuretic * hyperpolarises smooth muscle cells: causes K+ to move out of the cells * causing relaxation/dilation of the arteriole: more Ca2+ moves * and a decrease in total peripheral resistance
66
Explain Hypoglycaemia
* low blood glucose: activates the release of adrenaline, mobilises glucose release from the liver * leads to tremor, palpitation and sweats * symptoms of hypoglycaemia are blocked by Beta-blockers * _beta-blockers and thiazides are contraindications to diabetics_
67
Give examples of types of beta-blockers
* Non-selective ß1 and ß2: P***ropranolol*** * selective ß1 antagonist: ***Bisoprolol***
68
Explain vasodilators, including an example
* alpha-1 antagonists (IP3) * used to treat hypertension in patients with benign prostatic hypertrophy * e.g Doxazosin, * minoxidil open K+ channels
69
What is the BP equation?
BP= CO x SVR (systemic vascular resistance) CO= HR x SV
70
What is clinically defined as hypertension? and how you'd you diagnose it?
Clinic ≥140/90 mmHg **and** ABPM/HBPM ≥135/85 mmHg Sustained high blood pressure Take a second measurement during the consultation if the second measurement is substantially different from the first take a third record the lower of the two readings * offer ambulatory blood pressure monitor to confirm the diagnosis * offer home blood pressure morning
71
What are confoundings that could impact the diagnosis of hypertension?
* Cuff being too small * Back/arm/feet being unsupported * patient talking/active listening * distended bladder * smoking within 30 mins * Pain * not resting
72
What are some symptoms of Hypertension?
* asymptomatic * headache * blurred vision * dizziness * palpitations * epistaxis
73
What examinations would be useful to identify Hypertension?
* Cardiovascular * Abdominal * Fundoscopy
74
What are NICE guidelines for treating hypertension when diagnosed?
75
What are non-drug treatments of Hypertension?
* Weight reduction → 5-10 mmHg per 10kg weight loss * DASH eating plan → 8-14mmHg * Dietary sodium restriction * Physical activity * Alcohol moderation
76
What is the pharmacological treatment pathway for HTN?
77
What are target Blood pressures when monitoring treatment
In clinic * 140/90 mmHg in people aged under 80 * 150/90 mmHg in people aged 80 and over ABPM/HBPM * below 135/85 mmHg in people aged under 80 * below 145/85 mmHg in people aged 80 and over.
78
What is a hypertensive emergency?
Severe “hypertension” (BP≥ 180/120 mmHg) _with acute damage_ to the target organs → Lower BP in minutes to hours!!
79
What is Hypertensive urgency?
Severe “hypertension” _without acute damage_ to the target organs → Lower BP after a review within 7 days
80
When and who should be offered statins?
* Those under 84 years should have CV risk estimated and offered lifestyle modification * Atorvastatin should be offered for 1 10% or greater Q-risk score * For people over 85 years or older atorvastatin should also be offered * Statin should also be offered in T1DM and CKD (Atorvastin is renal friendly) or CVD without Q risk estimate
81
What is Ezetimibe
* Ezetimibe monotherapy is recommended as an option for treating primary (heterozygous‑familial or non‑familial) hypercholesterolaemia in adults in whom initial statin therapy is contraindicated or not tolerated * Ezetimibe co‑administered with statin might be appropriate
82
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
83
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
84
What medications are useful in treating hypertriglyceridemia?
Fibrates
85
What are the risks associated with hypertriglyceridemia?
* Pancreatitis * Metabolic syndrome * CVD
86
What are different cardiovascular calculators? which one is better and why?
* QRISK 2 * QRISK 3 * adds use of atypical antipsychotics and severe mental illness * migraines, SLE, erectile dysfunction , HIV/AIDs and steroid use
87
What is measured in the QRISK 3?
* **BP treatment** * **Family History** * **Deprivation** * **Ethnicity** * **Reproducibility** * **Generalisability** * **Statistical validity** * **Face validity** * **Atypical antipsychotic medication; Severe mental illness** * **Migraine, SLE, Erectile dysfunction; HIV/AIDs; Steroid use**

308: Pharmacology (11 decks)

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