Cardiology Flashcards
How often should patients recieving amiodarone be clinically reviewed and what should this entail?
Patients taking amiodarone should have a routine 6-monthly clinical review, including liver and thyroid function tests, including a review of side effects.
Why would CCB be used in heart failure patients? Which ones?
To treat hypertension or angina.
Amlodipine is drug of choice.
Verapamil, diltiazem or short-acting dihydropyridine agents should be AVOIDED.
When would diuretics be used in a a patient with heart failure?
To treat congestive symptoms and fluid retention. Diagnosis and treatment of HF with preserved ejection fraction should be made by a specialist.
What dose of a suitable diuretic would be used in a patient with heart failure?
Less than 80mg furosemide per day.
What monitoring accompanies the use of ARBs in HF patients? (4)
- Serum urea
- Serum electrolytes
- Creatinine
- eGFR
Risk of renal impairment and/or hyperkalaemia.
When would digoxin be used to treat a HF patient?
When first-line and second-line ineffective.
What monitoring accompanies the use of digoxin?
Routine monitoring of serum digoxin concentration is not recommended. A digoxin concentration measured within 8-12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence.
What is the CCB drug of choice in the treatment of hypertension/angina in heart failure patients?
Amlodipine.
Avoid verapamil, diltiazem or short-acting dihydropyridine agents.
The use of beta blockers in HF treatment is associated with what monitoring requirements?
‘Start low, go slow’
- HR
- BP
- Clinical state after each titration.
ARBs are associated with what electrolyte imbalances?
Hyperkalaemia
What is the first-line treatment of HF?
ACEI + BBs
What is the second-line treatment of HF?
Seek specialist advice if the patient is still symptomatic despite optimal therapy with ACEI and BB.
Add in an aldosterone antagonist licensed for heart failure or an ARB or hydralazine in combination with a nitrate.
How do ACEI work?
Produce vasodilation by inhibiting the formation of angiotensin II, which is a vasocontrictor formed by the proteolytic action of renin (from the kidneys) on angiotensinogen to form angiotensin I.
How do ARB work?
They block the action of angiotensin II at its receptors on muscles surround blood vessels. As a result, blood vessels enlarge and BP is reduced.
How does digoxin work?
Increases the force of the heart muscle contraction, reducing the conductivity of the atrioventricular node and reducing the heart rate.
How does ivabradine work?
On the funny ion current, which is highly expressed in the sinoatrial node. Blocking this channel reduces cardiac pacemaker activity, selectively slowing the heart rate and allowing more time for blood to flow to the myocardium.
How do aldosterone antagonists such as spironolactone work?
Antagonise action of aldosterone at mineralcorticoid receptors which inhibits sodium resportion in the collecting duct of the nephron in the kidneys. This reduces urinary potassium excreation and weakly increases water excretion.
What is heart failure?
The condition in which the heart can’t pump enough blood to meet the body’s needs.
What is Class I of the NYHA HF classification?
Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. no shortness of breath when walking, climbing stairs etc.
What is Class II of the NYHA HF classification?
Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
Why does heart failure cause SOB?
The shortness of breath occurs because blood in the body backs up in the blood vessels that return blood from the lungs to the heart due to the heart not pumping blood out of the heart effectively. This causes fluid to leak into the lungs, also known as congestion.
What is angina?
Angina is caused by reduced blood flow to your heart muscle. Your blood carries oxygen, which your heart muscle needs to survive. When your heart muscle isn’t getting enough oxygen, it causes a condition called ischemia. The most common cause of reduced blood flow to your heart muscle is coronary artery disease (CAD).
What is Class III of the NYHA HF classification?
Class III: Marked limitation in activity due to symptoms, even during less-than-ordinary activity e.g. walking short distances (20-100m).
What is Class IV of the NYHA HF classification?
Severe limitations, experiences symptoms even while at rest. Mostly bedbound patients.
Why are aldosterone antagonists used in congestive heart failure?
They are used in addition to other drugs for additive diuretic effect, which reduces oedema and the cardiac workload.
A typical initial dose and dosing regimen for ramipril in heart failure____
Initially 2.5mg od, increased as tolerated to 10mg max daily (divided doses). Increased at intervals of 1-2 weeks.
What is a typical initial dose and dosing regimen for losartan and when would it be used in heart failure?
Initially 12.5mg od, increased if tolerated to max 150mg daily in divided doses, at intervals of at least 2 weeks.
Used when ACEI unsuitable/ not tolerated.
What is a typical dose of bisprolol as an adjunct in heart failure?
Initially 1.25mg once daily (in morning) for 1 week then, if tolerated, increased to 2.5mg once daily for 2 week etc.
What is the first line symptom control medication for heart failure?
Diuretics to deal with the fluid imbalances, oedema. Loop diuretics such as furosemide and bumetanide.
What is the second line symptom control medication for heart failure?
Aldosterone antagonists like spironolactone for the oedema etc.
What is the third line treatment for symptom control in heart failure?
Digoxin, concentration monitoring not really needed unless suspected adverse effects: nausea and vomitting etc.
Need to monitor Ca2+, Mg2+ and K+ very closely.
If a patient is over 60 and has heart failure and hypertension, what is first-line?
They should be on ACEI as works for both heart failure and hypertension, not CCB as would be expected RE NICE guidance for hypertension over 55s.
What is a vascular assessment, who is offered them?
All people over 40 should have a routine cardiovascular risk assessment. A risk factor calculator is used by doctors and nurses to assess the risk of a patient developing a cardio diseas.
What are the modifiable risk factors for primary prevention of CHD? (6)
Smoking status Hypertension Physical inactivity Uncontrolled diabetes BMI High Cholesterol
What is/ are Acute Coronary Syndromes (ACS)?
A range of disorders, includes heart attack and unstable angina: caused by sudde reduction of blood flow to part of the heart muscle.
What is an STEMI?
ST elevation MI
How would a STEMI patient by stabilised?
S/L GTN (IV if needed) for chest pain –> vasodilator.
Morphine for pain if needed. (+anti-emetic –> Metoclopramide)
How would we reduce the damage in a STEMI patient?
Antiplatelets etc. Dual antiplatelet. STAT aspirin and clopidogrel. Aspirin: 300mg, 75mg lifelong. Clopidogrel: 300/600mg (unlicensed but maybe local guidelines), 75mg for 12 months post STEMI.
Why are anticoagulants used with PCI?
There is a risk of clotting downstream due to disturbance of the plaque/break down.
What secondary prevention treatment needs to be initiated for a patient post STEMI?
ACEI
Dual antiplatelet therapy (for a year, aspirin for life)
Beta-blocker
Statin.
A positive Exercise Tolerance Test (ETT) result means what?
Highly likely the patient has coronary heart disease.
What is the GRACE risk scoring tool used for?
Calculating a patient’s risk of future CV events.
What does the GRACE tool take into account? (10)
Tropinin levels. Renal function. Age. Heart rate. Systolic mmHg. CHF class. Use of diuretics. Renal failure Y/N. ST-segment deviation Y/N. Cardiac arrest at admission Y/N.
