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PH4703-Practical therapeutics > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Background

A
  • In the UK 7.4 million people are affected by CVD
  • Cardiovascular disease is still the leading cause of death worldwide and one of the leading causes of death in the UK
  • CVD causes more than a quarter (28%) of all deaths per year in the UK
  • >200,000 Hospital visits due to heart attack per year
  • >100,000 strokes each year
  • Complex and co-morbidities
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2
Q

Today

A
  • 460 people will lose their lives to CVD
  • More than 110 of these people will be less than 75 yr old
  • 540 people will be admitted to the hospital for a heart attack
  • 180 people will die from CHD
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3
Q

Managing HTN- NICE Guidelines August 2019

A
  • Hypertension groups are now dependent on diabetes
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4
Q

Blood pressure thresholds for diagnosis and treatment of HTN

A
  • CVD risk to start treatment has decreased from 20% to 10%
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5
Q

Direct oral anti-coagulants - Dabigatran

A
  • Action: Thrombin inhibitor
  • Indication: Prophylaxis TKR/THR; Treatment of DVT/ PE; Non-valvular AF
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6
Q

Direct oral anti-coagulants- Apixaban

A
  • Action: Inhibits activated factor X (Xa)
  • Indication: Prophylaxis TKR/THR; Treatment DVT/PE; Non-valvular AF
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7
Q

Direct oral anti-coagulants- Rivaroxaban

A
  • Action: Inhibits activated factor X (Xa)
  • Indication: Prophylaxis TKR/THR; Non-valvular AF; Treatment DVT/PE; Secondary prevention in ACS
  • Black triangle drug
  • Must be taken with food
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8
Q

Direct oral anti-coagulants- Edoxaban

A
  • Action: Inhibits activated factor X (Xa)
  • Indication: Treatment DVT/PE; Non-valvular AF
  • Black triangle- new indication
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9
Q

Direct oral anti-coagulants

A
  • Prevention of stroke and systemic embolism in patients with non-valvular AF
  • Must have one of the following risk factors
    • Previous stroke/TIA/systemic emboli
    • Symptomatic HF/LEVF <40%
    • >75yrs
    • Diabetic or has CAD or HTN (for Dabigatran patients need to be >65 yrs)
  • Advantages versus warfarin- No INR monitoring
  • Interactions?
    • Inducers of CYP enzymes
  • However any reversal agents?
    • Renal failure- dose adjustments
  • Risk of major haemorrhage is decreased compared to warfarin
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10
Q

Idarucizumab for reversal of dabigatran

A
  • RE-VERSE AD- uncontrolled cohort study
  • 5g dose of idarucizumab completely reversed the anticoagulant effect of dabigatran in adults who had either serious bleeding or required urgent surgery
    • Median investigator- reported time to cessation of bleeding was 11.4 hrs
    • Normal intraoperative haemostasis was seen in 92%
  • High sorbitol content
  • Expensive (£2500 per dose), use fresh frozen plasma before intervention with praxbind
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11
Q

Andexanet alfa for the reversal of rivaroxaban and apixaban

A
  • Biological agent
  • Acts as a decoy receptor- has an affinity to the drug and stops binding
  • Does NOT work against dabigatran
  • FDA approval was given May 2018
  • The FDA’s post-marketing requirement calls for a clinical trial that randomises patients to receive either Andexxa or usual care. The study is expected to start in 2019 and report 2023
  • European Commission has approved conditional marketing authorisation in adults when the reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding
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12
Q

Anti-arrhythmics

A
  • Dronedarone
    • Multichannel blocking anti-arrhythmic
    • TA 197: Patient’s in sinus rhythm after cardioversion in paroxysmal or persistent AF when alternatives have failed/unsuitable AND have CVD risk factors
  • PALLAS study: AF patients >65yr= increased risk of CV related mortality and events vs placebo
  • Postmarketing surveillance- liver and pulmonary toxicity
  • Additional contraindications
    • HF OR LVSD
    • Permanent AF
    • Liver and lung toxicity related to the previous use of amiodarone
    • MHRA drug safety update
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13
Q

Newer angina treatment: nice CG 126

A
  • BB- useful if recent MI- Caution in asthma
  • Don’t use verapamil/diltiazem with BB- severe lowering of heart rate
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14
Q

Newer angina treatments 1- Ivabradine

A
  • Slows firing of the SA node (blocks If current, which regulates pacemaker activity thus HR)- limits use
  • Reduces HR without affecting the contractile force
  • For B-blocker intolerance or in combination stable angina
  • Also now in combination with standard therapy for HF if EF <35% and HR >75 beats/min
  • CI-angina (Don’t initiate) HR <70; HF (don’t initiate HR <75: acute MI, unstable angina, unstable or acute HF post CVA, with verapamil and diltiazem
  • Side effects- visual disturbance ‘luminous phenomena’ or ‘Phosphenes’ (resolves spontaneously or after discrimination), bradycardia, heart block, headache, dizziness
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15
Q

Newer angina treatment- Ranolazine

A
  • Inhibits the late Na influx in myocardial cells thus reducing the ventricular abnormalities associated with ischaemia
  • Increases exercise tolerance, reduces angina attacks and use of GTN
  • Does not reduce HR or BP- thus useful if other anti-anginal are limited by HR <50bom; BP <90mmHg
  • Side effects dizziness, nausea, constipation, possible prolongation of QT interval
  • CYP3A4 + P-GP substrate- check interactions
  • Use cautiously in those under 60kg
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16
Q
A
17
Q

NICE CG 167 STEMI protocol

A
18
Q

Alternatives to clopidogrel- Prasugrel

A
  • Licensed for ACS patients undergoing PCI
  • Faster time to maximal effect than clopidogrel- no metabolic step
  • NICE TA317 PCI for ACS treatment, previous stent thrombosis with clopidogrel or diabetic patients
  • 1st line unless the previous history of CVA/TIA; is >75 or <60kg lower doses but may prefer clopidogrel
19
Q

Alternatives to clopidogrel- Ticagrelor

A
  • Licensed for ACS patients
  • Slightly different mode of action; more potent effective
  • NICE TA236: Primary PCI for STEMI, NSTEMI, stable angina (strict criteria)
  • Higher risk of bleeding; both STEMI and 2nd line ACS protocols, mainly for patients who have already occluded with other agents or whilst on the table
20
Q

Alternatives to clopidogrel- Cangrelor

NB- No evidence submitted to NICE

A
  • With aspirin for patients undergoing percutaneous coronary intervention (PCI)
  • When oral P2Y12 inhibitor prior to the PCI procedure and in whom oral therapy with P2Y12 inhibitors is not feasible or desirable
  • Bolus dose followed by infusion
21
Q

Alternatives to clopidogrel- Rivaroxaban

NB- NICE TA published

A
  • As an alternative to clopidogrel or addition to aspirin- clopidogrel combination
  • Bleeding risk assessment
  • Dose is 2.5mg BD
22
Q

Dual/Triple therapy

A
  • The combination only for selected patients (if starting warfarin)
    • Stop anti-platelet for primary prophylaxis, peripheral artery disease or previous stroke and in stable IHD (>12 months post-acute MI)
    • Continue if one single antiplatelet agent <12 months following an ACS, continue aspirin until 12 months post ACS (unless high bleeding risk)
    • Continue aspirin and clopidogrel, following an ACS or stent placement, carefully assess bleeding risk and discussed with their cardiologist, with a view to introducing warfarin and minimising the duration of triple therapy (usually 3-6 months)
  • If already on warfarin
    • If stent needed consider bare metal stent to minimize the duration of triple therapy (4 weeks vs 12 months; then continue aspirin for 11 months)
    • If no stent then triple therapy for 4 weeks with aspirin for 11 months
23
Q

Dual/Triple therapy- ESC

A
  • Continued for certain patients e.g. ACS + AF
  • OAC refers to warfarin or DOACS
  • In NSTEMI if PCI: Has bled (0-2) low risk, up to 6 months triple therapy, then dual therapy for 6 months
  • In ACS if PCI has bled high >3 triple or dual therapy for 4 weeks, then dual for 11 months
  • Med managed/CABG dual therapy for 12 months
  • Prasugrel/Ticagrelor not recommended in triple therapy combinations with DOACor warfarin
  • Gastro protection is recommended: hx of bleeding, advanced age, concurrent use of anticoags, H.Pylori, steroids, NSAID inc high dose aspirin
24
Q

Aldosterone antagonist- Eplerenone

A
  • Adjunct in stable HF patient (LVEF <40%) following MI- within 3-14 days of the event
  • Adjunct in CHF (LVEF <30%)- spironolactone 1st line?
  • Monitor K+
  • Side effects: GI, hyperkalaemia, renal impairment, muscle spasm, gynecomastia, pyelonephritis
  • Dose reduction when EGFR <60 mL/minute/1.73m2
25
Q

Sacubitril-Valsartan

A
  • NICE TA388
  • Sacubitril (pro-drug) inhibits the breakdown of natriuretic peptides, increasing diuresis, natriuresis and vasodilation
  • Valsartan in this combination (ARB) is more bioavailable than other tablet formulations
  • Symptomatic chronic HF with reduced ejection fraction:
    • NYHA class II to IV
    • Left ventricular ejection fraction of 35% or less
    • Who are already taking a stable dose of ACEI or ARBs
  • Second-line stage
  • Monitor: BP, renal function, renal function, potassium
  • BNP is not a suitable biomarker as it is a neprilysin substrate
  • Side effects: Anaemia, Hypotension, diarrhoea, gastritis, hyperkalaemia, hypoglycaemia, nausea, vertigo
26
Q

Renin-inhibitors

Aliskiren

A
  • Directly inhibits renin
  • Essential HTN
  • Similar side-effect profile as ACEI/ AngII
  • Not recommended for use with ACEI/ AngII
  • Altitude study found adverse CV and renal events when used in combination with ACEI/ AngII
  • In practice rarely used- very select patient under specialist advice
  • Not for use with P-pg inhibitors
  • Interaction with grapefruit juice
  • No fruit juices to be taken at same time
27
Q

NSAIDs and CV risk

A
  • Long term use of NSAID and COX-2 inhibitors associated with increased risk of CV events i.e. strokes and MI
  • Diclofenac and ibuprofen (Max doses) is associated with the same level of risk as COX-2
  • Hence EMA/MHRA recommends avoiding patients with HF, previous strokes/ MI, circulatory and heart disease
  • Ibuprofen (<1.2g OD) and naproxen associated with a lower risk of thrombotic event and not associated with MIs
28
Q

Top trumps

A
  • Cardiac amyloidosis- contra-indication to certain drugs
  • HF- prevention of cardiac re-modelling and symptom reduction
  • STEMI/NSTEMI- optimisation of cardiac function and prevention of repeat epidote (should prevent HF)
  • AF- a rate of rhythm control and stroke prevention
  • Angina- prevention of ischemic pain
  • HTN- reduce BP to within desired range
29
Q
A

PH4703-Practical therapeutics (36 decks)

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