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
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
3
Q
Managing HTN- NICE Guidelines August 2019
A
- Hypertension groups are now dependent on diabetes
4
Q
Blood pressure thresholds for diagnosis and treatment of HTN
A
- CVD risk to start treatment has decreased from 20% to 10%
5
Q
Direct oral anti-coagulants - Dabigatran
A
- Action: Thrombin inhibitor
- Indication: Prophylaxis TKR/THR; Treatment of DVT/ PE; Non-valvular AF
6
Q
Direct oral anti-coagulants- Apixaban
A
- Action: Inhibits activated factor X (Xa)
- Indication: Prophylaxis TKR/THR; Treatment DVT/PE; Non-valvular AF
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
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
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
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
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
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
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
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
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
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
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