Cardiology questions 1 Flashcards
HYPERTENSION
An 81-year-old man attended the hypertension clinic for
review. He also had atrial fibrillation and chronic renal
impairment. He was already taking aspirin, digoxin (rate limiting CCB), indapamide (Diuretic) and ramipril.
On examination, his pulse was 65 beats/minute and irregular, and his blood pressure was 185/88 mmHg.
What is the most appropriate additional treatment for his
hypertension?
- Amlodipine
- Atenolol
- Dozaxosin
- Spironolactone
- Verapamil
Amlodipine
Name the steps of hypertensive drugs
- Ace inhibitor Or ARB less <55 years old, not black or have diabetes.
Over >55 years, or patients with Afrocaribbean CCB (Amlodipine). If not tolorated, offer thiazide-like diuretic like Indapamide - ACE/ARB + CCB
- ACE OR ARB + CCB
- Add Spirolactone, selective A-blocker or B-blocker
DISCUSS ACE INHIBITORS CLINICAL PHARM INFORMATION
Angiotensin converting enzyme inhibitor
Drugs: Ramipril, lisinoprol, ptrindopril
MOA: Angiotensin converting enzyme Inhibitor block the action ACE to prevent the conversion of angiotensin I to II.
Angiotensin II is a vasoconstrictor and stimulates aldosterone secretion whichh reduces vascular afterload reducing BP.
Indications:
- Hypertension
- Heart failure
- IHD
- Diabetic nephropathy & CKD (proteinuria)
Adverse effects:
- Hypotension
- Dry cough
- Angioedema
- Hyperkalaemia
- Worsen renal failure
Warnings (Caution):
- Monitor kidney function as it can worsen
- Potassium elevating drugs
- NSAIDs
Contraindications:
- Renal artery stenosis
- Pregnancy
- Breastfeeding
- Acute kidney injury
Interactions:
Potassium elevating drugs and supplements. NSAIDs increase risk of nephrotoxicity
Monitoring:
1.25 mg daily starting dose 10mg max
Explain side effects, dry cough, dizziness
Blood test monitoring for egfr 1-2 weeks into treatment and after titrating dose.
DISCUSS ANGIOTENSIN RECEPTOR BLOCKER
ARBS: Angiotensin receptor blockers
MOA: Angiotensinn receptor nlockrt block the action of angiotensin II on the angiotensin type 1 AT 1 receptor. It is also a vasoconstrictor and stimulate aldosterone secretion. Blocking afterload reduces BP.
Drugs: LOSARTAN, CADENSARTAN
- Indications:
- Hypertension
- Heart failure
- IHD
- Diabetic nephropathy and CKD
Adverse effects:
- Hypotension
- Hyperkalaemia
- Renal failure
- Dizziness
Warnings (Caution):
- Dose should be monitored on renal function effect
- Potassium elevating drugs
- NSAIDs
- Hypertrophic cardiomyopathy
- Angiodema
Contraindications:
- Renal artery stenosis
- Acute kidney injury
- Pregnancy
- Breastfeeding
- Diabetes with eGFR (less than 60ml)
Interaction:
- ▴Potassium-elevating drugs, potassium supplements
- Potassium sparing diuretics
- NSAIDs increase risk of nephrotoxicity
Monitoring:
Check electrolytes and renal function
Repeat this 1–2 weeks into treatment and after increasing the dose. Check if symptoms has improved
DISCUSS CCB CLINICAL PHARM INFORMATION
CALCIUM CHANNELL BLOCKER
Drugs: Dihydropyridines: Amlodipine and nifedipine for vasculature
Non-dihydropyridines: Verapamil most cardioselective, Diltiazem
MOA:
- Calcium channel blocker relaxation and vasodilation in arterial smooth muscle, lowering arterial pressure.
- Calcium channel blocker reduce myocardial contractility
- Reduces cardiac contractility and myocardial oxygen demand
Indications
- Hypertension
- Stable angina
- Supraventricular arrhythmias (tachycardia, atrial flutter)
- Adverse effects:
- Ankle swelling
- Flushing
- Palpitations
- Headache
- (Verapamil- Constipation, Heart failure, heart block)
Warnings (Cautions):
- Patients with poor left ventricular function
- AV nodal conduction delay
- CCB and B-Blockers should not be prescribed unless specialist supervision as
they can cause HF, Bradycardia.
Contraindications:
- Amlodipine and nifedipine contraindicated in unstable angina, (increase cardial
oxygen demand)
- Severe aortic stenosis, cause collapse.
Interactions:
- Verapamil and diltiazem should not be prescribed with B-blockers as both can cause HF, bradycardia
Monitoring: Regular BP monitoring Help reduce cardiovascular risk HTN usual dose is 5mg - 10mg Amlodipine Supra ventri arrhythmias: Diltiazem 90mg orally 12hr
DISCUSS THIAZIDE LIKE DIURETIC CLINICAL PHARM INFORMATION
Thiazide like diuretics:
MOA: Thiazide inhibit NA/Cl, Co transporter in distal convulated tubule of the nephron and may mediate vasodilation.
Drugs: Indapamide, Bendroflumethiazide, chloralidone
- Indications:
- Hypertension, first line or add on.
Adverse effects
- Hyponatraemia
- Hypokalaemia (excess sodium exchanged for potassium)
- Arrhythmias
- Impotence
Warnings (Caution)
- NSAIDs
- Hyponatraemia
- Gout
Contraindication
- Hypokalaemia
- Hyponatraemia
- Pregnant women
Interactions:
- Nsaids reduces effectiveness
- Lowers serum potassium loop diuretics
Monitoring:
Patient starting measure serum electrolyte 2-4 weeks before and after
A 67 year old patient is experiencing chest pain which radiates to his jaw, he was on a jogging session while this came on. He stopped at rest and used his GTN spray after 5 min and after 15 mins the pain continued. What does this patient have?
Unstable angina
Discuss Nitrates clinical pharmacology.
MOA: Nitrates convert into nitric oxide. NO increases cyclic guanosine monophosphate synthesis and reduces ontracellular Ca2 in vascular smooth cells causing relaxation. Relaxation of the venous vessels reduce cardiac preload, cardiac work and O2 demand.
GTN (Sublingual glyceryl trinitrate – first line instable angina
Indications:
- Acute angina and Acute Coronary Syndrome
- Long-acting nitrates (Isosorbide mononitrate) used for prophylaxis of angina
- Pulmonary oedema
Adverse effects:
- Flushing
- Headaches
- Light headedness
- Hypotension
- Tolorance
Contraindications:
- Severe aortic stenosis
- Haemodynamic instability
- Hypotension
Interactions:
- Phosphodiesterase PED inhibitors (Sildenifl) prolong hypotension
Monitoring:
Patient may experience headache, flushing etc but shortlived
- Use this before doing tasks that initate chest pain
- Postural hypotension risk, patient should sit 5 mins after using
- Ensure BP monitoring should not drop below 90mmhg
Discuss Beta blocker clinical pharmacology.
Beta blocker
MOA: Mechanism of action:
- B1 receptors reduce force of contraction and speed of conduction in the heart relieving myocardial ischaemia.
- Slow down ventricular rate by prolonging the refractory period of arioventricular node.
- Reduces BP by reducing renin secretion
- Indications:
- IHD – Ischemic heart disease
- CHF – Chronic heart failure
- AF – Atrial fibrillation
- SVT – supraventricular tachycardia
- HTN – Hypertension
Drugs: B1 selective are: Bisoprolol, metoprolol. Non-selective Propranolol
and carvedilol)
- Adverse effects:
- Fatigue
- Cold extremities
Headache
Gi disturbances (Nausea)
Impotence
Nightmares.
Warnings (Caution)
- Heart failure
- Hepatic failure
- COPD
- Haemodynamic instability
Contraindications
- Asthma
- Heart block
- Hepatic failure
Interactions:
- Non dihydropyridine calcium channel blocker (Verapamil, diltiazem)
Monitoring:
- Should be take once daily same time each day
- Common side effects like impotence can occur impotence
- HF initial deterioration, seek medical attention
- Patients with obstructive airway diseases if breathing get worse seek medicial attention.
Review treatment in 2-4 weeks
Discuss Alpha blocker clinical pharmacology
Alpha blocker
MOA: Drugs in this class are highly selective a1-adrenoceptor found in the smooth muscles, blood vessels and urinary system. Stimulation induces contraction; blockade induces relaxation. α1-blockers therefore cause vasodilatation and a fall in blood pressure (BP), and reduced resistance to bladder outflow
Drug names: Doxazosin, Tamsulosin, Alfuzosin
Indications:
- Benign prostate enlargement
- Resistant hypertension (usually fourth line)
Adverse effects:
- Postural hypertension
- Dizziness
- Syncope
Caution/warnings
- Postural hypotension
- Raynaud’s phenomenon
Contraindication
- Modified-release doxazosin tablets in people with gastrointestinal obstruction, oesophageal obstruction, or any degree of stricture.
Interactions:
- Pronounced first-dose hypotension, it may be prudent to omit doses of one or more existing antihypertensive drugs on the day the α-blocker is started.
Monitoring:
Doxazosin is licensed both for benign prostatic enlargement and hypertension; it is typically started at a dose of 1 mg daily and increased at 1–2 week intervals according to response.
Tamsulosin given for benign prostatic enlargement only. Efficacy is the patient’s urinary symptoms and/or BP, as applicable. For tolerability and safety, adverse effects such as hypotension
Mr. Solomon is a 63-year old gentle man who has been under your care for a variety of medical problems during the past 5 years. He has been treated for two myocardial infarctions, hypertension, non-insulin dependent diabetes and stasis dermatitis of the left leg. He had an aorto-coronary bypass one year ago. Today he presents in the office with shortness of breath which has been progressive over the past five days. He has, however, experienced episodes of shortness of breath during the past four months, especially when exerting himself. He fatigues easily and has lost “all my energy to do anything.” He also complains of anorexia. Last night he awoke suddenly from sleep because “I couldn’t catch my breath”. He sleeps on 3 pillows.
WHAT DOES HE HAVE?
- Heart failure
How do you manage heart failure?
- Ace inhibitors: Ramipril or ARB: Losartan
- Beta blocker: Bisoprolol or Carvediolol (Stopped if the patient has heart rate less than 50 beats per minute)
- IV loop diuretics: Furosemide (first line in diuretics)
- Digoxin (Sinus rhythm patients symptomatic after first and second line)
- Thiazide diuretics: bendroflumethiazide, Cause a more gentle and slower onset diuresis.
- Potassium sparing diuretics: Low dose spironolactone or amiloride
- Amiodarone in arrhythmic patients
A stepwise approach
ACE inhibitors or ARB
ADD diuretic
ADD beta-blocker (once euvolaemia)
ADD aldosterone antagonist (spironolactone or amiloride)
then – increase all above to maximum tolerated doses
CONSIDER ARNI (and cease ACE-i) for patients who remain with an EF <40%
CONSIDER ivabridine
DISCUSS LOOP DIURETICS CLINICAL PHARM INFORMATION
Loop diuretics
MOA: Loop diuretics act principally on the ascending limb of the loop of Henle, where they inhibit the Na+/K+/2Cl− co-transporter. Loop diuretics have a direct effect on blood vessels, causing dilatation of capacitance veins.
Drug names: Furosemide, bumetanide
Indications:
Acute pulmonary oedema
Chronic heart failure
Symptomatic treatment of fluid overload (Eg. Renal disease or liver failure)
Adverse effects:
- Dehydration
- Hypotension
- Low electrolyte state due to increases excretion of magnesium, calcium and hydrogen ions
- Hearing loss
- Tinnitus
Cautions/warnings
- ▴Hepatic encephalopathy
- Severe ▴hypokalaemia
- ▴hyponatraemia
- Gout
Contraindication
- ✗hypovolemia
- ✗dehydration
Interactions:
- Potential to affect drugs that are excreted by the kidneys
- ▴Lithium levels are increased due to reduced excretion.
- Risk of ▴digoxin toxicity may also be increased
- Loop diuretics can increase the ototoxicity and nephrotoxicity of ▴aminoglycosides.
Monitoring:
- The medicine will inevitably cause them to need to pass water more often.
- Improvements in the patient’s symptoms, tachycardia, hypertension and oxygen requirement
- Monitoring of serum sodium, potassium and renal function
DISCUSS SPIRONOLACTONE CLINICAL PHARM INFORMATION
Spironolactone
MOA: Aldosterone antagonists inhibit the effect of aldosterone by competitively binding to the aldosterone receptor. This increases sodium and water excretion and potassium retention
Drug names: Spironolactone, eplerenone
Indications:
- Ascites and oedema due to liver cirrhosis: spironolactone is the first-line diuretic.
- Chronic heart failure
- Primary hyperaldosteronism
Adverse effect:
- Hyperkalaemia
- Gynaecomastia
- Liver impairment and jaundice and are a cause of Stevens–Johnson syndrome
Warnings/cautions
- ▴pregnant or lactating women.
Contraindications:
- ✗severe renal impairment
- ✗hyperkalaemia
- ✗Addison’s disease
Interactions:
- ▴potassium-elevating drugs
- ▴ACE inhibitors and ▴ARBs, increases the risk of hyperkalaemia
- ✗Potassium supplements
Monitoring:
- Possibility of growth and tenderness of tissue under the nipples and impotence.
- Reassure them that such effects are benign and reversible.
- e.g. reduction in ascites, oedema and/or blood pressure. Safety should be monitored by checking renal function and serum potassium concentration.
A 54 year old female has a recent blood test which has come back with LDL cholesterol elevated beyond the normal. You have calculated her score to be QRISK 17%. What is the diagnosis and how will you treat them?
- Hyperlipidemia
