Cardiovascular Flashcards
Ectopic beats treatment
- ectopic beats are spontaneous - rarely need treatment
- if treatment required - b-blockers
Atrial fibrillation treatment summary
- stroke risk
- ventricular rate or sinus rhythm control
Life threatening AF treatment
- haemodynamic instability = emergency electrical cardioversion ASAP for anticoagulation
AF onset < 48 hours - acute treatment
rate OR rhythm control
AF onset > 48 hours - acute treatment
rate control
What is used for urgent rate control
- IV b-blocker OR
- verapamil LVEF > > 40 %
If cardioversion (rhythm control) agreed:
- pharmacological = flecainide or amiodarone
- electrical = IV anticoagulation to rule out left atrial thrombus
AF maintenance treatment
- rate control monotherapy - b-blocker (not sotalol) or RLCCB (digoxin - sedentary in non-paroxysmal)
- rate control dual therapy
- rhythm control - electrical or pharmacological cardioversion
AF > 48 hours - maintenance treatment
- electrical preferred = risk of clotting so fully anticoagulated for at least 3 wks before and 4 wks after
Drug treatment post cardioversion
b-blocker OR 1 of:
Sotalol
Propafenone
Amiodarone
Flecainide
What is used with electrical cardioversion to improve success of procedure
amiodarone 4 wks before and up to 12 months after
Paroxysmal AF treatment
- ventricular rhythm control = b-blocker
- SPAF
- episodes of symptomatic paroxysmal AF = ‘pill-in-pocket’ - felcainide/propafenone PRN on symptoms
CHA2DS2VASc score
- congestive HF - 1
- hypertension - 1
- age 75+ - 2
- diabetes - 1
- stroke/tia - 2
- vascular disease - 1
- age 65-74 - 1
- sex = female = 1
- men > >1, women > >2 = thromboprophylaxis
Stroke risk treatment AF
DOAC in non-valvular AF or warfarin
Atrial flutter treatment
- rate or rhythm control but less effective
- rate control temporary until sinus rhythm restored = b-blocker or RLCCBS
- rhythm control = direct current cardioversion for rapid control. pharmacological, catheter ablation for recurrent flutter
- assess for stroke risk
- anticoagulant for 3 weeks if flutter lasted > 48 hours
Paroxysmal supraventricular tachycardia treatment
- terminate spontaneously/alone - no tx
- reflex vagal stimulation - valsalva manoeuvre with ECG monitoring - face in ice cold water/carotid sinus massage
- IV adenosine
- IV verapamil
- recurrent = catheter ablation, prophylaxis = b-blockers or RLCCBs
Ventricular tachycardia treatment
- pulseless VT or VFib = resuscitation (ECG = random)
- unstable sustained VT = direct current cardioversion - IV amiodarone - repeat current cardioversion
- stable VT = IV amiodarone - direct current cardioversion not sustained VT = b-blocker
- high risk cardiac arrest = maintenance = implantable cardioverter defibrillator, can add b-blocker alone or with amiodarone
Torsade de pointes (QT prolongation) treatment
- drug induced or caused by hypokalaemia and severe bradycardia = amiodarone, sotalol, macrolides, haloperidol, SSRIs, TCAs, antifungals
- self limiting but can be recurrent - impaired consciousness
- if not controlled = Vfib = death
- treat with IV magnesium sulfate
- b-blocker (not sotalol) and atrial/ventricular pacing considered
- no anti-arrhythmias = prolongs QT interval = worsens condition
Anti-arrhythmic drugs
- classified into acting on: supraventricular arrhythmias, ventricular arrhythmias or both
- also according to electrical behaviour:
1. membrane stabilising drugs (lidocaine, flecainide)
2. b-blockers
3. amiodarone, sotalol
4. RLCCBs ONLY - not ‘pines’
Warfarin and INR limits
- INR 2.5 = VTEs, AF, cardioversion, MI, cardiomyopathy
- INR 3.5 = recurrent VTEs or mechanical heart valves
- major bleed = stop warfarin - IV phytomenadione & dried prothrombin
- INR > 8, minor bleed - stop warfarin & IV vit K
- INR > 8, no bleeding - stop warfarin & oral vit K
- INR 5-8, minor bleed - stop warfarin & IV vit K
- INR 5-8, no bleed - withhold 1-2 doses of warfarin
- start warfarin when INR < 5
- monitor INR every 1-2 days in early tx, then very 12 weeks
Warfarin MHRA warning
skin necrosis & calciphylaxis (painful skin rash)
Warfarin side effects
- haemorrhage - vit K
- teratogenic - avoid in 1st and 3rd trimester - use contraception
Warfarin interactions
- vit K foods (leafy greens) - reverses warfarin
- pomegranate and cranberry juice - increase INR
- miconazole (OTC daktarin gel) - increases INR
- CYP 450 inhibitors/inducers - increase/decrease warfarin conc
Warfarin and surgery
- minor, low bleeding risk = INR < 2.5, warfarin restarted within 24 hours
- risk of bleeding = stop warfarin 3-5 days before, INR <1.5 day before surgery (vit K to reduce), if high risk VTE bridge with LMWH - stop LMWH 24 hours before restart LMWH 48 hours after
- emergency surgery = IV vit K and prothrombin complex, if can be delayed 6-12 hours - IV vit K alone
Apixaban VTE dose
10mg BD for 7 days then 5mg BD
Apixaban AF dose
- 5mg BD
- 2.5mg BD of 2 of: 80 yrs +, < < 60kg, CrCl > > 133 mol/L
Rivaroxaban VTE dose
15mg BD for 3 weeks then 20mg OD - with food
Rivaroxaban AF dose
20mg OD - with food
Dabigatran VTE dose
- 150mg BD aged 18-74
- 110-150mg BD aged 75-79
- 110mg BD aged 80+
Dabigatran AF dose
- 150mg BD aged 18-74
- 110-150mg BD aged 75-79
- 110mg BD aged 80+
Edoxaban VTE dose
- 60mg OD
- 30mg OD if weigh <61kg
Edoxaban AF dose
- 60mg OD
- 30mg OD if weigh <61kg
Amiodarone loading dose
200mg TDS for 7 days then BD for 7 days then OD maintenance
Amiodarone side effects
- reduce HR so avoid in bradycardia and heart block
- corneal microdeposits - reversible - blurred/dazzled headlights
- thyroid disorders - hypo/hyper due to iodine content
- photosensitivity reactions - avoid sun, use sunscreen for months after tx ends - long t1/2
- hepatotoxicity - stop if jaundice, dark urine, abdo pain, NV, pale stools
- pulmonary toxicity - SOB, cough
Amiodarone interactions
- long t1/2 = potential for months after ending
- drugs that cause hypokalaemia, QT prolongation, bradycardia - b-blockers, RLCCBs
- CYP substrates (amiodarone = inhibitor)
- grapefruit (inhibitor)
- warfarin, contraceptives, statins
- 1/2 digoxin dose with amiodarone - digoxin = enzyme inhibitor
Amiodarone monitoring
- LFTs, TFTs - before tx, then 6 monthly
- CXR - before tx, serum conc of K+ - before tx
- annual eye examinations
- IV use = ECG and liver transaminase
- sofosbuvir, daclatasvir, simeprevir, ledipasvir = extreme monitoring, risk of severe heart block = fatal
Digoxin AF loading dose
- 125-250mcg OD
- different formulations = different bioavailability
Digoxin therapeutic range
- 0.7 - 2.0 ng/ml
- toxicity from 1.5 - 3.0 ng/ml - tx with digoxin-specific antibody (digifab)
- levels 6 - 12 hours after dose, monitor electrolytes & renal function
Digoxin toxicity
bradycardia, SA/AV block, DV, dizziness, confusion, depression, blurred or yellow vision. Sick and slow
Digoxin interactions
- b-blockers = increased risk of AV block and increases in plasma concs
- TCAs - can induce arrhythmias
- drugs that cause hypokalaemia - increased risk of digoxin toxicity
- CYP 450 inducers - reduces plasma concs
- CYP 450 inhibitors - increases plasma concs
What is VTE
clot in vein - obstructs bloods flow
What is DVT
in legs or pelvis - unilateral localised pain or swelling
What is PE
in lungs - chest pain or SOB
Risk factors of VTE
surgery, trauma, immobility, malignancy, obesity, pregnant, COC, HRT
Diagnostic test for VTE
d-dimer
VTE prophylaxis
mechanical (stockings), or pharmacological (anticoags) - start within 14 hours of admission, VTE > bleed, ORBIT or HASBLED
VTE prophylaxis - surgery
- mechanical until mobile/discharged
- pharmacological when VTE > bleed
- LMWH suitable in all general and ortho surgeries
- UFH in renal impairment - lower t1/2 than LMWH
- fondaparinux for lower limb immobilisation or pelvis fragility fractures
- at least 7 days post op, or until sufficient mobility
- 28 days after cancer surgery in abdomen
- 30 days after spinal surgery
VTE prophylaxis in elective hip replacement
- LMWH 10 days then 75mg aspirin 28 days OR
- LMWH 28 days + stockings until discharge OR
- rivaroxaban 10mg OD for 35 days
VTE prophylaxis elective knee replacement
- 75mg aspirin for 14 days OR
- LMWH 14 days + stockings until discharge OR
- rivaroxaban 10mg OD for 35 days
General medicine patients with increased risk of VTE
pharmacological prophylaxis for at least 7 days or mechanical until mobile
VTE prophylaxis in pregnancy
- if VTE > bleeding - LMWH during admission until no risk of VTE or discharged
- birth/miscarriage/abortion in past 6 wks = LMWH 4-8 hours after event, min 7 days + mechanical if immobilised until mobile/discharged
- Tx of VTE = LMWH; UFH if increased risk of haemorrhage
Proximal DVT or PE treatment
- apix or rivarox - 3 months min (3-6 months if active cancer)
- if unsuitable = LMWH 5 days min then dabigatran or edoxaban OR LMWH + warfarin 5 days min or until INR > > 2 x 2 in a row then warfarin alone
Distal DVT treatment
- 6 weeks tx
Provoked DVT/PE treatment
- e.g. immobile/COC - stop at 3 months if provoking factor resolved
Unprovoked DVT/PE treatment
3 months +
Recurrent DVT/PE treatment
longterm
All heparins information
- avoid in heparin-induced thrombocytopenia
- can cause hyperkalaemia
- haemorrhage = tx with protamine sulfate - only effective for UFH
UFH information
- quick initiation & elimination
- good for increased bleeding risk (monitor APTT)
- increased risk of heparin induce thrombocytopenia
- preferred in renal impairment
LMWH information
preferred in pregnancy
Bleeding disorders information
- bleeding disorder = cant stop blood from running (doesn’t clot)
- tx help formation of clots
- tranexamic acid for surgeries, dental extraction, menorrhagia = GI, NV
- desmopressin for mild-mod haemophilia and von willebrands disease
Haemorrhagic stroke management
- manage BP (will be very high)
- avoid statins
Ischaemic stroke initial management
- initial = 300mg aspirin
- TIA = 300mg daily until diagnosis established
- ischaemic = 300mg for 14 days following alteplase within 4.5 hours
Ischaemic stroke long-term management
- clopidogrel 75mg OD
- dipyridamole MR and aspirin 75mg
- dipyridamole MR or aspirin 75mg
- start high intensity statin 48 hours after as troke
- manage hypertension to achieve < 130/80
- DONT use b-blockers
Stage 1 hypertension targets
- 140/90 - 159/99 - clinic
- 135/85 - 149/94 - ambulatory
- tx if < 80 yrs with kidney disease, diabetes, CVD, or QRISK > 10 %
- drug tx and lifestyle if < 60 yrs with QRISK < 10%
- drug tx if > 80 yrs with BP over 150/90
Stage 2 HTN targets
- 160/100 - 180/120 - clinic
- > 150/95 - ambulatory
- tx all
Stage 3 HTN targets
- > 180/120
- medical emergency
HTN treatment <55 yrs or T2DM
- ACEi or ARB
- & CCB or TLD
- ACEi/ARB + CCB + TLD
- K+ < 4.5 = spiro, K+ > 4.5 = a or b-blocker
HTN treatment > 55 year or afro-carribbean
- CCB
- & ACEi or ARB
- ACi/ARB + CCB + TLD
- K+ < 4.5 = spiro, K+ > 4.5 = a or b-blocker
- ARB in black, ACEi in diabetes, black and diabetes = ARB
HTN in pregnancy treatment
- high risk of pre-elampsia if kidney disease, diabetes, autoimmune disease
- aspirin from week 12 until birth
- if BP > 140/90:
1. labetolol - avoid in asthma
2. nifedipine - avoid in HF
3. methyldopa - stop 48 hours after birth - BP target = 135/85 - clinical
BP Targets
- age < 80 = 140/90 (clinical)
- age > 80 = 150/90 (clinical)
- renal disease = 140/90 (clinical)
- pregnancy = 135/85 (clinical)
- diabetes = 140/90
- diabetes + > 80 years = 150/90
- diabetes + kidney disease = 130/80
ACEi side effects
- Cough (ARB instead)
- Hyperkalaemia
- Hepatic impairment
- Angioedema
- Renal impairment
- Dizziness & headaches
CHHARD
ARB side effects
same side effects as ACEi (CHHARD) except cough and angioedema
ACEi/ARB interactions
- increased risk of renal failure - ARBs, K+ sparing diuretics, NSAIDs
- hyperkalaemia - heparins, NSAIDs, Ksparing diuretics, b-blockers
- risk of volume depletion - diuretics
- increased plasma levels of lithium
Cardioselective b-blockers
- less likely to cause bronchospasms (better in asthma)
- Bisoprolol
- Atenolol
- Metoprolol
- Acebutolol
- Nebivolol
- BAtMAN
Water soluble b-blockers
- less likely to cross BBB = less nightmares
- Celiprolol
- Atenolol
- Nadolol
- Sotalol
- water CANS
Intrinsic sympathomimetic b-blockers
- less likely to cause cold extremities
- Pindolol
- Acebutolol
- Celiprolol
- Oxprenolol
- Ice PACO
b-blockers side effects
- bradycardia or HF
- blunts effects of hypoglycaemia (palpitations, tremors, sweating)
- can cause hyperglycaemia
- bronchospasm - contraindicated in asthma
b-blockers interactions
- digoxin, Amiodarone - heart block/bradycardia
- any other hypotensive drugs
Dihydropyridine CCBs
amlodipine, felodipine, lacidopine, lercanidipine, nifedipine
Rate limiting CCBs
diltiazem, verapamil
CCBs side effects
- dizziness
- gingival hyperplasia
- vasodilatory effects (flushing, headaches, ankle oedema) - more in dihydropyridines
- complete AV block - more in RLCCBs
Cholesterol level ranges
- total cholesterol = 5 or below
- HDL (good) = 1 or above
- LDL (bad) = 3 or below
- non-HDL (bad) = 4 or below
- triglycerides = 2.3 or below
Lipid lowering agents offered in:
- under 85 with QRISK > 10%
- T2DM with QRISK > 10%
- T1DM with age > 40, diabetes for > 10 years, established nephropathy
- CKD
- familial hypercholesterolaemia
Statins names and administration time
- atorvastatin, rosuvastatin = anytime
- simvastatin, fluvastatin, pravastatin = at night
- cholesterol produced at night
- atorvastatin 80mg = strongest = 2ndary prevention
Statins monitoring
- rule out thyroid disorders - if hypo = manage before statin initiation
- high risk of diabetes = FBG or HbA1c before statin initiation - repeat after 3 months
- before initiation = LFTs, TFTs, renal, full lipid profile
- LFTs before, 3 months, 12 months - stop if 3x UL
- CK if muscle pain - 5xUL = remeasure in 7 days, if still 5xUL = don’t start, if raised but not 5xUL = statin at lower dose
Statins interactions
- CYP 450 inducers - reduce concentration of statins
- CYP 450 inhibitors - increase conc of statins = rhabdomyolysis
- macrolides = hold statin
- grapefruit juice
- oral fusidic acid = hold statin and restart 7 days after last dose
CYP 450 enzyme inducers
- Carbamazepine
- Rifampicin
- Alcohol
- Phenytoin
- Griseofulvin
- Phenobarbital
- St Johns Wort
CYP 450 enzyme inhibitors
- Sodium valproate
- Isoniazid
- Cimetidine
- Ketoconazole
- Fluconazole
- Alcohol
- Chloramphenicol
- Eryhtro/clarithromycin
- Sulfonamides
- Ciprofloxacin
- Omeprazole
- Metronidazole
- Grapefruit
- Amiodarone
- Verapamil
- Itraconazole
- Diltiazem
Statins side effects
- myopathy and rhabdomyolysis = muscle toxicity = medical advice
- interstitial lung disease = med attention if dyspnoea, cough, weight loss
- teratogenic = stop 3 months before conceiving
Max doses of statins
- amiodarone/amlodipine/RLCCBs + simvastatin = 20mg
- ticagrelor + simvastatin = 40mg
- ciclosporin + atorvastatin = 10mg
- tipranavir + atorvastatin = 10mg
Other lipid lowering agents
- ezetimibe or fibrates (bezafibrate, ciprofibrate, fenofibrate, gemfibrozil)
- dont give either with statin - risk of rhabdomyolysis
- fibrates = myotoxicity in renal impairment
- fibrates = LFTs every 3 months for first year
What is myocardial ischaemia
- build up of atherosclerotic plaques = restrict arteries = lowers blood and oxygen to the heart
- stable angina
- ACS (unstable angina, NSTEMI, STEMI)
Stable angina initial treatment
- predictable chest pain or pressure due to physical exertion or emotion
- prophylactically or when symptoms arise
- GTN dose at 5 minute intervals - 999 after 3rd dose
Stable angina long term prevention
- b-blocker (RLCCBs if bb contraindicated - never together)
- b-blocker + CCB (‘pines’)
- long acting nitrate, nicorandil, ivabradine or ranolazine
- nicorandil = GI and mucosal ulceration
- implement healthy life style and introduce 75mg aspirin and low dose statin
Nitrates key information
- GTN sublingual tabs = discard 8 wks after opening bottle
- nitrate free period to prevent tolerance
- 2nd dose after 8 hours not 12
- transdermal = leave off for 8-12 hours a day
- side effects = dizziness, flushing, headaches, risk of falls
ACS risk factors
- family history
- hypertension
- hypercholesterolaemia
- diabetes
- smoking
ACS initial Management
- aspirin 300mg stat, pain relief - GTN +/- IV morphine, oxygen if needed
- test result to determine type of ACS
- PCI for STEMI within 2 hours - heparin if done through radial access
What is unstable angina and NSTEMI
- partial blockage of artery (myocardial necrosis in NSTEMI)
- NSTEMI = ST not elevated
What is STEMI
- complete blockage of artery = myocardial necrosis
- ST elevated
Secondary prevention for all ACS
- DAPT - lifelong aspirin, 12 months of either clopi, prasugrel, ticagrelor. Prasugrel preffered for STEMI
- ACEi - ARB if contraindicated
- Statin - atorvastatin 80mg
- B-blocker - stopped after 12 months if reduced LV ejection fraction
- if NSTEMI - consider PCI to prevent future MI
- assess risk of HF
Heart failure symptoms
SOB, persistent coughing, wheezing, ankle swelling, reduced exercise, fatigue, multiple pillows
Heart failure treatment
- ACEi (ARB if CI) + b-blocker - titrate both up
alt: hydralazine + nitrate if not tolerated - & aldosterone antagonist - spiro/eplerenone
- & amiodarone, digoxin, sac+val, ivabradine or dapagliflozin (dapa = water loss)
- digoxin if sinus rhythm worsening or severe HF
- digoxin loading dose in HF = 62.5 - 125 mcg OD
- loop diuretics to relieve SOB and oedema in fluid retention
What is oedema
water retention in system = pulmonary (lungs) or peripheral (rest of body e.g. ankle) oedema
Thiazide diuretics key information
- bendroflumethiazide, indapamide
- inhibits sodium reabsorption at beginning of distal convoluted tubule
- long half life - give early to avoid sleep disturbance
Loop diuretics key information
- furosemide, bumetanide, toresamide
- preferred over thiazide if prone to urinating through night
- inhibits reabsorption from ascending limb of loop of henle
- in pulmonary oedema due to left ventricular failure
- last 6 hours so can be given BD w/o interfering sleep
Potassium sparing diuretics key information
- amiloride, triamterene (blue urine)
- prevents sodium reabsorption in the distal convoluted tubule collecting duct
- hyperkalaemia - dont take K+ supplements
- aldosterone antagonists ( a type of K+ sparing diuretics) = spiro/eplerenone. Inhibit potassium secretion in distal tubule collecting duct. Stop if dehydrated due to vomit and/or diarrhoea
All diuretics side effects
- hyponatraemia
- hypomagnesaemia
Loop and thiazide diuretics side effects
- hypokalaemia
- exacerbate diabetes
- loop only - exacerbates gout
- hypotension
Potassium sparing diuretics side effects
- hyperkalaemia
- change in libido
- breast pain or tenderness
Diuretics side effects
- loop and thiazide = hypokalaemia inducing drugs
- K+ sparing = hyperkalaemia inducing drugs
- Loop and aminoglycosides = nephro and oto - toxicity
- spiro/loop + lithium = reduced lithium secretion = lithium toxicity
Occlusive peripheral vascular disease key information
- normally caused by atherosclerosis
- reduced risk with healthier lifestyle , statins and antiplatelets
Vasospastic peripheral vascular disease (Raynaud’s) key information
- bad circulation to extremities
- avoid exposure to cold
- smoking cessation
- further tx = nifedipine
Which beta-blocker has a long duration of action
nadolol
What drug class is metolazone
thiazide-like diuretic
Rivaroxaban administration post hip replacement
10mg OD for 35 days
INR level if switching from warfarin to apixaban
<2
Which drugs increase the risk of QT interval prolongation when given with sotalol
- haloperidol
- citalopram
Perindopril administration directions
30 - 60 minutes before food
Reye’s syndrome symptoms
- vomiting
- seizures
- increased white cell count
- increased LFTs
- delirium
- lack of energy
- irritability
- aggression
- coma
Lifestyle measure to reduce BP
- restrict salt intake to 6g per day
- 30 minutes exercise 5x week
- healthy diet including 5 fruit or veg per day
Max dose of ramipril when eGFR 30-60
5mg
What is ticagrelor not licensed with
- aspirin AND low dose rivaroxaban together
- licensed with aspirin alone
Which PPI is the least suitable with clopidogrel
- omeprazole and esomeprazole
How long should ramipril be taken before the response is determined
4 weeks
Which drugs increase the risk of gout
diuretics
Dipyridamole MR capsules key information
- keep in original container
- discard 6 weeks after opening
Is warfarin okay to use whilst breastfeeding
yes
Which diuretic can be given BD without risking interfering with sleep
furosemide
Which drugs can cause secondary hypertension
- ciclosporin
- leflunomide
- NSAIDs
Which drug is not known to cause secondary hypertension
progesterone only pill
