Cardiovascular 2 Flashcards by Rachel Cornish

Epidemiology of angina

Just under £2 mill people

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Symptoms of angina

Chest, jaw, arm pain, sweating, indigestion, nausea

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Pathogenesis of angina

Atherosclerosis
Smooth muscle cells migrate and release collagen
Fibrous plaque formation
Atheromatous plaque

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Causes of vasospastic (prinzmetals) angina

Smoking
Electrolyte disturbance (mg/k)
Cocaine 
Cold 
Insulin resistance

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What is cardiac x syndrome

Angina like pain
Positive evidence of MI
Normal coronary angiogram

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Management of angina

Aspirin 300mg stat then 75mg OD

SL or buccal GTN

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Angina prophylaxis

1) BB (atenolol, bisop, metop, propranolol)
2) rlCCB (diltiazem, verapamil)
3) ISMN
4) nicorandil
5) ivabradine
6) ranolazine

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Drugs used in pharmacological stress test

Adenosine
Dipyridamole
Dobutamine
Thallium-201 radio labelled

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How do nitrates work

Stimulate cGMP production and inhibit thromboxane synthase

Nitrates are converted into nitric oxide NO which is identical to endothelin derived relaxing factor (EDRF) and endogenous vasodilator

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How does nicorandil work

Potassium channel activator acts to increase permeability of K+ channels and also as a nitric oxide donor:

Arterial vasodilation reducing afterload
NO donor produces peripheral venous relaxation and a reduction in preload

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Side effects of nicorandil

GI ulcers, skin and mucosal ulceration

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Nicorandil study

The impact of nicorandil in angina (IONA)

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How do BB work in angina

Reduce myocardial oxygen demand via reduction in sympathetic stimulation of the heart

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When do you use CBBs for angina

Second line rlCCBs

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Can you use rlCCB in sick sinus syndrome and heart block

NO!

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Can you use CCBs in angina and patients with congestive heart failure or low ejection fraction

no but you can use amlodipine (PRAISE trial)

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True or false - ranolazine effects HR, BP or inotrooic state of the myocardium

No it doesn’t

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How does ranolazine work?

Inhibits late sodium current and calcium overload during ischaemia therefore reducing ischaemia

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Interactions with ranolazine

Contraindicated with potent CYP3A4 inhibitors such as rifampicin, carbamazepine. It doubles plasma level of sim a statin and increases digoxin level by 1.5 times

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Ranolazine should be used with caution in:

<60kg
CHF
Elderly

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Can ranolazine prolong QT

Yes

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Ranolazine is contraindicated in what renal function

<30ml/min

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Ivabradine is used when

Angina with sinus rhythm who are intolerant of BB (can also be used in addition to BB)

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Can you use ivabradine with rlCCB

NOOOO

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Most common side effect of ivabradine

Luminous visual phenomena

Studies for ramipril in stable CAD

HOPE

Study for perindopril in stable CAD

EUROPA

Contraindications to prasugrel

Previous stroke Age >75yrs Low body weight <60kg

Why can ticagrelor cause on administration

Transient dyspnoea

MOA of thrombolytic drugs

Converts plasminogen into active plasmin, which degrades fibrin and so breaks up thrombi. Also they produce clot dissolving and pro-coagulant actions

Name 4 thrombolytic drugs

Streptokinase Alteplase Reteplase Tenecteplase

Pre-disposing factors for arrhythmia

``` Post-MI necrosis Hypertension Diabetes Inflammatory heart condition Sympathetic stimulation Drugs Electrolyte abnormalities Hypovolaemia Systemic infection Pericarditis Pulmonary disease Post-Op Hyperthyroid ```

Signs and symptoms of arrhythmias

``` Palpitations Fatigue Chest pain SoB Syncope Light headed ness ```

Patient with sinus bradycardia who is unstable can have what treatment

IV atropine 0.5-1mg every 3-5 mins up to 3mg total

Causes of sinus tachycardia

``` Exercise Excitement Heammorhage Infection Hypovolaemia Anaemia PE Shock Thyrotoxicosis Drugs (nicotine, thyroxine, isoprenaline, aminophylline, atropine) ```

Three management objectives for AF

Prevention of stroke Preservation of ventricular function Control of the arrhythmia

Which classes should be avoided in the acute management of AF

Class 1 and 2

Non cardiac causes of AF

``` Nicotine Alcohol Caffeine Physical and mental stress Hyperthyroid Premenstrual Electrolyte disturbance Drugs Anaemia Anxiety Fever Infection ```

Cardiac causes of AF

``` IHD MI CHF Cardiomyopathy Valvular disease Congenital heart disease Myocardial scarring eg TB Long QT syndrome Brugada syndrome ```

What scale is used for AF and what are they

EHRA scale 1) no symptoms 2) mild: normal daily activity unaffected 3) severe: normal daily activity affected 4) disabling: normal daily activity discontinued

What shoes AF on an ECG

Irregular R waves

What’s CHA2DS2VASC

``` CHF Hypertension Age >75 Diabetes Stroke Vascular disease Age 65-74 Sex (female) ```

HASBLED

``` Hypertension Abnormal liver/renal Stroke Bleeding Labile INR Elderly >65 Drugs (alcohol) ```

Anticoagulant in crcl < 15ml/min

Warfarin

What’s paroxysmal AF

Self limiting <48hrs

What’s persistent AF

AF episode continues > 7 days or necessitates termination via cardioversion

What’s long-standing persistent AF

Lasts longer than 1yr

Management of acute AF in a stable patient

Oral BB or rlCCB

Acute management of AF in severely compromised patient

IV verapamil or metoprolol Acute setting target HR 80-100 Amiodarone can be used in selected patients

Acute AF with a slow ventricular response can be treated with what

Atropine 0.5-2mg IV

Drug options for pharmacological cardioversion in AF

Flecainide 2mg/kg over 10mins Propfenone AF<48hrs 2mg/kg over 10-20mins Amiodarone 5mg/kg for 1st hr then 50mg/hr via central line

Anticoagulation should be in place for direct current cardioversion for how long prior and post?

3 weeks prior unless AF <48hrs and up to 4 weeks post

For pharmacological cardioversion in AF can you use flecainide or propafenone in IHD CHF and asthma/COPd for propafenone

NO use amiodarone

Why should rlCCB be avoided in HF

Negative inotropic effect

Does digoxin work during exercise

Nope

Half life of amiodarone

30-120 days

What is dronedarone

Rate control similar to amiodarone structure

Two types of ventricular arrhythmia

Ventricular tachycardia | Ventricular fibrillation

Management of ventricular tachycardia in a haemodynamically stable patient

Correct electrolyte abnormalities Use amiodarone or lidocaine infusion If persists use DCC or further amiodarone

Management of ventricular tachycardia in haemodynamically unstable patient

Use DC cardioversion | Then amiodarone

Treatment of ventricular fibrillation

Defibrillation always required Once rhythm re-established use amiodarone or procainamide Can sometimes use lidocaine

How many classes are there in the Vaughan Williams classification

How do class 1a drugs work in the Vaughan Williams classification and give examples

Slow phase 0 and depress phase 4 depolarisation Used in VT associated with Wolff-Parkinson-white syndrome Procainamide Disolyramide

How do class 1b drugs work in the Vaughan Williams classification and give examples

Shorten refractoriness and the action potential as well as WT internal Lidocaine Phenytoin

True or false: phenytoin is a class 1b anti-arrhythmia drug that the IV prep is strongly alkaline and may crystallise in tissues

True dat

Contraindications of lidocaine

Sinoatrial disorder AV block Myocardial depression Porphyria

How do class 1c drugs work in the Vaughan Williams classification and give examples

Sodium channel blockers which prolong PR, QRS and QT interval but no effect on refractory period Flecainide Propafenone

Contraindications to flecainide

Severe cardiac failure Cardiomyopathy Recent MI

Cautions to propafenone use

Contraindicated in asthma and bronchispastic disease | Increases plasma digoxin levels

How does the class 2 of the Vaughan Williams classification drugs work and give examples

Beta blockers - modulate sympathetic stimulation Bisoprolol

How does the class 3 of the Vaughan Williams classification drugs work and give examples

Blockade of the potassium channels increasing refractoriness action potential and QT interval Amiodarone Sotolol Bretylium

Benefit of dronedarone over amiodarone

Amiodarone without the iodine atom therefore no thyroid toxicity

Cautions with sotalol

Diuretics and hypokalaemia

How does the class 4 of the Vaughan Williams classification drugs work and give examples

Calcium channel blockers Verapamil Diltiazem

Other drugs for arrhythmias not in the Vaughan Williams classification

Digoxin | Adenosine (caution asthma)