Cardiovascular drugs 1 Flashcards
Describe the pathophysiology of atrial fibrillation
Chaotic atrial electrical activity
What is fibrosis and loss of atrial wall muscle mass related to?
Age
Chamber dilation
Inflammation
Genetic
List the risk factors of atrial fibrillation
Hypertension Valvular heart disease Coronary artery disease Cardiomyopathy Congenital heart disease Previous cardiac surgery Pericarditis Lung disease - PE, pneumonia, COPD Hyperthyroidism Alcohol
Describe the classification of atrial fibrillation
Lone AF
Paroxysmal <7 days
Persistent >7 days
Permanent >7 days and cardioversion
List the clinical features of atrial fibrillation
Asymptomatic Palpatiations SOB Chest pain Syncope Pre-syncope Heart failure
Describe the aims of treatment of AF
Anticoagulation
Rate control
Rhythm control
How is compromised AF treated?
DC shock
How is uncompromised AF treated?
Pharmacotherapy
How is AF <48hrs treated?
Attempt rhythm control
How is AF>48hrs treated?
Rate control
When is rhythm control preferred in the treatment of AF?
Symptom improvement
Younger patient
Heart failure related to AF
Adequacy of rate control
Describe rate control of acute AF without heart failure
Beta blocker or CCB
Add digoxin
Describe rate control of acute AF with heart failure
Digoxin
Amiodarone
Describe rate control of permanent or paroxysmal AF
Beta blocker or CCB
Digoxin
Describe rhythm control of AF with acute cardioversion in a normal heart
Flecainide, sotalol
Describe rhythm control of AF with acute cardioversion in an abnormal heart
Amiodarone
Describe rhythm control of AF when maintaining sinus rhythm in a normal heart
Flecainide, sotalol
Describe rhythm control of AF when maintaining sinus rhythm in an abnormal heart
Amiodarone
Name some non-cardioselective beta blockers
Propanolol
Carvedilol
Sotalol
Name some cardioselective beta blockers
Atenolol Bisoprolol Esmolol Metoprolol Nebivolol
Name some vasodilatory beta blockers
Labetalol
Carvedilol
Name some rate limiting calcium channel blockers
Verapamil
Diltiazem
Name some dihydropyridine calcium channel blockers
Amlodipine Nifedipine Felodipine Lercanidipine Nimodipine
What score is used to calculate the need for anticoagulation?
CHA2DS2VASC
Describe the CHA2DS2VASC score
C - congestive heart failure - 1 H- hypertension - 1 A2 - Age >75 - 2 D- diabetes - 1 S2 - previous stroke, TIA or thromboembolism - 2 Vascular disease - 1 Age - 65-74 - 1 Sc - Sex category (female gender) - 1
What CHA2DS2VASC score indicates warfarin or direct oral anticoagulant?
> 2
What must be considered when deciding on anticoagulation in AF?
The risk benefit ratio
What scoring system is used to determine bleeding risk?
HASBLED
Describe the HASBLED scoring system
H- hypertension - 1 A- abnormal renal/liver function - 1 point each S- stroke in the past - 1 B - bleeding history - 1 L- Labile INR - 1 E- elderly - 1 D - drugs/alcohol - 1 point each
What HASBLED score indicates a significant risk of bleeding?
Greater than 3
List some non pharmacological treatments of AF
Radiofrequency catheter
Cyro-ablation
Left atrial appendage occlusion (LAAO)
Describe the classification of stroke
Ischaemic
Haemorrhagic
What are the aims of stroke treatment?
Lipid modification
Treat hypertension
List some secondary causes of increased lipids
Excess alcohol Uncontrolled diabetes Hypothyroidism Liver disease Nephrotic syndrome
When do you refer to a lipid specialist?
Total cholesterol > 7,5mmol/L and family history of premature coronary artery disease
Total serum cholesterol >9mmol/L
Describe lipid modification in primary prevention
Offer atorvastatin to
- People who have greater than a 10% chance of developing CVD in 10 years
- Adults with type 1 diabetes
- People with chronic kidney disease
Describe lipid modification in secondary prevention
Offer atorvastatin in secondary prevention of CVD in any patient who has had a stroke or MI
Describe Ezetimibe
Monotherapy for treating primary (heterozygous familial or non familial) hypercholesterolemia in adults in whom initial statin therapy is contraindicated or not tolerated
May be appropriate to co administer with initial statin therapy
Name some proprotein convertase subtilisin/kexin type 9 inhibitors (PCSKi)
Alirocumab
Evolocumab
Describe the pathophysiology of heart failure
Activation of sympathetic system - Vasoconstriction
Renin angiotensin aldosterone system - Sodium and fluid retention
What are the treatment aims of heart failure
Relieve symptoms
Relieve mortality
List the types of treatment for heart failure
Lifestyle measures - exercise, decrease alcohol, stop smoking
Drugs
Devices
Surgery
List some classes of drugs used to treat heart failure
Diuretics ACE inhibitors Beta blockers Aldosterone antagonists ARBs Hydralazine/Nitrates Digoxin
List the different types of diuretic
Loop
Thiazide
K+ sparing
Give examples of loop diuretics
Furosemide
Give examples of thiazide diuretics
Bendroflumethiazide
Metolazone (thiazide like)
Give examples of K+sparing diuretics
Spironolactone
Amiloride
Where do loop diuretics act?
Na/K/Cl symporter
Where do thiazide diuretics act?
Na/Cl symporter
Where do the K sparing diuretics act?
Epithelial Na channel
Describe diuretics
Provide symptom control
Reduces cardiac preload
Side effects
Describe ACE inhibitors
Increases life expectancy
Effect more marked in patients with more severe LV dysfunction
Benefit for all NYHA classes
Reduces risk of hospitalisation
List some examples of ACE inhibitors
Ramipril Lisinopril Enalapril Perindopril Captopril
List some examples of ARBs
Losartan
Candersartan
Valsartan
Describe the ARBs
Reduces mortality
Symptom of control - increases QOL
Used in patients who cannot tolerate ACE inhibitors
Describe beta blockers
Increase life expectancy
All NYHA classes
Reduces hospitalisation
Low dose, titrate up, monitor BP, HR and clinical progression
List some examples of beta blockers
Bisoprolol
Carvedilol
Metoprolol
Describe spironolactone
Patients with severe heart failure Increases life expectancy Reduces hospital admission Low dose (12.5-25mg) Prevent aldosterone secretion
List the treatment for chronic heart failure
Diuretics
ACE inhibitors (ARBs)
Beta blockers
Spironolactone
Describe ivabradine
Used with or in place of beta blcokers if heart rate is too high > 75bpm
Describe the use of hydralazine and nitrate
Used if ARBs and ACEi not tolerated or contraindicated or in people of african origin
Describe SGLT2 inhibitors
Inhibitors of sodium glucose cotransporter 2
Dapagliflozin
S1 segment proximal tubule where 90% glucose reabsorption occurs
Describe the basic measures of treating acute heart failure
Sit patient upright
High dose oxygen
Describe the initial drug treatment of acute heart failure
Intravenous loop diuretics - Causes venodilation and diuresis
Intravenous opiates and opioids (morphine/diamorphine)) - Reduces anxiety and preload
Intravenous/buccal/sublingual nitrates - Reduce preload and afterload, ischaemia and pulmonary pressures
Continue beta blockers but do not initiate
List some non pharmacological treatments of heart failure
Coronary revascularisation
Cardiac resynchronisation therapy
Cardiac transplantation