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308: Clinical Pharamacology & Therapeutics > Cardiovascular drugs 1 > Flashcards

Cardiovascular drugs 1 Flashcards

1
Q

How is atrial fibrillation characterised on ECG

A

Irregularly irregular, no p waves, absence of isoelectric baseline, variable ventricular rate

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2
Q

What is the pathophysiology of A fib

A
  • Chaotic atrial electrical activity
  • Fibrosis and loss of atrial muscle mass related to: ageing, chamber dilatation (due to HTN, valve disease), inflammation, genetic
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3
Q

Give 5 risk factors for A fib

A
  • HTN
  • Valvular heart disease
  • Coronary artery disease
  • Cardiomyopathy
  • Congenital heart disease
  • Previous cardiac surgery
  • Pericarditis
  • Lung disease- PE, pneumonia, COPD
  • Hyperthyroidism (always do TFTs if patient presents with AFib)
  • Alcohol
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4
Q

Outline the classification of A fib

A

Lone AF
- usually younger patient, no established cause

Paroxysmal (<7 days)

Persistent (>7 days)

Permanent (>7 days +/- cardioversion)

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5
Q

What are the clinical features of AFib?

A
  • Asymptomatic
  • Palpitations
  • SOB
  • Chest pain
  • Syncope
  • Pre syncope
  • Heart failure
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6
Q

What are the categories of treatment options for AFib?

A
  1. Rate control
  2. Rhythm control
  3. Anticoagulation
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7
Q

How would you treat recent onset AF in

a) compromised patient
b) not compromised patient

A

a) DC shock

b) Pharmacotherapy

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8
Q

How would you treat recent onset AF of

a) <48hr duration
b) >48hr duration

How do you determine this?

A

Symptoms onset will help pinpoint exactly when it started

a) Attempt rhythm control
b) Rate control- after 48hrs the risk of thromboembolism increases significantly

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9
Q

When is rhythm control preferred?

A
  • For symptom improvement
  • In younger patients
  • HF related to AF
  • Adequacy of rate control
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10
Q

How do you rate control in acute AF without HF?

A

Beta blocker or CCB (Diltiazem, Verapamil)

2nd line: add digoxin

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11
Q

How do you rate control in acute AF with HF?

A

Digoxin, Amiodarone

2nd line: amiodarone

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12
Q

How do you rate control in permanent AF or paroxysmal AF?

A

Beta blocker or CCB

2nd line: add digoxin

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13
Q

What complication can occur when using the rate control drugs in combination?

A

Beta blocker + CCB can lead to heart bloc

  • although not completely contraindicated
  • may be of use in young patient
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14
Q

For the the following indications provide the rhythm control drug

a) Acute cardioversion, normal heart
b) Acute cardioversion, abnormal heart
c) Maintain sinus rhythm, normal heart
d) Maintain sinus rhythm, abnormal heart

A

a) Flecainide, sotalol (non selective)
b) Amiodarone
c) Flecainide, sotalol
d) Amiodarone

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15
Q

Outline the mechanism of action of beta blockers

A
  • B1/B2 adrenergic blockade therefore blockinf the effects of adrenaline/NA at B1 receptor
  • Slows down contractility og the heart by inhibting cAMP formation, such that PK-A is not activated. The L type calcium channel is not phosphorylated and therefore there is not an influx of Ca
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16
Q

Give an example of a

a) Non cardioselective beta blocker
b) Cardioselective beta blocker
c) Vasodilatory beta blockers

A

a) Propanolol, carvedilol, sotalol
b) Atenolol (>90% renal clearance), bisoprolol, esmolol, metoprolol (liver clearance), nebivolol
c) Labetalol, carvedilol

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17
Q

Which rate limiting CCBs are used to treat AF?

A
  • Verapamil

- Diltiazem

18
Q

Give 3 examples of dihydriopyridine CCBs

A
  • Amlodipine
  • Nifedipine
  • Felodipine
  • Lercanidipine
  • Nimodipine (used in subarachnoid haemorrhage as it has a high lipid solubility and can cross BBB)
19
Q

What is the CHA2DS2VaSc score?

If greater or equal to 2 how do you proceed?

A

A scoring system which calculates the risk of stroke in patients with AF. Consider factors such as congestive HF, HTN, age, DM, previous stroke, TIA or thromboembolism, vascular disease and sex

Warfarin or DOAC

20
Q

What is the HAS-BLED score?

What does a score greater than or equal to 3 mean?

A

A scoring system which estimates bleeding risk for patients on anticoagulation in patients with AF. Considers factors such as: HTN, abnormal renal/liver function, past stroke, bleeding Hx, labile INRs, elderly, drugs/alcohol

Significant risk of bleeding

21
Q

What other treatments are used in AF?

A
  • Radiofrequency catheter or cryo-ablation: used in the younger patient
  • Left atrial appendage occlusion (LAAO): most clots that form in heart, form here. This procedure can reduce risk of strokes in the older patient
22
Q

What are the categories of drugs used to treat stroke

A
  • Fibrinolysis
  • Antithrombotics (aspirin, clopidogren, warfarin or DOAC)
  • Lipid modification
  • HTN treatment
23
Q

Consider lipid modification for primary and secondary prevention of stroke/MI

When should you refer to lipid specialist?

What should be excluded?

A

Total serum cholesterol >7.5mmol/L + FHx of premature CAD

Total serum cholesterol >9mmol/L

Exclude secondary causes of hyperlipidaemia: excess alcohol, uncontrolled DM, hypothyroidism, liver disease, nephrotic syndrome

24
Q

When is primary prevention indicated?

What should be used?

A
  • People with >10% 10yr risk of developing CVD
  • Adults with T1DM
  • Those with CKD

Offer atorvastatin

25
Q

When is secondary prevention indicated?

A

Offer atorvastatin for the secondary prevention of CVD in any patient who has had a stroke or MI

26
Q

Describe the alternative for treating primary hypercholesterolaemia in adults whom statin therapy is contraindicated/poorly tolerated?

A

Ezetimibe

  • Minimises absorption of dietary cholesterol by the gut (lots of gut side effects)
  • Given as monotherapy
  • Sometimes coadministered with inital statin therapy
27
Q

New drugs are emerging for the treatment of hyperlipidaemia

How do proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) work?

Give an example

A
  • PCSK9 are responsible for degrading LDL-r
  • The inhibitors block this process thus aiding the removal of LDL from circulation
  • Alirocumab, Evolocumab
28
Q

Outline the pathophysiology of HF

A

Poor ventricular fucntion.myocardial dmaage –> HF

This results in decreased SV and CO –> neurhormonal response

Which activates

  1. Sympathetic system
  2. RAAS

Leading to vasoconstriction, sodium and fluid retention

This causes further stress on the ventricular wall and dilatation leading to worsening ventricular function

–> Further HF

29
Q

What are the aims of treatment for HF?

A
  • Relieve symptoms

- Reduce mortality

30
Q

Broadly speaking, what is the management for HF?

A
  1. Lifestyle: exercise, cut down alcohol, smoking cessation
  2. Pharmacomanagement
  3. Devices
  4. Surgery
31
Q

Give an example of each type of diuretic used in HF

A

Loop diruetic- furosemide

Thiazide

  • Bendroflumethiazide
  • Metolazone (Thiazide like)

K+ sparing

  • Spironolactone
  • Amiloride
32
Q

What are the pros and cons of using diuretics for HF

A
  • Very good at symptom control
  • Reduces cardiac preload
  • Side effects!
33
Q

Why are ACEi used in HF

Give 2 examples

A
  • Increases life expectancy, effect more marked in severe LV dysfunction
  • Reduces risk of hospitalisation

-Rampril, Lisinopril, Enalapril. Perindopril, Captopril

34
Q

When are ARB used in HF?

What do they do?

Give example?

A
  • For patients who cant tolerate ACEi
  • Reduces mortality

Losartan, Candersartan, Valsartan

35
Q

What is the role of beta blockers in HF?

A
  • Reduces mortality, and hospitalisation
  • Symptom control
  • Start on low dose and titrate up, monitor HR, BP and clinical progression
36
Q

What is the role of spironolactone in HF?

A
  • Mineralocorticoid receptor antagonist
  • For patients with severe HF
  • Increases life expectancy
  • Reduces hospitalisation
  • Give low dose: 12.5-25mg
37
Q

What is the treatment for chronic HF?

A
  • Diuretics
  • ACEi (ARBs)
  • Beta blocker
  • Spironolactone
38
Q

What alternate drugs are used in chronic HF?

A

Ivadradine

  • works on funny receptor
  • used with or in place of b-blocker if HR >75bpm

Hydralazine + nitrate
- used if ARB/ACEi not tolerated/contraindicated/people of African origin

Sacubitril (neprilysin inhibitor)/ Valsartan (ARB)

  • LV ejection fraction <35% already taking stable dose of ACEi/ARB
  • with class 2-4 symptoms

SGLT2 inhibitors
- prevent reuptake of sodium and glucose in proximal tubule

39
Q

Outline the management of acute HF

A
  • Sit upright, high dose O2 to correct hypoxia
  • IV loop diuretic –> venodilatation and diuresis
  • IV opiates –> reduce anxiety and preload (venodilatation)
  • IV, buccal or sublingual nitrates –> reduce preload and afterload, ischaemia and pulmonary artery pressures

Contine b-blockers but do not initiate

40
Q

What alternate forms of therapy are used in HF?

A
  • Coronary revascularisation
  • Cardiac resynchronisation therapy
  • Cardiac transplantation

308: Clinical Pharamacology & Therapeutics (10 decks)

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