Cardiovascular Drugs Flashcards
Antiplatelet drugs - Aspirin irreversibly acetylates … …-…, preventing production of thromboxane A2, thereby inhibiting platelet . Used in low dose for secondary prevention following MI, TIA/Stroke and for patients with angina or peripheral vascular disease. May have a role in primary prevention.
Aspirin irreversibly acetylates cycle-oxygenate, preventing production of thromboxane A2, thereby inhibiting platelet aggregation. Used in low dose for secondary prevention following MI, TIA/Stroke and for patients with angina or peripheral vascular disease. May have a role in primary prevention.
ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less gastric irritation. They have a role if truly intolerant of aspirin; with aspirin after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.
ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less … irritation. They have a role if truly intolerant of …; with … after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.
ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less gastric irritation. They have a role if truly intolerant of aspirin; with aspirin after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.
What is acute coronary syndrome? (ACS)
A spectrum of conditions - unstable angina, NSTEMI, STEMI
Reduction of blood through coronary arteries
Usually after atherosclerotic plaque rupture
Treatment aims of ACS:
Reduce cardiac ischaemia: - Revascularisation - Thrombolysis - Medical management Reduce myocardial oxygen demand Prevent recurrence (Secondary prevention)
ACS - immediate management
Oxygen, nitrates, anti-emetics,
Anti platelet loading
Fondaparinux/LMWH
MONA - morphine, oxygen, nitrates, aspirin
What long term management and secondary prevention would you expect an ACS patient to be discharged home with?
Long term management and secondary prevention
• DAPT - Aspirin + Clopidogrel/Prasugrel/Ticagrelor • ACE-inhibitors/ARB’s
• Beta-blockers
• Statins
• GTN spray
• Lifestyleadvice
Aspirin - what is the loading dose?
300mg
Aspirin - what is the maintenance dose?
75mg OD
Aspirin should be taken with ….
Food
What is clopidogrel loading dose?
300 or 600mg as per ESC
What is the maintenance dose for clopidogrel?
75mg OD
How long is clopidogrel usually given following MI?
About a year
Ticagrelor loading dose?
180mg STAT
Ticagrelor maintenance dose?
90mg BD
Side effect of ticagrelor?
SOB
Side effect of prasugrel?
GI bleeding
Loading dose for prasugrel?
60mg STAT
Prasugrel maintenance dose
>60kg =, <60kg or over 75yrs =
> 60 kg = 10mg OD
<60 kg or over 75yrs = 5mg OD
Contraindications for ticagrelor:
Active bleeding, history of intracranial haemorrhage
Contraindications for prasugrel:
History of stroke or TIA, active bleeding
Beta-blockers - how do they work on the SA node? And how do they lower BP?
Slow the SA node - slow heart rate allows left ventricle to fill completely and lowers heart workload - also dilate arteries = lower blood pressure
Contraindications and cautions for beta blockers
In history of asthma and obstructive airway disease
In 2nd and 3rd degree heart block
Unstable heart failure
Side effects of beta blockers
Fatigue Cold hands/feet Nightmares/sleep disturbances Breathing difficulties in asthmatics Bradycardia Masks symptoms of hypoglycaemia Do not stop taking without doctor’s advice as you can get rebound tachycardia
Why should you not stop taking beta blockers without doctor’s advice?
Chance of rebound tachycardia
…. should be used within 24 hours following an MI in patients with ventricular enlargement due to a poorer prognosis
ACE inhibitors should be used within 24 hours following an MI in patients with ventricular enlargement due to a poorer prognosis
With ACEi, it is important to monitor what?
Renal function and electrolytes
Side effects of ACEi
Postural hypotension - advised take at night initially
Loss of taste/appetite
Persistent dry cough
Statins - side effects
Muscle pain - must be reported to GP or cardiac rehab team Headache Nausea, vomiting and abdominal pain Alcohol - avoid high intake Avoid grapefruit
What to avoid when taking statins?
High alcohol intake and grapefruit
Target cholesterol levels: total cholesterol
≤ 5
Target cholesterol levels: Non-HDL cholesterol
≤ 4
Target cholesterol levels: Triglycerides
≤ 2.3
Target cholesterol levels: LDL cholesterol
≤ 3
Target cholesterol levels: HDL cholesterol
≥ 1
What cholesterol is ‘bad’?
LDL
Why is it advised to avoid grapefruit with statins?
Can cause the statin to stay in your body for longer, causing statin level to increase in blood and increases possibility of side effects
How do nitrates help in angina?
Dilation of veins and collaterals - decreased oxygen demand of the heart and increasing coronary flow
How do nitrates help in HF?
Dilation of conduit arteries, dilation of veins leads to reduced left ventricular end diastolic pressure, reduced wall stress and a reduction of mitral regurgitation
ACS - nitrate effect
Dilation of conduit arteries, dilation of collaterals, antiaggregant effects leading to increased oxygen supply
Reasons for using nitrates…
To relieve or prevent expected chest pain (GTN)
To prevent regular chest pain (nitrate tablets/patches)
Side effects of nitrates:
Flushing, headache, dizziness, postural hypotension
Does the headache with nitrates improve, stay the same, or get worse over time?
Usually reduces and becomes less severe over time
What particular medications have an interaction with nitrates?
Medication for erectile dysfunction i.e. Sildenafil, verdenafil, tadalafil - causing significant drop in BP
This patient is suffering from paroxysmal atrial fibrillation. In the absence of other cardiovascular co-morbidities, this patient can be managed with ….
This patient is suffering from paroxysmal atrial fibrillation. In the absence of other cardiovascular co-morbidities, this patient can be managed with flecainide.
Which of the following best describes the pharmacological mechanism of aspirin?
A Irreversible inhibition of cyclooxygenase
B Direct inhibition of thrombin
C Inhibition of the adenosine diphosphate (ADP) receptor
D Potentiates the action of anti-thrombin III to inhibit factor Xa
E Inhibition of the glycoprotein IIb/IIIa receptor
Aspirin is commonly used in patients with, or at risk, of ischaemic heart disease. It works through irreversible inhibition of cyclooxygenase.
Direct inhibition of thrombin. …
Direct inhibition of thrombin. Dabigatran
C: Inhibition of the adenosine diphosphate (ADP) receptor. …
C: Inhibition of the adenosine diphosphate (ADP) receptor. Clopidogrel
D: Potentiates the action of anti-thrombin III to inhibit factor Xa.
Low molecular weight heparin.
Which of the following is not a recognised adverse-effect of amiodarone?
A Hypothyroidism B Hyperthyroidism C Interstitial pneumonitis D Interstitial nephritis E Hepatotoxicity
All of the above are considered direct adverse-effects of amiodarone, except interstitial nephritis.
Which of the following statements is false regarding aortic regurgitation?
A It may be caused by connective tissue diseases (e.g. Marfan’s disease)
B Acutely it may cause haemodynamic compromise
C Quincke’s sign refers to pulsation of nail beds
D It causes a pansystolic machinery murmur
E Müller’s sign refers to pulsation of uvula
Aortic regurgitation causes an early diastolic murmur that is heard loudest at the left sternal edge.
A pan systolic murmur may be heard in mitral regurgitation and with an interventricular septal defect. The latter may occur following a myocardial infarction with ischaemia to the interventricular septum or may be due to a congenital heart defect.
Warfarin is one of the older indirect anticoagulants. Warfarin works on the vitamin K-dependent clotting factors (II, VII, IX, X) through the ..
Warfarin is one of the older indirect anticoagulants. Warfarin works on the vitamin K-dependent clotting factors (II, VII, IX, X) through the inhibition of vitamin K reductase.
Which of the following is not a recognised adverse-effect of amiodarone?
Hypothyroidism Hyperthyroidism Interstitial pneumonitis Interstitial nephritis Hepatotoxicity
All of the above are considered direct adverse-effects of amiodarone, except interstitial nephritis.
