Cardiovascular Drugs Flashcards
how to treat acute CCF?
“UNLOAD FAST”
Upright position Nitrates Loop diuretic Oxygen ACEi Digoxin
Fluids (↓)
Afterload (↓)
Sodium restriction
Test (digoxin level, ABGs, K+ level)
Tx for acute attacks of stable angina?
long-term prevention?
1st line sublingual glyceryl trinitrate
1) B-block (atenolol, bisoprolol, metoprolol, propranolol)
2) CCB (verapamil or diltiazem) if beta-blockers CI (HF or Prinzmetal’s angina - amlodipine)
3) B-block + CCB
4) long-acting nitrate as monotherapy (ivabradine, nicorandil, or ranolazine)
Tx for STEMI?
“MONAT”
M - morphine - 2.5-10mg IV (metoclopramide 10mg IV)
O - oxygen - only if desaturating - 15 litre non-rebreathe
N - nitrates - GTN 2 puffs sublingual
A - aspirin - 300mg oral
T - ticagrelor 180mg/clopidogrel 300mg
+ if present w/n 12 hrs of Sx, primary PCI within 120 mins
+ (if no reperfusion therapy) give fondaparinux (LMWH analogue)
+ β-blocker (atenolol 5mg oral) (unless LVF/asthma)
+ transfer CCU
Tx for NSTEMI?
MONAT + GRACE score risk
if no PCI/reperfusion therapy, give LMWH/fondaparinux
long term Tx of MI?
“CRABS”
Clopidogrel Ramipril Aspirin B-blocker Statin
Tx of chronic HF?
1) ACEi (unless asthma - ARB)
+ B-block if congested chronically
if neither ACEi or ARB tolerated hydralazine + nitrate
2) aldosterone antagonist (SPIRINOLACTONE, eplerenone, amilioride - fluid offload)
which Tx improves PROGNOSIS of Chronic HF?
spirinolactone
furosemide only improves Sx not prognosis
how to Tx AF>48 hours?
RATE CONTROL:
- otherwise 1st line = CCB (verapamil + diltiazem) “Vera & Dill - sweet slow old ladies with AF)
- if FAST AF then B-blocker (not in asthma!!)
(if CI then digoxin)
why is digoxin generally used in older patients?
affects exercise tolerance
narrow therapeutic window
how to Tx AF<48 hours?
RHYTHM CONTROL
- amiodarone/flecanide (“Amy & Flec” the crazy rhythm drummers)
- or DC cardioversion
what Ix is needed before Tx with Amy & Flec (amiodarone and flecanide)?
CXR - can cause ILD
when is the choice of either amiodarone/flecanide CI?
structural heart disease
just give amiodarone
when to DC cardiovert for AF?
life-threatening haemodynamic instability caused by new-onset atrial fibrillation (rhythm control)
which kind of cardioversion for AF>48 hours?
what risk to remember?
electrical DC cardioversion (rather than pharmacological)
consider amiodarone therapy starting 4 wks before and <12 months after electrical cardioversion to maintain sinus rhythm
HIGH RISK OF THROMBOEMBOLISM therefore anticoagulate someone who is being cardioverted with AF> 48 hours
Tx acute heart failure?
ABC + 15L non-rebreathe sit the patient up morphine + metoclopramide GTN furosemide 40-80mg IV \+/- isosorbide (nitrate infusion) \+/- CPAP
how to assess non-sinus ↑HR? (>125bpm) + haemodynamically unstable?
- DC cardiovert, then amiodarone 300mg IV over 10-20 mins & repeat
what could cause non-sinus stable but broad complex (>0.12 s) ↑HR? (>125bpm)?
get HELP
AF + BBB
polymorphic VT- torsade de pointes
VT
SVT + BBB
Tx polymorphic VT - torsades de pointes?
magnesium 2g over 10 min
Tx ventricular tachycardia ?
Amiodarone 300mg IV over 20–60 min, then ↑
how to assess non-sinus stable, regular, but narrow complex (<0.12 s) ↑HR? (>125bpm)?
vagal manoeuvres
adenosine 6mg rapid IV bolus (if this works, re-entry paroxysmal SVT)
how to assess non-sinus stable, irregular, but narrow complex (<0.12 s) ↑HR? (>125bpm)?
Probable AF
control rate with: β-blocker or diltiazem (+/- digoxin or amiodarone if evidence of heart failure)
when to Tx HT?
ambulatory BP monitoring: ●BP >150/95 mmHg ●or >135/85 mmHg + - vascular disease (IHD), stroke, PVD) - HT organ damage (intracerebral bleed, CKD, LVH, retinopathy)
target BP in HT?
●<80 years, <140/85 (clinic) /<135/85 (ambulatory)
●>80 +10 mmHg to systolic
Tx chronic HF?
● ACEi
● B-blocker
● then ↑
● then if mild, + ARB
● then if mod-severe + African–Caribbean: + hydralazine
+ isosorbide
● then if moderate–severe (other patients): add spironolactone
what does CHA2DS2-VASc stand for?
stroke risk (clotting) in AF
C - congestive HF (or LHF alone) H - HT A - age >75 (2 points) D - DM S- stroke/TIA before (2 points) V - vascular disease (e.g. PAD or IHD) A - age 65–74 S - sex (female)
CHA2DS2-VASc score of 0, 1, 2, indication?
0 - aspirin 75 mg daily
1 - aspirin or warfarin (aiming INR 2.5)
2/>2 - warfarin aiming INR 2.5
when is rhythm control preferable in AF? (amy & flec)
young
Sx
1st episode
secondary to treated precipitant
cardioversion: electrical or pharmacological (amiodarone 5 mg/kg IV over 20–120 mins). The patient will require anticoagulation if more than 48 hours since onset.
when is rate control preferable in AF?
old/long-standing AF w/ HR >90
1) B-blocker
2) CCB
3) + digoxin (1st line if B-blockers + CCB CI)
Tx for stable angina? (3)
1) GTN spray PRN
2) secondary prevention: aspirin, statin + cardiovascular risk factor modification
3) one anti-anginal drug, either B-blocker or CCB
● then ↑ dose B-blocker or CCB
● then + 2nd anti-anginal therapy
● then + lisosorbide or nicorandil (K+ channel activator)
● then PCI or CABG
(Even if controlled with medical management, patients should be referred routinely for consideration of revascularization)
DDx central crushing chest pain + *sweating or V?
sweating or V makes STEMI or NSTEMI more likely than unstable angina (at rest) or stable angina (OE, better with GTN and rest)
what are ACS?
unstable angina
NSTEMI
STEMI
Ix suspected ACS? (3)
● ECG, troponin and 12 hr troponin
● if troponin ↑ = STEMI/NSTEMI ⇒ look at ECG to determine which
(Nb ST ↓ in anterior leads (V1–4) may be anterior ischaemia (i.e. stable/unstable angina) or posterior infarction: add leads V7–9 posteriorly to confirm ST ↑ for latter)
● if 1st trop NOT ↑ then use ECG:
- if normal/ST depression then angina, but need to exclude NSTEMI with 12 h troponin
- if ST ↑ then STEMI + trop will be ↑ even if having to await 12 h trop
1st line Tx for chronic HF to ↓ morbidity and mortality?
ACEi or B-blocker - these affect mortality/morbidity
patients are often on diuretics to ↓ Sx but this DOESN’T affect mortality
time of day to dive furosemide?
in the morning due to subsequent diuresis. (i.e. not at night.)
which is the only ACEi to give in the morning?
perindopril erbumine/perindopril arginine
both are licensed in HT but the differing doses stress the need to write full names
how to write out GTN prescription for acute angina?
“GTN spray (glyceryl trinitrate)” (can write 400 micrograms/metered dose if you want next to this)
“2 sprays sublingual”
Tx acute pulmonary oedema?
loop diuretics
(furosemide can be given IV)
20-50 mg IV
how to check efficacy of ACEi in HF?
exercise tolerance test
role of beta-blockers in HF?
CHRONIC: improve morbidity/mortality
but
ACUTE/UNCONTROLLED: contraindicated as worsen Sx
medications that may exacerbate heart failure?
- pioglitazone is contraindicated as it causes fluid retention
- verapamil (negative inotropic effect)
- NSAIDs/glucocorticoids (caution: fluid retention)
- (low-dose aspirin is an exception - many patients will have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks)
- class I antiarrhythmics: flecainide (negative inotropic and proarrhythmic effect)
patient with angina is being Tx with atenolol and verapamil - why are you worried?
beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
if beta-blocker + CCB prescribed, use long-acting (e.g. modified-release nifedipine)
Tx high cholesterol in someone with a Hx of CVD (PAD, etc) - (secondary prevention)?
atorvastatin 80mg
who should be on a statin?
- established CVD (stroke, TIA, IHD, PAD)
- 10-year cardiovascular risk >10%
- T2DM: QRISK2
- T1DM diagnosed >10 years ago OR are aged >40 OR have established nephropathy
