Cardiovascular System Flashcards
1
Q
What is arrhythmia?
A
Abnormal rhythm and rate
Due to problems with the electrical conducting system of the heart
2
Q
Symptoms of arrhythmias
A
Palpitations
Abnormally fast, slow or irregular pulse
Dizziness or feeling faint
Shortness of breath
Chest pain which sometimes develop
3
Q
What can cause arrhythmias?
A
May occur as complications of heart conditions
Coronary heart disease
Heart valve disease
Hypertension
Ageing
Cardiomyopathy (disorder of the heart muscle)
Congenital (from birth) abnormalities
4
Q
Different types of arrhythmias?
A
Ectopic beat
AF (main one for the exam)
Paroxysmal AF
Atrial flutter
Paroxysmal supraventricular tachycardia
Ventricular tachycardia
Supra ventricular arrhythmias
5
Q
Treatment of arrhythmias?
A
Medication
Cardio version
Artificial pacemakers
Implantable cardioverter defibrillation
6
Q
Aims of treatment of arrhythmias?
A
Reduce symptoms
Prevent complications
7
Q
What risk calculators are needed for AF?
A
Stroke risk
Bleeding risk
8
Q
How is stroke risk calculated?
A
CHA2DS2-VASc
Risk factors; CHF, hypertension, Age (75+ 2 points 65-74 is 1), Diabeties, stroke/TIA/VTE , vascular disease, sex (female is 1)
Low risk = men score of 0 and women with score 1
Higher points would require treatment with anticoagulation as long as risk > than risk of bleeding
9
Q
How is bleeding risk calculated?
A
Has bled tool replaced by ORBIT
Score of 0-7
Factors; males with HBA1C <130 g/L or females <120, prior history of bleeding, age > 74, EGFR <60 mL/min/1.73m2 and taking anti platelets
10
Q
What is torsade de pointes?
A
Prolonged QT interval
Self limiting
Can lead to ventricular fibrillation
Treat IV Mg sulphate
11
Q
What drugs are used in rate control?
A
Beta blockers (NOT sotalol)
Verapamil
Diltiazem (unlicensed)
Drug treatment usually mono-therapy but combine if mono-therapy fails
Digoxin only considered for initial rate control with non paroxysmal AF with predominantly sedentary or others is unsuitable, accompanied by HF and AF
12
Q
Drugs used for rhythm control after cardioversion?
A
1st line is Beta blockers
If not
Flecanide
Amiodarone
13
Q
When to avoid flecanine
A
Avoid if also have isachaemic or structural heart disease, HF etc
14
Q
How to treat supraventricular arrhythmias?
A
Verapamil, adenosine and cardiac glycosides
15
Q
How to treat ventricular arrhythmias?
A
Lidocaine and sotalol
16
Q
How to treat supraventricular and ventricular arrhythmias ?
A
Amiodarone and beta blockers
17
Q
What is digoxin?
A
Cardiac glycoside
Increases force of myocardial contraction and reduces conductivity in a the atrio ventricular node
Useful in controlling AF, atrial flutter and HF (for pts with sinus rhythm)
Has a long half life maintenance dose around 125-250 mcg)
Dose dependent on renal function
18
Q
What is the therapeutic range of digoxin?
A
0.7 to 2.0 nano grams / mL
19
Q
What is toxicity level of digoxin?
A
1.5 to 3
Toxicity can occur within normal range (0.7 - 2)
20
Q
Contraindications for digoxin?
A
Ventricular tachycardia and fibrillation
Heart conduction problems
21
Q
Signs of digoxin toxicity?
A
Arrhythmias
Cardiac conduction disorder
Diarrhoea
Dizziness
Nausea and vomiting
Skin reactions
Vision disorders (yellow)
22
Q
Risk factors of digitalis toxicity?
A
Hypokalaemia
Hypomagnesaemia
Hypercalcaemia
Hypoxia
Special care in elderly; more susceptible to digitalis reduce dose as they have poor reduced kidney function
23
Q
Interactions with digoxin
A
CCB (increase concentration)
Rifampicin (decrease concentration)
Amiodarone (half the digoxin dose)
St John’s wart (decrease concentration)
Erythromycin
Diuretics
TCS, venlaflaxine, TCA, venlafaxine, trazadone
24
Q
What happens if digoxin toxicity occurs?
A
Withdraw digoxin
Serious manifestations require urgent specialist care
Life threatening overdose - reverse with digoxin specific antibody fragments
25
Monitoring requirements for digoxin?
Plasma- digoxin concentration
Serum electrolytes
Renal function (reduce dose in renal impairment)
26
Tranexamic Acid
Inhibits fibrinolysis (prevents you from bleeding)
Prevents bleeding (e.g surgery, dental extraction)
Management of menorrhagia ( 1 g TDS for up to 4 days)
Used in hereditary angioedema, epistaxis and thrombocytes overdose
27
Two types of venous thromboembolism?
DVT clot in body usually the legs
PE blockage of artery in lungs
28
Venous thromboembolism prophylaxis
All patients admitted to hospital need to be assessed for their risk of VT on admission
29
Who are high risk for VT?
Substantial reduction in mobility
Obesity >30 BMI
Malignant disease
Hx of VT
Thrombophilic disorder
Patient over 60 years
Pregnancy / co-morbidities
30
Mechanical prophylaxis for venous thromboembolism?
Anti embolism stockings
Continue until patients is mobile
Move around and raise legs etc
31
Pharmacological PROPHYLAXIS for venous thromboembolism?
Undergoing general orthopaedic surgery who are at high risk
Choice depends on type of surgery
Stop depends on condition / surgery or when patient mobile again (no fixed time)
LMWH suitable for all types of patients e.g dalteparin, tinzaparin and enoxaparin
Fondaparinux sodium to patients undergoing (hip/knee replacement surgery, hip fracture, GI bariatic)
Oral anticoagulation for thromboprophylaxis following knee / hip surgery
32
Treatment for Venous thromboembolism?
Use LMWH (enoxaparin, dalteparin and tinzaparin) for initial treatment of DVT and PE
Give IV unfractionated heparin as alternative
Start oral anticoagulant (usually warfarin) at same time as LMWH or unfractionated heparin; once out of hospital continue oral
33
Venous thromboembolism in pregnancy
Heparins don’t cross the placenta
LMWH preferred (lower risk of osteoporosis and of heparin induced thrombocytopenia) and are eliminated more rapidly in pregnancy, dose alteration is required
34
What are LMWH?
Dalteparin
Tinzaparin
Enoxaparin
35
What is common side effect of LMWH?
Haemorrhage - Withdraw heparin or LMWH if this occurs
Osteoporosis
Heparin-induced thrombocytopenia (can manifest 5 to 10 days after)
Hyperkalaemia; heparin inhibits aldosterone secretion, high risk DM and CKD monitor 7+ day use
36
What is reversal agents for LMWH?
Promoting sulphate
Partial reversal agent
37
3 types of strokes
Transient ischaemic stroke (TIA); aka mini stroke <24 h
Intracerebral haemorrhage
Acute isachaemic stroke (full blown stroke) >24 H
38
Signs of stroke
Face dropped
Arm weakness
Speech slurred
Time (999)
F.A.S.T
39
TIA treatment
300 mg Aspirin daily OR alternatively 75 mg clopidogrel immediately until established diagnosis
Once diagnosed;
Secondary prevention; High intensity statin if not already taking
Symptoms usually resolve within minutes or a few hours at most if not = STROKE
40
Short term treatment of Acute Isachaemic stroke?
Timing important;
Alteplase within 4.5 hours from onset of symptoms
300 mg Aspirin or clopidogrel given 24 hours after alteplase for 14 days
Anticoagulants not recommended except for patients with AF
41
Long term management for isachaemic stroke?
Clopidogrel
MR dipyridamole 200 mg and aspirin IF clopidogrel is CI
MR dipyridamole alone IF aspirin and clopidogrel is CI
Aspirin alone IF clopidogrel and dipyridamole is CI
High intensity statin treatment 48 hours after
Monitor BP target for <130/80 mmHg
Advice patients on lifestyle changes (modify diet, exercise, weight alcohol intake, smoking)
42
Intracerebral haemorrhage treatment
Surgery to remove haematoma and relieve intracranial pressure
DONT GIVE ANTICOAGULANTS - reverse effects expect for pts DVT/PE not given even in AF patients
Avoid statins unless CV event outweighs risk of haemorrhage
Aspirin only given with patients of cardiac isachaemic event
BP measured and treatment initiated
43
What are anticoagulants used for?
Prevent thrombus formation in veins
Examples. Warfarin, acenococoumarol and phenindione
Antagonise vitamin K
Takes at least 48 to 72 hours to get the full effect (oral)
Injections give a immediate effect e.g give heparins
44
Pregnancy and warfarin
Teratogenic
Cross the placenta leading to foetal abnormalities
Avoid esp in the 1st and 3rd trimester and last few weeks of pregnancy as delivery as increase in bleeding risk
Risk of haemorrhage increased by vitamin K deficiency
45
Interactions with warfarin?
Increase warfarin; miconazole, antifungals, benzafibrate, amiodarone, cranberry juice, pomegranate, greeny fruit and veg
Increases bleeding risk; antidepressants, aspirin
Decreases warfarin; carbamazepine, alcohol, St John’s wart
46
MHRA warnings with warfarin?
Risk interactions with treatment of hepatitis C- closely monitor INR
Calciphylaxis - rare skin rash
47
Warfarin target value INR 2.5 for?
Treatment of DVT and PE
AF
Cardioversion
Dilated cardiomyopathy
Mitral stenosis
48
Warfarin INR target value of 3.5 ?
Recurrent DVT and PE or mechanical prosthetic heart valve
49
What is a target value?
Target the INR should be rather than a given range
INR measured can be 0.5 above and below the target value if more = adjustment is required from the dose
50
Warfarin advantages and disadvantages?
+ can be used renal impairment patients
+ effects are reversible
- regular INR testing
- lots food and drug interactions
51
Warfarin main side effects
Nose bleeds; < 10 mins is normal
Haemorrhage
Bleeding gums
Bruising
Caliphylaxisl report painful skin rash = risk factor end stage renal disease
52
When to stop warfarin
Bleeding OR if INR is >8; stop warfarin and give vitamin K by IV (restart INR <5)
No bleeding and INR >8; stop warfarin and given vitamin K orally (restart INR <5)
No bleeding and INR 5-8; withold one or two doses and reduce subsequent maintenance doses
53
Peri operative anticoagulants
Stop warfarin 5 days before elective (planned) surgery
High risk patients of VT stopping warfarin before surgery maybe given LMWH which is stopped 24 hours before surgery
Emergency surgery which can be delayed 6-12 hours give IV vitamin k
If surgery cant be delayed give vitamin K and prothrombin complex
54
Anticoagulant and antiplatelet therapy?
Higher risk of bleeding with clopidogrel and warfarin than aspirin and warfarin
55
Heparin
Short duration of action compared LMWH
‘Standard’ - unfractionated
Used for high risk patients as its effects are shorter; but this means more doses
Can be used in pregnancy doesn’t cross the placenta
56
LMWH examples
Dalteparin, enoxaparin and tinzaparin
57
LMWH used?
Used prophylaxis and treatment of DVT, PE and MI
Preferred over heparin; effective and lower risk of heparin-induced thrombocytopenia
Doesn’t require monitoring
Longer duration of action then heparins can be given OD s/c = convenient
58
Antiplatelets used for?
aspirin, clopidogrel and dipyridamole
Decrease platelet aggregation and inhibit thrombus formation in the arterial circulation
No benefit for primary prevention only secondary
PPI given for patients high risk of bleeding (over 65+, NSAIDs etc)
59
Rivaroxaban
MHRA alert; strengths 15 mg+ to be taken with food
Prophylaxis of stroke and systemic embolism in patients with non-valvular AF with at least 2 of the following risk factors;
CHF, hypertension, previous stroke/TIA, age > 75 or DM
S/e; anaemia, constipation, diarrhoea, dizziness, headache
60
Apixaban
Reduced to 2.5 BD for prophylaxis of stroke due to non-valvular AF with at least 2 of the following;
Age (80+), Body weight (less 60) CrCl (greater 133) Otherwise 5 mg is standard dose
S/e; anaemia, haemorrhage, nausea and skin reactions
61
Edoxaban
Prophylaxis of stroke and systemic embolism in non-valvular AF, in patients with at least one risk factor such as CHF, hypertention, age 75+, DM, previous stroke or TIA
30 mg OD body weight up to 61 kg OR 60kg and above
S/e abdominal pain, anaemia, dizziness, haemorrhage, headache, nausea, skin reactions
62
Dabigatran etexilate
Avoid CrCl less 30 mL/min ; assess renal function before at least annually
Prophylaxis of stroke and systemic embolism in non-valvular AF and with one or more risk factors such as previous stroke or TIA symptomatic HF, age 75+, DM or hypertention
Special container 4 months expiry
S/E; anaemia, diarrhoea, GI discomfort, haemorrhage
63
Reversal agents for DOACS
Apixaban and rivaroxaban; Andexanet Alfa (ondexxya)
Dapigatran etexilate; idarucizumab (praxbind)
Edoxaban has no reversal agent
64
Dabigatran, apixaban and rivoroxaban
Direct thrombin inhibitors (factor Xa)
Rapid onset of action
Prophylaxis VTE in adults after hip/knee surgery and prophylaxis of stroke and systemic embolism
FBC, LFT and U&E recommended annually if not renal impairment (more U&E if renal impairment)
Limited by renal impairment
Monitor signs; bleeding, anaemia, stop if severe bleeding occurs
Common s/e haemorrhage
65
What patients are high risk of developing hyperlipidaemia?
Diabeties
Chronic kidney disease
Familial hypercholestrolaemia
Risk increases with age (>85 years at high risk esp if smoke/hypertention)
10 year risk of CVD >10%
Drugs; antipsychotics, immunosuppressants, corticosteroids, antimalarials
66
CVD measures for primary prevention
Provide lifestyle advice to all patients at high risk; diet, exercise, weight management
If above not effective give statins as first line choice
67
CVD measures for secondary prevention
Offer statins to ALL
68
Statins for CVD
Statins reduce the risk of CVD
1st drug of choice in primary and secondary prevention CVD
Address secondary causes of dyslipidaemia before starting statins (uncontrolled DM, hepatic disease, nephrotic syndrome and excessive alcohol consumption)
Correcting hypothyroidism may resolve lipid abnormality (treat patients itch hypothyroidism with thyroid replacement first)
69
What is a high intensity statin?
Atorvastatin; 20 mg, 40 mg and 80 mg
Rosuvastatin; 10 mg, 20 mg and 40 mg
Simvastatin; 80 mg
70
Primary prevention for statins for CVD
Give high intensity statin for 10 year risk >10%
High intensity statin is one that produces a greater LDL-cholesterol reduction than simvastatin 40 mg (or = greater atorvastatin 20 mg)
Patients over 35 years help reduce risk of non fatal MI
71
Secondary prevention with statin for CVD
Atorvastatin 80 mg recommended
Give statins to all patients with type I diabeties (esp those > 40 years and have diabeties for over 10 years, established nephropathy or other risk factors
72
Statin and blood test
Total cholesterol
HDL cholesterol
Non HDL cholesterol
3 months after starting
73
Types of cholesterol
Total cholesterol; total cholesterol in your blood (5 or below)
HDL; good cholesterol (1/+)
LDL or non-HDL; bad cholesterol (3 or below for LDL and 4 or below for non HDL)
Triglycerides; 2.3 or below (fat lipids)
74
Diagnosis for hyperlipidaemia
6 mmol/L total cholesterol
75
Treatment lines for high lipids?
First line statins
Second line is ezetimbe (if statin not effective or CI)
Fenofibrate maybe added to statin if triglyceride is high (SPECIALIS USE NOW)
Then consider nicotine acids, bile and sequestration and omega 3 fatty acid compounds
76
Statin and fibrate interaction
Statin + fibrate (or nicotine acid) increase risk of s/e; rhabdomylosis
Especially statin + gemfibrozil (fibrate) increase rhabdomylosis considerably
77
Which statins can be taken at any time during the day?
Rosuvastatin and atorvastatin
78
Statins and pregnancy
Adequate contraception is required during treatment and 1 month after
Avoided in pregnancy
Discontinue 3 months before conceiving attempt
Congenital abnormalities and the decrease synthesis of cholesterol can possibly affect foetal development
79
Statin monitoring requirements
Full lipid profile and LFT before treatment, at 3 months and then 12 months
Creatinine kinase only for patients with unexplained muscle pain; if results are x5 normal range = discontinue and reintroduce if still high stop
Monitor liver function
Address any secondary causes first
80
Can you use statins in hepatic impairment?
Use in caution in those with liver disease
Avoid in active liver disease or unexplained elevations in serum transaminase
81
Side effects of statins
Muscle toxicity (higher risk; family hx, high alcohol intake, renal impairment) more likely in high doses
Pt to report any unexplained muscle pain, tenderness or weakness
Simvastatin 80 mg MHRA; Rhabdomylosis
82
Simvastatin dose
10-20 mg at night (increase to 80 mg) primary hypercholestolaemia
40 mg at night (can increase to 80 mg) homozygous familial hypercholestolaemia
20 - 40 mg at night increases prevention CV events in patient in DM or otherosclerotic CVD
MAX 10 mg with fibronates
83
Atorvastatin dose
Primary prevention in CV events in patients with high risk CV events; 20 mg OD dose interval increase 4 weeks if necessary to 80 mg
Secondary prevention CV event 80 mg daily
Primary hypercholesterolaemia / heterozygous familial hypercholestalaemia 10 mg initially
Max 10 mg with Ciclosporin
84
Rosuvastatin dose
Consider routine monitoring of renal function when using 40 mg daily
5 mg initially up to max 20 mg with clopidogrel
85
Simvastatin MHRA warning
Max dose 20 mg with
Amlodopine, verapamil and amiodarone
Higher doses are off license
86
Statin drug interactions
Carbamazepine; increase the risk of hepatotoxicity
Clarithryomycin / erythromycin; increase exposure to simvastatin so stop whilst on treatment
Grapefruit juice increases exposure and ketoconazole and miconazole
Oral fusidic acid must be restated after 7 days of last dose
87
P450 inhibitors
Sodium valproate, Isonaside, Cimetidine, Ketoconazole, Fluconazole, Alchohol, Chlorepteniol, Erythromycin . Ciprofoxacin, Omeprzole Metronidazole
SICKFACE.COM
88
P450 inducers
Carbamezapine, Rifampicin, Alcohol, Phenytoin, Grisefluvin Phenobarbital Sulphonylurea
CRAP GPS
89
What is heart failure?
Heart isn’t functioning as well as it should; not working at its maximum capacity
Acute
Chronic
90
What is Acute HF?
Sudden
Emergency - hospital admission required
91
What is Chronic HF?
Progressive
Slow onset and gradual
Can worsen and turn to acute
92
What is ejection volume?
How much blood the heart manages to pump out with each heart beat
93
Symptoms of HF
Breathlessness; may occur when you exert yourself, lay flat / wake up from sleep
Fluid retention; swollen ankles, swelling of legs, bottom or tummy
Lethargic
Persistent cough / wheezing
Light headed or dizzy or having faint spells
Loss of appetite
Constipation
Reduced exercise tolerance
Risk greater in men, smokers, diabetics and patients with higher age
94
What causes HF?
Coronary heart disease; most common cause especially after MI
Cardiomyopathy; disease of the heart muscle not pumping effectively
Hypertension esp in Afro-Caribbean origin
Disease of the heart valves
Arrhythmias
Medicine that can damage the heart; cocaine, some chemo, excess alcohol
Non-Heart related issues; thyroidism, severe anemia
95
Lifestyle advice for HF patients
Diet
Exercise
Smoking cessation
Alcohol intake
96
Diagnosis for HF?
Physical; echocardiogram, fast pulse, signs of fluid retention
Blood tests; high NT-proBNP
Other tests; ECG, chest X-ray, urine, spirometer, breathing tests
97
New York classification HF
1) No symptoms normal during activities
2) comfortable at rest but symptoms at normal activities
3) comfortable at rest but symptoms at minor activity
4) discomfort at rest and at any level of activity
98
What is the main HF aims?
Relieve symptoms
Improve exercise tolerance
Reduce exacerbations
99
What is drug treatment for HF?
1) Offer diuretics for congestive symptoms and fluid retention (often loop); relieves breathlessness, oedema and fluid retention. Furosemide first choice followed by bumetinide or TLD if not worked
2) If HF with PRESERVED ejection fraction manage co-morbidities and offer cardiac rehab if stable
2) HF with REDUCED ejection fraction give ACEi/ARB and BB
3) if symptoms continue would give aldosterone antagonist such as spironolactone or eplerone
4) If symptoms not helping SPECIALIST CARE (digoxin, hydralazine, ivabradine and nitrates would be initiated)
100
What ACEi/ARB is used in HF?
Valsartan or candersartan
101
What beta blockers are used in HF?
Bisoprolol, carvidiol, nebivolol
102
What class of drugs should be avoided in HF?
CCB need to be avoided
E.g verapamil / diltiazem and short acting dihydropyridlines e.g nifedipine and nicardipine as they reduce cardiac contractility
103
What are the three types of Acute Coronary Syndrome (ACS)?
Unstable angina
NSTEMI ; non-ST elevated MI
STEMI; ST elevated MI
104
Angina VS MI?
Angina is a partial block of blood into the heart
MI is a complete block so no blood is getting to the heart muscles so they begin to die
105
What causes ACS?
Plaque ruptures from within the coronary artery
Obstruction causes restriction of blood supply to the heart and lack of oxygen leads to isachaemic; angina is often first signs
106
STEMI Vs NSTEMI
STEMI; more serious; elevated ECG caused complete obstruction and cardiac cell muscles die
NSTEMI; partial block heart attack in between angina and STEMI; some cells die some are ok
107
Symptoms of angina
Chest pain (tight, sharp stabbing, dull, heavy)
Spread to L arm, neck, jaw or back
Triggered by physical exertion or stress
Stops within a few minutes of resting
Nause
Fatigue
SOB
Dizziness
Sweating
108
Stable angina VS unstable angina
Stable angina is predictable; symptoms occur during exercise/activity/stress and stop on rest
Unstable angina is unpredictable; occurs chest pain while resting pain last longer / more recurring and revere
109
Management of unstable angina and NSTEMI
1) OXYGEN is initial management
2) administer NITRATES if evidence of hypoxia, pulmonary oedema or continuing MI; to relieve isachaemic pain, give IV if sublingual not effective, if pain continues IV diamorphine or morphine or antiemetic
3) aspirin and clopidogrel (ticagrelor or prasugrel as alternative)
4) unfractionated heparin, LMWH or fondaparinux sodium
110
Prevention of CV events
Advise to reduce risk
Lifestyle changes e.g stop smoking, weight loss, management other co-morbidities
Long term management; consider statins, ACEi, aspirin, beta blockers
111
Angina prophylaxis
BB or CCB (e.g diltiazem, verapamil)
Vasodilators; long acting nitrates, ivabradine, ranolazine
Nicorandil
112
Nicorandil
MHRA; 2nd line risk of ulcer complications
Caution; diverticula’s disease., HF, hyperkalaemia
S/e; dizziness, haemorrhage, headache, nausea
For long term angina treatment
K channel activator with nitrate compound
113
Nitrates
For angina
Coronary vasodilators but principle benefit is a reduction in venous return which reduces left ventricular work
S/E; flushing, headaches and postural hypotension
114
Types of nitrates
Sublingual GTN most effective providing rapid symptom relief
Tablet 300 mcg (P med) also available as 500 and 600 mcg
Aerosol spray as an alternative for S/L
Transdermal patches can also be used have a long duration of action
Dinitrate MR preparations and mononitrate MR preparations
115
Dinitrate MR preparations
BD duration for 12 hours
Not seen as much anymore
Slow onset of action
IV used more severe symptoms
Dinitrate is broken down to mononitrate therefore activity depends production of active metabolite
116
Mononitrate MR preparations
OD
Angina prophylaxis
IM up to 2-3 times a day
Less tolerance as if OD than BD/TDS
117
Nitrate tolerance
Need to keep a nitrate free period for 6-8 hours to prevent tolerance
Pt on long acting or transdermal patches; develop tolerance (decreases therapeutic effect) if tolerance occurs = leave off patch for 8-12 hours in each 24 hours then put back on
118
Caution or further information nitrate
Don’t give conventional IR preps mononitrate; give MR OD to avoid tolerance, more than BD unless small doses
Avoid abrupt withdrawal
In case Dinitrate MR or conventional mononitrate second dose of BD should be given 8 hours after rather than 12 hours
119
GTN tablet dispensing and storage requirements
Available in strengths of 300, 500 and 600 mcg
Supplied in glass container of no more than 100
Closed with foil line cap
No cotton wool waddling
Discard after 8 weeks
Rectal ointment (rectogesic) should be discarded 8 weeks after opening
120
How to measure hypertention?
Home blood pressure monitoring (HBPM); standard machine
Within a clinical setting
Ambulatory 24 hour monitoring (ABPM); monitors automatically for the day
121
What are the risk factors for hypertension?
Main cause is unknown
Age, ethnicity, dietary salt, exercise, alcohol, caffeine, smoking
Secondary causes renal disease and endocrine causes
122
Which organs are ‘target organ damage’?
Heart
Brain
Kidney
Eye
123
What is the normal blood pressure reading?
120/80 mmHg
124
Stages of hypertension
Stage 1; clinic BP >140 / 90 OR ambulatory/home reading >135/85
Stage 2; clinic BP > 160/100 OR ambulatory/home reading >150/95
Severe hypertention clinic systolic >180 OR ambulatory/home reading >110
125
What to do if high reading in clinic?
Offer ambulatory blood pressure monitor to confirm hypertension diagnosis
Meanwhile; test for CV risk assessment, investigate target organ damage
126
What happens if hypertension is diagnosed?
Offer urine/blood test
Lifestyle intervention
Drug treatment
127
Stage 1 hypertention
Investigate for secondary causes of hypertension
Pts with persistent stage 1 with one/+; target organ damage, established CVD, renal disease, diabeties
Clinic BP >140/90 or ambulatory/home >135/85
128
Stage 2 hypertention
Treat all regardless of age
Clinic BP >160/100 or amublatory/home >150/95
129
Severe hypertention
Treat promptly with IV antihypertensive
Clinic systolic >180 mmHg or clinic diastolic >110
130
What is first line treatment for hypertention?
ACEi/ ARB if patient is diabetic or under 55 and not of Afro-Carribean
CCB if patient is Afro-Caribbean or over the Agee 55+
131
What is 2nd and 3rd step intervention for hypertention?
ACEi/ARB + CCB
OR
CCB + thiazide like diuretic
OR
ACEi/ARB + thiazide like diuretic
Thirst step; is all 3 together
132
Hypertension and HF patients
Don’t give CCB as it will make HF worse need to avoid
Give ARBs or thiazide like diuretics
133
What is the 4th step stage for hypertention treatment?
Confirm resistant hypertention; confirm elevated BP with Ambuatory home blood pressure monitor
Consider expert advice on adding;
Low dose spironolactone if blood pottasoum is <4.5
Alpha blocker or BB if blood potassium is >4.5
134
Target clinic BP for hypertension in diabetics?
Target clinic of <140 / 80
OR
<130 / 80 if kidney, eye or cerebrovascular disease present
ACEi/ARB to manage nephropathy
135
Hypertension in pregnancy
ACEi / ARBs / thiazide like diuretics; increase congenital abnormalities
1) first choice is lobetalol to achieve BP <138/85
2) if unsuitable consider nifedipine MR (unlicensed manufacture avoid pre 20 weeks)
3) Methyldopa (unlicensed) to discontinue 2 days after birth and switch to alternative
Methyldopa and lobetalol are the safest
Review bp 2 weeks after birth and medication review 6-8 weeks
136
Breast feeding and hypertention
Enalapril
Treat hypertention in post natal period
For black afro give amlodipine/ nifedipine
137
BB mechanism of action
Block beta adrenoceptors in the heart, bronchi, pancreas, liver and peripheral vasculature
Slow the heat
B1 receptors in the heart
B2 receptors in the lungs
138
ISA activity BB
ICE PACO
Pindolol, Acebutolol, Celiprolol, Oxprenolol
Causes less bradycardia and less coldness of extremities
139
Soluble BB
WATER CANS
Celiprolol, Atenolol, Nadolol, Sotalol
Less likely to enter the brain
Causes less sleep disturbances and nightmares; used to treat these conditions
Excreted in the kidneys; decrease dose in impairment
140
Cardioselective BB
BATMAN
Bisoprolol Atenolol T Metoprolol Acebutol Nebivolol
Less effects on airways, selective but not specific, higher affinity for B1 heart receptor
141
Long duration BB
BACON
Bisoprolol Atenolol Celiprolol O Nadolol
Once daily preparations
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Sotalol
Rejected child
Non cardioselective
Causes bronchospasm
Not to be used for asthmatics
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Side effects for BB
Fatigue
Coldness of extremities (less common ISA)
Sleep disturbances (less common water soluble)
Bradycardia
Bronchospasm
Claudication
Vivid dreams
Diziness,
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Patient and carer advice for BB
Do not stop abruptly due to risk of worsening ischaemic heart disease
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Contraindication and caution with BB
ABCDE
Asthma
Block (heart); avoid unstable HF, 2/3rd degree heart block
COPD
Diabeties - avoid in patients with frequent episodes of hypoglycaemia as it masks symptoms
Electrolyte disturbances (hyperkaemia)
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Side effects BB in asthmatics
Precipitate bronchospasm
Can be given if asthma is well controlled
For co-existing conditions e,g HF or following MI; give cardioselective
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Are BB contra indicated in diabetics?
Caution in use
Affects carbohydrate metabolism
Avoid in patients with frequent hypoglycaemia episodes; can masks symptoms of hypoglycaemia e.g tachycardia
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BB uses
Hypertention - reduce cardiac output
Angina - improve exercise tolerance and angina
MI - reduce recurrence rate; atenolol metoprolol
Arrhythmias - esmolol sotalol
HF; only in stable HF Bisoprolol, carvediol, nebivolol
Anxiety, migraine or thyrotoxicosis give propranolol
Glaucoma give timolol
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BB and verapamil
AVOID
Precipitate HF or cause AV block
Risk hypotension and HF
Verapamil is highly negative ionotropic; slows heart rate
Is a CCB
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BB drug interactions
Aminophylline
Amiodarone
Diltiazem
Digoxin
Flecainide
Theophylline
Verapamil
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CCB classes
Dihydropyridines - act on blood vessels more peripherally e.g amlodipine, nifedipine, lercanidipine etc
Phenylaklyamines - work mainly heart e.g verapamil
Benzothiazepines - works in between both classes; both cardiac depressants and vasodilators effects e.g diltiazem
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How does CCB work
Blocking calcium entry into cells decreasing the contraction of smooth muscle which lines blood vessels
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Side effects of CCBs
Vasodilators effects
Diziness
Flushing
Headaches
Postural hypotension
GI disorders
Ankle swelling
Skin reactions
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Contraindications and cautions in CCB?
HF
Hepatic impairment; avoid nifedipine
Renal impairment
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Withdrawal of CCB
Sudden withdrawal may exacerbate angina
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Diltiazem prescribing and dispensing information
Different version of MR preparation contains more than 60 mg may not have same clinical effect
Prescribe by Brand
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Thiazide and related diuretics mechanism of action?
Works by reducing re absorption of electrolyse in the renal tubules main sodium and chloride
Used for hypertension and oedema
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How long do thiazide diuretics take to work?
Act within 1 to 2 hours
Effects lasts for 12 to 24 hours (longer duration than loop)
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Patient and carer advice for thiazide and related diuretics?
Give in the morning to avoid diuresis at night
Moderately potent
Be aware of postural hypotension ensure dose is taken in the morning
Elderly more susceptible to s/e so give lower initial dose
Adjust dose in response to renal function
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Adverse diuretic effects
Postural hypotension
HYPERglycaemia
HYPOkalaemia
HYPOnatraemia
HYPOmagnesaemia
HYPERcalcaemia
GI disturbances
Cardiac arrhythmias
Dizziness and headache
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Which diuretics have higher HYPOkalaemia risk?
Greater in thiazide than loop
Hypokalaemia in hepatic failure can lead to encephalopathy particularly in alcoholic cirrhosis
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What conditions can thiazides exacerbate?
Thiazide and related diuretics can exacerbate diabeties and gout
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Pregnancy and thiazide and related diuretics
Should not be used for gestational hypertention
Can cause; neonatal thrombocytopenia, bone marrow suppression, jaundice and electrolyte imbalances
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Hepatic and renal impairment in diuretics
Use with caution and avoid in severe liver disease
Ineffective in EGFR <30 and should be avoided
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Loop diuretics
E.g furosemide and bumetanide
Used in pulmonary oedema due to left ventricular failure and in CHF
Stronger than thiazides and can be used for resistant oedema
Can exacerbate diabeties
Work within 1 hour and last up to 6 hours
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Contra indications in loop diuretics
Renal failure
Severe hypokalaemia
Severe hyponatraemia
Liver cirrhosis
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Renal impairment and loop diuretics
High doses or rapid IV administration can cause tinnitis and deafness (ototoxicity)
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Thiazide and related diuretics interactions
Medications that lower blood pressure
Amisulpride
Amino and theophylline
NSAID
Amiodarone
Digoxin
TCAs
Lithium
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What drugs should be given with potassium sparing diuretics?
E.g of K sparing epelerone, spironolactone, amiloride etc
Potassium supplements = hyperkalaemia
ACEi = can cause severe hyperkalaemia
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Mannitol
Osmotic diuretic used to treat cerebral oedema and raised IOP
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Acetazolamide
Carbonic anhydrase inhibitor
Weak diuretic
Used for motion sickness prophylaxis
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Dorzolomide and brinzolomide
Acts as diuretics by inhibiting formation of aqueous humour and used in glaucoma
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ACEi mechanism of action
Inhibit conversion of angiotensin I to angiotensin II (prevents breakdown of bradykinin = lowering bp)
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ACEi indications
Hypertention
HF
Secondary prevention of CV events
Nephropathy
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Contraindications of ACEi use
Afro-Caribbean origin; increased risk of angioedema
Previous or family hx of angioedema
Pregnancy and breastfeeding
Renal impairment due to increased risk of hyperkalaemia
Not to be used with alskinen
EGFR <60
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When to take ACEi
First dose hypotension ; first dose at night once stabilised then continue morning
Higher risk in HF patient, taking diuretics
Discontinue potassium sparing duretics; risk hyperkalaemia
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ACEi interactions
A2RBs
Diuretics
Allopurinol
NSAIDs
Digoxin
Lithium
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Initiation under specialist supervision with ACEi
Severe or unstable HF
Pts receiving high doses diuretics
Concomitant use of ACE II receptor antagonist or alskiren
Known renovascular disease
Hyponatraemia
Hypotension
Pts with hypovolaemia
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Side effects of ACEi
Dry cough persistent ; consider switching to ARBs
Diziness
Headaches
Abdominal discomfort; constipation, diarrhoea, nausea vomiting
Alopecia
Angioedema (higher in afro-Caribbean or delayed)
Skin reactions
Hyperkalaemia
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ACEi and monitoring
Renal function
Electrolytes
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ARBs
Less likely to cause dry cough
E.g candersartan, irbesartan, losartan valsartan
Used with ACEi is CI
Hypotension, Diziness, hyperkalaemia, oral ulcers, taste disturbances
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What drugs to avoid in AKI
Nephrotoxic drugs
Diuretics, ACEi, Metformin and NSAIDs
DAMN
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Renin inhibitors
Aliskiren
Licensed hypertention alone or in combo with other antihypertensives
ACEi and aliskiren = hyperkalaemia , hypotension or renal impairment
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Raynauds syndrome
Blood circulation issue; fingertip and toes change colour
Pain numbness, pin/needles, difficulty moving affected area
Treat; nifedipine, exercise, keeping warm, stopping smoking
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Chilblains
Small itchy patches on skin from being out in the cold; worse once you warm up
Self limiting; soothing lotion, whitch hazel to relieve the itching
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Amiodarone side effects
Corneal micro-deposits; night time glare
Phototoxicity
Slate/grey skin on light exposed areas
Peripheral neuropathy; numbness tingly feet etc
Pulmonary fibrosis (dry cough), pneumonitis
Thyroid dysfunction (contains iodine; hyperthyroid symptoms)
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Monitoring requirements in amiodarone
Annual eye checks
X-ray prior to treatment
LFTs ever 6 months
TSH levels before treatment and every 6 months
BP and ECG
Serum potassium
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Amiodarone interactions
Has a long half life - be aware even if stopped
Increase concentrationn with statins and grapefruit juice
Interacts QT prolongation drugs; increases ventricular arrhythmias risk
Enzyme inhibitors; half dose with digoxin, warfarin and phenytoin
Bradycardia, av block ad myocardial depression
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Chest pain clinical features
Oxygen saturation <92%
HR >130 bpm
Respiratory rate >30 BPM
Altered state consciousness
Hyperthermia 38.5 +
BP diastolic <60 or systolic <90
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What does QRISK calculate
CV risk of someone over the next 10 years
