Cardiovascular System Flashcards
1
Q
Management of ectopic beats
A
Spontaneous
- beta blocker
2
Q
Managing life-threatening AF
A
Emergency electrical cardioversion
Without delay to achieve anticoagulation
3
Q
Managing AF without life threading haemodynamic instability
A
RATE OR RHYTHM control
Less than 48 hours = either
More than 48 hours or uncertain = rate control.
4
Q
Drug used for urgent rate control
A
IV beta blocker
Verapamil - if left ventricular ejection fraction is >40%
5
Q
When to avoid CCB in AF
A
Patients with suspected concomitant acute decompensated HF.
Seek advice from a specialist for the use of BB.
6
Q
Ways of rhythm control
A
- Electrical cardioversion
- Pharmacological cardioversion - flecanide or amiodarone
7
Q
When do you avoid flecanide?
A
Known structural or ischaemic heart disease
8
Q
Electrical cardioversion is preferred to pharmacological cardioversion. If it’s been more than 48 hours then electrical cardioversion is preferable but should be avoided until the patient is fully anticoagulated. Why? And how?
A
Why?
To make sure there’s not atrial thrombus.
How?
Coagulate the patient for 3 weeks before.
- If not possible then rule out left atrial thrombus and start the patient on parenteral heparin before.
- electrical cardioversion
- oral anticoagulation with amiodarone for 4 weeks after.
9
Q
Rhythm control is preferred in 5 types of people?
A
- New onset AF
- Atrial flutter suitable for ablation strategy
- AF with a reversible cause
- Heart failure caused by AF
- Rhythm control is more suitable based on clinical judgement.
10
Q
Management options for AF
A
Step wise approach.
1st line - Rate control
- standard BB
- diltiazem
- verapamil monotherapy
- digoxin - primarily sedentary
2nd line - combination with two drugs - not verapamil
- if ventricular rate is diminished LVEF < 40%
(BB licensed in HF With digoxin)
3rd line - anti-arrhythmic drugs
11
Q
Need to prevent stroke in patients with AF. How?
A
Cha2Ds2Vas for stroke risk
Congestive heart failure
Hypertension
Age > 75
Diabetes
Stroke (previous) / TIA/ thromboembolism
Vascular disease
Age 65-75
Sex (female)
ORBIT risk tool
Older age > 74 years
Reduced haemoglobin/ anaemia
Bleeding history
Insufficient kidney function
Treatments (other bleeding risks)
Low risk = 0-2
Medium risk = 3
High risk > 4
12
Q
Options for coagulation for stroke prevention?
(Who is it given to? And what’s first line/second line? What can you not give?)
A
- offered to patients with confirmed diagnosis of AF and sinus rhythm not restored within 48 hours.
- risk of stroke > risk of bleeding
1st line - oral anticoagulation with DOAC
2nd line - warfarin review annually
If pt already on warfarin review annually to switch to DOAC if appropriate.
Not aspirin monotherapy.
13
Q
Atrial flutter
A
Control of ventricular rate is usually an interim measure pending restoration of sinus rhythm.
Direct current cardioversion is usually the treatment of choice.
Recurrent atrial flutter - catheter ablation
Flecanide or propafenone - can slow the atrial flutter resulting in 1:1 conduction. And should be given together with ventricular rate control (BB, diltiazem, verapamil or digoxin).
Assess the patient for stroke risk.
14
Q
Arrhythmia after myocardial interaction
A
In patients with proximal tachycardia or rapid irregularity of pulse - oral anti-arrythmic but not without an ECG.
Bradycardia - IV atropine
risk of Asystole / not responded to atropine - iv infusion of adrenaline. Dose adjusted according to response.
15
Q
Transient ischaemic attack
A
1st line - aspirin immediately 300mg
(Can add PPI)
2nd line - clopidogrel 75mg
Secondary prevention
With long term management-
1st line - Clopidogrel 75mg
Alternative - MR dipyridamole + aspirin
- MR dipyridamole alone
- aspirin alone
16
Q
Acute ischaemic stroke treatment?
A
1st - Alteplase within 4.5 hours
2nd - start aspirin 300mg for 14 days within 24 hours of symptoms.
Alternative - clopidogrel 75mg
17
Q
Long-term management of stroke/TIA
A
1st option - clopidogrel 75mg
Alternative - MR dipyridamole + aspirin
- MR dipyridamole alone
- Aspirin alone
Also initiate a high intensity STATIN
(Within 48 hours)
18
Q
What do you do if the patient is taking anticoagulation for prosthetic heart valves who have an ischaemic stroke and a significant risk of haemorrhagic stroke?
A
Stop anticoagulant treatment for 7 days and substitute with aspirin.
19
Q
Management if intracerebral haemorrhage?
A
Initial management
- surgical intervention to remove the haematoma and relieve intracranial pressure.
(Not to give rapid BP lowering drugs to patients with Glasgow coma scale of less than 6 or an underlying structural cause or early neurosurgery).
- Rapid blood pressure lowering in pts without any exclusions. Within 6 hours and have a systolic pressure between 150-220mmHg.
- Aim for 140mmHg
- not to let it drop more than 60mmHg within 1 hour.
- those who present after 6 hours with systolic BP > 220mmHg. Consider lowering Bp on a case by case basis.
Patients taking anticoags should have treatment stopped and reversed.
Long term management
- NO aspirin
- NO statins usually
- BP drugs only if indicated.
20
Q
Lifestyle factors to reduce BP
A
- regular exercise
- healthy diet
- low salt
- reduce alcohol mistake
- not to have excessive caffeine
- stop smoking
21
Q
Hypertension threshold stages
A
> 140/90mmhg in clinic
Offer - ABPM/ HBPM
Stage 1 : 140/90 - 159/99
Stage 2 : 160/100 - 179/119
Severe HTN : >180/120
22
Q
HTN threshold for treatment
A
Stage 1 140/90-159/99
Treat Under 80
1) Stage 1 + one of the following
- target organ damage
- established CVD
- renal disease
- diabetes
- 10 year risk > 10%
2) stage 2
3) severe HTN - promptly
Consider treatment
Under 60 and 10 year CV risk < 10%
Seek specialist advise
Under 40 with STAGE 1
23
Q
Same day referral
A
- suspected phaeochromocytoma
(Labial or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis) - clinic BP 180/120 with signs of retinal haemorrhage, papilloedema, or life-threatening symptoms (confusion, chest pain, signs of heart failure, AKI)
- severe HTN and no symptoms - investigate for target organ damage. If target organ damage = treat
- severe HTN + no target organ damage + no symptoms = repeat BP within 7 days.
24
Q
HTN treatment targets
A
Under 80 - 140/90
Over 80 - 150/90
25
For black African / African Caribbean do you give ACEi or an ARB?
ARB
26
Treatment options for:
- under 55
- diabetic
1. ACEi or ARB
2. + CCB or thiazide-like diuretic
(Thiazide if HF present)
3. ACEI/ARB + CCB + Thiazide-like
4. Option of
- low dose spironelactone if k+ <4.5mmol/l
- alpha blocker
- beta blocker
27
Treatment options for:
- over 55 years
- black African / African Caribbean
1. CCB
2. + ACEi / ARB / thiazide like diuretic
3. CCB + thiazide-like + ACEI/ARB
4. Addition of
- low dose spironelactone if k+ <4.5mmol/l
- alpha blocker
- beta blocker
28
HTN in diabetes
Type 1 diabetes based on albumin:creatinine ratio.
Under 80 + ACR<70mg/mmol = 140/90
Under 80 + ACR>70mg/mmol = 130/80
Over 80 = 150/90mmHg
Type 2 diabetes is the same as normal
29
HTN in renal disease
Targets are based on albumin:creatinine ratio and CKD
CKD + ACR<70mg/mmol = 140/90
CKD + ACR>70mg/mmol = 130/80
30
HTN in pregnancy
(chronic/gestational/pre-eclampsia)
Can be in 4 ways
1. Before pregnancy
2. Develops in the 20 weeks - chronic HTN
3. Develops after 20 weeks - gestational HTN
4. Pre-eclampsia - after 20 weeks and multi-organ involvement
Above 140/90mmHg = treat
Target if <135/85mmHg
Options
1. Oral labetolol
2. Nifedipine MR
3. Methyldopa
Above 160/110mmHg = IV immediately
1. IV labetolol
2. IV hydralazine
3. Oral nifedipine MR
31
Symptoms of pre-eclampsia
- severe headache
- problems with vision
- severe pain below ribs
- vomiting
- sudden swelling of hands, feet and face
- significant proteinuria
- BP>140/90mmHg
32
Aspirin for pre-eclampsia in pregnancy?
One or more moderate risk factors or high risk of developing pre-eclampsia. Give aspirin from 12 weeks until the baby is born.
33
Magnesium sulfate in pre-eclampsia
Give IV magnesium sulfate in women with severe HTN or severe pre-eclampsia or if they have had a previous eclamptic fit.
If birth planned in the next 24 hours and pt has severe pre-eclampsia - give IV magnesium sulfate
Females with pre-eclampsia where early birth is considered or likely in 7 days - consider antenatal corticosteroids for fetal lung maturation.
34
Antihypertensives whilst breast-feeding
1. Enalipril 1st line
2. Amlodipine/nifedipine (black African or African Caribbean)
3. Labetolol (option)
4. Atenolol
If one doesn’t help. Consider combination with above.
35
Complication of heart failure?
- CKD
- atrial fibrillation
- depression
- cachexia
- sexual dysfunction
- sudden cardiac death.
36
Drugs that can cause or worsen heart failure need to be stopped?
PAC-MAN
PIOGLITAZONE
ANTI-ARRYTHMICS
CCB
METFORMIN
ANTI-DEPRESSANTS
NSAIDS
37
Thiazide diuretics only work in certain patients with HF. When is it okay to give?
eGFR > 30ml/min/1.73m2
Mild fluid retention
38
Treatment of chronic HF with reduced ejection fraction?
1st line
ACEi/ARB (licensed for HF: candesartan, losartan, valsartan) + BB (licensed for HF: bisoprolol, carvedilol, nebivolol)
2nd line + spironelactone/epleronone
Symptoms persist : ADD
- amiodarone
- digoxin
- sacubitril with valsartan
- ivabradine
- empagliflozin / dapagliflozin
Option 2
Hydralazine + nitrate can be considered under the advice of a specialist.
39
Complications that can occur due to stable angina?
- stroke
- unstable angina
- MI
- sudden cardiac death.
40
What is prinzmetals or vasopastic angina?
Rare form of angina, caused by a narrowing or occlusion of proximal coronary arteries due to spasm. Pain is experienced at rest rather than during activities.
41
Treatment of an acute attack of angina?
Sublingual GTN.
Can also be used as preventative before performing activities that bring on an attack.
42
Treatment of stable angina?
Preventative
1st line
Beta-blocker
Alternative
CCB - rate limiting - diltiazem/verapamil
2nd line
- Combination of BB + CCB (diltiazem)
- can also combine CCB/BB with one of the following options:
1) long acting nitrate
2) ivabradine
3) nicorandil
4) ranolazine
(These drugs can also be used alone if both CCB and BB’s are contr-indicated)
Non-drug treatment
Revascularisation - coronary artery bypass graft / percutaneous coronary intervention.
43
Secondary prevention of cardiovascular events in patients with angina?
- low dose aspirin
- statin
- ACEi if patients also diabetic
44
Unstable angina and NSTEMI
45
STEMI
46
Secondary prevention of ACS/cardiovascular events
47
Amiodarone
- loading dose
- side-effects
- monitoring
- pregnancy
Loading dose
200mg TDS for 1 week, 200mg BD for 1 week then 200mg OD.
Side effects
1. Corneal micro-deposition
2. Thyroid function
3. Hepatotoxicity - treatment discontinued if severe liver abnormalities or signs of liver damage
4. Pulmonary toxicity - new progressive shortness of breath or cough = pneumonitis
5. Phototoxicity
Monitoring
- TFTs before then every 6 months
- LFTs before then every 6 months
- serum K - before
- chest x-ray - before
- with IV USE - ECG and resuscitation facilities should be available
Pregnancy
Use only if no alternatives
Possible neonatal goitre
48
Sotalol
- Prolongs the Qt interval and can occasionally cause life threatening ventricular arrhythmias.
- Hypokaleamia and hypomagnesaemia should be be corrected before sotalol is started
- contra-indications = long QT syndrome and torsades
- monitoring of ECG and electrolytes.
49
Digoxin
- cardiac glycosides
- positive ionotrope and negative chronotrope
Dose
- Plasma concentration 0.8-1mcg
- dose of digoxin can be determined at ventricular rate at rest
- should not be allowed to fall <60bpm
- reduce dose by half if given with amiodarone, dronedarone or quinine
Toxicity
- toxicity ranges from 1.5-3mcg/L
- toxicity is increased with electrolyte disturbances like HYPOKALEAMIA
- symptoms SICK AND SLOW
BRADYCARDIA, HEART BLOCK
NAUSEA, VOMITING, ABDOMINAL PAIN AND DIARRHOEA
YELLOW VISION
Antidote
- antidote - digoxin specific antibody fragments - Digifab
- atropine sulfate can also be used to reverse the bradyarrythmias and ventricular arrhythmias
Monitoring
- plasma concentration - 6 hours after the dose is given
- serum electrolytes
- renal function
50
Oral anticoagulants
Warfarin
DOACS
51
Parenteral anticoagulants
Heparin unfractioned
LMWH
52
Anti-platelet drugs
Examples - aspirin, clopidogrel, dipyridamole, prasugrel, ticagrelor.
High blood pressure needs to be controlled before aspirin is given
Dual anti-platelet increases risk of bleeding.
53
Aspirin
- doses (suspected TIA, ACUTE ischaemic stroke, AF following a disabling i schematic stroke, ischaemic stroke in pts receiving anti-coagulation)
- Reye’s syndrome
- symptoms of overdose
- pregnancy
- Dose
Suspected TIA - 300mg daily until confirmed.
Acute stroke - 300mg OD for 14 days
AF Followinh ischemic stroke - 300mg OD for 14 days
Ischaemic stroke in pts on anti-coags - 300mg OD, stop anticoagulat for a week and substitute with aspirin
- Avoid in children under 16.
- symptoms of salicylate poisoning are, hyperventilation, tinnitus, deafness, vasodilation and sweating. coma is uncommon but can happen in severe overdose.
- pregnancy
Avoid high doses in 3rd trimester. Interuterine growth restriction, delayed onset and duration of labour with increased blood loss, teratogenic.
54
DOACS
- examples?
- how long do the effects last?
- reversal agents?
- MRHA alerts? (4)
- apixaban dose change
- edixaban dose change
- rivaroxaban dose change
Examples - Apixaban, dabigatran, edoxaban and rivaroxaban.
The anticoagulant effect lasts 12-24 hours. Therefore omitted or delayed doses could lead to reduction in anticoagulant effects.
Idarucizumab is the reversal agent for dabigatran.
Andexanet Alfa is the reversal agent for apixaban and rivaroxaban.
MHRA alerts
1. Contra-indicated in patients with major bleeding risk (current/recent GI ulcerations, malignant neoplasm @ high risk of bleeding, recent brain or spinal injury, recent surgery to brain, spine or eye, recent intracranial haemorrhage, oesophageal varcies, vascular aneurysm, or any vascular abnormalities)
2. Recurrent thrombotic events in patients with antiphospholipid syndrome (DOACS not recommended)
3. Reminder of bleeding risk and availability or reversal agent.
4. Monitoring during COVID-19 pandemic.
5. Avoid rivaroxaban in pts with prosthetic heart valves including patients who have undergone TAVR - Increased risk of all cause death and bleeding.
Apixaban - reduce to 2.5mg in pts
> 80age, weight < 60kg and crcl > 133micromol/L
Edoxaban - reduce dose to 30mg OD with concurrent ciclosporin, dronedarone, erythromycin, or ketoconazole.
Rivaroxaban - reduce dose to 15mg if crcl 15-49ml/minute.
55
Heparins (unfractioned)
Also referred to as a standard.
- Rapid anticoagulation
- Shorter duration of action
- preferred in patients with high risk of bleeding because the effects can be terminated quickly by stopping the infusion.
Preferred in patients with renal impairment.
Side effect-
1. Haemorrhage - sufficient to withdraw and rapid reversal with profaning sulfate.
2. Heparin induced thrombocytopenia - if suspected or confirmed… stop and use alternative anticoagulant. Ensure platelet count returns to normal range in those who require warfarin.
3. Hyperkaleamia - risk is higher in patients with diabetes, renal failure, acidosis, those taking potassium supplements. Risk increases with prolonged use.
Monitoring - 1. Plasma-Potassium concentration (if given for longer than 7 days) 2.platelet counts (if given for longer than 4 days)
56
LMWH
Examples - dalteparin, enoxaparin, tinzaparin
- longer duration of action the unfractioned heparin
- lower risk of heparin induced thrombocytes
- does not require anticoagulant monitoring
Preferred in pregnancy.
Side effect-
1. Haemorrhage - sufficient to withdraw and rapid reversal with profaning sulfate.
2. Heparin induced thrombocytopenia - if suspected or confirmed… stop and use alternative anticoagulant. Ensure platelet count returns to normal range in those who require warfarin.
3. Hyperkaleamia - risk is higher in patients with diabetes, renal failure, acidosis, those taking potassium supplements. Risk increases with prolonged use.
Monitoring - 1. Plasma-Potassium concentration (if given for longer than 7 days) 2.platelet counts (if given for longer than 4 days)
57
Vitamin K antagonists
- examples?
- how long do they take to work?
- main adverse effect and what to do?
Examples - warfarin, acenocoumarol and phenindione.
Takes 48-72 hours for full effect to develop
Target INR = 2.5
For everything except recurrent DVT/PE (INR=3.5)
Duration for isolated calf-vein DVT = 6 weeks.
Adverse effect
- HAEMORRHAGE
What needs to be done?
1. Withdraw - check INR 2-3 days later.
2. Investigate the cause
Bleeding.. INR > 8.0 or 5 - 8.0
stop warfarin > give IV phytomenandione
Only restart if INR < 5.0.
INR 5 - 8.0 no bleeding
Withhold doses and reduce maintenance dose of warfarin.
58
Warfarin
- important safety info (4)
- conception/contraception and pregnancy
- Vitamin K antagonist
Important safety information
1. Acute illness can increase INR (COVID19)
2. Interactions with anti-vitals and antibacterial.
3. Stop warfarin before starting DOAC.
4. Side-effect of calciphylaxis - pts to report any painful skin rashes.
Conception/contraception and pregnancy
- dangers of teratogenicity
- risk of congenital malformation
- avoid in 1st and 3rd trimester - placental, fetal and neonatal haemorrhage.
59
ACE inhibitors
When are ACEi initiated under supervision ?
The use of ACEi when someone is already on a diuretic?
What are they used in?
Cautioned?
Side-effects/ further information?
Monitoring?
- Potassium supplements and potassium diuretics should be discontinued before introducing ACEi because of hyperkaleamia. However, low dose spironelactone is used in heart failure.
- initiated under specialist supervision:-
• Multiple or high dose diuretic therapy (80mg or more furosemide)
• with hypovolaemia
• hyponatreamia (130mmol/L or less)
• hypotension (90mmHg or less)
• pts with unstable heart failure
• known renovascular disease
- in some patients the diuretic therapy may need to be reduced or discontinued at least 24 hours before initiating. However, in heart failure may cause rebound pulmonary oedema.
AVOID IN SEVERE BILATERAL RENAL ARTERY STENOSIS
Used in
1. Heart failure
2. Hypertention
3. Diabetic nephropathy
4. Prevention of cardiovascular events
5. Acute coronary syndrome.
Caution - diabetes (may lower blood glucose)
Side-effects - angioedema and cough.
Further information - reports of cholestatic jaundice, hepatitis, hepatic necrosis or hepatic failure - discontinue if marked elevation of hepatic enzyme or jaundice occurs.
Monitoring
- renal function
- electrolytes (hyperkalaemia)
60
ARBs
How are they different to ACEi?
What are they used in?
- they do not inhibit the breakdown of bradykinin and other kinins so not likely to cause persistent dry cough.
Used in
1. Heart failure
2. Hypertention
3. Diabetic nephropathy
4. Prevention of cardiovascular events
5. Acute coronary syndrome.
61
Beta-Blockers
62
Calcium channel blockers
63
Thiazide and related diuretics
64
Hydrochlorothiazide
65
Aldosterone antagonist
66
Bile acid sequestrants
Eg colesevlam, colestyramine
67
Ezetimibe
Inhibits the intestinal absorption of cholesterol
68
Fibrates
69
Statins
70
Ranolazine
71
Ivabradine
72
Nicorandil
73
Fibrinolytic drugs
Eg. Alteplase
74
Nitrates
75
Adrenaline
76
Loop diuretics
77
Types of AF
Proxymal - returns to sinus rhythum within 7 days
Non-proxymal - returns to sinus rhythm after 7 days
Permanent - does not return to sinus rhythm
78
What is VENOUS THROMBOEMBOLISM
Deep vein thrombosis
Pulmonary embolism
79
What is hospital acquired VTE?
VTE that occurs within 90 days of hospital admission. It is common and a preventable problem.
80
Risk factors for VTE
- surgery
- trauma
- immobile
- malignancy
- obesity
- pregnancy or postpartum
- inherited or acquired hypercoagulable states
- hormonal therapy (contraceptives/HRT)
81
Symptoms of DVT
Unilateral localised pain, swelling, tenderness, skin changes, vein distension.
82
Pulmonary embolism - what is it and symptoms?
Occurs when a blood clot (usually from a DVT) travels in the blood to the lungs and obstructs blood flow.
Symptoms are shortness of breath, chest pain and haemoptysis.
83
Methods of thromboprophylaxis?
2 types of thromboprophylaxis -
1. Mechanical
2. Pharmacological
Mechanical
- anti embolism stockings - worn day and night and calf pressure of 14-15mmHg
- intermittent pneumatic compression
84
Who should not get anti-embolism stockings?
- acute stroke
- peripheral arterial disease
- peripheral neuropathy
- severe leg oedema
- local conditions (gangrene or dermatitis)
85
VTE prophylaxis in surgical patients
How to reduce the risk?
Which surgeries do you offer mechanical prophylaxis in?
Which surgery do you offer pharmacological prophylaxis?
How long is it used for?
To reduce the risk of VTE regional anaesthesia over general anaesthesia should be used.
Mechanical prophylaxis to be offered in
1. Pts with major trauma
2. Cranial surgery (30 days after surgery)
3. Abdominal surgery
4. Bariatric surgery
5. Thoracic surgery
6. Maxillofacial, ear, nose or throat surgery
7. Cardiac surgery
8. Elective spinal surgery (30 days)
(Continue until the patient is mobile or discharged from hospital)
Pharmacological prophylaxis should be considered in:-
1. General surgery (continue for upto 7 days or until mobile)
2. Orthopaedic surgery
3. Major cancer surgery (extend to 28 days)
For pharmacological prophylaxis LMWH is used.
In renal impairment heparin unfractioned is preferred.
86
Which anticoagulant is used in pts with renal impairment?
Heparin unfractioned
87
Thromboprophylaxis in pts undergoing elective hip replacement?
- LMWH for 10 days followed by aspirin for further 28 days
- LMWH for full 28 days + anti-embolism stockings
- rivaroxiban
Alternatives are apixaban or dabigatran.
If contra-indicated then anti-embolism stockings until discharge.
88
Patients undergoing elective knee replacement surgery?
- low dose aspirin for 14 days
- LMWH for 14 days + anti-embolism stockings
Rivaroxaban
Alternatives - apixaban or dabigatran
Contra-indicated - intermittent pneumatic compression
89
VTE prophylaxis in medical patients
Acutely ill patients and high risk
Pharmacological prophylaxis
- LMWH
- fondaparinux sodium
(for minimum 7 days)
Mechanical prophylaxis is an alternative of contra-indicated.
90
Thromboprophylaxis in acute stroke
Mechanical prophylaxis with intermittent pneumatic compression is considered. Use needs to be started within 3 days and continued for 30 days or until mobile.
Anti-embolism stockings are unsuitable.
91
Thromboprophylaxis in pregnancy
All pregnant women (in active labour)
Given birth
Miscarried
Termination of pregnancy during the past 6 weeks
________________________
- LMWH
Until no longer a risk or discharged
_________________________
Start 4-8 hours after event unless contraindicated and then for a minimum of 7 days.
92
How do you treat confirmed VTE or PE?
Before starting treatment do baseline tests:
- FBC
- renal function
- hepatic function
- prothrombin time
- activated partial thromboplastin time.
Treatment options
1. Apixaban or rivaroxiban
2. Unsuitable :-
- LMWH for 5 days followed by dabigatran or edoxaban
- LMWH for 5 days with vitamin K antagonist for 5 days or until INR is 2.0
Followed by vitamin K antagonist.
93
Duration of anticoagulation following confirmed PE/VTE?
Provoked DVT/PE - treat for 3 months (3-6 month if it’s active cancer)
Unprovoked DVT/PE - consider continuing anticoagulation beyond 3 months (6 months for active cancer)
94
What is used to treat DVT/PE in pregnancy?
- LMWH
Can also use elastic graduated compression stocking on the affected leg to help with pain and swelling.
95
Anticoagulation before surgery
Elective surgery -
- stop 5 days before
- give phytomenandione the date before the surgery if the INR > 1.5
- resume warfarin the next day.
What if high risk of thromboembolism?
Can use bridging with LMWH. And stop the LMWH 24 hours before the surgery.
Emergency surgery
- DELAY for 6-12 hours and give Iv Phytomenandione.
- canNOT DELAY then give dried prothrombin complex alongside the IV phytomenandione.
96
Combined anticoagulation and antiplatelet therapy?
- keep the duration as small as possible
- aspirin + warfarin > warfarin + clopidogrel (more risk of bleeding)
97
Dabigatran
- what is it?
- MHRA alerts (4)
- direct thrombin inhibitor.
MHRA ALERTS
1. Contra-indicated in patients with major bleeding risk (current/recent GI ulcerations, malignant neoplasm @ high risk of bleeding, recent brain or spinal injury, recent surgery to brain, spine or eye, recent intracranial haemorrhage, oesophageal varcies, vascular aneurysm, or any vascular abnormalities)
2. Recurrent thrombotic events in patients with antiphospholipid syndrome (DOACS not recommended)
3. Reminder of bleeding risk and availability or reversal agent.
4. Monitoring during COVID-19 pandemic.
98
Vasodilators as antihypertensives
What happens if the patient is given these?
What do we add alongside to reduce the side effects?
Vasodilators are accompanied by increase cardiac output and tachycardia. The patient will also develop fluid retention. Because of this the patient should also be on a diuretic or on a beta- blocker
Examples
- hydralazine
- sodium nitroprusside - given IV infusion for severe hypertensive emergencies
- minoxidil
