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Victor BNF Notes > Cardiovascular System Part 2 > Flashcards

Cardiovascular System Part 2 Flashcards

1
Q

What is Heart Failure

A

when the heart fails to pump enough blood for the body

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2
Q

What are heart failure symptoms

A
  • Dyspnoea (shortness of breath)
  • Fatigue
  • Oedema:
    — Pulmonary oedema (breathlessness)
    — Peripheral Oedema (swollen ankles, legs)
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3
Q

Heart failure with preserved ejection fraction

A

treat co-morbidities and offer non-pharmacological advice

comorbidities include:
- hypertension
- diabetes
- arterial fibrillation
- heart disease

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4
Q

Chronic heart failure (reduced ejection fraction) in adults treatment 1st line treatment

A

ACEi/ARB + Beta Blocker

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5
Q

Main ARBs licensed in heart failure

A
  • Candesartan
  • Valsartan
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6
Q

Beta blockers for left ventricular systolic dysfunction (LSVD)

A
  • Bisoprolol
  • Cardevilol
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7
Q

Chronic heart failure (reduced ejection fraction) in adults treatment 2nd line treatment

A

Add Mineralocorticoid receptor antagonists

  • spironolactone
  • eplerenone (if LSVD, acute MI)
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8
Q

Examples of Mineralocorticoid receptor antagonists

A
  • spironolactone
  • eplerenone
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9
Q

If patient can’t tolerate ACEi and ARB what should the management for heart failure be?

A

Hydralazine

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10
Q

Chronic heart failure (reduced ejection fraction) in adults treatment 3rd line treatment

A

Replace ACEi/ARB with Sacubitril
valsartan

if ejection fraction
<35%

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11
Q

Chronic heart failure (reduced ejection fraction) in adults treatment 4th line treatment

A

Add Ivabradine

if patient is in sinus rhythm with
heart rate >75 and
ejection fraction
<35%

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12
Q

Chronic heart failure (reduced ejection fraction) in adults treatment 5th line treatment

A

Add Digoxin

if worsening or severe heart failure

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13
Q

What is fluid overload in heart failure

A
  • Heart does not pump out enough blood
  • Causes fluids to build up in your body.
  • If you consume too much sodium, this can lead to fluid retention.
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14
Q

Symptoms of fluid retention

A
  • swelling
  • weight gain
  • shortness of breath.
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15
Q

Treatment for fluid overload in heart failure

A

Loop diuretic

  • furosemide
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16
Q

Treatment for fluid overload in mild heart failure

A

Thiazide Diuretics

  • Indapamide

(although these are not effective in eGFR <30)

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17
Q

What is Hyperlipidaemia

A

high blood levels of cholesterol and or triglycerides

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18
Q

Hyperlipidaemia causes atherosclerosis which can develop into…

A
  • Coronary heart disease (angina, myocardial infarction)
  • Strokes
  • Peripheral arterial disease
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19
Q

QRISK3

A

10 year cardiovascular event risk calculator

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20
Q

At which QRISK score do you offer primary prevention treatment

A

10% or more

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21
Q

Why is QRISK3 unsuitable in some patients

A

because their score will be underestimated as some conditions can increase the risk of a cardiovascular event.

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22
Q

Which patients are QRISK underestimated in

A
  • type 1 diabetes
  • established cardiovascular disease
  • over 85
  • CKD (eGFR <60)
  • family history pf hypercolesterolemia
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23
Q

Total Colesterol Targets

A

Healthy adult
=<5mmol/L

High risk adults
=<4mmol/L

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24
Q

Low density lipid (LDL) level targets

A

Healthy Adults
=< 3mmol/L

High Risk Adults
=< 2mmol/L

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25
Q

High Density Lipid (HDL) level target

A

> 1mmol/L

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26
Q

Triglyceride Level target

A

<1.7mmol/L

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27
Q

Drugs that cause Hyperlipidaemia

A
  • Antipsychotics
  • Immuosuppressants
  • Corticosteroids
  • Antiretrovirals
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28
Q

Conditions that cause Hyperlipidaemia

A
  • Hypothyroidism
  • Liver/kidney disease
  • Diabetes
  • History of high cholesterol
  • Lifestyle
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29
Q

What are 7 types of Lipid regulating drugs

A
  • Statins
  • Fibrates
  • Ezetimibe
  • Bile Acid Sequestrates
  • Nicotinic Acid group
  • Lomitapide
  • Alirocumab
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30
Q

Statin mode of action

A

lowers LDL cholesterol synthesis by the liver via inhibition of HMG-CoA reductase. Also reduces triglycerides and increases HDL cholesterol

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31
Q

Statin Dose times

A

every statin must be taken at night except Atorvastatin

(cholesterol synthesis is greater at night)

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32
Q

Simvastatin warning

A

80mg increases risk of myopathy

(myopathy is a term to describe multiple diseases that affect voluntary muscle movement)

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33
Q

Primary and familial hypercholesterolaemia treatment

A

1st choice:
Statin

2nd choice:
increase statin dose
or…
if statin not tolerated, use ezitimibe

3rd Choice:
Statin + Ezitimibe

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34
Q

Moderate hypertriglyceridaemia treatment

A

1st line:
Statin

2nd Line:
increase statin dose
or…
if statin not tolerated, use fibrate

3rd Line:
if triglycerides still high, use statin and fibrate / nictotinic acid

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35
Q

Statin Side effects

A
  • myopathy
  • myositis (degeneration of muscle tissue)
  • rhabdomyolysis (destruction of striated muscle cells)
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36
Q

Manage these conditions before starting statins

A
  • hypothyroidism
  • uncontrolled diabetes
  • nephrotic syndrome (large amount of protein in urine)
  • Liver disease
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37
Q

Patient counselling for statins

A

tell them to report any tender, weak and painful muscles

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38
Q

Patient conditions with high risk of statin muscle toxicity

A
  • family history of muscle disorder
  • high alcohol intake
  • renal impairment
  • hypothyroidism
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39
Q

Which 3 (types) drugs increase the risk of myopathy with concomitant use with statin

A
  • Ezetimibe
  • Fibrates
  • Fusidic acid
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40
Q

What is myopathy?

A

any disease that affects the muscles that control voluntary movement in the body.

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41
Q

Interstitial lung disease (ILD)

A

An umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs

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42
Q

Statins and Diabetes

A

Statins can raise HbA1c levels.

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43
Q

Statin Monitoring

A
  • lipid profile
  • renal function
  • thyroid function
  • HbA1c levels (if at risk of developing diabetes)
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44
Q

Stop taking statins if..

A
  • severe muscle symptoms
  • if creatine kinase levels are 5x normal
    (normal levels are 20 to 200 U/L)
  • if liver transaminases 3x normal

(if creatine kinase levels drop, statin at low dose can be introduced)

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45
Q

Which drugs increase levels of statin?

A
  • Amiodarone
  • Grapefruit juice
  • Calcium channel blockers
  • Amlodipine
  • Imidazole/triazole antifungals e.g. Itraconazole
  • Ciclosporin
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46
Q

What can higher levels of statin lead to?

A

Myopathy

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47
Q

Macrolide Antibiotic: eg Clarithromycin and Statins

A

don’t take statin until antibiotic course is done (no need to contact prescriber)

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48
Q

AVOID what when taking statins

A

Ezetimibe / Fibrates
(especially Gemfibrozil)

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49
Q

You start the statin 7 days after the last oral dose of this drug? What drug is it?

A

Fusidic Acid Oral

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50
Q

Statin Dose Adjustments due to interactions: Simvastatin

A

10mg max:
with fibrate

20mg max:
with amiodarone, amlodipine, diltiazem and verapamil

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51
Q

Statin Dose Adjustments due to interactions: Atorvastatin

A

max 10mg:
with ciclosporin

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52
Q

Statin Dose Adjustments due to interactions: Rosuvastatin

A

initially 5mg

max 20mg:
with clopidogrel

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53
Q

Statins are teratogenic

A

Able to disturb the growth and development of an embryo or fetus.

AVOID 3 months before conception and start after breastfeeding

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54
Q

Ezetimibe mode of action

A

reduces blood cholesterol by inhibiting the absorption of cholesterol by small intestine

alternative to statin

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55
Q

Use Ezetimibe as alternate to statin if

A

statin is contraindicated or not tolerated in primary or familial hypercholesterolaemioa

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56
Q

Fibrates mode of action

A
  • lowers blood triglyceride levels by reducing the livers production of VLDL (triglyceride carrying particle)
  • speeds up removal of triglycerides from blood.
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57
Q

Examples of fibrates

A
  • Bezafibrate
  • Fenofibrate
  • Ciprofibrate
  • Gemfibrozil
58
Q

Bile Acid Sequestrants

A

Binds and sequesters bile acid. The liver then produces more bile acids to replace those that have been lost using cholesterol.
Reduces LDL

59
Q

Bile Acid Sequestrants examples

A
  • Colesevelam
  • Colestipol
  • Colestyramine
60
Q

Bile Acid Sequestrants interactions

A

take drugs 1 hour before or 4 hours after

Colesevelam (4 hours before and after)

61
Q

What is myocardial ischaemia (angina)

A

reduced blood flow through one or more coronary artery

62
Q

Acute angina attacks treatment

A

short acting nitrates
- glyceryl trinitrate
- isosorbide dinitrate (Sublingual)

63
Q

Long term angina treatment

A
  • MR isosorbide dinitrate
  • isosorbide mononitrate
  • beta blocker
  • ccb
  • ivabradine
  • ranolazine
  • nicorandil
64
Q

Glyceryl trinitrate mode of action

A

converted to nitric oxide which is a short acting vasodilator, increase blood supply

65
Q

Glyceryl trinitrate formulations

A

sublingual tablet and spray

lasts 20-30 mins

66
Q

Glyceryl trinitrate sublingual tablets

A

sublingal tabs have a special container

expires 8 weeks after opening

67
Q

Glyceryl trinitrate dose timings

A

PRN or before doing any activity

max 3 doses

68
Q

How to take Glyceryl trinitrate

A

sitting down as dizziness can occur

1st dose wait 5 mins
2nd dose wait 5 mins
3rd dose wait 5 mins

1 dose = 1-2 sprays / 1 tablet

69
Q

Glyceryl trinitrate red flag

A

if pain still present after taking GTN call 999

70
Q

Angina prophylaxis

A

1st Line:
Beta blocker or CCB

2nd Line:
Beta-blocker and CCB

(if both contra-indicated, use vasodilator)

71
Q

Vasodilator examples

A
  • long acting nitrate
  • ivabradine (only if sinus rhythm is normal)
  • ranolazine
  • Nicorandil
72
Q

Nicorandil

A
  • K-channels activator
  • adults only
  • risk of ulcer complications (mouth, skin, eye and gastro-intestinal)
  • don’t drive until established performance is not impaired
73
Q

Nitrates mode of action

A

nitrates are potent coronary vasodilators and reduce venous return and cardiac output.

74
Q

Short Acting Nitrate example

A

Glyceryl Trinitrate (GTN)

75
Q

Long Acting Nitrate

A
  • Isosorbide Mononitrate
  • Isosorbide Dinitrate
76
Q

Nitrate talking points

A
  • leave patches 8 to 12 hours off
  • Take second dose ofter 8 hours not 12 (both mononitrate and dinitrate are BD)
  • MR Isosorbide Mononitrate is taken OD (therefore reduces tolerance)
77
Q

Nitrate Side effects

A
  • vasodilations
    -flushing
  • throbbing headache
  • dizziness
  • postural hypotension
  • tachycardia
  • dyspepsia
  • heartburn
78
Q

Nitrate injection side effects

A

GTN/Isosorbide dinitrate

  • severe hypotension
  • sweating
  • apprehension
  • muscle twitching
  • palpitations
79
Q

Nitrate what to avoid

A

avoid abrupt withdrawal and CCB as it worsens angina

80
Q

What is a Myocardial infarction

A

heart attack, with prolonged blood loss

81
Q

NSTEMI

A

Non-ST Elevated Myocardial Infarction

NSTEMI is caused by a block in a minor artery or a partial obstruction in a major artery.

82
Q

STEMI

A

ST Elevated Myocardial Infarction

STEMI occurs when a ruptured plaque blocks a major artery completely.

83
Q

What is Myocardial Ischaemia

A

reduced blood flow to heart myocardium

84
Q

what can myocardial ischaemia cause

A

Hypoxia

Ischaemia pain

Angina

85
Q

What is hypoxia

A

low levels of oxygen in body tissues

86
Q

Hypoxia symptoms

A

confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin.

87
Q

Hypoxia treatment

A
  • Oxygen therapy
  • maintain patient airways
88
Q

Ischaemiac Pain

A

plaque buildup in the arteries in your legs. leading to pain in your legs, feet and toes; poor circulation; and wounds that won’t heal.

89
Q

Ischaemiac Pain Mangement

A
  • Analgesic
  • diet and lifestyle advice
  • cholesterol medication
  • GTN
90
Q

What is reperfusion

A

restoring blood flow to organ or tissue after blockage

91
Q

Reperfusion treatment

A

Aspirin 300mg + Clopidogrel 300mg / ticagrelor

92
Q

Prevention of re-occlusion

A

Parenteral Anticoagulant

(low molecular weight heparin)

93
Q

Long-term management of Myocardial Ishcaemia

A

Statin, ACE Inhibitor, Aspirin (for life) and Beta-Blocker

SAAB

94
Q

What is PCI

A

Percutaneous Coronary Intervention
- adding stent to widen blood vessel

95
Q

Percutaneous Coronary (PCI) (stent) adjunct therapy

A

Dual antiplatelet therapy

  • Aspirin (for life)
  • Clopidogrel
96
Q

Emergency prophylaxis: Unstable angina and NSTEMI

A

Aspirin 300mg + GTN spray/sublingual tablet

97
Q

Emergency prophylaxis: STEMI

A

Aspirin 300mg + GTN spray/sublingual tablet

+

(IV diamorphine/ morphine) + metoclopramide

98
Q

What is Cardiac Arrest

A

heart stops pumping blood

99
Q

What is cardiopulmonary resurrection for cardiac arrest

A

30 compressions: 2 breaths
+
100 compressions/min

100
Q

Cardiopulmonary resurrection + IV medication for cardiac arrest

A

IV Adrenaline (1 in 1000 every 3-5 min)

or…

if ventricular fibrillation present use:
IV Amiodarone

101
Q

What is oedema

A

build up of liquid in body, affecting the tissue

102
Q

When to take oedema medication?

A

Morning to avoid sleep disturbances

103
Q

Loop Diuretic Examples

A

BUMETANIDE (most potent)

FUROSEMIDE (gout)

TORASEMIDE (musculoskeletal pain)

104
Q

Thiazides Examples

A

BENDROFLUMETHIAZIDE

CYCLOPENTHIAZIDE

105
Q

Thiazide Diuretic Examples

A

CHLORTALIDONE (long half life)

INDAPAMIDE (less aggravation of diabetes)

METOLAZONE (still works in severe renal failure)

106
Q

Potassium-Sparring Diuretic Examples

A

AMILORIDE

TRIAMTERENE (blue urine in some lights)

107
Q

Aldosterone Antagonists Examples

A

SPIRONOLACTONE (ascites liver failure)

EPLERENONE (use in post- acute Myocardial infarction)

108
Q

Osmotic Diuretics Examples

A

MANNITOL (use in Cerebral oedema)

109
Q

Carbonic Anhydrase Inhibitors Examples

A

ACETOZOLAMIDE (use in Glaucoma)

110
Q

Diuretics mode of action

A

increase urine output by the kidneys (promotes diuretics by inhibiting sodium reabsorption in nephron).

111
Q

Loop Diuretics mode of action

A

inhibits NA+/K+/CL- co-transporter in ascending limb of loop of henle

1 hour onset
6 hour duration

112
Q

Loop Diuretic side effects

A

Ototoxicity (hearing of balance problem)(tinnitus, deafness)

Acute Urinary Retention (inability to voluntarily pass urine)
- caution in benign prostatic hyperplasia

113
Q

Loop/Thiazide/Thiazide Like Cautions and Diabetes

A

Diabetic patients are at risk of hyperglycaemia when using a loop diuretic.

114
Q

Loop/Thiazide/Thiazide Like Diuretics Caution and Gout

A

Furosemide

Increase likelihood of Hyperuricemia (uric acid in blood).

Increases chances of gout

115
Q

Loop/Thiazide/Thiazide Like Diuretics Electrolyte imbalances

A

Hypo K+ / CL- / Mg2+ / Ca2+

116
Q

Loop Diuretics Cardiac Indications

A

Heart Failure

Resistant Hypertension

117
Q

Loop Diuretics Heart Failure Dose

A

BD (last dose at 4pm)

(20-40mg OM Furosemide)

118
Q

Loop Diuretics
Resistant Hypertension Dose

A

Bumetanide (most potent)

Torasemide (musculoskeletal Pain)

Furosemide

119
Q

Thiazide and Thiazide Like Diuretic Mode of Action

A

Inhibits NA+/CL- transporter in distal convoluted tubule

1-2 hour onset
12-24 hour duration

120
Q

Thiazide and Thiazide Like Diuretic Side effects

A

GI Disturbances

Impotence (erectile dysfunciton)

High LDL/Triglycerides

121
Q

Thiazide and Thiazide Like Diuretic eGFR therapeutic index

A

ineffective if eGFR below 30

unless Metolazone

122
Q

Thiazide and Thiazide Like Diuretic Indications

A

Heart Failure

Hypertension

123
Q

Thiazide and Thiazide Like Diuretic Heart Failure Doses

A

OM 5mg (Bendroflumethiazide)

124
Q

Thiazide and Thiazide Like Diuretic Hypertension Doses

A

OM 2.5mg
(Bendroflumethiazide)

125
Q

Potassium-sparing diuretics

A

promotes urination without loss of potassium by inhibiting sodium channels in distal convoluted tubule

(weak, and used as combination with loop and thiazide)

126
Q

Potassium-sparing diuretics use

A

preferred over potassium supplements for hypokalaemia

127
Q

Potassium-sparing diuretics side effects

A

hyperkalaemia

128
Q

Potassium-sparing diuretics interactions

A

avoid use with medication that cause hyperkalaemia

  • ACEi/ARB
  • K+ supplement
  • Aldosterone Antagonist
129
Q

Aldosterone Antagonist mode of action

A

inhibits aldosterone causing sodium reabsorption via NA+/K+/H+ co-transporter.

Less potassium and hydrogen ions exchanged for sodium therefore less lost to urine

reduction in sodium reabsorption and potassium excretion

130
Q

Aldosterone Antagonist side effects

A
  • Gynocomastia
  • hypertrichosis
  • change in libido
  • hyperkalaemia
  • hyperuraemia (high uric acid in blood)
  • hyponastraemia (low sodium)
131
Q

Aldosterone Antagonist interactions

A

avoid any medication that can cause hyperkalaemia

-potassium sparing diuretics
- potassium supplement
- ACEi/ARB

Must monitor blood electrolytes

132
Q

Osmotic Diuretics mode of action

A

inhibits sodium and water reabsorption by increasing osmolarity of blood and renal filtrate. Only acts on water permeable part of nephron (proximal convoluted tubule and descending loop of henle

133
Q

Osmotic Diuretics uses

A

Cerebral Oedema

High intracranial pressure

134
Q

What is simple Gravitational Oedema in Elderly

A

normal oedema, but due to gravity, fluid falls down, causing puffy feet and ankles

135
Q

simple Gravitational Oedema treatment

A

low-dose diuretic

short term use only
- stockings
- raising legs
- moving

136
Q

What is peripheral vascular disease

A

the reduced circulation of blood to a body part other than the brain or heart.

137
Q

What is Occlusive vascular disease

A

inadequate blood flow to the heart due to narrowing of the arteries from buildup or disease

138
Q

What is Vasospastic vascular disease

A

conditions where small blood vessels near the surface of the skin have spasms that limit blood flow.

139
Q

Occlusive vascular disease treatment

A

Aspirin 75mg daily + Statin (for secondary cardiovascular event preventions)

140
Q

Vasospastic vascular disease treatment

A
  • stop smoking
  • avoid exposure to cold
  • Nifedipine to treat Raynaud’s Syndrome
    (some areas of your body to feel cold, sore or numb, or change colour.

Victor BNF Notes (25 decks)

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