Cardiovascular System Part 2 Flashcards
What is Heart Failure
when the heart fails to pump enough blood for the body
What are heart failure symptoms
- Dyspnoea (shortness of breath)
- Fatigue
- Oedema:
— Pulmonary oedema (breathlessness)
— Peripheral Oedema (swollen ankles, legs)
Heart failure with preserved ejection fraction
treat co-morbidities and offer non-pharmacological advice
comorbidities include:
- hypertension
- diabetes
- arterial fibrillation
- heart disease
Chronic heart failure (reduced ejection fraction) in adults treatment 1st line treatment
ACEi/ARB + Beta Blocker
Main ARBs licensed in heart failure
- Candesartan
- Valsartan
Beta blockers for left ventricular systolic dysfunction (LSVD)
- Bisoprolol
- Cardevilol
Chronic heart failure (reduced ejection fraction) in adults treatment 2nd line treatment
Add Mineralocorticoid receptor antagonists
- spironolactone
- eplerenone (if LSVD, acute MI)
Examples of Mineralocorticoid receptor antagonists
- spironolactone
- eplerenone
If patient can’t tolerate ACEi and ARB what should the management for heart failure be?
Hydralazine
Chronic heart failure (reduced ejection fraction) in adults treatment 3rd line treatment
Replace ACEi/ARB with Sacubitril
valsartan
if ejection fraction
<35%
Chronic heart failure (reduced ejection fraction) in adults treatment 4th line treatment
Add Ivabradine
if patient is in sinus rhythm with
heart rate >75 and
ejection fraction
<35%
Chronic heart failure (reduced ejection fraction) in adults treatment 5th line treatment
Add Digoxin
if worsening or severe heart failure
What is fluid overload in heart failure
- 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.
Symptoms of fluid retention
- swelling
- weight gain
- shortness of breath.
Treatment for fluid overload in heart failure
Loop diuretic
- furosemide
Treatment for fluid overload in mild heart failure
Thiazide Diuretics
- Indapamide
(although these are not effective in eGFR <30)
What is Hyperlipidaemia
high blood levels of cholesterol and or triglycerides
Hyperlipidaemia causes atherosclerosis which can develop into…
- Coronary heart disease (angina, myocardial infarction)
- Strokes
- Peripheral arterial disease
QRISK3
10 year cardiovascular event risk calculator
At which QRISK score do you offer primary prevention treatment
10% or more
Why is QRISK3 unsuitable in some patients
because their score will be underestimated as some conditions can increase the risk of a cardiovascular event.
Which patients are QRISK underestimated in
- type 1 diabetes
- established cardiovascular disease
- over 85
- CKD (eGFR <60)
- family history pf hypercolesterolemia
Total Colesterol Targets
Healthy adult
=<5mmol/L
High risk adults
=<4mmol/L
Low density lipid (LDL) level targets
Healthy Adults
=< 3mmol/L
High Risk Adults
=< 2mmol/L
High Density Lipid (HDL) level target
> 1mmol/L
Triglyceride Level target
<1.7mmol/L
Drugs that cause Hyperlipidaemia
- Antipsychotics
- Immuosuppressants
- Corticosteroids
- Antiretrovirals
Conditions that cause Hyperlipidaemia
- Hypothyroidism
- Liver/kidney disease
- Diabetes
- History of high cholesterol
- Lifestyle
What are 7 types of Lipid regulating drugs
- Statins
- Fibrates
- Ezetimibe
- Bile Acid Sequestrates
- Nicotinic Acid group
- Lomitapide
- Alirocumab
Statin mode of action
lowers LDL cholesterol synthesis by the liver via inhibition of HMG-CoA reductase. Also reduces triglycerides and increases HDL cholesterol
Statin Dose times
every statin must be taken at night except Atorvastatin
(cholesterol synthesis is greater at night)
Simvastatin warning
80mg increases risk of myopathy
(myopathy is a term to describe multiple diseases that affect voluntary muscle movement)
Primary and familial hypercholesterolaemia treatment
1st choice:
Statin
2nd choice:
increase statin dose
or…
if statin not tolerated, use ezitimibe
3rd Choice:
Statin + Ezitimibe
Moderate hypertriglyceridaemia treatment
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
Statin Side effects
- myopathy
- myositis (degeneration of muscle tissue)
- rhabdomyolysis (destruction of striated muscle cells)
Manage these conditions before starting statins
- hypothyroidism
- uncontrolled diabetes
- nephrotic syndrome (large amount of protein in urine)
- Liver disease
Patient counselling for statins
tell them to report any tender, weak and painful muscles
Patient conditions with high risk of statin muscle toxicity
- family history of muscle disorder
- high alcohol intake
- renal impairment
- hypothyroidism
Which 3 (types) drugs increase the risk of myopathy with concomitant use with statin
- Ezetimibe
- Fibrates
- Fusidic acid
What is myopathy?
any disease that affects the muscles that control voluntary movement in the body.
Interstitial lung disease (ILD)
An umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs
Statins and Diabetes
Statins can raise HbA1c levels.
Statin Monitoring
- lipid profile
- renal function
- thyroid function
- HbA1c levels (if at risk of developing diabetes)
Stop taking statins if..
- 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)
Which drugs increase levels of statin?
- Amiodarone
- Grapefruit juice
- Calcium channel blockers
- Amlodipine
- Imidazole/triazole antifungals e.g. Itraconazole
- Ciclosporin
What can higher levels of statin lead to?
Myopathy
Macrolide Antibiotic: eg Clarithromycin and Statins
don’t take statin until antibiotic course is done (no need to contact prescriber)
AVOID what when taking statins
Ezetimibe / Fibrates
(especially Gemfibrozil)
You start the statin 7 days after the last oral dose of this drug? What drug is it?
Fusidic Acid Oral
Statin Dose Adjustments due to interactions: Simvastatin
10mg max:
with fibrate
20mg max:
with amiodarone, amlodipine, diltiazem and verapamil
Statin Dose Adjustments due to interactions: Atorvastatin
max 10mg:
with ciclosporin
Statin Dose Adjustments due to interactions: Rosuvastatin
initially 5mg
max 20mg:
with clopidogrel
Statins are teratogenic
Able to disturb the growth and development of an embryo or fetus.
AVOID 3 months before conception and start after breastfeeding
Ezetimibe mode of action
reduces blood cholesterol by inhibiting the absorption of cholesterol by small intestine
alternative to statin
Use Ezetimibe as alternate to statin if
statin is contraindicated or not tolerated in primary or familial hypercholesterolaemioa
Fibrates mode of action
- lowers blood triglyceride levels by reducing the livers production of VLDL (triglyceride carrying particle)
- speeds up removal of triglycerides from blood.
Examples of fibrates
- Bezafibrate
- Fenofibrate
- Ciprofibrate
- Gemfibrozil
Bile Acid Sequestrants
Binds and sequesters bile acid. The liver then produces more bile acids to replace those that have been lost using cholesterol.
Reduces LDL
Bile Acid Sequestrants examples
- Colesevelam
- Colestipol
- Colestyramine
Bile Acid Sequestrants interactions
take drugs 1 hour before or 4 hours after
Colesevelam (4 hours before and after)
What is myocardial ischaemia (angina)
reduced blood flow through one or more coronary artery
Acute angina attacks treatment
short acting nitrates
- glyceryl trinitrate
- isosorbide dinitrate (Sublingual)
Long term angina treatment
- MR isosorbide dinitrate
- isosorbide mononitrate
- beta blocker
- ccb
- ivabradine
- ranolazine
- nicorandil
Glyceryl trinitrate mode of action
converted to nitric oxide which is a short acting vasodilator, increase blood supply
Glyceryl trinitrate formulations
sublingual tablet and spray
lasts 20-30 mins
Glyceryl trinitrate sublingual tablets
sublingal tabs have a special container
expires 8 weeks after opening
Glyceryl trinitrate dose timings
PRN or before doing any activity
max 3 doses
How to take Glyceryl trinitrate
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
Glyceryl trinitrate red flag
if pain still present after taking GTN call 999
Angina prophylaxis
1st Line:
Beta blocker or CCB
2nd Line:
Beta-blocker and CCB
(if both contra-indicated, use vasodilator)
Vasodilator examples
- long acting nitrate
- ivabradine (only if sinus rhythm is normal)
- ranolazine
- Nicorandil
Nicorandil
- K-channels activator
- adults only
- risk of ulcer complications (mouth, skin, eye and gastro-intestinal)
- don’t drive until established performance is not impaired
Nitrates mode of action
nitrates are potent coronary vasodilators and reduce venous return and cardiac output.
Short Acting Nitrate example
Glyceryl Trinitrate (GTN)
Long Acting Nitrate
- Isosorbide Mononitrate
- Isosorbide Dinitrate
Nitrate talking points
- 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)
Nitrate Side effects
- vasodilations
-flushing - throbbing headache
- dizziness
- postural hypotension
- tachycardia
- dyspepsia
- heartburn
Nitrate injection side effects
GTN/Isosorbide dinitrate
- severe hypotension
- sweating
- apprehension
- muscle twitching
- palpitations
Nitrate what to avoid
avoid abrupt withdrawal and CCB as it worsens angina
What is a Myocardial infarction
heart attack, with prolonged blood loss
NSTEMI
Non-ST Elevated Myocardial Infarction
NSTEMI is caused by a block in a minor artery or a partial obstruction in a major artery.
STEMI
ST Elevated Myocardial Infarction
STEMI occurs when a ruptured plaque blocks a major artery completely.
What is Myocardial Ischaemia
reduced blood flow to heart myocardium
what can myocardial ischaemia cause
Hypoxia
Ischaemia pain
Angina
What is hypoxia
low levels of oxygen in body tissues
Hypoxia symptoms
confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin.
Hypoxia treatment
- Oxygen therapy
- maintain patient airways
Ischaemiac Pain
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.
Ischaemiac Pain Mangement
- Analgesic
- diet and lifestyle advice
- cholesterol medication
- GTN
What is reperfusion
restoring blood flow to organ or tissue after blockage
Reperfusion treatment
Aspirin 300mg + Clopidogrel 300mg / ticagrelor
Prevention of re-occlusion
Parenteral Anticoagulant
(low molecular weight heparin)
Long-term management of Myocardial Ishcaemia
Statin, ACE Inhibitor, Aspirin (for life) and Beta-Blocker
SAAB
What is PCI
Percutaneous Coronary Intervention
- adding stent to widen blood vessel
Percutaneous Coronary (PCI) (stent) adjunct therapy
Dual antiplatelet therapy
- Aspirin (for life)
- Clopidogrel
Emergency prophylaxis: Unstable angina and NSTEMI
Aspirin 300mg + GTN spray/sublingual tablet
Emergency prophylaxis: STEMI
Aspirin 300mg + GTN spray/sublingual tablet
+
(IV diamorphine/ morphine) + metoclopramide
What is Cardiac Arrest
heart stops pumping blood
What is cardiopulmonary resurrection for cardiac arrest
30 compressions: 2 breaths
+
100 compressions/min
Cardiopulmonary resurrection + IV medication for cardiac arrest
IV Adrenaline (1 in 1000 every 3-5 min)
or…
if ventricular fibrillation present use:
IV Amiodarone
What is oedema
build up of liquid in body, affecting the tissue
When to take oedema medication?
Morning to avoid sleep disturbances
Loop Diuretic Examples
BUMETANIDE (most potent)
FUROSEMIDE (gout)
TORASEMIDE (musculoskeletal pain)
Thiazides Examples
BENDROFLUMETHIAZIDE
CYCLOPENTHIAZIDE
Thiazide Diuretic Examples
CHLORTALIDONE (long half life)
INDAPAMIDE (less aggravation of diabetes)
METOLAZONE (still works in severe renal failure)
Potassium-Sparring Diuretic Examples
AMILORIDE
TRIAMTERENE (blue urine in some lights)
Aldosterone Antagonists Examples
SPIRONOLACTONE (ascites liver failure)
EPLERENONE (use in post- acute Myocardial infarction)
Osmotic Diuretics Examples
MANNITOL (use in Cerebral oedema)
Carbonic Anhydrase Inhibitors Examples
ACETOZOLAMIDE (use in Glaucoma)
Diuretics mode of action
increase urine output by the kidneys (promotes diuretics by inhibiting sodium reabsorption in nephron).
Loop Diuretics mode of action
inhibits NA+/K+/CL- co-transporter in ascending limb of loop of henle
1 hour onset
6 hour duration
Loop Diuretic side effects
Ototoxicity (hearing of balance problem)(tinnitus, deafness)
Acute Urinary Retention (inability to voluntarily pass urine)
- caution in benign prostatic hyperplasia
Loop/Thiazide/Thiazide Like Cautions and Diabetes
Diabetic patients are at risk of hyperglycaemia when using a loop diuretic.
Loop/Thiazide/Thiazide Like Diuretics Caution and Gout
Furosemide
Increase likelihood of Hyperuricemia (uric acid in blood).
Increases chances of gout
Loop/Thiazide/Thiazide Like Diuretics Electrolyte imbalances
Hypo K+ / CL- / Mg2+ / Ca2+
Loop Diuretics Cardiac Indications
Heart Failure
Resistant Hypertension
Loop Diuretics Heart Failure Dose
BD (last dose at 4pm)
(20-40mg OM Furosemide)
Loop Diuretics
Resistant Hypertension Dose
Bumetanide (most potent)
Torasemide (musculoskeletal Pain)
Furosemide
Thiazide and Thiazide Like Diuretic Mode of Action
Inhibits NA+/CL- transporter in distal convoluted tubule
1-2 hour onset
12-24 hour duration
Thiazide and Thiazide Like Diuretic Side effects
GI Disturbances
Impotence (erectile dysfunciton)
High LDL/Triglycerides
Thiazide and Thiazide Like Diuretic eGFR therapeutic index
ineffective if eGFR below 30
unless Metolazone
Thiazide and Thiazide Like Diuretic Indications
Heart Failure
Hypertension
Thiazide and Thiazide Like Diuretic Heart Failure Doses
OM 5mg (Bendroflumethiazide)
Thiazide and Thiazide Like Diuretic Hypertension Doses
OM 2.5mg
(Bendroflumethiazide)
Potassium-sparing diuretics
promotes urination without loss of potassium by inhibiting sodium channels in distal convoluted tubule
(weak, and used as combination with loop and thiazide)
Potassium-sparing diuretics use
preferred over potassium supplements for hypokalaemia
Potassium-sparing diuretics side effects
hyperkalaemia
Potassium-sparing diuretics interactions
avoid use with medication that cause hyperkalaemia
- ACEi/ARB
- K+ supplement
- Aldosterone Antagonist
Aldosterone Antagonist mode of action
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
Aldosterone Antagonist side effects
- Gynocomastia
- hypertrichosis
- change in libido
- hyperkalaemia
- hyperuraemia (high uric acid in blood)
- hyponastraemia (low sodium)
Aldosterone Antagonist interactions
avoid any medication that can cause hyperkalaemia
-potassium sparing diuretics
- potassium supplement
- ACEi/ARB
Must monitor blood electrolytes
Osmotic Diuretics mode of action
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
Osmotic Diuretics uses
Cerebral Oedema
High intracranial pressure
What is simple Gravitational Oedema in Elderly
normal oedema, but due to gravity, fluid falls down, causing puffy feet and ankles
simple Gravitational Oedema treatment
low-dose diuretic
short term use only
- stockings
- raising legs
- moving
What is peripheral vascular disease
the reduced circulation of blood to a body part other than the brain or heart.
What is Occlusive vascular disease
inadequate blood flow to the heart due to narrowing of the arteries from buildup or disease
What is Vasospastic vascular disease
conditions where small blood vessels near the surface of the skin have spasms that limit blood flow.
Occlusive vascular disease treatment
Aspirin 75mg daily + Statin (for secondary cardiovascular event preventions)
Vasospastic vascular disease treatment
- 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.
