Chapter 2: CVS Flashcards

Question

A 55-year-old man has just suffered from transient ischaemic stroke with low bleeding risk. His daughter calls 999 and paramedics arrived in an ambulance shortly after. The man has not been given any medication and there are no signs or symptoms of haemorrhage. NKDA Which medication would you expect the patient to be administered when he initially presents in hospital? A. Ticagrelor 90mg B. Aspirin 300mg C. Alteplase 900mcg D. Aspirin 300mg plus clopidogrel 300mg E. Clopidogrel 75mg

Answer 1

D. Aspirin 300mg plus clopidogrel 300mg (day 1), then reduce Aspirin 75mg and clopidogrel 75mg for 21 days

Answer 2

>Antiplatelet drug >Caution – anaemia, asthma, ulcer, uncontrolled hypertension >Contraindicated – bleeding disorders, severe cardiac failure, haemophaelia >Causes reyes syndrome in patients under 16yrs (except for Kawasaki disease) >Can pregnant women take aspirin? Yes, pre-eclampsia in 2nd and 3rd trimester (75/150mg OD dependent on BMI), OTC only if prescribed (check SCR) >Toxicity symptoms include – tinnitus, deafness, sweating , vasodilation , coma. >Antidote: sodium bicarbonate >CVD PREVENTION – PRIMARY VS SECONDARY >Drug interactions – warfarin, anti-platelet drugs, asthmatic patients Aspirin | Drugs | BNF | NICE see link for doses of Aspirin in stroke

Answer 3

WHAT ARE THE SYMPTOMS OF STROKE??? ACT FAST face drooping, slurred speech, paralysis, numbness, confusion >There are three types of strokes: TIA, Ischceamic stroke, haemorrhagic >Initial management and long-term treatment >Haemorrhagic stroke (deadly) >Control blood pressure if high. Might need scan and medical procedures >No statins, No aspirin or anticoagulant unless risk of DVT or PE >Transient Ischaemic attack >Immediately give Aspirin. Plus PPI if necessary >Ischaemic stroke (70%) >Give Alteplase within 4.5 hours of symptoms of acute ischaemic stroke. Not in intracranial haemorrhage. Give Aspirin within 24 hours if no haemorrhage . No warfarin in acute phase.

Answer 4

>Transient ischaemic attack and minor ischaemic stroke >Patients suspected of having a transient ischaemic attack should immediately receive aspirin, unless contraindicated. Patients with aspirin hypersensitivity, or those intolerant of aspirin despite the addition of a proton pump inhibitor, should receive a suitable alternative antiplatelet. >Patients presenting within 24 hours of transient ischaemic attack or minor stroke who have a low risk of bleeding, should be considered for dual antiplatelet therapy with clopidogrel plus aspirin followed by clopidogrel monotherapy. Ticagrelor [unlicensed use] plus aspirin dual antiplatelet therapy followed by either ticagrelor [unlicensed use] or clopidogrel [unlicensed use] monotherapy is also an option. For patients who are not appropriate for dual antiplatelet therapy, clopidogrel monotherapy [unlicensed use] should be given. >A proton pump inhibitor should be considered for patients with a history of dyspepsia associated with aspirin, or for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.

Answer 5

>Initial management **rule out any intracranial bleeding >Alteplase or tenecteplase [unlicensed use] are recommended in the treatment of acute ischaemic stroke if it can be administered within 4.5 hours of symptom onset and if intracranial haemorrhage has been excluded by appropriate imaging techniques. It should be given by medical staff experienced in the administration of thrombolytics and the treatment of acute stroke, within a specialist stroke centre. Some patients may also be eligible for surgical management. Provided that intracranial haemorrhage has been excluded, patients who received thrombolysis should be started on an antiplatelet after 24 hours, unless contraindicated. >Patients with disabling acute ischaemic stroke should be started on aspirin (unless contraindicated) as soon as possible within 24 hours and continued for 2 weeks after stroke onset, when long-term antithrombotic treatment should be started. Patients being transferred to care at home before 2 weeks should be started on long-term antithrombotic treatment earlier. >Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm (only in DVT/Pulmonary Embolism). However, anticoagulants may be indicated in patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism. Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis. Warfarin sodium should not be given in the acute phase of an ischaemic stroke. Patients already receiving anticoagulation for a prosthetic heart valve who experience a disabling ischaemic stroke and are at significant risk of haemorrhagic transformation, should have their anticoagulant treatment stopped for 7 days and substituted with aspirin. >Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore only be instituted in the event of a hypertensive emergency, or in those patients considered for thrombolysis.

Answer 6

Avoid aspirin, antiplatelets, statins >Surgical intervention may be required following intracerebral haemorrhage to remove the haematoma and relieve intracranial pressure. >Rapid blood pressure lowering treatment should not be given to patients who have an underlying structural cause, have a score on the Glasgow Coma Scale of below 6, are going to have early neurosurgery to evacuate the haematoma, or who have a very large haematoma with a poor expected prognosis. >Consider rapid blood pressure lowering for patients who present within 6 hours of symptom onset with a systolic blood pressure between 150 and 220 mmHg and who do not fit any exclusion criteria. Aim for a systolic blood pressure target of 130 to 139 mmHg within 1 hour and sustained for at least 7 days, ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment. Rapid blood pressure lowering should also be considered on a case-by-case basis for patients who present beyond 6 hours of symptom onset or who have a systolic blood pressure greater than 220 mmHg and who do not fit any exclusion criteria. Seek specialist paediatric advice if considering blood pressure lowering in patients aged 16 or 17 years who do not fit any exclusion criteria. >Patients taking anticoagulants should have this treatment stopped and reversed. Anticoagulant therapy has, however, been used in patients with intracerebral haemorrhage who are symptomatic of deep vein thrombosis or pulmonary embolism; placement of a caval filter is an alternative in this situation. >Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis.

Answer 7

Blood Pressure and Cholesterol >Specialist advice should be sought for patients with atrial fibrillation and those at a high risk of ischaemic stroke or cardiac ischaemic events, as aspirin and anticoagulant therapy are not normally recommended following an intracerebral haemorrhage. >Blood pressure should be measured and treatment initiated where appropriate, taking care to avoid hypoperfusion. For guidance on blood pressure lowering therapy and treatment targets, see Hypertension. After a stroke, don't start beta blocker treatment for hypertension. >Statins should be avoided following intracerebral haemorrhage, however they can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage. Patients should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk and the underlying cause of the haemorrhage. For further information, see Cardiovascular disease risk assessment and prevention. Put on Atorvastatin 80mg as soon as they can swallow

Answer 8

>Bloods - clopidogrel, ticagrelor , aspirin >BP control 130/80 - Anti-hypertensives but not beta-blockers >Cholesterol control – High intensity Statins >Give lifestyle advice such as stop smoking , physical activity , alcohol reduction, diet, weight loss

Answer 9

likelihood of patient developing a stroke CONGESTIVE HEART FAILURE 1 HYPERTENSION 1 AGE 75 OR MORE 2 DIABETES 1 STROKE 2 -VASCULAR DISEASE 1 AGE 65 TO 74 1 SC SEX CATEGORY 1 Statin for primary prevention: Atorvastatin 20mg and BP Higher the score, higher the risk.

Answer 10

A. Calculates the likelihood of a patient having a major cardiovascular event over the following ten years. Start, Stop criteria for elderly.

Answer 11

>Myocardial infarction or M is a serious medical emergency in which the supply of blood to the heart is suddenly blocked or reduced usually by atherosclerosis or blood clot. >STEMI >A STEMI or ST-elevation myocardial infarction is caused by a sudden complete (100 percent) blockage of a heart artery (coronary artery). >NSTEMI >A non-STEMI is usually caused by a severely narrowed artery but the artery is usually not completely blocked. The diagnosis is initially made by an electrocardiogram (ECG or EKG).

Answer 12

Unstable Angina: rupture or artery causes chest pain, GTN STEMI: complete blockage NSTEMI: plaque narrows

Answer 13

QT interval ST segment: if elevated (STEMI), if stays as is -- or dips (NSTEMI)

Answer 14

DRUG TREATMENT NSTEMI – MONA HB Morphine, oxygen, Nitrates, Aspirin, Betablockers, heparin (low molecular weight) DRUG TREATMENT STEMI – OBAMA SN Morphine, Oxygen , Nitrates, Betablockers, Aspirin, Ace-inhibitors, statins.

Answer 15

>Stable angina >occurs predictably. It happens when you exert yourself physically or feel considerable stress. Stable angina doesn't typically change in frequency, and it doesn't worsen over time. >Unstable angina >is chest pain that occurs at rest or with exertion or stress. >DRUG TREATMENT - acute – nitrates – GTN. Instruct the person that if they experience chest pain they should: >Stop what they are doing and rest. >Use their glyceryl trinitrate spray or tablets as instructed. >Take a second dose after 5 minutes if the pain has not eased. >Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell >Long-term – betablocker, CCB, Long-acting nitrates, ivabradine, nicorandil (can't break blisters, built in desiccant) or ranolazine.

Answer 16

As a general guide: >normal blood pressure is considered to be between 90/60mmHg and 130/80mmHg >high normal: 13/81-139/89 >high blood pressure is considered to be 140/90mmHg or higher >low blood pressure is considered to be 90/60mmHg or lower >New NHS blood pressure monitoring service !!!! Stage 1 hypertension: 140/90 – 160/100 mmHG Stage 2 hypertension: 160/ 100 – 180/120 mmHg Severe hypertension: More than 180/ 120 mmhg Example: Stage 1 or 2=>lifestyle advice and ABPM for 24hrs or HBPM (monitor at home), then refer if still high Send to A/E if severe hypertension

Answer 17

HYPERTENSION IN PREGNANCY >BP in pregnancy <140/90 on no BP meds >In hypertension, on BP med, a target blood pressure of <135/85 mmHg is recommended. >List three drugs used in Rx high BP in pregnancy. 1. labetolol (contraindicated in asmathics, contracts airways) 2. M/R nifedipine (afro carribean can take while breastfeeding or amlodipine, other ethnicities take enalapril as first line in breastfeeding) 3. Methyldopa (stop within 2 days after delivery, reduce risk of postpartum depression) If already on ACE/ARB/Diuretic and planning to get pregnant, must stop and switched to something safer like amlodipine until they become pregnant changed to 1, 2 , 3.

Answer 18

>Same-day specialist referral >Refer patients for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis). >Patients should also be referred for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension), or life-threatening symptoms for example new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Answer 19

<130/80 mmHg

Answer 20

RENAL IMPAIRMENT : less than 140/90, comorbidity: less than 130/80 ELDERLY (over 80): less than 150/90 DIABETIC: type 1 (ACR less than 70mmol: less than 140/90, more than 70 mmol: 130/80), type 2 (less than 140/90) PREGNANCY: no BP meds (140/90), with BP meds (135/85) What about sympathomimetics (on cold and fly medicines, can increase BP) and High BP? Dont give psuedoephidrine

Answer 21

>UNDER 55 YRS NOT afro-carribeans or diabetic type 2 ACE inhibitor, ccb, thiazide-like, **only stop if not tolerated, add with not managed *** after ccb, and patient develop ankle oedema=>give diuretic (indapamide, clotalidone) ACE inhibitor or ARB, ccb OR thiazide-like, ACE inhibitor, ccb, thiazide-like, ACE or ARB plus CCB, thiazide-like, spirorolactone –check K +, alpha blocker >OVER 55 YRS / afro-carribeans CCB CCB plus ACE inhibitor or ARB OR thiazide-like, CCB plus ACE or ARB, thiazide-like, CCB plus ACE or ARB, thiazide-like, spirorolactone –check K , alpha blocker

Answer 22

Give ARB, not ACE B. candesartan

Answer 23

ACE INHIBITORS >First dose hypotension (make them feel sleepy/drowsy, first dose taken as close to bedtime as possible and take next dose in morning), (ARB/Alpha blockers/nitrates also cause first dose hypotension) >desensitising vaccines (for those subject to serious allergic reactions, avoid giving vaccine to patients on ACE,BB, and asthmatics), jaundice (high bilirubin, liver biomarkers), diabetes >Side-effects >drug interactions >Renal function (protects kidneys in diabetic patients but otherwise are nephrotoxic to other patients reducing eGFR) >Electrolytes imbalance: causes increase in potassium

Answer 24

>What is NICE guidelines first choice in hypertension treatment? indapamine/chlotalidone >Onset and duration of action of loop diuretics : onset 30 min, duration 6 hrs >Onset and duration of action of thiazide-related diuretics: onset 1-2hrs, duration 12-24hrs (bendro, hydro) >Loop and thiazide-related diuretics can exacerbate diabetes and gout. Can also affect digoxin due to hypokalaemia >Worsen gout and diabetes , cause skin cancer - hydrochlorothiazide (monitored by MHRA, stop taking and refer) >Drink adequate volume of fluid daily >Avoid potassium supplements and preparations when taking potassium sparing diuretics (aldosterone antagonists) >Increase potasssium levels: spironolactone, ACE/ARB, ciclosporin, heparins, trimethoprim, eplerenone)

Answer 25

>A woman takes isosorbide mononitrate tablets BD and complains of tolerance issues. What advise can you give to assist her with nitrate tolerance? reduce interval period from 12 to 8hrs (take within 8 hrs to reduce tolerance issues) >How long can nitrate tablets be kept after opening? nitrEIGHT (8 weeks max before discarded) >First dose hypotension with nitrates tablets. What advice would you give? >Side-effects – dizziness, drowsy, flushing, headache ● Postural hypotension - should sit down when using GTN spray. ● Tolerance >Name four drugs which increase risk of first dose hypotension

Answer 26

CALCIUM CHANNEL BLOCKERS >Verapamil and diltiazem are non-dihydropyridine calcium channel blockers and exert their effect on cardiac muscle. >Dihydropyridine CCBs (amlodipine, felodipine, lacidipine, lercanidipine, and nifedipine) cause relaxation of peripheral blood vessels. (amlodipine before pregnancy/while breastfeeding) >What is the most common side-effect of CCBs ? Ankle swelling >Diltiazem and verapamil should not be given to patients with heart failure!!! >What is the most common side-effect of verapamil? constipation >SIDE-EFFECTS dizziness, headache, tachycardia, palpitations, abdominal pain, flushing

Answer 27

>contraindications- >Cautionary labels: do not stop taking unless doctor has asked you to do so >side-effects - coldness of extremities, weigh gain, nausea, syncope (fainting), causes bradycardia (lower HR) >soluble (less likely to cross BBB and less cause to nightmares, CANS: celiprolol, atenolol, nadolol, soltalol)/ insoluble >Cardioselective (atenolol, bisoprolol) and non-cardioselective (timolol, propranolol=>more likely to interact with beta agonist) >Drug interaction: Beta Blockers and Beta agonists (salbutamol) >taking BB+CCB causes heart block

Answer 28

>Statins HMG CoA reductase >Muscle effects can occur with all statins especially as dose increases. (rhabdomyosis) > NEW UPDATE: Myasthenia gravis >Interstitial lung disease **Use with caution in asian origin: rosuvastatin 5mg min-20mg max** susceptible to muscle breakdown Monitoring requirements >Before treatment - At least one full lipid profile (Total less than 5, Trig less than 2.3, LDL less than 3, HDL more than 1) >liver function test >diabetes >Creatinine kinase: if 5 times upper limit, red flag (indicates breakdown of muscle) >Thyroid test: correct before starting

Answer 29

>Pregnancy - Statins should be avoided in pregnancy and whilst trying to conceive. >Rosuvastatin should be used with caution in Asian patient >Statins Drug interactions Macrolides – erythromycin , clarithromycin (stop 7 days and resume treatment on day 8) Fusidic acid (stop statins, start 7 days after last dose before initiating statins again) Colchicine (next 24 hrs) Amlodipine, 20mg simvastatin max Fibrates (monitor) Amiodarone (20mg statin max with amiodarone)