Clinical Case Studies Week 1 (Diabetes, VTE & PE, Angina) Flashcards

Question 1

Q

What should management of type 2 diabetes always include?

Answer

A

Management of type 2 diabetes should always focus on dietary intake and regular exercise. This lifestyle modification can facilitate weight loss, improve glycaemic control, minimise cardiovascular disease risk factors and the need for additional medication, and improve patient outcomes.

Lifestyle modification alone can often significantly improve the glycated haemoglobin (HbA1c).

Question 2

Q

General target of HbA1c levels? Also what is the level for diabetes of longer duration or with established cardiovascular disease?

Answer

A

53 mmol/mol (7%) or less

Question 3

Q

How to diagnose diabetes? Provide FOUR different ways.

Answer

A

Venous BGL (Fasting)

Normal < 6mmol/L
Intermediate Hyperglycaemia: 6.1-6.9 mmol/L
Diabetes ≥ 7 mmol/L

Venous BGL (Random)

Normal < 6mmol/L
Diabetes ≥ 11.1 mmol/L

HbA1c

Diabetes ≥ 48 mmol/mol

Oral glucose tolerance test (2-hour venous BGL)

Normal < 7.7mmol/L
Intermediate Hyperglycaemia: 7.8-11 mmol/L
Diabetes ≥ 11.1 mmol/L

If symptoms present –> a single test is sufficient

No symptoms –> repeat on another day

> OGTT only needed when BGLs indefinite 2 occasions or screening of gestational diabetes

Question 4

Q

General blood glucose concentration targets

A) fasting and preprandial

B) postprandial

Answer

A

A)

4 to 8 mmol/L

B)

Less than 10 mmol/L, aiming to avoid hypoglycaemia

Question 5

Q

Optimising antihyperglycaemic treatment is important to achieve and maintain glycaemic targets, why? What are the complications of diabetes?

Answer

A

To minimise other risk factors for microvascular and macrovascular complications associated with diabetes, such as dyslipidaemia and elevated blood pressure

Acute complications of diabetes are

hypolgycaemia
diabetic ketoacidosis
hyperosmolar hyperglycaemia

Microvascular complications of diabetes include

diabetic kidney disease
diabetic retinopathy
diabetic neuropathy

Macrovasuclar complications

atheroslertoic cardiovascular diseasem including cerebrovascular and peripheral vascular disease

Question 6

Q

Non drug management for type 2 diabetes?

Answer

A

Dietary intake

Even modest weight loss (5 to 10%) improves glycaemic control
Low-carbohydrate diets may be used as part of an individualised management plan to assist in glycaemic control, but there is no evidence that they are superior to higher-carbohydrate diets in the longer term.
Consumption of foods with a low glycaemic index (GI) (eg wholegrain breads, pasta, fruits, dairy products) helps optimise glycaemic control.

> However, the GI value should not be interpreted in isolation. For example, foods rich in fat and refined carbohydrate (eg potato chips, ice cream, chocolate) have a low GI because fat delays gastric emptying.

Reducing sugar intake is more effective than substituting a non-nutritive sweetener (eg saccharin, aspartame, stevia). While these sweeteners are widely used, they may interfere with central satiety mechanisms and with the gut microbiota

Physical activity and exercise

Regular physical activity for patients with type 2 diabetes (eg walking briskly for 150 minutes per week, jogging for 90 minutes per week) improves glycaemic control and patient wellbeing
Combined aerobic and resistance exercise may have additive benefit in patients with type 2 diabetes.
Minimising sedentary behaviour by interrupting sitting every 30 minutes can also improve glycaemic control

Question 7

Q

What is the cornerstone of management of patients with type 2 diabetes?

Answer

A

Lifestyle modification (dietary intake and physical activity)

Question 8

Q

What are some factors influencing the choice of antihyperglycaemic drugs used in type 2 diabetes?

Answer

A

Patient-related factors

degree of hyperglycaemia

risk of hypoglycaemia

weight

comorbidities (eg kidney or liver impairment, cardiovascular disease)

patient preference—impact of drug-related factors

patient life expectancy

drug related factors

efficacy in lowering blood glucose concentration

potential nonglycaemic effects (eg cardiovascular benefits for patients with established cardiovascular disease, slowing progression of kidney disease)

risk of inducing hypoglycaemia

effect on patient weight

contraindications to use and adverse effects

ease of use—complexity of dosage regimen and route of administration

cost

Question 9

Q

Advantages and disadvantages of using metformin for type 2 diabetes?

Answer

A

Advantages

hypoglycaemia unlikely [NB3]
assists in weight loss
improves cardiovascular outcomes in overweight patients
extensive experience with use
low cost

Disadvantages

gastrointestinal adverse effects
vitamin B12 deficiency
lactic acidosis (rare)

> reduce dose in patients with kidney impairment

Question 10

Q

Advantages and disadvantages of using sulfonylureas (gliclazide, glibenclamide) for type 2 diabetes?

Answer

A

Advantages

Extensive experience with use
Low cost

Disadvantages

Weight gain
Significant hypoglycaemia, especially in older patients (glibenclamide, glimepiride)

> avoid in patients with kidney impairment (glibenclamide, glimepride)

Question 11

Q

Advantages and disadvantages of using DDP-4 inhibitors (linagliptin, saxagliptin, sitagliptin) for type 2 diabetes?

Answer

A

Advantages

hypoglycaemia unlikely [NB3]
no weight gain
improve postprandial glucose control
safe in patients with cardiovascular disease (except saxagliptin and possibly alogliptin)

disadvantages

avoid in patients with heart failure (saxagliptin, possibly alogliptin)
avoid in patients with acute pancreatitis or history of pancreatitis
can cause musculoskeletal pain
reduce dose in patients with kidney impairment (except linagliptin)

Question 12

Q

Advantages and disadvantages of using GLP-1 receptor agonists (dulaglutide, exenatide, liraglutide) for type 2 diabetes?

Answer

A

Advantages

hypoglycaemia unlikely [NB3]
cause weight loss
improve postprandial glucose control
reduce rate of secondary cardiovascular events (dulaglutide, liraglutide)
slow the progression of kidney disease (dulaglutide, liraglutide)

Disadvantages

avoid in patients with:

> acute pancreatitis or history of pancreatitis

> family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2 (liraglutide)

can cause gastrointestinal adverse effects (often transient)

careful in kidney impairment

Question 13

Q

Advantages and disadvantages of using SGLT2 inhibitors (dapagliflozin, empagliflozin, ertugliflozin) for type 2 diabetes?

Answer

A

Advantages

hypoglycaemia unlikely [NB3]
cause weight loss
reduce rate of secondary cardiovascular events, including overall mortality
reduce blood pressure
slow the progression of kidney disease

Disadvantages

avoid in patients:

> periprocedurally

> who are fasting

> who are on very low-carbohydrate diets

can cause:

> genitourinary infection

> reversible increase in creatinine

> volume depletion (rare)

> diabetic ketoacidosis (uncommon), which may occur without hyperglycaemia

reduced glycaemic efficacy with kidney impairment

Question 14

Q

Advantages and disadvantages of using insulin for type 2 diabetes?

Answer

A

Advantages

nearly universal response
theoretically unlimited efficacy
allows for flexible dosage regimen

Disadvantages

can cause

signifcant hypoglycaemia
weight gain

Question 15

Q

What is first line drug for type 2 diabetes?

Answer

A

Metformin, continued lifelong unless contraindicated

If glycaemic targets not achieved with lifestyle modification and maximum toleraterd dose of metofrmin, try alternative therapy.

Question 16

Q

How to monitor glycaemic control?

Answer

A

Monitor response to a change in treatment by measuring HbA1c every 3 months

Also, assess and manage other comorbidities or treatments impacting glycaemic control, check patient understanding and self-management, and reinforce the need to continue lifestyle modification.

Question 17

Q

At diagnosis of type 2 diabetes, lfestyle modification (dietary intake and physical activity) and continue lifelong, what is the stepwise apporach if HbA1c less than 69 mmol/mol (8.5%)

Answer

A

Start metformin immediately

OR

start metformin after 2 to 3 months if glycaemic target not achieved with lifestyle modification alone

> if glycaemic target not achieved after 3 months add a second drug

Second drug: sulfonylurea, DPP-4 inhibitor or SGLT2 ihibitor
Or use a GLP-1 recepotr agonist, insulin, acarbose or thiazolidenidone
If history of CVD or significant risk factors for CVD –> consider an SGLT2 inhibitor or GLP-1 receptor agonist.

> if glycaemic target not achieved after 3 months, add or substitute a third drug

sulfonylurea, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist or insulin

> if glycaemic target not achieved after 3 months, escalate treatment

if using triple drug therapy, change one or more of the oral drugs to GLP-1 receptor agonist or insulin
If using regimen including GLP1 receptor agonist

–> change to a basal or mixed insulin regimen

–> add a basal or mixed insulin regimen

If using a regimen including basal insulin

–> add a SGLT2 inibitor or GLP-1 receptor agonist

THE ULTIMATE REQUIREMENT IS LIKELY TO BE EITHER A MIXED INSULIN REGIMEN (GIVEN AT LEAST TWICE DAILY) OR A BASAL PLUS INSULIN REGIMEN COMBINED WITH METFORMIN AND/OR AN SGLT2 INHIBITOR, DPP-4 INHIBITOR OR GLP-1 RECEPTOR AGONIST

Question 18

Q

At diagnosis of type 2 diabetes, lfestyle modification (dietary intake and physical activity) and continue lifelong, what is the stepwise approach if HbA1c 69 mmol/mol (8.5%) or more?

Answer

A

Start metformin + a second drug immediately

Second drug: sulfonylurea, DPP-4 inhibitor or SGLT2 ihibitor

Or use a GLP-1 recepotr agonist, insulin, acarbose or thiazolidenidone
If history of CVD or significant risk factors for CVD –> consider an SGLT2 inhibitor or GLP-1 receptor agonist.

> if glycaemic target not achieved after 3 months, add or substitute a third drug

sulfonylurea, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist or insulin

> if glycaemic target not achieved after 3 months, escalate treatment

if using triple drug therapy, change one or more of the oral drugs to GLP-1 receptor agonist or insulin
If using regimen including GLP1 receptor agonist

–> change to a basal or mixed insulin regimen

–> add a basal or mixed insulin regimen

If using a regimen including basal insulin

–> add a SGLT2 inibitor or GLP-1 receptor agonist

THE ULTIMATE REQUIREMENT IS LIKELY TO BE EITHER A MIXED INSULIN REGIMEN (GIVEN AT LEAST TWICE DAILY) OR A BASAL PLUS INSULIN REGIMEN COMBINED WITH METFORMIN AND/OR AN SGLT2 INHIBITOR, DPP-4 INHIBITOR OR GLP-1 RECEPTOR AGONIST

Question 19

Q

What to do if changing from immediate release to modified release metformin? How to limit GI side effects of metformin?

> metformin MOA: reduces glucose production in the liver and reduces insulin requirements

Answer

A

Start with a dose of modified release equivalent to the total daily immediate release dose.

Gastrointestinal effects can be minimised by starting treatment with metformin modified-release formulation at a low dose, titrating gradually, and taking with food.

Question 20

Q

Which sulfonylureas to avoid in older patients? Which ones to use?

> sulfonylurea MOA: increase insulin secretion via the pancreatic sulfonylurea receptor

Answer

A

Avoid longer-acting sulfonylureas (glibenclamide, glimepiride) in older patients because they increase the risk of severe prolonged hypoglycaemia

> . Shorter-acting gliclazide and glipizide are converted to inactive metabolites by the liver and are preferred

Question 21

Q

Adding a DPP4 inhibitor (sitagliptin….) to a GLP1 receptor agonist doest what?

DPP4 inhibitor MOA: increase the endogenous concentration of incretin hormones (GLP1) that are produced in the gut following indigestion of food –> stimulation of insulin release and reduction in glucagon sceretion

Answer

A

Nothing mate

does not improve glycaemic control compared to using the GLP-1 receptor agonist alone as both are incretin mimetics

Question 22

Q

What to tell patients for GLP1 agonists (exenatide, dulaglutide)?

Answer

A

They increase insulin secretion and reduce glucagon secretion –> delay gastric emptying and increase satiety, causing weight loss

> more effective than DPP4 for lowering blood glucose concentrations

Because they delay gastric emptying, GLP-1 receptor agonists often cause significant gastrointestinal adverse effects. Warn patients to expect to feel nauseous, but reassure them that this effect is transient and improves as treatment continues
Consider dulaglutide or liraglutide for patients with type 2 diabetes and established cardiovascular disease because they reduce the risk of myocardial infarction, stroke and cardiovascular death in this patient grou

Question 23

Q

When is SGLT2 inhbitors (dapa, empagliflozin…) not apporpriate?

Answer

A

not effective for glycaemic control in patients with impaired kidney function –> act on the proximal convoluted tubule to inhibit reabsorption of glucose

Question 24

Q

When to have caution for SGLT2 inhibitors?

Answer

A

SGLT2 inhibitors are also weak diuretics, contributing to blood pressure reduction and a sustained increase in haematocrit. Use a loop diuretic with caution in patients taking an SGLT2 inhibitor because of additive effects of dehydration and diuresis.

Question 25

Q

Which SGLT2 inhibitor best for cardiovascular disease?

Answer

A

empagliflozin in patients with type 2 diabetes and established cardiovascular disease, or with two or more cardiovascular disease risk factors; it improves overall survival and lowers the rates of death from cardiovascular causes and the incidence of hospitalisation for heart failure in this populatio

Question 26

Q

types of insulin to add to a patient’s usual antihyperglycaemic drugs?

Answer

A

Basal insulin
a once-daily fixed-dose combination (biphasic premixed or coformulation) insulin
a twice-daily fixed-dose combination (biphasic premixed or coformulation) insulin

For most patients with type 2 diabetes, start insulin treatment with once-daily basal insulin.

However, in patients with a high glycated haemoglobin (HbA1c) (eg more than 69 mmol/mol [8.5%]), and when a target HbA1c of less than 53 mmol/mol (7%) is the aim, basal insulin alone may not achieve the target; a more intensive regimen such as a ‘basal plus’ or mixed insulin regimen may be required.

Question 27

Q

What antidiabetic medications are necessary for self-monitoring of blood glucose concnetrations?

Answer

A

Self-monitoring blood glucose concentrations (SMBG) is a useful and necessary tool for all patients with type 2 diabetes using insulin and sulfonylureas, to:

self-adjust diet, exercise or insulin doses
identify and guide treatment of hyperglycaemia and hypoglycaemia
assist the multidisciplinary diabetes team in modifying diabetes management
reinforce the merits of optimal dietary intake and physical activity
monitor blood glucose concentrations during illness or around other times of change (eg lifestyle change).

BECAUSE OF RISK OF HYPOLGYCAEMIA

Question 28

Q

Depression itself is associated with hyperglycaemia and a greater risk for diabetic complications. Treating concurrent depression can help improve glycaemic control. True or False.

Question 29

Q

Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 2 diabetes?

Answer

A

Glycaemic control (assess every 3 to 4 months)

HbA1c
Episodes of hyoglycaemia
management goals
dietary intake
physcial activity and exercise
self management education
medications

Physical signs (every3 to 4 months)

Weight, with or without waist circumference

Blood pressure (every 3 to 4 mon ths)

Lipid levels (at least every 12 months and more frequently if not at target)

Eyes (retinopathy)

Kidney disease (at least every 12 months)

Nueropathy (foot exmination and peripheral neuropathy at least every 12 months)

Pyschosocial (diabetes distress every 3 to 4 months)

Other aspects (tobacco smoking, contraception and prepregnancy panning, immunisations, dental care) –> assess every 12 months and more frequently if circumstancesa change

Question 30

Q

Alcohol inhibits glucose production in the liver and increases the risk of hypoglycaemia. Patients with type 2 diabetes who are using insulin and/or a sulfonylurea are at increased risk of hypoglycaemia

true or false

Question 31

Q

Procedure for perfoming an oral glucose tolerance test

Answer

A

An oral glucose tolerance test (75 g glucose load) can be used to diagnose diabetes in asymptomatic patients, particularly if the fasting blood glucose concentration is elevated, but does not reach the threshold for diabetes.

> see the attached image

Normal < 7.7mmol/L
Intermediate Hyperglycaemia: 7.8-11 mmol/L
Diabetes ≥ 11.1 mmol/L

Question 32

Q

Beta blockers and diabetes, what is the issue?

Answer

A

Beta-blockers may mask important signs of acute hypoglycaemia (eg tachycardia, tremor). They may also increase the incidence and severity of hypoglycaemia but data are conflicting.

Beta1-selective beta-blockers (eg metoprolol) and beta-blockers with alpha1-blocking activity (eg carvedilol) are preferred because they are safe and effective in patients with type 2 diabetes. Due to their morbidity and mortality benefits, they should be considered in diabetic patients with heart failure and/or ACS.

Question 33

Q

What are some medications that can reduce blood glucose?

Answer

A

Alcohol

Beta-blockers

Sulphonamides

Monoamine oxidase inhibitors

Salicylates - in high doses

Gemfibrozil

Question 34

Q

What are some medications that can increase blood glucose?

Answer

A

Adrenergic compounds

Oestrogens

Glucocorticoids

Thiazide diuretics (high dose)

Phenytoin

Question 35

Q

What is the most common cause of T1DM? What are the S and S?

Answer

A

10% of DM

Most common cause

T cell-mediated destruction of pancreatic B-cells = absolute insulin deficiency

No interventions demonstrated to delay or prevent onset

Rapid onset of S and S

Polyuria, polydipsia, polyphagia
Fatigue, weight loss, irritability

> requires insulin treatment

Question 36

Q

to wrap up

Answer

A

Involving the multidisciplinary diabetes team can assist to empower the patient and give them confidence about managing their diabetes. Using principles of motivational interviewing may also assist patient empowerment. Education on diabetes self-management should be started as soon as possible after diagnosis.

Psychosocial wellbeing assists in the effectiveness of diabetes self-management. Consideration of psychosocial wellbeing should be included in education about self-management. Psychological disorders and diabetes commonly occur concurrently. Assess patients for diabetes distress or other mental health conditions so appropriate supports and treatment can be started.

Question 37

Q

VTE and PE from this card onwards

Question 38

Q

Define;

A) PE (Pulmonary embolism):

B) DVT (Deep vein thrombosis):

collectively known as venous thromboembolism

Answer

A

A)

A pulmonary embolism (PE) occurs when a clot breaks loose and travels through the bloodstream to the lungs

B)

Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body

> hip

> leg

> calf

Question 39

Q

Majority of thrombus forms in the deep veins of the legs, thighs, or pelvis

true or false

Question 40

Q

Anticoagulant therapy is indicated in most cases of VTE because it is highly effective in preventing thrombus extension or recurrence.

Tue or false

Answer

A

True

> Most deaths from PE occur either before the pulmonary embolus has been diagnosed or before intervention has been started. These consequences of VTE formation highlight the importance of VTE prophylaxis in any situation predisposing to VTE

Question 41

Q

For complications of DVT

A) How often does recurrent DVT occur within 10 years?

B) What is post-thrombotic syndrome? What are the signs and symptoms associated with it?

C) How is PE related to DVT?

Answer

A

A)

30% within 10 years

B)

Long term complication caused by damage to the venous valves
Develop in 25-50% of patients
S and S: chronic lower extremity swelling, pain, tenderness, skin discoloration, ulceration

C)

Approx 70% of patients with PE have concomitant DVT
Silent PE present in at least 1/3 patients with symptomatic DVT

Question 42

Q

What are the signs and symptoms of PE? Divide answer into common and less common.

Answer

A

Common

Shortness of breath –> sudden onset or evolving over days to weeks
Palpitations (tachycardia)
Dull central chest pain (may also be substernal or compressing)

Less common

Haemoptysis
Syncope or dizziness (with massive PE)
Pleural rub due to inflammation
Fever (with co-existing infection and/or pulmonary infarction)

Question 43

Q

What are the THREE risk factors for VTE? (Virchow’s triad)

Answer

A

Endothelial/ vessel wall injury

Altered blood flow/stasis

Blood hypercoagulability

Question 44

Q

What does the term distal DVT mean?

Answer

A

Clot below the knee

Question 45

Q

For Pharmacological Prevention of VTE;

What are the 5 types of drugs used? Describe why they are used where appropriate?

Answer

A

Low molecular weight heparins (LMWHs) –> dalteparin, enoxaparin, nadroparin
Unfractionated heparin (UFG) –> preferred for patients with severe renal impairment or when rapid reversal of anticoagulation is necessary
DOACs (apixaban, dabigatran, rivaroxaban) for VTE prophylaxis following hip or knee replacement
Fondaparinux (Factor Xa inhibitor) –> alternative for patients undergoing major orthopedic surgery of lower limbs or abdominal surgery
Danaproid/ (fondaparinux) for patients with known or suspected HIT (heparin-induced thrombocytopenia)

Question 46

Q

For prevention of VTE, what to use for

A) Total hip replacement, hip fracture surgery

B) Total knee replacement

C) Major general surgery

Answer

A

A)

LMWH or fondaprinux (or DOAC for total hip replacement) –> contiue for 28-35 days

B)

LMWH or fondaparinux or DOAC –> continue for 10-14 days

C)

LMWH or UFH –> continue for upto 1 week or until fully mobile

Question 47

Q

For prevention of VTE for non surgical patients (e.g. heart failure, ischaemic stroke with immobility, active cancer), what to use? LMWH or UFH better? LMWHs are preferred over UFH because they are more effective, safer, and heparin-induced thrombocytopenia occurs less commonly with LMWH.

Answer

A

ischaemic stroke with immobility: Depending on degree of immobility, consider LMWH or UFH [NB2]; continue until the acute medical condition is stable

heart failure, active cancer: LMWH or UFH [NB2]; continue until resolution of acute medical illness, mobilisation or hospital discharge

LMWHs are preferred over UFH because they are more effective, safer, and heparin-induced thrombocytopenia occurs less commonly with LMWH.

Question 48

Q

When do you give apixaban, dabigatran, ab rivaroxaban for VTE prophylaxis?

Answer

A

Apixaban, dabigatran and rivaroxaban are effective for VTE prophylaxis following surgery for hip or knee replacement, and are given orally

Question 49

Q

For Mechanical Prophylaxis;

A) Is it effective alone?

B) When is it preferred over pharmacological prophylaxis?

C) Which patients to avoid using in?

D) What are the methods? Provide THREE answers.

Answer

A

A)

YES, it is effect alone
Additive effect in combination with pharmacological prophylaxis

B)

When risk of local bleeding is unacceptable (after neurosurgery, ophthalmic surgery

C)

Avoid in patients at risk of ischaemic skin necrosis (e.g. severe peripheral arterial disease or peripheral neuropathy)

D)

Graduated compression stockings providing 16-20 mmHg pressure at the ankle (antiembolism stockings)

> must be profesionally fitted

> Surgical patients: fitted and worn preoperatively, continuing postoperatively until the patient is fully mobile

Intermittent pneumatic compression devices
Pneumatic foot compression or pump

Question 50

Q

Long-distance travel refers to travel by air, road or rail for more than 4 hours. However, the association between travel and venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) is strongest for air travel lasting longer than 8 to 10 hours, particularly if the traveller has other risk factors for developing VTE. The risk of VTE is increased 2- to 3-fold with long-distance travel, with risk increasing as duration of travel increases, and persisting for up to 8 weeks after travelling. However, absolute risk of developing travel-related VTE is very low.

True or false

Question 51

Q

What do for long distance travel (non-pharm)?

Answer

A

Advise all long-distance travellers to remain ambulant if possible before, during and after travelling. During travel, leg exercises should be performed while seated

Question 52

Q

Despite lack of evidence to support use of an anticoagulant, pharmacological prophylaxis may be considered. Suitable regimens for travel-related VTE prophylaxis are?

Answer

A

apixaban 2.5mg orally 12 hourly
rivaroxaban 10mg orally 24 hourly
enoxaparin 40mg subcut, immediately before departure and 24 hourly

Question 53

Q

What to use to treat venous thromboembolism during pregnancy and the postpartum period, including for breastfeeding women?

Answer

A

Low molecular weight heparin (LMWH) (eg dalteparin, enoxaparin) is safe and effective

Question 54

Q

Treatment of VTE

A) When is anticoagulation. required and when is it not?

B) What type of anticoagulation is preferred? Give 3 examples of these type of drugs.

Answer

A

A)

Mainstay of treatment

Recommended in all cases of proximal DVT and PE
May not be required in distal DVT (DVT below the knee)

B)

DOACs preferred (dose in lecture notes)

Apixaban
Rivaroxaban
Dabigatran –> 5 days of LMWH or UFH first –> stop and change to dabigatran 150mg orally bd

Oral factor Xa inhibitors (eg apixaban, rivaroxaban) are preferred to dabigatran or warfarin to treat proximal DVT and PE because they do not require parenteral anticoagulation for initiation. Apixaban and rivaroxaban do not require routine anticoagulation monitoring;

Question 55

Q

What to do if using warfarin to treat VTE?

Answer

A

Warfarin –> start LMWH or UFH concurrently, and continue for 5 days or until INR > 2 on two occasions.

Target INR 2-3

Question 56

Q

When are parenteral anticoagulants used to treat VTE?

Answer

A

For initial treatment with warfarin and dabigatran, and for VTE during pregnancy and cancer-associated VTE.

dalteparin

enoxaparin

nadroparin

UFH for patients with severe renal impairment or high bleeding risk

fondaparinux –> for patients with HIT

Question 57

Q

The duration of anticoagulant therapy for DVT and PE is influenced by the presence or absence of provoking factors, the patient’s risk factors for recurrence of VTE or bleeding, and patient preference. Examples of major provoking factors include major surgery, hospitalisation with immobilisation, estrogen therapy, and pregnancy and the postpartum period.

True or False?

Question 58

Q

For patients with proximal DVT or PE caused by a major provoking factor that is no longer present, treat with anticoagulant therapy for?

Question 59

Q

For patients with unprovoked distal DVT, proximal DVT or PE, there is good evidence that less than 3 months of anticoagulant therapy is associated with a higher subsequent VTE recurrence rate than 3 months of therapy. Although continuing therapy for longer than 3 months reduces the risk of VTE recurrence during therapy, it does not further reduce the recurrence rate after anticoagulant therapy has stopped.

True or false

Question 60

Q

What are some common factors that predict the recurrence of a venous thromboembolism?

Answer

A

Prior VTE
Active cancer
Unprovoked VTE –> no provoking factor in the 3 months before the development of VTE (surgery, medical illness with reduced mobility, trauma, estrogen therapy)
Proximal DVT or PE (rather than distal DVT)
Male sex
Common thrombophilias = antithrombin deficiency, protein C or S deficiency

Question 61

Q

Deep vein thrombosis (DVT) is associated with the development of post-thrombotic syndrome, which is characterised by chronic dependent swelling and pain, discomfort on walking, and skin discolouration. Symptom severity may vary over time and the most severe manifestation is a lower-leg venous ulcer.

What is a potential treatment option?

Answer

A

Wearing graduated compression stockings may reduce the risk of developing post-thrombotic syndrome for a patient with a venous thromboembolism of the lower limbs. If post-thrombotic syndrome develops, the stockings reduce the patient’s symptoms.

> To be effective, graduated compression stockings should provide 30 to 40 mmHg pressure at the ankle and extend to just below the knee. An experienced professional should fit the stockings because not all types of support stockings provide sufficient pressure.

Question 62

Q

Angina from this card onwards…

Question 63

Q

For Angina;

A) What are the goals?

B) Aims of maintenance therapy? Provide FOUR aims.

C) Management? Provide FOUR ways.

D) How is it relieved?

Answer

A

A)

Symptom management

Reduce risk of MI

B)

To prevent symptoms

Increase effort tolerance

Prevent the development of ACS e.g. MI

Prevent arrythmia and death

C)

Medication

Therapeutic treatment of risk factors

Patient counselling essential

Revascularisation (PCI, CABG), if Sx not satisfactorily controlled by medical treatment

D)

Generally relieved by GTN within 1-5 minutes

Question 64

Q

How to improve symptoms of stable angina

Answer

A

Short-acting GTN

Then try beta blocker (titrate to full dose)

No or little effect, try: CCB, long acting nitrate, nicorandil, ivabradine, perhexiline

Answer 56

A

Give clopidrogrel + low dose aspirin

Aspirin duration: life long/indefinitely
Clopidogrel duration: depends on type of stent used, until a layer of endothelium covers stent (6 weeks - 12 months)

Can also consider other antiplatelet agents

> Revascularisation (PCI or CABG) –> patients with a coronary stent in place require antiplatelet medication to prevent stent thrombosis

Answer 57

A

Cardiac rehabilitation
Essential appropriate use of medication
Promote regular moderate exercise
Avoid heavy sudden and unaccustomed exertion
Avoid acute emotional stress where possible

Answer 58

A

Angina is defined as retrosternal chest discomfort (pain or tightness) that lasts 10 minutes or less and subsides promptly with rest. It occurs when myocardial oxygen demand exceeds supply, which is usually restricted by atherosclerotic obstruction. Angina is commonly triggered by physical activity or emotional stress.

Answer 59

A

high BP
smoking
dyslipidaemia
exercise and healthy eating
excess body weight
diabetes

> Screen patients for depression and treat if present.

Answer 60

A

Give all patients a written chest pain action plan [Note 2].

Advise patients to stop activities as soon as angina pain is felt. To shorten an episode, use:

glyceryl trinitrate spray 400 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses if tolerated
glyceryl trinitrate tablet 300 to 600 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses if tolerated.

> A patient with an initial episode of angina should use the lower dose of glyceryl trinitrate tablet (300 micrograms); a patient with established angina should use the higher dose (600 micrograms).

> Advise the patient that if pain persists for more than 10 minutes despite taking two doses of glyceryl trinitrate, they should take a third dose and call an ambulance for transfer to the nearest hospital.

Answer 61

A

Instruct all patients on the use of glyceryl trinitrate and warn of possible adverse effects. Before taking glyceryl trinitrate, they should sit down, to avoid orthostatic hypotension. Consider giving a single trial dose of glyceryl trinitrate under supervision when the patient is asymptomatic so that they will recognise its effect.

Answer 62

A

Treatment to prevent angina aims to reduce myocardial oxygen demand, and increase oxygen supply and exercise tolerance.

> Optimal treatment of underlying coronary artery disease adds to the effectiveness of antianginal therapies; in particular, treatment with aspirin and a statin and treatment of blood pressure

Answer 63

A

Treat angina with a combination of two antianginal therapies from different classes (beta blockers, dihydropyridine calcium channel blockers or long-acting nitrates)

> If a beta blocker is contraindicated, it may be replaced by a nondihydropyridine calcium channel blocker.

> The choice of drug depends on the patient’s comorbidities and the adverse effects of the drug.

Answer 64

A

For a patient with stable angina, beta blockers are usually first-line therapy to prevent episodes of angina, unless contraindicated.

> atenolol 25mg orally, daily, increasing if required upto 100mg daily

OR

> metoprolol tartrate 25mg orally, twice daily, increasing if required upto 100mg twice daily

(For patients with left ventricular dysfunction (left ventricular ejection fraction less than 40%), use one of the beta blockers recommended for heart failure (carvedilol, bisoprolol, nebivolol or metoprolol succinate) instead of atenolol or metoprolol tartrate)

Answer 65

A

Nondihydropyridine calcium channel blockers (diltiazem, verapamil) reduce heart rate and can be used as an alternative if beta-blocker therapy is contraindicated or not tolerated

> Do not use diltiazem or verapamil in combination with a beta blocker because of the risk of causing severe bradycardia and heart failure

To prevent symptoms of angina

diltiazem modified-release 180 mg orally, daily, increasing if required up to 360 mg daily
verapamil modified-release 120 mg orally, daily, increasing if required up to 480 mg daily.

Answer 66

A

Amlodipine 2.5mg orally daily, increase upto 10mg daily

Nifedipine MR 30mg orally, daily, increasing if required upto 60mg daily

Dihydropyridine calcium channel blockers can be used alone for angina, but caution is needed because of the possibility of increased sympathetic tone and heart rate
Do not combine a dihydropyridine calcium channel blocker with a nondihydropyridine calcium channel blocker.

Answer 67

A

Added either to a beta blocker, or to a nondihydropyridine calcium channel blocker (diltiazem, verapamil)

> Tolerance to all forms of nitrate therapy develops rapidly. To avoid this complication, allow a nitrate-free period (ie modified-release isosorbide mononitrate taken once daily, glyceryl trinitrate patch worn for less than 14 hours per day).

glyceryl trinitrate 5 mg transdermally, once daily, increasing if required up to 15 mg once daily. Apply for a maximum of 14 hours in a 24-hour period
isosorbide mononitrate modified-release 30 mg orally, daily, increasing if required up to 120 mg daily.

Answer 68

A

Nicorandil is an option for patients with refractory angina despite optimal therapy with the preceding drugs. Add to beta-blocker, diltiazem or verapamil therapy:

> nicorandil 5 mg orally, twice daily, increasing after 1 week to 10 mg twice daily. If required, increase to 20 mg twice daily.

Answer 69

A

A)

Symptom management and reducing morbidity/mortality

B)

Same as STEMI –> may undergo PCI (percutaneous coronary intervention)
Will not get thrombolytics /fibrinolytic –> this type of clot is different in UA and NSTEMI, and does not respond to fibrinolytic as well

C)

Antiplatelet (1 month to 12 months) and aspirin
Consideration of CABG, PCI
SAAB GT

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Clinical Case Studies Week 1 (Diabetes, VTE & PE, Angina) Flashcards

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