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

Question 1

What should management of type 2 diabetes always include?

Answer 1

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

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

Answer 2

53 mmol/mol (7%) or less

Question 3

How to diagnose diabetes? Provide FOUR different ways.

Answer 3

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

General blood glucose concentration targets

A) fasting and preprandial

B) postprandial

Answer 4

A)

• 4 to 8 mmol/L

B)

• Less than 10 mmol/L, aiming to avoid hypoglycaemia

Question 5

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

Answer 5

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

Non drug management for type 2 diabetes?

Answer 6

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

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

Answer 7

Lifestyle modification (dietary intake and physical activity)

Question 8

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

Answer 8

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

Advantages and disadvantages of using metformin for type 2 diabetes?

Answer 9

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

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

Answer 10

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

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

Answer 11

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

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

Answer 12

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

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

Answer 13

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

Advantages and disadvantages of using insulin for type 2 diabetes?

Answer 14

Advantages

• nearly universal response
• theoretically unlimited efficacy
• allows for flexible dosage regimen

Disadvantages

​can cause

• signifcant hypoglycaemia
• weight gain

Question 15

What is first line drug for type 2 diabetes?

Answer 15

Metformin, continued lifelong unless contraindicated

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

Question 16

How to monitor glycaemic control?

Answer 16

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

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 17

• 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

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 18

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

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 19

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

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

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

Answer 20

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

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 21

Nothing mate

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

Question 22

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

Answer 22

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

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

Answer 23

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

Question 24

When to have caution for SGLT2 inhibitors?

Answer 24

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

Which SGLT2 inhibitor best for cardiovascular disease?

Answer 25

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

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

Answer 26

* 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

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

Answer 27

**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

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

Answer 28

True :(

Question 29

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

Answer 29

**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

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

Answer 30

true

Question 31

Procedure for perfoming an oral glucose tolerance test

Answer 31

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

Beta blockers and diabetes, what is the issue?

Answer 32

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

What are some medications that can reduce blood glucose?

Answer 33

Alcohol Beta-blockers Sulphonamides Monoamine oxidase inhibitors Salicylates - in high doses Gemfibrozil

Question 34

What are some medications that can increase blood glucose?

Answer 34

Adrenergic compounds Oestrogens Glucocorticoids Thiazide diuretics (high dose) Phenytoin

Question 35

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

Answer 35

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

to wrap up

Answer 36

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

VTE and PE from this card onwards

Question 38

Define; A) PE (Pulmonary embolism): B) DVT (Deep vein thrombosis): collectively known as venous thromboembolism

Answer 38

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

Majority of thrombus forms in the deep veins of the legs, thighs, or pelvis ## Footnote **true or false**

Answer 39

**true**

Question 40

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

Answer 40

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

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 41

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

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

Answer 42

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

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

Answer 43

Endothelial/ vessel wall injury Altered blood flow/stasis Blood hypercoagulability

Question 44

What does the term distal DVT mean?

Answer 44

Clot below the knee

Question 45

For Pharmacological Prevention of VTE; What are the 5 types of drugs used? Describe why they are used where appropriate?

Answer 45

1. Low molecular weight heparins (LMWHs) --\> dalteparin, enoxaparin, nadroparin 2. Unfractionated heparin (UFG) --\> preferred for patients with severe renal impairment or when rapid reversal of anticoagulation is necessary 3. DOACs (apixaban, dabigatran, rivaroxaban) for VTE prophylaxis following hip or knee replacement 4. Fondaparinux (Factor Xa inhibitor) --\> alternative for patients undergoing major orthopedic surgery of lower limbs or abdominal surgery 5. Danaproid/ (fondaparinux) for patients with known or suspected HIT (heparin-induced thrombocytopenia)

Question 46

For prevention of VTE, what to use for A) Total hip replacement, hip fracture surgery B) Total knee replacement C) Major general surgery

Answer 46

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

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 47

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

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

Answer 48

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

Question 49

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 49

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

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

Answer 50

True

Question 51

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

Answer 51

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

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

Answer 52

1. apixaban 2.5mg orally 12 hourly 2. rivaroxaban 10mg orally 24 hourly 3. enoxaparin 40mg subcut, immediately before departure and 24 hourly

Question 53

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

Answer 53

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

Question 54

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 54

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

What to do if using warfarin to treat VTE?

Answer 55

Warfarin --\> start LMWH or UFH concurrently, and continue for 5 days or until INR \> 2 on two occasions. Target INR 2-3

Question 56

When are parenteral anticoagulants used to treat VTE?

Answer 56

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

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?

Answer 57

True

Question 58

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

Answer 58

3 months

Question 59

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

Answer 59

True

Question 60

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

Answer 60

* 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

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 61

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

Angina from this card onwards...

Question 63

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 63

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

How to improve symptoms of stable angina

Answer 64

Short-acting GTN Then try beta blocker (titrate to full dose) No or little effect, try: CCB, long acting nitrate, nicorandil, ivabradine, perhexiline

Question 65

What is the process for medications given to a patient who has stable angina? Why would they need antiplatelet medication?

Answer 65

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

Question 66

FIVE things to counsel patients on for stable angina?

Answer 66

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

Question 67

What is angina

Answer 67

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.

Question 68

Treatment of stable angina aims to relieve symptoms, which involves treatment of episodes of angina and treatment to prevent angina. It also aims to prevent cardiovascular events by ensuring optimal management of underlying coronary artery disease and modifiable risk factors, including?

Answer 68

* high BP * smoking * dyslipidaemia * exercise and healthy eating * excess body weight * diabetes \> Screen patients for depression and treat if present.

Question 69

How to rteat episodes of angina, pharm and non-pharm advice pls kind sir

Answer 69

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.

Question 70

Before taking glyceryl trinitrate, what to do?

Answer 70

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.

Question 71

What does treatment to prevent angina aim to do?

Answer 71

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

Question 72

What drugs to use to prevent angina?

Answer 72

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.

Question 73

Short-acting glyceryl trinitrate can be taken before exercise that is likely to provoke angina; see Treatment of episodes of angina for dosage. Beta blockers enhance exercise tolerance by reducing myocardial oxygen demand. **true or false**

Answer 73

true

Question 74

For patients with stable angina, what is first line therapy?

Answer 74

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)

Question 75

What to use if beta blocker contraindicated or not tolerated?

Answer 75

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.

Question 76

A dihydropyridine calcium channel blocker can be added to a beta blocker if angina persists. Which one to add?

Answer 76

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.

Question 77

A long-acting nitrate (transdermal glyceryl trinitrate, modified-release isosorbide mononitrate can be added to what?

Answer 77

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.

Question 78

If a combination of two of the recommended antianginal drugs (beta blockers, calcium channel blockers or long-acting nitrates) does not provide sufficient symptomatic relief, other drugs can be added, what drug to use?

Answer 78

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.

Question 79

For Unstable Angina and NSTEMI A) What are the goals? B) What is the treatment? Why is there no need for thrombolytics? C) What is long term treatment

Answer 79

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