Clinical Case Studies Week 1 (Diabetes, VTE & PE, Angina) Flashcards
What should management of type 2 diabetes always include?
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).
General target of HbA1c levels? Also what is the level for diabetes of longer duration or with established cardiovascular disease?
53 mmol/mol (7%) or less
How to diagnose diabetes? Provide FOUR different ways.
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
General blood glucose concentration targets
A) fasting and preprandial
B) postprandial
A)
- 4 to 8 mmol/L
B)
- Less than 10 mmol/L, aiming to avoid hypoglycaemia
Optimising antihyperglycaemic treatment is important to achieve and maintain glycaemic targets, why? What are the complications of diabetes?
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
Non drug management for type 2 diabetes?
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
What is the cornerstone of management of patients with type 2 diabetes?
Lifestyle modification (dietary intake and physical activity)
What are some factors influencing the choice of antihyperglycaemic drugs used in type 2 diabetes?
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
Advantages and disadvantages of using metformin for type 2 diabetes?
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
Advantages and disadvantages of using sulfonylureas (gliclazide, glibenclamide) for type 2 diabetes?
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)
Advantages and disadvantages of using DDP-4 inhibitors (linagliptin, saxagliptin, sitagliptin) for type 2 diabetes?
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)
Advantages and disadvantages of using GLP-1 receptor agonists (dulaglutide, exenatide, liraglutide) for type 2 diabetes?
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
Advantages and disadvantages of using SGLT2 inhibitors (dapagliflozin, empagliflozin, ertugliflozin) for type 2 diabetes?
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
Advantages and disadvantages of using insulin for type 2 diabetes?
Advantages
- nearly universal response
- theoretically unlimited efficacy
- allows for flexible dosage regimen
Disadvantages
can cause
- signifcant hypoglycaemia
- weight gain
What is first line drug for type 2 diabetes?
Metformin, continued lifelong unless contraindicated
- If glycaemic targets not achieved with lifestyle modification and maximum toleraterd dose of metofrmin, try alternative therapy.
How to monitor glycaemic control?
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.
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%)
- 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
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?
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
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
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.
Which sulfonylureas to avoid in older patients? Which ones to use?
> sulfonylurea MOA: increase insulin secretion via the pancreatic sulfonylurea receptor
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
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
Nothing mate
- does not improve glycaemic control compared to using the GLP-1 receptor agonist alone as both are incretin mimetics
What to tell patients for GLP1 agonists (exenatide, dulaglutide)?
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
When is SGLT2 inhbitors (dapa, empagliflozin…) not apporpriate?
not effective for glycaemic control in patients with impaired kidney function –> act on the proximal convoluted tubule to inhibit reabsorption of glucose
When to have caution for SGLT2 inhibitors?
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.
Which SGLT2 inhibitor best for cardiovascular disease?
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
types of insulin to add to a patient’s usual antihyperglycaemic drugs?
- 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.
What antidiabetic medications are necessary for self-monitoring of blood glucose concnetrations?
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
Depression itself is associated with hyperglycaemia and a greater risk for diabetic complications. Treating concurrent depression can help improve glycaemic control. True or False.
True :(
Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 2 diabetes?
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
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
true
Procedure for perfoming an oral glucose tolerance test
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
Beta blockers and diabetes, what is the issue?
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.
What are some medications that can reduce blood glucose?
Alcohol
Beta-blockers
Sulphonamides
Monoamine oxidase inhibitors
Salicylates - in high doses
Gemfibrozil
What are some medications that can increase blood glucose?
Adrenergic compounds
Oestrogens
Glucocorticoids
Thiazide diuretics (high dose)
Phenytoin
What is the most common cause of T1DM? What are the S and S?
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
to wrap up
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.
VTE and PE from this card onwards
Define;
A) PE (Pulmonary embolism):
B) DVT (Deep vein thrombosis):
collectively known as venous thromboembolism
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
Majority of thrombus forms in the deep veins of the legs, thighs, or pelvis
true or false
true
Anticoagulant therapy is indicated in most cases of VTE because it is highly effective in preventing thrombus extension or recurrence.
Tue or false
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
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?
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
What are the signs and symptoms of PE? Divide answer into common and less common.
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)
What are the THREE risk factors for VTE? (Virchow’s triad)
Endothelial/ vessel wall injury
Altered blood flow/stasis
Blood hypercoagulability
What does the term distal DVT mean?
Clot below the knee
For Pharmacological Prevention of VTE;
What are the 5 types of drugs used? Describe why they are used where appropriate?
- 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)
For prevention of VTE, what to use for
A) Total hip replacement, hip fracture surgery
B) Total knee replacement
C) Major general surgery
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
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.
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.
When do you give apixaban, dabigatran, ab rivaroxaban for VTE prophylaxis?
Apixaban, dabigatran and rivaroxaban are effective for VTE prophylaxis following surgery for hip or knee replacement, and are given orally
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.
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
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
True
What do for long distance travel (non-pharm)?
Advise all long-distance travellers to remain ambulant if possible before, during and after travelling. During travel, leg exercises should be performed while seated
Despite lack of evidence to support use of an anticoagulant, pharmacological prophylaxis may be considered. Suitable regimens for travel-related VTE prophylaxis are?
- apixaban 2.5mg orally 12 hourly
- rivaroxaban 10mg orally 24 hourly
- enoxaparin 40mg subcut, immediately before departure and 24 hourly
What to use to treat venous thromboembolism during pregnancy and the postpartum period, including for breastfeeding women?
Low molecular weight heparin (LMWH) (eg dalteparin, enoxaparin) is safe and effective
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.
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;
What to do if using warfarin to treat VTE?
Warfarin –> start LMWH or UFH concurrently, and continue for 5 days or until INR > 2 on two occasions.
Target INR 2-3
When are parenteral anticoagulants used to treat VTE?
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
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?
True
For patients with proximal DVT or PE caused by a major provoking factor that is no longer present, treat with anticoagulant therapy for?
3 months
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
True
What are some common factors that predict the recurrence of a venous thromboembolism?
- 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
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?
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.
Angina from this card onwards…
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?
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
How to improve symptoms of stable angina
Short-acting GTN
Then try beta blocker (titrate to full dose)
No or little effect, try: CCB, long acting nitrate, nicorandil, ivabradine, perhexiline
What is the process for medications given to a patient who has stable angina? Why would they need antiplatelet medication?
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
FIVE things to counsel patients on for stable angina?
- Cardiac rehabilitation
- Essential appropriate use of medication
- Promote regular moderate exercise
- Avoid heavy sudden and unaccustomed exertion
- Avoid acute emotional stress where possible
What is angina
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.
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?
- high BP
- smoking
- dyslipidaemia
- exercise and healthy eating
- excess body weight
- diabetes
> Screen patients for depression and treat if present.
How to rteat episodes of angina, pharm and non-pharm advice pls kind sir
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.
Before taking glyceryl trinitrate, what to do?
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.
What does treatment to prevent angina aim to do?
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
What drugs to use to prevent angina?
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.
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
true
For patients with stable angina, what is first line therapy?
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)
What to use if beta blocker contraindicated or not tolerated?
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.
A dihydropyridine calcium channel blocker can be added to a beta blocker if angina persists. Which one to add?
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.
A long-acting nitrate (transdermal glyceryl trinitrate, modified-release isosorbide mononitrate can be added to what?
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.
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?
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.
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
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
