Clinical Case Studies Week 1 (HTN,AF,HF) Flashcards
Reference range for potassium?
Reference Range: 3.5 – 5.0 mmol/L
Reference range for sodium
Reference range: 135 – 145 mmol/L
What mmol/L indicates a diabetic patient for 2 hour postprandial glucose challenge?
< 7.8 mmol/L indicate normal glucose
>7.8 and < 11.0 mmol/L indicate impaired glucose tolerance
> 11.1 mmol/L indicate diabetes is likely
Fasting blood glucose levels, what is the level for a diabetic patient?
A fasting blood sugar level less than (5.6 mmol/L) is normal.
A fasting blood sugar level from (5.6 to 6.9 mmol/L) is considered prediabetes.
If its higher than (7 mmol/L) or higher on two separate tests, you have diabetes
What is the glycosylated hemoglobin (HbA1c) test? What is the target?
Reflect average of your blood glucose level over the past 10–12 weeks (average life cycle for RBC)
Target: ≤53 mmol/mol or ≤7%
Total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides level target?
Total cholesterol < 5.5 mmol/L
LDL cholesterol <2 mmol/L
HDL cholesterol> 1.0 mmol/L
Triglycerides <1.7 mmol/L
Hypercholesterolaemia is defined as total cholesterol > 5.5 mmol/L
Hypertriglyceridaemia is defined as triglyceride level of > 1.7 mmol/L
What is the blood pressure readings for hypertension?
Systolic BP (pressure during ventricular contraction –> pumping) > 140 mmHg
Diastolic BP (pressure during ventricular filling / relaxation –>filling) > 90 mmHg
Adverse effects of ace inhibitors?
Hypotension (especially first dose effect)
Angioedema
Dry Cough (5-20% of patients)
Hyperkalaemia (especially in Type I Diabetes, and in patients with renal impairment).
Headache, facial flushing –> renal impairment, skin rashes, l
Dose of the following ace inhibitors for hypertension:
A) Ramipril
B) Perindopril
C) Lisinopril
D) Quinapril
E) Captopril
A)
Adult, oral 2.5 mg once daily, increase after 2–3 weeks to 5 mg if necessary. Maximum 10 mg daily in 1 or 2 doses.
B)
Perindopril arginine, adult, oral, start at 5 mg once daily. Maximum 10 mg once daily.
Perindopril erbumine: 4 to 8 mg orally, daily
C)
Adult, oral, initially 5–10 mg once daily; if necessary, increase at intervals of 2–4 weeks up to 20 mg once daily. Maximum 40 mg daily.
D)
Adult, oral, initially 5–10 mg once daily; increase at 4‑week intervals to 10–40 mg daily in 1 or 2 doses.
E)
Oral, initially 12.5 mg twice daily, increased at intervals of 2–4 weeks to 25–50 mg twice daily.
ARB and ACE inhibitors have the same drug interactions except for?
Lithium –> decreased excretion of Lithium and increased risk of lithium toxicity in Angiotensin Receptor Blockers (ARB)
Common and infrequent AE of ARB?
Common adverse effects
Dizziness, hyperkalaemia, headache.
dont use in pregnancy
Infrequent adverse effects
First dose orthostatic hypotension
Rash, diarrhoea, dyspepsia, muscle cramps
Insomnia, nasal congestion.
Doses of the following ARB (sartans) for hypertension:
A) Candersartan
B) Irbesartan
C) Olmesartan
D) Telmisartan
E) Valsartan
A)
Adult, oral, initially 8 mg once daily; usually 8–16 mg once daily; increase if necessary to 32 mg once daily.
B)
Adult, oral, usually 150 mg once daily; increase if necessary to 300 mg once daily.
C)
Oral, initially 20 mg once daily; after 8 weeks, increase if necessary to 40 mg once daily.
D)
Hypertension, oral, usually 40 mg once daily; increase if necessary to 80 mg once daily.
E)
Adult, oral, usually 80 mg once daily; increase if necessary to 160 mg once daily. Maximum 320 mg once daily
Common and infrequent/rare AE of CCB?
common AE
headache, flushing, peripheral oedema & palpitations (DHPs especially)
> gingival hyperplasia
> bradycardia (diltiazem, verapamil)
> constipation (verapamil)
infrequent/rare AE
Dyspepsia (DHPs especially)
AV block, hepatitis, development or worsening of heart failure (diltiazem, verapamil)
Diltiazem/verapamil with digoxin?
Increased digoxin concentration
Dihydropyridines/verapamil with hepatic enzyme inducers such as carbamazepine, phenobarbitone, phenytoin, rifampicin
Increase metabolism of dihyropyridines and verapamil –> reduce efficacy of dihydropyridines
Diltiazem with lithium
Increased risk of lithium neurotoxicity
What are the doses for the following CCB for hypertension:
A) Amlodipine
B) Nifedipine
C) Felodipine
D) Nimodipine
E) Diltiazem
F) Verapamil
A)
Adult, child >6 years: initially 2.5–5 mg once daily, increasing if necessary after at least 1–2 weeks to a maximum of 10 mg once daily.
B)
Controlled release tablet: initially 30 mg once daily, increase to a maximum of 90 mg once daily (angina) or 120 mg once daily (hypertension)
Conventional tablet: initially 10–20 mg twice daily, increase to 20–40 mg twice daily.
C)
Adult, oral, initially 5 mg once daily; maintenance dose 5–10 mg once daily; maximum dose 20 mg once daily
D)
Adult, oral 60 mg every 4 hours.
E)
Controlled release products, oral, initially 180–240 mg once daily; increase as required up to 360 mg once daily.
F)
Conventional tablet, adult, initially 80 mg 2 or 3 times daily; maintenance dose, 160 mg 2 or 3 times daily.
Controlled release tablet, adult, initially 120–180 mg once daily; usual maintenance dose 240 mg once daily; increase if necessary to a maximum of 240 mg twice daily. Give daily doses >240 mg in 2 doses.
What beta blockers to use in hypertension? When are they used? What is the dose used?
Not first line –> less effective than first line drugs in reducing risk of stroke. Useful in patients with both elevated BP and stable angina, and after myocardial infarction
- atenolol 25 to 100 mg orally, daily
- metoprolol tartrate 25 to 100 mg orally, twice daily.
Thiazide diuretic to reduce blood pressure? What dose? When to use?
Thiazide and thiazide-like diuretics are not recommended as first-line therapy in younger patients because they are associated with new-onset diabetes
> used as first-line therapy for uncomplicated elevated BP in patients over 65 years
> avoid in those with gout
- chlortalidone 12.5 to 25 mg orally, daily
- hydrochlorothiazide 12.5 to 50 mg orally, daily
- indapamide 1.25 to 2.5 mg orally, daily
- indapamide modified-release 1.5 mg orally, daily.
What to monitor patients taking ACE inhibitor/ARB therapy for?
Hypotension, kidney impairment and hyperkalaemia.
- A small rise in serum creatinine (up to 25%) or serum potassium (within the normal range) should not necessarily prompt dose reduction or cessation of the ACEI.
Normal serum creatinine range for males and female
For adult men (65.4 to 119.3 micromoles/L)
For adult women (52.2 to 91.9 micromoles/L)
What can DHP CCB cause?
Their vasodilatory action can cause peripheral oedema, if the peripheral oedema does not subside, it may be necessary to reduce the dose or stop therapy.
What is the aim to reduce BP to?
BP to below 140/90 mmHg
What antihypertensive drugs is safe to use in pregnancy? Include doses
labetalol
Adult, oral, initially 100 mg twice daily, increased each week according to response; maintenance 200–400 mg twice daily (maximum 2.4 g daily in 3 or 4 doses).
Nifedipine
initially 10–20 mg twice daily, increase to 20–40 mg twice daily.
CR tablet: initially 30 mg once daily, increase to a maximum of 90 mg once daily (angina) or 120 mg once daily (hypertension)
Methyldopa
Maintenance, 125–500 mg 2–4 times daily.
When used with other antihypertensives daily dose is usually 500 mg or less.
digoxin also safe to use in pregnancy
Non-pharmacological management of elevated blood pressure?
regular aerobic exercise (can reduce daytime BP by 3.2/2.7 mmHg)
reduction of alcohol intake
moderate sodium restriction
healthy eating
weight reduction in overweight patients (5 kg weight loss can reduce BP by 7/3 mmHg).
- Nonpharmacological strategies should continue even if drug therapy is started; they have a complementary effect on BP and improve cardiovascular outcomes beyond their effect on BP.
What is first line drugs used foor blood pressure?
Angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptors blockers (ARB), dihydropyridine calcium channel blockers, and thiazide and thiazide-like diuretics are suitable first-line drugs for uncomplicated elevated BP
- Overall, these drug classes have similar efficacy in reducing BP.
Beta blockers are no longer recommended as first-line therapy in patients with uncomplicated elevated BP, why? When are they used?
They are less effective than the first-line drugs in reducing the risk of stroke. However, they have a clear place in the management of patients with heart failure with reduced ejection fraction (HFrEF) and patients with coronary heart disease.
Stepwise appproach to reducing blood pressure?
Patients commonly require two or more drugs to reach BP target
Start BP-lowering treatment with a single drug, usually at a low to moderate dose.
If the BP target has not been reached after 3 months of treatment, add a low dose of a second drug from a different class. This is usually more effective than increasing the dose of the initial drug.
If BP remains above the target and both drugs are well tolerated, increase the dose of one of the drugs incrementally to the maximum dose, then increase the dose of the second drug, if required.
- a thiazide or thiazide-like diuretic with an ACEI, ARB or beta blocker
- an ACEI or ARB with a calcium channel blocker
- a beta blocker with a dihydropyridine calcium channel blocker
- an ACEI or ARB with a dihydropyridine calcium channel blocker and a thiazide or thiazide-like diuretic.
Atrial fibrillation after this card…
How to prevent AF?
Weight loss
- >- 10% or BMI < 27
Effective BP control
Tight glycaemic and lipid control
- HbA1c
Limiting alcohol
Physical activity
Managing OSA (Obstructive sleep apnoea) with CPAP B-blockers and antiarrhythmics for post-op AF
How to diagnose AF through ECG, S and S and blood tests?
ECG: Irregular ventricular rate of 110-140 BPM (upto 160-180 BPM)
S and S: lethargy or fatigue, palpitations, chest pain/tightness, sleeping difficulties, psychosocial distress
Blood tests: U and Es, FBP, TFTs, renal function
What does rate control mean?
Accepting AF and controlling the ventricular rate
Atenolol and metoprolol are used to maintain long-term control of ventricular rate? What doses are used?
atenolol 25 mg orally, daily, increasing if required up to 100 mg daily
metoprolol tartrate 25 mg orally, twice daily, increasing if required up to 100 mg twice daily.
- left ventricular ejection fraction less than 40% –> use beta blockers that are used for HF such as carvedilol or bisoprolol
Alternatively, if beta blockers are contraindicated or not tolerated, to attain and maintain long-term control of ventricular rate, use either diltiazem or verapamil. What doses are used?
diltiazem modified-release 180 mg orally, daily, increasing if required up to 360 mg daily
verapamil modified-release 180 mg orally, daily, increasing if required up to 480 mg daily.
- Avoid in HFrEF (ejection fraction less than 40%)
Amiodarone is usually added to the drugs mentioned previously for rate control, what is the dose?
Amiodarone 200mg orally, daily
Amiodarone can be useful for rate control in patients with left ventricular dysfunction (ejection fraction less than 40%)
When is digoxin used in rate control? What is the dose?
Second line drug treatment for AF
> useful addition if above drugs do not control heart rate and in patients with both atrial fibrilation and heart failure
> Digoxin 62.5-250 microgram daily
What antiarrhythmic drugs safe in pregnancy?
Digoxin, flecainide, sotalol, procainamide
What drug to add if HR >110 BPM after beta blocker and CCB tried?
Digoxin
- If still >110 BPM
> add CCB and or amiodarone
> add beta blocker and or amiodarone
> add amiodarone
What does rhythm control mean?
Acute restoration and maintenance of sinus rhythm
- Pharmacological/electrical (DC) cardioversion
Amiodarone IV or flecainide IV is used for rhythm control, what is the dose used?
> Amiodarone IV: 300 mg by intravenous infusion, over 1 to 2 hours, followed by 900 mg by intravenous infusion over 24 hours.
> Flecainide IV: 2mg/kg (max 150mg) over at least 10 minutes
What is the pill-in-the-pocket approach for rhythm control?
Useful in paroxysmal AF due to triggers (exercise, alcohol, caffeine) with no structural heart disease
- self-administration of flecainide 200-300mg orally when symptoms occur ( plus beta blocker)
Is stroke associated with AF? Why?
Yes, AF is responsible for 20-30% of all strokes
- Due to the embolism of clots from the left atrial appendage (LAA)
- Thrombus formation may occur within 48hours
- Also systemic embolic events
Clinical risk factors for stroke, transient ischaemic attack and systemic embolism in the CHA2DS2-VASc score
What is used for long-term rhythm control for AF? Include dose.
AF with normal left ventricular function, to maintain synus rhythm: flecainide 50 mg orally, twice daily, increasing if required up to 150 mg twice daily.
For patients in atrial fibrillation, flecainide should be used in combination with an AV nodal blocking drug (beta blocker)
- sotalol 40 mg orally, twice daily, increasing if required up to 160 mg twice daily.
If flecainide and sotalol are not suitable to maintain sinus rhythm in a patient in atrial fibrillation, amiodarone may be used.
- amiodarone 200 mg orally, 3 times daily for 1 week, then twice daily for 1 week, then once daily.
Anticoagulant dose to prevent thormboembolic events (stroke) in patients with AF:
A) Apixaban
B) dabigatran
C) rivaroxaban
warfarin titrated to INR 2-3
A)
apixaban 5 mg orally, twice daily
elderly and underweight: 2.5mg bd
B)
dabigatran 150 mg orally, twice daily
CrCL 30 to 50ml/min or elderly: 110mg orally twicve daily
C)
rivaroxaban 20mg orally once daily
CrCL less than 49ml/min: 15mg orally once daily
CIR (common, infrequent and rare) AE of Atenolol and Metoprolol
Common: bradycardia, hypotension, izziness, abnormal vision, alteration of glucose and lipid metabolism
Infrequent/rare: hallucinations, insomnia, nightmares, depression, heart block, rash, alopecia, exacerbation of psoriasis, impotence, muscle cramp, nasal congestion, hypersensitivity reaction, thrombocytopenia, increased aminotransferase concentrations, hepatotoxicity
Precautions of amiodarone?
Electrolyte disturbances (eg hypokalaemia, hyperkalaemia, hypomagnesaemia)—increase risk of arrhythmias; correct before starting treatment if possible.
GI adverse effects are more frequent in the elderly, are usually dose-related and improve with time
Rare AE of amiodarone?
Amiodarone has serious adverse effects including potential to worsen arrhythmia; these are slow to resolve after it is stopped (very long half-life).
rare: hepatotoxicity (may be fatal), optic neuropathy (see Ocular effects below), bronchospasm, alveolar haemorrhage, acute respiratory distress syndrome, heart failure, torsades de pointes, severe bradycardia, thrombocytopenia, decreased libido, alopecia, allergic rash, SIADH
pulmonary toxicity: may respond to corticosteroids
thryoid dysfunction
ocular effects: Reversible benign corneal microdeposits occur in most patients but rarely affect vision (photophobia, visual haloes may occur). Stop amiodarone if optic neuropathy or neuritis occurs.
IR AE of diltiazem
I: palpitations, tachycardia, gingival hyperplasia, tinnitus, rash, itch
R: taste disturbance, elevation of hepatic enzymes, extrapyramidal reactions, gynaecomastia, hypersensitivity reactions, including Stevens-Johnson syndrome, exfoliative dermatitis, angioedema
IR AE of verapamil
Infrequent: AV block, development or worsening of HF
Raare: ileus (lack of movement somewhere in the intestines, buildup and blockage of food material)
IR AE of Flecainide?
I: bradyarrhythmias, heart block (second‑ or third-degree), hallucinations, amnesia, confusion
R: cardiac arrest, sudden death, myalgia, arthralgia, fever, decreased libido, urinary symptoms, hepatic dysfunction, pneumonitis (with long-term use)
Infrequent AE of sotalol?
I: new or worsening arrhythmia, prolonged QT interval, torsades de pointes, first-degree heart block, tachycardia, cardiogenic shock, oedema, fainting, cough, cutaneous thickening, itching, nightmares, retroperitoneal fibrosis (IV infusion)
Heart failure from this slide onwards…
What are some drugs that cause/exacerbate HF?
Drugs causing Na/H20 retention
Corticosteroids, NSAIDs, thiazolidenidiones, high Na+ drugs, licorice
-ve inotropes (reduce the force of cardiac contraction)
Beta-blockers (unstable/unsuitable patients), non-DHP CCBs, tricyclic antidepressants, type 1 antiarrhythmic agents
Other CV drugs
Drugs that prolong QT interval, minoxidil, moxonidine
How to manage HF without the use of drugs?
Patient/carer education
Fluid restriction (1.5 L/day in patients with overt congestion)
Daily weights (see GP if weight increases 2kg over 2 days)
Restrict sodium intake to <2g/day (where sodium goes –> water goes)
Regular up to moderate-intensity continuous exercise in stable patients
Make sure iron levels are adequate, patients with HF are at increased risk of developing iron deficiency.
How to manage HFrEF with drugs?
AABCD
ACEIs and ARBs, and other vasodilators
Aldosterone antagonists (MRAs)
B-blockers
Cardiac glycosides (digoxin)
Diuretics
Why use ace inhibitors for HF? What to monitor?
First-line therapy
- decrease mortality and decrease hospitlisation
- Start low, go slow
Monitoring:
BP, cough, angioedema
K+ > 5.5 mmol/L
Kidney function –> 30% decreased eGFR from baseline (increase in creatinine)
Monitor for hypotension
Doses of Ace Inhibitors used in heart failure?
Rramipril is only approved by the (TGA) for post–myocardial infarction heart failure
- Ramipril 2.5mg orally, twice daily, increasing to maximum 5mg twice daily
Why use ARB for HF? What to monitor?
Alternative to ACEIs for patients with C/Is or who are intolerant (due to angioedema or cough)
- ARB therapy requires frequent monitoring for hypotension, kidney impairment and hyperkalaemia.
Doses of ARB used in HFrEF?
Candesartan and Valsartan only ARB approved by TGA for tx of HF
- Candesartan 4-32 mg daily or valsartan 40-160mg bd
Why is beta blockers used with ace inhibitors/arb?Which ones are used? What to be cautious about?
reduces the symptoms of heart failure, improves left ventricular ejection fraction, and reduces hospitalisations and mortality
- bisoprolol, carvedilol, metoprolol succinate and nebivolol.
> can initially worsen HF, cause severe hypotension and bradyarrhythmias
–> start low, increase dose gradually, monitor symptoms frequently and measure weight daily, start when euvolaemic. Double dose every 2 to 4 weeks.
What is the dose of bisoprolol, carvedilol, metoprolol succinate and nebivolol used?
Bisoprolol 1.25mg daily, increasing to 10mg daily
Carvedilol 3.125 mg bd, increasing to 25mg bd
Metoprolol XL 23.75mg daily, increasing to 190mg daily
Nebivolol (elderly) 1.25 mg daily, increasing to 10mg daily
- Monitor BP, HR and S+S
When is aldosterone antagonists (MRA) recommended? What does it do?
Spinorolactone and eplerenone
Recommended in all patients with HFrEF unless contraindicated or not tolerated
Decrease mortality and decreased HF hospitalisation
What are the doses for the Aldosterone antagonists? What are some side effects?
Spironolactone 12.5-25mg (max 50mg daily)
Anti-androgenic side effects: gynaecomastia, sexual dysfunction
Eplerenone 25-50mg daily
More selective –> less endocrine adverse effects
More expensive, CYP3A4 interactions
Reduce overall mortality and CV death (hospitalisation) when commenced early post MI in patients with HF
What to beware of when adding a aldosterone antagonist to an ACEI or ARB?
life-threatening hyperkalaemia in a patient with kidney impairment
- Check at baseline, within 1-2 weeks and regularly thereafter
> consider starting at a lower dose in patients with kidney impairment
When is Sacubitril and Valsartan used (vasodilator) in HF? What are some treatment considerations? Dose?
Replacement therapy for an ACEI or ARB if symptoms persist despite ACEI/ARB + B-blocker +/- MRA. Change to sacubitril/valsartan if HFrEF <40%.
Considerations
- C/I in previous angioedema
- Stop ACEI 36 hours before initiating therapy
- Dose: 49/51mg (or 24/26mg), doubling every 2-4 weeks to 97/103 mg bd
- Reduce dose in hypotension risk, elderly, renal or hepatic impairment
What to monitor for in sacubitril + valsartan?
frequent monitoring for hypotension, kidney impairment and hyperkalaemia
When is hydralazine + isosorbide dinitrate (vasodilator) used in HF?
Reserved for patients who are intolerant of ACEIs/ARBs where no other option exists
Reduces mortality, effect on hospitalisation rates less certain
HF in black patients
Poorly tolerated
When is Cardiac Glycosides used in HF? What has to be monitored? Dose?
Digoxin can be added to therapy for patients with persistent symptomatic heart failure that is not adequately controlled by optimal doses of ACEI (or ARB), beta blocker, loop diuretic and aldosterone antagonist.
digoxin 62.5 to 250 micrograms daily according to age, body weight and CrCL
Monitor digoxin conc –> Aim for a trough concentration of 0.5 to 0.8 micrograms/L
Also monitor: HR, TDM (due to low therapeutic index), renal function, S and S of digoxin toxicity
Why use loop diuretics in HFrEF?
reduce the signs and symptoms of congestion (eg breathlessness, peripheral oedema) and improve exercise tolerance
- NO MORTALITY BENEFIT) –> MAY CAUSE HYPOTENSION, ELECTROLYTE DISTURBANCES IF EXCESSIVE DIURESIS
What happens when loop diuretic used with ACE inhibitor?
An increase in serum creatinine (a fall in estimated glomerular filtration rate)
- Reduce the diuretic dose and monitor weight, kidney function and electrolytes closely
What dose type of loop diuretic to use and at what dose?
Furosemide 20 to 40mg orally, daily
Bumetanide 0.5 to 1 mg orally, daily
Etacrynic acid 50mg orally, daily
Why may be ivabradine used in HF?
Direct sinus node inhibitor –> slows HR
- Add onto an ACEI/ARB + maximally tolerated B-blocker +/- MRA if LVEF < 35% and patient has 70 BPM at least.
> may be used if B-blocker not tolerated
> only for use in SR
> decreases combined CV mortality and HF hospitalization
Dose: 2.5-7.5 mg bd (target HR 50-60BPM)
WHAT THREE DRUG CLASSES ARE USED FOR ALL PATIENTS IN HF?
ACE I (ARB)
BETA BLOCKER
MRA (Aldosterone Antagonists)
How to monitor HF therapy? Provide 5 ways.
Signs and symptoms
Oedema, dyspnoea, orthopnoea; dehydration
Daily weights
Seek medical advice if >2kg weight change over 2 days, or symptoms develop
BP and HR
Laboratory tests
Urea and electrolytes (especially K+ and Cr), FBP, BSL and lipids
Drugs that can worsen HF
Absolute CV risk assessment
What medications to use in pregnant patients with heart failure?
Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively.
