Clinical Guidelines Flashcards
Which agents have proven efficacy for pharmacological conversion in AF?
Amiodarone Flecainide (not if >60 yrs and/or any structural heart disease)
What is the target ventricular response rate for patients who are rate controlled in AF?
VR rate of 60-80 bpm at rest and between 90-115 bpm during moderate exercise
Which agents may be appropriate for rate control treatment?
Beta blockers
Non-dihydropyridine calcium channel antagonists
Digoxin
Amiodarone (but risk reverting to SR and thromboembolic complications)
BB are better than digoxin for exercise rate control
Digoxin should be considered in HFrEF
Which agents are appropriate for maintenance of sinus rhythm post DC cardioversion for AF?
Many patients need prophylactic anti-arrhythmic drug therapy to maintain sinus rhythm.
Agents that may be used are:
- Amiodarone
- Sotalol
- Flecainide (only in < 60 yrs and no structural heart disease).
Side effects of bDMARDs (8)
- Infections, especially TB, also bacterial and viral hepatitis
- Malignancy- exact risk unknown but bDMARDs are contraindicated within 5 years (excluding skin SCC/BCC)
- Injection site/infusion reactions- mild to moderate reactions are common. Managed with antihistamine, corticosteroids and slowing the infusion rate.
- Severe CCF - possible exacerbation with TNFi
- Neurological syndromes -
- Demyelinating conditions (GB, MS, optic neuritis) - TNFi should not be started and/or stopped if these conditions developed. Not a contraindication to rituximab.
- Rituximab has been associated with increase risk of PML in patients with SLE and RA
- Autoimmune-like syndromes
- Increase antibodies (ANAs, dsDNAs) with infliximab. Rare clinical drug induced lupus.
- Skin reactions eg. pustular psoriasis
- Other:
- Haematological transient neutropaenias
- Abnormal LFTs (especially IL-6)
What is the recommended management of bDMARDs in pregnancy?
To date, no identified increased teratogenicity.
Recommendation to cease treatment 3 months before pregnancy is planned, or to discontinue if unexpected pregnancy occurs.
However, many patients are continuing treatment through pregnancy now.
Breast feeding is safe.
What are the recommendations around vaccination for patients of bDMARDs?
TNFi (especially if on concurrent MTX) confers slightly reduced efficacy after vaccination.
Vaccinations should be given before starting treatment:
- Eg. Influenza, polysaccharide Pneumovax, Hep B
and then ongoing as appropriate when indicated.
Live attenuated vaccinations are contraindicated
Which of the vaccinations are live attenuated?
MMR BOYZ JT
MMR - measles, mumps, rubella BCG Oral polio Yellow fever Zoster
Jap encephalitis
Typhoid/rotavirus
What is the recommendations are bDMARDs perioperatively?
Withhold etanercept for 2-4 weeks prior to major surgical procedures
Withhold adalimumab, certolizumab, golimumab, infliximab for 4-8 weeks prior to major surgical procedures
Treatment can be restarted post-op if there is no evidence of infection and wound healing is satisfactory.
What are common aetiologies of HFpEF? (4)
Hypertension - esp female and elderly
IHD
Hypertrophic cardiomyopathy
Aortic stenosis
Other aetiologies:
- Valvular disease (I.E, native valve disease)
- Pulmonary disease (Pulmonary hypertension)
What are some non-pharmacological strategies in Heart Failure management?
- Multidisciplinary patient support programs
- Regular (low-moderate level) physical activity, tailored to NYHA class
- Management of sleep apnoea
- Dietary sodium restriction to <2 g/day
- Fluid intake restriction <1.5 L/day
- EtOH <1-2 standard drinks/day
- Daily weigh
- UTD vaccination against influenza and pneumococcus
- Limited saturated fat
- Smoking cessation
Outline the role and side-effects of ACEi in HFrEF
ACEi is recommended in all patients with HFrEF (EF <40%) unless contraindicated or not tolerated
- Mortality benefit
- Reduced hospitalisations
Side effects:
- Hypotension
- Precipitate AKI
- HyperK
- Cough -
- Angioedema
Outline the role and side effects of BB in HFrEF?
Recommended in all patients with HFrEF once stabilised and with no/minimal congestion
Decreases mortality and hospitalisation
Side effects
Bradycardia
May initially worsen HF
Asthma
Outline the role and side effects of MRAs (Spironolactone) in HFrEF
Recommended in addition to ACEi/ARB +/- Beta-blocker
Decreases mortality; decreases hospitalisation for heart failure
Side effects:
- HyperK
- Anti-androgenic
Outline the role of an ARNI in HFrEF?
ARNI is recommended as a replacement for an ACEi/ARB in patients with LVEF <40%
Decreases hospitalization and decreases mortality
Outline the role of Ivabradine in HFrEF?
Ivabradine is a direct sinus node inhibitor
Ivabradine should be considered in patients with HFrEF <35% and sinus HR >70 bpm who are already on maximal tolerated or target doses of ACE/ARB, BB +/- MRA
Decreased combined endpoint of cardiovascular mortality and hospitalisation for heart failure
Outline the role of digoxin in HFrEF
May be considered in patients with HFrEF w NYHA III-IV symptoms who are in sinus rhythm.
Decreases hospitalisation for heart failure.
No mortality benefits.
Outline the role for CRT in HFrEF
CRT is recommended for symptomatic patients with HFrEF who are
- In sinus rhythm
- LVEF <35%
- QRS >130 msec (highest level of evidence QRS >150 msec)
Despite OMT
Weaker recommendation/evidence for patients in AF.
When are ICD recommended?
Primary prevention - decreased mortality
- 1 month post MI and LVEF <30%
- HFrEF and ICM/DCM and LVEF <35%
Secondary prevention - decreased mortality
What are contraindications to heart transplant?
- Active infection
- Severe peripheral arterial or cerebrovascular disease
- Pharmacologically irreversible pulmonary hypertension
- Active neoplasm
- Irreversible CKD (CrCl <30 ml/min)
- Systemic disease with multi-organ involvement
- Other serious co-morbidity with poor prognosis
- Pre-transplant BMI >35 kg/m2
- Current EtOH or drug abuse
- Poor social supports
- Non-compliance
Outline the management strategies for HFpEF?
- Optimally manage underlying cause(s) – diabetes, HTN, ischaemia
- Manage and treat arrhythmias. Ideally maintain sinus rhythm (patients with diastolic dysfunction decompensate in AF)
- Avoid over diuresis – that diuretics may over-reduce filling pressures
What are some situations where eGFR results may be unreliable?
- AKI
- Dialysis
- Exceptional dietary intake (eg. vegetarian, high protein, recent consumption of cooked meat, creatine supplements)
- Extremes of body size
- Diseases of skeletal muscle, paraplegia, amputees (may overestimate eGFR)
- High muscle mass (may underestimate eGFR)
- Children <18 years
- Severe liver disease present
- eGFR > 90 mL/min/1.73 m2
- Drugs interacting with creatinine excretion (eg. Fenofibrate, trimethoprim)
What are the 4 most common causes of CKD in Australia?
- Diabetic nephropathy (36%)
- Glomerulonephritis (19%)
- Hypertensive vascular disease (12%)
- Polycystic kidney disease (5%)
- Other (28%)
Symptoms of ESKD?
Typically asymptomatic
ESKD symptoms:
- Lethargy
- Nocturia
- Malaise
- Anorexia/nausea/vomiting
- Pruritis
- Restless legs
- Dyspnea
What are potential confounders in interpretation of albuminuria? (7)
- Menstruation or vaginal discharge
- Heavy exercise within 24 hours
- Acute febrile illness
- Urinary tract infection
- High dietary protein intake
- CCF
- Drugs, especially NSAIDs
Management of a patient with EGFR <30
OR
Management of a patient with macroalbuminuria
Investigate for underlying cause, and for any complications of CKD (Hb, Ca, Phosph) Measures to reduce progression Review every 1-3 months Assess for CV risk and manage appropriately Avoid nephrotoxins Adjust renal excreted medication doses Refer to nephrology Consider if dialysis is appropriate
What is the recommended BP target in CKD?
Target: <140/90
OR
<130/80 in patients with albuminuria
What is the suggested management for albuminuria in CKD?
- Albuminuria is an important prognostic factor in CKD
- The degree of albuminuria related to the severity of CKD and the likelihood of progression to ESKD
- Reduction in the amount of albuminuria is associated with improved outcome
Management – Aim to reduce ACR by 50%
- ACEi or ARB
- Reduction in salt intake
- Spironolactone (use with caution, monitor K)
What is the standard glycaemic targets in CKD?
Optimal glucose control significantly reduces the risk of developing microalbuminuria, macroalbuminuria and/or overt nephropathy in T1DM and T2DM
Targets:
BSL 6-8 mmol/L post-prandial
HbA1c <7%
What is the role of cinacalcet in patients with CKD?
Cincacalcet is a calcimimetic agnet, used for hyperparathyroidism in patients on dialysis.
What are the Hb and Ferritin targets in CKD?
Target Hb: 100-115 g/L
Target Ferritin: 200-500 ug/L with Tsat >20% (with EPO replacement)
Significant hyperparathyroidism and systemic inflammation may contribute to anaemia and cause refractoriness to erythropoietin therapy
Outline the management of acidosis in patients with CKD
Patients with eGFR <30 mL/min/1.73 m2 are at increased risk of acidosis.
This may lead to demineralisation of bone and increased protein degradation.
In patients not suitable for dialysis, supplementation with sodium bicarbonate (SodiBic) may be considered.
Aim bicarb > 22 mmol/L
SodiBic carries risk of fluid retention and may worse BP control.
Management of HyperK in patients with ESKD
Cease any offending meds (ACEi/ARB/Spironolactone) Correct metabolic acidosis if present Resonium Low K diet Dialysis if suitable
Targe K <5
Which multidisciplinary treatment options may be considered for chronic pain syndrome?
- Rehabilitation program
- Physical therapy. PT techniques include transcutaneous electrical nerve stimulation (TENS)
- Occupation therapy. OT techniques include initiating gentle active measurements and preliminary desensitisation techniques with patients who have chronic pain, especially regional CPS.
- Recreational therapy
Which analgesia options are appropriate for patients with chronic pain syndrome?
SImple: Paracetamol, ibuprofen.
TCAs eg. Amitryptiline.
Pregabalin and gabapentine.
SSRIs: Fluoxetine, paroxetine, sertraline.
Avoid opiates.
List the possible respiratory complications of CF (8)
- Bronchiectasis
- Micro colonisation: staph/haemophilus in childhood; pseudomonas in adults
- RFTs: Obstructive picture
- Asthma (reversible component) may occur
- Pulmonary haemorrhage
- Spontaneous pneumothorax
- Respiratory failure and secondary pulmonary hypertension
- Sinusitis
List the possible pancreatic complications of CF? (2)
- Exocrine insufficiency - malabsorption
2. Endocrine insufficiency - diabetes
What is the mechanism of action of CFTR modulators?
Aim to improve or restore the function of the defective CFTR protein
Mutations specific, and aim to treat the cause of CF and slow the decline in lung function.
- Kalydeco
- Orkambi
- Symdeko
Indications for transplant work-up in CF?
Progressive pulmonary function impairment, manifest by FEV <30% predicted (<40% in females)
Severe hypoxaemia, and/or hypercarbia, even if the FEV1 exceeds 30% predicted and recovery from an acute illness
Increasing frequency and duration of hospital treatment for pulmonary exacerbation
Increasing functional impairment
Major life-threatening pulmonary complications, eg. Recurrent massive haemoptysis.
OGTT - diagnostic value for diabetes
0h: >7.0
2h: >11.1
Diabetes - lifestyle measures
Dietary modification
Regular exercise
Smoking cessation
