CV Drugs Flashcards

Question

What dose should aspirin, ticagrelor and prasugrel be given?

Answer 1

Aspirin: Loading at 300mg, then carry on at 75mg Ticagrelor: Loading at 180mg, 90mg BD Prasugrel: 60mg stat then 10 or 5 mg daily (PCI)

Answer 2

ABICIXIMAB,EPTIFIBRATIDE, TIOFIBRAN

Answer 3

Action: Inhibit the final common pathway involved in platelet aggregation Use: prevention of ischaemic cardiac complications in patients undergoing PCI Short term prevention of MI in patients with unstable angina not responding to conventional treatment & who are scheduled for a PCI

Answer 4

Bleeding, back pain, fever, headaches, hypotension, nausea Active internal bleeding, hypertensive retinopathy, majorly surgery within last 2 months.

Answer 5

Heparin- Enoxaparin, deltaoarin, tinzaparin Fondaparinux- subcutaneous injection Uses: thromboprophylaxis, unstable angina, STEMI, NSTEMI, DVT, PE

Answer 6

Prevents blood from clotting by suppressing the synthesis or function of various clotting factors Anti- thrombotic Doesn’t thin the blood, it just makes it less likely to clot

Answer 7

Side effects- bleeding, hyperkalaemia, HIT Contra indication- after major trauma, peptic ulcer, severe hypertension

Answer 8

Heart failure, hypertension, prophylaxis post MI

Answer 9

Prevention and long term management of angina Potassium channel activator with nitrate component too Arterial and venous vasodilating

Answer 10

Headaches, Ulceration, Dizziness, Flushing Severe hypotension, LV Failure, hypovolaemia, acute pulmonary oedema

Answer 11

Use s an adjunct in stable angina Facilitates myocardial relaxation (decreases calcium)- does not affect heart rate or BP

Answer 12

Dizziness, headache, constipation, nausea, vomiting CI - Severe renal impairment, Caution long QT syndrome

Answer 13

Use- treatment of angina in patients with normal sinus rhythm Action- lowers heart rate by acting on sinus node - decreases myocardial oxygen demands - no effect on BP or contraction

Answer 14

GI, nausea, constipation, diarrhoea CI heat rate <75 Acute MI, unstable angina, unstable heart failure (MANY DRUG INTERACTIONS)

Answer 15

Primary or secondary prevention of CV events, hyperlipidaemia Action- HMG - CoA reductive inhibitors Block the enzyme involved in cholesterol synthesis

Answer 16

Muscle aches and pains Myopathy - Rhabdomyolysis Nausea, insomnia CI - liver disease

Answer 17

Streptokinase, Tenectoplase, Alteplase Use between 6-12 hours of symptoms, ideally within 90mins in primary PCI unavailable Use for: acute myocardial infarction, PE, ischaemic stroke

Answer 18

Fibrinolytic drug activate plasminogen which turns to plasmin which then degrades the fibrin in th clot, breaking up the thrombus Side effects: risk of cerebral bleed (MANY ABSOLUTE/RELATIVE CONTRAINDICATIONS) - must decide what is more beneficial towards the patient

Answer 19

Aspirin - 75 mg once daily Another antiplatelets eg clopidogrel or ticagrelor (low risk of bleeding) for up to 12 months Atorvastatin - 80mg once daily ACE Inhibitors (eg ramipril titrated as tolerated to 10mg once daily) Atenolol or other beta blocker (bisnoprolol) titrated as high as tolerated Aldosterone antagonist for those with clinical heart failure (ie eplerenone titrated to 50mg once daily)

Answer 20

Either a beta blocker or a calcium channel blocker first line If the symptoms are not adequately controlled (or cannot tolerate) consider switching to an alternative or use a combination of the first two If the patients symptoms are not adequately controlled by one or a combination then consider a third line – long acting nitrate, ivabradine or ranolazine If in combination with a beta blocker – not verapamil or diltiazem Only if patient cannot tolerate calcium channel blockers or beta blockers should monotherapy with nitrate, ivabradine or ranolazine be offered. Triple therapy should be considered whilst awaiting revascularisation

Answer 21

Sub lingual GTN or IV nitrates § Morphine Oral Beta Blockers Aspirin Ticagrelor / Clopidogrel § ACE inhibitor Statin Fondaparinux

Answer 22

B- Beta blockers unless contraindicated A – Aspirin 300mg stat dose T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative) M – Morphine titrated to control pain A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days) N – Nitrates (e.g. GTN) to relieve coronary artery spasm O - oxygen only if their oxygen saturations are dropping (i.e. <95%).

Answer 23

§ Pain relief & antiplatelets § Diamorphine / Morphine § Oxygen § Sublingual GTNitrate or IV § Aspirin § Cyclizine or metoclopramide § Thrombolysis with or without heparin § IV beta blockers, IV nitrates (if suitable) § Aspirin , ACE inhibitors , oral beta blockers . Lipid lowering agents, dual antiplatelets § Angiography as needed , revascularisation as needed

Answer 24

Bisoprolol

Answer 25

Loop (target the loop of Henley) Thiazide (target the distal convoluted tube) Aldosterone antagonist

Answer 26

Furosemide , Bumetanide , Torasemide

Answer 27

Inhibit reabsorption from the ascending limb of the loop of Henlé in the renal tubule • Inhibit the sodium-potassium-chloride cotransporter in the thick ascending limb • This transporter normally reabsorbs about 25% of the sodium load • leads to both diuresis (increased water loss) and natriuresis (increased sodium loss). • They – Reduce preload, thus reducing ventricular filling – Improve pulmonary vascular congestion by decreasing filling pressures.

Answer 28

Measure of: Renal Function Serum Electrolytes Blood pressure Make sure to start on a low dose Recheck measurements 1-2 weeks after starting treatment and each time dose increases. • Earlier monitoring (after 5-7 days) may be required for people: • With existing chronic kidney disease stage 3 or higher. • Aged 60 years or over. • With relevant comorbidities such as diabetes mellitus or peripheral arterial disease. • Taking a combination of a diuretic plus an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin-II receptor antagonist (AIIRA), or an aldosterone antagonist.

Answer 29

Titrate the dose of loop diuretic up or down according to symptoms and signs of fluid overload; use the lowest possible dose to control symptoms. ● once a day, in the morning, but it can be given twice a day (morning and lunchtime) for additional diuresis. ● Adjust the timing of doses to suit their social needs. ● With heart failure and preserved ejection fraction the maximum initial dose is up to 80 mg furosemide. ● SICK DAY RULES : If they develop diarrhoea and vomiting while taking, a diuretic, they should ● maintain their fluid intake and stop the diuretic for 1-2 days until they recover. ● If symptoms persist beyond 2 days they should see a GP and have their bloods checked..

Answer 30

Do not prescribe loop diuretics to people with: – Hypovolaemia and dehydration (with or without accompanying hypotension). – Severe hypokalaemia or severe hyponatraemia. – Anuria, acute kidney injury or chronic kidney disease due to nephrotoxic or hepatotoxic drugs, or associated with hepatic coma. – Chronic kidney disease (CKD) with a creatinine clearance below 30 mL/min/1.73m2. – Addison's disease. – Liver cirrhosis associated with comatose and pre-comatose state. – Porphyria. – Cardiac arrhythmias (contraindication for torasemide).

Answer 31

Adverse effects of loop diuretics include: – Water and electrolyte imbalance : Na , Chloride, K , Mg, Ca •Hyponatraemia e.g. confusion, muscle cramps, muscle weakness, dizziness, drowsiness, and vomiting •Hypochloraemia, •Hypokalaemia, - neuromuscular symptoms (muscular weakness and paralysis), intestinal symptoms (including vomiting and constipation), renal symptoms (polyuria), and cardiac symptoms (including palpitations). •Hypomagnesaemia •Hypocalcaemia Hypotension

Answer 32

Bendroflumethiazide, indapamide, metolazone, chlorthalidone

Answer 33

Bendroflumethiazide, indapamide, metolazone, chlorthalidone • Inhibit the sodium-chloride transporter in the distal tubule. • Less efficacious than loop diuretics in producing diuresis and natriuresis. • Can be added in addition to Loop diuretic to potentiate their action • Maximum diuresis at low doses • Act within 1-2 hours and last 6-24 hours • Oral only

Answer 34

spironolactone, eplerenone

Answer 35

Block the activity of aldosterone, an adrenal cortex hormone that causes sodium retention. • Useful in heart failure following an MI • Recommended in moderate-to-severe heart failure • Aldosterone antagonists (spironolactone and eplerenone) are recommended in patients with – NYHA class II to IV heart failure – LVEF of 35% or less, unless contraindicated • Decrease the morbidity and mortality associated with symptomatic chronic heart failure • Spironolactone and eplerenone can both cause hyperkalaemia If experiencing gynacasmastia swap to eplerenone

Answer 36

• Reduce the load on the heart pre & post load • Decrease symptoms, slow disease progression & prolong life in heart failure • Most appropriate vasodilators as they lower both the arterial & venous resistance by preventing the increase in angiotensin 2 often present in heart failure. • Cardiac output increase because the renovascular resistance falls there in an increase in renal blood flow. • Can use ARB ( ACE II) if ACE not tolerated • E.g. ramipril, lisinopril, candesartan, losartan

Answer 37

• Measure renal function, serum electrolytes, and blood pressure before prescribing – Recheck 1-2 weeks after starting treatment & dose titration. • Maintain at the target dose (or highest tolerated dose) indefinitely unless adverse effects occur. • Once treatment is stable, measure renal function and serum electrolytes at least every 6 months. • Sick day rules : – Advise the person that if they develop diarrhoea and vomiting while taking they should maintain their fluid intake and stop for 1-2 days until they recover. – If symptoms persist beyond 2 days they should see a GP and have their renal function checked.

Answer 38

• Acutely can decrease myocardial contractility & worsen heart failure. • Long term improve survival of stable patients with heart failure by blocking the damaging effects of overactive sympathetic activity • Avoid adverse effects by starting low dose • Carvedilol, bisoprolol & metoprolol given with an ACE inhibitor & diuretic for about 1 year have been found in trials to decrease mortality from 11-17% to 7-12% • Most patients with heart failure with reduced ejection fraction should be offered treatment with a beta blocker • the beta-blockers licensed in the UK for the treatment of heart failure are bisoprolol, carvedilol, and nebivolol.

Answer 39

• In some situations HF patients are unable to tolerate either or both ACEI or ACEII • Can be used as alternative vasodilator in these patients. • This combination improves exercise tolerance in heart failure patients but produces only modest reduction in mortality. • Evidence available suggests this combination is of particular benefit to Afrocarribean patients although its benefit to Caucasians is yet to be fully established.

Answer 40

• In the UK, ivabradine is now recommended for patients with symptomatic heart failure with reduced ejection fraction (class II to IV) who : – Are in sinus rhythm with a resting heart rate of 75 beats per minute or more, and – Are symptomatic in spite of standard treatment including a beta blocker, an ACE inhibitor and an aldosterone antagonist OR who are genuinely intolerant of beta blockers, and – Have a left ventricular ejection fraction of 35% or less • Carefully monitor patients taking ivabradine for bradycardia or its symptoms (for example dizziness, fatigue and hypotension)

Answer 41

• Beneficial in patients with current or prior symptoms of heart failure or reduced LVEF, especially those with atrial fibrillation. • When added to ACE inhibitors, beta-blockers, and diuretics, digoxin can reduce symptoms, prevent hospitalisation, control rhythm, and enhance exercise • Digoxin should be used cautiously with plasma level monitoring. • Digoxin toxicity ( digifab anti toxin) Check bloods 6 hour post dose

Answer 42

Stops breakdown of BNP • Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people: – with New York Heart Association (NYHA) class II to IV symptoms and – with a left ventricular ejection fraction of 35% or less and – who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor-blockers (ARBs). • Concomitant administration of an angiotensin-II receptor antagonist plus neprilysin with an ACE inhibitor, or within 36 hours of the last dose of an ACE inhibitor, is not recommended. • Treatment with sacubitril/valsartan reduces cardiovascular death by reducing both worsening heart failure and sudden cardiac death • The most commonly reported adverse reactions during treatment with sacubitril valsartan were hypotension, hyperkalaemia and renal impairment

Answer 43

• Dapagliflozin & Empagliflozin are recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction in adults, only if it is used as an add-on to optimised standard care with: • ACE inhibitors or ARBs, with beta blockers, and, if tolerated, MRAs, or • sacubitril valsartan, with beta blockers, and, if tolerated, MRAs. • Start treatment of symptomatic heart failure with reduced ejection fraction with on the advice of a heart failure specialist. • Monitor for adverse events

Answer 44

• To relieve symptoms of fluid overload: o Prescribe a diuretic (e.g. furosemide). o Titrate the dose up or down according to symptoms. o Review the dose and adjust as necessary after introducing other drug treatments for heart failure. • To reduce morbidity and mortality prescribe: o An angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker. o An angiotensin-II receptor antagonist (AIIRA) may be considered if the person develops intolerable side effects to the ACE inhibitor. • Introduce one drug at a time. • Add the second drug once the person is stable on the first drug.

Answer 45

Reduce salt consumption Fluid restriction 1.5 - 2litres Stop smoking/ alcohol Increase PA Improve nutritional status Recommend immunisations

Answer 46

Complications of heart failure • Cardiac arrhythmias • Depression – Major depressive disorder is present in up to 20% of people with heart failure • Cachexia (wasting) – This is defined as the loss of 6% or more of total body weight within the previous 6-12 months. Wasting occurs in lean tissue (muscle mass), and fat • Chronic kidney disease (CKD) – CKD is common in people with heart failure and is strongly associated with increased morbidity and mortality • Sexual dysfunction – Sexual dysfunction is common in people with heart failure. This may be related to cardiovascular disease, fatigue, weakness, the use of drugs (such as beta-blockers), or depression and anxiety • Sudden cardiac death – About half of the deaths in people with heart failure are related to sudden cardiac death

Answer 47

• Develops rapidly and can be immediately life-threatening due to a lack of time to undergo any compensatory changes. • Due to acute infection (sepsis), acute myocardial infarction, heart valve dysfunction, severe arrhythmias or operations (cardiopulmonary bypass). • managed by pharmacological, mechanical and surgical interventions despite its aetiology Symptoms: Coughing up pink foamy mucus Lack of appetite/ nausea Sudden swelling of the abdomen, legs, ankles and feet Severe shortness of breath Rapid, irregular heart beat Fatigue and weakness Sudden weight gain from fluid retention

Answer 48

Breathlessness Palpitations Syncope or dizziness Chest discomfort Stroke or transient ischaemic attack

Answer 49

Perform a manual pulse palpate on to assess for presence of an regular pulse Perform 12 lead ECG to diagnose AF If suspected paroxysmal AF do ambulatory ECG

Answer 50

To assess the risk of using an anti coagulation against the risk of bleeding out

Answer 51

Haemodynamically unstable - direct current cardioversion HD Stable 1) Rate control 2) Anti-coagulate (check CHADSVAS) 3) consider cardioversion: If AF <48 hours + low risk of stroke = cardiovert + anticoagulants for 4 weeks If AF >48 hours + risk of stroke either TEE echocardiogram to check for a current clot in atrium if not present cardiovert + oral AC for 4 weeks or if thrombus present oral AC for 3 weeks, re check then potentially cardiovert

Answer 52

Block the AV node to decrease HR Beta Blockers - Bisoprolol, Atenolol Contra Indication - COPD as block B2 receptors Calcium Channel Blockers - Veraprimil, diltiazem Contra Indication- Heart Failure Digoxin - take a while to kick in Good for hypertension / HF Amioderone (Rhythm + Rate)

Answer 53

Drug = pharmacological cardioversion Type 1a Type 1c Type 3 CI- Increase risk of tossades de point Flecanide, BB- sotalol, Amiodarone ○ Long term rhythm control drugs: ▪ Beta blockers – 1st line ▪ Dronedarone – 2nd line, maintain normal rhythm when they’ve had successful cardioversion ▪ Amiodarone – in patients with heart failure or left ventricular dysfunction

Answer 54

CHF +1 HTN +1 Age >75 +2 Diabetes +1 Stroke/ TIA +2 Vascular Disease +1 Age 65-74 +1 Sex- Female +1 2 or more = AC NEEDED

Answer 55

Warfarin DOACs Heparin

Answer 56

Vagal Monouver - Increases vagal tone, Decrease AV node Adenosine (6mg) - Blocks AV Node AFlut or FAT BB/CCB Cardiovert - priority if haemodynamically unstable Long Term: Catheter Ablation

Answer 57

TREAT FOR VTACH Put pads on first Amiodarone or Procainimide Cardioversion

Answer 58

Adenosine Cardioversion Look for underlying cause If MI- PCI? Auto implantable cardiac debrillators?

Answer 59

Amiodarone Cardiovert D Fib on stand by Once stable give Mg Sulphate, K+, discontinue offending meds, isoprotenolol to increase HR DONT GIVE ABCD (adenosine, beta blocker, CCB, Digoxen)

Answer 60

Discontinuation of AV nodal blocking drugs Atropine to decrease PNS and increase HR Epi PACE Once patient is stable treat underlying cause: Inferior wall MI Hypercalaemia Overdose on CCB/BB/Digoxen Limes disease

Answer 61

Benefits Can save life & limb from thrombo-embolism For people with AF – overall 60% reduction of stroke -about 80-90 strokes will be prevented each year for every 1000 -about 25 strokes will be prevented each year for every 1000 Problems Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm & admissions to hospital (NPSA 2007) Major cause of bleeding which can be fatal (NPSA 2007) Major cause of litigation (use or non-use) stroke vs bleeding risk Dose adjustments frequently required to avoid over or under anticoagulation

Answer 62

AF Deep Vein Thrombosis Pulmonary Embolism

Answer 63

Inhibits vitamin K clotting factors. Use with heparin as doesn’t work instantly Prevents the vitamin K promoted carboxylation of glutamic acid residues of factors II, VII, IX and X. 50% drop in factor VII levels in 24 hours 50% drop in factor II levels in 4 days Full anticoagulation in 48-72 hours Rapid fall in protein C and S levels-in first 2-3days can increase risk of thrombosis.

Answer 64

International normalised range As 1 size doesn’t fit all To see the dose of warfarin which should be used in AC medication

Answer 65

Bleeding risk Haemorrhagic stroke Pregnancy Re occurrent falls Uncontrolled hypertension Medication - eg ibroprofen, aspirin as increase risk of GI bleed

Answer 66

Prothrombin time (PT) Activated partial thromboplastin time (APTT) u Platelet count Full Blood Count Liver Function Test Baseline INR (if INR >1.4 review management plan) check why its higher than 0

Answer 67

1mg brown 3mg blue 5mg pink 0.5mg white

Answer 68

Acenocoumarol Phenindione DOACs - rivaroxaban Heparins

Answer 69

AnticoagulantHigh molecular weight molecule- highly ionised Therefore – not absorbed via the GI tract So – it must be given by IV infusion or by subcutaneous injection. When do you use? : High risk patients / renal impairment Monitoring & dose adjustment needed – check your trust protocol! Protamine used to reverse action

Answer 70

Prothrombin time (PT) - heparin Activated partial thromboplastin time (APTT) - heparin Platelet count - HIT (heparin infused thrombolysis <100 don’t use AC) Full blood count Liver function test Potassium

Answer 71

Enoxaparin, dalteparin, tinzaparin sodium, bemiparin Longer half life - once or twice a day dosing Dosage based on body weight Advantages: fixed dose , no lab, highly predictable plasma levels Disadvantages: more expensive

Answer 72

PE DVT Thromboprophylaxis Acute coronary syndrome Examples Fondaparinux Enoxaparin Daltaparin Tinzaparin DOSE ADJUSTMENTS – Renal , Body weight, Increased risk

Answer 73

Risk of bleeding, Low platelet BNF: Acute bacterial endocarditis; after major trauma; avoid injections containing benzyl alcohol in neonates; epidural anaesthesia with treatment doses; haemophilia or other haemorrhagic disorders; peptic ulcer; recent cerebral haemorrhage; recent surgery to eye; recent surgery to nervous system; spinal anaesthesia with treatment doses; thrombocytopenia (including history of heparin-induced thrombocytopenia)

Answer 74

Dabigatran Rivaroxaban Apixaban Edoxaban

Answer 75

Licensed for: Non-valvular AF (NB differences in criteria) DVT / PE Treatment & prophylaxis of recurrent VTE Thromboprophylaxis of DVT or PE after an acute DVT/PE Thromboprophylaxis after hip or knee replacement (except edoxaban) Rivaroxaban : Prophylaxis of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers (in combination with aspirin alone or aspirin and clopidogrel) Check NICE guidance as indications can change regularly.

Answer 76

Small half life - good if they need taking off them No need for INR monitoring Predictable Anticoagulant response Rapid onset (1-4 hours) Lower risk of bleed overall with much reduced intracranial bleed (0.3% vs. 0.76%) Give stroke protection equivalent to Warfarin (only Dabigatran 150mg gives added benefit) Rivaroxaban , Apixaban & Edoxaban : can go in compliance aids / can be crushed

Answer 77

Patients who cannot tolerate Warfarin due to: Significant side effects e.g. Alopecia Poor INR control despite being compliant (Time in therapeutic range should be less than 65%- Rosendaal score- Cardiac Network ) INR> 5 while compliant with no known cause more than twice in a year Now first line treatment in majority of patients with PE / DVT/ non valvular AF

Answer 78

• a lesion or condition, if considered a significant risk factor for major bleeding. This may include: • current or recent gastrointestinal ulceration • presence of malignant neoplasm at high risk of bleeding • recent brain or spinal injury • recent brain, spinal, or ophthalmic surgery • recent intracranial haemorrhage • known or suspected oesophageal varices • arteriovenous malformation • vascular aneurysms, or major intraspinal or intracerebral vascular abnormalities • concomitant treatment with any other anticoagulant agent—eg: • unfractionated heparin • low molecular weight heparin (such as enoxaparin or dalteparin) • heparin derivatives (such as fondaparinux) • oral anticoagulants (such as warfarin).

Answer 79

Check; Interactions Indications ( may differ ) Age (Apixaban & Dabigatran dosage advice) Weight (Apixaban & Edoxaban ) Renal function - - impaired renal function may constitute a contraindication or recommendation not to use the anticoagulant medicine, or may require a dose reduction - -other conditions, procedures, and concomitant treatments (eg, non-steroidal anti- inflammatory drugs, antiplatelets), which may increase the risk of major bleeding Rivaroxaban : WITH FOOD 80% biovailability with food u 66% without food

Answer 80

Specific reversal agents are available for dabigatran (Praxbind▼, idarucizumab) Apixaban and Rivaroxaban (Ondexxya▼, andexanet alfa) Currently no specific authorised reversal agent available for Edoxaban.