Cv medicine Flashcards
What are 3 irreversible risk factors for CV diseas e?
- Age
- Sex
- Family History
What are 4 reversible risk factors for CV disease?
- Smoking
- Obesity
- Diet
- Exercise
What are 3 primary preventions for CV disease?
- Exercise
- Diet
- Not smoking
What is hypertension?
High blood pressure
What is hyperlipidaemia?
- High Cholesterol
What are the 4 things a patient needs to have for a patient centred and controlled was of reducing their risk of getting CV disease?
- Information
- Belief
- Motivation
- Behavioural change
What does primary prevention do?
- Stops the risk that is going to give you the disease before you actually get the problem
What is meant by secondary prevention?
- Once you have the disease, how can you stop it from getting worse
What is an example of secondary prevention?
- Medical treatment to reduce the risk
Primary prevention is an opportunistic approach. What do you need to look at for primary prevention of CV disease? (6 points)
- Family history
- Diet
- Smoking
- Test cholesterol
- Test blood pressure
- Test for diabetes (type 2)
What is claudication?
- A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries
What 4 conditions are you trying to prevent when providing secondary intervention for CV disease?
- Angina
- Heart Attack
- Stroke
- Claudication
One approach to prevention is to control total cholesterol levels. How can we do this and what level do we want it to be?
- Statin treatment
- Reduce cholesterol <5.0mmol/L or 25%
In order to control hypertension what do you want to reduce the blood pressure to?
A target of <140/85
When would you give anti-platelet drugs like aspirin in the prevention of CV disease? ( 2 points)
- When identified CV disease
- When HIGH RISK with no identified disease
What 2 things are drugs used in the CV system used to do?
- Prevent further disease
- Reduce symptoms of current disease
What are 4 examples of drugs used in the CV system that are used to prevent further disease?
- Anti platelet drugs
- Lipid lowering drugs
- Anti-arrhythmics
- Anticoagulants
What are 5 examples of drugs used in the CV system that are used to reduce the symptoms of the current disease?
- Diuretics
- Anti-arrhythmics
- Nitrates
- Calcium channel blockers
- Ace inhibitors
What are 3 examples of anti-platelet drugs?
- Aspirin
- Clopidogrel
- Dipyridamole
What does aspirin do as an anti-platelet drug? (3 points)
- Inhibits platelet aggregation
- Alters the balance between thromboxane A2 and prostacyclin
- Irreversible for the life of the platelet
What does Clopidogrel do as an anti-platelet drug?
- Inhibits ADP induced platelet aggregation
Does giving Aspirin and Clopidogrel together change their effect?
- Yes, it gives an added effect
What does Dipyridamole do as an anti-platelet drug?
- Inhibits platelet phosphodiesterase
What happens when anti-platelet drugs are used in combination?
- Increases the effect
What do anti-platelet drugs significantly reduce the chances of? (2 points)
- Heart attack
- Stroke
What is a negative aspect of using anti-platelet drugs?
- Prolong the bleeding time following dental extraction
- Not significant problem individually but drug combinations increase the risk
What are the names of 2 new antiplatelet drugs?
- Prasugrel
- Ticagrelor
What can prasugrel and ticagrelor only be prescribed in conjunction with?
- Aspirin
What are Prasugrel and Ticagrelor only licenced for?
- Acute coronary syndromes
What is there poor evidence of for Prasugrel and Ticagrelor in dentistry?
- Bleeding risk
What are 4 examples of oral anticoagulants?
- Warfarin
- Rivaroxiban
- Apixaban
- Dabigatran
Warfarin is the most common oral anticoagulant. What varies between each patient for warfarin?
- The dose as each patient needs a very specialised dose
What are antiplatelet drugs?
- Drugs that stops platelets from sticking to blood vessel walls and platelets together (have an effect on platelets)
What are anticoagulants?
- Drugs which reduce clot formation but have no effect on platelets
What is another name for Warfarin?
- Coumarin based anticoagulant
What does Warfarin do?
- Inhibits synthesis of Vitamin K dependent clotting factors:
- 2, 7, 9, 10
- Protein S and Protein C
How long does it take for Warfarin to act on The vitamin K dependent clotting factors 2, 7, 9 and 10?
- Slow - 2 days
How long does it take for Warfarin to act on Protein C and Protein S?
- Quick
How long does anticoagulation take to work?
- 2-3 days
What is Herparin?
- A compound occurring in the liver and other tissues which inhibits blood coagulation
- It is often used concurrently initially with Warfarin to produce initial hypercoagulation
Once stabilised, how long will it take for the effect of Warfarin to stop if the drug is stopped?
2-3 days
Why must Warfarin be monitored regularly?
Drug and food interaction with:
- Plasma protein binding
- Liver metabolism
What test is Warfarin monitored with and what is the therapeutic range for Warfarin?
- International normalised ratio test: standardised prothrombin time (PT)
- Usually the therapeutic rnge is 2-4 (if less than 2 then patient is not receiving a high enough dose and they are at risk of a clot)
If the therapeutic INR range for Warfarin for a patient is within the wanted range what should a dentist do?
- No alteration needed for dental care
If the therapeutic INR range for Warfarin for a patient is out with the wanted range what should a dentist do?
- Refer for medical advice before treating
Should local haemostatic measure be used for a patient on Warfarin?
- Yes, always
What drugs interact with Warfarin?
- Assume all drugs interact with warfarin
Which drugs are safe to use with Warfarin?
- Local anaesthetics
What are 4 examples of drugs that interact with Warfarin?
- Amoxycillin
- Metronidazole
- Erthromycin
- NSAID’s
What are 3 examples of new oral anticoagulants and hoe often can you have these ?
- Rivaroxiban (1x daily)
- Apixaban (2x daily)
- Dabigatran (2x daily)
What is the half life of new oral anticoagulants?
- Short half life - effect rapidly lost
What anticoagulant test is used for new oral anticoagulants?
- No test used
- Bioavailability predictable
Are NOAC’s safe with dental antibiotics?
- Yes, except Macrolides (Erythromycin and Clarithromycin)
Are NOAC’s safe with Antifungals?
- Yes, topical and fluconazole
Are NOAC’s safe with LA?
- Yes
Are NOAC’s safe with Antivirals?
- Yes
What is the problem with the interaction between NOAC and NSAID’s?
- They will prolong the action and inhibit platelets - AVOID
What other drugs, apart from warfarin, are used to prevent CV disease? (5 points)
- Statins
- Beta-adrenergic blockers
- Diuretics
- Calcium channel blockers
- ACE inhibitors
Statins are lipid lowering drugs. What is another name for these?
- HMG coA Reductase inhibitors
What are 3 types of statins?
- Simvastatin
- Atorvastatin
- Rosuvastatin
Sim vastatin is a ‘prodrug’. What does this mean?
- It is metabolised in the liver to give an active drug
What do statins do?
- They inhibit cholesterol synthesis in the liver
- Reduce total cholesterol and LDL-cholesterol
What are the side effects of taking statins?
- Possible myositis with some drug interactions - includes antifungals
- Myositis = inflammation of the muscles that are used to move the body
What is Myositis?
- Inflammation of the muscles that are used to move the body
Which antifungal interacts with statins and what should you do when a patient is on statins but needs antifungals?
- FLUCONAZOLE - causes plasma levels of the statins to go up a lot and trigger muscle pain
- Omit statin during antifungal treatment
- This will not make a difference as taking statins is a lonf time benefit
Atenolol is a selective beta-adrenergic blocker. What does this mean?
- B1 only
- Block the affects of adrenaline on the heart and therefore better for CVD patient (makes the heart slower and function less well to prevent stress on the heart)
Propranolol is a non-selective beta-adrenergic blocker. What does this mean and what is it good for?
- B1 and B2
- Good for anxious patients - Not so much CV patients
What do beta-adrenergic blockers do in relation to the heart? (2 points)
- Stop arrhythmias leading to cardiac arrest (ventricular fibrillation - VF)
- Reduced heart muscle excitement
Beta-adrenergic blockers prevent an increase in heart rate. What are the consequences of this (good and bad)? (2 points)
- Cause postural hypotension
- Prevent unusual heart rhythms which can lead to heart attacks
What is postural hypotension?
- A drop in blood pressure due to a change in the body position when a person moves to a more vertical position e.g. from sitting to standing
beta blockers reduce heart efficiency. What des this make worse?
Heart failure
There are beta blocker receptors in the lungs. What does this make worse?
- Makes asthma worse or more difficult to treat
What is the function of diuretics? (3 points)
- increase salt and water LOSS
- Reduce plasma volume
- Reduce cardiac workload
What conditions are diuretics used for? (2 points)
- Antihypertensive
- Heart failure
What are the 2 types of diuretics and what is an example of these?
- Thiazide diuretics (bendroflumethazide)
- Loop Diuretics (frusemide)
What is the common side effect of diuretics?
- Can lead to a sodium/potassium imbalance if not carefully monitored
What is a common side effect for the elderly when taking diuretics?
- Dry mouth
What is an example of a short acting nitrate and what is it used for?
- Glyceryl Trinitrate (GTN)
- Emergency management of angina pectoris
What is an example of a long-acting nitrate and what is this used for?
- Isosorbide Mononitrate
- Prevention of angina pectoris
What is angina pectoris?
- A condition marked by severe pain in the chest, often also spreading to the shoulders, arms and neck, owing to an inadequate blood supply to the heart
Nitrates dilate veins. What does this reduce?
- The preload to the heart
Nitrates dilate resistance arteries. What does this reduce? (2 points)
- Reduces cardiac workload (afterload)
- Reduces cardiac oxygen consumption
Nitrates dilate collateral coronary artery supply. What does this reduce?
- Anginal pain
Nitrates are inactivated by first pass metabolism. What are the ways in which nitrates can be put into the body? (3 points)
- Sublingual
- Transdermal
- Intravenous
What is meant by transdermal?
- Relating to the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body
How quickly do nitrates work if they are given as a spray (sublingually)?
- Short acting - works in minutes
How quickly do nitrates work if they are given as a transdermal patch?
- Works for many hours
How long a shelf life do nitrates have?
- Short shelf life
What is a common side effect of nitrates?
- Headaches
What condition are calcium channel blockers used for?
- Hypertension
What do calcium channel blockers do?
- Block calcium channels in smooth muscles
- Some more active on peripheral blood vessels (relaxation and vasodilation)
- Some more active on heart muscle (slow conduction of pacing impulses)
Some Calcium channel blockers are more active on peripheral blood vessels. Give 2 examples of these?
- Nifedipine
- Amlodipine
Some calcium channel blockers are more active on the heart muscle. Give an example of one of these?
- Verapamil
What is a side effect of taking calcium channel blockers?
- Lumpy, fibrous gums
also seen with cyclo sporin and phenytoin
What does ‘ACE’ inhibitors stand for?
- Angiotensin Converting Enzyme
What are 3 examples of ACE inhibitors?
- Enalapril
- Ramapril
- Lisinopril
(-pril)
What do ACE inhibitors do?
- Inhibit conversion of angiotensin I to angiotensin II
- This prevents aldosterone dependent reabsorption of salt and water
What effects do ACE inhibitors have on blood pressure and fluid retention?
- Reduce blood pressure
- Reduce excess salt and water retention
What are 2 side effects of ACE inhibitors?
- Cough
- Hypotension (low blood pressure)
Angiotensin II blockers inhibit the same system as ACE inhibitors but by a different system as they block the receptor but don’t stop you making it. What is an example of an angiotensin II blocker?
- Losartan
One side effect on taking ACE inhibitor is the development of angio-oedema. What is this?
- A condition characterised as a severe swelling under the skin surface
