CVD MANAGEMENT Flashcards
FAST (Face Arm Speech Test)
fast drools
arms weaken
inability to speak properly or at all
For people who are admitted to the emergency department with a suspected stroke or TIA, what do we use to establish a diagnosis of stroke
the ROSIER tool
(Recognition of Stroke in the Emergency Room)
which medication is started ASAP within 4 hours of onset of stroke symptoms
Alteplase
treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms and
* intracranial haemorrhage has been excluded by appropriate imaging technique
describe how we manage acute ischaemic stroke with thromboectomy
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if not contraindicated and within the licensed time window), to people who have:
* acute ischaemic stroke and
* confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or
magnetic resonance angiography (MRA
describe how we use aspirin and anticoagulants in the treatment of acute ischaemic stroke
Offer the following as soon as possible, but certainly within 24 hours, to everyone** presenting with acute stroke who has had a diagnosis of intracerebral
haemorrhage excluded by brain imaging:
* aspirin 300 mg orally if they do not have dysphagia **or
- aspirin 300 mg rectally or by enteral tube if they do have dysphagia.
Continue aspirin daily 300 mg until 2 weeks after the onset of stroke symptoms, at which time **start definitive long-term antithrombotic treatment.
Start people on long-term treatment earlier if they are being discharged before 2 weeks.
- Offer a proton pump inhibitor, in addition to aspirin, to anyone with acute ischaemic **stroke for whom previous dyspepsia associated with aspirin **is reported.
remember that with aspirin a diagnosis of intracerebral harmmrrhage needs to be excluded before it’s use
if someone experiences a haemorrhagic stroke, what do we do straight away before the treatment of their stroke or alongside it
haemorrhage=bleeding
Return clotting levels to normal as soon as possible in people with a primary intracerebral haemorrhage who were receiving warfarin before their stroke (and have elevated international normalised ratio).
Do this by reversing the effects of the warfarin using a combination of prothrombin complex concentrate and intravenous vitamin K
how do we treat people with disabling ischaemic stroke who are in AF (atrial fibrillation)
treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment is considered
some pharmacological and non pharmacological methods for Secondary prevention following a stroke
or TIA
Control of blood pressure as per NICE guidance –** target of 130/80** in established cerebrovascular disease
✓Antiplatelet agents – The standard treatment clopidogrel 75mg daily (licensed for use in ischaemic stroke, off-label use in TIA).
✓Cholesterol lowering – high intensity statin e.g., atorvastatin 80mg
✓Lifestyle advice
lifestyle advice for those with stroke or TIA or even at risk of them
Encourage physical activity every day:
- Advise the person to minimize time spent sitting for long periods (unless there are contraindications).
- Individualized exercise programs (which may include muscle strengthening,
balance, and co-ordination activities) for people with stroke should be prescribed,
delivered, and monitored by the rehabilitation team. - Advise smokers to stop and non-smokers to avoid passive smoking
*Advise the person that diet optimization can help reduce cardiovascular disease (CVD) risk — they should aim to:
✓ Eat at least five portions of fruit and vegetables (from a variety of sources) per day
and two portions of oily fish per week.
✓ Reduce intake of saturated fats.
✓Keep salt intake low — salt should not be added at the table, and processed foods should be kept to a minimum.
how do we detect or diagnose AF
Perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of atrial fibrillation.
- Perform a 12-lead electrocardiogram (ECG) to make a diagnosis of atrial fibrillation if an irregular pulse is detected
- use a 24-hour ambulatory ECG monitor if asymptomatic episodes are suspected or symptomatic episodes are less than 24 hours apart
- TTE / TOE – echocardiogram
AF classified into** paroxysmal**(episodes last longer than 30 secs but less than 7 days), persistent( lasts more than 7 days ) and permanent( fails to terminate using
cardioversion, AF that is terminated but relapses
within 24 hours, or longstanding AF (usually longer
than 1 year) in which cardioversion has not been
indicated or attempted (sometimes called accepted
permanent AF))
what tool is used to assess someone’s risk of stroke
what do you know about this tool
CHA2-DS2-VASC2
the max score one can get is 9
assesses patient’s based on;
congestive heart faulure
hypertension
age>= 75
diabetes mellitus
stroke/TIA/thrombo-embolism
vascular diseases
age 65-74
sex category(i.e male or female )
a point is awarded for each category, apart from if age>=75 or is stroke/TIA/ or thromboembolism, each for which a score of 2 is awarded
a point is awarded for being a female
how do we treat those under 65 with AF and no other risk factors of stroke or TIA other than their sex(in other words very low risk), i.e a score of 0 for men or 1 for women
Do not offer stroke prevention therapy at all. lifestyle modification indicated
what do we do for men with a CHA2-DS2-VASC2 score of 1
consider antocoagulation and take into account their bleeding risk
for people with a CHA2-DS2-VASC2 score of 2 or above, what do we do
Offer anticoagulation to people with a CHA2DS2-
VASc score of 2 or above, taking bleeding risk into
account.
DOACs are first line, i.e Apixaban, dabigatran,
edoxaban and rivaroxaban are recommended
- If direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist. (Warfarin)
- If warfarin is contraindicated consider referral to a cardiology specialist, who may advise other risk reducing procedures including left atrial appendage closure (LAAC).
follow this for most if not all of the coagulation therapies mentioned in subsequent flashcards
what does the orbit score do
it assesses the bleeding risk in patients on anticoagulation therapy
low risk-1 or 2
moderate risk- 3
high risk-4 and above
max score is 9
treatment for AF
first line- rate control with beta blockers, CCBs(NDHPs) or digoxin if others not effective
then rhythm control with amiodarone or cardioversion
**note that combination of a BB, diltiazem or digoxin may be used in single therapies are not sufficient **
then anticoagulation therapy
note that if onset of symptoms < 48hours then rate control not always first line, as rhythm control can also be used.
if onset >48hours then rate control 100% first line
drug treatment used in long-term rhythm control in AF
Standard beta-blocker e.g. atenolol, bisoprolol
- Second line agents can include; amiodarone if evidence of structural heart disease.** flecainide** 50-100mg BD (not if IHD or structural heart problems) or ** Dronedarone** for theMaintenance of sinus rhythm after cardioversion 400 mg twice daily
how do we treat acute STEMI in those ith acute STEMI who are having primary PCI
Primary percutaneous coronary intervention (PPCI), also known as primary angioplasty or coronary angioplasty, is a minimally invasive procedure used to treat blocked coronary arteries in the heart, particularly during a heart attack
offer prasugrel, as part of dual antiplatelet therapy with aspirin, if they are not already taking an oral anticoagulant (for people aged 75 and over,
think about whether the person’s risk of bleeding with prasugrel outweighs its effectiveness, in which case offer ticagrelor or clopidogrel as alternatives)
offer clopidogrel, as part of dual antiplatelet therapy with aspirin, if they are already taking an oral anticoagulant.
Primary percutaneous coronary intervention (PPCI), also known as primary angioplasty or coronary angioplasty, is a minimally invasive procedure used to treat blocked coronary arteries in the heart, particularly during a heart attack
if someone is having a heart attack, what do we do initially to help or manage it
ring 999 right away
While waiting for an ambulance, it may help to chew and then swallow a tablet of aspirin (ideally 300mg), as long as the person having a heart attack is not allergic to aspirin
If they have tablets or a spray, let them take it.
name some drugs or classes of drugs used post MI
ACEi or ARBs
Beta Blockers
Verapamil
Statins
DAPT(Dual Antiplatelet Therapy = 2 Antiplatelets used together for 12 months. Reduces platelet aggregation and thrombus formation to some degree)
name some anti anginal agents
- Isosorbide Mononitrate – Vasodilatory effects due to mimicking effect of NO. (Longer term anti anginal)
- Glyceryl Trinitrate – Very short vasodilatory action; fast acting – Useful in acute angina.
- Calcium Channel Blockers – Vasodilatory effect secondary to relaxation of vascular smooth muscle. Reduces effect of Calcium in contraction therefore
longer time in relaxation.
