cvs Flashcards
What is the management of stable angina?
First line= Mono therapy of a beta blocker or calcium channel blocker
Symptomatic relief- GTN spray
Second line= the above two together
Third line= add an additional anti angina- ivabradine or nicorandil and refer to cardiology for revascularisation
How does GTN work?
Converted to nitrous oxide which stimulates vascular smooth muscle relaxation through stimulation of cGMP dependent protein kinase with resultant reduction in intracellular calcium
State the effects of nitrates…
Venous dilatation- decreases preload
Arterial dilatation- decreases afterload
Coronary dilatation- improved myocardial oxygen supply
What are the uses of nitrates?
Oesophageal spasm
Angina
Heart failure
Topical use in anal fissure (GTN cream)
What are the side effects of nitrates?
Headache
Postural hypotension
Nausea and vomiting
What is the first line of heart failure?
ACE-I and beta blocker
What is the second line treatment for heart failure?
Aldosterone antagonist (spironolactone)
What is an important consideration of ACE-I and aldosterone anatagonist use?
Likely to be on both in heart failure, can cause hyperkalaemia therefore potassium should be monitored.
What is digoxin strongly indicated in?
It is strongly indicated in heart failure if there is co-existent heart failure
What vaccinations should be offered to heart failure patients?
Annual influenza and pneumococcal vaccination
What is the difference between cardio selective and non cardio selective drugs?
Cardio selective- selectively bind to and competitively inhibit the action of adrenaline and noradrenaline on beta 1 receptors, resulting in suppression of sympathetic nervous system
No cardio selective- inhibit the action of adrenaline and noradrenaline on both the beta 1 and beta 2 receptors
What effects do beta blockers have?
Reduce contractility, reduce heart rate, reduce electrical conduction, vasoconstrict
What are beta blockers used for?
Hypertension Post MI Migraine prophylaxis Rate control for AF Stable AF
Side effects of beta blockers?
Fatigue, headache, brachycardia, postural hypotension, nausea and vomiting
What is the 3rd line management for heart failure?
Cardiac resynchronisation therapy
What are examples of ACE-I
RAMIPRIL, LISINOPRIL etc
How do ACE- I work?
Inhibit ACE which usually converts angiotensin 1 to 2 and therefore prevents aldosterone production
Ultimately results in a reduced preload and afterload
What are the clinical indications of ACE-I
First line for under 55 year olds in hypertension First line in heart failure Used post MI Used in stable angina Diabetic nephropathy
What effect do ACE- I have on the kidneys?
Ang 2 is the major determinant of efferent vasoconstriction
This helps to maintain the GFR when-renal perfusion is low (old people with CCF, bilateral renal artery stenosis) blocking this protective mechanism in these patients can cause deterioration in kidney function and AKI.
What are the side effects of ACE-I?
Dry cough (build up of bradykinin) Hypotension Angio oedema Hyperkalaemia Renal impairemem t
When shouldn’t ACE-I be used?
Pregnancy and renal artery stenosis
Give an example of an angiotensin 2 receptor and what the MOA is
Competitively inhibit the action of angiotensin 2 at AT1 receptors
What are the effects of angiotensin 2 receptors?
Vascular smooth muscle relaxation
Reduced tubular sodium and water reabsorption
Reduced aldosterone secretion
How do aldosterone antagonists work?
They inhibit the action of aldosterone on the sodium- potassium exchange pumps in the distal convoluted tubule
What are aldosterone antagonists used in?
Conns
Refractory hypertension
Refractory heart failure
Peripheral oedema
What is the important adverse effect of spironolactone?
Hyperkalaemia
What is the secondary prevention medical management for those with angina?
Atorvastatin AMLODIPINE Aspirin Another anti platelet ACE-I Spironolactone in those with CCF
What is first line management for stable angina?
Aspirin
Statin
Sublingual GTN
Beta blocker or rate limiting CCB
When would you offer cardioversion for AF?
If it is reversible
If it has presented within the last 48 hours
If it causing heart failure
They remain asymptomatic despite being effectively rate controlled
What are the treatment opetions for AF?
Rate control- beta blockers and non dihypyridone CCBs are first line
Rythm control is favourable over rate control in persistent AF in a young patient/ disabling features of AF
Flecainide
Amiodarone (for structurally abnormal hearts)
What is paroxysmal AF and how should you treat this?
When AF comes and goes in episodes, not lasting more than 48 hours
Patients should be anti coagulated based on their CHADSVASC score and may be appropriate for a pill in the pocket, they have to have infrequent episodes without any underlying structural heart disease,
How do you reverse warfarin?
Vit K
How do you monitor warfarin and what are the side effects?
INR
SE: bleeding
Alopecia, nausea, vomiting
A patient with tachycardia and adverse features should be offered synchronised shock, what are these adverse features?
Heart failure
Ischaemia
Shock
Syncope
How do you treat a stable patient with tachycardia?
IV amiodarone
What is the treatment of tachycardia if the patient is unstable?
Synchronised DC shocks- 3 atempts then give 300mg Amiodarone and repeat then give amiodarone 900mg over 24 hours
How do you treat narrow complex tachycardia in a stable patient
AF- rate control with a beta blocker or CCB
A trial flutter- beta blockers
SVT- treat with vagal manoeuvres and adenosine
How do you treat broad complex tachycardia in a stable patient?
Ventricular tachycardia/unclear= amiodarone infusion
How would you treat a patient in atrial flutter?
Rate/ rythm control with beta blockers or cardioversion
Treat the underlying condition- hypertension, thyrotoxicosis
Radio frequency ablation of the re entrant rythm
Anticoagulation based on CHA2DS2VASc
What is the definition of AF?
Uncoordinated atrial contraction
What is the management of stable patients with SVT?
Valsalva manouvre Carotid sinus massage Adenosine (Verapamil as an alternative) If above fails then Direct current cardioversion
How does adenosine work?
Primarily works through the AV node and interrupts the AV node and accessory pathway during SVT and resets it back to sinus rhythm.
It actually briefly causes a period of asystole or bradycardia which is scary for both the patient and the doctor, however it is quickly metabolised and sinus rythm should return
When should you avoid using adenosine?
If patient has asthma, heart failure, heart block or severe hypotension
What is the dose for adenosine
Initially 6mg then 12mg
Can give a further 12mg if no improvement between doses
What is the long term management in patients with paroxysmal SVT?
Meds- CCB, beta blockers, amiodarone
Radio frequency ablation
