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Cardiology > Heart drugs 1 - AF and Heart failure > Flashcards

Heart drugs 1 - AF and Heart failure Flashcards

1
Q

What is the pathophysiology of atrial fibrilation?

A

Chaotic atrial electrical activity

Fibrosis and loss of atrial muscle mass due to factors like:
-ageing
-chamber dilatation
-inflammation (scarring)
-genetic

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2
Q

What are the risk factors for AF?

A

-HTN
-Valvular heart disease
-Coronary heart disease
-Cardiomyopathy
-Congenital heart disease
-Previous cardiac surgery
-Pericarditis
-Lung disease e.g., PE, pneumonia, COPD
-Hyperthyroidism (do a TFT)
-Alcohol

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3
Q

What is the classification of AF?

A

Lone AF

Paroxysmal (< 7 days) - AF comes in waves

Persistent (>7 days)

Permanent (>7 days +/- cardioversion)

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4
Q

What is cardioversion?

A

A medical procedure that uses quick, low-energy shocks to restore a regular heart rhythm

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5
Q

What are the clinical features of AF?

A

Asymptomatic

Palpitations

SOB

Chest pain

Syncope (i.e., actually passing out)

Pre-syncope (i.e., feeling that one is going to pass out)

Heart failure

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6
Q

What are the 3 main categories of AF treatment?

A

Rate control

Rhythm control

Anticoagulation

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7
Q

For someone with recent onset AF who is compromised, what Tx should be given?

A

DC shock

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8
Q

For someone with recent onset AF who is uncompromised, what Tx should be given?

A

Pharmacotherapy

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9
Q

For someone with recent onset AF that is < 48 hours duration, what Tx should be given?

A

Attempt rhythm control

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10
Q

For someone with recent onset AF that is > 48 hours duration, what Tx should be given?

A

Rate control

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11
Q

In which situations is rhythm control preferred?

A

Symptom improvement

Younger patient

Heart failure related to AF

Adequacy of rate control

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12
Q

For someone with acute AF without HF what are the 1st and 2nd line drugs?

A

1st = Beta blocker OR CCB (Diltiazem, Verapamil)

2nd = add digoxin

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13
Q

For someone with acute AF with HF what are the 1st and 2nd line drugs?

A

1st = Digoxin, amiodarone

2nd = Amiodarone

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14
Q

For someone with permanent or paroxysmal AF what are the 1st and 2nd line drugs?

A

1st = Beta blocker OR CCB

2nd = add digoxin

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15
Q

What are the indications for rhythm control and what drugs are used for each?

A

Acute cardioversion (normal heart) = fleicanide, sotalol

Acute cardioversion (abnormal heart) = amiodarone

Maintain sinus rhythm (normal heart) = fleicanide, sotalol

Maintain sinus rhythm (abnormal heart) = amiodarone

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16
Q

Name the non-selective beta blockers

A

Propranolol

Sotalol

Carvedilol

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17
Q

Name the cardioselective beta blockers

A

Atenelol - 90% of the drug is renally cleared

Bisoprolol

Esmolol

Metoprolol

Nebivolol

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18
Q

Name the vasodilatory beta blockers

A

Labetalol

Carvedilol

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19
Q

Name the rate limiting CCBs

A

Verapamil

Diltiazem

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20
Q

Name the dihydropyridine CCBs

HINT: the “dipines”

A

Amlodipine - can cross BBB

Nifedipine

Felodipine

Lercanidipine

Nimodipine

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21
Q

What is the CHA2DS2 VASc score and what are the components?

A

Score that predicts stroke risk in someone with AF

C – Congestive heart failure=1
H – Hypertension=1
A 2– Age >75years=2
D – Diabetes=1
S2 – Previous Stroke, TIA or thromboembolism=2
V – Vascular disease=1
A – Age 65-74 years=1
Sc – Sex category (female gender) =1

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22
Q

What should be done for a CHA2DS2VASc ≥2 ?

A

Give warfarin OR DOACs (e.g., rivaroxaban, endoxaban)

23
Q

What is the HAS-BLED score and what are its components?

A

Estimates risk of major bleeding for patients on anticoagulation to assess quality of AF care

H – Hypertension = 1
A – Abnormal renal/liver function = 1 point each
S – Stroke in the past = 1
B – Bleeding history = 1
L – Labile INRs = 1
E – Elderly = 1
D – Drugs/Alcohol concomitantly = 1 point each

24
Q

An HAS-BLED score ≥ which number indicates significant risk of bleeding?

A

3

25
Q

What other Tx are available for AF?

A

Radiofrequency catheter or Cryo- ablation

Left atrial appendage occlusion (LAAO) - (used for older persons that cannot be anticoagulated)

26
Q

What are the main Tx aims for heart failure

A

Relieve symptoms

Reduce mortality

27
Q

What are the main Tx categories for HF?

A

Lifestyle measures – Exercise
– ↓Alcohol
– Smoking Cessation
Drugs

Devices

Surgery

28
Q

Which of the HF drugs improve symptoms? (use + to indicate how well they improve symptoms)

A

Diuretics +++

ACEi +

Beta-blockers ++

Aldosterone antagonists ++

ARBs +

Hydralazine/Nitrates +

Digoxin +

29
Q

Which of the HF drugs reduce mortality? (use + to indicate how well they reduce mortality)

A

ACEi ++

Beta-blockers +++

Aldosterone antagonists ++

ARBs +

Hydralazine/Nitrates +

30
Q

Name the diuretics used in HF?

A

Loop (most commonly used ) e.g.,
furosemide

Thiazides e.g.,
-bendroflumethiazides
-metolazone (thiazide like)-causes profound diuresis

K+ sparing e.g.,
-spironolactone (a mineralocorticoid receptor antagonist)
-amiloride

31
Q

What are the actions of the different diuretics?

A
32
Q

What are the main aims of diuretics?

A

Provide symptom control

Reduce cardiac pre-load

NOTE: beware of the side-effects they have

33
Q

What are the benefits of ACEi in HF?

A

Increased life expectancy vs placebo

Effect more marked in patients with more severe LV dysfunction

Benefit for all NYHA classes

Reduces risk of hospitalisation

34
Q

What are the actions of ACE-i and ARBs?

A
35
Q

Name ACEi

A

Ramipril

Lisinopril

Enlapril

Perindopril

Catopril (was the first one but not commonly used today due to short half-life)

36
Q

Name some ARBs

A

Losartan

Candesartan

Valsartan

37
Q

What are the benefits of ARBs and in which situation are they used?

A

Reduces mortality

Some data on QoL, symptom control

Used in patients that cannot tolerate ACEi (as it often causes a dry cough)

38
Q

What are the benefits of beta blockers?

A

Increase life expectancy vs placebo (shown in RCT/meta-analyses)

All NYHA classes

Reduces hospitilisation

Evidence for bisoprol, carvedilol and metoprolol

39
Q

How should you use beta blockers in HF?

A

Start on low dose and titrate up

Monitor HR, BP and clinical progression

40
Q

In which group of HF patients is spironolactone used?

A

Severe heart failure (NYHA III-IV)

41
Q

What are the advantages of spironolactone in HF?

A

Increased life expectancy

Reduces hospital admission

42
Q

Which dose of spironolactone should be used HF?

A

Low dose - 12.5-25mg

43
Q

What other drugs are used in chronic HF?

A

Ivabradine (acts on fun ion channels)- used instead of beta blockers if HR too high (> 75bpm). Works to reduce the HR

Hydralazine + nitrate - used if ACEi/ARB not tolerated/contraindicated or in people of African origin

Sacubritil (neprilysin inhibitor)/Valsartan (ARB)

SGLT2 - can reduce risk for heart failure in patients with T2DM and can decrease risk of major cardiovascular events in patients with HF and diabetes

44
Q

What are the criteria for prescribing Sacubritil (neprilysin inhibitor)/Valsartan (ARB)?

A

New York Heart Association class II to IV symptoms

AND

a left ventricular ejection fraction of 35% or less

AND

who are already taking a stable dose of an ACE inhibitor or angiotensin II receptor antagonist.

45
Q

What are the basic measures for treating someone with acute HF?

A

Sit patient upright

High dose O2 = corrects hypoxia

46
Q

What are the initial drug Tx for someone with acute HF?

A

IV loop diuretics (e.g., furosemide) = cause venodilatation and diuresis

IV opiates/opioids (e.g., morpine/diamorphine) = reduce anxiety and preload (venodilatation)

IV, buccal or sublingual nitrates = reduce preload and afterload, ischaemia and pulmonary artery pressures

If they are already on beta blockers continue but DO NOT initiate it

47
Q

What other forms of therapy are there for HF (i.e., other non-pharmacological)?

A

Coronary revascularisation

Cardiac resynchronisation therapy

Cardiac transplantation

48
Q

Sources

A

Cardiovascular drugs 1 lecture - 20.11.2019

https://journals.lww.com/tnpj/Fulltext/2021/07000/SGLT2_inhibitors__What_role_do_they_play_in_heart.7.aspx#:~:text=Sodium%2Dglucose%20cotransporter%2D2%20(,in%20patients%20with%20HF%20only.

https://www.nice.org.uk/guidance/ng196/chapter/Recommendations#stroke-prevention

https://www.nice.org.uk/guidance/conditions-and-diseases/cardiovascular-conditions/embolism-and-thrombosis/products?GuidanceProgramme=TA

49
Q

What are the risk factors for use of dabigatran as anticoagulant in patients with AF?

A

previous stroke, TIA or systemic embolism

left ventricular ejection fraction below 40%

symptomatic heart failure of New York Heart Association (NYHA) class 2 or above

age 75 years or older

age 65 years or older with one of the following: diabetes mellitus, coronary artery disease or hypertension.

50
Q

What are the risk factors for use of endoxaban as anticoagulant in patients with AF?

A

congestive heart failure

HTN

diabetes

prior stroke or TIA

age 75 years or older.

51
Q

What are the risk factors for use of rivaroxaban as anticoagulant in patients with AF?

A

congestive heart failure

HTN

age 75 years or older

diabetes mellitus

prior stroke or TIA

52
Q

What are the risk factors for use of apixaban as anticoagulant in patients with AF?

A

prior stroke or TIA

age 75 years or older

HTN

diabetes mellitus

symptomatic heart failure.

53
Q

DOACs are 1st line anticoagulants in AF. If they are not tolerated what class of drugs can be used instead?

A

Vitamin K antagonists - e.g., warfarin, coumarol, acenocoumarol

Cardiology (15 decks)

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