Lecture 20: Pharmaceutical Care in Cardiovascular disease Flashcards
What are the causes of heart failure?
- Myocardial Infarction
- Hypertension
- Atrial Fibrillation
- Alcohol / drugs
- Valve diseases
- Viral / thyroid
What are the clinical symptoms of heart failure? (5)
- breathlessness
- nocturnal symptoms
- fatigue
- ankle oedema
- poor exercise tolerance
What investigations should be done for heart failure?
- Chest x-ray
- Echocardiogram
- Ejection Fraction
- Electrocardiogram
- BNP
What blood tests are done for heart failure?
- Full blood count
- Urea and electrolytes
- TFTs
- Iron studies
What is New York Heart Classification?
I - Asymptomatic, even on exercise
II - Heart failure symptoms, but only on exercise
III - Heart failure symptoms on very mild exercise
IV - Heart failure symptoms at rest
What is Non-pharmacological management for heart failure?
- Education for patients and carers
May include self-management advice (e.g. diuretic adjustment within pre-defined and individualised limits) - Self-monitoring of weight
Gain of >2kg in 2-3 days seek advice or self-adjust diuretic dose - Dietary measures
Reduce salt intake (care with salt substitutes)
Fluid restrict in advanced heart failure (1.5-2.0L/day)
Moderate alcohol intake
Weight reduction if obese - Other lifestyle issues
Smoking cessation
Exercise; best rest in acute heart failure, exercise training programs encouraged for stable patients
What is heart failure?
Left ventricular systolic Dysfunction
What is left ventricular systolic dysfunction?
Damage to the left ventricle
What are the signs for heart failure?
- Elevated jugular venous pressure
- Pulmonary crackles
- Peripheral Oedema
How is heart failure examined?
- Auscultation
- Heart rate may be very fast
- Jugular venous pressure (JVP) may be elevated
What are the investigations for heart failure?
- Chest xray
- Echocardiogram
- Ejection fraction
- BNP
- Electrocardiogram
What blood tests are done for heart failure?
- Full blood count
- Urea and electrolyte
- Thyroid function tests
- Iron studies
What is NYH I?
Asymptomatic, even on exercise
What is NYH II?
Heart failure symptoms but only on exercise
What is NYH III?
Heart failure symptoms on very mild exercise
What is NYH IV?
Heart failure symptoms at rest
What is the non pharmacological management for heart failure?
- Education for patients and carers
- Self monitoring of weight
- Dietary measures
- Smoking cessation
- Exercise
What is self monitoring of weight in heart failure patients?
Gain of more than 2kg in 2-3, seek advice or self adjust diuretic dose
What are the dietary measures for heart failure?
- Reduce salt intake
- Fluid restrict in advanced heart failure (1.5-2L a day)
- Moderate alcohol intake
- Weight reduction if obese
What are the therapeutic options for heart failure?
- Diuretics
- ACE inhibitors
- Angiotensin receptor blockers
- Beta blockers
- Aldosterone antagonists
- Digoxin
- Vasodilators
- Sacubitril/ Valsartan
- Dapagliflozin
What monitoring is required with diuretics?
- Renal function and electrolytes
- Monitor weight and adjust dose
What are the counseling points for diuretics?
- Counsel patients on flexible dosing time
- Inconvenience as you need to pee a lot
- Diuretics can cause gout
What are diuretics place in therapy?
Used to control symptoms
How are diuretics usually given?
- Loop diuretic is usually given
- Combination of loop diuretic and thiazide may be required
- May be given orally/ intravenously
What is furosemide 40mg equivalent to?
Bumetamide 1mg
What are ACE inhibitor place in therapy?
- Improve survival and symptoms and reduce hospitalization
- Indicated for all grades of heart failure unless contraindicated
What monitoring is required with ACE inhibitors?
Renal function and electrolytes before and after each dose change and initial dose
When can you combine an ARB with an ACE inhibitor?
In patients who remain symptomatic for additional benefits
What is the choice for ARB?
- Candesartan
- Valsartan
What are beta blockers place in therapy?
- Reduce hospitalization, morbidity and mortality
- Indicated for stable patients in addition to an ACE inhibitor or angiotensin receptor blocker
What is the choice of beta blocker?
- Carvedilol
- Bisoprolol
- Nebivilol
- Metopralol
What are the practical points for beta blockers?
- Patients heart failure should be stable at initiation
- Heart failure symptoms may be exacerbated during titration
- Avoid abrupt withdrawal
What beta blocker is better for a hypertensive patient with heart failure?
Bisoprolol - a cardio selective beta blocker
What is ivabradines place in therapy?
- Reduces mortality and hospitalization
- NYHA II- IV
- Used in patients intolerant to beta blockers or in addition to beta blocker if HR>75
What are the practical points of ivabradine?
- Avoid grapefruit
- Bradycardia
- Sinus Rythm
What are aldosterone antagonists place in therapy?
- Spironolactone reduces morbidity and mortality when added to usual treatment in advanced heart failure patients ( Class III-IV)
- Eplerenone reduces morbidity and mortality when added to usual treatment in MI complicated by heart failure or in spironolactone intolerant heart failure patients
What needs to be checked before initiation of aldosterone antagonists?
Serum creatinine and potassium levels
What is the initial dose of spironolactone?
12.5-25mg OD
What is the initial dose of eplerenone?
25mg OD
When do serum and potassium levels need to be re checked when first given a aldosterone antagonist?
After 4-6 days
What are vasodilators place in therapy?
- Hydralazine combined with isosorbide dinitrate improve survival
- Only indicated if patient remains symptomatic or if all other options have been considered
What are heart failure exacerbating drugs?
- NSAIDS/ COX inhibitors
- Rate limiting calcium channel blockers
- Chemotherapy
- Anti psychotic drugs
- Glitazones
- Corticosteroids
- Medicines with a high sodium content
