Myocardial ischaemia (stable angina) + oedema Flashcards by Michelle Mwangi

what are some short-acting nitrates for acute angina attacks?

-glyceryl trinitrate
-isosorbide dinitrate (S/L)

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what are some long-acting nitrates used for long term prophylaxis of angina?

-MR isosorbide denigrate
-isosorbide mononitrate

-beta blockers
-CCB
-ivabradine
-ranolazine
-nicorandil

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how does glyceryl trinitrate work?

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what formulation does glyceryl trinitrate come in?

-sublingual tablet or spray
-effects last 20-30mins
-if using more than twice a week- needs long term prophylaxis

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what are the special requirements for sublingual tablets glyceryl trinitrate tablets?

-expires 8 weeks after opening
-foil-lined container with no cotton wadding

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how do you take a glyceryl trinitrate?

-when required or before angina-inducing activities e.g. exercise
-take it sitting down as dizziness can occur
~take 1st dose under tongue and wait 5 mins
~take 2nd dose and wait 5 mins
~IF NOT GONE AWAY CALL FOR HELP 999
(CALL AFTER 5 MINS OF THE 2ND DOSE)

1 dose=1 tablet or 1-2 sprays

-if pain persists call 999

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-what drugs can be used for angina long term prophylaxis?

first line -b-blocker or RL CCB e.g. diltiazem
second line -b-blocker + dihydropyridine CCB (if one or both are contra-indicated add/use vasodilator
third line- Ranolazine, long acting nitrate, nicorandil, ivabradine

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what side effects can nicorandil cause?

GI and mucosal ulceration

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what are some examples of vasodilators?

-long-acting nitrate
-ivabradine (only in normal sinus rhythm)
-ranolazine
-nicorandil in adults only (K-channel activator) (now given as second line risk of ulcer complications )
-dont drive until it is established performance is not impaired

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what are nitrates?

are potent coronary vasodilators and reduce venous return and cardiac output.

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how is a tolerance built when using nitrates?

-with long-acting preparations or transdermal
-they maintain effectiveness by reducing blood nitrate conc to low levels for 4-12 hours
-leave patches off for 8-12 hours (overnight) in a day
-take second dose after 8hrs not 12 hours ~for MR isosorbide denigrate (BD) and isosorbide mononitrate (BD)
-MR isosorbide mononitrate is taken OD~ therefore doesn’t produce tolerance

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what are some side effects of nitrates?

-vasodilation
-flushing
-throbbing headaches
-dizziness
-postural hypotension
-tachycardia
-dyspepsia
-heartburn

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what can be the side effects of injection GTN and isosorbide dinitrate in MI?

-severe hypotension, sweating, apprehension, restlessness, muscle twitching, retrosternal discomfort and palpations

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what should you avoid doing with nitrates?

sudden withdrawal and CCB as it can worsen angina

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what is the umbrella term acute coronary syndrome used for?

-myocardial infarction: nstemi/stemi
-unstable angina

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What is the primary management for acute coronary syndrome?

-O2 if hypoxia
-ischaemiac pain= GTN/IV isosorbide dinitrate, IV diamorphine/morphine with metoclopramide
-reperfusion= aspirin 300mg +clopidogrel 300mg, PCI or thromolytic (alteplase within 4.5hrs, streptokinase within 12hrs-avoid 4 days after
-prevent re-occlusion systemic and embolisation=parenteral anticoagulant

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what is secondary prevention for NSTEMI/STEMI/ UNSTABLE ANGINA?

-long term management=SAAB: statin, ACEi, aspirin indefinitely, b-blocker, clopidogrel, PRASGUREL or ticagrelor

prasugrel is they’ve had a PCI for STEMI

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What’s the difference between NSTEMI and STEMI?

STEMI= complete blockage of the artery
NSTEMI= partial blockage

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what is PCI?

Percutaneous coronary intervention

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what is used as part of dual-anti platelet therapy?

aspirin (forever) + clopidogrel (elective=one month, bare metal stent= 12 months, drug eluting stent=12+ months)

-aspirin + prasugrel is they’ve had a PCI for STEMI

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what is the management of a medical emergency in the community for unstable angina and NSTEMI?

-dispersible/chewable ASPIRIN 300mg STAT +note.
-GTN as required sublingually (0.3-1mg) or spray 1-2

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what is the management of a medical emergency in the community for STEMI?

-dispersible/chewable ASPIRIN 300mg STAT +note.
-GTN as required sublingually (0.3-1mg) or spray 1-2
-IV diamorphine /morphine +metoclopramide

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what is the management for a cardia arrest?

-cardiopulmonary resuscitation= 20 compressions:2 breaths
~100 compressions per min
-IV adrenaline 1 in 1000 every 3-5min (sympathomimetic ionotrope used in cariogenic shock)
-if ventricular fibrillation present: IV amiodarone

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what time of day do you take medication for oedema?

-in the morning to avoid sleep disruption

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what are some examples of loop diuretics?

bumetanide furosemide torasemide

what are some examples of thiazides?

-bendroflumethaizide -cyclopenthiazide

what are some examples of thiazide related diuretics?

chlortalidone -indapamide -metolzaone -xipamide

what are some examples of potassium-sparing diuretics?

triamterene amiloride

what are some examples of aldosterone antagonists?

-spironolactone -eplerenone

what are some examples of osmotic diuretics?

mannitol (used in cerebral oedema)

what are some examples of carbonic anhydrase inhibitor?

-acetozolamide

what is a diuretic and how do they work?

-increase urine output by the kidney i.e. promotes diuresis by inhibiting reabsorption at diff parts of the renal tubular system

how do loop diuretics work? Onset of action and duration of action

-inhibit Na+/K+/Cl- co-transporter in ascending limb of loop of henle. -1 hour onset -6 hours duration

what are some of the side effects of loop diuretics?

-ototoxicity (tinnitus, deafness) -acute urinary retention ~too rapid diuresis, caution in benign prostatic hyperplasia -can cause hyperglycaemia in diabetics and hyperuricaemia in ppl with gout (furosemide).

what other levels can be reduced when using loop diuretics?

~low- potassium, sodium, chloride and magnesium (alcoholic cirrhosis ~low calcium

what loop diuretics are used in heart failure?

(BD take last dose at 4pm) 20-40mg OM- furosemide doses

what loop diuretics are used in resistant hypertension?

-bumetanide -torasemide -furosemide

how do thiazides & related diuretics work?

-inhibit Na+/Cl- transporters in the distal convoluted tubule.

what is the onset of action for thiazides and related diuretics?

1-2 hours

what is the duration of action for thiazides and related diuretics?

12-24 hours

what are some side effects of thiazides and related diuretics?

gI disturbances. Impotence high LDL/triglycerides -hyperglycaemia in diabetes -hyperuricaemia in gout

what thiazides and related diuretics do to electrolytes?

-Hypo K+, Na+ Cl-, Mg2+ (alcoholic cirrhosis) -Hyper Ca2+ -ineffective if eGFR <30ml/min except metolazone

what is the dose of thiazides and related diuretics for HF AND hypertension?

HF= OM 5mg hypertension= OM 2.5mg -bendroflumethiazdie doses

when is metolazone used?

in severe RF

which patients groups is indapamide used less in?

diabetics

what is the dosing for chlortalidone?

it has a long t1/2 therefore given on alternative days if acute retention is a problem or dislikes frequent urination

what are potassium-sparing diuretics?

they promote urination without the loss of potassium by inhibiting sodium channels in the distal convoluted tubule. They are weak diuretics used as an adjunct to loop and thiazides diuretics

what are examples of 2 potassium-sparing diuretics?

-triamterene (urine looks blue in some lights -amiloride another sub group of them= MRA/aldosterone antagonist: spironolcatone/ eplerenone

what is the use of potassium-sparing diuretics?

they are preferred over potassium supplements in counteracting hypOkalaemia?

what are some side effects of potassium-sparing diuretics?

hypERkalaemia, hypotension, hyponautreamia, dehydration, gynaecomastia, change in libido, (spirononlactone= decrease lithium levels)

what are some interaction of potassium-sparing diuretics?

-hypERkaleamia = avoid concomitant ACEi/ARB, K+ supplements, aldosterone antagonist

what are aldosterone antagonists?

they inhibit aldosterone which causes Na+/K+/H+ co-transporter. Less potassium and hydrogen ions are exchanged for sodium and therefore less lost in the urine

what are some some examples of aldosterone antagonist?

-spirnolactone (used in ascites in liver failure) -eplerononewhat

are some SE of aldosterone antagonist? (spironolactone)

-gynaecomastia, being breast tumour, menstrual disturbances -hypertrichosis -change in libido -hypERkaleamia, hyperaemia, hypOnatraemia

what are some main interactions withaldosterone antagonist?

-severe hypERkalaemia =potassium-sparing diuretics, potassium supplements, ACEi/ARBs

what are osmotic diuretics?

-inhibits sodium and water reabsorption by increasing the osmolarity (solute concentration) of blood and renal filtrate. Osmotic diuretic act on the parts of the nephron that are water permeable; proximal convoluted tubule and descending limb of the loop of henle.

what are some examples of an osmotic diuretic?

mannitol (pharmacologically inert sugar)

what is the use of mannitol?

-cerebral oedema -high intracranial pressure

what is the management for simple gravitational oedema in the elderly?

low dose diuretic -not long term use. try alternatives first e,g. stockings, rising legs and movement

what is peripheral vascular disease? types and management

2 types: can be occulsive -e.g. intermittent claudication caused by atherosclerosis. This is known as peripheral arterial disease management= aspirin 75mg and statin as secondary prevention can be vasospstic= e.g. raynauds syndrome= stop smoking and avoid the cold environments = nifedipine used to treat raynauds syndrome