NICE Guidelines Flashcards
Whats CHadsvasc
The CHADS₂ score and its updated version, the CHA₂DS₂-VASc score, are clinical prediction rules for estimating the risk of stroke in people with non-rheumatic atrial fibrillation
What is advice around atrial fibrillation
Remember beta blocker + Anticoagulation (DOAC 1st line)
Summarise the guidelines for the treatment of atrial fibrillation
- Stroke Prevention and Anticoagulation
CHA₂DS₂-VASc Score: Assess stroke risk using the CHA₂DS₂-VASc score.
Anticoagulation is recommended for people with a score of 2 or more (men) or 3 or more (women).
For those with a score of 1 (men) or 2 (women), consider anticoagulation based on individual risk factors and preferences.
DOACs (Direct Oral Anticoagulants), such as apixaban, rivaroxaban, dabigatran, or edoxaban, are the preferred first-line therapy for stroke prevention over warfarin unless contraindicated or not tolerated.
Warfarin is only recommended if DOACs are unsuitable or not well-tolerated, with regular monitoring of INR levels. - Rate Control
First-line therapy for most patients, especially those with permanent or persistent AF.
Beta-blockers (e.g., bisoprolol, metoprolol) or rate-limiting calcium channel blockers (e.g., diltiazem, verapamil) are recommended for initial rate control.
If monotherapy is inadequate, a combination of two of the following may be considered:
Beta-blocker
Diltiazem/verapamil
Digoxin (usually added for sedentary patients or in combination for more active patients).
Digoxin monotherapy is generally reserved for less active individuals with permanent AF. - Rhythm Control
Rhythm control is considered for patients where rate control has failed or if AF is causing severe symptoms.
Cardioversion is an option for people with newly diagnosed AF, with either:
Pharmacological cardioversion (with anti-arrhythmic drugs such as flecainide or amiodarone).
Electrical cardioversion if pharmacological methods are ineffective or not suitable.
Anti-arrhythmic drugs:
Flecainide or propafenone is recommended for people with no structural heart disease.
Amiodarone is reserved for patients with structural heart disease or where other drugs are not effective.
Long-term rhythm control may include anti-arrhythmic drugs or catheter ablation, depending on patient-specific factors.
BMJ guidelines:For heart failure with reduced ejection fraction (HFrEF), the “four pillars” of treatment include:
ACE inhibitors/ARBs/ARNIs: To manage neurohormonal dysfunction.
Beta-blockers: To control heart rate and reduce strain on the heart.
Mineralocorticoid receptor antagonists (MRAs): For reducing fluid retention and improving survival.
SGLT2 inhibitors: A recent addition that significantly reduces heart failure-related hospitalizations.
Diuretics are commonly used to manage symptoms but do not improve mortality. Monitoring and titration are key.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- Heart Failure with Reduced Ejection Fraction (HFrEF)
This applies to patients with left ventricular ejection fraction (LVEF) of ≤40%.
First-line Therapies
ACE Inhibitors (e.g., ramipril, enalapril) or Angiotensin II Receptor Blockers (ARBs) (e.g., candesartan, losartan):
Start in all patients with HFrEF unless contraindicated.
ARB is used if the patient cannot tolerate ACE inhibitors.
Monitor kidney function and potassium levels before and during treatment.
Beta-blockers (e.g., bisoprolol, carvedilol, metoprolol):
Initiate in all patients with HFrEF, regardless of symptoms.
Start at a low dose and titrate slowly to the target dose, ensuring tolerance.
Mineralocorticoid Receptor Antagonists (MRAs) (e.g., spironolactone, eplerenone):
Add to ACE inhibitors (or ARBs) and beta-blockers for patients with symptomatic HFrEF.
Regularly monitor potassium and renal function.
Second-line and Additional Therapies
ARNI (Angiotensin Receptor-Neprilysin Inhibitor): (e.g., sacubitril/valsartan)
Consider switching from an ACE inhibitor/ARB to an ARNI in patients with ongoing symptoms despite optimal treatment.
SGLT2 Inhibitors (e.g., dapagliflozin, empagliflozin):
Recommended in addition to first-line therapy to improve outcomes in HFrEF, even in patients without diabetes.
Ivabradine:
Consider if the patient has a heart rate of ≥75 bpm, is in sinus rhythm, and is already on optimal doses of beta-blockers (or if beta-blockers are contraindicated).
Hydralazine and Nitrate:
Consider in patients of African or Caribbean origin, or those who cannot tolerate ACE inhibitors or ARBs.
Digoxin:
Consider in patients with persistent symptoms of heart failure or for rate control in patients with atrial fibrillation (AF).
Heart Failure with Preserved Ejection Fraction (HFpEF)
Heart Failure with Preserved Ejection Fraction (HFpEF)
This applies to patients with an LVEF > 40-50%. There are no specific disease-modifying drugs for HFpEF, but treatment focuses on managing symptoms and comorbidities.
Diuretics:
First-line therapy to relieve symptoms of fluid overload (e.g., furosemide, bumetanide).
Manage comorbidities:
Treat hypertension, diabetes, coronary artery disease, and AF according to standard guidelines.
Consider MRAs (e.g., spironolactone) for symptom relief in selected patients with HFpEF.
3. Device Therapy
What is the NICE guidance for hypertension?
Step 1:
ACE inhibitors or ARBs for patients under 55.
Calcium-channel blockers (CCBs) for those over 55 or of African/Caribbean descent.
Step 2:
Combine ACE inhibitors/ARBs with CCBs.
Step 3:
Add thiazide-like diuretics if blood pressure remains uncontrolled.
Step 4:
Consider further treatment with alpha-blockers, beta-blockers, or other diuretics if necessary.
What are the guidelines for treating pericarditis?
The NICE guidelines for treating acute pericarditis recommend:
First-line therapy: Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, along with colchicine to reduce recurrence risk.
Corticosteroids: Used if NSAIDs and colchicine are ineffective or contraindicated, though they are generally avoided due to higher recurrence risks.
Treatment of the underlying cause: If pericarditis is due to infection, autoimmune disease, or cancer, the treatment should target the primary condition.
The NICE guidelines for treating stroke
The NICE guidelines for treating stroke focus on immediate care and long-term management:
Acute care:
Thrombolysis (using alteplase) within 4.5 hours for eligible patients with ischemic stroke.
Thrombectomy for large artery occlusion.
Aspirin (300 mg) within 24 hours for those not receiving thrombolysis or thrombectomy.
Secondary prevention:
Antiplatelet therapy (aspirin or clopidogrel).
Blood pressure control, statins, and anticoagulation for atrial fibrillation.
Here’s a more detailed breakdown of secondary prevention in the NICE guidelines for stroke:
Antiplatelet Therapy:
Start clopidogrel 75 mg daily long-term for patients with ischemic stroke.
If clopidogrel is not suitable, use a combination of aspirin 75 mg and dipyridamole MR (modified-release).
Blood Pressure Control:
Aim for a target blood pressure below 130/80 mmHg, with antihypertensives (e.g., ACE inhibitors, calcium channel blockers).
Anticoagulation:
For patients with atrial fibrillation, long-term anticoagulation with warfarin or DOACs (e.g., apixaban) is recommended.
Lipid Management:
Statins (e.g., atorvastatin) are recommended for all ischemic stroke patients with high cholesterol, aiming to reduce LDL-C by 50%.
WHat are the NICE guidelines for dementia?
The NICE guidelines for treating dementia recommend:
Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-to-moderate Alzheimer’s disease.
Memantine for moderate Alzheimer’s disease if acetylcholinesterase inhibitors are unsuitable, or for severe cases.
Treatment for Lewy body dementia and Parkinson’s disease dementia with acetylcholinesterase inhibitors.
Non-pharmacological interventions (cognitive stimulation, exercise) for managing symptoms.
Antipsychotics only for severe distress or risk of harm, with regular review.
Non-Pharmacological Interventions:
Cognitive stimulation, physical activity, and social engagement are recommended.
Managing behavioral and psychological symptoms (BPSD) using a patient-centered approach.
Monitoring:
Regular reviews of medication and overall care.
The NICE guidelines for treating non-cognitive symptoms of dementia focus on addressing behavioral and psychological issues such as agitation, aggression, depression, and psychosis:
Non-pharmacological interventions are first-line treatments:
Personalized care, including activities tailored to individual preferences.
Environmental modifications and caregiver support.
Antipsychotic medications (e.g., risperidone) are only used for severe distress or risk of harm, with close monitoring and regular review.
Antidepressants may be considered for depressive symptoms, while non-drug approaches are prioritized for anxiety and sleep issues.
What is the treatment for Focal seizures ?
Types of Focal Seizures:
Focal Aware Seizures:
Previously known as simple partial seizures.
Consciousness is not impaired, and the person is fully aware of what is happening.
Symptoms can include muscle twitching, unusual sensory experiences (like tingling or seeing flashing lights), and changes in emotions.
Focal Impaired Awareness Seizures:
Previously known as complex partial seizures.
Consciousness is altered, meaning the person may appear confused or unaware of their surroundings.
May involve repetitive movements like lip-smacking, hand movements, or wandering.
Focal to Bilateral Tonic-Clonic Seizures:
These start as focal seizures but spread to both sides of the brain, leading to a generalized seizure (formerly called secondary generalized seizures).
The person may lose consciousness and experience full-body convulsions.
Focal seizures with or without secondary generalisation
Consider lamotrigine or levetiracetam as first-line options
carbamazepine, oxcarbazepine, or zonisamide as second-line monotherapy
Lacosamide should be considered as third-line monotherapy
If monotherapy is unsuccessful, adjunctive treatment should be considered
What is the treatment for generalised seizures (tonic clonic)?
a type of generalized seizure that affects both sides of the brain and is characterized by two distinct phases:
- Tonic Phase:
In this initial phase, the muscles stiffen, and the person may fall to the ground due to a sudden loss of muscle control.
The back arches, and the person might cry out as air is forced out of the lungs.
This phase usually lasts for about 10-20 seconds. - Clonic Phase:
In the clonic phase, the muscles begin to jerk rhythmically in a pattern, usually involving the arms and legs.
This jerking may last for several minutes before slowing down and eventually stopping.
The person may bite their tongue, and their breathing might become irregular or even stop momentarily during the seizure.
Offer sodium valproate as first-line monotherapy for generalised tonic-clonic seizures in males, and females unable to have children. If treatment with sodium valproate is unsuccessful, consider lamotrigine or levetiracetam [unlicensed use] as alternative second-line options.
What is the treatment for absence seizures?
Offer ethosuximide as first-line treatment for absence seizures
consider sodium valproate as second-line monotherapy or adjunctive treatment for males, and females unable to have children
If treatment with sodium valproate is unsuitable or unsuccessful, lamotrigine or levetiracetam
Patients with absence seizures may have their seizures exacerbated if treated with carbamazepine, gabapentin, oxcarbazepine, phenobarbital, phenytoin, pregabalin, tiagabine, or vigabatrin.
Myoclonic seizures
Myoclonic seizures
Offer sodium valproate as first-line treatment for myoclonic seizures in males, and females unable to have children. If treatment with sodium valproate is unsuccessful, levetiracetam should be offered as second-line monotherapy
Atonic or tonic seizures
Offer sodium valproate as first-line treatment for atonic or tonic seizures in males, and females unable to have children. If treatment with sodium valproate is unsuccessful, lamotrigine should be offered as second-line monotherapy or adjunctive treatment.
What are other key aspects to consider with epilepsy? (driving, lifestyle, etc)
Switching or Stopping AEDs:
Gradual withdrawal is necessary if stopping AEDs, particularly in patients who have been seizure-free for 2 or more years.
Changing AEDs: Requires overlapping the old and new medications to minimize the risk of breakthrough seizures.
7. Driving and Legal Considerations:
Patients must be seizure-free for at least 12 months to drive legally.
Always advise patients on the DVLA (Driver and Vehicle Licensing Agency) rules related to epilepsy.
8. Lifestyle and Counseling:
Importance of medication adherence to avoid breakthrough seizures.
Provide advice on avoiding triggers (e.g., sleep deprivation, alcohol).
Non-drug interventions: Referral for vagus nerve stimulation (VNS) or surgical options in drug-resistant epilepsy.
