The practice of treating cardiovascular patients

Question 1

What will be covered:

Answer 1

Practical Treatment of
• HYPERTENSION
• HEARTFAILURE
• ANGINAPECTORIS
• MYOCARDIALINFARCTION • ATRIALFIBRILLATION
• STROKES

Question 2

Quick summary of drug uses:

Answer 2

For hypertension:
ACEI, beta blockers, calcium antagonists, diuretics

For heart failure:
ACEI, beta blockers, diuretics

For angina:
ACEI, beta blockers, calcium antagonists

Question 3

Discuss treatments of hypertension

Answer 3

A (B) C D
A - ACE Inhibitor /Angiotensin Blocker (B - Beta Blocker)
C - Calcium Antagonists
D - Diuretic esp Thiazide diuretic

Also Alpha Blocker (Doxazosin) Spironolactone

Question 4

Discuss treatment of hypertension in different ages

Answer 4

Sequence order crucial

Patient ≤ 55 years
Start A
Add C (if necessary) Add D (if necessary)
Then either B, alpha blocker or spironolactone

Patient ≥ 55 years
Start C
Add A (if necessary) 
Add D (if necessary )
Then either B, alpha blocker or spironolactone

Question 5

Discuss treatment for chronic heart failure

Answer 5

1. Give DAB to all (unless contraindicated) (Diuretic)
   ACE Inhibitor Beta Blocker
2. Give spironolactone/ eplerenone to nearly all
3. Selected treatments
   - SGLT2 Inhibitors esp Dapagliflozin
   - Cardiac Resynchronisation Therapy
   (= Biventricular Pacing) to those with long QRS
   - Sacubitril/Valsartan to replace ACEI/ARB
   - Implantable Cardiac Defibrillators to severe patients

Question 6

Discuss Sacubitril-Valsartan

Answer 6

To replace ACEI/ARB in severe heart failure
Valsartan = ARB
Sacubitril inhibits Neprilysin
which degrades BNP and other vasoactive peptides
Can cause Angioneurotic Oedema (like an ACEI)

Question 7

Discuss treatment of angina pectoris (chronic)

Answer 7

Different treatments to relieve symptoms versus prolonging survival.

1. To prolong survival, all get SAAB
   Aspirin Statin
   ACE Inhibitor Beta Blocker
2. To relieve symptoms, sequentially use Beta Blocker
   Calcium Antagonist or Nitrates Coronary Angioplasty
   New antianginals
   Ivabradine Ranolazine
   Coronary artery surgery

Question 8

Discuss treatment of acute chest pain

Answer 8

If non cardiac = outside of scope atm

If cardiac = determine troponin

If troponin negative = troponin negative unstable angina/Acute coronary syndrome

If troponin positive = MI and so determine ST elevation

If ST elevated = STEMI

If no ST elivation = NSTEMI

Question 9

Discuss the 4 entities of chest pain

Answer 9

1. STelevationMyocardialInfarction(STEMI)
2. NonSTelevationMyocardialInfarction
   (N STEMI)
3. TroponinnegativeUnstableAngina/ACS
4. NonCardiacChestPain

Question 10

Discuss STEMI treatment

Answer 10

Emergency
Aspirin
Angioplasty (if near hospital)
Thrombolysis ( if far away)

Also
Aspirin and Clopidogrel or Ticagrelor
Low MW Heparin or Fondaparinux

Statin
ACE Inhibitor
Beta Blocker i.e SAAB

Fondaparinux is synthetic pentasaccharide that inhibits activated factor x.

Question 11

Discuss NSTEMI treatment

Answer 11

Aspirin and Clopidogrel OR Ticagrelor Fondaparinux

Angioplasty (not as emergency)

Statin
ACE Inhibitor
Beta Blocker i.e. SAAB

Question 12

Discuss treatment of troponin negative unstable angina/ACS

Answer 12

Aspirin and Clopidogrel 
Selective use of Angioplasty 
ACE Inhibitor
Beta Blocker
Statin

i.e. SAAB plus selective Angioplasty

Question 13

Discuss treatment of atrial fibrillation

Answer 13

1. Prevent emboli
   Warfarin/ Rivaroxaban/NOACs
2. Control Rate (crucial)
   Beta Blocker
   Digoxin

3. Control Rhythm (seldom done) 
DC Cardioversion
Amiodarone if heart failure
Sotalol (II/III) possible
Flecainide (Ic) only if heart structure/function normal

Question 14

Discuss stroke (CVA, Cerebrovascular Accident) treatment

Answer 14

Causes
Cerebral Thrombosis
Cerebral Embolus
Cerebral Haemorrhage

Must have CT scan to differentiate haemorrhage from clot
If NO haemorrhage on CT scan
For emergency Thrombolysis
Thrombectomy
Aspirin (acutely & for 2 weeks) Thereafter Clopidogrel

Also
Statin
ACE Inhibitor
Indapamide

Question 15

Discuss common side effects of drugs mentioned

Answer 15

ACE Inhibitors
Cough
Renal dysfunction *(worsen or improve) Angioneurotic oedema
Never in pregnancy

Angiotensin Blockers
Renal dysfunction *(worsen or improve)
Never in pregnancy

Beta Blockers
Bradycardia /Heart Block Tired
Asthma (Not in asthmatics)

Calcium Antagonists
Ankle oedema for Amlodipine
Heart Block for Diltiazem & Verapamil

Diuretics
Hypokalaemia Diabetes Gout