BNF - Chapter 2 - Cardiovascular System (Part 2) Flashcards
1
Q
What is cardiovascular disease (CVD)?
A
it is a term that describes a group of disorders of the heart and blood vessels caused by atherosclerosis and thrombosis, which includes coronary heart disease, stroke, peripheral arterial disease, and aortic disease
2
Q
Which groups is the risk of CVD greater in?
A
- Men
- Patients with a family history of CVD
- Certain ethnic backgrounds such as South Asians
- patients aged over 50 years and increases with age
- Patients aged 85 years and over are at high risk
3
Q
What are some modifiable risk factors of CVD?
A
- Hypertension
- Abnormal Lipids
- Obesity
- Diabetes Mellitus
- Psychosocial factors such as depression, anxiety and social isolation
- Low physical activity
- Poor diet
- Smoking
- Excessive alcohol intake
4
Q
Priority for a full formal risk assessment of CVD should be given to which patients?
A
- patients with an estimated 10-year risk of 10% or more.
5
Q
After what age should patients have their estimate of CVD risk reviewed on an ongoing basis?
A
- Patients aged over 40 years
6
Q
Instead, what does SIGN 2017 recommend on the frequency of CVD risk assessment?
A
CVD risk assessments are offered at least every 5 years to all patients aged 40 years and over with no history of CVD, familial hypercholesterolaemia, chronic kidney disease or diabetes and who are not receiving treatment to reduce blood pressure or lipids. As well as to patients with a first-degree relative who has premature atherosclerotic CVD or familial dyslipidaemia, regardless of their age.
7
Q
Is a risk assessment with a calculator required in patients who are at increased or high risk of CVD?
A
Risk assessment with a calculator is not required in patients who are at increased or high risk of CVD. This includes those with established CVD, chronic kidney disease stage 3 or higher (eGFR <60 mL/minute/1.73 m2), albuminuria, or familial hypercholesterolaemia. In addition to these patients, NICE (2016) do not recommend the use of a risk calculator in patients with other hereditary disorders of lipid metabolism, or type 1 diabetes mellitus. Whereas SIGN (2017) do not recommend the use of a risk calculator in patients with diabetes mellitus aged 40 years and over, and in those aged under 40 years with diabetes mellitus who have either had it for more than 20 years, present with target organ damage (such as proteinuria, albuminuria, proliferative retinopathy, or autonomic neuropathy), or have other significantly elevated cardiovascular risk factors.
8
Q
What are CVD risk assessment calculators used for?
A
They are used to predict the approximate likelihood of a cardiovascular event occurring over a given period of time
9
Q
In which patient may CVD risk be underestimated in?
A
- patients with additional risk due to conditions or medications that can cause dyslipidaemia (e.g. antipsychotics, corticosteroids, or immunosuppressants).
- Patients who are already taking anti-hypertensives or lipid-regulating drugs or who have recently stopped smoking
10
Q
Which Risk calculators are used in England and Wales?
A
QRISK 2 and JBS3
11
Q
What conditions do these two risk calculators assess?
A
- CVD risk of coronary heart disease (Angina and myocardial infarction)
- stroke and TIA
12
Q
What factors are taken into account in the risk calculators?
A
- Lipid profile
- systolic blood pressure
- Gender
- Age
- Ethnicity
- Smoking status
- BMI
- Chronic kidney disease (stage 4 or above)
- Diabetes mellitus
- Atrial fibrillation
- treated hypertension
- Rheumatoid arthritis
- Social deprivation
- family history of premature CVD
13
Q
What additional info does the updated QRISK 3 include?
A
It considers additional risk factors such as chronic kidney disease (stage 3 or above), migraine, corticosteroid use, systemic lupus erythematosus, atypical antipsychotics use, severe mental illness, erectile dysfunction, and a measure of systolic blood pressure variability.
14
Q
What is the advantage of JBS3 calculator?
A
The JBS3 calculator is not only able to estimate short term (10-year) risk, but also lifetime risk of CVD events.
15
Q
Which patients may benefit from a JBS3 calculator?
A
Patients with a 10-year risk of CVD of less than 10% may benefit from an assessment of their lifetime risk using the JBS3 tool, and a discussion on the impact of lifestyle interventions and, if necessary, drug therapy.
16
Q
What is the ASSIGN cardiovascular risk assessment calculator?
A
It is tailored to the Scottish population and uses factors such as age, sex, smoking, systolic blood pressure, lipid profile, family history of premature CVD, diabetes mellitus, rheumatoid arthritis, and social deprivation to estimate cardiovascular risk. Other risk factors not included in this CVD risk assessment calculator (such as ethnicity, BMI, atrial fibrillation, psychological wellbeing, and physical inactivity) should also be taken into account when assessing and managing the patient’s overall CVD risk.
17
Q
What are all patients at any risk of CVD advised to make?
A
Should be advised to make lifestyle modifications that may include beneficial changes to diet (such as increasing fruit and vegetable consumption, reducing saturated fat and dietary salt intake), increasing physical exercise, weight management, reducing alcohol consumption, and Smoking cessation.
18
Q
What often should a review to discuss lifestyle modification, medication adherence and risk factors be done?
A
An annual review should be considered to discuss lifestyle modification, medication adherence and risk factors. The frequency of review may be tailored to the individual.
19
Q
Is aspirin recommended for the primary prevention of CVD?
A
No - Aspirin is not recommended for primary prevention of CVD due to the limited benefit gained versus risk of side-effects such as bleeding.
20
Q
For Primary prevention what two pharmacological therapy can be used?
A
- Antihypertensive therapy
- Lipid-lowering therapy
21
Q
Which patients should be given antihypertensive drugs as primary prevention?
A
- Antihypertensive drug treatment should be offered to patients who are at high risk of CVD and have a sustained elevated systolic blood pressure over 140 mmHg and/or diastolic blood pressure over 90 mmHg. For
22
Q
Before starting a lipid-lowering therapy for primary prevention of CVD what factors should be managed first?
A
All modifiable risk factors, comorbidities and secondary causes of dyslipidaemia (e.g. uncontrolled diabetes mellitus, hepatic disease, nephrotic syndrome, excessive alcohol consumption, and hypothyroidism) should be managed before starting treatment with a statin. Factors such as polypharmacy, frailty, and comorbidities should be taken into account before starting statin therapy.
23
Q
To which patients is a low dose atorvastatin recommended to start in for primary prevention of CVD?
A
for patients who have a 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator), and for patients with chronic kidney disease.
- Low-dose atorvastatin should be considered in all patients with type 1 diabetes mellitus, and be offered to patients with type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors.
Patients aged 85 years and over may also benefit from low-dose atorvastatin to reduce their risk of non-fatal myocardial infarction. SIGN (2017) recommend low-dose atorvastatin for patients who are considered to be at high risk of CVD and not on dialysis.
24
Q
How often should patients that are taking statins have a review?
A
Annual medication review, to discuss medication adherence, lifestyle modifications, CVD risk factors, and non-fasting, non-HDL cholesterol concentration (if testing deemed appropriate)
25
How long after initiating a statin should total cholesterol, HDL-cholesterol and non-HDL cholesterol concentration be checked?
After 3 months of starting treatment with a high intensity statin
26
What percent reduction in non-HDL cholesterol concentration should be aimed for?
Aiming for a reduction in non-HDL-cholesterol concentration of greater than 40% is recommended.
27
If a patient is intolerant to three different statins, then what should be sought?
Specialist advice
28
When can ezetimibe and bile acid sequestrants such as colestryamine and colestipol be considered for primary prevention?
In patients with an elevated CVD risk in whom statin therapy is contraindicated, and in patients with familial hypercholesterolaemia.
29
Are fibrates recommended for primary prevention?
NO but there are exceptions - patients with a combination of high CVD risk, marked hypertriglyceridaemia and low HDL-cholesterol concentration
30
What can be used if cholesterol removes above the target concentration despite other tolerated lipid-lowering therapy in patients at high risk of vascular events?
The use of PCSK9 inhibitors, such as alirocumab and evolocumab should be considered.
31
For secondary prevention of CVD which antiplatelet therapy should be used?
- Aspirin
- Alternatively, clopidogrel can be considered in patients who are intolerant to aspirin or in whom it is contraindicated
32
Which antiplatelet therapy is initiated for secondary prevention for stroke and TIA?
- Clopidogrel
- OR dipyridamole with aspirin
To patients who are in sinus rhythm
33
Which drug therapies are recommended for secondary prevention of CVD?
- Antiplatelet therapy
- Anti-hypertensive therapy
- Lipid-lowering therapy
34
For secondary prevention is a low or high dose statin offered?
Primary = low dose statin
Secondary = high dose statin (however, a lower dose can be used if patient is at an increased risk of side-effects or drug interactions)
Low dose atorvastatin with patients with established CVD and chronic kidney disease
35
Why is high dose simvastatin generally avoided?
- Due to the risk of myopathy, unless the patient has been stable on this regimen for at least one year.
36
a 40% reduction in non-HDL cholesterol or greater is recommended with satin treatment. What recommendation does JBS3 give instead?
A target non-HDL cholesterol concentration below 2.5mmol/L.
37
What consideration of psychological risk factors should be included when managing secondary prevention of CVD (Lipid-therapy)?
- considered in patients with mood and anxiety disorders and comorbid CVD
- complex patients may require referral to mental health services
- SSRIs should be considered for treatment in patients with depression and coronary heart disease
38
What is heart failure?
Heart muscle is too weak, so heart cannot pump blood effectively around the rest of the body. So, the rest of the body does not receive the oxygen and supply of blood that it requires to meet its tasks.
Reduced cardiac output
39
What is heart failure characterised by which symptoms?
- Shortness of breath
- Persistent coughing or wheezing
- ankle swelling
- Reduced exercise tolerance and fatigue
These symptoms may be accompanied by signs such as elevated jugular venous pressure, pulmonary crackles, and pulmonary oedema
40
Which patients is the risk of heart failure greater in?
- Men
- smokers
- Diabetic patients
- increases with age
41
What is the most common cause of heart failure?
The most common cause of heart failure is coronary heart disease, however, patients of African or Afro-Caribbean origin are more likely to develop heart failure secondary to hypertension.
42
In addition to coronary heart disease what other conditions does it tend to co-exist with in patients?
In addition to coronary heart disease, heart failure often co-exists with other co-morbidities such as chronic kidney disease, atrial fibrillation, hypertension, dyslipidaemia, obesity, diabetes mellitus, and chronic obstructive pulmonary disease.
43
What are the complications of heart failure?
- Chronic kidney disease
- Atrial fibrillation
- Depression
- Cachexia
- Sexual dysfunction
- sudden cardiac death
44
What can heart failure be defined as (two types)?
- Reduced ejection fraction
- Preserved ejection fraction
Both conditions present with symptoms of heart failure
45
Why is it called reduced ejection fraction?
In heart failure with reduced ejection fraction, the left ventricle loses its ability to contract normally and therefore presents with an ejection fraction of less than 40%.
46
What is the difference in preserved ejection fraction?
In heart failure with preserved ejection fraction, the left ventricle loses its ability to relax normally therefore the ejection fraction is normal or only mildly reduced.
47
What tool is used to define the progression of chronic heart failure according to severity of symptoms and limitation to physical actvity?
The New York Heart Association (NYHA) functional classification tool
48
What non-drug treatment is advised for heart failure?
- make lifestyle changes
- smoking cessation
- reducing alcohol consumption
- increasing physical exercise where appropriate
- weight control
- dietary changes such as increasing fruit and vegetable consumption and reducing saturated fat intake.
49
What weight gain advice should be given (self-measurement)?
Patients should be encouraged to weigh themselves daily at a set time of day and to report any weight gain of more than 1.5–2.0 kg in 2 days to their GP or heart failure specialist.
50
Should salt and fluid intake be restricted in heart failure?
No they should only be restricted if these are high and a salt intake of less than 6g per day is advised.
Patients with dilutional hyponatraemia should only restrict their fluid intake.
51
What important information should patients be counselled on regarding salt substitutes?
Salt substitutes containing potassium should be avoided to reduce the risk of hyperkalaemia
52
To be able to get implantable cardioverter defibrillators and cardiac resynchronisation therapy what percentage of reduced ejection fraction is required?
Heart failure with reduced ejection fraction less than 35%.
53
Which drugs should be avoided in patients who have heart failure with reduced ejection fraction?
Rate limiting calcium-channel blockers (verapamil, diltiazem) and short acting dihydropyridines (nifedipine or nicardipine)
These reduce cardiac contractility
54
Can amlodipine be used in heart failure?
YEs it can be safely used with heart failure and angina
55
For heart failure with reduced ejection fraction - which choice of diuretics are used when required?
Diuretics are recommended for the relief of breathlessness and oedema in patients with fluid retention.
Loop diuretics such as furosemide, bumetanide, or torasemide are usually the diuretics of choice.
56
Which patients in heart failure with reduced ejection fraction may thiazide diuretics benefit?
may only be of benefit in patients with mild fluid retention and an eGFR greater than 30 mL/minute/1.73 m2
57
Which beta-blockers are licensed to be used in heart failure?
- Carvedilol
- Bisoprolol
- Nebivolol
58
Can ACE inhibitors be used for heart failure?
Yes it is given first line alongside a beta-blocker that is licensed for heart failure
59
What is first line treatment of heart failure with reduced ejection fraction?
ACE inhibitor with Beta-blocker (licensed one for heart failure)
60
What if a patient is already taking a beta-blocker from before for example due to hypertension?
- The beta-blocker should be switched to a beta-blocker licensed for heart failure
61
For chronic heart failure with reduced ejection fraction, is an ACE inhibitor and beta-blocker started at the same time?
Clinical judgement should be used when deciding whether to start an ACE inhibitor or beta blocker first. The additional drug should only be initiated when the patient is stable on their existing treatment. Treatment should be initiated at a low dose and slowly titrated up to the maximum tolerated dose.
62
Can an ARB be considered if an ACE inhibitor is not suitable/ tolerated?
Yes it can
63
If first line treatment with ACE and beta blocker is not working for heart failure then what drug should be added next?
Consider adding an aldosterone antagonist such as spironolactone or eplerenone
64
If a patient is not tolerant to both ACE and ARB then which drug can be considered?
Hydralazine combined with a nitrate under the advice of a heart failure specialist
65
If symptoms still persist, then advice should be sought from a heart failure specialist to use which drugs?
- Amiodarone
- Digoxin
- Sacubitril with valsartan
- Ivabradine
- Dapagliflozin
66
Despite optimal treatment, for patients in sinus rhythm which drug can be used as an add-on therapy in worsening or severe heart failure?
- Digoxin
| Although digoxin does not reduce mortality, it may decrease symptoms and hospitalisation due to acute exacerbations
67
Is routine monitoring of serum levels recommended in heart failure?
No
68
When should anticoagulation be considered in patients with heart failure?
- If they have a history of thromboembolism , left ventricular aneurysm or intracardiac thrombus.
- And they need to be in sinus rhythm
69
When initiating ACE or ARB which parameters should be monitored?
- Serum potassium and sodium
- renal function
- blood pressure
70
When on ACE or ARB, how often should blood pressure be checked?
- before starting treatment
- 1-2 weeks after starting treatment
- and at each dose increment
Once the target, or maximum tolerated dose is achieved, treatment should be monitored monthly for 3 months and then at least every 6 months and if the patient becomes acutely unwell.
71
When initiating a beta-blocker what should be assessed?
- heart rate
- blood pressure and symptom control
Should be assessed before starting treatment and after each dose increment
72
Who should patients with heart failure with preserved ejection fraction be treated by?
should be managed under the care of a heart failure specialist.
-
73
For the relief of fluid retention symptoms in chronic heart failure with preserved ejection fraction, what strength loop diuretic should be prescriebed?
- A low to medium dose loop diuretic should be prescribed
74
What is a symptom of advanced heart failure?
- Breathlessness and it may occur even with optimal management and in the absence of clinical pulmonary oedema.
75
Is long term oxygen therapy recommended in patients with heart failure?
- No although it may be considered in patients with heart failure and additional co-morbidities that would benefit from oxygen therapy such as chronic obstructive pulmonary disease.
76
When can nebivolol be used for chronic heart failure?
For mild to moderate HF in patients over 75.
77
What is heart failure with reduced ejection fraction also known as?
Heart failure due to left ventricular systolic dysfunction. (LVSD)
78
In heart failure combination drug entresto can be used, what drug does this have and when is it used?
The combination of valsartan with sacubitril (Entresto), which is an angiotensin-II receptor blocker + Neprilysin inhibitor is a suitable alternative for patients stabilised on an ACE inhibitor or Angiotensin-II receptor antagonist
79
In chronic heart failure with reduced ejection fraction if patients cannot tolerate ACE i or ARB or it is CI, then which drug may be given?
Isosorbide dinitrate + hydralazine but it is poorly tolerated.
This combination may be considered in addition to standard therapy with an ACEI + Beta-blocker in patients who continue to remain asymptomatic particularly in Afro-Caribbean’s
80
If a patient with heart failure requires a diuretic but has poor renal function (less than 30mls/min/1.73m2) then which type of diuretic is preffered?
Loop diuretic and not thiazide like diuretic
81
What type of diuretic is Co-flumactone?
A potassium sparing diuretic - An aldosterone antagonist
82
What drugs is co-flumactone a combination of?
Spironolactone + Hydrochlorothiazide
83
What type of diuretic is eplerenone?
A potassium sparing diuretic - An aldosterone antagonist
84
What type of diuretic is spironolactone?
A potassium sparing diuretic - An aldosterone antagonist
85
What is the mechanism of action of phosphodiesterase type-3 inhibitors and their role in heart failure?
- they exert most of their effect on the myocardium it has positive inotropic properties and vasodilator activity
86
Give examples of names of drugs that are phosphodiesterase type-2 inhibitors?
- Enoximone
| - Milrinone
87
What class of drug is first choice for treatment of hypercholesterolaemia and moderate hypertriglyceridemia?
Statins
88
What may Severe hypercholesterolaemia or hypertriglyceridaemia not adequately controlled with a maximal dose of a statin require?
- an additional lipid-regulating drug such as ezetimibe; should be supervised by a specialist
89
Are statins better at lowering LDL concentrations or triglyceride concentrations?
Statins are better at reducing LDL concentrations
90
Which drug is better than statins at reducing triglyceride levels?
Fibrates
91
If triglyceride levels remains high when on statin treatment, then which drug should be added?
Fenofibrate
92
What is familial hypercholesterolaemia?
FH is an inherited condition that is passed down through families ad is caused by one or more fault genes. It is caused by a genetic mutation that means your liver is unable to remove excess 'bad' cholesterol, known as LDL.
93
Patients with familial hypercholesterolaemia are at high risk of what??
Premature coronary heart disease
94
What should be offered for familial hypercholesterolaemia?
Life long lipid modifying therapy an advice on lifestyle changes
95
What is the first lin therapy for familial hypercholesterolemia?
A high-intensity statin, defined as the dose at which a reduction in LDL-cholesterol of greater than 40% is achieved
96
What should the dose of statin be titrated to?
The dose of the statin should be titrated to achieve a reduction in LDL-cholesterol concentration of greater than 50% from baseline
97
What drug should be considered in patients with primary heterozygous familial hypercholesterolaemia who have CI to or are intolerant of statins?
Ezetimibe as monotherapy
98
When is a combination of statin and ezetimibe recommended?
if the maximum tolerated dose of a statin alone fails to provide adequate control of LDL-cholesterol, or a switch to an alternative statin is being considered.
99
Can statin and fibrates be given together?
The combination of a statin with a fibrate carries an increased risk of muscle-related side-effects (including rhabdomyolysis) and should be used under specialist supervision.
100
Can statin be given together with gemfibrozil?
No - he concomitant administration of gemfibrozil with a statin increases the risk of rhabdomyolysis considerably—this combination should not be used.
101
Which monoclonal antibodies can be used for primary heterozygous familial hypercholesterolaemia if maximum tolerated lipid-lowering therapy fails?
- Alirocumab and Evolocumab
102
Which statins are considered high-intensity statins, including the doses?
Atorvastatin - 20mg, 40mg, 80mg
Rosuvastatin - 10mg, 20mg and 40mg
simvastatin - 80mg
103
Which statins are considered medium-intensity statins, including the doses?
Atorvastatin - 10mg
Fluvastatin - 80mg
Rosuvastatin 5mg
Simvastatin 20mg, 40mg
104
Which statins are considered low-intensity statins, including the doses?
Fluvastatin - 20mg, 40mg
Pravastatin - 10mg, 20mg
Simvastatin - 10mg
105
What is the MAO of bile acid sequestrants?
- Bile acid sequestrants act by binding to bile acids, preventing their reabsorption;
- this promotes hepatic conversion of cholesterol into bile acids; the resultant increased LDL-receptor activity of liver cells increases the clearance of LDL-cholesterol from the plasma
106
Can bile acid sequestrants be used in breastfeeeding?
- can but should be used with caution as although the drugs are not absorbed, they may cause fat-soluble vitamin deficiency on prolonged use.
107
Give examples of bile acid sequestrants?
- Colesevlam
- Colestipol
- Colestryamine
(HINT- 'Cole')
108
What class of drug does ezetimibe belong to?
Cholesterol absorption inhibitors (Lipid-modifying drugs)
109
What is the mechanism of action of ezetimibe?
- it inhibits the intestinal absorption of cholesterol. If used alone it has modest effect on lowering LDL-cholesterol, with little effect on the other lipoproteins
110
What is the MAO of fibrates?
Fibrates act by decreasing serum triglycerides; they have variable effect on LDL-cholesterol.
111
Give examples of fibrates?
Bezafibrate
Ciprofibrate
Fenofibrate
Gemfibrozil
112
Can fibrates be used in pregnancy?
No - manufacturers says avoid
113
Which nicotinic acid derivatives can be used for lipid-modifying therapy?
- Acipimox
| - Nicotinic Acid
114
What is the drug action of statins?
Statins competitively inhibit 3-hydroxy-3-mthylglutaryl coenzyme A (HMG CoA) reductase, an enzyme in cholesterol synthesis, especially in the liver.
115
Which side effect should be reported with statins?
Muscle toxicity - likelihood increases with high doses.
116
What is the differences between myopathy, myositis and rhabdomyolysis?
Myopathy is a general term referring to any disease that affects the muscles that control voluntary movement in the body.
Myositis is the name for a group of rare conditions. The main symptoms are weak, painful or aching muscles. This usually gets worse, slowly over time.
Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage.
117
What signs and symptoms should patients look out for who are taking statins that could indicate interstitial lung disease?
- Dyspnoea -(shortness of breath)
- Cough
- Weight loss
118
When on statins can you get pregnant?
No (discontinue 3 months before attempting to conceive). Decreased synthesis of cholesterol possible affects fetal development
119
Is contraception required when on statin treatment?
Adequate contraception is required during treatment and for 1 month afterwards
120
Before starting treatment with statins what should be monitored?
- At least one full lipid profile (non-fasting) should be measured, including total cholesterol, HDL-cholesterol, non-HDL cholesterol and triglyceride concentrations,
- TSH
Renal function
- NICE recommends liver enzymes are measured before, 3 months after starting and at 12 months
121
Before initiating statin, does creatinine kinase concentrations need to be measured?
- should only be measured in patients who have had persistent, generalised, unexplained muscle pain( whether associated or not associated with previous lipid-therapy).
- If the creatinine kinase level is 5 times the upper limit; then repeat measurement should be taken after 7 days
- If it is still above limit 5 times then treatment should not be started
- If concentrations are still raised but less than 5times the upper limit, the statin should be started at a low dose
122
For starting Statin, does HbA1c need to be measured?
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1c checked before starting statin treatment, then repeated after 3 months.
123
What signs can indicate muscle problem when taking a statin?
- unexplained muscle pain
- tenderness
- weakness
124
Give examples of statins?
- Atorvastatin
- Fluvastatin
- Pravastatin
- Rosuvastatin
- Simvastatin
125
Inegy is the brand name for which two lipid-lowering drugs?
Ezetimibe 10mg tabs
| Simvastatin 20mg tabs
126
Cholib is the brand name for which two lipid-lowering drugs?
Simvastatin 20/40mg + Fenofibrate 145mg
127
What is the MAO of Alirocumab?
- Alirocumab binds to a pro-protein involved in the regulation of LDL receptors on liver cells; receptor numbers are increased, which results in increased uptake of LDL-cholesterol from the blood
128
What is the MAO of Bempedoic acid?
Bempedoic acid is an adenosine triphosphate citrate lyase (ACL) inhibitor which inhibits cholesterol synthesis in the liver, thereby lowering cholesterol.
129
What is the MAO of evolocumab?
- Similar to Alirocumab
- - Alirocumab binds to a pro-protein involved in the regulation of LDL receptors on liver cells; receptor numbers are increased, which results in increased uptake of LDL-cholesterol from the blood
130
What is the MAO of lomitapide?
it is an inhibitor of microsomal triglyceride transfer protein (MTP), reduces lipoprotein secretion and circulating concentrations of lipoprotein-borne lipids such as cholesterol and triglycerides
131
Which indications can omega-3-acid ethyl esters be used?
- Adjunct to diet and statin in type IIb or III hypertriglyceridemia
- Adjunct to diet in type IV hypertriglyceridemia
132
What is the MAO of volanesorsen?
- It is an antisense oligonucleotide which inhibits the formation of the apolipoprotein apoC-III, thereby lowering serum triglycerides
133
What is myocardial ischaemia?
Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is obstructed by a partial or complete blockage of a coronary artery by a buildup of plaques (atherosclerosis). If the plaques rupture, you can have a heart attack (myocardial infarction).
134
What is stable angina?
It is characterised by predictable chest pain or pressure, often precipitated by physical exertion or emotional stress causing an increase in myocardial oxygen demand.
135
Where might pain radiate to in stable angina?
Although pain typically occurs in the front of the chest, it may also radiate to the neck, shoulders, jaw or arms; the pain is relieved with rest
136
What is stable angina a result from?
From atherosclerotic plaques in the coronary arteries that restrict blood flow and oxygen supply to the heart.
137
What can stable angina lead to (CVD complications)?
- It can lead to cardiovascular complications such as stroke, unstable angina, myocardial infarction (heart attack) and sudden cardiac death.
138
What is Prinzmetal's or vasospastic angina?
It is a rare form of angina caused by narrowing or occlusion of proximal coronary arteries due to spasm, in which pain is experienced at rest rather than during activity.
139
How should acute attacks of stable angina be managed?
With sublingual glyceryl trinitrate
140
Can sublingual trinitrate be used as a preventative measure?
Yes, immediately before performing activities that are known to bring on an attack
141
For long term prevention of chest pain (angina) which drug should be considered?
1st line - beta blocker (such as atenolol, bisoprolol, metoprolol or propranolol)
Alternative - a rate limiting calcium-channel blocker (such as verapamil or diltiazem) should be considered as an alternative if beta-blockers are contra-indicated.
142
In patients with Prinzmetal's angina can a beta blocker be used for long-term prevention of chest pains?
- Dihydropyridine derivates such as amlodipine may be effective with Prinzmetal's angina
143
If beta blocker fails to control symptoms of stable angina then what should be tried next?
- Next a combination of beta-blocker and a calcium channel blocker should be considered.
- If this combination is not appropriate due to intolerance, or contra-indications to, either beta blocker or calcium channel blockers, should consider addition of either long-acting nitrate, Ivabradine, nicorandil or ranolazine
144
Can a long-acting nitrate be used as monotherapy?
yes should be considered as monotherapy in patients who cannot tolerate beta-blockers and calcium channel blockers, if both are contraindicated, or when they both fail to adequately control angina symptoms
145
How often should response to long-term prevention of stable angina be assessed?
Response to treatment should be assessed every 2–4 weeks following initiation or change of drug therapy; drug doses should be titrated to the maximum tolerated effective dose.
146
What if a combination of two drugs fails to control symptoms of angina?
- Patient should be considered for referral to specialist
147
Why is secondary prevention of CVD needed for all patients with angina?
- All patients with angina are assumed to be at high-risk for CVD events
148
How can the occurrence of cardiovascular events be prevented in patients with stable angina?
through the management of CVD risk factors through lifestyle changes (such as smoking cessation, weight management, increased physical activity), psychological support and drug treatment. (CVD secondary prevention drug management)
149
What are the non-drug treatment options for stable angina?
- Revascularisation by coronary artery bypass graft
- or percutaneous coronary intervention
These should be considered for patients with stable angina who remain symptomatic whilst on optimal drug therapy.
150
What are the three anti-anginal drugs that can be used for long-term management of stable angina?
- Ranolazine
- Ivabradine
- Nicorandil
151
Which level of renal impairment should ranolazine be avoided?
- If eGFR is less than 30ml/minute/1,73m2
152
What are the indications of ivabradine?
- Treatment of angina
| - Mild to severe chronic heart failure
153
What conditions come under the term acute coronary syndrome?
- Myocardial infarction with or without ST-segment (STEMI or NSTEMI respectively)
- unstable angina
154
What are acute coronary syndromes a result of?
- the formation of a thrombus on an atheromatous plaque in a coronary artery.
155
what is a definitive diagnosis of ACS based on?
- clinical presentation
- ECG changes
- Measurement of biochemical cardiac markers
156
What is the difference between STEMI and NSTEMI in terms of blockage of the artery?
- A STEMI is generally caused by a complete and persistent blockage of the artery resulting in myocardial necrosis with ST-segment elevation seen on the ECG
- In NSTEMI and unstable angina a partial or intermittent blockage of the artery occurs, which usually results in myocardial necrosis in NSTEMI but not in unstable angina.
157
What is myocardial necrosis?
Myocardial injury or myocardial necrosis refers to the cell death of cardiomyocytes and is defined by an elevation of cardiac troponin values.
158
How do they differentiate between an NSTEMI and unstable angina?
High-sensitivity blood tests for serum troponin are used to differentiate between NSTEMI and unstable angina.
NSTEMI = there is myocardial necrosis, therefore increased cardiac troponin
Unstable angina = no myocardial necrosis
159
What non drug treatment options are there for ACS?
Revascularisation procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) are often appropriate, alongside drug treatment, for patients with an ACS
160
Which immediate chest main relief is offered for ACS?
- glyceryl trinitrate (sublingual or buccal)
161
If acute myocardial infarction (MI) is suspected then what can be given IV for pain relief?
- Intravenous opioids such as morphine
162
For initial management of ACS, loading dose of which drug should be given?
- A loading dose of aspirin should be given as soon as possible.
- If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient.
163
All patients admitted to hospital with ACS should be closely monitored for what?
- Hyperglycaemia
164
Those admitted to hospital with ACS, with a blood-glucose concentration greater than what.... should receive insulin?
If greater than 11.0mmol/litre
165
What does the management of a STEMI aim to do?
Aims to restore adequate coronary blood flow as quickly as possible and to reduce mortality.
166
What is done first line for treatment of a STEMI?
Coronary reperfusion therapy (either primary PCI or fibrinolysis) should be delivered as soon as possible in eligible patients with a STEMI.
167
Within how many hours of symptom onset should primary PCI be given?
Primary PCI (if within 12 hours of symptom onset and within 120 minutes of the time when fibrinolysis could have been given) is the preferred strategy for most patients.
168
In addition to aspirin what else should be given for a STEMI?
In addition to aspirin, most patients with a STEMI should be offered a second antiplatelet agent (prasugrel, ticagrelor, or clopidogrel)
169
What does the choice of the second anti-platelet depend on?
The choice of second antiplatelet depends on the planned intervention (primary PCI, fibrinolysis or conservative management) and the patient's bleeding risk.
170
Which second anti-platelet is preferred for patients undergoing a primary PCI?
Prasugrel is the preferred agent for most patients undergoing a primary PCI, unless the risk of bleeding outweighs its effectiveness
171
Can aspirin be used alone in treatment of a STEMI?
Aspirin alone may be appropriate for some patients with a high bleeding risk not undergoing a PCI.
172
For patients undergoing primary PCI with radial access, what else should be given?
- Heparin (unfractionated)
| - IF femoral access is needed. bivalirudin should be considered instead (unlicensed)
173
For patients undergoing fibrinolysis, what else should be given at the same time?
An antithrombin agent should be given at the same time.
174
How are unstable and NSTEMI managed?
Unstable angina and NSTEMI are managed similarly and treatment aims to prevent further cardiac events and mortality.
175
Like STEMI, for the treatment of NSTEMI and unstable angina, is a second anti-platelet needed?
In addition to aspirin, most patients with unstable angina or NSTEMI should be offered a second antiplatelet agent (prasugrel, ticagrelor, or clopidogrel). The choice of second antiplatelet depends on the planned intervention (angiography with follow-on PCI if indicated, or conservative management), and the patient's bleeding risk.
176
For NSTEMI/ unsatble angina, what therapy should also be offered?
Antithrombin therapy with fondaparinux sodium should also be offered, unless the patient is undergoing immediate coronary angiography, or has a high bleeding risk
177
If patient has significant renal impairment then what alternative to fondaparinux can be given as antithrombin therapy?
Heparin (unfractionated)
178
Following an ACS, al patients should be offered which programme?
- a cardiac rehabillitation programme including advice for lifestyle changes, stress management and health education.
healthy eating, reducing alcohol consumption, regular physical exercise, smoking cessation and weight management
179
Which ACS require treatment for secondary prevention?
Treatment for secondary prevention should be initiated in all patients following a STEMI and NSTEMI. Clinical judgement should be used in patients with unstable angina
180
Which combination of drugs should be offered for ACS secondary prevention?
- ACE inhibitor/ ARB
- Beta-blocker
- Dual antiplatelet therapy
- A statin
181
How long should beta blocker be used for in ACS secondary prevention?
continued indefinitely for patients with a reduced left ventricular ejection fraction (LVEF). In those without reduced LVEF, it may be appropriate to discontinue beta-blocker therapy after 12 months;
182
Instead of a beta blocker can diltiazem or verapamil be used?
Diltiazem hydrochloride or verapamil hydrochloride may be considered as an alternative to beta-blocker therapy in patients who do not have pulmonary congestion or a reduced LVEF.
183
How long should treatment with aspirin and second anti-platelet therapy continue?
Treatment with aspirin should continue indefinitely. Dual antiplatelet therapy (aspirin with a second antiplatelet) should be continued for up to 12 months unless contraindicated. Clopidogrel monotherapy should be considered as an alternative to aspirin in patients who have aspirin hypersensitivity.
184
Is rivaroxaban recommended in antiplatelet therapy for secondary prevention in ACS?
Rivaroxaban, in combination with either aspirin alone or aspirin and clopidogrel is also recommended as an option for preventing atherothrombotic events following an ACS with elevated cardiac biomarkers.
185
Which patients is thrombolytic drugs indicated for?
- Any patient with acute myocardial infarction for whom the benefit is likely to outweigh the risk of treatment.
186
For use in acute myocardial infarction, within how many hours should altepase be given?
Within 6-12 hours of symptom onset
187
For use in acute myocardial infarction, within how many hours should reteplase and streptokinase be given?
Within 12 hours of symptom onset
188
For use in acute myocardial infarction, within how many hours should Tenecteplase be given?
Should be given as early as possible and usually within 6 hours of symptom onset.
189
What is urokinase licensed for?
urokinase can be used for other thromboembolic disorders such as deep-vein thrombosis and pulmonary embolism.
Urokinase is also licensed to restore the patency of occluded intravenous catheters and cannulas blocked with fibrin clots.
190
What is the MAO of fibrinolytics?
Fibrinolytic drugs act as thrombolytics by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.
191
Give examples of fibrinolytics?
- Altepase
- Streptokinase
- Tenecteplase
192
What are nitrates used for?
- they have a role in angina
193
What effect do nitrates have on the venous the ventricles?
Although they are potent coronary vasodilators, their principal benefit follows from a reduction in venous return which reduces left ventricular work.
194
What are the unwanted side effects of Nitrates?
- flushing
- headache
postural hypotension
195
How quickly do sublingual trinitrate provide symptomatic relief?
- Provide rapid symptomatic relief of angina, but its effect lasts only for 20 to 30 minutes.
196
What are transdermal preparations of glyceryl trinitrate used for?
used for the prophylaxis of angina; duration of action may be prolonged (but tolerance may develop)
197
Does isosorbide dinitrate have a short or long onset of action and how long does the effect last for?
Isosorbide dinitrate is effective by mouth for the prophylaxis and treatment of angina; although the effect is slower in onset, it may persist for several hours.
Modified-release preparations can have a duration of action up to 12 hours.
198
What is isosorbide dinitrate licensed for in angina?
prophylaxis and treatment of angina
199
What is isosorbide mononitrate a product of?
he activity of isosorbide dinitrate may depend on the production of active metabolites, the most important of which is isosorbide mononitrate
200
What is isosorbide mononitrate licensed for in angina?
For the prophylaxis of angina
201
When is glyceryl trinitrate intravenous injection licensed to be used?
- for the treatment of unstable angina and coronary insufficiency when the sublingual form is ineffective.
Glyceryl trinitrate and isosorbide dinitrate intravenous injections are licensed for the treatment of heart failure.
202
How often should a dose of glyceryl trinitrate be administered (repeated) when there is an episode of angina attack?
1 dose, may be repeated after 5 minutes intervals if required.
If symptoms have not resolved after 3 doses, medical attention should be sought.
203
What is the MAO of dobutamine?
Dobutamine is a cardiac stimulant which acts on beta 1 receptors in cardiac muscle, and increases contractility.
204
What ratio of CPR should be performed?
30 chest press
| 2 - breaths
205
In cardiac arrest what dose of adrenaline/epinepherine is recommended to be used?
Adrenaline/epinephrine 1 in 10000 (100 micrograms/mL) 1mg (10mls) is recommended by intravenous injection repeated every 3–5 minutes if necessary.
206
When can amiodarone be used in cardiac arrest?
Intravenous injection of amiodarone hydrochloride should also be given to treat ventricular fibrillation or pulseless ventricular tachycardia in cardiac arrest refractory to defibrillation
An additional dose of amiodarone hydrochloride can be given if necessary.
207
If amiodarone is not available then which drug can be used as an alternative?
Lidocaine hydrochloride, is an alternative if amiodarone is not available or a local decision has been made to use lidocaine instead
208
If during cardiopulmonary arrest, if intravenous access cannot be obtained then which route can be used instead?
Intaosseous route -
Intraosseous infusion (IO) is the process of injecting medications, fluids, or blood products directly into the marrow of a bone
209
What is the MAO of adrenaline/ epinepherine?
Acts on both alpha and beta receptors and increases both heart rate and contractility (beta1 effects); it can cause peripheral vasodilation (a beta2 effect) or vasoconstriction (an alpha effect).
210
When are thiazide like diuretics used?
- to relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure
211
When are loop diuretics used?
In pulmonary oedema to left ventricular failure and in patient with chronic heart failure
212
When may combination diuretic therapy be used?
may be effective in patients with oedema resistant to treatment with one diuretic.
213
Are thiazide diuretics potent diuretics?
- Moderately potent diuretics
214
Where do thiazide like diuretics work?
They inhibit sodium reabsorption at the beginning of the distal convoluted tubule.
215
How long does it take for diuretics to work and what is their duration of action?
They act within 1-2 hours of oral administration and most have a duration of action of 12 to 24 hours.
216
When is it best to administer thiazide diuretics?
Early in the day so that the diuresis does not interfere with sleep
217
Does a high does or low dose thiazide diuretic produce greater hypertensive effect?
In the management of hypertension a low dose of a thiazide produces a maximal or near-maximal blood pressure lowering effect, with very little biochemical disturbance.
Higher doses cause more marked changes in plasma potassium, sodium, uric acid, glucose, and lipids, with little advantage in blood pressure control
218
Which thiazide like diuretic is the preferred options used in the management of hypertension?
Chlortalidone and indapamide
219
When is Bendroflumethiazide used?
Bendroflumethiazide can be used for mild or moderate heart failure; it is licensed for the treatment of hypertension but is no longer considered the first-line diuretic for this indication, although patients with stable and controlled blood pressure currently taking bendroflumethiazide can continue treatment.
220
Which thiazide related compound diuretic can be given on alternate days to control oedema and why?
Chlortalidone - It has a longer duration of action than the thiazides
221
Which two thiazide like diuretics are chemically related to chlortalidone?
Xipamide and indapamide are chemically related to chlortalidone
222
What are loop diuretics indicated to treat?
Pulmonary oedema
| Also used in chronic heart failure
223
Can a loop diuretic be added to anti-hypertensive treatment to achieve better control of blood pressure?
If necessary, a loop diuretic can be added to antihypertensive treatment to achieve better control of blood pressure in those with resistant hypertension, or in patients with impaired renal function or heart failure.
224
what can loop diuretics exacerbate?
Loop diuretics can exacerbate diabetes (but hyperglycaemia is less likely than with thiazides) and gout.
225
How long do furosemide and bumetanide take to act?
both are similar in activity; both act within 1 hour of oral administration and diuresis is complete within 6 hours, if necessary, they can be given twice in one day without interfering with sleep.
226
Are amiloride and triamterene strong or weak diuretics?
Weak diuretics - they cause potassium retention and are therefore given with thiazide or loop diuretics as a more effective alternative to potassium supplements.
227
Can potassium supplements be given with potassium-sparing diuretics?
No they must not be given together
228
Give examples of two potassium sparing diuretics?
- Spironolactone
| - Eplerenone
229
What type of diuretic is mannitol?
Mannitol is an osmotic diuretic that can be used to treat cerebral oedema and raised intra-ocular pressure.
230
why are mercurial diuretics not used?
Mercurial diuretics are effective but are now almost never used because of their nephrotoxicity.
231
What is co-amilofruse a combination of?
Amiloride
| furosemide
232
Is amiloride a potassium sparing diuretic?
Yes
233
Is triamterene a potassium sparing diuretic?
Yes - it is usually given with a thiazide or loop diuretic for potassium conservation
234
What are the two types of peripheral vascular disease?
Peripheral vascular disease can be either occlusive (e.g. intermittent claudication) in which occlusion of the peripheral arteries is caused by atherosclerosis, or vasospastic (e.g. Raynaud’s phenomenon).
235
Is peripheral vascular or arterial disease associated with increased CVD risk?
Peripheral arterial occlusive disease is associated with an increased risk of cardiovascular events.
236
What should be offered with all patients with intermittent claudication?
A supervised exercise programme should be offered to all patients with intermittent claudication.
Revascularisation procedures may be appropriate if other measures fail
237
Which drug can be used if exercise alone is insufficient?
Naftidrofuryl oxalate can be considered if supervised exercise has not led to satisfactory improvement, and the patient prefers not to be referred for consideration of angioplasty or bypass surgery. Review treatment with naftidrofuryl oxalate after 3–6 months; discontinue if there has been no symptomatic benefit.
238
Which other drugs are licensed for the treatment of intermittent claudication?
Cilostazol and pentoxifylline are licensed for the treatment of intermittent claudication. Naftidrofuryl oxalate has shown a greater increase in maximum walking distance and pain-free walking distance than cilostazol and pentoxifylline.
239
What is the management of Raynaud's phenomenon?
- avoiding exposure to cold
| - Smoking cessation
240
Which drug can be trialled in Raynaud's phenomenon?
Nifedipine as prophylaxis
241
Are there evidence for drug treatment in chillblains?
no - and evidence does not support drug treatment for routine use
242
What is intermittent claudication?
Intermittent claudication is pain affecting the calf, and less commonly the thigh and buttock, that is induced by exercise and relieved by rest. Symptom severity varies from mild to severe. Intermittent claudication occurs as a result of muscle ischaemia during exercise caused by obstruction to arterial flow.
243
What is the indication of Cilostazol?
- intermittent claudication in patients with and no peripheral tissue necrosis
244
Which sclerosant drug is used for vein malformation?
Sodium tetradecyl sulfate - used for sclerotherapy of reticular veins and spider veins in legs and varicose veins
245
To summarise this BNF chapter, what is the treatment steps of AF?
1) beta blocker (not sotalol) or rate limiting calcium channel blocker
2) if single drug is insufficient then add digoxin
3) Achieve rhythm control with beta blocker if not effective or not tolerated then use an anti-arrhythmic drug such as sotalol, flecainide or amiodarone.
246
Name an antifibrinolytic drug and when it is used?
Tranexamic acid - inhibits fibrinolysis can be used to prevent bleeding associated with excessive fibrinolysis
247
What are the two types of VTE?
DVT
| Pulmonary embolism PE
248
For VTE which drug s preferred in patients with renal failure?
Unfractionated heparin
249
Does unfractionated heparin have faster onset of action than LMWH?
Yes but has shorter duration of action
250
Why is unfractionated heparin used in high risk patients, whys it preferred?
effects can be reversed quicker
251
What is the antitode to heparin?
Protamine
252
What are the main side effects in heparin?
- Thrombocytopenia
| - Hypokalaemia
253
For pregnant women, which is preferred UFH or LMWH?
Pregnant women can take Heparin for VTE as it does not cross the placenta. But LMWH are preferred due to their lower risk of osteoporosis and heparin-induced thrombocytopenia
254
What is the INR tagrets for different conditions?
INR: 2.5 for AF, DVT and PE,
3.5 for mechanical aortic valves and for recurrent DVT or PE.
255
If a patient on warfarin requires emergency surgery, what must be given?
- vitamin k1 + prothrombin complex
256
What is the difference between anticoagulant and anti-platelet in terms of clotting
Anti-platelet = prevent clotting
Anticoagulant = slow clotting
257
Is bleeding risk greater with aspirin + warfarin or Clopidogrel + warfarin?
- Aspirin + warfarin = lower risk
258
Can warfarin be used in renal impairment?
Yes but in severe impairment increased frequency of INR monitoring is needed
259
What counselling points should be given about diet to patients on warfarin?
avoid cranberry juice (increases anticoagulant effect). Avoid changing diet of liver, sprouts, broccoli and leafy green vegetables (rich in Vitamin K).
260
Can warfarin be used in pregnancy?
No - avoid
261
List the enzyme inducers?
Crap GP's shout BS
```
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbital
Sulphonylurea’s
St John’s Wort
Barbiturates
Smoking
```
262
List the enzyme inhibitors
```
Sodium Valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulphonamide’s
Ciprofloxacin
Omeprazole
Metronidazole
Grapefruit Juice
Fluoxetine
```
263
What should TIA be treated with?
Aspirin immediately 300mg od for two weeks
264
Which thrombolytic should be used initially for patients presenting with ischaemic stroke or TIA?
Altepase within 4.5 hours of onset of symptoms
265
What is the long term treatment (secondary prevention) of ischaemic stroke and TIA?
- Clopidogrel
| - Statin (regardless of patient's cholesterol)
266
Which DOAC is a thrombin inhibitor?
Dabigatran
267
What is the normal total cholesterol levels?
5mmol/L
268
What is the name given for high levels of cholesterol?
Hyperlipidaemia
269
Which statin is best to start with to treat hyperlipidaemia?
Atorvastatin
270
In terms of lowering LDLs and triglycerides, which is better at which between statins and fibrates?
Statins are superior at lowering LDL cholesterol
Fibrates are better at lowering triglycerides levels
271
WHat is the MAO of statins?
They inhibit the HMG co A reductase (enzyme) which is involved in cholesterol synthesis
272
Which two statins can be taken any time of the day?
Atorvastatin
| Rosuvastatin
273
What is the maximum dose of simvastatin w hen given with bezafibrate?
10mg simvastatin
274
What is the maximum dose of simvastatin if given with any of the following drugs; amiodarone, verapamil, diltiazem or amlodipine?
maximum dose is 20mg simvastatin
275
What are the two types of heart failure?
Heart failure with reduced ejection fraction (less than 40%) (Left systolic ventricular dysfunction)
Heart failure with preserved ejection fraction
276
What are the treatment steps summary of heart failure with reduced ejection fraction?
1) ACE inhibitor/ ARB + beta blocker (Carvediolol, bisoprolol)
2) candesartan + valsartan can be given as adjunct to ACEi
3) Add spironolactone / eplerenone
4) Add digoxin (decreases hospitalisation but not mortality)
277
Which diuretics are preferred in heart failure?
- loop diuretics
- Thiazide good for only mild heart failure + only effective in good renal function
- Thiazides are ineffective in poor renal function less than 30 eGFR and loop diuretic is preferred
- If single diuretic is not sufficient then combination can be used
278
What is the treatment steps for stable angina (myocardial ischaemia)
Acute attacks should be managed with sublingual GTN
Long term management=
1) Beta blocker or calcium channel blocker (not rate limiting ones as they reduce cardiac output)(use dihydropyridine ones)
2) A combination of a beta blocker and dihydropyridine CCB) ((amlodipine, felodipine or nifedipine)
3) If this combination is not appropriate due to intolerances or contraindications to either drugs then ADDITION of a long-acting nitrate, Ivabradine, Nicorandil or Ranolazine can be considered
4) 4. If there are intolerances or contraindications to both drugs, then MONOTHERAPY with a long-acting nitrate can be considered.
279
Where does Ivabradine act?
- Ivabradine lowers the heart rate by acting on the Sinus node.
. It is licensed to be used for patients with normal sinus rhythm in combination with a beta-blocker or when beta-blockers are contraindicated/not tolerated.
280
What 3 conditions is ACS the umbrella term for?
- Unstable angina
- NSTEMI
- STEMI
281
What is long-term management of NSTEMI/ unstable angina?
In patients with unstable angina/NSTEMI, Clopidogrel/Prasugrel/Ticagrelor is given with Aspirin for up to 12 months. An ACE inhibitor is also given.
282
What is the long term management following ACS?
1. Dual Antiplatelet therapy: Aspirin + Clopidogrel/Prasugrel/Ticagrelor. If patients are intolerant of Clopidogrel then Aspirin + Warfarin can be given. If patients are intolerant of Aspirin and Clopidogrel, then Warfarin alone can be used. NOTE: ASPRIN + CLOPIDOGREL/WARFARIN = RISK OF BLEEDING.
2. Beta-blockers should be given to all patients who are not contraindicated. Diltiazem or Verapamil may be considered if a beta-blocker cannot be used but they are contraindicated in left ventricular dysfunction
3. ACE inhibitor or Angiotensin-II receptor antagonist. High dose may be needed to produce benefit.
4. Statins: prevent narrowing of blood vessels as they reduce lipid levels. A high dose (80mg) is given
283
What are the two types of peripheral vascular disease?
Peripheral vascular disease can be either occlusive (e.g. intermittent claudication) in which occlusion of the arteries is caused by atherosclerosis (cramping leg pain is induced by exercise due to obstruction in the arteries)
- vasospastic (e.g. Raynaud’s syndrome)(spasms of arteries in the extremities)
284
What can naftidrofuryl be used for?
For peripheral vascular disease (peripheral arterial occlusive disease)
It can alleviate symptoms of intermittent claudication and improve pain-free walking distance
285
Which drug can be used for intermittent claudicaation for patients who do not have pain at rest?
Cilostazol can be used for intermittent claudication to improve walking distance in patients who do not have pain at rest. It is used 2nd line when lifestyle interventions have failed to control symptoms.
286
What are the management options for Raynaud's syndrome?
Management of Raynaud’s syndrome includes avoidance of exposure to cold and stopping smoking. More severe symptoms may require vasodilator treatment, which is often successful.
Nifedipine is used for reducing the frequency and severity of vasospastic attacks. Alternatively, Naftidrofuryl oxalate may produce symptomatic improvement.
287
Which two thiazide diuretics are used in eye drops for glaucoma?
- Acetazolamide and eye drops of dorzolamide + brinzolamide inhibit the formation of aqueous humour and are used in glaucoma
288
Do patients on diuretics need potassium supplements?
No many patients do not need potassium supplements
289
Do thiazide like diuretics cause high or low calcium?
High calcium
290
Can thiazide diuretics be given with lithium?
No, avoid giving with lithium - sodium depletion increases the risk of toxicity
291
What can rapid IV administration of loop diuretics cause?
Tinnitus or deafness
292
Can loop diuretics be given with aminoglycosides (e.g. gentamicin or vancomycin)?
No due to the risk of ototoxicity
293
Which CCB is licensed for treatment of acute life-threatening hypertension?
IV - Nicardipine
294
How do Vasoconstrictor sympathomimetics raise blood pressure?
- By acting on alpha adreno receptors to constrict peripheral vessels.
295
What is a major disadvantage of vasoconstrictor sympathomimetics?
Although they raise blood pressure, they may also reduce perfusion of vital organs e.g. the kidney.
