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Clinical pharmacology and therapeutics > Cardiology 1 and 2 > Flashcards

Cardiology 1 and 2 Flashcards

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1
Q

What is acute coronary syndrome?

A

A spectrum of conditions

  • Unstable angina
  • NSTEMI
  • STEMI

Reduction in blood flow through the coronary arteries - usually as a result of atherosclerotic plaque rupture

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2
Q

What is diagnosis of ACS based on?

A

Symptoms
ECG
Bloods

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3
Q

What does an ECG with sustained ST elevation indicate?

A

Full thickness ischaemia and necrosis

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4
Q

List some symptoms of ACS

A 
Heartburn
Chest pain - Radiates to neck or left arm
Sweating
Clammy
Cold
Grey pallor
Nausea
Vomiting
LOC
Arrest 
Anxiety
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5
Q

List the risk factors for ACS

A 
HTN
High cholesterol 
FH
Smoking
Male 
Obesity 
Diabetes
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6
Q

What score is used to predict the risk of death from MI after ACS?

A

GRACE 2 score

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7
Q

List the treatment aims of ACS

A

Reduce cardiac ischaemia
Reduce myocardial O2 demand
Prevent recurrence

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8
Q

How is cardiac ischaemia reduced

A

Revascularisation
Thrombolysis
Medical management

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9
Q

Describe revascularisation

A

Patient to catheter lab
Femoral/radial access
Angiography +/- Angioplasty +/- stenting (bare metal or drug eluting - dual antiplatelet therapy for up to 12 months - premature discontinuation leads to an increased risk of stent thrombosis)

Or coronary artery bypass graft

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10
Q

When is thrombolysis used to treat ACS?

A

Used in a STEMI

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11
Q

Which drugs are used in thrombolysis?

A

Alteplase
Reteplase
Streptokinase
Tenecteplase

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12
Q

When is thrombolysis contraindicated?

A 
Recent bleeding/trauma (<1 month)
Bleeding disorders
Hemorrhagic stroke 
Ischaemic stroke/TIA (<6 months)
On warfarin/DOAC
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13
Q

Describe the immediate management of ACS

A 
Oxygen 
Nitrates
Anti-emetics
Antiplatelet loading
Fondaparinux/LMWH
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14
Q

What long term management and secondary prevention would you expect an ACS patient to be discharged home with?

A 
DAPT - aspirin, clopidogrel/prasugrel/ticagrelor
ACE inhibitors/ARBs
Beta blockers
Statins 
GTN spray 
Lifestyle advice
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15
Q

What is the loading dose of aspirin?

A

300mg

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16
Q

What is the maintenance dose of aspirin?

A

75mg

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17
Q

What must aspirin be taken with?

A

Food

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18
Q

What is the loading dose of clopidogrel?

A

300 or 600mg depending on local guidelines

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19
Q

What is the maintenance dose of clopidogrel?

A

75mg OD

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20
Q

What is the loading dose of ticagrelor?

A

180mg STAT

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21
Q

What is the maintenance dose of ticagrelor?

A

90mg BD

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22
Q

What is the loading dose of prasugrel?

A

60mg STAT

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23
Q

What is the maintenance dose of prasugrel?

A

<60 Kg or >75years old - 5mg OD

>60 Kg 10mg OD

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24
Q

What is a common side effect of ticagrelor?

A

Shortness of breath

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25
What is a common side effect of prasugrel?
GI bleeding
26
Describe the mechanism of action of beta blockers
Affect receptors in heart and blood vessels Slow the SA node which initiates heart beat Slows heart rate and allows time for the left ventricle to fill completely and lowers heart workload Dilate arteries Lower blood pressure
27
List the contraindications and cautions of beta blockers
2nd and 3rd degree heart block Asthma and obstructive airways disease Unstable heart failure
28
What are the side effects of beta blockers?
``` Fatigue Cold hands/feet Nightmares/sleeping disturbances Breathing difficulties in asthmatics Bradycardia ```
29
What can beta blockers mask the symptoms of?
Hypoglycaemia
30
What may happen if a patient suddenly stops taking beta blockers?
Rebound tachycardia
31
Describe the use of ACE inhibitors in ACS
Ventricular enlargement causes a poorer prognosis so these patients should have an ACEi 24 hrs post MI Titrate up every 2 weeks to the maximum tolerated dose Prevent cardiac remodelling Continue indefinitely Monitor renal function and electrolytes
32
What are common side effects of ACE inhibitors?
Dry cough Loss of taste/appetite Postural hypotension - advised to take at night time
33
Describe the mechanism of action of statins
HMGCoA reductase inhibitors - prevent the synthesis of cholesterol in the liver Lowers LDL cholesterol but does not target dietary cholesterol Stabilises atherosclerotic plaques in coronary blood vessels. Anti inflammatory effect upon blood vessels.
34
When should simvastatin and pravastatin be taken?
At night
35
How much can statins reduce the risk of another cardiac event by?
60%
36
What is the target total cholesterol?
<5
37
What is the target Non-HDL cholesterol?
<4
38
What is the target LDL cholesterol?
<3
39
What is the target HDL cholesterol?
>1
40
What is the target triglycerides?
<2.3
41
List the side effects of statins
``` Muscle pain Headaches Nausea Vomiting Abdominal pain ```
42
What is angina pectoris?
Pian, discomfort or pressure typically located in the chest and caused by an insufficient supply of blood to the myocardium
43
Describe the effects of nitrates in angina pectoris
Dilation of veins and collaterals - decreased O2 consumption
44
Describe the effects of nitrates in heart failure
Dilation of conduit arteries and veins - reduced LVEDP, reduced wall stress and reduction of mitral regurgitation
45
Describe the effects of nitrates in ACS
Dilation of conduit arteries, collaterals and antiaggregant effects - increases O2 supply
46
Give some reasons for nitrate use
To relieve or prevent expected chest pain - GTN spray | To prevent regular chest pain (tablets/patches)
47
What are some side effects of nitrates
Flushing Headache - will reduce over time and become less severe Dizziness Postural hypotension
48
Which drugs interact with nitrates?
Sildenafil Vardenafil Tadalafil Cause significant drop in BP
49
Why must people be careful when driving and taking nitrate?
Causes dizziness
50
Should a person consume alcohol when taking nitrates?
No - may cause dizziness - Avoid directly after use
51
Describe the mechanism of action of nicorandil
Nitrate like action and K+ ATP channel opener
52
What are the side effects of nicorandil?
Dizziness Nausea Headache
53
Name the most common arrhythmia
Atrial fibrillation
54
Describe atrial fibrillation
Rapid atrial rate >300-600 beats per min followed by a rapid and irregular ventricular beat AV node restricts conduction, giving ventricular rate < 200 bpm
55
List the symptoms of atrial fibrillation
``` Palpitations Chest pain Fatigue Dizziness Dyspnoea Syncope Low exercise tolerance ```
56
What is persistent AF?
> 48hrs after onset but may be cardioverted back to SR using either electrical or pharmacological cardioversion
57
What is paroxysmal AF?
Intermittent, self terminating or recurrent arrhythmia combined with normal SR. Main aim of treatment is to maintain SR for as long as possible because cardioversion is ineffective
58
What is permanent AF?
Chronic condition which is permanent for >48hrs Cardioversion is either ineffective or unsuitable. Aim of treatment is to maintain the HR by controlling the ventricular rate
59
Describe rate control
Slow conduction through the AV node | Patient remains in AF but a more controlled/slow rate
60
Describe rhythm control
Electrical by cardioversion - immediate or elective | Chemical cardioversion - drug therapy alone or as an adjunct to electrical cardioversion
61
What is ablation?
A technique where a small amount of energy is applied directly onto the area responsible for the abnormal electrical circuit within the heart - the energy creates scar tissue which blocks the electrical transmission in these areas
62
List the drug treatments for AF
Anticoagulants Rate control - Beta blockers, rate lowering calcium antagonist (verapamil, diltiazem) and digoxin Rhythm control - Structural heart disease (beta blocker or amiodarone), No structural heart disease (beta blocker) Pill in the pocket - Flecainide and propafenone
63
Why is AF dangerous?
Most common cardiac disorder leading to stroke and thromboembolism
64
Where do thromboembolisms resulting from AF come from?
Left atria
65
What do AF strokes lead to?
High mortality and high levels of disability - larger strokes
66
How much does appropriate anticoagulation reduce the risk of stroke by?
2/3
67
Which drug class is commonly used to treat AF?
DOACs
68
Name some DOACS used to treat AF
Dabigatran Rivaroxaban Apixaban Edoxaban
69
When do you avoid the use of DOACS
If Cr CL is <15ml/min
70
How often would you check U&Es after starting a DOAC?
1 year
71
On initiation of DOAC treatment what monitoring must be carried out?
Renal function Patient weight Liver function Clotting screen
72
Describe the mechanism of action of warfarin
Vitamin K antagonist | Works on clotting cascade factors 2,7,9 and 10
73
What monitoring is needed when a patient is on warfarin?
Regular INR checks
74
How is warfarin dosed?
According to INR
75
What is warfarin licensed for use in?
``` AF PE DVT Recurrent DVT and PE Mechanical valves ```
76
Name a scoring system used to estimate the risk of stroke
CHA2DS2-VASc Score
77
Name a scoring system used to estimate the bleeding risk
HASBLED
78
List the components on the CHADVASC score
``` Congestive heart failure (1) Hypertension (1) Age >75 (2) Diabetes mellitus (1) Previous stroke, TIA or thromboembolism (2) Vascular disease (1) Age 65-74 (1) Sex (female = 1) ```
79
List the components on the HASBLED score
``` Hypertension (1) Abnormal renal and liver function (1 point each) Stroke (1) Bleeding (1) Labile INRs (1) Elderly - age >65 (1) Drugs or alcohol (1 point each) ```
80
Which drug is used in rhythm control?
Digoxin
81
Describe the mechanism of action of digoxin
Increases the force of contraction and reduces conductivity with the AV node
82
What is digoxin only effective for?
Controlling ventricular rate at rest
83
Which patient should digoxin be used in?
Monotherapy for sedentary patients
84
What should the dose of digoxin be determined by?
Ventricular rate at rest | HR should not fall below 60bpm
85
How is digoxin excreted?
Renally
86
What monitoring is required with digoxin?
The digoxin level
87
What is the ideal digoxin level?
0.5-2 micrograms/litre
88
How long after the dose are digoxin levels taken?
6 hrs
89
What can toxic levels of digoxin occur at?
>1.5-3 micrograms/litre
90
What is digoxin toxicity increased by?
AKI Hypokalemia Hypomagnesaemia Hypocalcaemia
91
List the signs of digoxin toxicity
``` Lethargy Confusion Vomiting Diarrhoea Visual changes ```
92
Are IV and PO digoxin doses equal?
No
93
Describe the loading dose of digoxin
750 micrograms - 1 mg in divided doses over 24 hours (reduce dose if elderly)
94
What is the adult maintenance dose of digoxin?
125-250 micrograms OD
95
How much amiodarone is required to load?
5-10g
96
Describe the loading dose of IV amiodarone
5mg/Kg given over 20-120 mins with ECG monitoring
97
Describe the loading dose of infusion amiodarone
1.2g/24hrs preferred central administration
98
Describe the loading dose and maintenance dose of oral amiodarone
200mg tds for 1 week, then 200 mg BD for 1 week and then maintenance dose of 200mg OD
99
Which bloods would you check if a patient was on amiodarone?
TFTs and LFTs
100
List the side effects of amiodarone
Cardiac - new/worsened arrythmia Skin - sensitive to the sun and or blue grey discolouration Eyes - corneal deposits in the eye - careful with driving Thyroid - precipitate under active thyroid disease or overactive thyroid disease (blood test before starting and every 6 months) Liver -rarely causes abnormal liver results (blood test before starting and at 6 months) Lun - rarely causes inflammation of lining of alveoli Altered taste and sleep disturbance
101
Name some calcium channel antagonist groups and state their effect
Dihydropyridine - antihypertensive effect | Non dihydropyridine - antiarrhythmic effect
102
Which food must patients avoid when taking calcium channel antagonists?
Grapefruit
103
Name some dihydropyridine CCBs
``` Felodipine Amlodipine Nimodipine Nifedipine Nicardipine ```
104
Name some non-dihydropyridine CCBs
Verapamil | Diltiazem
105
Describe the mechanism of action of monoamine oxidase inhibitors
Inhibit calcium ions from entering slow or voltage gated channels seen in vascular smooth muscle and the myocardium - increases myocardium oxygen delivery
106
List the side effects of MAOi
``` Constipation Facial flushing Headaches Ankle swelling Fatigue Dizziness ```
107
What is heart failure?
Clinical syndrome resulting in reduced cardiac output and/or elevated intracardiac pressure at rest or in times of stress
108
What is heart failure caused by?
Structural and/or functional abnormality in the heart
109
List the typical symptoms of heart failure
Breathlessness Ankle swelling Fatigue
110
List the typical signs of heart failure
Elevated jugular venous pressure Pulmonary crackles Peripheral oedema
111
Describe systolic heart failure
Heart failure with reduced ejection fraction - Fraction of blood ejected is <40% Left ventricle can not contract adequately to eject the blood into the aorta. Lack oxygen rich blood to meet the bodys needs
112
What is systolic heart failure predominately caused by?
Coronary artery disease
113
Describe diastolic heart failure
Heart failure with a preserved ejection fraction - Fraction of blood ejected >50% Heart muscles become stiff and do not relax properly resulting in an impaired filling process
114
What is diastolic heart failure predominately caused by?
Hypertension
115
Name a class system used to classify heart failure patients
New york heart association
116
List some causes of chronic heart failure
``` IHD HTN Valve disease Myocarditis Cardiomyopathy Arrhythmia ACS ```
117
Describe the treatment of systolic HF
ACEi/ARB/ARNi/BB AA (or MRA) Manage fluid status
118
Describe the treatment of diastolic HF
Manage fluid status
119
What are the goals of HF treatment?
Relieve signs and symptoms Prevent hospital admission Improve survival
120
Describe the physiological response to heart failure
Increase cardiac output Increase catecholamine release Activation of renin angiotensin system Structural changes
121
Describe the compensatory mechanisms in heart failure
CO = SV x HR Starling’s Law Sympathetic Nervous System Renin-Angiotensin-Aldosterone System Endothelin, Nitric oxide and prostaglandins Vasopressin Stretch and pressure response (ANP and BNP)
122
What drugs are used to treat HF?
``` Diuretics ACEi/ARB (if ACEi not tolerated) Beta-blockers Mineralocorticoid receptor antagonists Ivabradine Nitrates Sacubitril/Valsartan ```
123
Describe the site and mechanism of action of thiazide diuretics
Distal convoluted tubule - Inhibition of sodium & water reabsorption.
124
Describe the site and mechanism of action of loop diuretics
Ascending loop of henle - Inhibition of sodium & water reabsorption
125
Describe the site and mechanism of action of mineralocorticoid receptor antagonists (aldosterone antagonists)
Collecting duct - Inhibition of aldosterone ie allows excretion of sodium & water: potassium retained
126
What is the first line treatment for all left ventricular HF?
ACEi and ARBs
127
Describe the dosing of ACE inhibitors and ARBs
Start at low dose and titrate upwards every 2 weeks until maximum tolerated dose.
128
When are angiotensin 2 receptor antagonists recommended first line?
In patients who can not tolerate ACE inhibitors
129
Name some angiotensin 2 receptor antagonists
Candesartan, losartan and valsartan
130
Describe ivabradine
Licensed for Chronic HF 5mg BD for 2 weeks then increase to maximum 7.5mg BD (Resting HR >50 bpm) 2.5mg BD if >75 years or unable to tolerate higher dose NICE recommends it in combination with standard therapy when Beta blockers are not tolerated or contra-indicated ESC recommends it for EF<35% in SR with resting HR ≥ 70bpm when Beta blockers are not tolerated or contra-indicated
131
List the side effects of ivabradine
slow heart rate, headache, dizziness, vision disturbance.
132
List some lifestyle changes used in the treatment of heart failure
``` Monitor fluid intake Monitor breathlessness and oedema Smoking cessation Optimise BP Optimise diabetes management Diet and reduced salt intake Regular exercise providing condition is stable and doesn’t preclude this Flu vaccination Pneumococcal vaccination Compliance with medication ```

Clinical pharmacology and therapeutics (27 decks)

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