Cardiovascular and vascular Flashcards
What is the treatment pathway for stable Angina?
1st: PRN symptom relief = GTN spray/sublingual tab
With advice on when to call 999
2nd: First line treatment
- Beta-blocker or CCB
- Reassess in 2-4 weeks to see response
3rd: Secondary CVD prevention
(prevent more deadly events)
-Stop smoking, dietary advice and exercise
-Consider antiplatelet medication (Aspirin 75mg pday)
-Offer statin (Atorvastatin 20mg if primary, 80mg if secondary)
4th: Offer ACE-I if they have DM (Protective for DM nephthropathy)
Give ACE-I if they have;
HTN, HF, Asymptomatic LV dysfunction, CKD, Previous MI
5th: Revascularisation
-PCI with stent and dual antiplatelet therapy for 12M
Or - CABG (last resort)
What are the non-medical interventions for Stable Angina and ACS?
Smoking cessation (All who have expressed a desire to quit should be offered support and advice, and referral to an intensive support service: NHS Stop Smoking Services)
Healthy diet (Mediterranean-style diet: more bread, fruit, vegetables and fish)
Exercise (20-30 min per day)
Safe alcohol consumption (less than 14 units, divided over 3-4 days)
What is the initial treatment pathway for CV protection NSTEMI/Unstable angina?
(NOT the symptom treatment)
- 300mg Aspirin (CI: bleed risk or allergy)
- Antithrombin therapy:
- no angiography in next 24 hrs = Fondaparinux
- angiography in next 24 hrs = Unfractionated Heparin
- angiography in next 24 hrs and GRACE score is >3% 6month mortality = Bivalirudin
- if in a high risk group (60+, Previous MI/Stroke/TIA/CABG) = Ticagrelor - Assess risk of future CV events in next 6 months:
GRACE 6 month mortality score
- low = 1.5-3% mortality
- Intermediate = 3-6% mortality - If risk is low or more:
300mg Clopidogrel - If risk is intermediate or more, or if low risk but Ischemia comes back:
offer coronary angiography with PCI
What is the initial treatment pathway for symptomatic relief in diagnosed NSTEMI/Unstable angina?
(NOT the CV protection pathway)
- Low flow oxygen if:
- SpO2 <90%
Or - Dyspnoea - Analgesia: IV Morphine 5-10mg
- Antiemetic: IV Metoclopramide
- Nitrates: GTN spray/sublingual tablet
What is the acute treatment pathway for STEMI?
MONACH: (Morphine, O2, nitrates, aspirin, clopidogrel, LMWH)
1. Aspirin 300mg, GTN and high flow oxygen
2. Consider ticagrelor 180mg or prasogrel 60mg
3. Morphine 5-10mg IV
4. Antiemetic metoclopramide 10mg IV (Adjunct to opioid)
5. Fondaparinux
6 Surgery/Fibrinolysis:
- Only if within 12 hours of episode
- First choice = Angiography/PCI with Bivalirudin
- If PCI isn’t available within 2 hrs of presentation = Fibrinolysis
What is the long term treatment of ACS?
- Aspirin 75mg OD per day - for >1 year
- Second antiplatelet (clopidogrel) - for >1 year
- Consider PPI
- Beta blocker (unless CI)
- ACE-I if underlying condition requires
(DM, LV dysfunction, HTN) - High dose statin (Atorvastatin)
Also: echocardiogram to check LV function
What is cardiac rehabilitation?
Offered to all people who have had an MI
Assessment of: motivation to change lifestyle; body mass index; dietary habits; exercise habits and fitness; psychological status; physical symptoms such as chest pain or breathlessness; cardiovascular risk factors.
Education: On the condition and treatment
Referrals (quit smoking, dietary advice)
Exercise programmes
Advice on relaxation
In the aftermath of an MI, what kind of psychological support is offered?
Stress management should be offered
CBT is not offered
After medical treatment and rehabilitation , what advice do we give the patient about their day to day living post-MI?
e.g. driving, sex, air travel, erectile dysfunction,
Driving: check with DVLA, depends on treatment., and if you drive a truck/bus/coach (time off)
Back to work: depends on physicality of job
Sex: usually begin again 4 weeks post-MI
Erectile dysfunction: offer phosphodiesterase inhibitor (sildenafil, tadalafil or vardenafil)
Air travel: Check with civil aviation authority
In the treatment of essential hypertension:
what is the BP target when measured in clinic, for those under the age of 80 who are not pregnant and have no comorbidities?
<140/90 mmhg
If measured at home: 135/85 mmhg
In the treatment of essential hypertension:
what is the BP target when measured in clinic, for those over the age of 80 with no comorbidities?
(Remember that comorbidities often change the target BP)
<150/90 mmhg
If measured at home: <145/85
In the treatment of essential hypertension:
what is the BP target for those under the age of 80 who are pregnant but have no comorbidities?
<150/100 mmhg
Diastolic must be above 80 mmhg
In the treatment of essential hypertension:
what is the BP target for those under the age of 80 who are pregnant and have evidence of target organ damage?
<140/90 mmhg
Which antihypertensive drugs must we stop during pregnancy?
ACE-I’s
ARB’s
What is the treatment pathway for essential hypertension?
A (or B) or C (or straight to D)
then A+C
then A+C+D
then A+C+D+S/D(inc)
A = ACE-I If <55
(If not tolerated use ARB)
C = CCB if >55 or Afrocarribean
(Use thiazide diuretic instead if: oedematous, not tolerated, high risk of HF or evidence of HF)
D = Thiazide diuretic
(Indapamide or chlortalidone)
S = Low dose spironolactone
(If HTN still not controlled and Potassium is low: <4.5 mmol/L)
D(inc) = Increased dose of thiazide diuretic
(If HTN still not controlled and Potassium is >4.5 mmol/L)
B = beta blocker
(If intolerant of A, woman of childbearing potential, pregnant or evidence of increased sympathetic drive)
What is the treatment pathway for hypertension?
- Grade 1 HTN = lifestyle advice
2. Grade 1 HTN + X = antihypertensive medications Where X is; - Target organ damage - CVD - Renal disease - Diabetes mellitus type 1/2 - QRISK2 10 year risk of >20%
- Grade 2 or grade 3 HTN = antihypertensive medications
