Flashcards in Cardiovascular System Deck (95)
How do you manage acute non life- threatening AF?
If <48 hours,
Rate or rhythm control can be used.
If >48 hours/ uncertain,
Rate control only
What drugs are used for pharmacological cardio version?
IV amiodarone or flecainide
Do not give flecainide in structural heart disease
What drugs are used for rate control in AF?
Distinguish first line and second line options.
Beta blocker (not sotalol) or Rate- limiting calcium channel blocker (diltiazem or verapamil) monotherapy
Digoxin monotherapy (if non-paroxymal AF+sedentary)
Combination therapy with 2 of: a beta blocker, diltiazem, digoxin
DO NOT offer amiodarone for long term rate control.
How is stroke risk assessed in patients with AF?
CHA2DS2-VASc score tells you stroke risk.
HAS-BLED score tells you risk of bleeding.
Offer stroke prevention if
CHADSVASc is 1 or more for men or 2 or more for women, taking bleeding risk into account.
What medicines are used to prevent stroke in patients with AF?
Under what circumstances can you start treatment?
Wafarin, apixaban, dabigatran, rivaroxaban, edoxaban
Non-valvular AF with at least one of:
congestive HF, HTN, previous stroke or TIA, DM, age 75 or over.
What is torsade de pointes and how is it treated?
A form of ventricular tachycardia with an elongated QT. This is very serious and can lead to death.
STOP any anti-arrhythmic drugs - further prolong QT and exacerbate the condition
Treatment: IV magnesium infusion or beta blockers (not sotalol)
What are the Vaughan- williams classes of anti-arrhthmic drugs?
Class Ia- affect sodium channels ( e.g disopyramide)
Class Ib- lidocaine
Class Ic- flecainide
Class II- beta blockers
Class III- affect potassium channels e.g amiodarone, dronedarone
Class IV- affect calcium channels- diltiazem and verapamil
Class V- adenosine, digixin, magnesium
Which anti-arhythmic drugs can only be used in supraventricular arrhythmias?
Class IV + V antiarrhythmics:
Adenosine 1st line ( can be used after a b-blocker unlike verapamil)
Verapamil (preferable to adenosine in asthma)
NOTE: verapamil is only effective for supra ventricular arrhythmias.
Which anti-arhythmic drugs can only be used in ventricular arrhythmias?
Class Ib - IV lidocaine
What is a subarachnoid haemorrhage and how can it be managed?
Life-threatening type of stroke caused by bleeding into the space surrounding the brain.
It can be caused by ruptured aneurysms or head injury.
Nimodine ( a CCB) can be used for preventing ischaemic neurological defects following the bleed.
How are blood clots in catheters and lines managed?
UH, urokinase, epoprosterol (a prostaglandin)
What is the preferred treatment of VTE in pregnancy?
Heparins as they do not cross the placenta
What is the initial management for a suspected and confirmed TIA?
Aspirin 300mg stat (clopidogrel 75mg is altenative)
Following diagnosis, offer secondary prevention (anticoagulant)
How is acute ischemic stroke managed?
**Intracerebral haemorrhage must be excluded first.
If within 4.5 hours of onset, give alteplase.
If after 4.5 hours or cant give alteplase, give 300mg aspirin ( clopidogrel 75mg is alternative. Then aspirin 300mg OD for 2 weeks (24 hours after alteplase)
What is the long term treatment post stroke or TIA?
Clopidogrel 75mg OD (aspirin or dipyridamole if C/I)
Anticoagulants are not recommended if no AF
Warfarin should NOT be started in acute phase.
How long do coumarins and phenindione take to work?
What is the INR target in AF, singular DVT/PE, MI, cardioversion?
2.5 but within 0.5 of target is okay, (2-3)
In what circumstances is the INR target not 2.5 (or 2-3) and what is the target?
Recurrent DVT+ PE and mechanical/prosthetic heart valves. INR target is 3.5 (3-4) as higher risk of a clot.
What action should be taken if a patient on warfarin has a MAJOR bleed?
give phytomenadione 5mg stat - slow IV (vitamin K)
give octaplex (prothrombin complex)
if octaplex unavailable give fresh frozen plasma octaplasLG (not as effective)
What action should be taken if a patient on warfarin has a MINOR bleed (INR >8)?
When can warfarin then be restarted?
give phytomenadione 5mg stat - slow IV (vitamin K). Repeat after 24 hours of INR still high.
Restart warfarin when INR <5
What action should be taken if a patient on warfarin presents with an INR >8 NO bleed?
give phytomenadione 5mg stat - ORAL (vitamin K). Repeat after 24 hours of INR still high.
Restart warfarin when INR <5
What action should be taken if a patient on warfarin presents with an INR 5-8 MINOR bleed?
give phytomenadione 5mg stat - Slow IV (vitamin K).
Restart warfarin when INR <5
What action should be taken if a patient on warfarin presents with an INR 5-8 NO bleeding?
Withhold 1-2 doses of warfarin and reduce subsequent maintenance dose.
What should you do if a patient on warfarin is due to have surgery electively?
What about emergency surgery?
Stop warfarin 5 days before.
If high risk of bleed, start a LMWH (bridging) and stop this 24 hours before surgery.
If INR >/= 1.5, give phytomenadione day before surgery.
Restart warfarin night of surgery if all OK.
If emergency surgery can be delayed by 6-12 hours give phytomenadione and check INR.
If it can't be delayed give phytomenadione and prothrombin complex and check INR
Which parenteral anticoagulant is preferred in renal impairment?
Unfractionated heparin (UFH)
Which parenteral anticoagulants have a lower risk of HIT: heparin or the LMWHs?
LMWHs- hence they are preferred.
Which parenteral anticoagulant is used in patients with history of HIT?
What is the partial reversal agent for LMWHs?
What is epoprostenol?
Inhibits platelet aggregation during renal dialysis when heparins are contraindicated
Also licensed for pulmonary hypertension.