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Cardiology > Heart drugs 1 - AF and Heart failure > Flashcards

Heart drugs 1 - AF and Heart failure Flashcards

(53 cards)

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1
Q

What is the pathophysiology of atrial fibrilation?

A

Chaotic atrial electrical activity

Fibrosis and loss of atrial muscle mass due to factors like:
-ageing
-chamber dilatation
-inflammation (scarring)
-genetic

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2
Q

What are the risk factors for AF?

A

-HTN
-Valvular heart disease
-Coronary heart disease
-Cardiomyopathy
-Congenital heart disease
-Previous cardiac surgery
-Pericarditis
-Lung disease e.g., PE, pneumonia, COPD
-Hyperthyroidism (do a TFT)
-Alcohol

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3
Q

What is the classification of AF?

A

Lone AF

Paroxysmal (< 7 days) - AF comes in waves

Persistent (>7 days)

Permanent (>7 days +/- cardioversion)

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4
Q

What is cardioversion?

A

A medical procedure that uses quick, low-energy shocks to restore a regular heart rhythm

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5
Q

What are the clinical features of AF?

A

Asymptomatic

Palpitations

SOB

Chest pain

Syncope (i.e., actually passing out)

Pre-syncope (i.e., feeling that one is going to pass out)

Heart failure

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6
Q

What are the 3 main categories of AF treatment?

A

Rate control

Rhythm control

Anticoagulation

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7
Q

For someone with recent onset AF who is compromised, what Tx should be given?

A

DC shock

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8
Q

For someone with recent onset AF who is uncompromised, what Tx should be given?

A

Pharmacotherapy

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9
Q

For someone with recent onset AF that is < 48 hours duration, what Tx should be given?

A

Attempt rhythm control

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10
Q

For someone with recent onset AF that is > 48 hours duration, what Tx should be given?

A

Rate control

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11
Q

In which situations is rhythm control preferred?

A

Symptom improvement

Younger patient

Heart failure related to AF

Adequacy of rate control

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12
Q

For someone with acute AF without HF what are the 1st and 2nd line drugs?

A

1st = Beta blocker OR CCB (Diltiazem, Verapamil)

2nd = add digoxin

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13
Q

For someone with acute AF with HF what are the 1st and 2nd line drugs?

A

1st = Digoxin, amiodarone

2nd = Amiodarone

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14
Q

For someone with permanent or paroxysmal AF what are the 1st and 2nd line drugs?

A

1st = Beta blocker OR CCB

2nd = add digoxin

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15
Q

What are the indications for rhythm control and what drugs are used for each?

A

Acute cardioversion (normal heart) = fleicanide, sotalol

Acute cardioversion (abnormal heart) = amiodarone

Maintain sinus rhythm (normal heart) = fleicanide, sotalol

Maintain sinus rhythm (abnormal heart) = amiodarone

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16
Q

Name the non-selective beta blockers

A

Propranolol

Sotalol

Carvedilol

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17
Q

Name the cardioselective beta blockers

A

Atenelol - 90% of the drug is renally cleared

Bisoprolol

Esmolol

Metoprolol

Nebivolol

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18
Q

Name the vasodilatory beta blockers

A

Labetalol

Carvedilol

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19
Q

Name the rate limiting CCBs

A

Verapamil

Diltiazem

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20
Q

Name the dihydropyridine CCBs

HINT: the “dipines”

A

Amlodipine - can cross BBB

Nifedipine

Felodipine

Lercanidipine

Nimodipine

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21
Q

What is the CHA2DS2 VASc score and what are the components?

A

Score that predicts stroke risk in someone with AF

C – Congestive heart failure=1
H – Hypertension=1
A 2– Age >75years=2
D – Diabetes=1
S2 – Previous Stroke, TIA or thromboembolism=2
V – Vascular disease=1
A – Age 65-74 years=1
Sc – Sex category (female gender) =1

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22
Q

What should be done for a CHA2DS2VASc ≥2 ?

Study These Flashcards
A

Give warfarin OR DOACs (e.g., rivaroxaban, endoxaban)

23
Q

What is the HAS-BLED score and what are its components?

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A

Estimates risk of major bleeding for patients on anticoagulation to assess quality of AF care

H – Hypertension = 1
A – Abnormal renal/liver function = 1 point each
S – Stroke in the past = 1
B – Bleeding history = 1
L – Labile INRs = 1
E – Elderly = 1
D – Drugs/Alcohol concomitantly = 1 point each

24
Q

An HAS-BLED score ≥ which number indicates significant risk of bleeding?

25
What other Tx are available for AF?
Radiofrequency catheter or Cryo- ablation Left atrial appendage occlusion (LAAO) - (used for older persons that cannot be anticoagulated)
26
What are the main Tx aims for heart failure
Relieve symptoms Reduce mortality
27
What are the main Tx categories for HF?
Lifestyle measures – Exercise – ↓Alcohol – Smoking Cessation Drugs Devices Surgery
28
Which of the HF drugs improve symptoms? (use + to indicate how well they improve symptoms)
Diuretics +++ ACEi + Beta-blockers ++ Aldosterone antagonists ++ ARBs + Hydralazine/Nitrates + Digoxin +
29
Which of the HF drugs reduce mortality? (use + to indicate how well they reduce mortality)
ACEi ++ Beta-blockers +++ Aldosterone antagonists ++ ARBs + Hydralazine/Nitrates +
30
Name the diuretics used in HF?
Loop (most commonly used ) e.g., furosemide Thiazides e.g., -bendroflumethiazides -metolazone (thiazide like)-causes profound diuresis K+ sparing e.g., -spironolactone (a mineralocorticoid receptor antagonist) -amiloride
31
What are the actions of the different diuretics?
32
What are the main aims of diuretics?
Provide symptom control Reduce cardiac pre-load NOTE: beware of the side-effects they have
33
What are the benefits of ACEi in HF?
Increased life expectancy vs placebo Effect more marked in patients with more severe LV dysfunction Benefit for all NYHA classes Reduces risk of hospitalisation
34
What are the actions of ACE-i and ARBs?
35
Name ACEi
Ramipril Lisinopril Enlapril Perindopril Catopril (was the first one but not commonly used today due to short half-life)
36
Name some ARBs
Losartan Candesartan Valsartan
37
What are the benefits of ARBs and in which situation are they used?
Reduces mortality Some data on QoL, symptom control Used in patients that cannot tolerate ACEi (as it often causes a dry cough)
38
What are the benefits of beta blockers?
Increase life expectancy vs placebo (shown in RCT/meta-analyses) All NYHA classes Reduces hospitilisation Evidence for bisoprol, carvedilol and metoprolol
39
How should you use beta blockers in HF?
Start on low dose and titrate up Monitor HR, BP and clinical progression
40
In which group of HF patients is spironolactone used?
Severe heart failure (NYHA III-IV)
41
What are the advantages of spironolactone in HF?
Increased life expectancy Reduces hospital admission
42
Which dose of spironolactone should be used HF?
Low dose - 12.5-25mg
43
What other drugs are used in chronic HF?
Ivabradine (acts on fun ion channels)- used instead of beta blockers if HR too high (> 75bpm). Works to reduce the HR Hydralazine + nitrate - used if ACEi/ARB not tolerated/contraindicated or in people of African origin Sacubritil (neprilysin inhibitor)/Valsartan (ARB) SGLT2 - can reduce risk for heart failure in patients with T2DM and can decrease risk of major cardiovascular events in patients with HF and diabetes
44
What are the criteria for prescribing Sacubritil (neprilysin inhibitor)/Valsartan (ARB)?
New York Heart Association class II to IV symptoms AND a left ventricular ejection fraction of 35% or less AND who are already taking a stable dose of an ACE inhibitor or angiotensin II receptor antagonist.
45
What are the basic measures for treating someone with acute HF?
Sit patient upright High dose O2 = corrects hypoxia
46
What are the initial drug Tx for someone with acute HF?
IV loop diuretics (e.g., furosemide) = cause venodilatation and diuresis IV opiates/opioids (e.g., morpine/diamorphine) = reduce anxiety and preload (venodilatation) IV, buccal or sublingual nitrates = reduce preload and afterload, ischaemia and pulmonary artery pressures If they are already on beta blockers continue but DO NOT initiate it
47
What other forms of therapy are there for HF (i.e., other non-pharmacological)?
Coronary revascularisation Cardiac resynchronisation therapy Cardiac transplantation
48
Sources
Cardiovascular drugs 1 lecture - 20.11.2019 https://journals.lww.com/tnpj/Fulltext/2021/07000/SGLT2_inhibitors__What_role_do_they_play_in_heart.7.aspx#:~:text=Sodium%2Dglucose%20cotransporter%2D2%20(,in%20patients%20with%20HF%20only. https://www.nice.org.uk/guidance/ng196/chapter/Recommendations#stroke-prevention https://www.nice.org.uk/guidance/conditions-and-diseases/cardiovascular-conditions/embolism-and-thrombosis/products?GuidanceProgramme=TA
49
What are the risk factors for use of dabigatran as anticoagulant in patients with AF?
previous stroke, TIA or systemic embolism left ventricular ejection fraction below 40% symptomatic heart failure of New York Heart Association (NYHA) class 2 or above age 75 years or older age 65 years or older with one of the following: diabetes mellitus, coronary artery disease or hypertension.
50
What are the risk factors for use of endoxaban as anticoagulant in patients with AF?
congestive heart failure HTN diabetes prior stroke or TIA age 75 years or older.
51
What are the risk factors for use of rivaroxaban as anticoagulant in patients with AF?
congestive heart failure HTN age 75 years or older diabetes mellitus prior stroke or TIA
52
What are the risk factors for use of apixaban as anticoagulant in patients with AF?
prior stroke or TIA age 75 years or older HTN diabetes mellitus symptomatic heart failure.
53
DOACs are 1st line anticoagulants in AF. If they are not tolerated what class of drugs can be used instead?
Vitamin K antagonists - e.g., warfarin, coumarol, acenocoumarol

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