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Diploma in Anaesthesia > Implications of cardiac drugs > Flashcards

Implications of cardiac drugs Flashcards

1
Q

What are ACE i used for

A

HPT. Compelling indication in diabetes to prevent diabetic nephropathy

Symptomatic LV dysfunction (afterload reduction)

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2
Q

What are the side effects of ACEi

A
  1. Cough (bradykinin)
  2. Angioedema
  3. Concomitant use with NSAID increase risk of renal damage
  4. Hypotension with GA
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3
Q

List the clinical indications for beta blockers

A 
HPT
HF
Arrhythmia
Angina
Other (anxiety)
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4
Q

How do BB lower BP

A

Decrease CO - Negative inotropy and chronotropy
Alter baroreceptor sensitivity
Reduce renin secretion

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5
Q

Why are BB used for angina

A

Beta-blockers improve exercise tolerance and relieve angina symptoms by reducing the heart rate.

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6
Q

Why are BB prescribed after MI

A

Beta-blockers reduce the recurrence rate after MI.

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7
Q

List the ‘other’ uses for BB

A 
Heart failure
Thyrotoxicosis
Anxiety
Migraine prophylaxis
Glaucoma (topical)
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8
Q

What are the side effects of BB

A

Bradycardia
Heart block
Heart failure

Mask autonomic response to hypoglycaemia

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9
Q

When are BB contraindicated

A

2nd/3rd degree heart block
Unstable heart failure
Asthma

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10
Q

Name 3 clinical indications for nitrates (GTN or isosorbide mononitrate

A
  1. Prophylaxis and treatment of angina
  2. Relief of cardiac ischaemic pain
  3. Prophylaxis and treatment of LVF
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11
Q

What are the side effects of Nitrates

A

Headache
Postural hypotension
Flushing

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12
Q

List the clinical indications for CCB

A

HPT
Prophylaxis of angina
SVT

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13
Q

What are the side effects of CCB

A

Hypotension
Bradycardia
Pedal oedema

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14
Q

What are the side effects of diuretics

A

Hypokalaemia
Hyponatraemia
Hypomagnasaemia
Postural hypotension

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15
Q

List the clinical indications for nicorandil and state its MOA

A

Prevention and long-term treatment of angina

MOA: K+ channel activator –> vasodilation

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16
Q

List the side effects of K+ channel activators

A

Bradycardia
First degree heart block
Ventricular extrasystoles

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17
Q

A patient with a drug-eluting cardiac stent is likely to be taking clopidogrel: true or false and why

A

True. The British Cardiovascular Interventional Society advise that patients with drug-eluting cardiac stents usually require clopidogrel for at least 12 months following their percutaneous coronary intervention. In these patients, clopidogrel should not be stopped without discussion with a cardiologist.

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18
Q

True or false and why: Digoxin, amiodarone and mexiletine may all be used for the treatment of supraventricular tachyarrythmias (SVT)

A

False. Digoxin and amiodarone are used for SVTs. However,

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19
Q

True or false and why: Impaired renal function may result from treatment of high cholesterol with a statin

A

False. Liver impairment may result, not renal impairment.

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20
Q

Why is clopidogrel important perioperatively

A
  1. Neuraxial blocks are contraindicated within 5 - 7 days of stopping clopidogrel due to risk of bleeding
  2. There is risk of stent thrombosis if clopidogrel is stopped during critical periods following insertion
  3. There is risk of excessive bleeding during surgery
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21
Q

What are the clinical indications for statins

A

Reduced LDL
Reduce CVS events: coronary, cerebral, peripheral
Reduce total mortality from CVS evetns

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22
Q

What are the side effects of statins

A

Impairment of liver function and deranged LFTs
Muscle pains
Rhabdomyolysis

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23
Q

What are the clinical indications for digoxin

A

Rx SVT (with impaired EF)
AF
Heart failure

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24
Q

What are the clinical indications of amiodarone

A

Rx arrhythmias (SVT/VT/AF/Flutter/Tachycardia associated with WPW syndrome)

25
Q

What are the clinical indications for alpha blockers

A 
Prostatic hyperplasia
Resistant HPT (along with BB)
26
Q

What are the side effects of alpha blockers

A

Postural hypotension

Severe hypotension with anaesthesia (Hold > 24hrs preop)

27
Q

Which CVS drugs are considered UNSAFE TO STOP in the perioperative period

A

Beta blockers (rebound ACS/arrhythmias)
Statins (stabilize atheromatous plaques - omission may result in rupture)
Anticoagulants
- clopidogrel: consult cardiology (usually must be continued)
- Warfarin changed to LMWH/UFH
- Aspirin: continue

28
Q

Which drugs should be omitted on the day of surgery

A
  1. ACEi (profound hypotension during anaesthesia)

2. alpha antagonists (Stop if used for BPH)

29
Q

How do thiazide diuretics cause hypokalaemia

A

Thiazides inhibit sodium reabsorption in the early DCT. The delivery of Na to the distal Na/K exchange site is increased –> increased Na/K exchange and increased K excretion

30
Q

How do loop diuretics cause hypokalaemia

A

Inhibit Na-K-Cl transporter in TAL LOH –> Increase Na delivery to distal nephron leading to increased K secretion and excretion

31
Q

How do ACEi and ARBs cause hypokalaemia

A

By inhibition of aldosterone release

32
Q

Which electrolyte abnormalities precipitate digoxin toxicity

A

Hypokalaemia
Hypomagnasaemia
Hypercalcaemia

33
Q

What are the ECG findings in digoxin toxicity

A

Prolonged PR
Heart block
T - wave inversion
ST depression (reverse tick)

34
Q

When should surgery be cancelled in the context of hypokalaemia

A

K < 3.5 if the patient taking digoxin and/or other anti-arrhythmic or in the presence of severe cardiac disease

In fit patients not on anti-arrhythmics a potassium of 2.5 to 3.5 may be acceptable

35
Q

What Urea : Creatinine ratio suggests a pre-renal cause

A

2:1

36
Q

List the the haematological parameters and factors in which neuraxial blockade should be avoided

A 
INR > 1.4
APTR > 1.4
Plts < 80 x 10^9/L
Clopidogrel < 7 days
UFH < 4 hours
Prophylactic dose LMWH < 12 hours
Treatment dose LMWH < 24 hours
37
Q

How long does IV vitamin K take to normalize INR

A

24 hours

38
Q

What can be administered for more rapid correction of INR

A

PCC

FFP

39
Q

How are ultrasound waves generated

A

When a voltage is applied to a piezoelectric crystal the crystals distort creating mechanical and kinetic energy

40
Q

How are ultrasound waves measured/received

A

Sound waves returning to the piezoelectric crystal cause mechanical distortion of the crystal which generates a voltage. The time taken for this voltage to be generated is measured and the distance away from the probe that these reflected sound waves originate can be calculated and an image formed on the monitor.

41
Q

What is the doppler principle

A

Due to the movement of the red blood cells the transducer detects a change in frequency of the ultrasound waves

Velocity = frequency (cycles/s) x wavelength (m).

As the blood cell moves towards the transducer the wavelength appears shorter because the high pressure regions of the wave become closer together –> this shortening of the wavelength is picked up as an increased frequency and it is the change in frequency which is used to calculate the velocity of the blood cells

42
Q

What are the three different types of Doppler Echocardiography

A

Continuous waveform Doppler

Pulsed wave Doppler

Colour Doppler

43
Q

What is the frequency range for ultrasound waves?

A

2.5 to 5 kHz

44
Q

What is continuous wave Doppler used for

A

To measure the peak velocity across the valve and to calculate the gradient across the valve and give and indication of severity of the lesion

45
Q

What are the indications for ECHO for the assessment of LV function

A

Symptoms and signs of heart failure

Unexplained dyspnoea where no respiratory cause has been found for their symptoms

IHD and poor exercise tolerance for patients who have never had an echo or have had a deterioration in symptoms since their last echo

Known ventricular impairment for patients who have had a deterioration in symptoms since their last echo

46
Q

What are the indications for ECHO for the assessment of valve function

A
  1. Undiagnosed murmur

2. Valve disease with worsening symptoms

47
Q

What is normal EF

A

> 60%

48
Q

What is severely impaired EF

A

< 40%

49
Q

What is the normal valve area of the aortic valve

A

2.6 - 3.5 cm^2

50
Q

What is the normal area of the mitral valve

A

4 - 6 cm^2

51
Q

What are the advantages and limitations of TTE

A

Advantage: Easy to obtain and noninvasive

May get poor views in patients with obesity, lung disease and chest wall deformity

52
Q

What are the advantages and limitations of TOE

A

Advantage

  • better for looking at posterior structures (left atrium and descending aorta)
  • Used to look for endocarditis and aortic dissection
  • Useful in patients that are poor subjects for TTE

Disadvantage - Invasive

53
Q

What is a stress ECHO

A

Dobutamine used to simulate ‘exercise’

Wall motion abnormalities that develop after the dobutamine is started indicate areas of myocardial ischaemia, whereas those present at the start indicate areas of infarction.

54
Q

Is an ECHO required if ventricular function was assessed during angiography?

A

No.

55
Q

What type of CT can be used to image the heart?

A

Electron beam CT is high speed and provides good resolution as it minimizes cardiac and respiratory motion interference

56
Q

What is myocardial perfusion scintigraphy

A 
Radioactive tracer (Thallium 201)
Areas of ischaemia show up as defects as the radioactive tracer requires coronary blood flow to be delivered to the myocardium
Defects present at rest are due to infarct. Defects present after stress are due to ischaemia
57
Q

Describe the Bruce protocol used in treadmill testing

A

7 stages of 3 minutes each
- Stage 1: 2.7 kmph at 10% incline = 4.8 METs
(each subsequent stage the speed is increased by 1.12 kmph and 2% incline)

58
Q

What is a modified Bruce protocol

A

Used for exercise testing within 1 week of MI - starts at lower work level and so takes longer to achieve the required heart rate

Diploma in Anaesthesia (73 decks)

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