Disease Management

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laurajane.price
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21732
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Disease Management
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2010-06-03 06:17:16
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Disease management flashcards
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  1. What do beta blockers do?
    • Reduce cardiac output
    • Reduce myocardial O2 demand
    • Reduce heart rate
    • Reduce blood pressure
  2. Beta blocker cautions and contrindications
    • C/I
    • - Asthma
    • - Uncontrolled heart failure
    • - 2nd or 3rd degree heart block

    • Caution
    • - Diabetics on insulin (masks hypoglycaemia)
    • - COPD
  3. Beta blocker side effects
    • Bradycardia
    • Fatigue
    • Bronchospasm
    • Peripheral vasoconstriction
    • Impotence
  4. Calcium channel blocker effects
    • Interfere with inward displacement of Ca2+ ions
    • Coronary artery vasodilation increases myocardial O2 supply
    • Also cause peripheral vasoconstriction and reduce BP
    • May affect force and rate of contraction (diltiazem, verapamil)
  5. Diltiazem
    • 1st choice is unable to use a beta blocker
    • Negative ionotropic and chronotropic effects
  6. Verapamil
    • Significant anti-arrhythmic and negative ionotropic properties
    • Impairs AV conduction
    • Verapamil/beta blocker combination contraindicated (can stop heart)
    • Constipation common in elderly
  7. Amlodipine and nifedipine
    • Ca2+ channel blockers
    • Potent coronary artery vasodilators
    • Dilation of peripheral arteries (swollen ankles, facial flushing, headache)
    • No effect on conducting tissues
  8. Nitrates
    • Relax vascular smooth muscle by releasing NO
    • Coronary artery vasodilation increases myocardial O2 supply
    • Reduce left ventricular workload by venous dilation and so reduce myocardial O2 demand as well
    • Reduce blood pressure to a lesser extent
  9. Nitrate side effects
    • Headache
    • Dizziness
    • Facial flushing
    • Hypotension
    • Tachycardia
    • Tolerance to effects - need to have a nitrate free period
  10. Nicorandil
    • Relaxes vascular smooth muscle
    • Potassium channel activator (indirect calcium channel blocker
    • Increase myocardial O2 supply - coronary artery dilation
    • Reduces myocardial O2 demand - venous dilation
    • Peripheral vasodilation still a problem
    • No real effect of BP or HR at normal doses
    • More expensive
    • Good evidence base - generally used 3rd line
    • Can be used in patients on b blockers +/or Ca channel blockers but still having chest pain (nitrate alternative)
    • Can be used in patients unable to tolerate or with C/I to one of the other drug groups
  11. Nicorandil side effects
    • Headache
    • Dizziness
    • Nausea
    • Palpitations
    • Fatigue
  12. Ivabradine
    • Selective sinus node inhibitor
    • Decreases resting heart rate
    • Licensed for chronic stable angina in pts with normal sinus rhythm who have a contraindication or intolerance of b-blockers
    • Interactions with verapamil and diltiazem due to heart block risk
    • Visual luminous phenomena in 1st 2 months to 30% of pts
    • Maybe useful in normo/hypotensive pts
  13. Ranolazine
    • Newest agent
    • Unknown mech
    • Lots of interactins
    • Causes; headaches, dizziness, weakness
    • Add on therapy if other combinations C/I or ineffective
  14. Aspirin
    • Inhibits platelet aggregation by blocking COX (reduces thromboxane A production)
    • Reduction of risk of non fatal MI and CVA by 33% and mortality by 25%
    • Side effects: GI irritation/ulceration, bruising, bronchospasm if atopic asthmatic
    • No reduction of ulceration and bleeding with enteric coated tablets
    • If GI intolerant add PPI
  15. Clopidogrel
    • Prevents ADP binding (blocks platelet activation)
    • Marginally better efficacy then aspirin
    • Overall bleeding prfile similar to aspirin
    • More expensive (only used with true aspirin allergy/significant GI intolerance)
  16. Who is at risk of developing an MI and should by targeted by primary prevention?
    • Hypertension
    • Hyperlipidaemia
    • Obesity
    • Diabetes
    • Family hx of premature heart disease
  17. How is CVD risk estimated?
    • Prediction charts based on
    • Gender
    • Age
    • Smoker/non-smoker
    • BP
    • Cholesterol

    Not validated for ethnic groups
  18. How to reduce CVD risk?
    • Excercise (30 min mod ex daily)
    • Sensible diet (5 a day- reduce risk by 30%, 2 portions fish weekly- reduce risk by 30%)
    • Lower cholesterol (diet, statins)
    • Preventing/treating obesity (diet, exercise, orlistat)
    • Treating hypertension (aim for <140/85mmHg, diabetic <140/80, neuropathy <130/80)
    • Smoking cessation (stopping for 2-3
    • Low dose aspirin
  19. Blood pressure treatment thresholds
    BP < 130/85 - recheck every 5 yrs

    BP <140/90 - reassess yearly

    BP140-159/90-99 - treat if at risk
  20. Hypertension "at risk patients"
    • Target organ damage (e.g. renal)
    • Established CV disease
    • 10 yr CV risk =/>20% (e.g. smoker with high cholesterol
    • Diabetes
  21. Thiazide diuretics in hypertension
    • First choice for many patients
    • Good response in elderly and afro-carribean pts
    • Inexpensive
    • Once daily
    • Low dose
    • Mild diuretic action increases excretion of K, Na and water
    • Reduced circulation vol = reduced preload, reduced cardiac output and BP
    • Long term auto-reguation restores cardiac output but results in decreased peripheral vascular resistance
  22. Thiazide side effects and contraindications
    • Side effects:
    • Hypokalaemia
    • Acute gout
    • Impaired glucose tolerance

    • C/I:
    • Hypokalaemia
    • Severe renal impairment
    • Avoid in diabetics
  23. Calcium channel blocker side effects and C/I's
    • Ankle oedema
    • Headache
    • Facial flushing
    • Bradycardia (rate limiting CCB)

    • C/I:
    • Pregnancy
    • Heart failure (rate limiting)
  24. Calcium channel blockers in hypertension
    • Alternative or supplementary
    • Alternative for patients with hypertension and angina
    • Dihydropyridines act mainly by peripheral vasodilation, e.g., amlodipine, felodipine, nifedipine
    • Other classes also slow heart rate and AV node conduction, e.g. verapamil, diltiazem
  25. ACE inhibitors in hypertension
    • First line use in patients with diabetes, proteinurea, heart failure
    • Other hypertensive patients recommended as alternative or supplementary
  26. ACE inhibitor side effects and C/I's
    • Dry cough
    • Hypotension
    • Hyperkalaemia

    • Reduce risk by carful initiation, montior BP and U&E's
    • Avoid potassium sparing diuretics and potassium supplements

    • C/I
    • Pregnancy
    • Bilateral renal artery stenosis
    • Aortic stenosis
    • Hypotension
    • Hyperkalaemia
  27. Angiotensin II antagonists in hypertension
    Reserve for patients unable to tolerate ACE inhibitor

    Alternative method of blocking RAAS
  28. Angiotensin II antagonist side effects
    • Similar to ACE inhibitors
    • Hyperkalaemia
    • Hypotension
    • Renal impairment
    • Angioedema
  29. Beta blockers in hypertension
    • Not preferred initial therapy
    • Alternative to ACE inhibitors in patients >55yrs in whom ACE is not tolerated or C/I
    • Less effective in afro-carribean and elderly
    • Mostly inexpensive
    • Mostly one daily
  30. Alpha blockers in hypertension
    • Effective at lowering BP, no evidence that prevent clinically important end-points
    • Not used first line
    • May be useful in men with prostatism
    • Block NA at peripheral post-synaptic alpha-1 receptors - fall in peripheral resistance
  31. Alpha blocker side effects
    • Headache
    • Fatigue
    • Postural hypotension
    • Urinary incontinence in women
  32. Centrally acting drugs in hypertension
    • e.g. methyldopa, clonidine, monoxidine
    • Stimulate alpha-2 adrenoceptors, reduce central sympathetic tone, leads to a fall in cardiac output and peripheral vascular resistance
    • Side effects include; sedation, dry mouth, fluid retention
    • Methyldopa safe to use in hypertensive pregnant women
  33. MI risk factors
    • Sex
    • Age
    • Family history
    • Diet
    • Lipids
    • Smoking
    • Exercise
    • Diabetes
    • Hypertension
  34. MI initial therapy
    • Aspirin 300mg - prevents 23 deaths for every 1000 patients treated
    • Morphine - pain, detachment, reduces anxiety therefore reduces heart workload
    • Antiemetic - (metoclopramide/clyclizine i.v.) - nausea
    • Oxygen
  35. STEMI therapy
    • Fibrinolytics (not first line now - angioplasty)
    • Only used in STEMI as clot = fibrin rich
    • Ideally given within 12 hrs (over 24h risks>benefits)
    • Streptokinase
    • Alteplase, reteplase, tenecteplase
    • 18% relative risk reduction in mortality at 35 days post MI
    • Saves 30 lives per 1000 (6h)
    • Treatment every hour earlier means 10 more lives saved per 1000 pts treated
    • Side effects:
    • Major haemorrhage
    • Stroke
    • Allergic reaction
    • Hypotension (starch fluid given to counteract)

    • C/I's
    • Surgery in last 2 weeks
    • Stroke in last 4 weeks
    • Active peptic ulcer
    • Trauma from prolonged CPR
    • Severe hypertension
    • Shock
    • Abnormal clotting
  36. Streptokinase in STEMI
    • Bacterial protein
    • 1 hr infusion 1.5 million units
    • Do not give again if pt has another MI (antibody risk)
    • Indirect plasminogen binding
    • Higher incidence of allergic reactions
    • Higher incidence hypotension
    • Similar instance major bleed
    • Lower incidence stroke
    • ~£80
  37. Alteplase in STEMI
    • Recombinant DNA tech
    • Identical to human tPA
    • Theoretically more effective
    • 2 i.v. dose regimens over 90 mins or 3 hrs
    • Can be repeated
    • Direct plasminogen binding
    • Lower allergic reactions
    • Lower instance hypotension
    • Similar instance major bleed
    • Greater incidence of haemorrhagic stroke - particularly in elderly
    • ~£600
    • Higher efficacy if thrombus in anterior coronary arteries
  38. Reteplase in STEMI
    • Genetically modified rTPA
    • Double bolus dose minutes apart
    • Similar efficacy to alteplase
    • Can be repeated
  39. Tenecteplase in STEMI
    • Genetically modified rTPA
    • Use within 6 hrs
    • Single i.v. bolus (0.5 mg/kg up to max 50 mg) quickest "door to needle" time
    • Can be repeated
    • ~£600
    • As effective as alteplase
    • same price as alteplase
    • ? use for all STEMI pts
    • Increased cost vs quickest door to needle time
    • NSF target door to needle time within 20-30 mins (60 min call to needle)
  40. Complications of MI
    • Cardiac arrhythmias
    • Acute heart failure
    • Pericarditis
    • Thrombus
    • Cardiac arrest
  41. Short term adjunct therapy in MI
    • Beta blockers
    • Heparins
    • Clopidogrel
  42. Beta blockers in short term MI treatment
    • iv atenolol/metoprolol at time of MI if BP will allow
    • reduced rate or reinfarction and cardiac arrest
    • Saves 7 lives per 1000 pts treated
  43. Long term use of beta blocker in MI
    • Oral beta blocker started within 7 days of MI
    • Continued for at least 3 years
    • Relative death and reinfarction risk reduced by ~20% to 30%
    • Prevents 15 deaths and 5 further MI's for every 1000 pts treated
    • Atenolol and bisoprolol used in practice
    • Few absolute C/I's (inc heart failure) apart from asthma
  44. Heparins in MI
    • Given with non-strep kinase thrombolytics only for 48h to prevent reocclusion and reinfarction
    • Unfractionated heparin vs LMWH
  45. Clopidogrel in MI
    • If going for coronary stent insertion
    • given 300-600mg stat
    • would then receive parenteral glycoprotein IIb IIIa inhibitors as well
  46. Secondary MI prevention non pharmacological interventions
    • Diet
    • Exercise
    • Smoking cessation
    • Weight reduction
    • Cardiac rehabilitation programmes
  47. Secondary MI prevention pharmacological interventions
    • Aspirin/clopidogrel
    • beta blockers
    • lipid lowering agents
    • ace inhibitors
    • angiotensin II antagonists
    • nitrates
    • calcium channel blockers
  48. Aspirin and clopidogrel in secondary prevention of MI
    • Aspirin:
    • Long term and short term benefits
    • Reduce strokes and non-fatal MI by 33% and mortality by 25%
    • 16 CV events prevented for every 1000 pts treated
    • 75 mg - min effective dose

    Aspirin and clopidogrel given for 1 month for STEMI or 12 months for NSTEMI or a stent
  49. Statins in secondary prevention of MI
    • HMG CoA reductase inhibitors
    • HMG CoA responsible for cholesterol production in liver
    • Side effects: change in bowel habit, myositis and liver dysfunction
    • 30% reduced death from any cause
    • 42% reduced death from any cardiac cause
    • 34% reduced MI
    • Aim to get total cholesterol <4mmol/L; LDL cholesterol <2mmol/L; TC/HDL <4
    • 1000 pts treated prevents; 6 deaths, 12 MI, 4 CHF, 11 revascularisations
    • Rosuvastatin most potent
    • Atorvastatin inc risk of muscle tox
  50. ACE inhibitors in secondary prevention
    • Pts with heart failure benefit most
    • if given within 24h of MI will prevent 5-8 deaths per 1000 pts
    • prevents 20-30 deaths per 1000 pts in those with clincal heart failure
    • but risk of hypotension
    • Long term;
    • mortality reduced by 10%
    • low LV ejection fraction: mortality reduced by 20%
    • clinical heart failure mortality recued by 30% or more
    • LV dysfunction: 60 death prevented by 1000 pts
    • No LV dysfunction: 18 deaths prevented by 1000 pts
  51. Angiotensin II antagonists in secondary prevention
    • Evidence of benefit post MI for valsartan
    • reserve for pts unable to tolerate ACE inh
  52. CCB in secondary prevention
    • No real evidence of benefit
    • symptomatic relief
    • rate limiting ones used when B-blockers C/I
    • Verapamil worsens heart failurew
  53. Eplerenone
    • Selective aldosterone receptor antagonist licensed for use post MI in pts with CHF
    • less affinity for androgen and progesterone receptors than spironolactone
    • 25-50mg daily
    • need to monitor serum K if on ACEI
  54. Who should get what in secondary prevention?
    SAAB

    Statin (fibrates alternative if C/I)

    ACE inh (AIIA alternative if C/I, strict glucose control if diabetic)

    Aspirin (if no C/I +clopidogrel short ter depending on STEMI or NSTEMI)

    B-blocker (CCB alternative if C/I)

    • Omacor if dont eat oily fish
    • eplerenone is LV dysfunction or heart failure post MI
    • amiodarone/antiarrhythmics if necessary
    • Warfarin only if LV thrombus

    Hope hospital uses COBRAA

    • Clopidogrel
    • Omacor
    • Bisoprolol
    • Ramipril
    • Aspirin
    • Atorvastatin
  55. Symptoms of heart failure
    • Dysnopoea
    • Nocturnal cough
    • Paroxysmal nocturnal dysnopoea
    • Confusion
    • Renal failure
    • Oedema
    • Reduced exercise tolerance, lethargy, fatigue
  56. Heart failure management
    • Improvement in symptoms;
    • diuretics
    • digoxin
    • ACEI

    • Improvement in survival;
    • ACEI
    • B-blockers
    • spironolactone
    • oral nitrates plus hydralazine
  57. Diuretics in heart failure
    • Combat oedema
    • Remove pulmonary congestion
    • Improves symptoms and exercise tolerance
    • Side effects: dehydration, hypotension, electrolyte imbalance (K esp)
    • Monitoring: renal failure and electrolyte imbalance (esp if also taking ACEI)
  58. ACEI in heart failure
    • All pts with LVD without C/I
    • Block arterial/venous constriction
    • Inc cardiac output and renal function
    • slow LV tissue damage
    • Reduced mortality 30-40%
    • Delay disease progression
    • Reduce hospital admissions and need for diuretics
    • Improvement in NYHA class
  59. AII antagonists in heart failure
    Pts unable to tolerate ACEI
  60. B-blockers in heart failure
    • Consider in pts with chronic stable heart failure resulting from LVD
    • Carvediol, bisoprolol, nebivolol (licensed for heart failure)
    • Used in addition to diuretics and ACEI
    • Low dose titrated up every 1-2 weeks
  61. Digoxin in heart failure
    • Consider for pts with heart failure due to AF
    • Positive ionotropic agent
    • Improved symptom control
    • Reduce hospital admissions
    • No change in mortality
    • More controversial in AF absence
    • CI;
    • severe heart block
    • Wolff-Parkinson-White syndrome
    • Side effects:
    • arrythmias, anorexia, nausea, vomiting, confusion
  62. Spironolactone in heart failure
    • Pts with moderate to severe who are symptomatic despite taking ACEI, diuretics and /or digoxin
    • Low dose 25mg daily
    • Improves symptom control
    • Reduce hospital admissions
    • Reduce mortality
    • C/I:
    • pregnancy
    • severe renal failure
    • Side effects;
    • hyperkalaemia
  63. Nitrates plus hydralazine in heart failure
    • Not really used in practice
    • Used if ACEI and AII C/I (e.g. severe renal impairment)
    • ACEI side effects
    • pt has other conditions (e.g. angina)
  64. Drugs to avoid in CHF
    • Class I antiarrythmic drugs e.g. lidocaine, flecanide
    • NSAIDs
    • Negative ionotropic calcium channel blockers e.g. diltiazem, verapamil
  65. Drugs exacerbating angina
    • short acting nifedipine
    • sumatriptan
    • sildenafil
    • excess thyroxine
  66. Important interactions
    • Warfarin and simvastatin
    • ACEI and NSAIDs
    • Amiodarone and antipsychotics
  67. Monitoring for ACEI
    Renal function and electrolytes
  68. Montoring for statins
    • LFT's before, 1-3 months q6m for a year
    • if muscle pain occurs - creatinine kinase
  69. Monitoring for amiodarone
    • TFT's before and q6m
    • LFT's before and q6m
    • CXR before
  70. Monitoring for warfarin
    INR daily or alternate days; longer intervals (up to 12 weeks depending on response)
  71. Counselling for amiodarone
    • phototoxic reactions;
    • shield skin from light
    • use a wide spec sunscreen
  72. Digoxin in AF
    • Controls heart rate
    • cannot cardiovert
    • inc toxicity in elderly, renal impairment, hypokalaemia, drug interactions
  73. Amiodarone in AF
    • Anti-arrythmic
    • Can cardiovert
    • long t1/2
    • "dirty" drug
    • - corneal microdeposits
    • - thyroid disease
    • - pulmonary fibrosis
    • - hepatotoxicity
    • - photosensitivity/skin discoloration
    • - serious interaction with warfarin and digoxin
  74. Sotalol in AF
    • B clocker with class III activity
    • used for long term control rather than amiodarone unless asthmatic
  75. Treatment of DVT
    • Once suspected start high dose i.v. unfractionated heparin (continuous infusion adjusted by lab monitoring)/LMWH (once daily dose based on weight, no need for monitoring)
    • Tests to confirm diagnosis
    • Oral anticoagulants started after diagnosis confirmed
  76. Target INR's
    2.5 for AF and treatment of DVT/PE or tissue prosthetic heart valves

    3.5 for recurrent DVT/PE or a mechanical prosthetic heart valve
  77. Warfarin antidotes
    • Phytomenadione (vit K) injection - dose depends on INR and is haemorrhage is life threatening
    • Clotting factor concentrates/fresh frozen plasma - immediate reversal
  78. Alarm symptoms for peptic symptoms
    • Recurrent vomiting
    • Dysphagia
    • Bleeding
    • Weight loss
    • Unexplained dyspepsia >55yr

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