BNF 85 (British National Formulary) March 2023 Cardiovascular System PDF

106 Cardiovascular system Cardiovascular system 2 BNF 85 Chapter 2 Cardiovascular system CONTENTS 1 Arrhythmias 2 Bleeding disorders 2.1 2.2 3 3.1 3.2 4 4.1 1 Coagulation factor deficiencies Subarachnoid haemorrhage Blood clots Blocked catheters and lines Thromboembolism Blood pressure conditions Hyp...

106 Cardiovascular system Cardiovascular system 2 BNF 85 Chapter 2 Cardiovascular system CONTENTS 1 Arrhythmias 2 Bleeding disorders 2.1 2.2 3 3.1 3.2 4 4.1 1 Coagulation factor deficiencies Subarachnoid haemorrhage Blood clots Blocked catheters and lines Thromboembolism Blood pressure conditions Hypertension 4.1a Hypertension associated with phaeochromocytoma 4.1b Hypertensive crises page 106 119 120 124 125 125 126 156 156 198 198 Arrhythmias Arrhythmias 10-Aug-2022 Overview Management of an arrhythmia requires precise diagnosis of the type of arrhythmia, and electrocardiography is essential; underlying causes such as heart failure require appropriate treatment. Ectopic beats If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, beta-blockers are sometimes effective and may be safer than other suppressant drugs. Copyright © 2023. Pharmaceutical Press. All rights reserved. Atrial fibrillation Treatment of patients with atrial fibrillation aims to reduce symptoms and prevent complications, especially stroke. All patients with atrial fibrillation should be assessed for their risk of stroke and thromboembolism. Atrial fibrillation can be managed by either controlling the ventricular rate (‘rate control’) or by attempting to restore and maintain sinus rhythm (‘rhythm control’). If treatment fails to control symptoms or if symptoms reoccur after cardioversion and specialised management is required, referral should be made within 4 weeks. Where drug treatment has failed to control the symptoms of atrial fibrillation or is unsuitable, ablation strategies can be considered. Acute presentation g All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo emergency electrical cardioversion, without delaying to achieve anticoagulation. In patients presenting acutely but without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than 48 hours; rate control is preferred if onset is more than 48 hours or is uncertain. h If urgent rate control is required, a betablocker can be given intravenously; a rate-limiting calcium channel blocker such as verapamil hydrochloride p. 180 (if left ventricular ejection fraction (LVEF) is 40%) may also be 4.1c Pulmonary hypertension 4.2 5 6 7 8 8.1 9 10 10.1 page 199 203 Hypotension and shock Cardiovascular risk assessment and prevention Heart failure Hyperlipidaemia Myocardial ischaemia Acute coronary syndromes 8.1a Cardiac arrest Oedema Vascular disease Vein malformations 207 210 215 229 233 242 246 253 255 given. g In patients with suspected concomitant acute decompensated heart failure, calcium-channel blockers should be avoided and senior specialist advice sought on the use of beta-blockers. Consideration of pharmacological or electrical cardioversion should be based on clinical circumstances in patients with new-onset atrial fibrillation who are to be treated with a rhythm-control strategy. If pharmacological cardioversion has been agreed, flecainide acetate p. 112 (if no structural or ischaemic heart disease present) or amiodarone hydrochloride p. 113 can be used. h Cardioversion Sinus rhythm can be restored by electrical cardioversion or by pharmacological cardioversion with an anti-arrhythmic drug such as flecainide acetate or amiodarone hydrochloride. g If atrial fibrillation has been present for more than 48 hours, electrical cardioversion is preferred to pharmacological cardioversion, but should be delayed until the patient has been fully anticoagulated for at least 3 weeks. If this is not possible, a left atrial thrombus should be ruled out and parenteral anticoagulation (heparin) commenced immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks. During the period prior to cardioversion, offer rate control as appropriate. Amiodarone hydrochloride started 4 weeks before and continued for up to 12 months after electrical cardioversion to maintain sinus rhythm, may also be considered. h Drug treatment g Rate control is the preferred first-line treatment strategy for atrial fibrillation except in patients with new-onset atrial fibrillation, with atrial flutter suitable for an ablation strategy, with atrial fibrillation with a reversible cause, or with heart failure primarily caused by atrial fibrillation, or if rhythm control is more suitable based on clinical judgement. Ventricular rate can be controlled with a standard betablocker (not sotalol hydrochloride), or with a rate-limiting calcium channel blocker such as diltiazem hydrochloride p. 174 [unlicensed indication] or verapamil hydrochloride as monotherapy. Choice of drug should be based on individual symptoms, heart rate, comorbidities, and patient preference; h for guidance on the use of rate-control drugs in patients with concomitant heart failure, see Chronic heart failure p. 210. Joint, F. C. (2023). Bnf 85 (british national formulary) march 2023. Pharmaceutical Press. Created from rps on 2024-02-25 14:25:52. Arrhythmias 107 Digoxin p. 118 monotherapy should only be considered for initial rate control in patients with non-paroxysmal atrial fibrillation who are predominantly sedentary, or in those where other rate-limiting drugs are unsuitable. When monotherapy fails to adequately control the ventricular rate, consider combination therapy with any 2 of the following drugs: a beta-blocker, digoxin, diltiazem hydrochloride. If symptoms are not controlled with a combination of 2 drugs, a rhythm-control strategy should be considered. h If ventricular function is diminished (LVEF 8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin sodium when INR 8.0, no bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR