Cardiovascular System Notes PDF

Cardiovascular System Arrhythmias ​ This is an abnormal rate and/or rhythm of the heartbeat due to some problems with the electrical conducting system of the heart. ​ They are detected via ECG ​ A normal heart rate= 60-100 beats per minute (bpm) ​ Below 60 = Bradycardia ​ Above...

Cardiovascular System Arrhythmias ​ This is an abnormal rate and/or rhythm of the heartbeat due to some problems with the electrical conducting system of the heart. ​ They are detected via ECG ​ A normal heart rate= 60-100 beats per minute (bpm) ​ Below 60 = Bradycardia ​ Above 100 = Tachycardia (Taky Taky rumba… makes your heart jump) ​ Paroxysmal Atrial Fibrillation Episodes of AF that stop within 7 days, usually within 48 hours, without any treatment. ​ Pill in pocket: The person self manages paroxysmal AF by taking anti arrhythmic drugs only when an episode of AF starts. Memory Trick: ARRHYTHMIA = A(Abnormal) R(Rate) & R(Rhythm) Signs and Symptoms of Arrythmias (S.A.D Palpitations) ​ Shortness of Breath ​ Abnormally fast, slow, or irregular pulse ​ Dizziness or feeling faint ​ Palpitations What are the causes of Arrythmias The main causes are things that affect your heart ​ Number one cause is Coronary Heart Disease (angina, Heart Attack) ​ Heart Valve Disease ​ Hypertension ​ Ageing (The heart muscles are getting weaker) ​ Cardiomyopathy (Disorder of heart muscle, so the heart is not pumping enough blood) ​ Congenital (from birth) abnormalities in the electrical pathway (so dealing with depolarisation with potassium) What are the different types of Arrythmias (LOOK AT YOUTUBE) Ectopic Beats ​ An extra heartbeat caused by a signal to the upper chamber of the heart. ​ If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient is often enough ​ If they are particularly troublesome, Beta-Blockers are sometimes effective and maybe safer than other suppressant drugs. Atrial Fibrillation (Most Common): Paroxysmal Atrial Fibrillation Episodes of AF that stop within 7 days, usually within 48 hours, without any treatment. Atrial Flutter: Paroxysmal supraventricular tachycardia: Supraventricular Arrythmias & Ventricular Arrythmias : (Amiodarone, Beta Blockers) Ventricular Arrythmias: (Lidocaine, Sotalol) Supraventricular arrythmias: (Verapamil, adenosine & cardiac glycosides) Treatment of Arrhythmias Each type of arrhythmia has a specific treatment option. You need to treat the underlying cause such as if the arrythmia is causes by hypertension and Coronary Heart Disease. Treatment Options available for Arrythmias ​ Medications ​ Cardioversion (electrical shock) which restores sinus rhythm (pharmacological includes flecainide/ amiodarone) or electrical cardioversion ​ Artificial Pacemakers ​ Implantable Cardioverter defibrillators (ICDs) Atrial Fibrillation The Aim of treatment is to Reduce symptoms and prevent complications, especially STROKE. Those with Atrial Fibrillation have a HIGH RISK of stroke. All patients with Atrial Fibrillation should be assessed for their risk of Stroke and thromboembolism (clot). How do you assess the risk of stroke and risk of bleeding? Use these tools to determine the risk prior and during anticoagulation Assessment tool for the risk of stroke CHA2DS2-VASc ​ The risk factors taken into account for stroke include history of ischaemic strokes, diabetes, hypertension, Cardiovascualr events females and patients over 65. Other tools include ATRIA stroke risk tool and QStroke calculator Assessment tool for the risk of Bleeding HAS-BLED ​ ORBIT- Higher accuracy than other tools e.g. HASBLED, ATRIA (Most accurate tool but not yet embedded in clinical pathways and electronic systems used by clinicians) When do we give anticoagulants? ​ When the risk of stroke is GREATER than the risk of bleeding, you give anticoagulants as they help prevents stroke by helping us bleed. ​ CHA2DS2-VASc score of GREATER than 2 will NEED an anticoagulant regardless if they are Male or Female. MNEMONIC ANTWOCOAGULANTS ​ No anticoagulant when Male = O and the Female = 1 CHA2DS2VASC Risk Factors Risk Factors Score Congestive Heart Failure 1 Hypertension 1 Age Greater than 75 2 Age 65-74 1 Diabetes mellitus 1 Stroke/TIA/Thrombo-embolism 2 Vascular Disease 1 Sex Female 1 Your Score 0 Vascular Disease (from Table) = Previous Myocardial Infarction, Peripheral Arterial Disease or Aortic Plaque. How do you assess the risk of Bleeding? ​ The HASBLED Tool ​ THREE makes you BLEED HASBLED TOOL Risk Factors Score A Hypertension 1 Abnormal renal/Liver Function 1 OR 2 Stroke 1 Bleeding Tendency 1 Labile INR 1 Age (e.g. Greater Than 65) 1 Drugs (e.g. NSAIDS, concomitant Aspirin, 1 OR 2 etc) or Alcohol Maximum score 9 score of 0-2 indicates a low risk of bleeding. A score of greater than THREE indicates a high risk of bleeding. Therefore, you DON’T need an anticoagulant, if already on an anticoagulant you are either going to stop the medication, reduce the Dose or give an antidote. ORBIT- TO ASSESS RISK OF BLEEDING HASBLED TOOL Risk Factors Score (Max score is 7) Older than 74yrs 1 Reduced Haemoglobin (History of 2 anaemia) Bleeding History (G.I Bleeding, 2 intracranial bleeding, or haemorrhage stroke) Inadequate Renal Function (GFR 10 = Give primary prevention drug (usually Atorvastatin) ​ QRISK 3: updated version of QRISK 2. It considers additional risk factors e.g. CKD (Stage 3 and above), migraine, corticosteroid use, systemic lupus erythematosus (SLE), atypical antipsychotics use, severe mental illness, erectile dysfunction, and systolic BP variability. ​ JBS3 Calculators is able to estimate short term (10 year) risk and also lifetime risk of CVD event There are certain patients at a very high risk of CVD and using a risk calculator underestimated the score which is dangerous. The high risk patients include:  ​ Type 1 Diabetes ​ Established CVD ​ Chronic Kidney Disease ​ Familial Hypercholesterolemia ​ Risk increases with age (more than 85 years of age are at a high risk especially if they smoke or have hypertension. ​ 10-year risk of CVD more than 10% Primary Prevention of Cardiovascular Disease: ​ Aspirin NOT recommended ​ Antihypertensive Only offered to patients at high risk and those with a high Blood Pressure of more than 140/90 ​ Lipid lowering Drugs NICE guidelines recommends low dose atorvastatin as First Choice for patients with a 10 year CVD risk of more than 10% ​ Aim of a reduction in non-HDL cholesterol less than 40% Secondary Prevention of Cardiovascular Disease: ​ Low dose Aspirin (75mg), Clopidogrel & dipyridamole (used to prevent Strokes) ​ Antihypertensive: Patients with Blood pressure higher than 140/90mmHg ​ Lipid Lowering Drugs: ATORVASTATIN is preferred over simvastatin. High dose simvastatin can increase the risk of myopathy (muscle weakness). Hyperlipidaemia: Hyperlipidaemia is high cholesterol or high triglycerides or both Primary and secondary Prevention ​ Preventative measures should be taken in patients with high risk of developing CV disease (primary prevention) and to prevent recurrence of events in those who already have CV diseases. What causes Hyperlipidaemia (have high lipids in the body)? Liver or Kidney disease Family history of High cholesterol (genetics) Diabetes Hypothyroidism Lifestyle factors; smoking, obesity etc. Drugs: Antipsychotics (especially 1st generation), immunosuppressant’s, Antiretroviral & corticosteroids. What patients are at a high risk of developing Hyperlipidaemia? These patients should be given a statin regardless of serum cholesterol levels Primary prevention: ​ Diabetes (Type 1)-All patients ​ Diabetes (Type2)-only if CVD risk is more than 10% ​ Chronic Kidney Disease ​ Familial hypercholesterolemia ​ Risk increases with age (≥ 85years at high risk especially if they smoke or have hypertension) ​ 10-year risk of CVD ≥ 10% Secondary prevention: ​ Established Cardiovascular Disease: Coronary Heart Disease (Myocardial Infarction & Angina), Cerebrovascular disease (Stroke/TIA) and Peripheral Arterial Disease. Cardiovascular Disease, measures for Primary prevention ​ Provide lifestyle advice to all patients at high risk (Diet, exercise, weight management, alcohol, smoking cessation) ​ If lifestyle measures are not effective, give Statin as first line drug. Cardiovascular Disease, measures for Secondary prevention ​ Offer STATINS to ALL patients including ELDERLY with CVD (e.g Coronary Heart disease, Angina, Myocardial Infarction, T.I.A, non- haemorrhagic stroke).  ​ Statins reduce the risk of Cardiovascular events ​ 1st Drug choice to reduce the risk of CVD events ​ Address secondary causes of dyslipidaemia before starting statins (uncontrolled diabetes, hepatic disease, nephrotic syndrome & excessive alcohol consumption) ​ Correcting hypothyroidism may resolve lipid abnormality (treat patients with hypothyroidism with thyroid replacement first). When thyroid hormone levels are low, LDL cholesterol builds up in the body. High Intensity Statins: A high Intensity Statin is a statin which reduces the LDL cholesterol (bad) by more than 40%. Therapy Intensity Drug Daily Dose (Reduction in LDL Cholesterol) Atorvastatin 20mg (43%) 40mg (49%) High Intensity 80mg (55%) Rosuvastatin 10mg (43%) 20mg (48%) 40mg (53%) Simvastatin 80mg (42%) For Primary Prevention ​ Give High Intensity statin to patients with a 10-year risk of CVD ≥ 10% for primary prevention ​ For patients more than 85 years, statins help reduce risks of non-fatal myocardial Infarction. For Secondary Prevention ​ Atorvastatin Recommended ​ Give statins to ALL patients with type 1 diabetes (especially those older than 40 years, had diabetes for more than 40 years, established nephropathy (kidney disease), or other risk factors for CVD. ​ Check lipid profile (Total cholesterol, LDL-cholesterol, HDL-cholesterol & triglycerides) 3 months after starting statins. ​ Aim for a reduction in non-HDL of more than 40% (Target non-HDL 1mmol/L ​ Triglycerides 50% LDL-cholesterol reduction. ​ Patients intolerant to statins can receive Ezetimibe or combination of statin & ezetimibe if statin on its own is not effective. ​ Refer patients who cannot take statin or ezetimibe to a specialist for bile acid sequestrants, nicotinic acid or a fibrate. ​ Ezetimibe can be added if statins are not effective ​ Fenofibrate may be added to statin if triglyceride is high as fibrates are better at reducing triglycerides than statins. ​ Nicotinic acid may also be used to lower triglyceride and LDL-cholesterol concentration Statins ​ Statins are more effective than other lipids regulating drugs at lowering LDL cholesterol ​ They are less effective than fibrates in reducing triglycerides. However, statins reduce CVD events and total mortality irrespective of initial cholesterol concentration. ​ In younger patients- statins are only considered if there is a target organ damage, poor glycaemic control (HbA1c greater than 9%), low HDL levels, and raised triglyceride concentration, hypertension or familial history of premature CV disease. Statins mechanism of Action: ​ Statins competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase, an enzyme involved in cholesterol synthesis, especially in the liver. Side Effects: ​ Muscle toxicity can occur with ALL statins and likelihood increases with dose. Patients advised to report muscle pain, tenderness or weakness Conception and contraception ​ For all STATINS adequate contraception is required during treatment and for 1 month afterwards Pregnancy ​ For all STATINS should be avoided in pregnancy (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development. ​ Adequate contraception required during treatment and 1 month afterwards Breastfeeding ​ Manufactures advises avoid Patient and carer advice for Statins: ​ For ALL Statins Advise patients to report promptly unexplained muscle pain, tenderness or weakness Monitoring Requirements Before starting statins: LOOK IN THE BNF MONITORING REQUIREMENTS ​ Before starting a statin, at least one full lipid profile (non-fasting) should be measured including (total cholesterol, HDL cholesterol, non HDL cholesterol, triglycerides. ​ Thyroid stimulating hormone ​ Renal function ​ Monitor Liver Function (Don’t start if more than 3 times upper limit) ​ Creatinine Kinase (Don’t start if more than 5 times upper limit). Check for this if patient has muscle pain ​ Patient at a high risk of diabetes mellitus should have fasting blood glucose concentration or HbA1c checked before stating statin treatment and then repeated after 4 months. Monitoring requirements AFTER starting statins: ​ Within 3 months of starting the statin, check HBA1c/fasting blood glucose ​ Within 3 months & 12 months, check liver enzymes (LFTs) Important Interactions: ​ Statin + Fibrate (or nicotinic acid) increases risk of side-Effects e.g. rhabdomyolysis (A breakdown of skeletal muscle). ​ Statin + Gemfibrozil increases the risk of rhabdomyolysis considerably (A breakdown of skeletal muscle). DO NOT USE THIS COMBINATION. ​ Carbamazepine (Enzyme Inducer) Increases the risk of hepatotoxicity ​ Clarithromycin/Erythromycin (Macrolides) Increases the exposure to simvastatin ​ Grapefruit juice Increases the exposure to simvastatin ​ Ketoconazole/miconazole (Antifungals) Increases the exposure to Simvastatin ​ Amlodipine Risk of rhabdomyolysis ​ Amiodarone, colchicine, Nicotinic acids, Fibrates Increases the risk of rhabdomyolysis. Statins & Hepatic Impairment ​ Use with caution in liver disease ​ Avoid in active liver disease or when there are unexplained persistent elevations in serum transaminases especially when it is 3x the limit. Statins & Renal ​ Discontinue if elevated creatine Kinase (sign of myopathy- muscle weakness) Which statins can be given at any time of the day? Atorvastatin & Rosuvastatin = Anytime as they are long-acting Fluvastatin, Pravastatin & Simvastatin = Night time (Half-Life = 2.5hrs) as they are short acting ​ Learn atorvastatin and Simvastatin Doses For example, Atorvastatin 20mg Once Daily (Primary prevention) Atorvastatin 80mg Once Daily (Secondary prevention) MHRA WARNING: ​ Simvastatin 80mg increases the risk of Rhabdomyolysis Heart Failure ​ Heart Failure is the progressive clinical syndrome caused by structural or functional abnormalities of the heart, resulting in reduced cardiac output. Types of Heart Failure: Defined By: ​ How sudden symptoms come on (chronic or acute) ​ How much blood the heart manages to pump out with each heart beat (reduced or preserved ejection volume). Acute Heart Failure: ​ Symptoms come on suddenly Chronic Heart Failure: ​ Symptoms have been going on for a while Symptoms of Heart Failure: ​ Shortness of Breath (exercising or at rest)-pulmonary oedema ​ Persistent coughing or wheezing ​ Ankle swelling ​ Reduced exercise tolerance ​ Fatigue These symptoms may be accompanied by signs such as pulmonary crackles and pulmonary oedema Other symptoms include: ​ Chest pains (if you have angina) ​ Palpitations (if you have arrythmia) ​ Risk is greater in men, smokers, diabetic patients & increase with age What are the causes of Heart Failure: ​ Coronary Heart (artery) Disease (CHD)- is the most common cause, especially after a heart attack (Myocardial Infarction). ​ Hypertension is a more common cause in African or Afro-Caribbean population ​ Cardiomyopathy (disease of the heart muscle) ​ Disease of heart valves ​ Arrythmias ​ Medicines that damage the heart muscle (excess alcohol, cocaine, some chemotherapies) ​ Non heart conditions (hypo or hyperthyroidism, severe anaemia can lead to reduced cardiac output). Diagnosis of Heart Failure: ​ Physical examination: Faster than normal pulse, enlarged heart, signs of fluid retention (e.g. swollen ankles, enlarged liver, crackles in lungs. ​ Blood tests: measure B-type natriuretic peptide, BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP). They increase in heart failure. ​ Other tests (ECG,Chest X-ray, Blood and urine tests) Aims of Treatment: ​ Reduce mortality ​ Relieve symptoms ​ Improve exercise intolerance ​ Reduce acute exacerbations Non Drug Treatment: ​ Lifestyle changes (e.g. smoking cessation, exercise, reduce alcohol consumption) ​ Patients should weigh themselves daily and report any weight gain of 1.5 – 2.0kg in 2 days to their GP ​ Restrict salt in Diet: less than 6g daily recommended Treatment for Heart Failure Memory Trick AIDS BAND ​ Amiodarone ​ Ivabradine ​ Digoxin ​ Sacubitril Valsartan ​ Beta Blocker licensed for heart failure (e.g, NBS, bisoprolol, carvedilol or nebivolol)-do not withhold beta blocker treatment for age, patients with diabetes, COPD, PVD, erectile dysfunction. ​ Ace Inhibitor (e.g. Ramipril, enalopril, Lisinopril, captopril, perindopril, quinapril & fosinopril) or an ARB if they are not responding well to ACE Inhibitors such as due to side effects like a dry cough (e.g Valsartan, losartan or candesartan licensed for HF). ​ Nitrate/ hydralazine ​ Diuretic (Loop diuretics to relief breathlessness and oedema in patients with fluid retention. Thiazides can only be used for mild fluid retention and eGFR More Than 30. ​ AVOID Calcium Channel Blockers (Except Amlodipine for patients with Heart Failure and Angina). ​ Digoxin, hydralazine, Ivabradine & nitrates are for patients with worsening heart failure despite above. ​ Mineralocorticoid Receptor Antagonist (MRA) (e.g spironolactone/eplerenone) ​ Offer annual influenza vaccine & vaccine against pneumococcal disease Good Points: ​ Stop all Drugs which worsen heart failure such as Calcium Channel Blockers ​ Prescribe Loop Diuretic to relief Oedema & Breathlessness ​ Prescribe ACE Inhibitor & BB but only one drug as a time first ​ Prescribe ACE inhibitor first if the patient has diabetes or fluid overload ​ Prescribe Beta Blocker if the patient has Angina ​ Prescribe ARB if unable to take an ACE Inhibitor (e.g dry cough) ​ For patients who ACE Inhibitors or ARBS are not tolerated, give Hydralazine hydrochloride + Nitrate if African-Caribbean. Chronic Heart Failure Management: ​ After Chronic Heart Failure has been diagnosed by a specialist, offer loop diuretic for congestive symptoms and fluid retention Heart Failure with reduced ejection fraction: First Line Treatment: ​ Either an ACE Inhibitor or a Beta Blocker to reduce mortality and morbidity and then you add them together after they are optimised. The choice of class depends on the patient for example if they are type 2 diabetic or has fluid overload, then you use an ACE Inhibitor. If the patient has angina, then a Beta Blocker is used. ​ If an ACE Inhibitor or Beta Blocker is not controlling the heart failure, then a Mineralocorticoid Receptor Antagonist like spironolactone/eplerenone (potassium-sparing diuretics) can be added. ​ Dapagliflozin (10mg ONCE Daily)- new indication for reduced ejection heart failure ​ Consider an ARB if they are not responding well to ACE Inhibitors such as due to side effects like a dry cough. ​ Consider hydralazine & nitrate if intolerant of ACE and ARB (particular in African-Caribbean patients). If symptoms persist despite first-line treatment, seek specialist advice and consider one of the following which are: ​ Replace ACE Inhibitor (or ARB) with Sacubitril Valsartan if ejection fraction is Less than 35%. ​ Add Ivabradine (In addition to the ACE Inhibitor, Beta Blocker and MRA) for sinus rhythm with heart rate more than 75 and ejection fraction less than 35%. ​ Add hydralazine and nitrate (especially if of African-Caribbean descent) ​ Digoxin for heart failure with sinus rhythm to improve symptoms. So if the patient has sinus rhythm, you can use Digoxin as add on therapy. Acute Coronary Syndromes There are three different types of Acute Coronary Syndrome: Mnemonic SUN ​ Unstable Angina ​ Non-STEMI ​ STEMI NSTEMI = Non ST Elevation Myocardial Infarction STEMI = ST Elevation Myocardial Infarction The diagnosis of Acute Coronary Syndrome is made on the basis of clinical presentation, ECG changes and measurement of biochemical cardiac markers such as troponin (a type of protein found in the muscles of your heart. When heart muscles become damaged, troponin is sent into the bloodstream. As heart damage increases, greater amounts of troponin are released in the blood. What causes Acute Coronary Syndrome: ​ Plaque ruptures from within a coronary artery which causes partial or complete obstruction of that artery. ​ The obstruction restricts blood supply to the heart, lack of oxygen leads to an ischaemia (chest pain/angina). Angina often first sign ​ If obstruction is extensive, some of the heart muscle begins to die (necrosis), leading to a myocardial Infarction (M.I.) So with Angina, there may be obstruction but the heart is still getting Blood. However, with myocardial Infarction, the heart is dead as there is complete obstruction resulting in no blood. Memory Trick NS = Not Serious (NSTEMI) S = Serious (STEMI) STEMI: ​ Worse form of Acute Coronary Syndrome ​ S-T segment is NOT flat but appears abnormally elevated on ECG (indicates classic full heart attack). ​ Complete obstruction of coronary artery resulting in death of cardiac muscle. NSTEMI: ​ Partial Heart Attack ​ In between Unstable Angina & STEMI ​ Partial obstruction of coronary artery (some muscle cells die, but most will survive) Symptoms of Angina: Angina is when there is not enough blood going through the arteries ​ Chest Pain (tight, sharp, stabbing, dull or heavy) ​ Spreads to left arm, neck, jaw or back ​ Triggered by physical exertion or stress ​ Stops within a few minutes of resting ​ Nausea and Fatigue ​ Shortness of Breath ​ Sweating & Dizziness What is the difference of stable and unstable angina? Stable Angina Unstable Angina Symptoms occur during exercise/activity/ Chest pain occurs while resting stress Chest pains lasts longer and more recurring Chest pains more severe Memory Trick Stable = Predictable Memory Trick Unstable = Unpredictable  Unstable Angina is more dangerous as its unpredictable What mediations are used in the management of unstable Angina & Myocardial Infarction (Heart Attack)? Memory Trick When you C Osama Bin, you have a heart attack “C Osama Bin” ​ Clopidogrel ​ Oxygen ​ Statin (STEMI) ​ ACE Inhibitor (STEMI) ​ Metoclopramide ​ Aspirin ​ Beta Blocker ​ LV Heparin, morphine, diamorphine ​ Nitrate Management of unstable Angina & NSTEMI: Initial Management: ​ Oxygen Administer oxygen if evidence of hypoxia, pulmonary oedema or continuing myocardial ischaemia. ​ Nitrates Used to relieve Ischaemic pain ​ If sublingual glyceryl trinitrate is NOT effective, give I.V. buccal glyceryl trinitrate or I.V. Isosorbide dinitrate. ​ If pain continues, give I.V. diamorphine or I.V. morphine, an antiemetic such as metoclopramide should also be given. ​ Aspirin & Clopidogrel ​ Aspirin 300mg chewed or dispersed given for antiplatelet activity given ASAP  ​ Clopidogrel should also be given (Prasugrel & Ticagrelor as alternatives) ​ Also give either unfractionated Heparin, LMWH or fondaparinux sodium. Other drugs; Beta Blockers (if BB not tolerated, give verapamil/diltiazem), glycoprotein Inhibitors eg. Eptifibatide can also be given. Long-term Management: ​ Most patients will require standard angina treatment to prevent recurrence of symptoms. Management of STEMI: Initial management: ​ Similar to NSTEMI but with addition of ACE Inhibitor. Long-term management: ​ Similar to NSTEMI but with the addition of statin. Management of stable Angina-Short Term: ​ Sublingual glyceryl trinitrate (GTN) ​ Acute Attacks: Short term, used as a preventative measure immediately before performing activities that are known to bring on an attack. Management of stable Angina-Long-term: ​ Long-term prevention of chest pain Beta Blockers 1st line therapy (e.g atenolol, bisoprolol, propranolol, metoprolol). ​ If Beta Blockers are contraindicated, give rate limiting calcium channel blockers (e.g Verapamil/diltiazem) ​ Give a combination of Beta Blockers and Calcium Channel Blockers if a Beta Blocker alone fails to control angina. ​ If the above fails, or a beta blocker or calcium channel blocker are not tolerated or contraindicated, consider adding Ivabradine, nicorandil or ranolazine. ​ All patients should be given low dose Aspirin and a statin. ​ Consider ACE Inhibitors particularly if the patient has diabetes. Prevention of cardiovascular Events ​ Patients with stable, unstable Angina or NSTEMI should be given advice and treatment to reduce CV risk. ​ Emphasise the importance of lifestyle changes, especially stopping smoking ​ Give Aspirin indefinitely ​ Initiate antihypertensive treatment if appropriate ​ Give a Statin  ​ Add ACE Inhibitor for patients with stable angina with diabetes ​ In patients with unstable angina or NSTEMI (give combination of Aspirin & Clopidogrel for up to 12 months). Give prasugrel or ticagrelor as alternatives to Clopidogrel. Also give an ACE Inhibitor. ​ Low dose Rivaroxaban in combination with aspirin alone or aspirin & Clopidogrel is licensed for the prevention of atherothrombotic events following an acute coronary syndrome elevated cardiac biomarkers. Nitrates ​ They are useful in the role of Angina ​ They are potent coronary vasodilators- so they dilate your blood vessels so that you get more oxygen through and blood flow, but principal benefit is a reduction in venous return which reduces left ventricular work. What are the three main forms of Sublingual GTN (Glyceryl Trinitrate) ​ Tablets ​ Spray ​ Patches- Not Sublingual Key elements of Nitrates ​ Side-Effects Headaches, Flushing, Postural Hypotension ​ Sublingual Glyceryl Trinitrate (GTN) is one of the most effective drugs in providing rapid symptom relief but effects only last for 20 – 30 minutes. ​ If using GTN spray more than TWICE a week, then long term prophylaxis is required. ​ The 300mcg tablet is appropriate when glyceryl Trinitrate is first used ​ Aerosol spray are an alternative for sublingual tablets ​ Transdermal Patches can also be used for prolonged action (but tolerance may develop). Glyceryl Trinitrate (GTN) Doses: GPHC EXAM QUEST Prophylaxis of Angina (Sublingual Tablets): ​ ONE Tablet before activity likely to cause angina Treatment of angina (Sublingual Tablets): Rule of 3 ​ ONE Tablet repeated at 5 minutes’ interval if required, if symptoms have not resolved after 3 doses, medical attention should be sought. ​ Spray: 1-2 doses under the tongue for prophylaxis or treatment ​ Transdermal Patch: One patch changed every 24hrs Nitrates (Isorsobide dinitrate) ​ Isorsobide dinitrate is active sublingually and effective for patients require nitrated infrequently. ​ Effective by mouth for prophylaxis (although slow onset of action)  ​ Effect may persist for several hours Nitrates Continued… ​ Modified Release preparations of dinitrate have a duration of up to 12 hours (Give TWICE A Day). ​ Activity of dinitrate may depend on the production of active metabolite (most important is Isosorbide mononitrate). MEMORY TRICK Di= Twice Mono= Once ​ Isosorbide mononitrate is licensed for Angina prophylaxis, MR Preparations (once daily admin) are available ​ IV glyceryl Trinitrate or IV Isorsobide dinitrate (used for more severe symptoms or when sublingual form is ineffective). What is the main caution with nitrates and how do you prevent it? ​ One of the main cautions is that the body can become tolerant to the drug. Therefore, different ways can be taken in order to prevent this such as: ​ Take MR Isosorbide mononitrate ONCE DAILY tablets as they have a less risk of causing tolerance. ​ For TWICE a day tablets, take the second dose after 6-8 hours and not 12 hours ​ Leave patches off for 8-12 hours (usually overnight) in each 24 hours. Dispensing and storage requirements of GTN: Sublingual GTN Tablets ​ Available in strengths of 300, 500 & 600mcg ​ Tablets should be supplied in glass containers of not more than 100 tablets ​ Closed with a foil line cap ​ No cotton wool wadding ​ Discard after EIGHT weeks ​ Rectal ointment should be discarded EIGHT weeks after opening. How is Glyceryl Trinitrate (GTN) taken? ​ It is taken before exertion, e.g before exercising ​ Taken when required ​ Take sitting down due to postural hypertension ​ Dose Usually ONE Tablet or (1-2 SPRAYS): Not more than THREE Doses are recommended at any one time. How to take doses (sublingual- take under the tongue): ​ Take 1st dose and wait 5 minutes ​ Take 2nd dose and wait 5 minutes ​ Take 3rd dose and wait 5 minutes ​ Call 999 if pain is still present after 3rd dose = Medical emergency Hypertension: Three common methods of measuring Hypertension (High Blood Pressure) ​ Take Blood pressure in a clinical setting (by a doctor) ​ Ambulatory which is a 24-hour monitoring device (ABPM)- This is the best and the most convenient. ​ Home Blood monitoring (HBPM) Causes of High Blood Pressure ​ Main cause is unknown ​ Risk factors: Age, ethnicity, dietary salt, exercise, alcohol, caffeine, smoking weight gain ​ Secondary causes: Renal disease (problems with kidneys) and endocrine causes What does Target Organ damage mean? ​ Heart ​ Brain ​ Kidney (CKD)- Chronic Kidney Disease ​ Eye (Retinopathy) Hypertension thresholds for treatment: ​ Patient presenting 120/80 mmHg is good and healthy ​ Patients presenting a Blood Pressure reading of 140/90 mmHg or higher when measured in a clinical setting should be offered ambulatory blood pressure monitoring (ABPM) or home BP monitoring if (ABPM) is unsuitable, to confirm the diagnosis and stage of hypertension. Different stages of Hypertension STAGE 1 HYPERTENSION ​ Clinic BP ≥ 140/90 – 160/100 mmHg (Ambulatory/Home BP ≥ 135/85mmHg) STAGE 2 HYPERTENSION ​ Clinic BP ≥ 160/100 – 180/120 mmHg (Ambulatory/Home BP ≥ 150/95mmHg SEVERE HYPERTENSION ​ Clinic systolic ≥ 180 mmHg or clinic diastolic BP ≥ 120 mmHg Accelerated Hypertension A.K.A Malignant Hypertension: ​ A severe increase in blood pressure to ≥ 180/120mmHg (and often over 200/120mmHg). ​ With signs of: Retinal damage, and/or Papilloedema (swelling of the optic nerve)  ​ Usually associated with target organ damage What happens in clinic ​ If the clinic Blood Pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension ​ Offer HBPM if ABPM is unsuitable While waiting for results the following are done: ​ Investigate target organ damage to see the cause of hypertension ​ Cardiovascular risk assessment- (QRISK2 & JBS3 Risk Calculators) used in England and Wales- to find out whether you need medication. Following from the results from taking blood pressure readings over a course of time and there is NO hypertension, but organ damage, then investigate causes of organ damage (heart, brain, kidney, eyes). If there is NO hypertension and NO organ damage, measure clinic Blood Pressure every FIVE YEARS (Measure more regularly if BP is close to 140/90 mmHg- maybe every TWO Years). If the patient does have hypertension (offer urine/blood tests, Lifestyle interventions and drug treatment) Drug Treatment Following Diagnosis Stage 1 Hypertension Age ˂80 Years with one or Age >80 Years Age ˂40 Years Age ˂60 Years more of the following with NO target organ damage Target organ damage (e.g. Clinic BP >150/90 Investigate for Estimated 10year CV retinopathy, CKD) mmHg. Then offer secondary cause risk below 10% drug treatment and of hypertension Lifestyle advice Offer Drug treatment and lifestyle advice. Established Cardiovascular Disease Renal Disease Diabetes 10 Year risk of cardiovascular disease ≥10% (new nice guidelines) In absence of the above conditions, advice lifestyle and monitor them. However,  if they do have one of the above then start medication. Stage 2 Hypertension (Treat all regardless of age) Stage 3 or Severe Hypertension Treat promptly with IV antihypertensive Same Day Specialist Referral: Refer patients for specialist assessment on the same day if they have severe hypertension (BP ≥ 180/120 mmHg) with any of the following signs: ​ Retinal haemorrhage ​ Papilloedema (accelerated hypertension) ​ Life threatening symptoms (e.g narrow onset confusion, chest pain, signs of heart failure or acute kidney injury) ​ Suspected phaeochromocytoma (e.g postural hypotension, headache, palpitations, abdominal pain, pallor, diaphoresis). ​ If the patient has severe hypotension but NO symptoms or signs indicating same day referral, carry out investigations for target organ damage as soon as possible. ​ If target organ damage, consider starting antihypertensive drug treatment immediately without waiting for results of home or ambulatory monitoring. ​ If there is NO target organ damage, repeat clinic BP measurement within SEVEN Days. Drug Treatment steps: Drugs used in Hypertension: Correct order (AC DDB) ​ ACE/ARB (A) ​ Calcium Channel Blockers (C) ​ Thiazide Diuretics (D) ​ Low Dose Spironolactone (D) ​ Beta Blockers/Alpha Blockers (B) Hypertension in Type 2 Diabetes: Mnemonic ACT ​ Step 1 ACE Inhibitors/ARBs ​ Step 2 ACE Inhibitors/ARBs + CCB or thiazide-like diuretic ​ Step 3 ACE Inhibitors/ARBs + CCB or thiazide-like diuretic ​ Step 4 Confirm resistant hypertension (Look at Diagram Below) ​ Hypertension in Type 1 Diabetes Type 1 Diabetes target (clinic Bp of less than or equal to 135/85 mmHg) Type 1 Diabetes with albuminuria (albumin in the urine) or features of metabolic syndrome (less than or equal to 130/80 mmHg). Drug Treatment (ABCD) ​ Step 1 ACE Inhibitor (First line)- start with low dose and titrate to max ​ Step 2 Beta Blockers ​ Step 3 Low Dose Thiazides in combination with beta Blockers ​ Step 4 Calcium Channel Blockers (use only long acting preparations e.g MR Nifedipine & Amlodipine) Side Effects of a drug or class should NOT prevent use in type 1 diabetes unless it is clinically significant (e.g. using selective beta blockers in patients on insulin). Ace Inhibitors are first line but the other have no specific order. DRUG AVOID Side-Effects ACE Inhibitors Afro-Caribbean Angioedema Sever Renal Disease Dry Cough Pregnancy/Breastfeeding Hyperkalaemia Aliskiren with (eGFR less than 60 or Angioedema)  ARB Severe Renal Disease Hyperkalaemia Pregnancy Angioedema Aliskiren with (eGFR less than 60 or Angioedema) Calcium Channel Blockers Oedema Oedema Heart Failure (except Amlodipine) Unstable angina, Uncontrolled Heart Failure Thiazide Diuretic Diabetes Hypokalaemia Gout Hyperuricaemia eGFR