The Practice of Treating Cardiovascular Patients PDF

The Practice of Treating Cardiovascular Patients Professor Allan Struthers BSc, MD, FRCP, FESC, FRSE, FMedSci Professor of Cardiovascular Medicine Division of Molecular and Clinical Medicine University of Dundee/Ninewells Hospital Practical Treatment of • • • • • • HYPERTENSION HEART FAILURE ANGI...

The Practice of Treating Cardiovascular Patients Professor Allan Struthers BSc, MD, FRCP, FESC, FRSE, FMedSci Professor of Cardiovascular Medicine Division of Molecular and Clinical Medicine University of Dundee/Ninewells Hospital Practical Treatment of • • • • • • HYPERTENSION HEART FAILURE ANGINA PECTORIS MYOCARDIAL INFARCTION ATRIAL FIBRILLATION STROKES Clot Strategies • ANTI-THROMBOTIC – Thrombectomy • Only in brain vessels Suck clot out – Thrombolysis • In brain and heart Put a drug in to get clot to dissolve – Angioplasty ± Stent • Heart especially • THROMBOPROPHYLAXIS – Anti-clotting factor drugs • Warfarin, NOAC (eg Rivaroxaban) – Anti-platelet drugs • Aspirin, Clopidogrel, Ticagrelor, Prasugrel Quick Summary Hypertension Heart Failure Angina ACE Inhibitors + + + Beta Blockers + + + Calcium Antagonists + - + Diuretics + + - Hypertension A (B) C D A - ACE Inhibitor /Angiotensin Blocker (B - Beta Blocker) C - Calcium Antagonists D - Diuretic esp Thiazide diuretic Also Alpha Blocker (Doxazosin) Spironolactone Hypertension Sequence crucial Patient ≤ 55 years Start A Add C (if necessary) Add D (if necessary) Add spironolactone (If necessary) Then B or alpha-blocker (If necessary) Patient > 55 years Start C Add A (if necessary) Add D (if necessary ) Add spironolactone (If necessary) Then B or alpha-blocker (If necessary) Chronic Heart Failure – Part 1 Heart is not pumping as well as it used to DRUGS - Furosemide or other diuretic patient is retaining fluid Four Pillars below • ACEI or ARB or Sacubitril-Valsartan (never ACEI and sacubitrilvalsartan together) • Beta blocker • Aldosterone(Mineralocorticoid) receptor blocker e.g., Spironolactone or Eplerenone • SGLT2 inhibitor Also used for diabetes as its a glucose transporter e.g., Dapagliflozin Chronic Heart Failure – Part 2 DEVICES to selected groups only 1. Cardiac Resynchronisation Therapy to long QRS patients (= Biventricular Pacing) 2. Implantable Cardiac Defibrillators to highly selected patients Senses rhythm and if it becomes abnormal will deliver a small shock TRANSPLANTATION to very selected few Sacubitril-Valsartan To replace ACEI/ARB in severe heart failure Valsartan = ARB Sacubitril inhibits Neprilysin which degrades BNP and other vasoactive peptides Can cause Angioneurotic Oedema (like an ACEI) Swelling of the tissue just like anaphylactic Angina Pectoris (Chronic) Different treatments to relieve symptoms versus prolonging survival. 1. To prolong survival, all get SAAB Aspirin / Anti-platelet Statin ACE Inhibitor Beta Blocker 2. To relieve symptoms, sequentially use Beta Blocker Calcium Antagonist or Nitrates Coronary Angioplasty New antianginals Ivabradine Ranolazine Coronary artery surgery Acute Chest Pain Chest Pain Cardiac Troponin Positive = MI ST elevation on ECG called STEMI Non Cardiac Troponin Negative = Troponin negative Unstable Angina/ACS No ST elevation on ECG called NSTEMI STEMI treatment Emergency Also Aspirin Angioplasty (if near hospital) Thrombolysis ( if far away) Aspirin / Anti-platelet Low MW Heparin or Fondaparinux Statin ACE Inhibitor Beta Blocker i.e SAAB Fondaparinux is synthetic pentasaccharide that inhibits activated factor x. NSTEMI / Unstable angina / ACS Treatment Aspirin / Anti-platelet (Fondaparinux) Angioplasty (not as emergency) (and to mainly NSTEMI) Statin ACE Inhibitor Beta Blocker i.e. SAAB + non-urgent angioplasty to some Atrial Fibrillation 1. Prevent emboli Warfarin/ Rivaroxaban/NOACs 2. Control Rate (crucial) Beta Blocker Digoxin 3. Control Rhythm (seldom done) DC Cardioversion acutely Amiodarone if heart failure Sotalol (II/III) possible Flecainide (Ic) only if heart structure/function normal Radioablation Stroke = CVA Causes Cerebral Thrombosis Cerebral Embolus Cerebral Haemorrhage Must have CT scan to differentiate haemorrhage from clot If NO haemorrhage on CT scan For emergency Thrombolysis Thrombectomy Aspirin (acutely & for 2 weeks) Thereafter Anti-platelet Also Statin ACE Inhibitor Indapamide Common Side Effects ACE Inhibitors Cough Renal dysfunction *(worsen or improve) Angioneurotic oedema Never in pregnancy Angiotensin Blockers Renal dysfunction *(worsen or improve) Never in pregnancy Beta Blockers Bradycardia /Heart Block Tired Asthma (Not in asthmatics) Calcium Antagonists Ankle oedema for Amlodipine Heart Block for Diltiazem & Verapamil Diuretics Hypokalaemia Diabetes Gout