Cardiovascular

If ectopic beats are spontaneous and the patient has a normal heart how do we treat it?

treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, beta-blockers are sometimes effective

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Atrial fibrillation can be managed by

either controlling the ventricular rate (‘rate control’) or by attempting to restore and maintain sinus rhythm (‘rhythm control’)

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How to treat all patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation

emergency electrical cardioversion

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How to treat patients presenting acutely but without life-threatening haemodynamic instability

if onset of arrhythmia is less than 48 hours, rate or rhythm control can be offered.
If rhythm control; can use electrical or pharmacological cardioversion (flecainide [if no structural/ischaemic heart disease] or amiodarone (if evidence of IHD)

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How to treat pts presenting acutely when symptoms last >48hrs or unsure

Rate control is preferred by giving IV B-blocker (sotalol) and rate-limiting CCB such as verapamil (if LVEF > 40%)
if rhythm control is chosen; electrical cardioversion is preferred

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If treating new-onset AF pts with pharmacological cardioversion which drugs should be used

Flecainide acetate (if no structural or ischaemic heart disease present)
or
Amiodarone hydrochloride

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If atrial fibrillation has been present for more than 48 hours and rhythm control is the chosen option, electrical cardioversion is preferred to pharmacological cardioversion but what must happen first

patient must be 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 and 4 weeks oral anticoag given after

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Rate control is the preferred first-line treatment strategy for atrial fibrillation except...

in new-onset atrial fibrillation,
pts with atrial flutter suitable for an ablation strategy,
pts with atrial fibrillation with a reversible cause, pts with heart failure primarily caused by atrial fibrillation or if rhythm control is more suitable

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Rate control is the preferred first-line treatment strategy for atrial fibrillation using

a standard beta-blocker (not sotalol hydrochloride), or with a rate-limiting calcium channel blocker such as diltiazem hydrochloride [unlicensed indication] or verapamil hydrochloride as monotherapy

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Digoxin 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

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When monotherapy fails to adequately control the ventricular rate, consider combination therapy with any 2 of...

a beta-blocker, digoxin, diltiazem hydrochloride.
If ventricular function is diminished (LVEF <40%), the combination of a beta-blocker (that is licensed for use in heart failure) and digoxin is preferred.
. Digoxin is also used when atrial fibrillation i

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flecainide acetate and propafenone hydrochloride should be avoided in patients with

known ischaemic or structural heart disease

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when should digoxin monotherapy be considered

it should be considered for initial rate control therapy for pts with non-paroxysmal AF and when other rate-limiting drugs are unsuitable.

If ventricular function is diminished (LVEF <40%), the combination of a beta-blocker (that is licensed for use in h

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If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion use:

standard beta-blocker (not sotalol hydrochloride) as first-line treatment
Dronedarone may be considered as a second-line treatment option in patients with persistent or paroxysmal atrial fibrillation

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patients with new-onset atrial fibrillation who are receiving subtherapeutic or no anticoagulation therapy should be given:

Parenteral anticoagulation (heparin)

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direct-acting oral anticoagulant include

apixaban, dabigatran etexilate, edoxaban, or rivaroxaban

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Can aspirin be used as monotherapy in AF stroke prevention

aspirin monotherapy solely for stroke prevention in patients with atrial fibrillation is not recommended.

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what is the treatment of choice If rapid conversion to sinus rhythm is necessary

Direct current cardioversion is usually the treatment of choice

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intravenous adenosine should be given to treat

paroxysmal supraventricula tachycardia

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If adenosine is ineffective or contra-indicated in Paroxysmal supraventricular tachycardia
give:

intravenous verapamil hydrochloride as an alternative, but it should be avoided in patients recently treated with beta-blockers.

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how to prevent Recurrent episodes of paroxysmal supraventricular tachycardia with medication?

diltiazem hydrochloride, verapamil hydrochloride, beta-blockers including sotalol hydrochloride, flecainide acetate or propafenone hydrochloride.

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In arrhythmia after a MI Bradycardia, particularly if complicated by hypotension, should be treated with

intravenous dose of atropine sulfate the dose may be repeated if necessary. If there is a risk of asystole, or if the patient is unstable and has failed to respond to atropine sulfate, adrenaline/epinephrine should be given by intravenous infusion

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Pulseless ventricular tachycardia or ventricular fibrillation require

Resuscitation

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Patients with unstable sustained ventricular tachycardia, who continue to deteriorate with signs of hypotension or reduced cardiac output, should receive

direct current cardioversion to restore sinus rhythm
If this fails, intravenous amiodarone hydrochloride should be administered and direct current cardioversion repeated

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Patients with sustained ventricular tachycardia who are haemodynamically stable can be treated with

intravenous anti-arrhythmic drugs
Amiodarone hydrochloride is the preferred drug. Flecainide acetate, propafenone hydrochloride, and, although less effective, lidocaine hydrochloride have all been used

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Non-sustained ventricular tachycardia can be treated with

A Beta Blocker

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Torsade de pointes is a form of

ventricular tachycardia associated with a long QT syndrome

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Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness. If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death so how do we treat this?

Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered.
Anti-arrhythmics can further prolong the QT interval, thus worsening the condition

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Anti-arrhythmic drugs can be classified clinically into

those that act on supraventricular arrhythmias e.g. verapamil hydrochloride),
those that act on both supraventricular and ventricular arrhythmias (e.g. amiodarone hydrochloride),
those that act on ventricular arrhythmias (e.g. lidocaine hydrochloride)

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Anti-arrhythmic drugs can also be classified according to their effects on the electrical behaviour of myocardial cells during activity (the Vaughan Williams classification)

Class I: membrane stabilising drugs (e.g. lidocaine, flecainide)
Class II: beta-blockers
Class III: amiodarone; sotalol (also Class II)
Class IV: calcium-channel blockers (includes verapamil but not dihydropyridines)

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Effect of hypokalemia on anti-arrhythmic drugs

hypokalaemia enhances the arrhythmogenic (pro-arrhythmic) effect of many drugs

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what is the drug of choice for terminating paroxysmal supraventricular tachycardia

Adenosine
Verapamil hydrochloride may be preferable to adenosine in asthma.

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What IV b blockers can be used in supraventricular arrhythmias

Intravenous administration of a beta-blocker such as esmolol hydrochloride or propranolol hydrochloride, can achieve rapid control of the ventricular rate

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Drugs for both supraventricular and ventricular arrhythmias include

amiodarone hydrochloride, beta-blockers, disopyramide, flecainide acetate, procainamide and propafenone hydrochloride

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Amiodarone hydrochloride is used in the treatment of arrhythmias, particularly when other drugs are ineffective or contraindicated. It can be used for

paroxysmal supraventricular, nodal and ventricular tachycardias, atrial fibrillation and flutter, and ventricular fibrillation. It can also be used for tachyarrhythmias associated with Wolff-Parkinson-White syndrome. It should be initiated only under hosp

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when is IV disopyramide usually given

Disopyramide can be given by intravenous injection to control arrhythmias after myocardial infarction (including those not responding to lidocaine hydrochloride),

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When is flecainide used

Flecainide acetate belongs to the same general class as lidocaine hydrochloride and may be of value for serious symptomatic ventricular arrhythmias. It may also be indicated for junctional re-entry tachycardias and for paroxysmal atrial fibrillation

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when is propafenone used

Propafenone hydrochloride is used for the prophylaxis and treatment of ventricular arrhythmias and also for some supraventricular arrhythmias

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What must one be cautioned of

weak beta-blocking activity (therefore caution is needed in obstructive airways disease—contra-indicated if severe

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Drugs for supraventricular arrhythmias include

adenosine, cardiac glycosides, and verapamil hydrochloride.

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Drugs for ventricular arrhythmias include

lidocaine hydrochloride.

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What can be used for the treatment of ventricular tachycardia in haemodynamically stable patients, and ventricular fibrillation and pulseless ventricular tachycardia in cardiac arrest refractory to defibrillation

Intravenous lidocaine hydrochloride
it is no longer the anti-arrhythmic drug of first choice

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Drugs for both supraventricular and ventricular arrhythmias include

amiodarone hydrochloride, beta-blockers, disopyramide, flecainide acetate, procainamide (available from ‘special- order’ manufacturers or specialist importing companies), and propafenone hydrochloride.
Mexiletine can be used for the treatment of life-thre

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Venous Thromboembolism consists of

deep-vein thrombosis (DVT) and pulmonary embolism (PE)

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Symptoms of a DVT include

unilateral localised pain, swelling, tenderness, skin changes, and/or vein distension

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Symptoms of a PE

chest pain, shortness of breath, and/or haemoptysis

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There are two methods of thromboprophylaxis

mechanical and pharmacological. Options for mechanical prophylaxis are anti-embolism stockings that provide graduated compression and produce a calf pressure of 14–15 mmHg
Patients with risk factors for bleeding should only receive pharmacological prophyl

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signs of haemodynamic instability

include pallor, tachycardia, hypotension, shock, and collapse

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for patients with a confirmed proximal DVT or PE offer

either apixaban or rivaroxaban

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If apixaban or rivaroxaban are unsuitable for proximal DVT or PE, offer either

low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran etexilate or edoxaban; or
LMWH given concurrently with a vitamin K antagonist for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings, followed by a vit

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For renally impaired patients (estimated creatinine clearance between 15–50 ml/min) with a confirmed proximal DVT or PE

offer; Apixaban; Rivaroxaban;
LMWH for at least 5 days followed by either dabigatran etexilate (if estimated creatinine clearance is 30 ml/min or above) or edoxaban;
LMWH or heparin (unfractionated), given concurrently with a vitamin K antagonist for at l

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Patients with a confirmed proximal DVT or PE should be offered anticoagulation treatment for

at least 3 months (3 to 6 months for those with active cancer

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if rapid reversal of the effects of the heparin is required

protamine sulfate is a specific antidote (but only partially reverses the effects of low molecular weight heparins)

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Patients suspected of having a transient ischaemic attack should immediately receive

aspirin.

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Following a transient ischaemic attack or an ischaemic stroke (not associated with atrial fibrillation), long-term treatment with

clopidogrel [unlicensed in transient ischaemic attack] is recommended
if contra-indicated or not tolerated, patients can receive modified-release dipyridamole in combination with aspirin;

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If starting or changing diuretic treatment for hypertension, offer

thiazide-like diuretic such as indapamide in preference to conventional thiazide diuretics, for example bendroflumethiazide or hydrochlorothiazide.

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In type 1 diabetes, aim for a clinic blood pressure of

135/85 mmHg

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Stage 1hypertension is a clinic blood pressure of

between 140/90 mmHg and 160/100 mmHg, and ambulatory daytime average or home blood pressure average of 135/85 mmHg or higher

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Stage 2hypertension is a clinic blood pressure of

160/100 mmHg and 180/120 mmHg, and ambulatory daytime average or home blood pressure average of 150/95 mmHg or higher
Treat all patients who have stage 2 hypertension, regardless of age.

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Severe hypertension is a clinic systolic blood pressure of

180 mmHg or higher, or a clinic diastolic blood pressure of 120 mmHg or higher.

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target clinic blood pressure for patients aged under 80 years

below 140/90 mmHg

Ambp 135/85 mmHg

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target clinic blood pressure for patients aged over 80 years

below 150/90 mmHg

Ambp 145/85 mmHg

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symptoms of HF

shortness of breath, persistent coughing or wheezing, ankle swelling, reduced exercise tolerance, and fatigue

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Which medications should be avoided in patients who have heart failure with reduced ejection fraction as these drugs reduce cardiac contractility

Rate-limiting calcium-channel blockers (verapamil hydrochloride, and diltiazem hydrochloride) and short-acting dihydropyridines (e.g. nifedipine, or nicardipine hydrochloride)
Patients with heart failure and angina may safely be treated with amlodipine.

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Thiazide diuretics may only be of benefit in patients with

mild fluid retention and an eGFR greater than 30 mL/minute/1.73 m2.

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first-line treatment for HF

An angiotensin-converting enzyme (ACE) inhibitor (e.g. perindopril, ramipril, captopril, enalapril maleate, lisinopril, quinapril or fosinopril sodium) and a beta-blocker licensed for heart failure (e.g. bisoprolol fumarate, carvedilol, or nebivolol) shou

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Which Diuretics are recommended for the relief of breathlessness and oedema in patients with fluid retention

Loop diuretics such as furosemide, bumetanide, or torasemide are usually the diuretics of choice

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a beta-blocker should not be withheld in the treatment of HF because of

age or the presence of diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, erectile dysfunction, or interstitial pulmonary disease

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What ARB's are licensed for heart failure

candesartan cilexetil, losartan potassium, or valsartan)

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If heart failure symptoms persist or worsen despite optimal first-line treatment what should be given?

an aldosterone antagonist such as spironolactone or eplerenone should be offered as add-on therapy unless contraindicated (e.g. due to hyperkalaemia or renal impairment).
Hydralazine hydrochloride with a nitrate can be considered in patients who are intol

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When initiating beta blockers what should be assessed at the start of treatment and after each dose change

heart rate, blood pressure and symptom control

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How to manage HF In patients with chronic kidney disease

lower doses and slower dose titrations of ACE inhibitors, ARBs, aldosterone antagonists and digoxin should be considered

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first choice for treating hypercholesterolaemia and moderate hypertriglyceridaemia

Statins

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Severe hypercholesterolaemia or hypertriglyceridaemia not adequately controlled with a maximal dose of a statin may require the use of an additional lipid-regulating drug such as

ezetimibe

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Although statins are more effective than other lipid-regulating drugs at lowering LDL-cholesterol concentration, they are less effective than fibrates in reducing...

triglyceride concentration

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what may be added to statin therapy if triglycerides remain high even after the LDL-cholesterol concentration has been reduced

fenofibrate

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A high-intensity statin is defined as

the dose at which a reduction in LDL-cholesterol of greater than 40% is achieved.
The dose of the statin should be titrated to achieve a reduction in LDL-cholesterol concentration of greater than 50% from baseline.

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Patients who have contra-indications to, or are intolerant of statins, can be considered for treatment with ______ as monotherapy

ezetimibe

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A combination of a statin and ezetimibe is recommended if

if the maximum tolerated dose of a statin alone fails to provide adequate control of LDL-cholesterol, or a switch to an alternative statin is being considered

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in patients for whom statins or ezetimibe are inappropriate Treatment with _________ or ________ can be considered under specialist advice

a fibrate or a bile acid sequestrant (such as colestyramine or colestipol hydrochloride)

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The combination of a statin with a fibrate carries an increased risk of

muscle-related side-effects (including rhabdomyolysis)
gemfibrozil with a statin increases the risk of rhabdomyolysis considerably—this combination should not be used.

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MABs that can be used to lower lipids

alirocumab and evorocumab

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why is high-dose (80 mg) simvastatin not recommended

there is an increased risk of myopathy

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Drugs used for high intensity lipid reduction

Atorvastatin (20,40,80mg) and Rosuvastatin (10,20,40mg)

Simvastating 80mg is not recommended due to myopathy risks

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Drugs used in low intensity (first line) lipid modification

Pravastatin (10,20,40mg), Fluvastatin (20,40mg) and Simvastatin (10mg)

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Drugs used in medium intensity lipid modification

Fluvastatin (80mg), Simvastatin (20,40mg), Rosuvastatin(5mg), Atorvastatin(10mg)

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Secondary causes of dyslipidaemia to be addressed before starting statins

hypothyroidism, uncontrolled diabetes, liver disease and kidney damage

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Cuation of statins in diabetes

Can raise HBA1c

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Interactions with statins that increase statin levels (increasing risk of myopathy)

Amiodarone, grapefruit juice, CCB's, antifungals (itraconazole, ciclosporin)

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If prescribed statin with macrolide antibiotic e.g. clarithomycin

stop taking statin until antibiotic course is finished

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If prescribed statin with fusidic acid

Restart statin 7 days after last fusidic acid dose

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Statins in pregnancy and breast feeding

AVOID

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Bile acid sequestrants interactions

Impairs absorption of fat soluble vitamins ADEK and other drugs so take other drugs 1 hour before except Colesevelam take 4 hours before
or
take bile acid sequestrant 4 hours after other drugs

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first-line therapy for long-term prevention of chest pain in patients with stable angina

a beta-blocker (such as atenolol, bisoprolol fumarate, metoprolol tartrate or propranolol hydrochloride)
If a beta-blocker alone fails to control symptoms adequately, a combination of a beta-blocker and a calcium-channel blocker should be considered

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an alternative if beta-blockers are contra-indicated in prevention of stable angina

A rate-limiting calcium-channel blocker (such as verapamil hydrochloride or diltiazem hydrochloride)

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A long-acting nitrate, ivabradine, nicorandil, or ranolazine, should also be considered in addition or as monotherapy to the treatment of stable angina when?

If combination is not appropriate due to intolerance of, or contra-indication to, either beta-blockers or calcium-channel blockers or as monotherapy in patients who cannot tolerate/CI/inadequate response to beta-blockers and calcium-channel blockers

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In stable angina response to treatment should be assessed every...

2–4 weeks

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All patients with stable angina due to atherosclerotic disease should be given long-term treatment with...

low-dose aspirin and a statin

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if the patient has diabetes with stable angina which drug is recommended

Treatment with an ACE inhibitor should be considered

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ACS initial management

Pain relief should be offered as soon as possible with glyceryl trinitrate (sublingual or buccal). Intravenous opioids such as morphine may also be administered.
A loading dose of aspirin should be given as soon as possible

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most patients with a STEMI should be offered a second antiplatelet agent in addition to aspirin such as

prasugrel, ticagrelor, or clopidogrel

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In STEMI and NSTEMI For secondary prevention, patients should be offered treatment with

angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, dual antiplatelet therapy and a statin
If intolerant to an ACE inhibitor, an angiotensin II receptor blocker (ARB) should be offered instead.

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In secondary prevention of ACS Treatment with aspirin should continue indefinitely. Dual antiplatelet therapy (aspirin with a second antiplatelet) should be continued for up to

12 months unless contraindicated

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Cardiovascular

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