Disease Management

• Reduce cardiac output
• Reduce myocardial O2 demand
• Reduce heart rate
• Reduce blood pressure

• C/I
• - Asthma
• - Uncontrolled heart failure
• - 2nd or 3rd degree heart block

• Caution
• - Diabetics on insulin (masks hypoglycaemia)
• - COPD

• Bradycardia
• Fatigue
• Bronchospasm
• Peripheral vasoconstriction
• Impotence

• 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)

• 1st choice is unable to use a beta blocker
• Negative ionotropic and chronotropic effects

• Significant anti-arrhythmic and negative ionotropic properties
• Impairs AV conduction
• Verapamil/beta blocker combination contraindicated (can stop heart)
• Constipation common in elderly

• Ca2+ channel blockers
• Potent coronary artery vasodilators
• Dilation of peripheral arteries (swollen ankles, facial flushing, headache)
• No effect on conducting tissues

• 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

• Headache
• Dizziness
• Facial flushing
• Hypotension
• Tachycardia
• Tolerance to effects - need to have a nitrate free period

• 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

• Headache
• Dizziness
• Nausea
• Palpitations
• Fatigue

• 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

• Newest agent
• Unknown mech
• Lots of interactins
• Causes; headaches, dizziness, weakness
• Add on therapy if other combinations C/I or ineffective

• 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

• 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)

• Hypertension
• Hyperlipidaemia
• Obesity
• Diabetes
• Family hx of premature heart disease

• Prediction charts based on
• Gender
• Age
• Smoker/non-smoker
• BP
• Cholesterol

Not validated for ethnic groups

• 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

BP < 130/85 - recheck every 5 yrs

BP <140/90 - reassess yearly

BP140-159/90-99 - treat if at risk

• Target organ damage (e.g. renal)
• Established CV disease
• 10 yr CV risk =/>20% (e.g. smoker with high cholesterol
• Diabetes

• 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

• Side effects:
• Hypokalaemia
• Acute gout
• Impaired glucose tolerance

• C/I:
• Hypokalaemia
• Severe renal impairment
• Avoid in diabetics

• Ankle oedema
• Headache
• Facial flushing
• Bradycardia (rate limiting CCB)

• C/I:
• Pregnancy
• Heart failure (rate limiting)

• 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

• First line use in patients with diabetes, proteinurea, heart failure
• Other hypertensive patients recommended as alternative or supplementary

• 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

Reserve for patients unable to tolerate ACE inhibitor

Alternative method of blocking RAAS

• Similar to ACE inhibitors
• Hyperkalaemia
• Hypotension
• Renal impairment
• Angioedema

• 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

• 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

• Headache
• Fatigue
• Postural hypotension
• Urinary incontinence in women

• 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

• Sex
• Age
• Family history
• Diet
• Lipids
• Smoking
• Exercise
• Diabetes
• Hypertension

• 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

• 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

• 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

• 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

• Genetically modified rTPA
• Double bolus dose minutes apart
• Similar efficacy to alteplase
• Can be repeated

• 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)

• Cardiac arrhythmias
• Acute heart failure
• Pericarditis
• Thrombus
• Cardiac arrest

• Beta blockers
• Heparins
• Clopidogrel

• 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

• 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

• Given with non-strep kinase thrombolytics only for 48h to prevent reocclusion and reinfarction
• Unfractionated heparin vs LMWH

• If going for coronary stent insertion
• given 300-600mg stat
• would then receive parenteral glycoprotein IIb IIIa inhibitors as well

• Diet
• Exercise
• Smoking cessation
• Weight reduction
• Cardiac rehabilitation programmes

• Aspirin/clopidogrel
• beta blockers
• lipid lowering agents
• ace inhibitors
• angiotensin II antagonists
• nitrates
• calcium channel blockers

• 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

• 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

• 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

• Evidence of benefit post MI for valsartan
• reserve for pts unable to tolerate ACE inh

• No real evidence of benefit
• symptomatic relief
• rate limiting ones used when B-blockers C/I
• Verapamil worsens heart failurew

• 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

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

• Dysnopoea
• Nocturnal cough
• Paroxysmal nocturnal dysnopoea
• Confusion
• Renal failure
• Oedema
• Reduced exercise tolerance, lethargy, fatigue

• Improvement in symptoms;
• diuretics
• digoxin
• ACEI

• Improvement in survival;
• ACEI
• B-blockers
• spironolactone
• oral nitrates plus hydralazine

• 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)

• 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

Pts unable to tolerate ACEI

• 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

• 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

• 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

• 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)

• Class I antiarrythmic drugs e.g. lidocaine, flecanide
• NSAIDs
• Negative ionotropic calcium channel blockers e.g. diltiazem, verapamil

• short acting nifedipine
• sumatriptan
• sildenafil
• excess thyroxine

• Warfarin and simvastatin
• ACEI and NSAIDs
• Amiodarone and antipsychotics

Renal function and electrolytes

• LFT's before, 1-3 months q6m for a year
• if muscle pain occurs - creatinine kinase

• TFT's before and q6m
• LFT's before and q6m
• CXR before

INR daily or alternate days; longer intervals (up to 12 weeks depending on response)

• phototoxic reactions;
• shield skin from light
• use a wide spec sunscreen

• Controls heart rate
• cannot cardiovert
• inc toxicity in elderly, renal impairment, hypokalaemia, drug interactions

• 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

• B clocker with class III activity
• used for long term control rather than amiodarone unless asthmatic

• 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

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

• Phytomenadione (vit K) injection - dose depends on INR and is haemorrhage is life threatening
• Clotting factor concentrates/fresh frozen plasma - immediate reversal

• Recurrent vomiting
• Dysphagia
• Bleeding
• Weight loss
• Unexplained dyspepsia >55yr