Peripheral Vascular Disease

Nota:

• only group aspirin treatment is allowed for primary prevention because in this case the risk of bleeding outweighs the benefit of CD risk reduction

1. Hypertension must be controlled at less than 150/90mmHg
2. Aspirin
3. NOT FOR DIABETICS

1. Angina
2. previous MI
3. previous stroke or TIA
4. Peripheral Arterial Disease
5. AF

1. Inhibit clotting factors produced in the liver with the help of Vitamin K

1. competetive vitamin K inhibitor
2. Monitoring
   1. Regular blood tests
   2. INR

      Nota:

      • daily or alternate days at the beginning of treatment, then longer intervals depending on response, then up to every 12 weeks
   3. anticoagulant treatment alert card
3. indications
   1. rheumatic heart disease
   2. AF
   3. Prosthetic valve
   4. DVT
   5. PE
   6. TIA
4. Interactions
   1. direct-acting antivirals in treatment of Hep C

      Nota:

      • changes in liver function may affect efficacy of vit K antagonists
   2. Vit K foods and supplements
   3. Pomegranate
   4. major changes in diet or alcohol consuptions may require redosing
5. Side Effects
   1. calciphylaxis

      Nota:

      • small blood clots, painful skin ulcers and potentially serious infections which can lead to death, as a result of calcium accumulations in small blood vessels of the fat and skin tissues
   2. Alopecia
   3. diarrhoea
   4. hepatic dysfunction
   5. jaundice
   6. pancreatitis
   7. purpura
   8. N&V
   9. skin ncecrosis
      1. increased risk with protein C or S deficiency
   10. Purple toes
   11. fatigue
6. Contraindications
   1. Bacterial endocarditis
   2. hyperthyroidism
   3. peptic ulcer
   4. post-partum (at least 1 week)
   5. uncontrolled hypertension
   6. recent surgery
   7. recent ischaemic stroke
   8. Conception & Pregnancy - Teratogenic!
   9. hepatic impairment
   10. renal impairment- caution
   11. breastfeeding- caution due to vit K deficieny

1. compete with vitamin K
2. Side Effects
   1. Rare
   2. rebound hyperlipidaemia ( following unfractionated heparin withdrawal)
   3. skin necrosis
   4. urticaria
   5. injection site reactions
   6. osteoporosis- lower risk in LMWH
   7. hyperkalaemia

      Nota:

      • LMWH can inhibit aldosteron secretion. Those with DM, chronic renal failure, acidosis, raised plasma potassium or taking postassium-sparing diuretics are more susceptible
   8. alopecia (prolonged use
   9. angiodema
   10. priapism
   11. Heamorrhage
       1. protamine sulfate atidote for rapid reversal
   12. Heparin- induced thrombocytopenia

       Nota:

       • immune mediated reaction that does not usually develop until after 5-10 days. Signs: 30% reduction of platelet count, thrombosis or skin allergy Alternative anticoagulant like danaparoid should be given 
3. Indications
   1. mild to moderate PE
   2. unstable angina
   3. acute peripheral arterial occlusion
   4. DVT
   5. VTE prophylaxis as inpatients
   6. VTE in pregnancy
   7. Haemodialysis
   8. prevention of clotting in extracorporeal circuits

      Nota:

      • injected direct to the device as a flush
   9. maintain patency of catheters, cannulas and other iv infusion decvise

      Nota:

      • injected direct to device as a flush
4. interactions
   1. antihistamines
   2. Aspirin
   3. NSAIDs
   4. Vit K foods and supplements
   5. Digoxin
   6. Quinine
   7. Tetracyclin antibiotics e.g doxycycline
5. contraindications
   1. Acute bacterial endocarditis
   2. major trauma
   3. epidural
   4. haemophilia and other haemorrhagic disorders
   5. peptic ulcer
   6. recent cerebral haemorrhage
   7. recent eye surgery
   8. recent nervous surgery
   9. severe hypertension
   10. thrombocytopenia
6. Monitoring
   1. Measure platelet count before treatment
   2. regulare platelet counts may be required if given for longer than 4 days to pick up heparin-induced thrombocytopenia
   3. plasma potassium conc should be measured in patients at risk of hyperrkalaemia before treatment and monitored regularly thereafter

1. high risk stroke
2. AF
3. Valve replacement

1. bruising
2. Skin rash
3. cerebral heamorrhages
4. GI bleeds

1. MoA
   1. Factor X inhibitor
2. Indications
   1. VTE prophylaxis after major orthopaedic surger or abdo surgery
   2. VTE prophylaxis in immobilised patients
   3. superficial-vein thrombosis
   4. unstable angina and nonn-ST MI
   5. STEMI
   6. DVT and PE
3. Side Effects
   1. anaemia
   2. bleeding
   3. purpura
   4. chest pain
   5. confusion
   6. dizziness/ drwosiness
   7. flushing
   8. headache
   9. hyperbilirubinaemia
   10. hypokalaemia
   11. injection site reactions
   12. vertigo
4. Contraindications
   1. Active bleeding
   2. bacterial endocarditis
5. interactions
   1. thrombolytic drugs e.g alteplase
   2. anticoaggulants
   3. antiplatelets

1. MoA
   1. Factor Xa inhibitor
2. side effects
   1. Anaemia
   2. Bruising
   3. Haemorrhage
   4. nausea
   5. hypotension
   6. rash
   7. thrombocytopenia
3. indications
   1. joint replacement prophylaxis
   2. treatment and propylaxis of recurrent DVT and PE
   3. Prophylaxis of stroke and systemic embolis in non-valvular AF and at least one risk factor
4. containdications
   1. Risk factors for major bleeding afformentioned
   2. prosthetic heart valve
   3. anaesthesia with postoperative indwelling epidural catheter
   4. Pregnancy and breastfeeding
5. interactions
   1. Antiplatelets
   2. heparin

1. Side Effects
   1. hepatobiliary disorders
   2. abdominal pain
   3. anaemia
   4. diarrhoea
   5. dyspepsia
   6. haemorrhage
   7. nausea
   8. oesophagitis
   9. GI ulcer
2. Indications
   1. VTE prophylaxis following knee or hip replacement
   2. DVT treatment and 2ndry prevention
   3. PE treatment and 2ndry prevention
   4. DVT or PE tratment and prophylaxis when Warfarin is contraindicated i.e renal and hepatic impoirment and increased risk of bleeding
   5. concomitant treatment with verapamil
   6. stroke and systemic embolism prophylaxis in non-valvular AF with ome or more risk factors e.g previous stroke, symptomatic HT...
3. Contraindications
   1. active bleeding
   2. prosthetic heart valve
   3. malignant neoplasms
   4. oesophageal varices
   5. recent breain surgery or intravcranial bleed
   6. recent GI ulcer
   7. recent opthalmic surgery
   8. recent spinal surgery
   9. vascular aneurysm
   10. anaesthesia with postoperative indwelling epidural catherter

       Nota:

       • risk of paralysis
   11. Caution
       1. <50Kg
       2. elderly
       3. GORD or gastritis
       4. bacterial endocarditis
       5. recent trauma
       6. thrombocytopenia
       7. bleeding disorders
   12. pregnancy, breast feeding
   13. severe liver disease
4. Monitoring
   1. in renal impairment moniter renal function > annually
5. Interactions
   1. Aspirin
   2. NSAIDS
   3. antiplatelets
   4. anticoagulants
6. MoA
   1. Direct thrombin hihibitor

1. Inhhibit the productions of thromboxane which recruits platelets

1. Asspirin
   1. side effects
      1. bronchospasm
      2. confusion
      3. heamorrhages
         1. GI
         2. Subconjuctival
      4. skin reactions in hypersensitivity
      5. tinnitus
      6. Salicylate poisoning
         1. hyperventilation
         2. tinnitus
         3. deafness
         4. vasodilation
         5. sweating
         6. coma in sever poisoning
   2. contraindications
      1. <16yrs old
         1. causes Reye's Syndrome
         2. Excepted idicated e.g for Kawasaki Disease
      2. severe HF
      3. peptic ulcers
      4. haemophilia
      5. caution in
         1. allergic disease
         2. anaemia
         3. elderly
         4. dehydration
         5. G6DP deficiency
         6. thyrotoxicosis
         7. uncontrolled hypertension
      6. Breastfeeding
      7. hepatic impairment
   3. interactions
      1. Live flu vaccine
      2. methotrexate
      3. varicella virus live vacine
      4. corticosteroids
   4. MoA
      1. Cox inhibitor. Cyclooxygenase required for prostaglandin and thromboxane synthesis
2. Clpidogrel
   1. MoA
      1. Inhibits P2Y2 ADP receptor, inhibiting platelet activation
   2. Interactions
      1. PPI

         Nota:

         • makes clopidogrel less effective - lanzoprazole may be ok
   3. Thienopyridines
      1. prasugrel
      2. ticagrelor
      3. ticlopidine
   4. Indications
      1. When aspirin isn't torelated or contraindicated
      2. Acute Coronary syndrome
      3. PAD
      4. Post stroke
   5. Side Effects
      1. abdo pain
      2. gastric ulverls
      3. parashtesia
      4. pruritus
      5. eosinophilia
      6. decreased platelets
3. Dipyridamole
   1. MoA
      1. inhibits adenosine deaminase and phosphodiesterase, preventing the breakdown of cAMP which inhibits platelet function by reducing thromboxane A2 activity.
   2. Side Effects
      1. angiodema
      2. dizziness
      3. GI disturbance
      4. hot flushes
      5. myalgia
      6. severe bronchospasm
      7. tachycardia
      8. thrombocytopenia
      9. urticaria
      10. worsoneing symptoms of coronary heat disease
   3. Interactions
      1. beta blockers

         Nota:

         • increases activity
      2. anitriptyline

         Nota:

         • increased hypotensive ability
   4. Contraindications
      1. aortic stenosis
      2. hypotension
      3. left ventricular outflow obstruction
      4. heart failure
      5. myathenia gravis
      6. recent MI
      7. worsening angina
   5. Indications
      1. adjuct to oral anticogulations for prophylaxis of thomboembolism associated wtih oristgetuc geart vakces
4. ticlopidine
   1. MoA
      1. blocks the ADP receptor that is involved in thromboxane release and platelet agreggation
   2. Indications
      1. if aspirin is contraindicated
      2. failure of aspirin to prevent thrombotic stroke
      3. monitor WBC and platelets
   3. Contraindications
      1. thrombocytopenia
      2. neutropenia
      3. TTP (thrombotic thrombocytopenia purpura
      4. apalstic anaemia
   4. Side Effects
      1. Diarrhea
      2. stomach upset
      3. dizziness
      4. tinitus
      5. pruritus
   5. Interactions
      1. NSAIDs
      2. antacids
      3. phenytoin
      4. theophylline

1. primary and secondary prevention of stroke
2. reduces severity of stroke if taken within two days
3. longterm prevention following TIA

1. history of liver or kidney disease
2. GI disease or peptic ulcers
3. hypertension
4. bleeding disorders
5. Asthma