CVD treatments

1. bendroflumethiazide 2.5mg OM
2. inhibit Na reabsorption in the early diluting segment of the distal tubule
   1. inhibit the Na/Cl co-transporter
3. side effects: hypokalemia, hyponatremia, hypomagnesaemia, hypercalcemia, hyperuricaemia, hyperglycemia,hyperlipidaemia, impotence(reversible)

1. cardioselective: bisoprolol, atenolol; nonselective: propranolol
2. decrease HR and contractile force thus decrease CO
3. vasodilation
4. decrease Na and water retention
5. SE:bradycardia, tiredness, fatigue, lipids, broncospasm, cold hands and feet, lipid soluble-nightmares, masking hypoglycaemia symp in insulin dep DM

1. lisinopril 10mg od
2. inhibit the formation of A2 form A1
   1. A2 is a potent vasoconstrictor and promotes aldosterone release
3. SE: hyperkalaemia(check U&E), acure renal failure(U&E), first dose hypotension, dry cough, skin rash and angioedema, alter sense of taste

1. losartan
2. SE: same as ACE inhibitors minus cough and angioedema

1. dyhydropyridines: amlodipine&nifedipine
   1. vasodilation of coronary and peripheral arteries
2. phenylalkamines: verapamil
   1. slow AV nodal conduction
      1. reduces HR & CO
   2. causes constipation
3. benzothiazipine derivatives: diltiazem

1. doxazosin up to 16mg od
2. dilate blood vessels and reduce PVR

1. simvastatin max 80mg od
2. partially block HMG Co A reductase
3. inhibit biosynthesis in liver
4. metabolised by CYP3A4
5. rhabdomylosis
6. SE: skin reactions, headaches, GI, myalgia

Nota:

• CI in gallbladder disease

1. benzafibrate 400mg/day
2. bind to PPAR alpha on hepatocytes
   1. increases VLDL clearance
3. also decrease hepatic TG secretion
4. SE: gi, headache, skin reactions, fatigue
5. increace warfarin conc by binding to albumin

Nota:

• ionic exchange resins insoluble in water mix with water and take with meal take other meds 1hr before or 4-6hrs after the resin

1. cholestyramine 4-36g/day
2. not absorbed! bind to bile acid in intestine
   1. increase bile excretion
3. reduced absorption of fat sol vit & many drugs eg digoxin
4. SE: significant GI

1. ezetimibe 10mg od
2. inhibits absorption of endogenous and biliary cholesterol in the GI

   Nota:

   • this is done using transporter protein NPC1L1
3. SE: headache, abdo pain, diarrhoea

Nota:

• poor side effects profile

1. inhibits hepatic TG production and VLDL secretion

Nota:

• -symptoms usually precipitate by exercise, cold environment and relieved by rest -burning sensation over the sternum, often radiates to the left jaw, shoulder and arm -chest tightness & shortness of breath -30s to 30min

1. modification of disease
   1. Antiplatelets
   2. ACE inhibitors
   3. Statins
2. symptomatic therapy
   1. nitrates

      Nota:

      • -dilate veins more then arteries -they reduce cardiac workload (angina) -low oral bioavailability need nitrate free period - 8-12 hours
      1. orally: *isosorbide dinitrate 30-120mg daily in 2-3 doses *isosorbide mononitrate 20-120mg daily in 1-2 doses
      2. GTN - sublingual glyceryl trinitrate

         Nota:

         • every 5 mins, up to 3 doses in total, if chest pain persists
   2. beta blockers

      Nota:

      • reduce myocardial O2 demand and prevent symptoms
   3. calcium channel blockers

      Nota:

      • dyhydropyridines - vasodilation & improve coronary blood flow - prevent symptoms verapamil & diltiazem - decrease AV node conduction - reduce cardiac workload
   4. potassium channel blockers
      1. nicorandil

         Nota:

         • -ATP dependent K channel activation & nitrate like activity -arterial and venous vasodilation may be used as monotherapy or with beta blockers or calcium channel blockers
   5. ivabradine

      Nota:

      • HR lowering drug use if beta blockers CI
   6. ranolazine

      Nota:

      • adjunctive therapy in patients who are inadequately controlled or intolerant of beta-blockers or calcium channel blockers -reduces calcium overload in ischaemic myocytes through inhibition of the late sodium current
3. surgical procedures
   1. Percutaneous transluminal coronary angioplasty (PTCA)
   2. coronary artery bypass grafting (CABG)

Nota:

• -burning or chest discomfort even at rest, severe new onset angina or increasing angina that lasts >20 min -pain may radiate to jaw, shoulder and down left arm -may also present with nausea, vomiting, shortness of breath

1. immediate care

   Nota:

   • to remove pain, prevent deterioration, prevent complications and improve cardiac function
   1. ECG monitoring
   2. oxygen
   3. slow IV diamorphine

      Nota:

      • reduce pain and anxiety
   4. metoclopramide 10mg IV

      Nota:

      • antiemetic
   5. SL or IV nitrate

      Nota:

      • for ischaemic pain
   6. clopidogrel 300mg & aspirin 300mg

      Nota:

      • antiplatelet to limit further extension of thrombus
   7. restoring patency of the occluded artery
      1. percutaneous coronary intervension
      2. thrombolytic agent

         Nota:

         • lyse thrombus and restore blood flow + anticoagulant
2. secondary prophylaxis

   Nota:

   • prevent further infraction/death; modification of risk factors
   1. antiplatelets
      1. eg aspirin, clopidogrel, prasugrel, ticagrelor
      2. aspirin inhibits COX enzyme irreversibly by acetylation
         1. reduces thromboxane, prostaglandins, and prostaglandins synthesis
      3. clopidogrel inhibits platelet aggregation by irreversibly blocking ADP pathway
         1. SE: thrombotic thrombocytopenia purpura
      4. if patients can't tolerate antiplatelets give warfarin INR 2-3 for up to 4 years
   2. Beta-blockers
   3. race limiting calcium channel blockers
   4. ACE inhibitors
   5. Aldosterone antaginists - Eplerenone
   6. nitrates
   7. lipid lowering treatment
3. initial management - drug therapy
   1. glycoprotein IIb/IIIa
   2. antiplatelets
   3. anticoagulant
   4. thrombolytic drugs

      Nota:

      • to break up thrombus and restore blood flow

1. loop
2. thiazide
3. K sparing

Nota:

• ADR: haemorrage - most common Major bleeding is less common in LMWH thank UFH

1. UFH

   Nota:

   • mixtures of sulfated mucopolysaccharides of variable lengths
   1. MOA: prevents the growth and propagation of a formed thrombus

      Nota:

      • -binds to antithrombin: causes conformational change. activation of heparin-antithrombin complex accelerates certain activated clotting factors (9a.10a,11a,12a,thromnin(2a)) -also binds directly to thrombin
2. LMWH

   Nota:

   • more expensive then UFH show similar efficacy
   1. MOA: enhance and accelerate the activity of antithrombin on factor Xa. Prevents growth and propagation of formed thrombi.
   2. eg enoxaparin, deltaparin, tinzaparin

Nota:

• a mixture of low molecular weight sulfated glycosaminoglycans

1. MOA: promotes inhibition of factor Xa by antithrombin but it does not prolong the APTT
2. danaparoid

Nota:

• eg lepirudin

1. MOA: they bind to the active site on thrombin

1. MOA: bind to antithrombin and accelerates antithrombin activity factror Xa

1. warfarin
2. MOA: bind to the hepatic reductase enzyme that converts vit K to the active form. Inhibits hepatic synthesis of vit K dependent clotting factors

Nota:

• only indicated in life-thretening acute massive pulmonary embolus

1. MOA: activate plasminogen, thus promote the breakdown of fibrin to fibrinogen

Nota:

• Recurrent, self terminating episodes of AF. Episode <7 days (most resolve within 24h)

1. rhythm control
   1. rate control (if rhythm fails)

Nota:

• Sustained AF that terminates with cardioversion

1. rate or rhythm control
   1. try other if previous fails

Nota:

• AF that is long standing, cardioversion failed of not attempted

1. rate control
   1. rhythm control (if rate fails)