What is the CHA2DS2-VAS score?
- a risk of stroke in those with non-rheumatic AF:
- Congestive HF = 1
- Hypertension = 1
- Age >75 = 2
- DM = 1
- Stroke = 2
- Vascular disease (MI, PAD, aortic plaque) = 1
- Age 65-74 = 1
- Sex category = 1
- Warfarin or NOAC if CHADVASc score >2
- If zero use aspirin alone or no antithrombotic therapy If it’s 1 oral anticoagulant (not aspirin)
What are some HTN treatments? What are the classes and their side effects?
- ACE I (conversion of ang 1- ang 2)
- cough common
- renal impairment
- angioedema
- low sodium
- ARB
- not with ACE I as increases hypotensive symptoms without BP effect)
- CCB (verapamil - central action non-dihydropyridines)
- contraindicated in beta-blockers (already ionotropic) - heart block
- can’t use in HF - oedema,
- flushing
- can cause constipation
- palpitations, bradycardia
- Beta-blockers
- useful in heart failure and AF
- can’t use in asthma
- bradycardia
- weight gain and insulin resistance
- Thiazide diuretics
- in fluid retention
- increased risk of new onset diabetes
- kidney trouble (care in gout)
- Most effective - ACEI + Ca2+ channel blocker (best profile) Likely side effects/concerns? Cough, peripheral oedema and bradycardia
- If she had heart failure - use ACEI + thiazide
- If she has MI/HF - use ACEI + Beta blocker
- If she has angina - use Beta blocker + Ca2+ channel blocker
- In Diabetics - avoid thiazides and Beta blockers - (affect glucose metabolism)
What are the treatments for Heart Failure?
Non-pharm:
- limit alcohol
- monitor weight
- educate patient
- MDC meetings - dietician, rehab, palliative care
Proven medications:
- normalise volume - ACE I early and ARB if they can’t take i
- Beta-blockers (chronic not acute)
- digoxins and nitrates
- new - sacubitril/valsartan - ARB and neprilysin inhbitor (inhibits bradykinin)
a 35 year old women is referred with hypertension. She is thin and has a blood pressure of 168/100mmHg and her potassium is 3.0mmol/L. What is the diagnosis?
Conn’s syndrome
- young
- HTN
- low potassium
- primary hyperaldosteronism
A 48 year old man is seen is hospital with malaise. HTN and previously started on ACE I by GP. Now his serum urea is 30.0 and creatinine 250. Whats the diagnosis?
Renal Artery Stenosis
- often precipitates declining renal function by ACEI
Talk through the screening for CVD for different populations
- absolute cardiac risk assessment every 2 years from 45 in normal or 35 for indigenous
- BP every 2 years or 6-12months if higher risk 18 onwards.
- cholestrol every 5 years or every 2 years for increased risk. (45 or 35 if indigenous)
- diabetes every 3 years or every 12mths if IGT (18 for indigenous, 40 onwards for normal).
Warfarin Counselling, what would you the tell and advise the patient?
- large doses of vitamin K will reverse the effects of warfarin
- initially affecting Protein C and S (shorter half life) might have a progulation (5-7 day process) - especially if you have a congenital deficiency of these. Anticoagulation in initial phase.
- daily INR in the initial phase but once stabilised can measure 1x a month
- CI - liver inability to synthesize clotting proteins, thrombocytopenia, oesophageal varices
- CYP2C9 drug interference i.e. metronidazole
- antibiotics affect the normal flora and therefore the normal vit K production
- they are on it for:
- prosthetic valves
- AF
- DVT prophylaxis
- teratogenic (avoid in pregnancy)
- history of falls is a strong Relative CI
What are the GP targets for cholestrol? Whats a good way to remember them?
Lipid Lowering therapy should be aiming for:
- total cholestrol <4mmol/L
- LDL cholestrol <2mmol/L
- TG <2mmol/L
- HDL >1mmol/L
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