Drugs to be given if STEMI is diagnosed
In the absence of contraindications, all patients should be given
- aspirin
- P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. This approached is supported in SIGN’s 2016 guidelines. They also recommend that prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention
- unfractionated heparin is usually given for patients who’re are going to have a PCI. Alternatives include low-molecular weight heparin
Choice of thrombolytics in STEMI
- tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase
- tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile
Examples of tissue plasminogen activators
alteplase, reteplase, and tenecteplase
What should be done following administration thrombolysis in STEMI
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
- if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
- for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation
Glycaemic control in ACS
- in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
- it recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
- intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as ‘DIGAMI’) regimes are not recommended routinely
A 72-year-old man with a history of chronic heart failure secondary to ischaemic cardiomyopathy is reviewed. He was discharged two weeks ago from hospital following a myocardial infarction. An echocardiogram done during his admission showed a left ventricular ejection fraction of 40% but did not demonstrate any valvular problems.
Despite his current treatment with furosemide, ramipril, carvedilol, aspirin and simvastatin he remains short of breath on minimal exertion such as walking 30 metres. On examination his chest is clear and there is minimal peripheral oedema. What is the most appropriate next step in management?
Stop aspirin
Refer for cardiac resynchronisation therapy
Switch carvedilol to bisoprolol
Add angiotensin-2 receptor blocker
Add an aldosterone antagonist
Add an aldosterone antagonist
Mrs Layton, a 29-year-old lady presents to the emergency department one evening with hypoxia, tachypnoea and tachycardia (110bpm). She reports a sudden onset of breathlessness starting this afternoon and reports coughing up small amounts of blood. She is on the combined oral contraceptive pill (COCP), and has flown back to the UK from Australia 4 days ago. She tells you that she has an allergy to contrast medium.
On examination, she is tachypnoeic and has left sided crackles on auscultation of her chest.
Her chest x-ray shows nothing focal or acute.
You are concerned that she might have a pulmonary embolus (PE) but radiology inform you that they will not perform a V/Q scan out of hours and would need to wait until tomorrow morning for this.
Which of the following would be most appropriate next step?
- Start the patient on treatment dose apixaban whilst awaiting a V/Q scan the next day
- Perform a CT chest without contrast
- Perform a CT pulmonary angiogram and give the patient fluids before and after the scan
- Perform a CT pulmonary angiogram whilst infusing hydrocortisone and chlorphenamine
- Start the patient on prophylactic dose low-molecular weight heparin whilst awaiting a V/Q scan the next day
Start the patient on treatment dose apixaban whilst awaiting a V/Q scan the next day
A 54-year-old man presents with fatigue. On examination, there is a soft diastolic murmur, heard loudest in the second intercostal space on the right. He has a blood pressure of 162/65 mmHg.
What is the most likely cause of the murmur? What would each of these sound like
Aortic regurgitation
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Pulmonary regurgitation
Aortic regurgitation - wide pulse pressure
Aortic stenosis would present with a systolic murmur with narrow pulse pressure
Mitral regurgitation would present with a systolic murmur loudest over the mitral valve.
Mitral stenosis would present with a diastolic murmur but it would be loudest over the mitral valve and would not have the characteristic wide pulse pressure.
Pulmonary regurgitation would present with a diastolic murmur but it would be the loudest over the 2nd intercostal space on the left and would not have the wide pulse pressure.
Areas of auscultation
Ao(R)tic: to the right
Pu(L)monary: to the left
T(R)icuspid: to the right (of left chest)
Mitra(L): to the left (of left chest region)
A 71-year-old man presents to the emergency department with an abnormal cardiac rhythm. After various unsuccessful attempts of restoring normal cardiac rhythm, the team decides to administer him a drug. After the administration, he complains of severe chest pain, which is self-limiting and terminates quickly.
What drug has this patient been given?
Adenosine
Amiodarone
Atropine
Flecainide
Glyceryl trinitrate
Adenosine
Mechanism of action of adenosine
- causes transient heart block in the AV node
- agonist of the A1 receptor in the atrioventricular node, which inhibits adenylyl cyclase thus reducing cAMP and causing hyperpolarization by increasing outward potassium flux
Half life of adenosine
- adenosine has a very short half-life of about 8-10 seconds
How should adenosine be administered?
ideally be infused via a large-calibre cannula due to it’s short half-life, followed by a flush and raising arm
Side effects of adenosine
- Transient flushing or feeling warm
- Chest pain (which can be intense)
- Bronchospasm
- can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
- arryhtmias
- Dry mouth
- Dyspnea
- Feeling of impending doom/ death
Drugs that can enhance o block effects of adenosine
The effects of adenosine are enhanced by dipyridamole (antiplatelet agent) and blocked by theophyllines
Antimuscarinics side effects
Common or very common
Constipation; dizziness;blurred vision, urinary retention, drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; vomiting
Rare or very rare
Angioedema; confusion (more common in elderly)
Side effects of atropine
visual sensitivity to light, blurred vision, dry eyes, hyperthermia, movement disorders, speech disorders, abdominal distension, taste loss, dysphagia, dry mouth, constipation, and decreased sweating
A 72-year-old woman with a 30 year history of type 2 diabetes mellitus comes for review. She was diagnosed with chronic kidney disease (secondary to diabetes) 8 years ago and has seen declining renal function since. Her current medication includes ramipril 10mg od, amlodipine 10mg od, simvastatin 40mg on and Novomix 30 insulin bd.
Her most recent renal function tests show the following:
Na+ 139 mmol/l
K+ 5.3 mmol/l
Urea 10.2 mmol/l
Creatinine 123 µmol/l
eGFR 40 ml/min/1.73m²
Blood pressure in clinic is 156/88 mmHg and this is confirmed on a second reading. What should be done regarding her blood pressure medication?
Add bisoprolol
Add indapamide
Add doxazosin
Add spironolactone
Add an angiotensin II receptor blocker
Add indapamide
A 35-year-old man is on the acute medical unit with a new diagnosis of hypertrophic obstructive cardiomyopathy. He is on cardiac monitoring, and the emergency buzzer is pulled after he is noted to become very tachycardic. An ECG shows a regular, broad complex tachycardia. The patient has a GCS of 15, blood pressure is 123/81mmHg and he reports feeling well.
What is the most appropriate management?
Defibrillation
IV adenosine
IV amiodarone
IV atropine
Synchronised cardioversion
IV amiodarone
A 63-year-old man attends GP for a hypertension review. His home readings show that his average blood pressure is currently 164/98mmHg. He feels generally well in himself, clinical examination is normal and previous investigations have shown no obvious underlying cause for his hypertension.
Recent blood tests are as follows;
Na+ 142 mmol/L (135 - 145)
K+ 4.9 mmol/L (3.5 - 5.0)
Bicarbonate 26 mmol/L (22 - 29)
Urea 6.8 mmol/L (2.0 - 7.0)
Creatinine 88 µmol/L (55 - 120)
He is currently taking ramipril, amlodipine and bendroflumethiazide.
Which would be the most appropriate medication to add for management of this patient’s hypertension?
Alpha-blocker or beta-blocker
Furosemide
Hydralazine
Indapamide
Spironolactone
Alpha-blocker or beta-blocker
A 52-year-old Caucasian man presents to his GP for a health review. He works as an accountant and reports being in good health over the last few months with no illnesses. His past medical history includes hypertension for which he is taking ramipril 10mg daily. There is no history of allergies.
His ambulatory blood pressure readings showed serial measurements of 156/90mmHg, 161/92mmHg and 158/91mmHg.
What is the next most appropriate step in the management of this patient?
Doxazosin
Increase ramipril dose
Indapamide
Losartan
Spironolactone
Indapamide
You are doing a medication review on a 79-year-old man. His current medications include aspirin, verapamil, allopurinol and co-codamol. Which one of the following is it most important to avoid prescribing concurrently?
Colchicine
Digoxin
Simvastatin
Tramadol
Atenolol
Atenolol
Side effects of beta blockers
- bronchospasm
- cold peripheries
- fatigue
- sleep disturbances, including
- nightmares
- erectile dysfunction
Contraindications to beta blockers
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
