THROMBOEMBOLIC DISEASE

THROMBOSIS AND THROMBOEMBOLISATION

Thrombosis refers to the process in which a mass of clot forms inside an artery or vein. It consists of a dense network of fibrin in which are trapped variable portions of red cells and platelets.

Thrombosis blocks the vessel and impairs blood flow.

Arterial thrombosis leads to ischaemic tissue damage (myocardial infarction, stroke and peripheral vascular disease), whereas in venous thrombosis the consequences are due to back pressure and local swelling (oedema).

If the clot disintegrates, parts of it can break off, producing emboli that travel onwards: in venous thrombosis through the veins to the lungs (pulmonary embolus), and in arterial thrombosis through the arteries to major organs such as the brain (cerebral embolus), limbs (peripheral embolus), kidneys (renal infarction) and intestine (acute bowel ischaemia).

Superficial thrombophlebitis

Thrombophlebitis is a painful inflammation of the superficial veins. Classically it is seen with infected venous cannulae, but it also commonly occurs in patients with varicose veins.

The clinical picture is of palpable and very tender cords of thrombosed and inflamed veins, with the overlying skin appearing reddened or bruised.

Thrombophlebitis is not in itself dangerous, but may accompany deep vein thrombosis.

Management is removing the cause and treating the symptoms.

Deep vein thrombosis (DVT)

Deep vein thrombosis is a more serious problem, because of the risk of fatal pulmonary embolus. Most DVTs start in the deep veins of the calf, termed the distal veins, where they cause local pain and swelling. One in five extend up the leg to involve the proximal veins in the thigh and pelvis (popliteal and iliofemoral thrombosis). The risk of a pulmonary embolus from a proximal vein thrombosis is very high. A significant proportion of the survivors will develop a postphlebitic syndrome in the affected leg, with chronic swelling, varicose veins, skin pigmentation, recurrent thrombosis and venous ulceration.

The management is based on preventing progression of the thrombotic process by using heparin for an immediate effect, followed by warfarin in the medium to long term. The aim of treatment is to stabilise the situation, prevent extension, reduce the chances of embolisation and lower the risk of recurrence.

Critical nursing tasks in suspected DVT

-Give the first dose of heparin immediately.

-Ensure there is adequate pain relief.

-Be vigilant for acute ischaemia.

-Care of the pressure areas.

-Reassure the patient.

-Document all current regular and intermittent medication.

-Document the target INR (usually 2.5).

-Ensure a warfarin loading schedule is followed by the prescribing doctors.

*Other causes of a swollen painful leg: cellulitis or necrotising fasciitis.

Pulmonary thromboembolism

Most pulmonary emboli arise from the proximal veins in the thigh and pelvis. Depending on their size, emboli that travel to the lung either become wedged in the main pulmonary arteries, where they block the outflow of blood from the right side of the heart, or pass onwards to become trapped in the lung peripheries.

-The former, termed massive pulmonary emboli, produce a disastrous decrease in cardiac output, leading to sudden death or acute hypotensive collapse. Massive pulmonary emboli can move or start to break up either naturally or during the course of cardiopulmonary resuscitation. Thrombolytic drugs can help to dissolve the embolus and are used in the unstable hypotensive patient. Heparin will prevent further emboli, and as most patients who survive the first embolus die from a recurrence within the first few hours, it is important to start treatment urgently. Warfarin is added for long-term prevention.

-The smaller emboli in the periphery of the lungs produce wedge-shaped areas of lung damage and give rise to overlying pleurisy. The management of smaller peripheral emboli is based on preventing further and possibly bigger emboli by giving heparin and, subsequently, warfarin.

Classic features of a pulmonary embolus:

-Pleuritic chest pain

-Breathlessness

-Respiratory rate > 20 breaths/min

-Haemoptysis

Critical nursing tasks in acute pulmonary embolus:

-ABCDE: immediate resuscitation.

-Ensure adequate oxygenation.

-Provide an adequate circulation.

-Relieve the patient´s symptoms.

-Assess the response to treatment.

-Anticipate the need for urgent heparin therapy or thrombolysis.

-Prepare the patient for further procedures.

Source:

-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011

HEART DISEASE

The management of heart disease must be based on an understanding of the unserlying conditions, particularly ischaemic heart disease, cardiac failure and atrial fibrillation. There have been important advances in the diagnosis and management of these conditions that have altered our approach to patients:

1. Active management of myocardial infarction:

-the use of troponin-T and other markers for risk stratification.

-urgent re-perfusion by medical intervention and/or balloon angioplasty in acute myocardial infarction.

-aspirin prophylaxis.

-beta-blockers and intensive lipid-lowering therapy with statins to improve long-term outlook.

-referral of unstable patients for CABG (coronary  artery bypass grafting) or angioplasty.

2. New approaches to cardiac failure:

-the use of ACE-inhibitors.

-the use of low dose beta-blockers.

-new pacing and electrophysiological techniques.

-effective antiarrhythmic drugs: amiodarone and flecainide.

3. Recognition of the frequency and significance of atrial fibrillation:

-increased use of anticoagulation in atrial fibrillation.

HEART FAILURE

Critical nursing tasks in acute left heart failure:
-Ensure adequate oxygenation.
-Measure the blood pressure.
-Evaluate the pulse.
Important nursing tasks in acute left heart failure:
-Ensure compliance with continuous oxygen.
-Assess the response to diuretics.
-Look for symptomatic improvement.
-Demonstrate normalisation of the pulse and blood pressure.

Acute on chronic congestive cardiac failure: the main clinical features are bilateral ankle oedema, debilitating tiredness and breathlessness on exertion.

Important nursing tasks in congestive cardiac failure:

-Identify posible causes of cardiac failure (uncontrolled hypertension, ischaemic heart disease, alcohol-induced cardiac failure, chronic rheumatic valve disease)

-Establish the exact preadmission drug regimen.

-Recognise significant hypotension.

-Assess the lower limbs and pressure areas.

-Assess the fluid balance (Symptoms and signs of congestion, symptoms and signs of fluid depletion).

ISCHAEMIC HEART DISEASE

Chest pain: commonly used descriptions in angina include pressure, weight, chest tightness and constriction. Patients often also describe a feeling of breathlessness. Serious anginal episodes are accompanied by pallor, sweating and hypotension. Prolonged pain (lasting more than 15 min), especially if it is accompanied by nausea and vomiting, is more in-keeping with an infarction than with angina, although the distinction can be difficult.

Ischaemic heart disease occurs when the enlargement of cholesterol-rich plaques within the coronary artery walls lead to arterial narrowing, which is sufficient to starve the heart muscle of oxygen. Slow progressive narrowing results in stable angina. However if plaque becomes unstable and ruptures, there is a sudden combination of platelet clumping and thrombosis which clots off the coronary artery. The resulting clinical conditions are termed Acute Coronary Syndromes (ACS). There are three types of ACS dependant on the extent of the blockage and the degree of resulting heart muscle damage: STEMI, NSTEMI and unstable angina.  

Critical nursing tasks in the patient with chest pain:

-ABC triage.

-Monitor oxygen saturation.

-Obtain a 12-lead ECG.

-Take an overall look at the patient.

-Ask key questions (where id the pain? what makes it worse a what relieves it? has it occurred before?).

ATRIAL FIBRILLATION AND ARTERIAL EMBOLI
In atrial fibrillation, organised atrial activity is replaced by random electrical impulses which spread chaotically through the atrium. The atrium responds by muscular activity that can be described as a shivering motion (fibrillation), rather than a coordinated contraction. There are two important consequences:
-The atrial "squeeze", which expels the final 10% of blood into the ventricle at the end of diastole, is lost.
-The AV node is activated at random by the chaotic atrial electrical activity at rates of anything between 60 and 140 times per minute. An irregular rate of 140beats/min will not be tolerated by the heart for long.
Also, atrial fibrillation reduces cardiac output due to loss of atrial contraction, ventricular response too rapid and irregular ventricular rate.

Critical nursing tasks in atrial fibrillation:
-Assess the rate of fibrillation.
-Identify chest pain.
-Look for heart failure.
-Document hypotension.
Important nursing tasks in atrial fibrillation:
-Observe for emboli (brain, limbs, intestine).
-Look for non-cardiac triggers (pneumonia, COPD exacerbations and sepsis).
-Obtain an accurate drug history.

INFECTIVE ENDOCARDITIS
Infective endocarditis is a serious condition in which there is infection of the heart valves, usually the mitral or aortic valve. The affected valve may fail suddenly as it is destroyed by infection. Pieces of infected material can break off and spread via the blood to vital organs, resulting in:
-foci of sepsis, especially in the kidneys.
-septic cerebral emboli (stroke-like illness).

How infective endocarditis presents:
-Pyrexia of unknown origin.
-Catastrophic valve failure.
-Infected emboli.

Principles of management in the first 24h.
1. Ensure the safety of the patient.
2. Secure the diagnosis.
3. Initiate antibiotic therapy: prepare the patient for a "long haul" of antibiotic therapy (several weeks).
4. Observe for complications: allergies, left heart failure, monitor temperature and urine output and look for septic emboli.

Source:
-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011.

LIPID-REGULATING DRUGS AND LOCAL SCLEROSANTS

Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It is mainly made by the liver but can also be found in some foods.

Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your health. High cholesterol itself does not cause any symptoms, but it increases your risk of serious health conditions.

Cholesterol is carried in your blood by proteins, and when the two combine they are called lipoproteins. There are harmful and protective lipoproteins known as LDL and HDL, or 'bad' and 'good' cholesterol:

-Low-density lipoprotein (LDL): LDL carries cholesterol from your liver to the cells that need it. If there is too much cholesterol for the cells to use, it can build up in the artery walls, leading to disease of the arteries. For this reason, LDL cholesterol is known as "bad cholesterol".

-High-density lipoprotein (HDL): HDL carries cholesterol away from the cells and back to the liver, where it is either broken down or passed out of the body as a waste product. For this reason, it is referred to as "good cholesterol" and higher levels are better.

LIPID-REGULATING DRUGS

-Statins:

They are more effective than other lipid-regulating drugs at lowering LDL-cholesterol concentration but they are less effective than the fibrates in reducing triglyceride concentration. However, statins reduce cardiovascular disease events and total mortality irrespective of the initial cholesterol concentration.

-Atorvastatin (Lipitor).

-Fluvastatin (Lescol).
-Pravastatin sodium (Lipostat).
-Rosuvastatin (Crestor).
-Simvastatin (Zocor, Inegy).
-Bile acid sequestrants: used in the management of hypercholesterolaemia.
-Colesevelam hydrochloride (Cholestagel).
-Colestyramine (Questran).
-Colestipol hydrochloride (Colestid).
-Ezetimibe: inhibits the intestinal absorption of cholesterol (Ezetrol).

-Fibrates: act mainly by decreasing serum triglycerides, they have variable effects on LDL-cholesterol.

-Bezafibrate (Bezalip).

-Ciprofibrate (Modalim).

-Fenofibrate (Lipantil, Supralip).

-Gemfibrozil (Lopid).

-Nicotinic acid group:

-Acipimox: indicated for hyperlipidaemias of types IIb and IV (Olbetam).

-Nicotinic Acid: adjunt to statin in dyslipidaemia or used alone if statin not tolerated (Niaspan).

-Omega-3- fatty acid compounds:

-Omega-3-Acid Ethyl Esters: indicated for hypertriglyceridaemia (Omacor).

-Omega-3-Marine Triglycerides: adjunt in the reduction of plasma triglycerides in severe hypertriglyceridaemia (Maxepa).

LOCAL SCLEROSANTS

-Ethanolamine oleate: indicated for sclerotherapy of varicose veins.
-Sodium Tetradecyl Sulphate: indicated for sclerotherapy of varicose veins (Fibro-vein).

Source:
-http://www.nlm.nih.gov/medlineplus/cholesterol.html
-BNF 57 March 2009

MYOCARDIAL INFARCTION, FIBRINOLYSIS, ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS

MYOCARDIAL INFACTION

Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart is starved of oxygen and heart cells die.

The medical term for this is myocardial infarction.

Causes

A substance called plaque can build up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells.

A heart attack may occur when:

-A tear in the plaque occurs. This triggers blood platelets and other substances to form a blood a clot at the site that blocks blood from flowing to the heart. This is the most common cause of heart attack.

-A slow buildup of plaque may narrow one of the coronary arteries so that it is almost blocked.

The cause of heart attack is not always known.

Heart attack may occur:

-when you are resting or asleep

-after a sudden increase in physical activity

-when you are active outside in cold weather

-after sudden, severe emotional or physical stress, including an illness.

Symptoms

Chest pain is the most common symptom of a heart attack.

You may feel the pain in only one part of your body OR pain may move from your chest to your arms, shoulder, neck, teeth, jaw, belly area, or back.

The pain can be severe or mild. It can feel like:

-a tight band around the chest

-bad indigestion

-something heavy sitting on your chest

-squeezing or heavy pressure.

The pain most often lasts longer than 20 minutes. Rest and a medicine to relax the blood vessels (called nitroglycerin) may not completely relieve the pain of a heart attack. Symptoms may also go away and come back.

Other symptoms of a heart attack can include: anxiety, cough, fainting, light-headedness, dizziness, nause or vomiting, palpitations, shortness of breath ans sweating.

Some people (the elderly, people with diabetes, and women) may have little or no chest pain. Or, they may have unusual symptoms such as shortness of breath, fatigue, and weakness. A "silent heart attack" is a heart attack with no symptoms.

FIBRINOLYTIC DRUGS
Fibrinolytic drugs act as thrombolytics by activating plasminogento form plasmin, which degrades fibrin and so breaks up thrombi.
-Alteplase (Actilyse).
-Reteplase (Rapilysin).
-Streptokinase (Streptase).
-Tenecteplase (Metalyse).
-Urokinase.

ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS
-Etamsylate: blood loss in menorrhagia (Dicynene).
-Tranexamic acid: it can be used to prevent bleeding or to treat bleeding associated withexcessive fibrinolysis (Cyklokapron).

Blood products:
-Antithrombin III concentrate: indicated for congenital deficiency of antithrombin III.
-Dried prothrombin complex.
-Drotrecogin alfa (activated).
-Factor VIIa (recombinant).
-Factor VIII fraction, dried.
-Factor VIII inhibitor bypassing fraction.
-Factor IX fraction, dried.
-Factor XIII fraction, dried.
-Fresh frozen plasma.
-Protein C concentrate.

Source:
-http://www.nlm.nih.gov/medlineplus/ency/article/000195.htm
-BNF 57 March 2009

SYMPATHOMIMETICS, ANTICOAGULANTS, PROTAMINE AND ANTIPLATELET DRUGS.

SYMPATHOMIMETICS

They act increasing both heart rate and contractility, it can cause peripheral vasodilation or vasoconstriction.

1. Inotropic sympathomimetics: 

-Dobutamine (Indications: inotropic support in infarction, cardiac surgery, cardiomyopathies, septic shock and cardiogenic shock).

-Dopamine Hydrochloride (Indications: cardiogenic shock in infarction or cardiac surgery).

-Dopexamine Hydrochloride (Indications: inotropic support and vasodilator in exacerbations of chronic heart failure and in heart failure associated with cardiac surgery).

2. Vasoconstrictor sympathomimetics (raise blood pressure transiently):

-Ephedrine Hydrochloride.

-Metaraminol.

-Noradrenaline Acid Tartrate/ Norepinephrine Bitartrate.

-Phenylephrine Hydrochloride.

3. Cardiopulmonary resuscitation:

-Adrenaline/Epinephrine.

ANTICOAGULANTS AND PROTAMINE

Mainly used to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation, prevention and treatment of deep-vein thrombosis in the legs. They are used to prevent thrombi forming on prosthetic heart valves.

1. Parenteral anticoagulants:

-Heparin.

-Bemiparin Sodium (Zibor).

-Dalteparin Sodium (Fragmin).

-Enoxaparin Sodium (Clexane).

-Tinzaparin Sodium (Innohep).

-Danaparoid Sodium (Orgaran).

-Bivalirudin (Angiox).

-Lepirudin (Refludan).

-Epoprostenol (Flolan).

-Fondaparinux Sodium (Arixtra).

2. Oral anticoagulants:

-Warfarin Sodium.

-Acenocoumarol (Sinthrome).

-Phenindione.

-Dabigatran Etexilate (Pradaxa).

-Rivaroxaban (Xarelto).

3. Protamine sulphate (Prosulf).

ANTIPLATELET DRUGS

-Abciximab.

-Aspirin (Angettes 75, Caprin).

-Clopidogrel (Plavix).

-Dipyridamole (Persantin).

-Eptifibatide (Integrilín).

-Tirofiban (Aggrastal)

Sources:

-http://www.evidence.nhs.uk

-BNF 57 March 2009

ANGINA

ANGINA

Angina is chest pain or discomfort you feel when there is not enough blood flow to your heart muscle. Your heart muscle needs the oxygen that the blood carries. Angina may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw, or back.

Angina is a symptom of coronary artery disease(CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow.

There are three types of angina:

-Stable angina is the most common type. It happens when the heart is working harder than usual. Stable angina has a regular pattern. Rest and medicines usually help.

-Unstable angina is the most dangerous. It does not follow a pattern and can happen without physical exertion. It does not go away with rest or medicine. It is a sign that you could have a heart attack soon.

-Variant angina is rare. It happens when you are resting. Medicines can help.

Nitrates, calcium-channel blockers and other antianginal drugs.
1. Nitrates:
-Glyceryl Trinitrate (GTN, Coro-Nitro Pump Spray, Glytrin Spray, Nitromin, Suscard, Nitrocine, Nitronal, Deponit, Minitran, Percutol, Nitro-Dur, Transiderm-Nitro, Trintek).
-Isosorbide Dinitrate (Angitak, Cedocard Retard, Isoket Retard).
-Isosorbide Mononitrate (Elantan, Ismo, Chemydur, Imdur, Isodur, Isotard. Isib, Modisal, Monomax, Monomil, Monosorb, Zemon).
2. Calcium-channel blockers:
-Amlodipine (Istin, Exforge).
-Diltiazem Hydrochloride (Tildiem, Adizem, Angitil, Calcicard, Dilcardia, Dilzem, Slozem, Tildiem, Viazem, Zemtard).
-Felodipine (Plendil).
-Isradipine (Prescal).
-Lacidipine (Motens).
-Lercanidipine Hydrochloride (Zanidip).
-Nicardipine Hydrochloride (Cardene).
-Nifedipine (Adalat, Adipine, Coracten, Fortipine, Hypolar Retard, Nifedipress, Tensipine, Vaini).
-Nimodipine (Nimotop).
-Verapamil Hydrochloride (Cordilox, Securon, Univer, Verapress, Vertab).
3. Other antianginal drugs:
-Ivabradine (Procoralan).
-Nicorandil (Ikorel).
4. Peripheral vasodilators and related drugs:
-Cilostazol (Pletal).
-Inositol Nicotinate (Hexopal).
-Moxisylyte (Opilon).
-Naftidrofuryl Oxalate (Praxilene).
-Pentoxifylline (Trental).

Sources:
-http://www.nlm.nih.gov/bsd/pmresources.html
-BNF 57 March 2009

HYPERTENSION AND HEART FAILURE

Hypertension

Blood pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body. Hypertension is another term used to describe high blood pressure.

Blood pressure readings are given as two numbers. The top number is called the systolic blood pressure. The bottom number is called the diastolic blood pressure. For example, 120 over 80 (written as 120/80 mmHg).

One or both of these numbers can be too high.

-Normal blood pressure is when your blood pressure is lower than 120/80 mmHg most of the time.

-High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.

-If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.

If you have heart or kidney problems, or you had a stroke, your doctor may want your blood pressure to be even lower than that of people who do not have these conditions.

Causes

Many factors can affect blood pressure, including:

-The amount of water and salt you have in your body

T-he condition of your kidneys, nervous system, or blood vessels

-Your hormone levels

You are more likely to be told your blood pressure is too high as you get older. This is because your blood vessels become stiffer as you age. When that happens, your blood pressure goes up. High blood pressure increases your chance of having a stroke, heart attack, heart failure, kidney disease, or early death.

You have a higher risk of high blood pressure if:

-You are African American

-You are obese

-You are often stressed or anxious

-You drink too much alcohol (more than 1 drink per day for women and more than 2 drinks per day for men)

-You eat too much salt

-You have a family history of high blood pressure

-You have diabetes

-You smoke.

Most of the time, no cause of high blood pressure is found. This is called essential hypertension.

High blood pressure that is caused by another medical condition or medicine you are taking is called secondary hypertension. Secondary hypertension may be due to:

-Chronic kidney disease

-Disorders of the adrenal gland

-Hyperparathyroidism

-Pregnancy or preeclamsia 

-Medications such as birth control pills, diet pills, some cold medicines, and migraine medicines

-Narrowed artery that supplies blood to the kidney (renal artery stenosis).

Symptoms

Most of the time, there are no symptoms. For most patients, high blood pressure is found when they visit their doctors or have it checked elsewhere.

Because there are no symptoms, people can develop heart disease and kidney problems without knowing they have high blood pressure.

Malignant hypertension is a dangerous form of very high blood pressure. Symptoms include:

-Severe headache

-Nausea or vomiting

-Confusion

-Vision changes

-Nosebleed.

Heart failure

Heart failure is a complex syndrome characterised by reduced heart efficiency and resultant haemodynamic and neurohormal responses (Poole-Wilson 1985).

Heart failure is caused by a number of pathological conditions. Some causes are reversible, but others are not.

Causes of heart failure:

-Ischaemic heart disease.

-Hypertension.

-Arrythmias.

-Valve disorders.

-Myocarditis.

-Alcohol-induced cardiomyopathy (heart muscle abnormalities).

-Chemotherapy-induced cardiomyopathy.

-Genetic cardiomyopathies.

-Amyloidosis.

-Sarcoidosis.

-Metabolic disorders.

(*This is a shortened list).

Patients can have acute heart failure without underlying chronic heart failure but more commonly acute presentations are due to destabilisation of chronic disease.

Patients who are well managed can have a good quality of life and extend their prognosis, but heart failure is unpredictable and difficult to prognosticate for individual patients.

Diagnosis

Heart failure should be diagnosed using the pathway in the European Society of Cardiology (ESC) guidelines (McMurray et al 2012).

Once diagnosis is confirmed the severity of the symptoms can be expressed using the New York Heart Association (NYHA) classification.

DRUGS USED IN HYPERTENSION AND HEART FAILURE

Angiotensin-converting enzyme inhibitors:

1. Vasodilator antihypertensive drugs:

-Ambrisentan (Volibris).

-Bosentan (Tracleer).

-Diazoxide (Eudemine).

-Hydralazine Hydrochloride (Apresoline).

-Iloprost (Ventavis).

-Minoxidil (Loniten).

-Sildenafil (Revatio, Viagra).

-Sitaxentan sodium (Thelin).

-Sodium Nitroprusside.

2. Centrally acting antihypertensive drugs:

-Clonindine Hydrochloride (Catapres, Dixarit).

-Methyldopa (Aldomet).

-Moxonidine (Physiotens).

3. Adrenergic neurone blocking drugs:

-Guanethidine Monosulphate (Ismelin).

4. Alpha-adrenoceptor blocking drugs:

-Doxazosin (Cardura).

-Indoramin (Baratol, Doralese).

-Prazosin (Hypovase).

-Terazosin (Hytrin).

-Phenoxybenzamine Hydrochloride (Dibenyline).

-Phentolamine Mesilate (Rogitine).

5. Drugs affecting the renin-angiotensin system:
The main indications of ACE inhibitors are heart failure and hypertension among others.
-Captopril (Capoten).
-Cilazapril (Vascace).
-Enalapril Maleate (Innovace).
-Fosinopril Sodium (Staril).
-Imidapril Hydrochloride (Tanatril).
-Lisinopril (Carace, Zestril).
-Moexipril Hydrochloride (Perdix).
-Perindopril Erbumine.
-Quinapril.
-Ramipril.
-Trandolapril.

Angiotensin-II receptor antagonists
-Candesartan Cilexetil (Amias).
-Eprosartan (Teveten).
-Irbesartan (Aprovel).
-Losartan Potassium (Cozaar).
-Olmesartan Medoxomil (Olmetec).
-Telmisartan (Micardis).
-Valsartan (Diovan).

Renin inhibitors
-Aliskiren (Rasilez).


Sources:
-http://www.nlm.nih.gov/medlineplus/
-BNF 57 March 2009
-nop.rcnpublishing.com/ September 2014/ Volume 26/ Number 7.

ANTI-ARRHYTMIC DRUGS AND BETA-ADRENOCEPTOR BLOCKING DRUGS

ARRHYTHMIAS

An arrhythmia is a disorder of the heart rate (pulse) or heart rhythm. The heart can beat too fast (tachycardia), too slow (bradycardia), or irregularly.

Causes

Arrhythmias are caused by problems with the heart's electrical conduction system:

-Abnormal (extra) signals may occur.

-Electrical signals may be blocked or slowed.

-Electrical signals travel in new or different pathways through the heart.

Some common causes of abnormal heartbeats are:

-Abnormal levels of potassium or other substances in the body

-Heart attack, or a damaged heart muscle from a past heart attack

-Heart disease that is present at birth (congenital)

-Heart failure or an enlarged heart

-Overactive thyroid gland

Arrhythmias may also be caused by some substances or drugs, including: alcohol, caffeine, or stimulant drugs, heart or blood pressure medicines, cigarette smoking (nicotine), drugs that mimic the activity of your nervous system and medicines used for depression or psychosis.

Sometimes medicines used to treat one type of arrhythmia will cause another type of abnormal heart rhythm.

Some of the more common abnormal heart rhythms are:

-Tachycardia: supraventricular tachycardia (SVT) or ventricular tachycardia (ventricular fibrillation).

-Bradycardia: sinus node dysfunction or heart block.

Other classification:                                                                                                                           Arrhythmias originating in the Atria:

-Atrial fibrillation.

-Atrial flutter.

-Supraventricular tachycardias (PSVT).

-Wolff-Parkinson-White syndrome.

-Premature supraventricular contraction or premature atrial contraction (PAC).

-Sick sinus syndrome.

-Sinus arrhythmia.

-Sinus tachycardia.

-Multifocal atrial tachycardia.

 Arrhythmias originating in the Ventricles:

-Premature ventricular contraction (PVC)

-Ventricular Fibrillation

-Ventricular tachycardia.

Symptoms

An arrhythmia may be present all of the time or it may come and go. You may or may not feel symptoms when the arrhythmia is present. Or, you may only notice symptoms when you are more active.

Symptoms can be very mild, or they may be severe or even life-threatening.

Common symptoms that may occur when the arrhythmia is present include: chest pain, fainting, light-headedness, dizziness, paleness, shortness of breath or sweating.

Treatment

When an arrhythmia is serious, you may need urgent treatment to restore a normal rhythm. This may include:

-Electrical "shock" therapy (defibrillation or cardioversion)

-Implanting a short-term heart pacemaker

-Medicines given through a vein (intravenous) or by mouth.

Sometimes, better treatment for your angina or heart failure will lower your chance of having an arrhythmia.

Medicines called anti-arrhythmic drugs may be used:

-To prevent an arrhythmia from happening again

-To keep your heart rate from becoming too fast or too slow

Other treatments to prevent or treat abnormal heart rhythms include: cardiac ablation, implantable cardiac defibrillator or a pacemaker.

ANTI-ARRHYTMIC DRUGS

-Adenosine: rapid reversion to sinus rhythm of paroxysmal supraventricular tachycardias. (Adenocor).

-Amiodarone hydrochloride: treatment of arrhythmias particularly when other drugs are ineffective or contraindicated. (Cordarone).

-Disopyramide: for ventricular or supraventricular arrhythmias. (Rythmodan). 

-Flecainide acetate (Tambocor).

-Propafenone hydrochloride: for ventricular arrhythmias and paroxysmal supraventricular tachyarrhythmias. (Arythmol).

-Lidocaine hydrochloride: for ventricular arrhythmias. (Minijet Lignocaine).

BETA-ADRENOCEPTOR BLOCKING DRUGS

Indicated for hypertension, angina, myocardial infarction, arrhythmias, heart failure and thyrotoxicosis among others.

-Propanolol hydrochloride (Inderal).

-Acebutolol (Sectral).

-Atenolol (Tenormin, with diuretic: Co-tenidone, Kalten, Tenoret 50 and Tenoretic, with calcium-channel blocker: Beta-adalat and Tenif).

-Bisoprolol fumarate (Cardicor, Emcor).

-Carvedilol (Eucardic).

-Celiprolol hydrochloride (Celectol).

-Esmolol hydrochloride (Brevibloc).

-Labetalol hydrochloride (Trandate).

-Metoprolol tartrate (Betaloc, Lopresor).

-Nadolol (Corgard).

-Nebivolol (Nebilet).

-Oxprenolol hydrochloride (Trasicor, with diuretic: Trasidex).

-Pindolol (Visken, with diuretic: Viskaldix).

-Sotalol hydrochloride (Beta-cardone, Sotacor).

-Timolol maleate (Betim, with diuretic: Prestim).

Sources:
-http://www.nlm.nih.gov/medlineplus/
-http://umm.edu/programs/heart/services/conditions/arrhythmias/types
-BNF 57 March 2009

POSITIVE INOTROPIC DRUGS AND DIURETICS - OEDEMA

POSITIVE INOTROPIC DRUGS

Positive inotropic drugs increase the force of contraction of the myocardium.

1. Cardiac glycosides: Cardiac glycosides are most useful in the treatment of supraventricular tachycardias, especially for controlling ventricular response in persistent atrial fibrillation.

-Digoxin: indicated for heart failure and supraventricular arrhtythmias (Lanoxin).

-Digitoxin: same indications as digoxin.

-Digoxin-specific antibody: indicated for the treatment of known or strongly suspected digoxin or digitoxin overdosage. (Digibind).

2. Phosphodiesterase inhibitors:

-Enoximone: indicated for congestive heart failure where cardiac output reduced and filling pressures increased. (Perfan).

-Milrinone: for short-term treatment of severe congestive heart failure unresponsive to conventional maintenance therapy and acute heart failure, including low output states following heart surgery (Primacor).

OEDEMA

Oedema is the medical term for fluid retention in the body.

The build-up of fluid causes affected tissue to become swollen. The swelling can occur in one particular part of the body – for example, as the result of an injury – or it can be more general.

This is usually the case with oedema that occurs as a result of certain health conditions, such as heart failure or kidney failure.

As well as swelling or puffiness of the skin, oedema can also cause:

-skin discolouration

-areas of skin that temporarily hold the imprint of your finger when pressed (known as pitting oedema)

-aching, tender limbs

-stiff joints

-weight gain or weight loss

-raised blood pressure and pulse rate.

Types of oedema

Oedema can occur anywhere in the body, but it's most common in the feet and ankles. This is known asperipheral oedema.

Other types of oedema include:

-cerebral oedema – affecting the brain

-pulmonary oedema – affecting the lungs

-macular oedema – affecting the eyes.

Idiopathic oedema is a term used to describe cases of oedema where a cause can't be found.

Causes

It's normal to have some swelling in your legs at the end of the day, particularly if you've been sitting or standing for long periods, inmobility and standing for long periods are the most common causes of oedema in the legs.

Oedema is often a symptom of an underlying health condition. It can occur as a result of the following conditions or treatments:

-pregnancy

-kidney, chronic lung, thyroid or liver disease

-heart failure

-malnutrition

-medication, such as corticosteroids, medicine for hypertension or the contraceptive pill.

Other possible causes include: a blood clot, severe varicose veins, a leg injury or leg surgery, burns to the skin.

Treatment

Oedema usually clears up by itself. However, your GP may suggest some self-help measures to reduce fluid retention, such as:

-losing weight (if you're overweight)

-taking regular exercise.

-raising your legs three to four times a day to improve your circulation

-avoiding standing for long periods of time

If an underlying condition is causing the fluid imbalance, it should clear up after the condition has been diagnosed and treated.

DIURETICS

1. Thiazides and related diuretics:

-Bendroflumethiazide: indicated for oedema and hypertension.

-Chlortalidone: indicated for ascites due to cirrhosis in stable patients, oedema due to nephrotic syndrome, hypertension, mild to moderate chronic heart failure and diabetes insipidus. (Hygroton).

-Cyclopenthiazide: indicated for oedema, hypertension and heart failure. (Navidrex).

-Indapamide: indicated for essential hypertension. (Natrilix, Ethibide).

-Metolazone: for oedema and hypertension. (Metenix).

-Xipamide: for oedema and hypertension. (Diurexan).

2. Loop diuretics:

-Furosemide: indicated for oedema and resistant hypertension. (Lasix).

-Bumetanide: indicated for oedema. (Burinex).

-Torasemide: for oedema and hypertension.(Torem).

3. Potassium-sparing diuretics and aldosterone antagonists:

Potassium-sparing diuretics:

-Amiloride hydrochloride: indicated for oedema and potassium conservation when used as an adjunt to thiazide or loop diuretics for hypertension, congestive heart failure or hepatic cirrhosis with ascites.

-Triamterene: indicated for oedema and potassium conservation with thiazide and loop diuretics. (Ditac).

Aldosterone antagonists:

-Eplerenone: adjunt in stable patients with left ventricular dysfunction with evidence of heart failure, following myocardial infraction. (Inspra).

-Spironolactone: for oedema and ascites in cirrhosis of the liver, malignant ascites, nephrotic sydrome, congestive heart failure and primary hyperaldosteronism. (Aldactone).

4. Potassium-sparing diuretics with other diuretics: the use of this combinations may be justified if compliance is a problem.

-Amiloride with thiazides (Co-amilozide, Navispare).

-Amiloride with loop diuretics (Co-amilofruse, Burinex-A).

-Triamterene with thiazides (Co-triamterzide, Dyazide, Dytide, Kalspare).

-Triamterene with loop diuretics (Frusene).

-Spironolactone with thiazides (Co-flumactone).

-Spironolactone with loop diuretics (Lasilactone).

5. Osmotic diuretics: 

-Mannitol: indicated for cerebral oedema and raised intra-ocular pressure, glaucoma.

7. Diuretics with potassium: Centyl, Diumide-k Continus, Neo-NaClex-k).

Sources:

-http://www.nhs.uk/

-BNF 57 March 2009

THE CIRCULATORY SYSTEM, THE HEART AND THE BLOOD

THE HEART

Valves (válvulas): 

-atrioventricular: tricuspid (tricúspide) and mitral

-semilunar: pulmonary (pulmonar) and aortic(aórtica). Valves prevent the backflow of blood (las válvulas previenen el retroceso de la sangre).

Right and left atrium/s (derecha e izquierda aurícula/s): upper receiving chambers (cámaras superiores receptoras).

Right and left ventricle/s (derecho e izquierdo ventrículo/s): responsible for the pumping action (responsables de la acción de bombeo).

THE CARDIAC CYCLE (from 1 heartbeat to another)

VOCABULARY

-MI: myocardial infarction (heart attack). (infarto de miocardio, ataque cardíaco).

-GTN: glyceril trinitrate, called nitrolingual. (nitroglicerina

-Thrombus (trombo).

-Coagulation-clot (coagulación-coágulo)

-Heparin e.g. warfarin (heparina)

-DVT: deep vein trombosis. (trombosis venosa profunda).

BLOOD

Functions:

-Transport (gases, nutrients, waste products, hormones, heat).

-Protection (leukocytes, antibodies, platelet factors...).

-Regulation (pH, water balance...)

Composition:

-Plasma, which is a clear extracellular fluid. Mixture of proteins (albumins, globulins, fibrinogen), amino acids, enzymes, nutrients, waste, hormones, gases and electrolytes.

-Formed elements: blood cells and platelets.

BLOOD CELLS on Prezi

Blood test

Blood cultures son lo que se conocen como hemocultivos, muestras que precisan una técnica aséptica pero también sirve como ejemplo para otras extracciones más comunes.

These are some of the blood samples that a doctor can ask for:

FBC or FBP (full blood count or full blood picture, the most common blood control).

U+E (electrolytes).

LFT (liver function test).

TFT (thyroid function test).
CRP ( general marker for inflammation and infection).
INR (coagulation, especially in people on warfarin).

B12Folate.

Ageing changes in the blood.

1. Rise in fibrinogen.

2. Rise in blood viscosity.

3. Rise in plasma viscosity.

4. Increased red blood cell rigidity.

5. Increased formation of fibrin degradation products.

6. Earlier activation of the coagulation system.

Vocabulary

-Haematocrit ( is the volume percentage (%) of red blood cells in blood).

-Haemopoiesis (production of the formed elements of blood).

-Erythropoesis (production of erythrocytes).

-Leukopoiesis (production of leukocytes).

-Thrombopoiesis (production of platelets in the blood).