Chapter 2: Cardiovascular system

Anticoagulants

Check for expired indications (e.g. temporary loss of mobility that has now resolved)

Much more effective for stroke prevention in AF than antiplatelets

CAUTION: Bleeding events. Avoid combinations of anticoagulants, antiplatelets, NSAIDs.

Ensure patient adherence to dosing/monitoring regimen

  • If patient is unfit for warfarin for cognitive reasons (NOACs may not be indicated either)
Antiplatelets

NOTE: Antiplatelets are no longer indicated for primary prevention of CHD.

Aspirin plus clopidogrel indicated for a maximum of 12 months after ACS only.

CAUTION: Bleeding events. Avoid combinations of anticoagulants, antiplatelets, NSAIDs.

  • Consider PPI in those with additional GI risk factors (consider lansoprazole or pantoprazole in preference to (es)omeprazole in patients taking clopidogrel)

Consider anti-platelets as part of secondary prevention strategy after CVD events.
First line anti-platelet for secondary stroke prevention is clopidogrel (rather than dipyridamole)

Diuretics

Usually essential for symptom control in heart failure

Note: Not indicated for dependent ankle oedema (consider medication causes, e.g. CCBs

CAUTION: AKI and electrolyte disturbances.

Advise patient to stop during intercurrent illness (See Sick Day Rule Cards); is U&E monitoring robust?

Spironolactone

CAUTION: Hyperkalaemia. Risk factors include: CKD (CI if eGFR<30ml/min), dose >25mg/d, co-treatment with ACEI/ARBs, amiloride, triamterene, potassium supplements.

Digoxin

CAUTION: Toxicity! Risk factors are: CKD, dose>125micrograms daily, poor adherence, hypokalaemia, drug-drug interactions.

Peripheral vasodilators

Rarely effective; rarely indicated long term

Quinine

Use short term only when nocturnal leg cramps cause regular disruption of sleep.

Review effectiveness regularly.

CAUTION: Thrombocytopenia, blindness, deafness.

Antianginals

Consider reducing antianginal treatment if mobility has decreased

CAUTION: Hypotension (consider use of other BP lowering drugs; avoid the combination of nitrates with PDE-5 inhibitors)

Antiarrhythmic - Amiodarone

In AF: Rate control usually has better benefit/risk balance than rhythm control.

CAUTION: Overdosing. Maintenance should be max 200mg/day
CAUTION: Thyroid complications. Ensure monitoring tests are being done
Monitor LFTs

Statins

Recommended for primary and secondary prevention in patients at high risk of CVD

CAUTION: Rhabdomyolysis: Check interactions (e.g. fibrates, dihydropyridines, antiinfectives).

Consider need for and intensity of treatment in light of life expectancy and ADR risk

BP lowering drugs

Limited evidence supporting tight BP control in the older frail group.

Individualise BP targets for primary and secondary prevention of CVD guidelines.

Consider need for and intensity of treatment in light of CVD risk life expectancy and ADR risk

Beta-blockers

Usually essential for rate and angina control in CHD and CHF (and often in AF).

BNF recommends up-titration of beta-blocker doses in CHF to evidence based target doses.

CAUTION: Bradycardia in combination with diltiazem/verapamil, digoxin and amiodarone.

ACEI/ARBs

Usually essential for symptom control in CHF. For other potential benefits: see NNT Table

BNF recommends up-titration of ACEI/ARB doses in CHF to evidence based doses.

CAUTION: Acute Kidney Injury. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration (See Sick Day Rule Cards).

CCBs

CAUTION: Constipation, ankle oedema

Dihydropyridines – CAUTION: Reflex tachycardia/cardiodepression: Avoid nifedipine in CHD/CHF

Diltiazem/verapamil – CAUTION: Bradycardia in comb. with beta-blockers or digoxin (digoxin levels increased)

Spironolactone

Recommended in moderate to severe CHF: See NNT section

CAUTION: Hyperkalaemia. Risk factors: CKD, combination with ACEI/ARB, triamterene, amiloride
CAUTION: AKI. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration