Drug Information

Drug Interaction:

EVIDENCE BASED MEDICINE (MIMS -March 2003)

2. STROKE PREVENTION

Comparative effectiveness of various interventions

PRIOR TO STROKE OR TRANSIENT ISCHAEMIC ACCIDENT (TIA)

Beneficial

1. Antiplatelet treatment

2. Cholestrerol reduction (for those patients who also have coronary heart disease)

3. Carotid endarterectomy (in patients with severe symptomatic carotid artery stenosis)

Unknown effectiveness

1. Cholesterol reduction (for patients without CHD)

2. Blood pressure reduction

3. Carotid endarterectomy (in patients with severe symptomatic carotid artery stenosis)

4. Catotid angioplasty

Likely to ineffective or even harmful

1. Oral anticoagulation

ATRIAL FIBRILLATION AND A PRIOR STROKE OR TIA

Beneficial

1. Oral anticoagulation

2. Aspirin for patients with contraindications to an anticoagulant

ATRIAL FIBRILLATION BUT NO OTHER MAJOR RISK FACTORS FOR STROKE

Likely to be beneficial

1. Oral anticoagulation

2. Aspirin for patients with contraindications to an anticoagulant

KEY POINTS

In patients with a prior stroke or TIA

1. Insufficient evidence to support routine blood presure reduction

2. Statins may prevent stroke in those with a history of CHD but evidence inconclusive in

those with no history of CHD.

3. Routine use of prolonged anti-platelet treatment beneficial ( if no contraindication)

4. Aspirin 75mg daily as effective as higher doses. No evidence that any other antiplatelet

regimen is definitely superior in the prevention of vascular events. Clopidogrel or

the combination of asprin and dipyridamole are safe and effective (but more costly)

alternatives to aspirin 5. No evidence of benefit from anti-coagulation in patients in

sinus rhythm, but an increased risk of serious bleeding

6. Carotid endarterectomy reduces risk of major stroke in patients with severe carotid

stenosis provided the risks of imaging and surgery are small.

7. Percutaneous transluminal angioplastys role has not been evaluated adequately

In patients with atrial fibrillation and aprior stroke or TIA

1. Anticoagulants reduce risk of stroke, provided there is low risk of bleeding and careful monitoring

2. Aspirin reduces risk of stroke but less effectively than anticoagulants. These findings support the use of aspirin among patients with atrial fibrillation and contra-indication to anticoagulants

In patients with atrial fibrillation but neither major risk factors for stroke

1. Anticoagulants are of net benefit, if low risk of bleeding and careful monitoring

2. Aspirin is a reasonable alternative in patients with contra-indications to anticoagulants.

Indication:

2.DISORDERS AND/OR ADVERSE REACTIONS- CARDIOVASCULAR SYSTEM

Refer Other information

Contents

1.Evidence Based Medicine i.Heart Failure ii. Stroke Prevention

2.Facts on Finger Tips i Rheumatic Fever ii.Congestive Heart Failure iii. Migraine

3.Disorders/and or/Adverse Reactions Items 1 to 18

EVIDENCE BASED MEDICINE- (MIMS- March 2003)

1. HEART FAILURE

Comparitive effectiveness of various interventions

Beneficial

1.ACE inhibitors such as captopril, enalapril,lisonopril,and perindopril

2.Digoxin

3.Appropriate use of beta-blockers

4.Spironolactone in severe cases

Likely to be beneficial

1.Multidisciplinary intereventions (nutrition, counselling)

2.Excercise

3.Angiotensin II receptor blockers

4.Amiiodarone

5.Implatable cardiac defibrillators

Unlikely to be beneficial

1.Calcium channel blockers

Likely to be ineffective or harmful

1.Positive inotropes(non-digitalis)

2.Non-amiodarone antiarrhythmic drugs

KEY POINTS

1. There is conflicting evidence of the efficacy of multidisciplinary approach

2. Pescribed excercise training improves functional capacity and quality of life and reduces the rate of adverses cardiac events

3. Ace inhibitors reduce mortality, admission to hospital for heart failue and ischaemic events in patients with heart failure but are still under-used.

4. One critical trial has found that angiotensin II receptor blockers are at least as effective

as ACE inhibitors for reducing clinical events(death or admission to hospitals).

They confer no advantage over ACE inhibitors but can be useful if ACE inhibitors are

not tolerated

5. Positve inotropic drugs improve symptoms but do not reduce mortality

6. Adding beta-blocker to ACE inhibitors decreases the rate of death and admission to hospitals

7. One clinical trial has found that in severe heart failure, adding an aldosterone receptor

antagonist to an ACE inhibitor reduces mortality compared with ACE inhibitors alone.

8. ACE inhibitors delay the onset of symptoms and reduce cardiovascular events in patients with asymtomatic left ventricular systolic dysfunction

Adverse Reaction:

Contra-Indications:

Facts on Finger Tips

1. RHEUMATIC FEVER

Salient Features- (MIMS)

Aetilogy-

1.Cardiac valvular damage resulting from cross reactivity

with Group A hemotologic streptococci

Epidemiology-

2.Peak incidence in childhood

3.Most common in developing countries like India

Clinical features-

1.Follows recent strptococci infection in the throat

2.Carditis is common amd may manifest as changing cardiac murmurs,

relative tachycardia or pericardial rub

3.Fitting ployarthritis

4.Chorea

5.Erythema mardinatum ( marginal erythema and central pallor)

6.Subcutaneous nodules

Investigations

1.Throat swabs

2. Blood tests: ASO titres, C-reactive protein

3.ECG, Echocardiogram, and X-Ray of joints

Managements

1.Penicilin antibiotics during illness

2.Analgesia for joint pain and haloperidol for chorea

3.Bed rest during illness

Key Points

1.Patients are at increased risk of endocarditis

2.Valvular disease is an important long term-complication

3.The oral contraceptives pill may precipitate telapse

Dosages/ Overdosage Etc:

2,.CONGESTIVE HEART FAILURE

Salient Features- (MIMS)

Definition

1. Pulmonary and peripheral congestion from insufficient cardiac output

Epidemiology

1.More common in older people

Risk Factors

1. Ischemic heart disease, hypertension, valvular heart disease and arrhythmias 2. High output states, such as pregnancy, anaemias, thytotoxicosis 3. Latrogenic -for examples, beta-blockers

Clinical features-

1. Shortness of breath 2. Paroxysmal nocturnal dyspepsia and orthopnoea 3. Signs suggesting left ventricular failure include tachycardia, dyspnoea, basal crackles and gallop rhythm 4.Signs suggesting right ventricular failure include raised jugular venous pressure, hepatomegaly and pitting oedema of the ankles

Investigations

1. Consider blood test- FBC, TFTs and U & Es 2. Chest X-ray may show signs of pulmonary oedema 3. Echocardiogram and ECG

Key Points

1. Echocardiography greatly improves diagnostic accuracy

Other Information:

2.DISORDERS/ AND OR ADVERSE REACTIONS- CARDIOVASCULAR SYSTEM- SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1.Dysarrhythmias- (1044)
2. Heart Failure ( 1035 )
3. Atrial fibrillation ( 1055 )
4. Atrial flutter ( 1054 )
5 .Hemolytic anemia - ( 270 )
6. Dyspnea ( 1038 )
7. Heart block ( 1059
8. Congenital heart disease ( 1075 )
9. Sick Sinus syndrome ( 1056 )
10. Ventricular Tachycardia ( 1074 )
11. Fluid retention or congestive heart failure- ( 1041 )
12. Exacerbation of Angina- ( 1118 )
13. Cardiomyopathy ( 1141 )
14. Pericarditis ( 1150 )
15. Hypotension ( also arrythmias ) (388 )
16. Hypertension ( 179 )
17. Thromboembolism ( 1182 )
18. Murmur (997)

1.Dysarrhythmias- (1044)

The term dysarrhythmias are not restricted to irregularities to the heartbeat but is applied also to disturbances of rate and of conduction. Certain dysarrhymias are especially likely to occur in the absence of detectable structural disease of the heart. These include sinus arrhythmias, sinus bradycardia and sinus tachycardia, atrial and ventricular premature beats, milder forms of first- degree atrioventricular AV block, paroxymal atrial tachycardia and on occassion atrial fibrillation or fluter.

Arrhythmias
Adverse reaction - Drugs
    1. Sympathomimetics
    2. Thyroid hormone
    3. Digitalis
    4. Quinidine
    5. Procainamide
    6. Verapramil
    7. Atropine
    8. Propranolol
    9. Guanethidine
    10. Emetine
    11. Propellants in aerosols
    12. Tricyclic antidepressants
    13. Phenothiazines, particularly thioridazine
    14. Lithium
    15. Anticholinesterases
    16. Papaverine
    17. Daunomycin
    18. Adriamycin
    19. Lincomycin ( intervenous )

2. Heart Failure ( 1035 )

Heart failure is charaterized by well known symptoms and physical signs.
Heart failure is considered to be pathophysiological state in which an abnormal cardiac function is responsible for the failure of the heart to pump blood at a rate communsurate with the requirement of the metabolizing tissues. Heart failure is frequently but not always caused by a defect in myocardial contraction, and then the term myocardial failure is appropiate,.

3. Atrial fibrillation ( 1055 )

This is a dysrhythmia in which the effective contraction of the atria is abolished and the AV node and the ventricles are bombarded with a very rapid and irregular series of stimuli. Many of these impulses are blocked at the AV node, but many are passed through, so that the ventricular contractions in the untreated patient are usually rapid and irregularly irregular.

4. Atrial flutter ( 1054 )

The dysrhythmia is less common than artial fibrillation. There is a considerable controversy
regarding its mechanism. A reciprocating rhythm or circus current movement is most likely. The atria contracts at a rate of 250 to 350 rates per minute. AV block is almost always present and its ratio is usually even numbered.

Digitalis slows the heart; normal sinus rhythm appear. Digitalis slows the ventricular rate, by
decreasing the degree of AV block, and commonly converts flutter to fibrillation. When the drug is withdrawn , the atrial flutter will frequently revert spontaneosuly to normal sinus rhythm. If this not occur quinidine may be employed to restore sinus rhythm.

5 .Hemolytic anemia - ( 270 )

Hemolytic anemias are encountered much less requently than the anemias due to decreased red cell production. Although they are a diverse group the hemolytic anemias have a number of clinical features common

6. Dyspnea ( 1038 )

Dyspnea or respiratory distress wich occurs as a result of increased effort in breathing, is the most common symptom of heart failure. It is at first observed only during activity , when it may simply represnt an aggrevation of breathlessness whic normally occurs under these circumstances. As heart failure advances however dyspnea appears with preggressively les strenous activity . Ultimately breathlessness is present when the patient is at rest.

7. Heart block ( 1059 )

The term heart block refers to a condition in which a wave of excitation from the atria is delayed pathologically ( or blocked ) at the junctional tisues ( AV node and His bundle ) . The PR interval represents thetime required for the impulse to traverse the atrium, AV node, His bundle,and the bundle braches

8. Congenital heart disease ( 1075 )

Congenital cardiovascular malformations are generally the result of aberrant embroynic development of a normal structure or a failure of such a structure to progress beyond an early stage of embroyonic development. Malformation s appear to result from a complex interaction between multifactorial genetic and environment systems, that does not allow a single specification of etiology, only rarely a causual factor is identifed

9. Sick Sinus syndrome ( 1056 )

The sick sinus syndrome or sinoartial dysfunction generally results from arteriolerotic , hypertensive,or rheumatic heart disease, although it may idiopathic . its manifestations include intermittant sinus arrest, sinus bradycardia, which persists despite excercise , atropine or isoprternol , synoartial block,AV junctional escape rhythm, and ectopic atrial complexes

10. Ventricular Tachycardia ( 1074 )

Ventriculatr tachcardia arises in patients with serious organic heart disease, usually it occurs in the wake of a myocatrdial infarction . The rapid heart action and aberrant activation of the myocardium seriously compromise cardiac function.

11. Fluid retention or congestive heart failure- ( 1041 )

Many of the clinical manifestations of heart failure are secondary to hypervolemia and expansion of the interstitial fliud volume when fluid retension due to heaet failure first becomes clinically enident, consideable expansion of extracellular space has already occured.and heart failure
is already advanced.

Adverse reaction - Drugs ( 388 )
    1. Estrogens
    2. Steroids
    3. Cabenoxaolone
    4. Phenylbutazone
    5. Indomethicin
    6. Propranol
    7. Mannitol
    8. Diazoxide

12. Exacerbation of Angina- ( 1118 )

Angina pectoris is a clinical syndrome resulting from transcient myocardial ischemia. The patient commonly declines to apply the word - pain- to his chest symptoms, may have difficulty describing the sensation and will usually select words such as heaviness, pressure smothering , tightness,choking, or squeezing. The typical discomfort is substernal in location, but other sites are also commonly involved.

Adverse Reaction- Drugs ( 388 )
   1. Vasopressin
   2. Oxytocin
   3. Ergotamine
   4. Methysergide
   5. Propranol withdrawal
   6. Excessive thyroxin
   7. Alpha blockers
   8. Hydralazine

13. Cardiomyopathy ( 1141 )

The term cardiomyopathy is used to indicate a disease entry in which the presenting signs and symptoms result in entirely or predomininantly from dysunction of the myocardium. However,myocardial lesions produced by ischemic herat disease , hypertensive cardiovascular disease , valvular heart disease and congenital heart disease are excluded

Adverse Reaction- Drugs ( 388 )
   1. Emetine
   2. Sympathomimetics
   3. Phenothiazines
   4. Lithium
   5. Sulfonamides
   6. Daunorubicin
   7. Adriamycin

14. Pericarditis ( 1150 )

Pain, a pericardial friction ryb, electrocardiographic changes, and pericardial effusion with
cardiac tamponade and paradoxic pulse are cardinal manifestations of many forms of pericarditis

Adverse Reaction- Drugs ( 388 )
   1. Procainamide
   2. Hydralazine
   3. Methysergide
   4. Emetine

15. Hypotension ( also arrythmias ) (388)

   Adverse reaction - Drugs
    1. Nitroglycerin
    2. Phenothiazine
    3. Morphine
    4. Diuretics
    5. Citrated blood
    6. Levodopa

16. Hypertension ( 179)

Patients with elevation of arterial pressure are usually systomatic and blood pressure abnormalilty oftern arouses attention only incidentally during military, life insurance, or other periodic physical examination.Because hypertension results in secondary organ damageand a reduced life span, it should be evaluated fully and when appropiate,treated

Adverse reaction - Drugs
   1. Oral contraceptives
   2. Sympathomimetics
   3. Clonidine withdrawal
   4. Monoamine oxidase inhibitors with sympathomimetics
   5. Tricyclic antidepressants with sympathomimetics
   6. Corticosteroids
   7. ACTH
   8. Phenybutazone

17. Thromboembolism ( 1182 )

Embolism - sudden interruption of the blood supply to all or a portion of an extremity results in a septrum of symptoms and signs which dependent upon on the location and extent of the occlusion and immediately available collateral circulation. The major causes of acute arterial occuclion are emboism, thrombosis, and injury

Adverse reaction - Drug ( 388 )
1. Oral contraceptives

18. Murmur (997)

Cardiac murmurs result from vibrations set up in the blood stream and the surrounding heart and great vessels as a result of turbulent blood flow, the formation of eddies, and cavitation ( bubble formation as a result of sudden decrease in pressure )

Patient Information:

Facts on Finger Tips

3. MIGRAINE

Salient Features- (MIMS)

Epidemology

1.Onset of migraine may be at any age, but symptoms most commonly

begin between the ages of 10 and 40.

2.Women are more commonly affected than men

3.About half of migraine sufferers have a positive family history

Pathogenesis

1.Incompletely inderstood, but dyregulation of cerebral flow appears to be

important

Triggers

1.Combined oral contraceptives

2.Insomina

3.Tiredness

4.Lack of food

5.Foods such as chocolate and cheese

Clinical features

1.Classically thereis an aura -usually -followed by throbbing, unilateral headache

2.Associated nausea, vomiting or both

3.Hypersensitivity to light, sound or smell

Investigations

1.Not normally needed

Management

1.Advice patients tom avoid trigger factors

2.Patients should rest in a quiet place during attack

3.Simple analgesics (preferably aspirin or paracetamol) and anti-emetics are often

effective

4.For resistant headaches, suggest a 5HT , agonist such as sumitriptan, natripan and

rizatriptan

5.Ergometrine is helpful in some patients, but its side effects limit its use

Key Points

1.Consider the possibility of underlying space-occupying lesion in patients with onset

of symptoms over the age of 40

2.Recommend prophylaxis for patients for patients who have frequent attacks. The

most commonly used drugs are betablockers and tricyclic antidepressants

3.When starting prophylaxis assess each drug by prescribing for at least two months

DISORDERS AND /OR ADVERSE REACTIONS - 2.CARDIO-VASCULAR SYSTEM - SUMMARY

Drug Interaction

Indication

Adverse Reaction

Contra-Indications

Dosages/ Overdosage Etc

Other Information

Patient Information

Drug Interaction:

Indication:

Adverse Reaction:

Contra-Indications:

Dosages/ Overdosage Etc:

Other Information:

Patient Information:

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