Peripheral Vascular Disease

Peripheral Vascular Disease

1. Primary prevention = diet and lifestyle, excercise, antihypertensives, cholesterol lowering drugs - not antiplatlets

2. Antiplatelet treatment for primary prevention of CVD

   • Patients with hypertension and reduced eGFR
     • only group aspirin treatment is allowed for primary prevention because in this case the risk of bleeding outweighs the benefit of CD risk reduction
     • Hypertension must be controlled at less than 150/90mmHg
     • Aspirin
     • NOT FOR DIABETICS

3. Antiplatelets fo 2ndry prevention

   • Aspirin + antiplatelets for up to 12 months post MI
   • Inditcations
     • Angina
     • previous MI
     • previous stroke or TIA
     • Peripheral Arterial Disease
     • AF
   • Clopidogrel monotherapy if aspirin contraindicated

4. Anticoagulants

   • MEchanism of Action
     • Inhibit clotting factors produced in the liver with the help of Vitamin K
   • Warfarin
     • competetive vitamin K inhibitor
     • Monitoring
       • Regular blood tests
       • INR
         • daily or alternate days at the beginning of treatment, then longer intervals depending on response, then up to every 12 weeks
       • anticoagulant treatment alert card
     • indications
       • rheumatic heart disease
       • AF
       • Prosthetic valve
       • DVT
       • PE
       • TIA
     • Interactions
       • direct-acting antivirals in treatment of Hep C
         • changes in liver function may affect efficacy of vit K antagonists
       • Vit K foods and supplements
       • Pomegranate
       • major changes in diet or alcohol consuptions may require redosing
     • Side Effects
       • calciphylaxis
         • small blood clots, painful skin ulcers and potentially serious infections which can lead to death, as a result of calcium accumulations in small blood vessels of the fat and skin tissues
       • Alopecia
       • diarrhoea
       • hepatic dysfunction
       • jaundice
       • pancreatitis
       • purpura
       • N&V
       • skin ncecrosis
         • increased risk with protein C or S deficiency
       • Purple toes
       • fatigue
     • Contraindications
       • Bacterial endocarditis
       • hyperthyroidism
       • peptic ulcer
       • post-partum (at least 1 week)
       • uncontrolled hypertension
       • recent surgery
       • recent ischaemic stroke
       • Conception & Pregnancy - Teratogenic!
       • hepatic impairment
       • renal impairment- caution
       • breastfeeding- caution due to vit K deficieny
   • Heparin
     • compete with vitamin K
     • Side Effects
       • Rare
       • rebound hyperlipidaemia ( following unfractionated heparin withdrawal)
       • skin necrosis
       • urticaria
       • injection site reactions
       • osteoporosis- lower risk in LMWH
       • hyperkalaemia
         • LMWH can inhibit aldosteron secretion. Those with DM, chronic renal failure, acidosis, raised plasma potassium or taking postassium-sparing diuretics are more susceptible
       • alopecia (prolonged use
       • angiodema
       • priapism
       • Heamorrhage
         • protamine sulfate atidote for rapid reversal
       • Heparin- induced thrombocytopenia
         • immune mediated reaction that does not usually develop until after 5-10 days. Signs: 30% reduction of platelet count, thrombosis or skin allergy Alternative anticoagulant like danaparoid should be given 
     • Indications
       • mild to moderate PE
       • unstable angina
       • acute peripheral arterial occlusion
       • DVT
       • VTE prophylaxis as inpatients
       • VTE in pregnancy
       • Haemodialysis
       • prevention of clotting in extracorporeal circuits
         • injected direct to the device as a flush
       • maintain patency of catheters, cannulas and other iv infusion decvise
         • injected direct to device as a flush
     • interactions
       • antihistamines
       • Aspirin
       • NSAIDs
       • Vit K foods and supplements
       • Digoxin
       • Quinine
       • Tetracyclin antibiotics e.g doxycycline
     • contraindications
       • Acute bacterial endocarditis
       • major trauma
       • epidural
       • haemophilia and other haemorrhagic disorders
       • peptic ulcer
       • recent cerebral haemorrhage
       • recent eye surgery
       • recent nervous surgery
       • severe hypertension
       • thrombocytopenia
     • Monitoring
       • Measure platelet count before treatment
       • regulare platelet counts may be required if given for longer than 4 days to pick up heparin-induced thrombocytopenia
       • plasma potassium conc should be measured in patients at risk of hyperrkalaemia before treatment and monitored regularly thereafter
   • Indications
     • high risk stroke
     • AF
     • Valve replacement
   • Side Effects
     • bruising
     • Skin rash
     • cerebral heamorrhages
     • GI bleeds
   • Fondaparinux
     • MoA
       • Factor X inhibitor
     • Indications
       • VTE prophylaxis after major orthopaedic surger or abdo surgery
       • VTE prophylaxis in immobilised patients
       • superficial-vein thrombosis
       • unstable angina and nonn-ST MI
       • STEMI
       • DVT and PE
     • Side Effects
       • anaemia
       • bleeding
       • purpura
       • chest pain
       • confusion
       • dizziness/ drwosiness
       • flushing
       • headache
       • hyperbilirubinaemia
       • hypokalaemia
       • injection site reactions
       • vertigo
     • Contraindications
       • Active bleeding
       • bacterial endocarditis
     • interactions
       • thrombolytic drugs e.g alteplase
       • anticoaggulants
       • antiplatelets
   • Apixaban
     • MoA
       • Factor Xa inhibitor
     • side effects
       • Anaemia
       • Bruising
       • Haemorrhage
       • nausea
       • hypotension
       • rash
       • thrombocytopenia
     • indications
       • joint replacement prophylaxis
       • treatment and propylaxis of recurrent DVT and PE
       • Prophylaxis of stroke and systemic embolis in non-valvular AF and at least one risk factor
     • containdications
       • Risk factors for major bleeding afformentioned
       • prosthetic heart valve
       • anaesthesia with postoperative indwelling epidural catheter
       • Pregnancy and breastfeeding
     • interactions
       • Antiplatelets
       • heparin
   • Dabigatran
     • Side Effects
       • hepatobiliary disorders
       • abdominal pain
       • anaemia
       • diarrhoea
       • dyspepsia
       • haemorrhage
       • nausea
       • oesophagitis
       • GI ulcer
     • Indications
       • VTE prophylaxis following knee or hip replacement
       • DVT treatment and 2ndry prevention
       • PE treatment and 2ndry prevention
       • DVT or PE tratment and prophylaxis when Warfarin is contraindicated i.e renal and hepatic impoirment and increased risk of bleeding
       • concomitant treatment with verapamil
       • stroke and systemic embolism prophylaxis in non-valvular AF with ome or more risk factors e.g previous stroke, symptomatic HT...
     • Contraindications
       • active bleeding
       • prosthetic heart valve
       • malignant neoplasms
       • oesophageal varices
       • recent breain surgery or intravcranial bleed
       • recent GI ulcer
       • recent opthalmic surgery
       • recent spinal surgery
       • vascular aneurysm
       • anaesthesia with postoperative indwelling epidural catherter
         • risk of paralysis
       • Caution
         • <50Kg
         • elderly
         • GORD or gastritis
         • bacterial endocarditis
         • recent trauma
         • thrombocytopenia
         • bleeding disorders
       • pregnancy, breast feeding
       • severe liver disease
     • Monitoring
       • in renal impairment moniter renal function > annually
     • Interactions
       • Aspirin
       • NSAIDS
       • antiplatelets
       • anticoagulants
     • MoA
       • Direct thrombin hihibitor

5. Antiplatelets

   • Mechanism of Action
     • Inhhibit the productions of thromboxane which recruits platelets
   • Drugs
     • Asspirin
       • side effects
         • bronchospasm
         • confusion
         • heamorrhages
           • GI
           • Subconjuctival
         • skin reactions in hypersensitivity
         • tinnitus
         • Salicylate poisoning
           • hyperventilation
           • tinnitus
           • deafness
           • vasodilation
           • sweating
           • coma in sever poisoning
       • contraindications
         • <16yrs old
           • causes Reye's Syndrome
           • Excepted idicated e.g for Kawasaki Disease
         • severe HF
         • peptic ulcers
         • haemophilia
         • caution in
           • allergic disease
           • anaemia
           • elderly
           • dehydration
           • G6DP deficiency
           • thyrotoxicosis
           • uncontrolled hypertension
         • Breastfeeding
         • hepatic impairment
       • interactions
         • Live flu vaccine
         • methotrexate
         • varicella virus live vacine
         • corticosteroids
       • MoA
         • Cox inhibitor. Cyclooxygenase required for prostaglandin and thromboxane synthesis
     • Clpidogrel
       • MoA
         • Inhibits P2Y2 ADP receptor, inhibiting platelet activation
       • Interactions
         • PPI
           • makes clopidogrel less effective - lanzoprazole may be ok
       • Thienopyridines
         • prasugrel
         • ticagrelor
         • ticlopidine
       • Indications
         • When aspirin isn't torelated or contraindicated
         • Acute Coronary syndrome
         • PAD
         • Post stroke
       • Side Effects
         • abdo pain
         • gastric ulverls
         • parashtesia
         • pruritus
         • eosinophilia
         • decreased platelets
     • Dipyridamole
       • MoA
         • inhibits adenosine deaminase and phosphodiesterase, preventing the breakdown of cAMP which inhibits platelet function by reducing thromboxane A2 activity.
       • Side Effects
         • angiodema
         • dizziness
         • GI disturbance
         • hot flushes
         • myalgia
         • severe bronchospasm
         • tachycardia
         • thrombocytopenia
         • urticaria
         • worsoneing symptoms of coronary heat disease
       • Interactions
         • beta blockers
           • increases activity
         • anitriptyline
           • increased hypotensive ability
       • Contraindications
         • aortic stenosis
         • hypotension
         • left ventricular outflow obstruction
         • heart failure
         • myathenia gravis
         • recent MI
         • worsening angina
       • Indications
         • adjuct to oral anticogulations for prophylaxis of thomboembolism associated wtih oristgetuc geart vakces
     • ticlopidine
       • MoA
         • blocks the ADP receptor that is involved in thromboxane release and platelet agreggation
       • Indications
         • if aspirin is contraindicated
         • failure of aspirin to prevent thrombotic stroke
         • monitor WBC and platelets
       • Contraindications
         • thrombocytopenia
         • neutropenia
         • TTP (thrombotic thrombocytopenia purpura
         • apalstic anaemia
       • Side Effects
         • Diarrhea
         • stomach upset
         • dizziness
         • tinitus
         • pruritus
       • Interactions
         • NSAIDs
         • antacids
         • phenytoin
         • theophylline
   • Indication
     • primary and secondary prevention of stroke
     • reduces severity of stroke if taken within two days
     • longterm prevention following TIA
   • Contraindications
     • history of liver or kidney disease
     • GI disease or peptic ulcers
     • hypertension
     • bleeding disorders
     • Asthma