Clinical Pharmacy · Short notes

Cardiovascular Therapeutics: Short Notes & Cheat Sheet

Treating hypertension, acute coronary syndrome, heart failure, atrial fibrillation, dyslipidaemia and venous thromboembolism.

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Short notes

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Treating heart failure with reduced ejection fraction

The four pillars reduce mortality and should all be started early; diuretics treat symptoms only.

Hypertension

First-line classes: ACE inhibitor or ARB, calcium channel blocker, and thiazide-like diuretic. Many guidelines start with a two-drug single-pill combination.
Aim for below 130/80 mmHg where tolerated (at least below 140/90).
Resistant hypertension (uncontrolled on three drugs including a diuretic): add spironolactone.
Compelling choices: diabetes with albuminuria or CKD → ACE inhibitor/ARB; pregnancy → labetalol, nifedipine or methyldopa; BPH → an α-blocker can help.
Hypertensive emergency (with organ damage): IV labetalol, nicardipine or nitroprusside, lowering mean pressure by no more than about 25% in the first hour.

Acute coronary syndrome

STEMI: primary PCI as soon as possible (within 120 minutes of diagnosis). If PCI is not available in time, give a thrombolytic, ideally within 30 minutes of arrival.
Immediate therapy: aspirin loading dose plus a P2Y12 inhibitor (ticagrelor, prasugrel or clopidogrel) and an anticoagulant (heparin, enoxaparin or fondaparinux).
Give oxygen only if saturation is below 90%. Use nitrates and morphine for pain, avoiding nitrates in hypotension or after recent sildenafil.
Secondary prevention: aspirin for life, a P2Y12 inhibitor for about 12 months (dual antiplatelet therapy), a high-intensity statin, a β-blocker, an ACE inhibitor, and an MRA if LVEF ≤ 40% with heart failure or diabetes.

Heart failure and atrial fibrillation

HFrEF (LVEF ≤ 40%) 'four pillars': ARNI (or ACE inhibitor/ARB), an evidence-based β-blocker, an MRA and an SGLT2 inhibitor. Loop diuretics relieve congestion.
Avoid in heart failure: NSAIDs, verapamil and diltiazem, pioglitazone and most antiarrhythmics except amiodarone.
AF rate control: β-blocker, diltiazem/verapamil (not in HFrEF) or digoxin. Rhythm control: cardioversion, amiodarone, or flecainide if there is no structural heart disease.
Stroke prevention uses the CHA₂DS₂-VASc score. DOACs are preferred over warfarin, except with mechanical valves or moderate-to-severe mitral stenosis (warfarin).

Lipids and VTE

High-intensity statins (atorvastatin 40–80 mg, rosuvastatin 20–40 mg) lower LDL by about 50% or more. Add ezetimibe, then a PCSK9 inhibitor, if targets are not met.
DVT and PE are treated with a DOAC (apixaban, rivaroxaban) or LMWH followed by warfarin.
When starting warfarin with heparin, overlap them for at least 5 days and until the INR is ≥ 2 for 24 hours.
Treat provoked VTE for about 3 months; unprovoked or recurrent VTE often needs longer treatment.
INR target is 2–3 for most indications and 2.5–3.5 for mechanical mitral valves.

Cheat sheet

High-yield facts in one place. Cover the right-hand column and test yourself.

Situation → drug

Situation	Drug
Hypertension in pregnancy	Labetalol, nifedipine, methyldopa
Resistant hypertension	Add spironolactone
STEMI without timely PCI	Thrombolysis (alteplase, tenecteplase)
Post-MI	Aspirin, P2Y12, statin, β-blocker, ACEi
HFrEF pillars	ARNI/ACEi, β-blocker, MRA, SGLT2i
AF with mechanical valve	Warfarin, not a DOAC
VTE treatment	Apixaban / rivaroxaban or LMWH → warfarin

Key numbers

Item	Value
BP target	< 130/80 (at least < 140/90)
PCI time goal	≤ 120 min from diagnosis
Door-to-needle (lysis)	≤ 30 min
DAPT after ACS	≈ 12 months
Warfarin INR	2–3; 2.5–3.5 mechanical mitral
Heparin–warfarin overlap	≥ 5 days and INR ≥ 2 for 24 h

Memory aids

HFrEF: 'ABMS' pillars: ARNI/ACEi/ARB, β-Blocker, MRA, SGLT2 inhibitor.

Exam traps

Routine oxygen in ACS is no longer recommended unless the patient is hypoxic.
Verapamil and diltiazem are avoided in heart failure with reduced ejection fraction.
DOACs are not used for mechanical heart valves.
Warfarin alone should not be started without heparin cover in acute VTE, because it is briefly prothrombotic.

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