IHD Treatment Guideline
Treatment:
This is a sample prescription for the intern doctors for the treatment of IHD (STEMI and Non-STEMI). The Brand Names of the drugs mentioned below are from different drug manufacturers of Bangladesh.
| Guideline | Admission | Release |
| Limit physical activities at least for 12 hours | Absolute bed rest | |
| Diet: restrict sodium intake | Diet: Soft and liquid | |
| Oxygen in patients with respiratory distress and oxygen saturation ≤94% | O2 inhalation 4L/min
stat and SOS |
|
| Tab. Aspirin 150-325 mg PO administered as soon as possible on admission.
Tab. Clopidogrel 300 mg stat and followed by 150 mg daily for 1 week and 75 mg daily thereafter. |
Tab. LOPIREL PLUS1
4 tabs stat by crushing then 0+1+0 (a/m) |
Tab. LOPIREL PLUS1
0+1+0 (খাবার পর) – চলবে |
| Tab. Nitroglycerine 0.3-0.6 mg sublingual | Tab. TROCER 2.6 SR2
1+0+1+0 |
|
| Spray TROCER
2 puffs S/L stat and SOS |
Spray TROCER
জিহ্বার নিচে দুই চাপ নিবেন |
|
| Continuous treatment with an oral β-blocker reduces long-term mortality | Tab. METOPROL XL 50mg3
½+0+ ½ |
Tab. BETALOC 25mg3
1+0+1 – চলবে |
| Tab. ANGINOX 20mg4
1+0+1 (a/m) |
||
| Irrespective of serum cholesterol concentrations, all patients should receive statin therapy after acute coronary syndrome | Tab. ANZITOR 20mg5
0+0+1 |
Tab. ANZITOR 10mg5
0+0+1 – চলবে |
| If no hypotension or contraindications and uncomplicated MI given Tab. Enalapril 5 mg 2 times a day PO | Tab. RAMORIL 2.5mg6
0+0+1 |
Tab. RAMORIL 2.5mg6
0+0+1 – চলবে |
| Tab. NEXUM 20
1+0+1 (b/m) |
Tab. NEXUM 20
1+0+1 (খাবার আধা ঘণ্টা পুর্বে) – ১৫ দিন |
|
| Sedation with a benzodiazepine agent may help if anxiety is present | Tab. EPICLON 0.5mg7
0+0+1 |
Tab. EPICLON 0.5mg7
0+0+1 – ১৫ দিন |
| Inj. Enoxaparin 1 mg/kg subcutaneously 12 hourly for 3-5 days | Inj. CLEXANE 60mg
1 PFS S/C around the umbilicus BD |
|
| If severe pain:
Morphine 15mg diluted with 14mℓ of water for injection or sodium chloride 0.9%. Give 1mℓ/min IV until pain relieved. (Initially, morphine sulphate 5–10 mg) |
||
| If within 6 hours of onset of pain and ST segment elevation above baseline or new LBBB on ECG.
Streptokinase 1.5 million IU diluted in 100mℓ dextrose 5% or sodium chloride 0.9% IV over 30–60 minutes. |
Inj. STK9 1.5 million IU
Dissolved in 100 cc N/S IV @ 100 microdrops/min |
| 1 | LOPIREL PLUS – Incepta | Aspirin + Clopidogrel
75mg + 75mg |
| 2 | TROCER 2.6 SR – Incepta
|
Glyceryl Trinitrate (nitroglycerine) |
| 3 | METOPROL XL – Beximco (50/100mg)
BETALOC – Drug Int. (25/50 mg) |
Metoprolol Tartrate ( blocker). Avoid in pregnancy, asthma, COPD, peripheral vascular disease, heart failure (pulmonary oedema), hypotension (systolic BP < 105 mmHg) or bradycardia (heart rate < 65/min).
|
| 4 | ANGINOX 20mg – General Pharma | Trimetazidine Dihydrochloride (anti-anginal & anti-ischemic drug) |
| 5 | ANZITOR – Square (10/20/40mg)
|
Atorvastatin (statin, anti-anginal & anti-ischemic drug) |
| 6 | RAMORIL – Incepta (1.5/2.5/5/10mg)
|
Ramipril (ACEi) |
| 7 | EPICLON – General (0.5/1/2mg)
|
Clonazepam (Benzodiazepine hypnotic, adjunct anti-epileptic) |
| 8 | CLEXANE – Sanofi (20/40/60/80mg)
CLOTINEX – Square (40/60/80mg)
|
Enoxaparin (anti-coagulant) |
| 9 | STK– Incepta (4500/-)
STREPTASE– Sanofi Aventis (3464/-) S-KINASE – Popular (3000/-)
|
Streptokinase (fibrinolytics) |
Advice:
| Guideline | Admission | Release |
| Cessation of smoking | Cessation of smoking | ধূমপান সম্পূর্ণ বন্ধ। |
| Initiate or maintain lifestyle modifi cation–weight-control, increased physical activity, alcohol moderation, sodium reduction, and emphasis on increased consumption of fresh fruits, vegetables, and low-fat diary products. | পাতে লবণ খাবেন না। | |
| Patient should avoid non steroidal anti-inflammatory drugs like ibuprofen and diclofenac, as they may precipitate angina. | ||
| Coronary angiography should be considered with a view to revascularisation in all patients at moderate or high risk |
Reference:
- Standard treatment guidelines of the Kingdom of Swaziland. Swaziland: Ministry of Health; 2012.
- Primary Care 101 Guideline 2013/14: The National Department of Health Private Bag x828 Pretoria 0001; 2013.
- Papadakis MA, McPhee SJ, Rabow MW. CURRENT Medical Diagnosis and Treatment 2017: McGraw-Hill Education; 2016.
- Walker BR, Colledge NR, Ralston S, Penman ID. Davidson’s Principles and Practice of Medicine: Churchill Livingstone/Elsevier; 2014.
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]]>Leprosy
- Definition, organs involved, mode of transmission. e45
- Classify leprosy? H69,
e45 - What are the cardinal features of leprosy? H70
- Features of tuberculoid leprosy. e46
- Tuberculoid vs. lepromatous leprosy. e46
- Paucilacillary vs. multibacillary. e47
- How can you confirm your diagnosis? H71
- From where slit skin smear is taken? H72
- What are the differential diagnoses for leprosy? H73
- How can you treat leprosy? H74/e48
Others
- Nerves commonly affected. e48
- Complications. e48
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]]>Questions on other viral infections
Rubella
- Complications. e23
Chicken pox
- Organism. am38
- Some common bullous lesions of skin. e24
- Lesions produced by chicken pox. e24
- Stages of lesion in chicken pox. am38
Mumps
- Complications*. am38, e24
- Organism. am37
- C/F. am37
- Diagnosis and tx. am38
Dengue
- What are the common causes of fever with maculopapular rash? H80
- What is the causative agent of dengue fever? H81
- What is the vector of dengue virus? H82
- What is the habit of biting? H83
- What is dengue syndrome? H84
Dengue fever
- What are the criteria of dengue fever? H85
- How can you treat dengue fever? H86
- Complications. e29
DHF
- Dx. e28/am148
- Mx. e30
- Who develops DHF? e30
DSS
- Dx. e28/am149
- Mx. e29
Extra
- What are the signs of circulatory failure, shock, don’ts and criteria for discharge in dengue? am152
Herpes zoster
- C/F. e33
Rabies
- Prevention/ management plan after bite. e35
Notes
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]]>Questions on diarrhoea
Diarrhoea
- Define diarrhea?
H30, 1e460, am140 - Classification
- What are the causes of acute diarrhea? 1e460, am104
- What are the electrolyte imbalances occurring in acute watery diarrhea? h, 1e461
- Patient presented with acute watery diarrhea, how will you manage the patient?
- What are the causes of chronic diarrhea? ie462
- What is the most common cause of chronic diarrhea? h, ie462
- Diagnose a case of chronic diarrhora. 1e463
- Classification and signs/ assessment of dehydration. am104,105
- What is steatorrhea? h
- What are the mechanisms responsible for malabsorption? h
Dysentery
- What is dysentery? e18, am105, h76i
- What are the causes of bloody diarrhea?
- Management
- Amoebic. e19
- Bacillary. e18, am108,
h79i
- Amoebic vs. bacillary. e20,
h78i
Rimikri
SOLVES
Notes
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]]>Questions on presenting problems in gastrointestinal disease
Dyspepsia
- What is dyspepsia? H10
- What are the alarm features of dyspepsia?
Vomiting
- What are the neurological causes of vomiting? H12
- Give the description of vomiting of gastric outlet obstruction, e.g. pyloric stenosis. H13
- Give the description of vomiting in raised intracranial pressure, e.g. brain tumor.
Hematemesis and melena
- What is hematemesis? H15
- What is melena?
- How can you differentiate between hematemesis and hemoptysis?
- What are the common causes of hematemesis?
- What are the clinical features of upper GI bleeding?
- How much blood is lost to cause postural hypotension?
- How much blood is lost to produce shock?
- What are the investigations done in acute upper GI bleeding?
- What is the management of acute upper GI bleeding?
- Which etiologies bear the worst prognosis?
- Mention the criteria of stool in melena?
- How much blood is required to cause melena?
- Why is stool black?
- What are the usual sites for hematemesis and melena?
- What are the causes of lower GI bleeding?
Diarrhoea
- Define diarrhea? H30
- What are the causes of acute diarrhea?
- What are the electrolyte imbalances occurring in acute watery diarrhea?
- What are the causes of bloody diarrhea?
- Patient presented with acute watery diarrhea, how will you manage the patient?
- What are the causes of chronic diarrhea?
- What is the most common cause of chronic diarrhea?
- What is steatorrhea?
- What are the mechanisms responsible for malabsorption?
Constipation
- Define constipation. H39
- What is the most common cause of constipation?
- What are the neurological causes of constipation?
- What are the metabolic/endocrine causes of constipation?
- What are the types of laxative?
Pathological weight loss
- Tell five common causes of pathological weight loss. h44
- What do you mean by significant weight loss?
- What are the causes of weight loss with increased appetite?
Acute abdomen
- What are the causes of acute abdominal pain (acute abdomen)? H47
- What are the medical causes of acute abdominal pain (acute abdomen)?
- What are the causes of abdominal distension?
Rimikri
SOLVES
Notes
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]]>Questions on examination of respiratory system
Rimikri
SOLVES
Breath sound
What are the causes of bronchial breath sound?
The causes of bronchial breath sound are:
- 3Cs
- Consolidation
- Cavitation
- Collapse with patent bronchus
- Fibrosis
* Pre-exam preparation for medicine, HN Sarker
What are the types of breath sound?
The types of breath sound are:
- Vesicular
- Vesicular with prolonged expiration
- Bronchial.
* Pre-exam preparation for medicine, HN Sarker
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]]>Rimikri
SOLVES
Obstructive pulmonary diseases
What are the obstructive pulmonary diseases?
The obstructive pulmonary diseases are:
- COPD
- Bronchial asthma.
* Pre-exam preparation for medicine, HN Sarker
What are the restrictive pulmonary diseases?
The restrictive pulmonary diseases are:
- Interstitial lung disease
- Pulmonary fibrosis.
* Pre-exam preparation for medicine, HN Sarker
How can you differentiate obstructive from restrictive lung diseases?
| Test | Obstructive | Restrictive |
| FEV1 (Forced expiratory volume) | ↓ ↓ | ↓ |
| VC (Vital capacity) | ↓ or normal | ↓↓ |
| FEV1/VC | ↓ | Normal or ↑ |
* Pre-exam preparation for medicine, HN Sarker
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]]>Questions on congenital heart disease
Rimikri
SOLVES
Congenital heart disease
Classify congenital heart diseases.
Classification:
Broadly based on the presence or absence of cyanosis in the affected child.
- Cyanotic CHD
- Tetralogy of Fallot (TOF)
- Transposition of great arteries (TGA)
- Total anomalous pulmonary venous drainage (TAPVD)
- Persistent truncus arterious
- Tricuspid atresia
- Ebstein anomaly
- Acyanotic CHD
- With left to right shunts
- VSD (commonest CHD)
- ASD
- PDA
- Without shunt
- Coarctation of aorta
- Pulmonary stenosis
- Aortic stenosis
- With left to right shunts
* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 120
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]]>Questions on cardiomyopathy
- What is cardiomyopathy? H197
- What are the types of cardiomyopathies? H198
Rimikri
SOLVES
Cardiomyopathy
What is cardiomyopathy?
Cardiomyopathy is defined as “a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic”.
* Pre-exam preparation for medicine, HN Sarker
What are the types of cardiomyopathies?
The types of cardiomyopathies are:
- Hypertrophic cardiomyopathy
- Dilated cardiomyopathy
- Arrhythmogenic right ventricular cardiomyopathy
- Obliterative cardiomyopathy
- Restrictive cardiomyopathy
* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 634
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]]>Questions on infective endocarditis
- Define infective endocarditis. H177
- What are the types of infective endocarditis? H178
- What are the common organisms involved in infective endocarditis? H179
- What are the peripheral stigmata of infective endocarditis? H180
- Tell the emperical therapy of infective endocarditis? H181
Rimikri
SOLVES
Definition and Classification
Define infective endocarditis.
This is due to microbial infection of a heart valve (native or prosthetic), the lining of a cardiac chamber or blood vessel, or a congenital anomaly (e.g. septal defect).
* Pre-exam preparation for medicine, HN Sarker
What are the types of infective endocarditis?
The types of endocarditis are:
- Acute infective endocarditis
- Subacute infective endocarditis
- Postoperative infective endocarditis.
* Pre-exam preparation for medicine, HN Sarker
Epidemiology
Etiology and Pathophysiology
What are the common organisms involved in infective endocarditis?
- Streptococcus— Viridens group and enterococci.
- Staphylococcus—Staphylococcus aureus and coagulase negative
- Gram-negative bacilli—Haemophilus anaerobes
- Others—Rickettsiae and fungi.
* Pre-exam preparation for medicine, HN Sarker
Clinical Manifestations
Examination
What are the peripheral stigmata of infective endocarditis?
The peripheral stigmata of infective endocarditis are:
- Clubbing
- Splinter hemorrhage
- Osler’s nodes
- Janeway lesions
- Purpura
- Roth’s spots.
* Pre-exam preparation for medicine, HN Sarker
Figure: Clinical features which may be present in endocarditis
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 627
Investigations
What investigations do you suggest in endocarditis?
Investigations
- Blood culture
- It is the crucial investigation because it may identify the infection and guide antibiotic therapy.
- Echocardiography
- For detecting and following the progress of vegetations, for assessing valve damage and for detecting abscess formation.
- ESR: Elevation
- CRP: Measurement of serum CRP is more reliable than the ESR in monitoring progress.
- Hb% and PBF: Normocytic normochromic anaemia
- CBC: Leucocytosis
- Urinalysis:
- Proteinuria may occur and microscopic haematuria is usually present.
- ECG
- Development of AV block (due to aortic root abscess formation) and occasionally infarction due to emboli.
- Chest X-ray
- Evidence of cardiac failure and cardiomegaly.
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 627, 628
Diagnosis
Describe the diagnosis of infective endocarditis (modified Duke criteria).
Diagnosis of infective endocarditis (modified Duke criteria)
Major criteria
- Positive blood culture
- Typical organism from two cultures
- Persistent positive blood cultures taken > 12 hrs apart
- Three or more positive cultures taken over > 1 hr
- Endocardial involvement
- Positive echocardiographic findings of vegetations
- New valvular regurgitation
Minor criteria
- Predisposing valvular or cardiac abnormality
- Intravenous drug misuse
- Pyrexia ≥ 38°C
- Embolic phenomenon
- Vasculitic phenomenon
- Blood cultures suggestive: organism grown but not achieving major criteria
- Suggestive echocardiographic findings
Diagnosis
- Definite endocarditis = two major, or one major and three minor, or five minor
- Possible endocarditis = one major and one minor, or three minor
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 627
Treatment
Tell the emperical therapy of infective endocarditis?
- Acute—Flucloxacillin and gentamicin.
- Subacute or indolent—Benzyl penicillin and gentamicin. In those with penicillin allergy, a prosthetic valve or suspected methicillin-resistant Staph. aureus (MRSA)
- Infection—Triple therapy with vancomycin, gentamicin, and oral rifampicin.
* Pre-exam preparation for medicine, HN Sarker
What are the indications of cardiac surgery in infective endocarditis?
Indications for cardiac surgery in infective endocarditis
- Heart failure due to valve damage
- Failure of antibiotic therapy (persistent/uncontrolled infection)
- Large vegetations on left-sided heart valves with evidence or ‘high risk’ of systemic emboli
- Abscess formation
N.B. Patients with prosthetic valve endocarditis or fungal endocarditis often require cardiac surgery.
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 629
Complications
Notes
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