C Flashcards
What is the indication of HAS-BLED tool?
Assess bleeding risk
Please note: NICE guidance recommends using the ORBIT bleeding risk assessment tool when considering starting anticoagulation in people with atrial fibrillation, and that a direct oral anticoagulant should be used first line in people considered to be at risk of stroke.
when does NICE guidance recommened the ORBIT tool instead of HAS- BLED tool?
when considering starting anticoagulation in people with atrial fibrillation,
and that a direct oral anticoagulant should be used first line in people considered to be at risk of stroke.
State the ORBIT tool, (Scores range from 0 to 7 based on the scores):
There is a score of 2 points for:
* Males with haemoglobin less than 130g/L or hematocrit less than 40%
- Females with haemoglobin less than 120g/L or hematocrit less than 36%
- People with history of bleeding for example Gl bleeding, intracranial bleeding or haemorrhagic stroke
There is a score of 1 point for:
* People aged over 74 years
- People with egfr of less than 60 ml/min
- People treated with antiplatelets
What do the ORBIT tool scores stipulate:
0-2 score = low risk
3 = medium risk
4-7 = high risk
What is the indication of CHA2-DS2-VASc tool?
Assess a person’ stroke risk
C = congestive heart failure/left ventricular dysfunction (1 score)
H = hypertension (1 score)
A2 = age 75 or aged 75+ (2 scores)
D = diabetes mellitus (1 score)
S2 = stroke/TIA (2 scores)
V = vascular disease, prior myocardial infarction, peripheral arterial disease or aortic
plaque (1 score)
A = age 65-74 (1 score)
Sc = sex category female (1 score)
What patients do not require antithrombotic for stroke prevention:
CHA2- DS2- VASc scores
Low risk:
Males = score 0
Females = score 1
What is recommended in treatment of acute ischaemic stroke:
Alteplase - if it can be administered within 4.5 hours of symptom onset and if intracranial hemorrhage has been excluded
Which direct-acting oral anticoagulant DOAC is given to people with AF and a CHADVASC score of 2+:
Apixaban, edoxaban, dabigatran, rivaraoxaban
If DOACS are not suitable then offer a vitamin k antagonist
what should we offer patients if DOACs are not suitable?
a vitamin K antagonsit
in what conditions do we need target INR of 2.5:
Treatment of DVT or pulmonary embolism
Atrial fibrillation
Cardioversion
Dilated cardiomyopathy
Myocardial infarction
in what conditions do we need a target INR of 3.5
Recurrent DVT
Mechanical prosthetic heart valves
State the advice of what to do when there is a haemorrhage in terms of: major bleeding
Major bleeding =
stop warfarin, give phytomenadione (vit k) by slow IV injection
Give dried prothrombin complex
Fresh frozen plasma can be given but is less effective
State the advice of what to do when there is a haemorrhage in terms of: INR > 8.0 minor bleeding
stop warfarin
give phytomenadione (vit k) by slow IV injection
repeat dose of phytomenadione if INR still too high
after 24 hours restart warfarin when INR < 5.0
State the advice of what to do when there is a haemorrhage in terms of: INR > 8.0, no bleeding:
Stop warfarin
give phytomenadione (vit k) by mouth using the intravenous preparation orall (unlicensed use)
repeat dose of phytomenadione if INR still too high
after 24 hours restart warfarin when INR < 5.0
State the advice of what to do when there is a haemorrhage in terms of: INR 5.0-8.0, minor bleeding
stop warfarin
give phytomenadione (vit k) by slow IV injection
restart warfarin when INR < 5.0
State the advice of what to do when there is a haemorrhage in terms of: NT 5.0-8.0, no bleeding:
Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose
Unexplained bleeding at therapeutic levels - always investigate possibility of underlying cause e.g., unsuspected renal or gastro-intestinal tract pathology
State the treatment of rate-control treatment:
Standard beta-blocker (other than sotalol) or a rate-limiting CB (diltiazem or verapamil) as first line treatment for most people with AF
Base the choice of drug on the person’s symptoms, heart rate, comorbidities and preferences
Note: do not offer amiodarone for long term rate-control
What could be prescribed for people with non-paroxysmal AF:
Digoxin
What is antidote for dabigatran
Idarucizumab
What is the antidote for rivaroxaban and apixaban
Andexanet alfa
Define Torsade de pointes:
Form of ventricular tachycardias associated with long QT syndrome
(hypokalaemia, severe bradycardia, genetic predisposition is also implicated)
Which beta-blocker drug should not be used in torsade de pointes:
Sotalol
What is the treatment for torsade de pointes:
IV magnesium sulphate
What conditions is IV adenosine contraindicated in:
COPD/Asthma
What is the duration of action of IV adenosine:
8-10 seconds
What is given if adenosine is contraindicated:
Verapamil
State ONE serious interaction with verapamil:
beta-blockers
State the classes of anti-arrhythmic drugs:
Class 1: membrane stabilising (lidocaine, fleicanide)
Class 2: beta-blockers (including sotalol)
Class 3: amiodarone
Class 4: CCBs (includes verapamil)
State some side effects of amiodarone:
Constipation, corneal deposits, hypothyroidism, photosensitivity, hypotension, taste altered,
Corneal microdeposits - if vision impaired or optic neuropathy occurs, amiodarone must be stopped to prevent blindness
Thyroid function - can cause hypo/hyperthyroidism
Hepatotoxicity - if severe liver dysfunction or if signs of liver disease occurs
Pulmonary toxicity - new or progressive shortness of breath or cough develops
What is the initial loading dose for amiodarone
200 mg 3 times a day for 1 week
then reduced to 200 mg twice daily for a further week
followed by maintenance dose, usually 200 mg daily or the minimum dose required to control arrhythmia.
What are the monitoring requirements for amiodarone:
Thyroid before and every 6 months
Lits before and every 6 months
Serum potassium before treatment
Chest x-ray before treatment
What are common significant interactions of amiodarone?
Amiodarone + grapefruit juice = increase plasma amiodarone concentrations
Amiodarone + (warfarin (phenytoin) (digoxin)
Amiodarone + statins = increased risk of myopathy
Amiodarone + (quinolones) (macrolides) (TCAs) (SSRIs) (Lithium) (chloroquine,
mefloquine) (sulpride, pimozide, amisulpride) = QT prolongation, increased risk of
ventricular arrythmia
If patient is taking amiodarone with concomitant sofofbuvir, daclatasvir, simeprevir, ledipasvir:
Recognise signs of bradycardia and heart block
SOB {shortness of breath)
light headedness
palpitations
Fainting,
unusual tiredness
chest pain
= seek urgent help
What is digoxin:
Narrow therapeutic cardiac glycoside drug that increases the force of myocardial contraction and reduces conductivity within the AV node
What are the therapeutic levels of digoxin
0.7-2.0 nanograms/mL
Blood samples taken 6 hours after the previous dose, but ideally 8-12 hours afterwards
What are the adverse effects of digoxin?
Cardiac adverse effects - sinoatrial and atrioventricular block
Premature ventricular contractions
PR prolongation and ST-segment depression
What are the non-cardiac adverse effects of digoxin?
Nausea, vomiting, and less commonly diarrhea. Nausea, in particular is indicative of overdose
Visual abnormalities i.e., blurred or yellow vision
CNS effects such as weakness, dizziness, co fusion, apathy, malaise, headache, depression and psychosis
Thrombocytopenia and agranulocytosis are rare
Gynaecomastia in men following prolonged administration
State the monitoring requirements for digoxin:
For plasma-digoxin concentration assay, blood should be taken at least 6 hours after a dose
Monitor serum electrolytes and renal function (toxicity increased by electrolyte disturbances)
What key drug interactions should you be aware of for digoxin:
Avoid TCAS
venlafaxine
beta-blockers
bupropion
diuretics
St john’s wart
PPi’s
CCB’s (diltiazem, verapamil, nifedipine)
What are the signs of digoxin toxicity?
Bradycardia
nausea
vomiting
diarrhea
abdominal pain
rash
blurred or yellow vision
Hypokalaemia
hypercalcaemia
hypoxia
hypomagnesemia
What is the maximum daily grams a female can take tranexamic acid:
4g
What can be given prior to general or orthopedic surgery for prophylaxis:
Low molecular weight heparin
What is preferred in patients with renal impairment:
Heparin (unfractionated)
Which anticoagulant is preferred for patient undergoing bariatric, abdominal, thoracic, cardiac, fragility, hip surgery:
Fondaparinux sodium
After surgery, parmacological prophylaxis should be carried on for:
7 days post-surgery
28 days post major cancer surgery in abdomen
30 days post spinal surgery
What is the thromboembolism prophylaxis in pregnancy:
Low molecular weight heparin (tinzaparin, enoxaparin, dalteparin)
Treatment stopped during onset of labour
What is the antidote for low molecular weight heparins:
Protamine sulphate
State the management of suspected TIA in primary care:
Give aspirin 300 mg immediately unless contra-indicated or taking aspirin regularly
Give PPI to anyone with dyspepsia associated with aspirin use
Advise people already taking low dose aspirin to continue - do not offer aspirin
300mg
What is the long-term management following a TIA or ischaemic stroke:
- Clopidogrel 75 mg daily
- Or M/R dipyridamole 200 mg BD
- Or aspirin 75 mg
Note: dual therapy with aspirin + clopidogrel (for up-to 90 days) or aspirin plus ticagrelor (for 30 days) may be initiated for some people i.e. those at high risk of
TIA or those with intracranial stenosis
State which statin to prescribe in primary prevention of CVD:
Atorvastatin 20 mg
State which statin to prescribe in secondary prevention of CVD:
High-intensity statin such as atorvastatin 80 mg
State what NICE recommends for patients who have a 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator):
Low-dose atorvastatin
Note: low-dose atorvastatin should be considered in all patients with type 1 diabetes mellitus and be offered to patients with type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors. Patients aged 85 years or over may also benefit from low-dose atorvastatin.
What is the long-term management of intracerebral hemorrhage:
Avoid aspirin, anticoagulants and statins - NSAIDS increase blood pressure
What is low dose aspirin used for:
75 mg - secondary prevention of CVD
What is the prescribing information for dipyridamole?
MR caps should be discarded after 6 weeks of opening
What are signs if patient gets heparin-induced thrombocytopenia:
30% reduction in of platelet count
thrombosis
skin allergy
Heparin should be stopped, and alternative anticoagulant commenced. Such as danaparoid
What is the risk of hyperkalaemia with unfractionated or LMWH:
Inhibition of aldosterone secretion can result in hyperkalaemia
Patients with diabetes, chronic renal failure, acidosis, raised plasma potassium or those taking potassium sparring drugs are more susceptible
State the MHRA warning of warfarin sodium:
Warfarin use may lead to calciphylaxis which is a painful skin rash
Most commonly observed in patients with known risk factors such as end stage renal disease
What is defined as Stage 1 hypertension:
Clinical BP of 140/90 or higher
Home BP of 135/85 or higher
What is defined as Stage 2 hypertension:
Clinical BP of 160/100 or higher
Home BP of 150/95 or higher
How long should an antihypertensive medication be taken for before determining the effectiveness of it:
4 weeks
What are the stages of treatment for a patient under 55 years old and who are not of black African or African-Caribbean family origin:
- ACE OR ARB
- ACE OR ARB + CCB/Thiazide like diuretic
Note: offer TLD if evidence of heart failure
- ACE OR ARB + CCB + Thiazide like diuretic
- Add low dose spironolactone if potassium level is 4.5mmol/litre or less OR add alpha blocker/beta-blocker if potassium level is greater than 4.5mmol/litre
What to do if a patient has type 2 diabetes and hypertension:
Offer an ARB to people of black-African African-Caribbean origin and not an ACE
Stages of hypertension treatment for: For patients over 55, and patients of any age who are of African or Caribbean family origin:
- CCB
- Thiazide like diuretic, indapamide
- CCB + ACE/ARB + TLD
State what is prescribed if there is evidence of heart failure:
Indapamide
What target clinical BP is recommended for a patient aged 80+:
150/ 90 mmhg
What is the target Home BP for a patient aged 80+:
145/85 mmhg or lower
Which age range is isolated systolic hypertension common in:
Patients over 60
What is the clinical target BP recommended for patients with diabetes:
Below 140/80 mmhg
Or 130/80 if kidney, eye or cerebrovascular disease also present
What is the treatment for diabetic nephropathy:
ACE or ARB
What is the antihypertensive treatment during pregnancy:
- Labetalol
- Nifedipine
- Methyldopa
If a woman has been taking methyldopa when should she restart her usual antihypertensive medication after birth and WHY:
Within 2 days of the birth = due to risk of depression
What does NICE define pre-eclampsia as:
New onset of hypertension (over 140mmHg systolic or diastolic over 90)
and coexistence of1 or more of the following new onset conditions:
CKS, diabetes, autoimmune disease, chronic hypertension (one of high-risk factors)
Two or more moderate factors: first pregnancy, aged 40+, pregnancy interval of more than 10 years, BMI of 35+, family history, multiple pregnancy
What should woman take if they have pre-eclampsia and from when?
Aspirin 150 mg once daily from 12 weeks until birth
What is antihypertensive treatment in postnatal period if a woman wishes to breastfeed:
Enalapril
(different in black- African women)
What is antihypertensive treatment in postnatal period if a black-African woman wishes to breastfeed:
Nifedipine or amlodipine if had it before
If not working, then dual therapy with enalapril considered
What should you advise to a female breastfeeding during taking antihypertensive medication after birth:
Monitor baby for signs of hypotension:
drowsiness, lethargy, pallor, cold peripheries or poor feeding
What is given to females with pre-eclampsia where birth is considered within 7 days and for what indication:
IM betamethasone for foetal maturation
State 2 side effects of hydralazine hcl if given alone:
Can cause tachycardia and fluid retention
State a disadvantage of taking clonidine hcl:
Sudden withdrawal of treatment can cause severe rebound hypertension
Clonidine must be withdrawn gradually due to risk of rebound hypertension
How doe ACE inhibitors work:
Inhibits conversion of angiotensin 1 to angiotensin 2
State one side effect of ACE inhibitors with patients on impaired renal function:
Hyperkalaemia
ACEi+ X= renal damage
x= NSAIDs
State one common side effect of ACE:
Dry cough - refer to GP to change to ARB if the dry cough with ACE persists or is bothersome to the patient
State one serious side effect of ACE:
Angioedema
State one serious side effect of CCB:
Swelling of ankles - ankle oedema
Note: ACE + ARB = not recommended due to risk of hyperkalaemia
What is the max dos of methyldopa for adult in g:
3 g
What should be monitored during methyldopa treatment
Monitor blood counts and LFTs before treatment and intervals during first 6-12 weeks and if unexplained fever occurs
Which betablockers have intrinsic sympathomimetic activities, (causing less bradycardia, and cause less coldness of extremities):
Celiprolol, pindolol, acebutolol, oxprenolol
Which beta-blockers are most water soluble:
Atenolol, celiprolol, nadolol, sotalol = less likely to enter brain and thus less likely to
cause nightmares and less sleep disturbance
Where is water soluble BB excreted:
Kidneys
Which condition is BB contraindicated in and why:
Asthma due to risk of precipitating bronchospasm
Which ACE has to be taken twice daily:
Captopril
Which ACE has directions to be taken 30-60 mins before food:
Perindopril
State cardio-selective beta-blockers:
Atenolol, bisoprolol, metoprolol nebivolol, acebutolol
State one side effect of using beta-blockers in angina:
Sudden abrupt withdrawal can cause exacerbation of angina and so gradual reduction of dose is required
What is the interaction between beta- blockers and verapamil
precipitate heart failure
State one side effect of sotalol:
Can induce torse de pointes/ prolong QT interval
Which BB is licensed for stable mild to moderate heart failure in patients over 70:
Nebivolol
Which 2 BB can reduce mortality in any grade of stable heart failure:
Bisoprolol, carvedilol
Which BB can reverse symptoms of clinical thyrotoxicosis within 4 days
Propranolol
State some side effects of BB:
Bradycardia, confusion, depression, heart failure, erectile dysfunction, rash, sleep disorders, diarrhea, nausea, dizziness
What do you monitor while patient is taking BB:
Lung function
State one common side effect of verapamil:
Constipation, principate heart failure, exacerbate conduction disorders, hypotension + not given with BETA BLOCKERS
What is verapamil:
Highly negatively ionotropic CB
State common side effects of CBS:
Peripheral edema, gingival hyperplasia, dizziness, nausea, rash, tachycardia, palpitations
State symptoms of CB poisoning:
Nausea, vomiting, dizziness, agitation, confusion, coma, metabolic acidosis, hyperglycaemia in severe poisoning
Which CCB can be used for chronic anal fissure: (unlicensed use)
Diltiazem hcl although this is second line treatment
State treatment of anal fissure:
Manage pain with paracetamol or ibuprofen (avoid codeine-based products)
Prescribe Glyceryl trinitrate TN 0.4% ointment for symptoms for 1 week or more
Ensure stools are soft and easy to pass
State the side effect of diltiazem overdose
Profound cardiac depressant effect causing hypotension and arrythmias, complete heart block and asystole
What is the prescribing info for diltiazem:
Diltiazem of more than 60 mg should be prescribed via brand name
Which CCB can inhibit labour:
Lacidipine
What does Nifedipine need to be prescribed by:
Brand name
Which oral anticoagulant is given in non-valvular AF:
Apixaban
edoxaban
rivaroxaban
dabigatran
