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1
Q

What is the first line drug therapy for SVT?

A

Adenosine

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2
Q

What is the MOA for adenosine?

A

Activation of GPCR on cell surfaces -> reduces spontaneous depolarisation, increases resistance to depolarisation. Increases refractoriness of AV node.

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3
Q

Adverse effects of adenosine

A

Bradycardia
Asystole
Sinking feeling in chest
Breathlessness

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4
Q

Absolute contraindications to adenosine

A

Hypotension
Coronary ischaemia
Decompensated HF
Asthma

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5
Q

Relative contraindications to adenosine

A

COPD

Heart transplant - particularly sensitive to effects

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6
Q

Adenosine interactions

A

Dipyramidole - blocks cellular uptake of adenosine

Theophylline, aminophylline, caffeine - competitive antagonists of adenosine receptors, block effect

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7
Q

Administration of adenosine

A

Initial dose 6mg, then 12 if needed
LARGE BORE cannula - green or above
Administered as rapid IV injection then flushed immediately

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8
Q

Other info - adenosine

A

Continuous cardiac rhythm strip needed - constant monitoring

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9
Q

What drug is administered as a vital part of anaphylaxis and ALS management?

A

Adrenaline

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10
Q

What is the MOA of adrenaline?

A

Agonist of α1, α2, β1 and β2 adrenoceptors - vasoconstriction of vessels supplying abdominal organs, vasodilation of vessels supplying heart

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11
Q

Adverse effects of adrenaline

A 
Adrenaline induced hypertension 
Anxiety
Tremor
Palpitations
Angina 
MI 
Arrhythmias
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12
Q

Absolute contraindications to adrenaline

A

None in cardiac resus protocols

Injection into areas supplied by an end artery eg extremities

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13
Q

Relative contraindications to adrenaline

A

Heart disease - used with caution

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14
Q

Interactions with adrenaline

A

β-blockers - may induce widespread vasoconstriction

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15
Q

Administration of adrenaline

A

1mg IV given after 3rd shock then every 3-5 mins

ANAPHYLAXIS - 500mg IM from minijet

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16
Q

What drug is first line for ascites and oedema due to liver cirrhosis?

A

Spironolactone

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17
Q

What drug is first line (with a β-blocker and ACE inhibitor) for chronic HF?

A

Aldosterone antagonists - spironolactone, epleronone

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18
Q

What is the MOA of aldosterone antagonists?

A

Inhibit the effect of aldosterone by competitively binding to the aldosterone receptor. This increases sodium and water excretion and potassium retention.

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19
Q

Adverse effects of aldosterone antagonists

A

Hyperkalaemia!!!!
Gynaecomastia
Liver impairment - Stevens-Johnson syndrome

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20
Q

Absolute contraindications of aldosterone antagonists

A

Severe renal impairment
Hyperkalaemia
Addison’s

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21
Q

Relative contraindications of aldosterone antagonists

A

Pregnant lactating women - can cross placenta and appear in breast milk
Potassium supplementation - should only be done in specialist practice

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22
Q

Interactions of aldosterone antagonists

A

Any potassium sparing drug eg ACE inhibitor, ARB - increases risk of hyperkalaemia

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23
Q

Administration of aldosterone antagonists

A

Only available as oral tablet
100mg daily orally for ascites
25mg daily orally for HF

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24
Q

Any other info on aldosterone antagonists

A

Spironolactone is weak diuretic, takes several days to act, so initially prescribed with loop or thiazide diuretic until it takes effect - this counteracts K wasting and potentiates diuretic effect
Normally 5:1 eg spiro 200mg furosemide 40mg

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25
Q

What drug is first line for BHP?

A

Alpha blockers

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26
Q

What drug is used in combination with ACE inhibitors, CCBs, and thiazide diuretics for resistant hypertension?

A

Alpha blockers eg doxazosin, tamsulosin, alfuzosin

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27
Q

What is the MOA of alpha blockers?

A

Block α1-adrenoceptor found in smooth muscle - causes vasodilatation and a fall in blood pressure, and reduced resistance to bladder outflow

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28
Q

Adverse effects of alpha blockers

A

Postural hypertension
Dizziness
Syncope
all more prominent after first dose

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29
Q

Absolute contraindications of alpha blockers

A

Existing postural hypertensions

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30
Q

Interactions of alpha blockers

A

Due to BP lowering effects, may be worth omitting one dose of current regime as BP tends to drop severely - particularly applicable to β-blockers

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31
Q

Administration of alpha blockers

A

Only available as oral tablet
Doxazosin 1mg orally daily then increased by 1mg weekly as needed (BPH and HTN)
Tamsulosin 400mcg orally daily (BPH only)

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32
Q

Any other info on alpha blockers

A

Due to hypertension risk, may be best to take this at bedtime

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33
Q

What drug is given as rhythm control for tachyarrhythmias eg AF, flutter, SVT, VT, VF?

A

Amiodarone

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34
Q

What is the MOA of amiodarone?

A

Blockade of sodium, calcium and potassium channels, and antagonism of α- and β-adrenergic receptors -> reduction in spontaneous depolarisation, can break reentry circuit and restore sinus rhythm

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35
Q

Adverse effects of amiodarone

A 
Hypotension - during IV infusion
Pneumonitis 
Bradycardia 
AV block 
Hepatitis 
Photosensitivity 
Grey discolouration 
Thyroid abnormalities
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36
Q

Absolute contraindications to amiodarone

A

Severe hypotensions
Heart block
Active thyroid disease

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37
Q

Interactions of amiodarone

A

Diltiazem, digoxin, verapamil - increases plasma concentrations of these, doses should be HALVED when started on amio

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38
Q

Administration of amiodarone

A

VF/pulseless VT - 300mg IV after 3rd shock

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39
Q

Any other info on amiodarone

A

IV infusion should always be accompanied by continuous cardiac monitoring

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40
Q

What is the drug that is first line for HTN?

A

ACEi

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41
Q

What is the drug that is first line for heart failure?

A

ACEi

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42
Q

What is the drug that is first line for ICD?

A

ACEi

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43
Q

What is the drug that is first line for diabetic nephropathy?

A

ACEi

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44
Q

What is the MOA of ACEi?

A

Block the action of the ACE, to prevent the conversion of angiotensin I to angiotensin II -> reducing of aldosterone promotes sodium and water excretion

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45
Q

Adverse effects of ACEi?

A 
Hypotension
Persistent dry cough 
Hyperkalaemia 
Renal failure 
Angioedema 
Anaphylactoid reactions
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46
Q

Absolute contraindications of ACEi

A

Renal artery stenosis
AKI
Pregnancy
Breastfeeding

47
Q

Relative contraindications of ACEi

48
Q

Interactions of ACEi

A

K elevating drugs - increased risk of hyperkalaemia

49
Q

Administration of ACEi

A

Ramipril 1.25mg orally OD (HF)

Ramipril 2.5mg orally OD everything else

50
Q

Any other info on ACEi

A

Best to take first dose before bed to counteract symptomatic hypertension

51
Q

What drugs are used when ACEi aren’t tolerated due to cough?

A

Angiotensin receptor blockers - losartan, candesartan, irbesartan

52
Q

What drug is first line for chronic heart failure?

53
Q

What drug is used for ischaemic heart disease?

54
Q

What are the three most commonly used ARBs?

A

Losartan, candesartan, irbesartan

55
Q

What is the MOA of ARBs

A

Block the action of angiotensin II on the AT1 receptor -> reduces afterload, lowers BP

56
Q

Adverse effects of ARBs

A

Hypotension
Renal failure
Hyperkalaemia

57
Q

Absolute contraindications of ARBs

A

Renal artery stenosis
AKI
Pregnancy
Breastfeeding

58
Q

Interactions of ARBs

A

K elevating drugs - increased risk of hyperkalaemia
Diuretics - in combination are associated with profound first dose hypotension
NSAIDs - in combination increases risk of renal failure

59
Q

Administration of ARBs

A

Losartan 12.5mg orally OD for HF
Losartan 50mg orally OD everything else
Can then be titrated up

60
Q

Any other info on ARBs

A

Need blood monitoring for kidney function

Avoid taking OTC NSAIDs eg ibuprofen - kidney damage

61
Q

What drugs are first line in the management of bradycardia?

A

Antimuscarinics eg atropine

62
Q

What drugs are first line in the treatment of IBD?

A

Antimuscarinics eg hyoscine butylbromide

63
Q

What drugs are used for management of respiratory secretions?

A

Antimuscarinics eg glycopyrronium

64
Q

What are the three most common antimuscarinics?

A

Atropine, hyoscine butylbromide, glycopyrronium

65
Q

What is the MOA of antimuscarinics?

A

Bind to the muscarinic receptor -> competitive inhibitor of acetylcholine -> increase heart rate and conduction; reduce smooth muscle tone and peristaltic contraction, reduce secretions from respiratory glands

66
Q

Adverse effects of antimuscarinics

A 
Tachycardia 
Constipation
Dry mouth
Urinary retention 
Blurred vision
Drowsiness and confusion in elderly
67
Q

Contraindications of antimuscarinics

A

Those susceptible to angle closure glaucoma

Arrhythmias

68
Q

Interactions of antimuscarinics

A

More pronounced effects when paired with other antimuscarinics eg tricyclic antidepressants

69
Q

Administration of antimuscarinics

A

Atropine IV in incremental doses eg 300-600mg every 1-2mins

Hyoscine butylbromide - 10mg 8hrly

70
Q

Any other info on antimuscarinics

A

If given for bradycardia, cardiac monitoring is needed

71
Q

What drug is first line for antiplatelet therapy?

72
Q

What is the MOA of aspirin?

A

Irreversibly inhibits COX to reduce production of the pro-aggregatory factor thromboxane from arachidonic acid, reducing platelet aggregation -> lasts for lifespan of platelet

73
Q

Adverse effects of aspirin

A

GI irritation
GI haemorrhage
Bronchospasm
Long term therapy causes tinnitus

74
Q

Contraindications of aspirin

A 
SHOULD NOT BE GIVEN TO CHILDREN UNDER 16 -> RISK OF REYE'S SYNDROME
Aspirin hypersensitivity
3rd trimester of pregnancy
Peptic ulceration 
Gout
75
Q

Interactions of aspirin

A

Acts synergistically with other antiplatelets - increased risk of bleeding
Can be given with anticoagulants but needs monitoring

76
Q

Administration of aspirin

A

ACS: loading dose 300mg, then 75mg orally OD
ICS: 300mg orally OD 2 weeks, then 75mg OD
AF/thrombosis prevention: 75mg orally OD
CONSIDER GI PROTECTION (omeprazole 20mg OD)

77
Q

Any other info on aspirin

A

To minimise GI irritation, take aspirin after food

Counsel patients to look out of bleeding/indigestion

78
Q

What drug is first line in ischaemic heart disease?

A

Beta blockers

79
Q

What drug is first line in SVT to restore sinus rhythm?

A

Beta blockers

80
Q

What drug is first line in AF to reduce ventricular rate?

A

Beta blockers

81
Q

What are the four most common beta blockers?

A

Bisoprolol, atenolol, propanolol, metoprolol

82
Q

What is the MOA of beta blockers?

A

Block β1 receptor -> reduce force of contraction, speed of conduction in the heart -> relieves myocardial ischaemia by reducing cardiac work and oxygen demand, increasing myocardial perfusion

83
Q

Adverse effects of beta blockers

A 
Fatigue
Cold extremities
Headache 
GI disturbance 
Nightmares
84
Q

Contraindications of beta blockers

A

Asthma
Heart block
Hepatic failure

85
Q

Interactions of beta blockers

A

NOT TO BE USED with non-dihydropiridine calcium channel blockers - verapamil, diltiazem - risk of bradycardia, HF, asystole

86
Q

Administration of beta blockers

A

Taken orally OD

IV metoprolol used only when rapid effect necessary

87
Q

Any other info on beta blockers

A

Warn of side effects

Safety net for HF deterioration and breathing difficulty on background of existing obstructive airway disease

88
Q

What is the drug that is given second line for HTN?

A

Calcium channel blockers

89
Q

What drug is given to control symptoms in stable angina?

A

Calcium channel blockers

90
Q

What drug is given to control cardiac rate in those with supraventricular arrhythmias?

A

Calcium channel blockers

91
Q

What are the four most common calcium channel blockers?

A

Amlodipine, nifedipine, diltiazem, verapamil

92
Q

What is the MOA of CCBs?

A

Decrease Ca2+ entry into vascular and cardiac cells -> reduction in intracellular calcium concentration -> relaxation and vasodilation in arterial smooth muscle, lowering arterial pressure

93
Q

Adverse effects of CCBs

A 
Ankle swelling
Flushing
Headache
Palpitations
Verapamil - constipation 
Bradycardia
Heart block
94
Q

Contraindications of CCBs

A

Unstable angina
Severe aortic stenosis
Poor LV function
AV nodal conduction delay

95
Q

Interactions of CCBs

A

Non dihydropyridine CCBs should be not be coprescribed with beta blockers - verapamil/diltiazem with bisoprolol, atenolol

96
Q

Administration of CCBs

A

HTN: amlodipine 5-10mg orally OD
Angina: diltiazem 90mg orally 12hrly
SVT: verapamil 40-120mg orally 8hrly

97
Q

Any other info on CCBs

A

Consider other measures to lower CV risk

Regular monitoring to judge efficacy on HTN/arrhythmias

98
Q

What drug is used to manage torsades de pointes?

A

Mag sulph IV

99
Q

What drug is co prescribed with aspirin for ACS?

A

Clopidogrel

100
Q

What drug is first line anti thrombotic?

A

Clopidogrel

101
Q

What is the MOA of clopidogrel?

A

Prevents platelet aggregation, reduces the risk of arterial occlusion -> binding irreversibly to ADP receptors (P2Y12 subtype) on platelet surface

102
Q

What drug is for coronary artery occlusion prevention?

A

Clopidogrel

103
Q

Adverse effects of clopidogrel

A

Bleeding - particularly GI
GI upset
Dyspepsia
Thrombocytopenia

104
Q

Contraindications to clopidogrel

A

Significant active bleeding

Renal and hepatic impairment

105
Q

Interactions of clopidogrel

A

Cytochrome P450 inhibitors may make clopidogrel less effective - omeprazole, cipro, erythomycin
Coprescription with antiplatelet drugs increases bleeding risk

106
Q

Administration of clopidogrel

A

300mg loading dose orally

75mg orally daily

107
Q

Any other info on clopidogrel

A

Binds irreversibly to platelets so should be stopped 7 days before surgery
Has synergistic action with aspirin

108
Q

What is given to expand circulating volume in circulatory compromise?

A

Colloid fluids

109
Q

What is the MOA of colloids?

A

Made up of ‘large’ molecules eg albumin, gelatin -> cannot diffuse out of cells -> osmotic pressure keeps fluid in plasma (70-80% remains in plasma, 20% of crystalloid remains in plasma)

110
Q

Adverse effects of colloids

A

Overadministration may cause CO fall and cardiac failure -> over stretching on Starling curve
Hypersensitivity reactions from gelatin
Oedema from Na in solution

111
Q

Contraindications of colloids

A

Fluid volume should be reduced in HF

Fluid balance needed in renal impairment

112
Q

Administration of colloids

A

IV
250ml in 10mins fluid challenge
Check for cannula patency

113
Q

What drug can cause hypokalaemia and flatten the T wave?

A

Thiazides - indapamide, bendroflumethazide

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