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Pre Reg- Furkan > Cardio > Flashcards

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1
Q

Which statin do you need to use in caution in Asian patients?

A

Rosuvastatin - higher risk of rhabdomyolysis
5-20mg max!

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2
Q

What are the four electrolyte imbalances with digoxin?

A

Hypokalaemia
Hypomagnesemia
Hypoxia
Hypercalcaemia

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3
Q

Which beta blocker has a long duration of action?

A

Nadalol

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4
Q

What is the VTE prophylaxis dose for rivaroxaban following hip replacement surgery?

A

10 mg once daily for 5 weeks, to be started 6–10 hours after surgery.

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5
Q

How long after opening GTN SL tablets do they need to be discarded?

A

8 weeks

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6
Q

What electrolyte imbalances are thiazides and related diuetics contraindicated in?

A

Hypokalaemia
Hyponatraemia
Hypercalcaemia

Addisons disease too

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7
Q

What are the contraindications of loop diuretics?

A

Hypokalaemia - can cause hepatic encephalopathy (use potassium-sparing diuretic to prevent this)
Hyponatraemia
Renal failure from nephrotoxic drugs

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8
Q

Name two weak potassium-sparing diuretics

A

Amiloride and triamterene

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9
Q

What drugs increase the risk of hyperkalaemia with potassium-sparing diuretics?

A

ACE/ ARB

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10
Q

Name two Aldosterone antagonists

A

Spironolactone
Eplerenone

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11
Q

Can you give potassium supplements with aldosterone antagonists?

A

No

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12
Q

Which beta blockers have intrinsic activity?

A

Causes less coldness extremities and bradycardia

Pindalol
Acebutolol
Celiprolol
Oxprenolol

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13
Q

Which beta blockers are more water-soluble?

A

Less of the drug moves to the brain = less sleep disturbance and nightmares
However, excreted by kidneys: caution in renal impairment

Celiprolol
Atenolol
Nadolol
Sotalol

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14
Q

Which beta blockers are once daily preparations?

A

Bisoprolol
Atenolol
Celiprolol
Carvedilol
Nadolol

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15
Q

Name a risk of the use of beta blockers in diabetic patients

A

Can mask the symptoms of hypoglycaemia as affects carbohydrate metabolism

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16
Q

Can beta blockers be suddenly stopped?

A

No because it can exacerbate angina

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17
Q

Can beta blockers be used with verapamil?

A

No because it can precipitate a risk of heart failure

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18
Q

What are the common side effects of beta blockers?

A

Dizziness
Fatigue
Blurred vision
Cold hands and feet
Bradycardia
Bronchospasm
Diarrhoea
Nausea

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19
Q

What are the contraindications for beta blockers?

A

Asthma
Block (heart block)
Cardiac failure
Diabetes mellitus (hypoglycaemic shock)
Extremities (occlusivearterial disease)

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20
Q

What are the main contraindications with rate-limiting calcium channel blockers?

A
  • Left ventricular dysfunction
  • Heart failure - participate HF
  • Diabetes - diltiazem may increase blood sugar
  • Unstable angina or MI - avoid within 1 month of MI, may increase mortality in patient with left ventricular dysfunction
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21
Q

What are some common calcium channel blocker side effects?

A

Ankle swelling
Flushing
Palpitations
Bradycardia (rate-limiting)
Hypotension
Dizziness
Gingival hyperplasia
Headache

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22
Q

What is the prescribing pathway for stable angina (myocardial ischaemia)?

A

1st line: BB
- Bisoprolol, propranolol, metaprolol, atenolol
2nd line: Rate-limiting CCB
- Verapamil or diltazium
3rd line: BB & CCB
4th line: Nitrate with BB/ CCB OR as monotherapy
- Ivabradine, nicroandil, ranolazine

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23
Q

How do you protect against cardiovascular events in patients with stable angina?

A

Low dose aspirin
Statin

Consider ACEi especially in diabetic patients

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24
Q

What are the common side effects for Ranolzine?

A

Asthenia
Constipation
Vomiting
Head

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25
Q

Can you use ranolzine in renal impairment?

A

Avoid if CrCl <30ml/min
Caution in CrCl between 30-80ml/min

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26
Q

What are some important contraindications for Ivabradine?

A

Do not initiate for angina if HR <70
Do not initiate for heart failure if HR <75
2nd and 3rd degree heart block
Severe hypotension

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27
Q

What are the common side effects of ivrabradine?

A

Arrthymias
Atrioventricular block
Dizziness
Headache
Hypertension
Vision disorders

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28
Q

What are the common side effects of Nicorandil?

A

Can cause serious skin, mucosal and eye ulcerations including GI ulcers - discontinue treatment

Asthenia
Dizziness
Haemorrhage
Headache
Nausea
Vasodilation
Vomiting

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29
Q

If max. dose statin fails to control statin, what would be the recommendation?

A

Max dose statin + ezetimibe

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30
Q

Can a patient be prescribed a statin and a fibrate?

A

It increases the risk of muscle-related side effects and rhabdomyolysis therefore, it must be done under specialist supervision

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31
Q

Which fibrate must not be used with statins?

A

Gemfibrozil - increases risk of rhabdomyolysis considerably

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32
Q

What drug management should you consider for patients with primary heterozygous familial hypercholesterolemia whose LDL-cholesterol is not controlled on maximum tolerated lipid-lowering therapy?

A

Alirocumab
Evolocumab

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33
Q

What should you measure if a patient is experiencing muscle side effects with statins?

A

creatine kinase concentrations

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34
Q

What symptoms should you seek medical attention for if developed with a statin?

A

dyspnoea
cough
weight loss

All signs of interstitial lung disease (scarring of the lungs)

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35
Q

What is the contraception requirements for statins?

A

Adequate contraception is required during treatment and for one month after

Must be stopped 3 months before attempting to conceive as teratogenic

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36
Q

Which liver function test may prompt discontinuation of statins?

A

If serum transaminases are more than 3 times the upper limit of the reference range

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37
Q

What factor increases the risk of rhabdomyolysis with statins?

A

Hypothyroidism

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38
Q

What are the main symptoms of heart failure

A

SOB
Persistent cough or wheezing
Ankle swelling
Reduced exercise tolerance
Fatigue

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39
Q

What are the risk factors of heart failure?

A

Men
Diabetes
Smokers
Increased age
African-Caribbean patients with hypertension
Coronary heart disease

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40
Q

What are the complications of heart failure?

A

AF
CKD
Depression
Cachexia
Sexual dysfunction
Sudden cardiac death

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41
Q

What is reduced ejection fraction heart failure?

A

The left ventricle of the heart loses its ability to contract normally and presents with less than 40% ejection fraction

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42
Q

What is preserved ejection fraction heart failure?

A

The left ventricle uses its ability to relax normally = ejection fraction is normal or mildly reduced

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43
Q

What is the maximum salt intake in heart failure?

A

6g

Salt substitutes containing potassium should be avoided - risk of hyperkalaemia

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44
Q

What drugs should be avoided in reduced ejection heart failure?

A

Rate-limiting CCB and short-acting dihydropyridines (nifedipine or nicardipine)

These drugs reduce cardiac contractility

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45
Q

Which kind of diuretic is usually recommended in heart failure?

A

Loop diuretics
- relief of breathlessness and oedema

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46
Q

When should thiazide diuretics be avoided in renal impairment?

A

eGFR <30ml/min

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47
Q

Which beta blockers are licensed for heart failure?

A

Bisoprolol
Carvedilol
Nebivolol

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48
Q

Which ARBs are licensed for heart failure?

A

Losartan
Candesartan
Valsartan

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49
Q

What is the treatment pathway for heart failure?

A

Loop diuretic for symptomatic relief
1st: ACEi/ARB or BB
2nd: Spironolactone/ eplerenone (add-on) - unless contraindicated due to hyperkalemia or renal impairment

If ACE/ARB not tolerated: under specialist advice, hydralazine combined with a nitrate can be given considered if pt intolerant of ACEi/ARB
If symptoms persist, specialist should consider: SGLT2 OR replace ACE with sacubitril valsartan OR digoxin in sinus rhythm OR ivabradine

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50
Q

How do you treat a patient in sinus rhythm with worsening or severe HF despite optimal treatment?

A

Add-on therapy of digoxin

Also, consider an anticoagulant in patients with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus

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51
Q

Which beta blocker is least likely to cause bronchospams?

A

Atenolol

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52
Q

Which beta blockers are cardioselective?

A

B A MAN

Bisoprolol
Atenolol
Metoprolol
Acebutolol (to a lesser extent)
Nebivolol

These have a lesser effect on airway resistance but are not completely free from bronchospasm as a side effect

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53
Q

What is the prescribing pathway for a pregnant woman with HTN?

A

1st line: Labetalol
2nd line: nifedipine
3rd line: methyldopa

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54
Q

What are the BP targets with patients with diabetes?

A

T2DM - <140/90
T1DM - <135/85

If T1/2DM with complications- <130/80

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55
Q

What are the risks of digoxin toxicity?

A

HypOkalaemia
HypOmagnesaemia
HyERrcalcaemia
Hypoxia
Renal impairment

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56
Q

What are the signs of digoxin toxicity?

A

GI signs: N/V, abdominal pain, diarrhoea
Metabolic signs: hyperkalemia
CVS signs: bradycardia, hypotension
CNS signs: lethargy, confusion
Eyes: blurred, eye vision

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57
Q

Which drugs interact with digoxin?

A

CRASED

CCBs
Rifampicin
Amiodarone
St Johns Wort
Erythromycin
Diuretics

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58
Q

What antibiotics interact with warfarin?

A

Co-trimoxazole
Metronidazole
Macrolides
Fluroquinolones
Rifampicin

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59
Q

What are the requirements for ivabradine to be considered for HF?

A

In sinus rhythm
HR >75bpm
Ejection fraction <35%

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60
Q

What antifungals interact with warfarin?

A

Miconazole
Fluconazole

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61
Q

What antidepressants interact with warfarin?

A

SSRIs

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62
Q

What are the side effects of amiodarone?

A

Corneal deposits
Phototoxicity
Slate-grey skin
Peripheral neuropathy
Pulmonary fibrosis
Hepatoxicity
Thyroid dysfunction

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63
Q

What are the contraindications for aspirin?

A

Active peptic ulceration
Bleeding disorders
Children under 16 due to risk of Reye’s syndrome - unless Kawasaki disease
Haemophilia
Previous peptic ulceration (analgesic dose)
Severe cardiac failure

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64
Q

What is the adrenaline dose for anyone >12?

A

500mcg IM (0.5ml)
OR
300mcg (0.3ml) if child is small or prepubertal

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65
Q

What is the adrenaline dose for children between 6-12?

A

300mcg IM (0.3ml)

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66
Q

What is the adrenaline dose for children <6?

A

150mcg (0.15ml)

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67
Q

What are the side effects of CCBs?

A

Dizziness
Flushing
Headache
Hypotension
Palpitations
Ankle swelling
Angioedema
ED
Gingival hyperplasia
Constipation - most likely with verapamil
Bradycardia, AV block and HF - with verapamil

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68
Q

What are the ADR of Ivabradine?

A

Visual effects (luminous phenomena)

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69
Q

Which heparin poses a higher risk of heparin-induced thrombocytopenia and osteoporosis?

A

Unfractioned heparin

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70
Q

Which heparin is preferred in renal impairment?

A

Unfractioned heparin

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71
Q

Which heparin is longer acting?

A

LMWH

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72
Q

Who should you not offer compression stockings to?

A

A patient admitted to the hospital with acute stroke or those that have:
- peripheral arterial disease
- peripheral neuropathy
- severe leg oedema
- local conditions

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73
Q

How quickly should you start thromboprophylaxis?

A

Within 14 hours of hospital admission

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74
Q

What type of surgical patients is fondaparinux preferred for?

A

Patients undergoing abdominal, bariatric, thoracic, and cardiac surgery or patients with lower limb immobilisation or fragility fractures to the pelvis, hip or proximal femur

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75
Q

What is the thromboprophylaxis treatment for a patient undergoing elective hip replacement?

A

Option 1: LMWH for 10 days followed by low dose aspirin for 28 days

Option 2: LMWH for 28 days with anti-embolism stockings until discharge

Option 3: rivaroxaban

If unsuitable, consider apixaban and dabigatran

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76
Q

What is the thromboprophylaxis treatment for a patient undergoing elective knee replacement?

A

Option 1: low-dose aspirin for 14 days

Option 2: LMWH for 14 days with anti-embolism stockings until discharge

Option 3: rivaroxaban

If unsuitable, consider apixaban and dabigatran

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77
Q

How do you treat proximal DVT or PE?

A

Apixaban or rivaroxaban

if unsuitable offer either:
- LMWH for at least 5 days followed by dabigatran or edoxaban
- LMWH with a vitamin K antagonist for at least 5 days or until INR at least 2 for 2 executive readings followed by a vitamin K antagonist on its own (this option is not routinely recommended fot proximal DVT/PE unless patient has renal impairment or at increased risk of bleeding)

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78
Q

What is the renal impairment limit for dabagatran?

A

Should not be used in eGFR <30ml/min

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79
Q

What do you use to reverse Heparin action?

A

Protamine sulfate

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80
Q

What is a transient ischaemia stroke (TIA)?

A

A stroke that only lasts a few minutes

Should receive aspirin immediately

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81
Q

What is the treatment for an acute ischaemia stroke?

A
  • Alteplase if administered within 4.5 hours of symptom onset and intracranial haemorrhage excluded
  • Aspirin should be started within 24 hours of symptom onset with a PPI if history of dyspepsia with aspirin
  • ONLY if high risk of VTE = parenteral anticoagulant
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82
Q

What drugs should you avoid in ischemic stroke?

A

Warfarin
Anticoagulants

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83
Q

What is the aspirin treatment for patients with disabling ischaemic stroke and atrial fibrillation?

A

Aspirin for at least 2 weeks before anticoagulants

84
Q

What is the long-term management of TIA or ischaemic stroke (not associated with AF?

A

Clopidogrel

If clopidogrel not tolerated or contraindicated: MR dipyridamole and aspirin

if aspirin and clopidogrel not tolerated or contraindicated: MR dipyridamole alone

If clopidogrel and dipyridamole contraindicated or not tolerated: aspirin alone

Also, add high-intensity statin within 48 hours after stroke symptoms if not already taking irrespective of serum-cholesterol concentration

85
Q

What class of drugs should not be used in the management of hypertension following stroke?

A

Beta-blockers unless they are indicated for co-existing conditions

86
Q

What is the onset of action of vitamin k antagonist?

87
Q

Within how many units is INR considered generally satisfactory?

88
Q

What is the course of action for a patient who has a major bleed while on warfarin?

A
  1. stop warfarin
  2. give IV phytomenadione
  3. give dried thrombin complex (if unavailable - give fresh frozen plasma can be given but less effective)
89
Q

What is the course of action for a patient with an INR of >8 and who has a minor bleed while on warfarin?

A
  1. stop warfarin
  2. give IV phytomenadione
  3. after 24 hours: if INR still high repeat phytomenadione dose
  4. when INR <5, restart warfarin
90
Q

What is the course of action for a patient with an INR of >8 but has no bleeding while on warfarin?

A
  1. stop warfarin
  2. give phytomenadione orally (but using the intravenous preparation orally)
  3. after 24 hours: if INR still high repeat phytomenadione dose
  4. when INR <5, restart warfarin
91
Q

What is the course of action for a patient with an INR of 5-8 with minor bleeding while on warfarin?

A
  1. stop warfrain
  2. give IV phytomenadione
  3. when INR <5, restart warfarin
92
Q

What is the course of action for a patient with an INR of 5-8 but has no bleeding while on warfarin?

A

Withhold 1 or 2 doses and reduce subsequent maintenance dose

93
Q

When should warfarin be stopped before elective surgery?

A

5 days before

If INR more than or equal to 1.5 the day before surgery - give phytomenadione orally

If hemostasis adequate - resume normal warfarin dose evening of surgery or next day

94
Q

What should you do if a warfarin patient requires surgery but is at high risk of VTE?

A

bridge with LMWH treatment dose but stopped 24 hours before the surgery

If surgery carries high risk of bleeding, LMWH should not be restarted until at least 48 hours after

95
Q

What should you do if a warfarin patient requires emergency surgery?

A

If surgery can be delayed by 6-12 hours: give IV phytomenadione to reverse warfarin effects

If surgery cannot be delayed: give IV phytomenadione and dried thrombin complex and check INR before surgery

96
Q

What is used for the reversal of dabigatran?

A

Adarucizumab

97
Q

What is used for the reversal of apixaban or rivaroxaban?

98
Q

What must be controlled before aspirin is given in primary prevention?

A

Hypertension

99
Q

How long after opening MR dipyridamole must they be discarded?

100
Q

Can you use apixaban in renal impairment?

A

Avoid in less than 15ml/min

Reduce dose to 2.5mg BD if serum creatinine 133micromol/L (CrCl 15-29ml/min) and over and is 80 or over or has a body weight of 60kg or less

101
Q

What is the secondary prevention of cardiovascular disease - acute coronary syndrome (STEMI, NSTEMI, stable angina)?

A

Aspirin 75mg daily + 2nd antiplatelet for 12 months

Options:
- clopidogrel 75mg daily
- Prasugrel 5 mg once daily (10 mg if body weight is 60 kg or more and the patient is under the age of 75)
- Ticagrelor 90 mg twice daily for up to 12 months (reduced to 60 mg twice daily if treatment is extended beyond 12 months)

102
Q

What must you discontinue in heart failure before introducing an ACEi?

A

Potassium supplements or potassium-sparing diuretics due to the risk of hyperkalemia

However, low-dose spironolactone can be used but monitor potassium closely

103
Q

What is the secondary prevention of cardiovascular disease - peripheral arterial disease (PAD)?

A

Clopidogrel 70mg is preferred for the preventions of occlusive vascular events

If contraindicated, low-dose aspirin

For those at high risk of ischaemic events and low risk of bleeding - specialists recommended rivaroxaban 2.5mg BD + aspirin

104
Q

What is the secondary prevention of cardiovascular disease - Percutaneous coronary intervention?

A

Those with stable coronary arterial disease undergoing PCI

  • Aspirin and clopidogrel 75mg for 6 months
    if high risk of bleeding = 1-3 month treatment
    high ischaemia risk but no bleeding complications = up to 36 months
105
Q

Patients with what condition are more susceptible to hyperkalemia with an ACEi?

A

Patients with diabetic nephropathy should not be given ACEi and ARB

106
Q

What is the interaction between lithium and furosemide?

A

Furosemide increases concentration of lithium = lithium toxicity

Side effects: Vomiting, diarrhoea, muscle weakness, tremor, confusion

107
Q

What are the electrolyte imbalances with furosemide?

A

Hyponatraemia
Hypomagnesaemia
Hypokalaemia
Hypocalcaemia

108
Q

What are other ADRs of furosemide other than electrolyte imbalances?

A

Ototoxicity
Hypotension
Metabolic acidosis
Renal impairment from dehydration and direct toxic effect
Hyperglycaemia but less common than with thiazides

109
Q

What are the main drugs that furosemide interacts with?

A

Lithium
Digoxin
Amiodarone
Citalopram
Quinine
Macrolide antibiotics

110
Q

What conditions can loop diuretics exacerbate?

A

Diabetes
Gout

111
Q

Which diuretic is used for cerebral oedema and raised intra-ocular pressure?

112
Q

What is the treatment for secondary prevention of an MI?

A
  1. anti-platelet therapy (aspirin longterm and ticagrelor for 12 months)
  2. ACEi
  3. BB
  4. Statin
113
Q

What is the management of AF maintenance?

A

1st RATE CONTROL:
- beta blocker (not sotalol)
- RL CCB
- Digoxin for non-paroxysmal AF (preferred for those with sedentary lifestyles)

2nd RHYTHM CONTROL
- pharmacological cardioversion: amiodarone, flecainide (if not structural heart disease), sotaolol

Reduce stroke:
- CHAD2DS2VASc if score more than 2 in women and more than 1 in men
- Warfarin or DOAC

114
Q

What is CHAD2DS2VASc score?

A

A tool to assess a person’s stroke risk

115
Q

What drugs does clopidogrel interact with?

A

Reduced antiplatelet effects:
Carbamazepine
Cimetidine
Chloramphenicol
Ciprofloxacin
Erythromycin
Fluconazole
Omeprazole

The antiplatelet effect enhances the anticoagulant effect – increased risk of bleeding:
Warfarin - avoid

116
Q

Which OTC painkiller should you avoid with ACEi/ARBs?

A

Ibuprofen - increased risk of hyperkalaemia especially when given with spironolactone or eplerenone

117
Q

What is the interaction between SSRI and rivaroxaban?

A

Increased risk of bleeding - severe interaction

118
Q

Do amiodarone and simvastatin interact?

A

yes - increased risk of muscle side effects because amiodarone increases exposure of simvastatin

119
Q

What drink interacts with amlodipine?

A

Grapefruit juice

120
Q

What is the maximum atorvastatin dose with ciclosporin?

A

Atorvastatin 10mg

121
Q

What is the maximum simvastatin dose with ticagrelor 90mg tablets?

A

Simvastatin 40mg

122
Q

What is the maximum simvastatin dose with amlodipine?

A

Simvastatin 20mg

123
Q

What is the maximum simvastatin dose with ranolazine MR 375mg tablets?

A

Simvastatin 20mg

124
Q

What are the administration instructions for perindopril?

A

Take 30-60 minutes before food

125
Q

Which antihypertensive, if stopped abruptly, can cause rebound hypertension?

A

Clonidine hydrochloride

126
Q

Which co-morbidity is least likely to co-exist with heart failure?

127
Q

What is the clinic reading for stage 3 hypertension?

A

180/120 mmHg

128
Q

Which thiazide diuretic is least likely to cause hyperkalemia?

A

Indapamide - causes hypokalaemia

129
Q

What are the side effects associated with indapamide?

A

Hyponatraemia
Hypokalaemia
Cardiac arrhythmias
May increase blood glucose
May increase LDL
Impotence in men

130
Q

What is the dose for bendroflumethiazide for hypertension and oedema?

A

Hypertension: 2.5mg OD
Oedema: 5mg OD

131
Q

What is the maximum dose of simvastatin with amiodarone?

A

Simvastatin 20mg

132
Q

What is the maximum simvastatin dose with amlodipine and diltiazem?

A

Simvastatin 20mg

133
Q

Which drug causes nightmares and sleep disturbances?

A

Propranolol

134
Q

What is an important MHRS warning for Hydrochlorothiazide?

A

Can cause non-melanoma skin cancer, particularly in long-term use
- Seek medical attention

135
Q

What is the general serum creatinine for a healthy male?

A

84-110 micromol/L

136
Q

What is the risk of furosemide in pregnancy?

A

hypovolaemia

137
Q

What is the interaction between statins and macrolides?

A

Risk of rhabdomyolysis

138
Q

What is the interaction between gentamicin and loop diuretics?

A

Risk of renal failure

139
Q

What is the interaction between ACEi and potassium-sparing diuretics?

A

Hyperkalaemia risk

140
Q

What is the interaction between ACEi and metformin?

A

Enhance hypoglycaemic effect

141
Q

What is the interaction between statins and amiodarone?

A

Risk of rhabdomyolysis

142
Q

What is the interaction between thiazide diuretics and PPIs?

A

Hyponatraemia

143
Q

What is the interaction between thiazide diuretics and lithium?

A

Increased lithium toxicity

144
Q

What is the initial ACS treatment?

A

Sublingual/ buccal GTN for pain releief
IV morphine also for pain relief especially in MI
Aspirin loading dose
2nd antiplatelet (prasugrel, ticagrelor (180mg) & clopidogrel - prasugrel preferred if undergoing primary PCI

145
Q

What is the secondary prevention of cardiovascular events?

A
  • ACEi/ARB
  • BB (continue indefinitely in reduced left ventricular ejection fraction otherwise discontinue after 12 months)
    Consider diltiazem or verapamil as an alternative to BB in pt’s who do not have pulmonary congestion or reduced LVEF
  • Dual antiplatelet therapy (aspirin indefinitely, 2nd antiplatelet for 12 months)
    if aspirin contraindicated = clopidogrel monotherapy
    Another option: rivaroxaban with either aspirin alone or aspirin and clopidogrel (this option is recommended for elevated cardiac biomarkers)
  • Statin
146
Q

What thrombolytic drugs are used to treat MI?

A

Streptokinase and alteplase - found to reduce mortality
For acute MI: reteplase and tenecteplase
- Alteplase: given within 6-12 hours of symptom onset
- Reteplase and streptokinase: within 12 hours of symptom onset
- Tenecteplase: usually within 6 hours
Ideally all should be given within an hour

147
Q

What is the digoxin dose for heart failure?

A

62.5mcg-125mcg

148
Q

What is the digoxin dose for AF?

A

125mcg-250mcg

149
Q

What drugs do you need to half the dose of digoxin dose with?

A

Amiodarone
Dronedarone
Quinine
If digoxin or another cardiac glycoside has been given in the preceding 2 weeks
In elderly

150
Q

When would you increase digoxin dose?

A

When switching from IV to oral - increase dose by 20-33% to maintain the same plasma digoxin concentration

151
Q

Which drugs increase plasma digoxin levels?

A

Amiodarone
Rate limiting CCB
Macrolides
Ciclosporin

152
Q

Which drugs decrease plasma digoxin levels?

A

St John’s Wort
Rifampicin

153
Q

What drug class is angioedema more likely to happen in?

A

ACEi - common
Uncommon - CCB

154
Q

Which drugs can cause hypokalaemia?

A

Diuretics
B2 agonists
Steroids
Theophylline

(These drugs predispose digoxin)

155
Q

Which drugs decrease renal excretion?

A

NSAIDs
ACEi/ARB

(reduce digoxin dose when taking these as digoxin is also renally excreted)

156
Q

What are the common side effects of Nicorandil?

A
  • Skin, mucosal and eye ulcers (including GI) - stop treatment if ulcers occur (e.g. anal ulcers)
  • Headache: common on initiation
  • Flushing
  • Asthenia
  • Hyperkalaemia
  • Abdominal pain
  • N/V
  • Diplopia (double vision)
157
Q

What is the treatment of stable angina?

A

1st line: BB (atenolol, bisoprolol, metoprolol, propranolol)/ rate limiting CCB (if BB contraindicated)
2nd line: BB + rate limiting CCB
3rd line: long-acting nitrate
- Ivabradine
- Nicorandil
Ranolazine

(secondary prevention = Aspirin + statin)

158
Q

What are the contraindications for BBs for stable angina?

A

Prinzmetals angina
Decompensated HF

159
Q

What drugs would you consider in prinzmetals angina?

A

Dihydropyridine derivatives
- Amlodipine

160
Q

What are the adverse effects of diuretics?

A

Hypotension
Ototoxicity
HYPO-Na/K/Mg/Ca
Hyperglycaemia (more common with thiazides)
Metabolic acidosis
Renal impairment from dehydration
Gout

161
Q

Which drugs should be avoided in heart failure with reduced ejection fraction?

A

Rate limiting CCBs
Short-acting dihydropyridines - nifedipine or nicardipine

They reduce cardiac contractility

162
Q

Which class of drugs turns your urine blue?

A

ENaC blockers e.g. Triamterene amiloride
Indication: used with thiazide or loop diuretics as an alternative to K supplementation
- Never give with aldosterone antagonists (spironolactone/ eplerenone)

163
Q

How do you treat fluid overload in HF?

A

Used to relieve breathlessness and oedema
Typically with Loop diuretics e.g. furosemide, bumetanide, torasemide

Thiazides only of benefit in patients with mild fluid retention and an eGFR of >30ml/min

164
Q

How is chronic heart failure with reduced ejection fraction treated?

A

1st line: ACEi/ARB +BB (bisoprolol, carvedilol, nebivolol)
2nd line: mineral corticosteroid receptor antagonist - spironolactone/ eplerenone (add-on therapy)

If intolerant of ACEi AND ARB: consider hydralazine + nitrate (esp in African Caribbean with moderate-severe HF)

3rd line: Amiodarone, digoxin, sacubitril with valsartan, ivabradine, empagliflozin, dapagliflozin

digoxin is recommended in sinus rhythm

165
Q

Which ARBs are licensed for heart failure?

A

Candasartan, Losartan, Valsartan

166
Q

What is the ADRs of spironolactone?

A

HYPERkaemia
HYPOnatraemia
HYPERchloraemic acidosis
HYPERtrichosis
Gynaecomastia
Change in libido
SCARS severe cutaneous adverse rxns
AKI

167
Q

What are the main interactions of spironolactone?

A

ACEi/ARB
Lithium
Digoxin
NSAIDs

168
Q

What is the interaction between isosorbide mononitrate and sildenafil?

A

Increased risk of hypotension - severe interaction avoid

169
Q

How is MR isosorbide mononitrate taken?

170
Q

When should you stop the use of isosorbide mononitrate in the elderly?

A

If prescribed a long-acting nitrate with persistent postural hypotension - recurrent drop in systolic BP less than or equal to 20mmHg

171
Q

What are some ADRs of isosorbide mononitrate?

A

FLushing
Dizziness
Hypotension
Headache
Tachycardia
Hypersensitivity
Circulation collapse

172
Q

What are the statin doses for primary prevention?

A

ATorvastatin 20mg
Simvastatin 40mg

173
Q

What are the modifiable risk factors for ACS?

A

Smoking
Obesity
HTN
Hyperlipidaemia
T2DM

174
Q

What are the non-modifiable risk factors for ACS?

A

Increasing age
Male
Family history of ischaemia heart disease

175
Q

What is the management of an NSTEMI?

A

Antiplatelet - aspirin 300mg and tricagrelor/pasugrel for 12 months
Anticoagulant - fondaparinux, UFH, LMWH
BB
Consider glycoprotein llb/llla antagonist (eptifibatide or trifiban) for those scheduled for angiography
Coronary angiography within 96 hours of admission

176
Q

What condition is nifedipine used first line for?

A

Raynaud’s syndrome - impact on blood circulation

Can cause painful vasospasm in response to cold or stress

Brand must be specified

177
Q

Which drug works by inhibiting the intestinal absorption of cholesterol?

178
Q

What is the target blood pressure for a pregnant woman?

A

135/85mmHg

179
Q

What is the interaction between CCBs and Alpha-blockers?

A

Enhanced hypotensive effect and increases risk of first dose hypotension

180
Q

What is the maximum infusion rate for furosemide?

A

4mg/minute

181
Q

What is the initial loading dose for amiodarone?

A

200mg TDS for 7 days
200mg BD for 7 days
200mg OD maintenance dose

182
Q

What is the contraindication for adenosine?

A

Asthma - bronchospams

183
Q

What drug enhances the effects of adenosine?

A

Dipyridamole
- dipyridamole increases exposure of adenosine

184
Q

What drug blocks the effects of adenosine?

A

Theophylline

185
Q

What are the adverse effects associated with adenosine?

A

chest pain

bronchospasm

transient flushing

can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

186
Q

How do you treat paroxysmal supraventricular tachycardia?

A

1st line: reflux vagal stimulation - immersing face in ice-cold water, carotid sinus massage, Valsalva manoeuvre
2nd line: IV adenosine, if contraindicated = IV verapamil

Recurrent episodes: catheter ablation/ diltiazem/ verapamil/ sotalol/ flecainide/ propafenone

187
Q

What are the adverse effects associated with ivabradine?

A

Visual effects, particular luminous phenomena, are common
headache
bradycardia
heart block

188
Q

What type of treatment is preferred for AF when onset of symptoms is more than 48hrs?

A

Rate control

189
Q

What class of drugs should be avoided in suspected concomitant acute decompensated HF with AF?

190
Q

How do you treat AF with rate control?

A

1st line: BB (not stall)
2nd line: Rate limiting CCB
3rd line: Digoxin - only for initial rate control in patients with non-paroxysmal AF who are predominantly sedentary or when rate-limiting drugs are unsuitable

If monotherapy fails = consider 2 drugs from above
If this fails = rhythm control
If ventricular function diminished (LVEF <40%) = BB + digoxin preferred

191
Q

How do you treat an acute presentation of AF for heamodynamically stable patients?

A

IV BB
OR
Verapamil if LVEF > or equal to 40%

192
Q

How do you maintain sinus rhythm post-cardioversion?

A

1st line: standard BB
2nd line: anti-arrhythmic drugs - amiodarone, flecainide, propafenone

193
Q

When should flecainide and propafenone be avoided?

A

Ischaemia or structural heart disease

For patients with left ventricular impairment or heart failure: consider amiodarone
- 2nd line would be considered dronedarone in patients with persistent or paroxysmal AF

194
Q

How can you treat episodes of symptomatic paroxysmal AF using rhythm control?

A

‘pill in pocket’

195
Q

How do you treat bradycardia post-MI (arrhythmias after MI)

A

Particularly if complicated by hypotension
Atropine sulfate
Failed to respond: adrenaline

196
Q

What is the VTE prophylaxis dose rivaroxaban following knee replacement?

A

10 mg once daily for 2 weeks, to be started 6–10 hours after surgery.

197
Q

What is the eGFR limit for flecainide?

A

If eGFR <35ml/min - reduce dose to maximum of 100mg daily

198
Q

What is a serious risk of SGLT2?

A

Fournier’s gangrene - redness and swelling around genitals and fever

199
Q

When are troponin I levels taken?

A

troponin I levels are taken immediately after chest pain is experienced and then after 12 hours to identify if the patients troponin levels have decreased

When heart muscle is damage, troponin leaks into blood stream and levels increase

200
Q

Which thiazide or thiazide related diuretic can be used in eGFR less than 30ml/min?

A

Metolazone

201
Q

Which type of CCB is vasocilatory adverse effects more associated with?

A

dihydropyridine calcium-channel blockers

Flushing, headaches, postural hypotension, ankle swelling

202
Q

Which lipid are fenofibrates best at lowering?

A

Triglyceride

203
Q

What monitoring is required when starts ACEi, ARB or mineralcorticoid receptor antagonist in HF?

A

1-2 weeks after starting treatment and at east dose increment then every 3 months then every 6 months:
Potassium
Sodium
Renal function

204
Q

What is monitored when BBs are initiated?

205
Q

What is the initial furosemide dose for patients with HF and preserved ejection fraction?

A

Furosemide 80mg

206
Q

What is the management of an NSTEMI?

A

300mg ASAP
Fondapabruinx
Reperfusion (PCI or fibrinolysis) therapy OR medicines management

Medication management:
- ticagrelor + aspirin (if high risk bleeding - clopidogrel + aspirin)

207
Q

Which beta blockers are licensed for AF?

A

Atenolol, acebutaolol, propranolol, metaprolol, nadolol, oxprenolol

Pre Reg- Furkan (14 decks)

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