Cardio

Question 1

ACS includes what?

Answer 1

Unstable angina, myocardial infarction with or without ST-segment elevation.

Question 2

Unstable angina and ST-segment elevation myocardial infarction (STEMI) are related acute coronary syndromes. Why do they usually occur?

Answer 2

As a result of atheromatous plaque rupture, and are often characterised by stable angina that suddenly worses, recurring or prolonged angina at rest, or new onset of severe angina.

Question 3

Patients with unstable angina differ from those with NSTEMI how?

Answer 3

Unstable angina = no evidence of myocardial necrosis, whereas in NSTEMI, myocardial necrosis (less significant than with STEMI) will be evident.

Question 4

What five drugs/drug classess are used in the initial management of ACS?

Answer 4

Oxygen if evidence of hypoxia, pulmonary oedema.Nitrates to relieve ischaemic pain, if sublingual is not effective, intravenous or buccal glycerl trinitrate or IV isosorbide dinitrate is given. Diamorphine hydrochloride or morphine can be given by slow IV injection; an antiemetic such as metoclopramide should also be given. Aspirin (chewed or dispersed in water) is given for its antiplatelet effect. Clopidogrel as well should be given. Also heparin, LMWH or fondaparinux sodium. Patients without contra-indications should receive beta-blockers which should be continued indefinitely.

Question 5

When is oxygen administered in the treatment of ACS?

Answer 5

If there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia. Caution with COPD.

Question 6

Why are nitrates used in ACS management? What different ones should be used?

Answer 6

Used for ischaemic pain. If sublingual glyceryl trinitrate is not effective then IV or buccal routes or IV isosorbide dinitrate.

Question 7

What form of isosorbide is used in the management of ACS?

Answer 7

Dinitrate

Question 8

When are opioids used in ACS?

Answer 8

If pain continues despite nitrates, diamorphine or morphine can be given by slow intravenous injection; an antiemetic such as metoclopramide should also be given.

Question 9

What drugs should be given for their antiplatelet effects in ACS?

Answer 9

Aspirin (Chewed or dispersed in water) should be given and so should clopidogrel.

Question 10

What is an alternative to clopidogrel in certain patients undergoing PCI?

Answer 10

Prasugrel.

Question 11

When would eptifibatide or tirofiban be used for unstable agina or for NSTEMI?

Answer 11

When patients at a high risk of either MI or death.Glycoprotein IIb/IIIa inhibitors. Eptfibatide must be used with heparin (unfractionated) and aspirin. Tirofiban must be used with heparin (unfrac), aspirin and clopidogrel.

Question 12

What must the glycoprotein IIb/IIIa inhibitor Eptfibatide be used in combination with?

Answer 12

Heparin (unfrac) and aspirin.

Question 13

What must the glycoprotein IIb/IIIa inhibitor Tirofiban be used in combination with?

Answer 13

Heparin (unfrac), aspirin and clopidogrel.

Question 14

In ACS, patients without contra-indications should receive beta-blockers which should be continued indefinitely. In patients without left ventricular dysfunction and in whom beta blockers are inappropriate, what can be given?

Answer 14

Rate-limiting CCBs diltiazem and verapamil.

Question 15

What is the main difference between the treatment of STEMI of UA/NSTEMI?

Answer 15

Because a STEMI is sudden complete blockage of a heart artery, the patency of the occluded artery can be restored by PCI or by giving a thrombolytic drug. PCI is preferred and patients undergoing PCI chould be given either heparin (unfrac) or a LMWH; bivalirudin is an alternative to the combination of a glycoprotein IIb/IIIa inhibitor plus a heparin.

Question 16

What is the difference between NSTEMI and STEMI?

Answer 16

STEMI is caused by a sudden complete (100%) blockage of a heart artery. An NSTEMI is caused by a severely narrowed artery but the artery is not normally completely blocked.

Question 17

In patients recieving treatment for STEMI who cannot be offered percutaneous coronary within 90 minutes, what should be offered?

Answer 17

A thrombolytic drug should be administered along with either heparin (unfrac) (for a maximum of 2 days), a low molecular weight heparin or fondaparinux sodium.

Question 18

Patients with STEMI who do not reveive reperfusion therapy (with percutaneous coronary intervention or a thrombolytic) should be treated with what?

Answer 18

Either fondaparinux sodium, enoxaparin sodium, or heparin (unfrac).

Question 19

ACEi and ARB (if ACEi not tolerated) should be started within how many hours of STEMI and continued for how long?

Answer 19

Within 24 hours, continued for at least 5-6 weeks.

Question 20

Following an STEMI, what drugs should ideally be started in a patient with no previous regular medicines or contra-indications/intolerances to medicines?

Answer 20

Aspirin + the addition of clopidogrel. Beta-blockets such as acebutolol, metoprolol, propranolol and timolol. For patients with left ventricular dysfunction: carvedilol, bisoprolol or a long-acting metoprolol may be appropriate. ACE inihbitor or ARB if ACEi intolerant at high doses. Nitrates if angina. A statin ideally.

Question 21

Prevention of cardiovascular events in patients with unstable angina or NSTEMI is comprised of what?

Answer 21

Clopidogrel is given, in combination with aspirin, for up to 12 months (most benefit during first 3 months) alongside an ACEi. Prasugrel or ticagrelor are alternatives to clopidogrel in certain patients.

Question 22

Which NOAC in low-doses, in combination with aspirin alone or aspirin and clopidogrel, is licensed for the prevention of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers.

Answer 22

Rivaroxaban.

Question 23

What are the two types of peripheral vascular disease?

Answer 23

Occlusive (Intermittent Claudication) in which occlusion of the peripheral arteries is caused by atherosclerosis, or vasoplastic (e.g. Raynaud’s syndrome).

Question 24

Naftifrofuryl oxalate can alleviate the symptoms of what type of peripheral vascular disease? intermittent claudication or Raynaud’s?

Answer 24

BOTH:Intermittent claudication. IT can improve pain-free walking distance in moederate disease.Patients taking naftidrofuryl oxalate should be assessed for improvement after 3-6 months.

Question 25

Cilostazol is licensed for use in what? intermittent claudication or Raynaud’s?

Answer 25

Cilostazol is licensed for use in intermittent claudication to improve walking distance in patients without peripheral tissue necrosis who do not have pain at rest; use is restricted to second-line treatment where lifestyle modifications and other appropriate interventions have failed to improve symptoms.

Question 26

Patients receiving cilostazol for intermittent claudication should be assessed for improvement after how long?

Answer 26

3 months; consider discontinuation of treatment if there is no clinically relevant improvement in walking distance.

Question 27

What is a treatment option for critical limb ischaemia in patients unsuitable for surgery? (Off-label use)

Answer 27

Intravenous iloprost.

Question 28

What does the management of Raynaud’s syndrome comprise of? (2)

Answer 28

1. Avoidance of exposure to cold.2. Stopping smoking.

Question 29

Which CCB is useful for reducing the frequency and severity of vasospastic attacks in Raynaud’s?

Answer 29

Nifedipine.

Question 30

What are alternatives to nifedipine for the treatment of Raynaud’s?

Answer 30

Naftidofuryl oxalate may produce symptomatic improvement;Inositol nicotinate (a nicotinic acid derivative) may also be considered. Pentoxifylline, prazosin and moxisylyte are not established as being effective for the treatment of Raynaud’s syndrome.

Question 31

Cardiac arrest can be associated with ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity (electromechanical dissociation). What is recommeneded by IV injection repeated every 3-5 minutes if necessary?

Answer 31

Adrenaline/epinephrine 1 in 10000 (100mcg/mL).

Question 32

Administration of adrenaline 100mcg/mL is via what results in a faster response than peripheral administration?

Answer 32

Central line, however placement of a centreal line must not interfere with chest compressions.

Question 33

Drugs administered peripherally must be followed by a flush of at least what ml of Sodium Chloride 0.9%?

Answer 33

20ml to aid entry into the central circulation.

Question 34

Intravenous injection of amiodarone hydrochloride should be considered after adrenaline to teat what?

Answer 34

To treat ventricular fibrillation or pulseless ventricular tachycardia in cardiac arrest refractory to defibrillation.

Question 35

What is an alternative to amiodarone hydrochloride if it is not available?

Answer 35

lidocaine hydrochloride.

Question 36

Alteplase should be given within how long of symptom onset?

Answer 36

6-12 hours of symptom onset.

Question 37

Reteplase and streptokinase should be given within how long of symptom onset?

Answer 37

12 hours.

Question 38

Tenecteplase should be given within how long of symptom onset?

Answer 38

6 or less

Question 39

Alteplase, streptokinase and urokinase can be used for other thromboembolic disorders such as what?

Answer 39

DVT and PE

Question 40

Alteplase is also licensed for use in what condition? (other than DVT, PE and MI)

Answer 40

Acute ischaemic stroke.

Question 41

Urokinase is also licensed for what? (other than DVT, PE and occlusive periphral disease)

Answer 41

Urokinase is also licensed to restore the patency of occluded intravenous catheters and cannulas blocked with fibrin clots.

Question 42

Reteplase and tenecteplase are licensed for use in what?

Answer 42

Both only in acute MI

Question 43

How is digoxin toxicity treated?

Answer 43

Digoxin-specifc antibody fragments are indicated for the treatment of known or strongly suspected life-threatening digoxin toxicty associated with ventricular arrhythmias or bradyarrhythmias unresponsive to atropine sulfate and when measures beyong the withdrawal of digoxin and correction of any electrolyte abnormalities are considered necessary.

Question 44

What is digoxin most useful for?

Answer 44

Controlling ventricular response in persistent and permanent atrial fib and atrial flutter. Digoxin also has a role in heart failure.

Question 45

For the management of atrial fibrillation the maintenance dose of digoxin can usually be determined by what?

Answer 45

The ventricular rate at rest, which should not usually be allowed to fall persistently below 60 beats per minute.

Question 46

In patients with heart failure who are in sinus rhythm a loading dose is not required, and a satisfactory plasma-digoxin concentration can be achieved over what period?

Answer 46

A week

Question 47

Digoxin has a long half-;ofe and maintenance doses need to be given only once daily, what is the most important determinant of digoxin dosage?

Answer 47

Renal function

Question 48

The plasma concentration of digoxin alone cannot indicate toxicity reliably, but the likelihood of toxicity increases progressively through the range 1.5 to __ micrograms/litre.

Answer 48

It can sometimes be difficult to distinguish between toxic effects and clinical deterioration because symptoms of both are similar. The plasma concentration alone cannot indicate toxicity reliably, but the likelihood of toxicity increases progressively through the range 1.5 to 3 micrograms/litre for digoxin. Digoxin should be used with special care in the elderly, who may be particularly susceptible to digitalis toxicity.

Question 49

What electrolyte imbalance predisposes a patient to digitalis toxicity?

Answer 49

HYPOKALAEMIA

Question 50

Hydralazine hydrochloride is given by mouth as an adjunct to other antihypertensives for the treatment of ________ ________ but is rarely used; when used alone it causes ______ and ____ _________.

Answer 50

Hydralazine hydrochloride is given by mouth as an adjunct to other antihypertensives for the treatment of resistant hypertension but is rarely used; when used alone it causes tachycardia and fluid retention.

Question 51

Minoxidil should be reserved for the treatment of _______ hypertension resistant to other drugs. Vasodilatation is accompanied by increased _____ ______ and tachycardia and the patients develop ____ _______.

Answer 51

Minoxidil should be reserved for the treatment of severe hypertension resistant to other drugs. Vasodilatation is accompanied by increased cardiac output and tachycardia and the patients develop fluid retention. For this reason the addition of a beta-blocker and a diuretic (usually furosemide, in high dosage) are mandatory. Hypertrichosis is troublesome and renders this drug unsuitable for females.

Question 52

Why is minoxidil unsuitable for females?

Answer 52

Hypertrichosis is troublesome and renders this drug unsuitable for females.

Question 53

Why are the addition of a beta-blocker and a diuretic to minoxidil therapy mandatory?

Answer 53

Minoxidil causes vasodilation accompanied by increased cardiac output and tachycardia with patients developing fluid retention.

Question 54

Prazosin, doxazosin, and terazosin have what properties that allows them to be used as antihypertensives?

Answer 54

Prazosin, doxazosin, and terazosin have alpha-blocking and vasodilator properties.

Question 55

Ambrisentan, bosentan, iloprost, macitentan, sildenafil, and tadalafil are licensed for the treatment of what?

Answer 55

Pulmonary arterial hypertension

Question 56

Epoprostenol is a prostaglandin and a potent vasodilator which can be used in what patients?

Answer 56

Those with primary pulmonary hypertension resistant to other treatments.

Question 57

Epoprostenol can be used in patients with primary pulmonary hypertension resistant to other treatments. What other properties does it have?

Answer 57

Epoprostenol is a prostaglandin and a potent vasodilator. It is also a powerful inhibitor of platelet aggregation.

Question 58

Bosentan is licensed for the treatment of pulmonary arterial hypertension and also what else?

Answer 58

Bosentan is also licensed to reduce the number of new digital ulcers in patients with systemic sclerosis and ongoing digital ulcer disease.

Question 59

Riociguat is licensed for the treatment of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension; it should be used under specialist supervision. What is its mechanism of action?

Answer 59

Riociguat is a stimulator of soluble guanylate cyclase (sGC), an enzyme in the cardiopulmonary system and the receptor for nitric oxide (NO). When NO binds to sGC, the enzyme catalyzes synthesis of the signaling molecule cyclic guanosine monophosphate (cGMP).It is contraindicated in people using sildenafil etc and vice versa

Question 60

Drugs licensed for pulmonary hypertension include what? (6)

Answer 60

Ambrisentan, bosentan, iloprost, macitentan, sildenafil, and tadalafil are licensed for the treatment of

Question 61

Methyldopa is a centrally acting antihypertensive. What can it be used for?

Answer 61

Methyldopa is a centrally acting antihypertensive; it may be used for the management of hypertension in pregnancy.

Question 62

Withdrawal of the centrally acting antihypertensive clonidine hydrochloride can cause what?

Answer 62

Clonidine hydrochloride has the disadvantage that sudden withdrawal of treatment may cause severe rebound hypertension.

Question 63

Moxonidine, a centrally acting drug, is licensed for what?

Answer 63

Moxonidine, a centrally acting drug, is licensed for mild to moderate essential hypertension. It may have a role when thiazides, calcium-channel blockers, ACE inhibitors, and beta-blockers are not appropriate or have failed to control blood pressure.

Question 64

Adrenergic neurone blocking drugs prevent the release of noradrenaline from postganglionic adrenergic neurones. For what reason have they largely fallen from use?

Answer 64

Adrenergic neurone blocking drugs prevent the release of noradrenaline from postganglionic adrenergic neurones. These drugs do not control supine blood pressure and may cause postural hypotension. For this reason they have largely fallen from use, but may be necessary with other therapy in resistant hypertension.

Question 65

Why should prazosin, doxazosin, indoramin and terazosin be introduced with caution?

Answer 65

Prazosin has post-synaptic alpha-blocking and vasodilator properties and rarely causes tachycardia. It may, however, reduce blood pressure rapidly after the first dose and should be introduced with caution. Doxazosin, indoramin, and terazosin have properties similar to those of prazosin.

Question 66

What drugs are indicated for benign prostatic hyperplasia? (6)

Answer 66

Alfuzosin hydrochloride, doxazosin, indoramin, prazosin, tamsulosin hydrochloride, and terazosin are indicated for benign prostatic hyperplasia.

Question 67

In general, thiazides are used for what?

Answer 67

To relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure.

Question 68

In general, loop diuretics are used in what?

Answer 68

In pulmonary oedema due to left ventricular failure and in patients with chronic heart failure.

Question 69

Thiazides and related compounds are moderately potent diuretics, how do they work?

Answer 69

They inhibit sodium reabsorption at the beginning of the distal convoluted tubule.

Question 70

How rapid is the onset of action of thiazide and related compounds?

Answer 70

Thiazides and related compounds are moderately potent diuretics; they inhibit sodium reabsorption at the beginning of the distal convoluted tubule. They act within 1 to 2 hours of oral administration and most have a duration of action of 12 to 24 hours; they are usually administered early in the day so that the diuresis does not interfere with sleep.

Question 71

Thiazide and related compounds have a duration of action of what?

Answer 71

Thiazides and related compounds are moderately potent diuretics; they inhibit sodium reabsorption at the beginning of the distal convoluted tubule. They act within 1 to 2 hours of oral administration and most have a duration of action of 12 to 24 hours; they are usually administered early in the day so that the diuresis does not interfere with sleep.

Question 72

In the management of hypertension, what dose of thiazide produces a maximal or near-maximal response?

Answer 72

In the management of hypertension a low dose of a thiazide produces a maximal or near-maximal blood pressure lowering effect, with very little biochemical disturbance. Higher doses cause more marked changes in plasma potassium, sodium, uric acid, glucose, and lipids, with little advantage in blood pressure control.

Question 73

What are the preffered thiazide diuretics in the management of hypertension?

Answer 73

Chlortalidone and indapamide are the preferred diuretics in the management of hypertension. Thiazides also have a role in chronic heart failure.

Question 74

Bendroflumethiazide is licensed or the treatment of hypertension but is no longer considered first-line diuretic for this indication. What else can it be used in?

Answer 74

Mild to moderate heart failure. Those who have a stable blood pressure on bendro therapy should continue on it.

Question 75

Chlortalidone is a thiazide-related compound with what duration of action?

Answer 75

Chlortalidone, a thiazide-related compound, has a longer duration of action than the thiazides and may be given on alternate days to control oedema

Question 76

How does the longer duration of action of chlortalidone vs thiazides impact its use in therapy?

Answer 76

Chlortalidone, a thiazide-related compound, has a longer duration of action than the thiazides and may be given on alternate days to control oedema

Question 77

Xipamide and indapamide are chemically related to the thiazide-like chlortalidone. Why is does indapamide see wider clinical use?

Answer 77

Xipamide and indapamide are chemically related to chlortalidone. Indapamide is claimed to lower blood pressure with less metabolic disturbance, particularly less aggravation of diabetes mellitus.

Question 78

Metozalone is what type of drug?

Answer 78

Thiazide-like

Question 79

Diuretic-resistant oedema can be treated with a loop diuretic combined with a thiazide or related diuretic except in what circumstances?

Answer 79

Diuretic-resistant oedema (except lymphoedema and oedema due to peripheral venous stasis or calcium-channel blockers) can be treated with a loop diuretic combined with a thiazide or related diuretic (e.g. bendroflumethiazide or metolazone).

Question 80

Loop diuretics can exacerbate what metabolic condition?

Answer 80

Loop diuretics can exacerbate diabetes (but hyperglycaemia is less likely than with thiazides) and gout. If there is an enlarged prostate, urinary retention can occur, although this is less likely if small doses and less potent diuretics are used initially.

Question 81

Loop diuretics can exacerbate diabetes but hyperglycaemia is less likely than with what?

Answer 81

Loop diuretics can exacerbate diabetes (but hyperglycaemia is less likely than with thiazides) and gout. If there is an enlarged prostate, urinary retention can occur, although this is less likely if small doses and less potent diuretics are used initially.

Question 82

The use of loop diuretics can cause urinary retention if what is present?

Answer 82

An enlarged prostate. Although this is less likely if small doses and less potent diuretics are used initially.

Question 83

Furosemide and bumetanide are loop diuretics which have similar activity. Both act within how long of oral administration?

Answer 83

Furosemide and bumetanide are similar in activity; both act within 1 hour of oral administration and diuresis is complete within 6 hours so that, if necessary, they can be given twice in one day without interfering with sleep.

Question 84

Following intravenous administration furosemide has a peak effect within how long?

Answer 84

Furosemide and bumetanide are similar in activity; both act within 1 hour of oral administration and diuresis is complete within 6 hours so that, if necessary, they can be given twice in one day without interfering with sleep. Following intravenous administration furosemide has a peak effect within 30 minutes. The diuresis associated with these drugs is dose related.

Question 85

Amiloride and triamterene on their own are what strength diuretics?

Answer 85

Weak.

Question 86

Why are amiloride and triamterene used with thiazide or loop diuretics?

Answer 86

Amiloride and triamterene (blue wee) cause retention of potassium and are therefore given with thiazide or loop diuretics as a more effective alternative to potassium supplements

Question 87

Why should potassium supplements not be given spironlactone?

Answer 87

hyperkalaemia

Question 88

Administration of a potassium sparing diuretic to a patient receiving an ACE inhibitor or an ARB is not advised why?

Answer 88

Severe hyperkalaemia

Question 89

Spironolactone potentiates thiazide or loop diuretics by antagonising what?

Answer 89

Aldosterone.

Question 90

Spironolactone is of value in the treatment of oedema and ascites caused by cirrhosis of the liver. It can also be used in Conn’s syndrome. What is this?

Answer 90

Conn’s syndrome is primary hyperaldosteronism - spironolactone is given before surgery or if surgery is not appropriate at the lowest effective dose for maintenance.

Question 91

Eplerenone is a potassium sparing diuretic lincensed for what uses?

Answer 91

1. Adjunct in left ventricular dysfunction with evidence of heart failure after myocardial infarction. 2. Adjunct in chronic mild heart failure with left ventricular systolic dysfunction.

Question 92

Potassium-sparing diuretics are not usually necessary in the routine treatment of hypertension unless what develops?

Answer 92

Hypokalaemia

Question 93

Mannitol is what type of diuretic?

Answer 93

Mannitol is an osmotic diuretic that can be used to treat cerebral oedema and raised intra-ocular pressure.

Question 94

Mannitol is an osmotic diuretic used to treat what? (2)

Answer 94

Mannitol is an osmotic diuretic that can be used to treat cerebral oedema and raised intra-ocular pressure.

Question 95

Acetazolamide is a weak diuretic used little for its diuretic effect. How does it work?

Answer 95

Acetazolamide = carbonic anhydrase inhibitor

Question 96

What is acetazolamide used for as an unlicensed indication?

Answer 96

Prophylaxis against mountain sickness but it is not a substitute for acclimatisation.

Question 97

Why are acetazolamide, eye drops of dorzolamide and eye drops of brinzolamide used in glaucoma?

Answer 97

They inhibit the formation of aqueous humour and reduce intra-ocular pressure.

Question 98

Individuals at high risk of developing cardiovascular disease include who? (4)

Answer 98

1. Those who have diabetes mellitus. 2. Chronic kidney disease (eGFR <60mL/minute/1.73m2 and/or albuminuria. 3. Those with familial hypercholesterolaemia. 4. Those aged over 85 who smoke or have hypertension.

Question 99

Both QRISK2 and JBS3 assess cardiovascular risk (coronary heart disease [angina and myocardial infarction], stroke and TIA based on what factors? (12)

Answer 99

1. Lipid profile 2. Systolic blood pressure3. Gender4. Ethnicity 5. Smoking status 6. BMI7. Chronic kidney disease8. Diabetes mellitus9. Atrial fibrillation 10. Treated hypertension11. RA12. Family history of premature cardiovascular disease.

Question 100

Risk assessment tools such as QRISK2 and JBS3 underestimate risk in patients with additional risk due to existing conditions or medication, such as what?

Answer 100

1. Serious mental disorder2. Autoimmune disorders such as systemic lupus erythematous and other systemic inflammatory disorders. 3. Antiretroviral treatment 4. Medication causing dyslipidaemia as a side-effect e.g. antipsychotics, corticosteroids, or immunosuppressants. 5. Triglycerides >4.5 mmol/litre

Question 101

A statin reduces the risk of cardiovascular disease events, and is the drug of first choice for primary and secondary prevention of cardiovascular disease. Before starting treatment with statins, secondary causes of dyslipidaemia such as what should be addressed? (5)

Answer 101

1. Uncontrolled diabetes2. Hepatic disease3. Nephrotic syndrome 4. Excessive alcohol consumption5. Uncorrected hypothryoidism as correcting hypothyroidism may resolve the lipid abnormality.

Question 102

For primary prevention, NICE CG 181 recommends what high-intensity statin be prescribed at an unlicensed dose of at least 20mg/day to all those with a 10-year risk of CVD of equal to or greater than what?

Answer 102

Atorvastatin 20mg od to all with 10% or more

Question 103

For secondary prevention what high intensity statin is recommened?

Answer 103

also atorvastatin also unlicensed indication

Question 104

A statin should be considered for all adults with type 1 diabetes mellitus, particularly those aged 40 years and over, or who have what other risk factors? (3)

Answer 104

1. Diabetes more than 10 years OR2. established nephropathy OR 3. any of the other CVD risk factors

Question 105

Total cholesterol, HDL-cholesterol, and non-HDL cholesterol concetration should be checked how long after starting treatment with a high intensity statin?

Answer 105

3 months.

Question 106

NICE CG 181 recommends aiming for a reduction in non-HDL cholesterol of greater than what value if a patient is receiving a high intensity statin?

Answer 106

reduction in non-HDL cholesterol greater than 40%.

Question 107

JBS3 recommends a target non-HDL cholesterol concentration below what value?

Answer 107

2.5mmol/litre

Question 108

If a reduction in non-HDL cholesterol greater than 40% or a target non-HDL cholesterol concentration of below 2.5mmol/litre is not achieved, what should be done?

Answer 108

Ensure lifestyle modifications are optimised and consider increasing the dose of the statin if started on less than atorvastatin 80mg.

Question 109

What drugs should not routinely be used for primary or secondary prevention of CVD?

Answer 109

Fibrates.

Question 110

The use of what drugs is now no longer recommended for either the primary or secondary prevention of CVD?

Answer 110

Nicotinic acidBile acid sequestrantsOmega-3 fatty compounds

Question 111

A statin is also the drug of choice for treating hypercholesterolaemia and moderate hypertriglyceridaemia. Severe hyperlipidaemia not adequately controlled with a maximal dose of a statin may require the use of what?

Answer 111

Severe hyperlipidaemia not adequately controlled with a maximal dose of a statin may require the use of an additional lipid-regulating drug such as ezetimibe; such treatment should generally be supervised by a specialist.

Question 112

What can be added to statin therapy if triglycerides remain high even after the LDL-cholesterol concentration has been reduced adequately?

Answer 112

Fenofibrate. Nicotinic acid may also be used to further lower triglyceride or LDL-cholesterol concentration.

Question 113

Combination of a statin with a fibrate or with nicotinic acid carries an increased risk of side-effects such as what?

Answer 113

Rhabdomylsis: monitoring of liver function and creatine kinase should also be considered.

Question 114

The concomitant administration of gemfibrozil with a statin greatly increases what?

Answer 114

Gemfibrozil + statin = rhabdomyolysis and should not be used.

Question 115

A statin is recommended for all patients with familial hypercholesterolaemia. A high-intensity statin such as what should be considered in order to achieve the recommended reduction in LDL-cholesterol of greater than 50% from baseline?

Answer 115

rosuvastatin or atorvastatin.

Question 116

What is a high-intensity statin defined as?

Answer 116

A high-intensity statin is one that produces a greater LDL-cholesterol reduction than simvastatin 40mg.

Question 117

Patients with heterozygous familial hypercholesterolaemia who have contra-indications to, or are intolerant or, statins should receive what?

Answer 117

Ezetimibe (can also be used in combination)

Question 118

Patients for whom statins and ezetimibe are inappropriate, should be referred to a specialist for consideration of treatment with what?

Answer 118

Either a bile acid sequestrant, nicotinic acid, or a fibrate.

Question 119

The MHRA have advised that there is an increased risk of myopathy associated with what dose simvastatin?

Answer 119

The 80 mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.

Question 120

Statins are more effective than other lipid-regulating drugs at lowering LDL-cholesterol concentration but are less effective than the fibrates at reducing what?

Answer 120

TrigylceridesHowever, statins reduce cardiovascular disease events and total mortality irrespective of the initial cholesterol concetration.

Question 121

Alirocumab and evolucumab are both licensed for what?

Answer 121

Alirocumab and evolocumab are licensed for the treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia as an adjunct to dietary measures. They can be used in combination with a statin, or with a statin and other lipid-regulating therapies, in patients unable to achieve their LDL-cholesterol treatment goals with the maximum tolerated dose of a statin. They can be used alone or in combination with other lipid-regulating therapies if a statin is contra-indicated or not tolerated. Evolocumab is also licensed for the treatment of homozygous familial hypercholesterolaemia in combination with other lipid-lowering therapies.

Question 122

As well as for the treatment of primary hypercholesterolaemia or mixed dyslipidaemia as an adjunct to dietary measures, Evolocumab is also licensed for what?

Answer 122

Alirocumab and evolocumab are licensed for the treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia as an adjunct to dietary measures. They can be used in combination with a statin, or with a statin and other lipid-regulating therapies, in patients unable to achieve their LDL-cholesterol treatment goals with the maximum tolerated dose of a statin. They can be used alone or in combination with other lipid-regulating therapies if a statin is contra-indicated or not tolerated. Evolocumab is also licensed for the treatment of homozygous familial hypercholesterolaemia in combination with other lipid-lowering therapies.

Question 123

Bile acid sequestrants effectively reduce LDL- cholesterol but can aggravate what?

Answer 123

Bile acid sequestrants effectively reduce LDL-cholesterol but can aggravate hypertriglyceridaemia. Treatment with bile acid sequestrants may be appropriate under specialist supervision if statins and ezetimibe are inappropriate, and when LDL-cholesterol is severely raised, for example in familial hypercholesterolaemia.

Question 124

Fibrates are mainly used in those whose serum-triglyceride concentration is above what?

Answer 124

10 mmol/litre or in those who cannot tolerate a statin.

Question 125

What is lomitapide?

Answer 125

Lomitapide is an inhibitor of the microsomal triglyceride transfer protein (MTP or MTTP) which is necessary for very low-density lipoprotein (VLDL) assembly and secretion in the liver. It is licensed as an adjunct to dietary measures and other lipid-regulating drugs for the treatment of familial hypercholesterolaemia.

Question 126

The value of nicotinic acid is limited by what?

Answer 126

Its side effects, especially vasodilation.

Question 127

Acipimox differs from nicotinic acid how?

Answer 127

Acipimox seems to have fewer side-effects than nicotinic acid but may be less effective in its lipid-regulating capabilities.

Question 128

How does acipimox work?

Answer 128

Like niacin (nicotinic acid), acipimox acts on the niacin receptor 1, inhibiting the enzyme triglyceride lipase. This reduces the concentration of fatty acids in the blood plasma and their inflow into the liver. Consequently, VLDL cholesterol production in the liver is reduced, which leads indirectly to a reduction in LDL and increase in HDL cholesterol.

Question 129

Statins interact with potent inhibitors of what CYP?

Answer 129

CYP3A4:Itra + ketoconazole, erythromycin, clarithromycin, telithromycin, and HIV protease inhibitors.

Question 130

Can simvastatin be used with ketoconazole?

Answer 130

No.All CYP3A4 inhibitors are contrainidicated with simvastatin.

Question 131

Can atorvastatin be used with erythromycin?

Answer 131

Avoid if possible: consider temporary suspension of atorvastatin if interacting drug is taken for a short period.

Question 132

Can atorvastatin be used with itraconazole?

Answer 132

Avoid if possible. If needed, do not exceed 40mg atorvastatin daily if itraconazole is being used.

Question 133

Can atorvastatin be used with clarithromycin?

Answer 133

Do not exceed 20mg clarithromycin daily.

Question 134

Can simvastatin or atorvastatin be used with HIV protease inhibitors?

Answer 134

Sim: noAtorvastatin: the advice is to monitor lipid levels to ensure lowest necessary dose of atorvastatin is used.

Question 135

What are the dose restrictions on statin use in patients receiving ciclosporin treatment?

Answer 135

Do not exceed 10mg daily of either simvastatin or atorvastatin. Ciclosporin interacts with all statins and is contraindicated with rosuvastatin.

Question 136

Can Danazol be used with statins? What is Danazol used for?

Answer 136

Danazol is a mediacation which is used in the treatmet of endometriosis, fibrocystic breast disease, hereditary andiodema etc. Fine with Atorvastatin but simvastatin should not exceed 10mg daily.

Question 137

Verapamil and amiodarone interact with statins. What are the restrictions on the use of simvastatin and atorvastatin in patients taking verapamil or amiodarone?

Answer 137

Do not exceed 20mg sim daily,Monitor lipid levels to ensure lowest dose of atorvastatin is used.

Question 138

What does of simvastatin should not be exceeded in a patient taking diltiazem?

Answer 138

40mg daily (atorvastatin: monitor lipid levels to esure lowest dose needed is used(

Question 139

Can you drink grapefruit juice when taking simvastatin or atorvastatin?

Answer 139

Avoid if on sim, small amounts or avoid if on atorv

Question 140

What is the recommendations for patients on warfarin who need a statin?

Answer 140

The INR should be monitored before initiating a statin, during treatment and at any dose change.Statins may affect coumarin anticoagulation and increase the risk of haemorrhagic events.

Question 141

Inducers of CYP3A4, such as what may reduce plasma concentrations of simvastatin and atorvastatin?

Answer 141

EfavirenzRifampicinSt John’s WortColestipol

Question 142

If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, what treatment should be used?

Answer 142

If ectopic beats are spontaneous and the patient has a normal heart, treatment is rarely required and reassurance to the patient will often suffice. If they are particularly troublesome, beta-blockers are sometimes effective and may be safer than other suppressant drugs.

Question 143

Atrial fibrillation can be managed by either controlling the ventricular rate (‘r______ control’) or by attempting to restore and maintain sinus rhythm (‘______ control’).

Answer 143

Atrial fibrillation can be managed by either controlling the ventricular rate (‘rate control’) or by attempting to restore and maintain sinus rhythm (‘rhythm control’).

Question 144

All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo what without delaying to achieve anticoagulation?

Answer 144

All patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo emergency electrical cardioversion without delaying to achieve anticoagulation.

Question 145

In patients presenting acutely but without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than __ hours; _____ control is preferred if onset is more than __ hours or uncertain.

Answer 145

In patients presenting acutely but without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than 48 hours; rate control is preferred if onset is more than 48 hours or uncertain.

Question 146

If pharmacological cardioversion has been agreed, intravenous _____________, or alternatively _______ acetate, can be used (_______ hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

Answer 146

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

Question 147

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a ________ or ___________can be given intravenously.

Answer 147

If pharmacological cardioversion has been agreed, intravenous amiodarone hydrochloride, or alternatively flecainide acetate, can be used (amiodarone hydrochloride is preferred if there is structural heart disease). If urgent rate control is required, a beta-blocker or verapamil hydrochloride can be given intravenously.

Question 148

If atrial fibrillation has been present for more than 48 hours, _________ cardioversion is preferred and should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced.

Answer 148

If atrial fibrillation has been present for more than 48 hours, electrical cardioversion is preferred and should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced, an

Question 149

What is the preferred first-line drug treatment strategy for atrial fibrillation except in patients with new-onset AF, heart failure secondary to AF AF suitable for ablation therapy or with a rerversible cause?

Answer 149

Rate control is the preferred first-line drug treatment strategy for atrial fibrillation except in patients with new-onset atrial fibrillation, heart failure secondary to atrial fibrillation, atrial flutter suitable for an ablation strategy, atrial fibrillation with a reversible cause, or if rhythm control is more suitable based on clinical judgement.

Question 150

Ventricular rate can be controlled with what? (2)

Answer 150

1. Standard beta-blocker (NOT sotalol)2. A rate-limiting CCB such as diltiazem or verapamil monotherapy.

Question 151

Digoxin should be used only in what AF patients?

Answer 151

Digoxin is only effective at controlling the ventricular rate at rest, and should only be used as monotherapy predominantly in patients who are sedentary with non-paroxysmal atrial fibrillation.

Question 152

If rate control monotherapy of AF fails what can be done?

Answer 152

When a single drug fails to adequately control the ventricular rate, a combination of two drugs including a beta-blocker, digoxin, or diltiazem hydrochloride can be used.

Question 153

If rate control dual therapy of AF fails what can be done?

Answer 153

If symptoms are not controlled with a combination of two drugs, a rhythm-control strategy should be considered. If ventricular function is diminished, the combination of a beta-blocker (that is licensed for use in heart failure) and digoxin is preferred. Digoxin is also used when atrial fibrillation is accompanied by congestive heart failure.

Question 154

In AF, if ventricular function is diminished, the combination of a beta-blocker licensed for use in heart failure and what is preffered?

Answer 154

If symptoms are not controlled with a combination of two drugs, a rhythm-control strategy should be considered. If ventricular function is diminished, the combination of a beta-blocker (that is licensed for use in heart failure) and digoxin is preferred. Digoxin is also used when atrial fibrillation is accompanied by congestive heart failure.

Question 155

If drug treatment is required to maintain sinus rhythm (rhythm control) post-cardioversion, what should be used?

Answer 155

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

Question 156

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective what should be considered?

Answer 156

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

Question 157

Dronedarone may be considered in what AF?

Answer 157

If drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion, a standard beta-blocker is used. If a standard beta-blocker is not appropriate or is ineffective, consider an oral anti-arrhythmic drug such as sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride; dronedarone may be considered in paroxysmal or persistent atrial fibrillation (see NICE guidance).

Question 158

If necessary, amiodarone can be started how long before and continued for how long after electrical cardioversion to increase the success of the procedure, and to maintain sinus rhythm?

Answer 158

4 weeks before and for 12 months after

Question 159

Flecaine acetate or propagenone hydrochloride should not be given in what circumstances?

Answer 159

If there is known ischaemic or structural heart disease.

Question 160

In symptomatic paroxysmal atrial fibrillation, ventricular rhythm is controlled with a standard beta-blocker. Alternatively, if symptoms persist or a standard beta-blocker is not appropriate, what can be given? (5)

Answer 160

Alternatively, if symptoms persist or a standard beta-blocker is not appropriate, an oral anti-arrhythmic drug such as dronedarone (see NICE guidance), sotalol hydrochloride, flecainide acetate, propafenone hydrochloride, or amiodarone hydrochloride can be given.

Question 161

In selected paroxysmal atrial fibrillation patients with infrequent episodes, what approach can be taken?

Answer 161

Sinus rhythm can be restored using the ‘pill-in-the-pocket’ approach; this involves the patient taking oral flecainde or propafenone hydrochloride to self-treat an episode of AF when it occurs.

Question 162

Oral anticoagulation should be offered to patients with confirmed diagnosis of atrial fibrillation with what risk factors?

Answer 162

1. Sinus rhythm not successfully restored within 48 hours of onset. 2. high risk of recurrence of AF such as those with structural heart disease, prolonged history of AF (>12 mths), a history of failed attempts at cardioversion.3. Patients whom the risk of stroke outweighs the risk of bleeding.

Question 163

Why should aspitin not be offered as monotherapy soley for stroke prevention in AF?

Answer 163

Aspirin is less effective than warfarin sodium at preventing emboli; the modest benefit is offset by the risk of bleeding, and aspirin should not be offered as monotherapy solely for stroke prevention in atrial fibrillation.

Question 164

In what types of AF can oral anticoagulation be acheived with apixaban, dabigatran, edoxaban or rivaroxaban?

Answer 164

Non-valvular AF

Question 165

Like atrial fibrillation, treatment options for atrial flutter involve either controlling the ventricular rate or attempting to restore and maintain sinus rhythm. However, atrial flutter generally responds less well what?

Answer 165

Like atrial fibrillation, treatment options for atrial flutter involve either controlling the ventricular rate or attempting to restore and maintain sinus rhythm. However, atrial flutter generally responds less well to drug treatment than atrial fibrillation.

Question 166

If the duration of atrial flutter is unknown, or it has lasted for over 48 hours, cardioversion should not be attempted until the patient has been fully anticoagulated for at least __ weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.

Answer 166

If the duration of atrial flutter is unknown, or it has lasted for over 48 hours, cardioversion should not be attempted until the patient has been fully anticoagulated for at least 3 weeks; if this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks.

Question 167

What are the non-drug treatment options for paroxysmal supraventricular tachycardia? (3)

Answer 167

1. Reflex vagal stimulation such as the Valsalva manoeuvre.2. immersing the face in ice-cold water3. Carotid sinus massage

Question 168

In PSVT, if the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, what should be given?

Answer 168

IV adenosine.

Question 169

If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, intravenous adenosine should be given. If adenosine is ineffective or contra-indicated, what is an alternative?

Answer 169

If the effects of reflex vagal stimulation are transient or ineffective, or if the arrhythmia is causing severe symptoms, intravenous adenosine should be given. If adenosine is ineffective or contra-indicated, intravenous verapamil hydrochloride is an alternative, but it should be avoided in patients recently treated with beta-blockers.

Question 170

In the management of arrhythmias after myocardial infarction, Bradycardia, particularly if complicated by hypotension should be treated how?

Answer 170

Bradycardia, particularly if complicated by hypotension, should be treated with an intravenous dose of atropine sulfate the dose may be repeated if necessary.

Question 171

What is torsade de pointes?

Answer 171

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome (usually drug-induced, but other factors including hypokalaemia, severe bradycardia, and genetic predisposition are also implicated). Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness. If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death. Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered. Anti-arrhythmics can further prolong the QT interval, thus worsening the condition.

Question 172

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome which is usually drug induced, what other factors can cause it/are implicated? (3)

Answer 172

1. hypokalaemia2. Severe bradycardia3. Genetic predisposition

Question 173

Intravenous infusion of what is usually effective in the treatment of Torsade de pointes?

Answer 173

Torsade de pointes is a form of ventricular tachycardia associated with a long QT syndrome (usually drug-induced, but other factors including hypokalaemia, severe bradycardia, and genetic predisposition are also implicated). Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness. If not controlled, the arrhythmia can progress to ventricular fibrillation and sometimes death. Intravenous infusion of magnesium sulfate is usually effective. A beta-blocker (but not sotalol hydrochloride) and atrial (or ventricular) pacing can be considered. Anti-arrhythmics can further prolong the QT interval, thus worsening the condition.

Question 174

Anti-arrhytmic drugs can be classified how? (3)

Answer 174

Into:1) Those that act on supraventicular arrhythmias such as verapamil.2) those that act on both supraventricular and ventricular arrhythmias such as amiodarone. 3) Those that act on ventricular arrhythmias only: Lidocaine

Question 175

Most drugs that are effective in countering arrhythmias can also provoke them, moreover what electrolyte imbalance can enhance the arrhythmogenic (pro-arrhythmic) effect of many drugs?

Answer 175

HYPOKALAEMIA

Question 176

What is usually the drug of choice in terminating paroxysmal supraventricular tachycardia?

Answer 176

Adenosine: feeling of dread.

Question 177

Adenosine has a very short duration of action (half-life 8-10s) so its side effects are short lived. What drug prolongs the half-life of adenosine?

Answer 177

The antiplatelet dipyridamole

Question 178

In terminating paroxysmal supraventricular tachycardia, why may verapamil be preferable to adenosine?

Answer 178

In Asthma.

Question 179

Unlike verapamil, adenosine can be used after what?

Answer 179

a beta blocker.

Question 180

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in arrhytmias associated with what?

Answer 180

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in supraventricular arrhythmias associated with accessory conducting pathways (e.g. Wolff- Parkinson-White syndrome).

Question 181

Cardiac glycosides are contra-indicated in SV arrhythmias associated with what syndrome?

Answer 181

Oral administration of a cardiac glycoside (such as digoxin) slows the ventricular response in cases of atrial fibrillation and atrial flutter. However, intravenous infusion of digoxin is rarely effective for rapid control of ventricular rate. Cardiac glycosides are contra-indicated in supraventricular arrhythmias associated with accessory conducting pathways (e.g. Wolff- Parkinson-White syndrome).

Question 182

Verapamil hydrochloride is usually effective for supraventricular tachycardias. An initial intravenous dose (important: serious beta-blocker interaction hazard) may be followed by oral treatment; what may occur with large doses?

Answer 182

Verapamil hydrochloride is usually effective for supraventricular tachycardias. An initial intravenous dose (important: serious beta-blocker interaction hazard) may be followed by oral treatment; hypotension may occur with large doses.

Question 183

Intravenous administration of a what can achieve rapid control of the ventricular rate in supraventricular arrhythmias?

Answer 183

A beta-blocker: propranolol or esmolol.

Question 184

What are the drugs used for both supraventricular and ventricular arrhythmias?

Answer 184

Amiodarone, propranolol, disopyramide, flecainamide and propafenone.

Question 185

Amiodarone hydrochloride may be given by IV infusion as well as by mouth, and has the advantage of causing little or no what?

Answer 185

myocardial depression

Question 186

How long is the half-life of amiodarone?

Answer 186

Extends to several weeks. Only needs to be given once daily. Many weeks or months may be required to achieve steady-state plasma-amiodarone concentration.

Question 187

Beta-blockers act as anti-arrhythmic drugs principally by attentuating what?

Answer 187

The effects of the sympathetic system on automaticity and conductivity within the heart. Sotalol has a role in the management of ventricular arrhythmias.

Question 188

What can and what can’t the beta-blocker sotalol be used for?

Answer 188

Can:Management of ventricular arrhythmias. Can’t:Control ventricular rate. Be used in the management of torsade de pointes.

Question 189

Disopyramide can be given by intravenous injection to control arrhythmias after myocardial infarction (including those not responding to lidocaine hydrochloride) but it impairs what?

Answer 189

Cardiac contracility. It also has an antimuscarinic effect which limits its use in patients suceptible to angle-closure glaucoma or with prostatic hyperplasia.

Question 190

What are the risks of flecainide use?

Answer 190

It can precipitate serious arrhythmias in a small minority of patients (including those with otherwise normal hearts).

Question 191

Why is propafenone hydrochloride cautioned for use in patients with obstructive airway disease?

Answer 191

Propafenone hydrochloride is used for the prophylaxis and treatment of ventricular arrhythmias and also for some supraventricular arrhythmias. It has complex mechanisms of action, including weak beta-blocking activity (therefore caution is needed in obstructive airways disease—contra- indicated if severe).

Question 192

Drugs for ventricular arrhythmias include what? (3)

Answer 192

1. Adenosine2. Cardiac glycosides3. Verapamil

Question 193

Broadly speaking, arrhythmias are split according to two things, what are they?

Answer 193

The site and the heart rate.

Question 194

Broadly speaking, arrhythmias are split according to two things: site and heart rate.What may the site of abnormality be?

Answer 194

Supraventricular ORVentricular

Question 195

Broadly speaking, arrhythmias are split according to two things: site and heart rate.What may the heart rate be?

Answer 195

Tachyarrhythmiasbradyarrhythmias

Question 196

The two big supraventricular tachyarrhythmias are what?

Answer 196

Atrial flutterAtrial fibrillation Also includes Wolff-Parkinson-White syndrome and also Re-entry supraventricular tachycardia where a second electrical connection between atria and ventricles exist.

Question 197

Ventricular tachyarrhythmias are essentially split into narrow complex tachycardia, or broad complex tachycardia which consists of: (3)

Answer 197

Ventricular fibrillationVentricular tachycardia Torsades de Pointes

Question 198

Bradyarrhythmias are essentially due to a blockage of the hearts conduction system. What are the different types?

Answer 198

Heart block - problems of the atrioventricular node. Bundle branch block - problem of the purkinje fibres

Question 199

The main use of anticoagulants is to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation, where the thrombus consists of what?

Answer 199

The main use of anticoagulants is to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation, where the thrombus consists of a fibrin web enmeshed with platelets and red cells.

Question 200

Anticoagulants are of less use in preventing thrombus formation in arteries. Why?

Answer 200

In faster-flowing vessels, thrombi are composed mainly of platelets with little fibrin.

Question 201

The oral anticoagulants warfarin sodium, acenocoumarol and phenindione, antagonise the effects of vitamin K, and take at least how long for anticoagulant effect to develop fully?

Answer 201

48 to 72 hours.If an immediate effect is required, unfractionated or low molecular weight heparin must be given concomitantly.

Question 202

Coumarins and phenindione should not be used in what as first-line therapy?What should be used?

Answer 202

These oral anticoagulants should not be used in cerebral artery thrombosis or peripheral artery occlusion as first-line therapy; aspirin is more appropriate for reduction of risk in transient ischaemic attacks.

Question 203

An INR which is within how many units of the target value is generally satisfactory?

Answer 203

0.5 units within the target value.

Question 204

What is the target INR for MI?

Answer 204

2.5

Question 205

What is the target INR for recurrent DVT or PE in patients currently receiving anticoagulation and with an INR above 2?

Answer 205

3.5

Question 206

What is the target INR for AF?

Answer 206

2.5

Question 207

What is the target INR for the treatment of DVT or PE?

Answer 207

2.5

Question 208

What duration of treatment with warfarin is recommended for VTE provoked by surgery or other transient risk factor (e.g. COC use, pregnancy, plaster cast)?

Answer 208

3 months

Question 209

What duration of treatment with warfarin is recommended for isolated calf-vein deep-vein thrombosis?

Answer 209

6 weeks

Question 210

What duration of treatment with warfarin is recommended for unprovoked proximal DVT or PE?

Answer 210

At LEAST 3months; long-term anticoagulation may be required.

Question 211

What should be done for major bleeding with warfarin use?

Answer 211

Stop warfrain. Give phytomednadione (Vit K) by slow intravenous injection. Give dried prothrombin complex (factors II, VII, IX and X); if dried unavailable then fresh frozen plasma but it is less effective.

Question 212

What should be done for INR >8.0, minor bleeding?

Answer 212

Stop Warfarin, give vit K1 by slow IV injection. Repeat the dose of vit k if the INR still too high after 34 hours; Restart when INR <5

Question 213

What should be done for INR >8.0, no bleeding?

Answer 213

Stop warfarin, give vit k by MOUTH, repeat dose if INR still too high after 24 hours, restart when <5,0

Question 214

What should be done for INR 5.0-8.0, minor bleeding?

Answer 214

Stop warfarin. Give Vit K by slow IV injection. Restart warfarin when INR <5.0.

Question 215

What should be done when INR 5.0-8.0, no bleeding?

Answer 215

Withhold 1 or 2 doses of warfarin and reduce subsequent maintenace dose.

Question 216

Warfarin should usually be stopped how many days before elective surgery?

Answer 216

5 days.

Question 217

Warfarin sodium should usually be stopped 5 days before elective surgery; What should be given the day before surgery if the INR is >1.5?

Answer 217

Phytomenadione (vitamin K1) by mouth.

Question 218

Patients stopping warfarin sodium prior to surgery who are considered to be at high risk of thromboembolism (e.g. those with a venous thromboembolic event within the last 3 months, atrial fibrillation with previous stroke or transient ischaemic attack, or mitral mechanical heart valve) may require interim therapy (‘bridging’) with what?

Answer 218

LMWH which should be stopped at least 24 hours before surgery and if the surgery carries a high risk of bleeding, the LMWH should not be restarted until at least 48 hours after surgery.

Question 219

Patients on warfarin sodium who require emergency surgery that can be delayed for 6–12 hours can be given intravenous phytomenadione (vitamin K1) to reverse the anticoagulant effect. If surgery cannot be delayed, what can be given in addition to IV phytomenadione (vit K1)?

Answer 219

Dried prothrombin complex.

Question 220

How does warfarin work?

Answer 220

Warfarin inhibits the vitamin K-dependent synthesis of biologically active forms of the calcium-dependent clotting factors II, VII, IX and X, as well as the regulatory factors protein C, protein S and protein Z.The protein C and S inhibition can cause a transient increase in clotting when warfarin initiated.