Cardiology Flashcards
1
Q
Initial NSTEMI treatment
A
Aspirin (chewed/dispersed in water - alert if aspirin given before hospital),
Clopidogrel (ticagelor, prasugrel in some patients that have a PCI),
O2 (extra care needed if COPD),
Nitrates ( GTN sublingual then IV/Buccal or iso) and Morphine for pain
2
Q
STEMI treatment
A
Initial = Aspirin (chewed/dispersed in water alert if aspirin given before hospital), Clopidogrel (ticagelor, prasugrel in some patients that have PCI),
O2 (extra care needed if COPD),
Nitrates ( GTN sublingual then IV/Buccal or iso) and Morphine for pain (antiemetic too)
PCI/thrombolytic drug (reperfusion therapy) to open artery, PCI preferred.
glycoprotein iib/iiia inhibitors can also be used e.g.abciximab, eptifibatide, and tirofiban to reduce occlusion
3
Q
What beta blockers should be used if Left ventricular dysfunction
A
bisoprolol, carvedilol, metoprolol
4
Q
What CCB to use if beta blockers are contraindicated in those with left ventricular dysfunction
A
Diltiazem and verapamil
5
Q
What diuretic is used for left ventricular dysfunction heart failure
A
Epleronone
6
Q
How to manage Von Willebrand Disease haemophilia
A
Desmopressin
7
Q
what fibrinolytic (plasminogen activator) treats DVT
A
Streptokinase
8
Q
What drug inhibits fibrinolysis
A
Tranexamic acid
9
Q
what fibrinolytic (plasminogen activator) treats PE
A
Alteplase
10
Q
Role of hydralazine
A
adjunct to other antihypertensives for resistant HT, hypertensive crisis, heart failure
11
Q
Concerns with Thiazides in renal impairment
A
Not to be used below 30mL/minute/1.73 m2 (Metolazone can still be used)
12
Q
Thiazide use in pregnancy and breastfeeding
A
Not to be used in pregnancy but alright in breastfeeding women
13
Q
What are the side effects of minoxidil and how are risks reduced
A
Increasing cardiac output and fluid retention so needs to be given with beta blockers and diuretic, causes excessive hair growth too
14
Q
What is methyldopa
A
a centrally acting antihypertensive, can be used in pregnancy
15
Q
What is clonidine
A
a centrally acting antihypertensive
16
Q
Aspirin’s cardiovascular uses
A
MI, CVD secondary prevention, AF, post CABG, strokes, and stent placement
17
Q
Common clopidogrel side effects
A
Diarrhoea; gastrointestinal discomfort; haemorrhage; skin reactions
18
Q
Long Term STEMI treatment
A
Dual antiplatelet therapy, Beta blocker, ACE, Statin
19
Q
Length of clopidogrel treatment for NSTEMI
A
Initially 300 mg, then 75 mg daily for up to 12 months
20
Q
Length of clopidogrel treatment for STEMI
A
Initially 300 mg, then 75 mg for at least 4 weeks. (if >75yo then 75mg)
21
Q
Dipyradimole uses
A
An adjunct to oral anticoagulation to prevent thromboembolism associated with valve replacements, the MR version can be used in secondary prevention of strokes/TIA
22
Q
When is DAPT needed
A
After PCI
23
Q
DAPT combinations
A
Aspirin +cangrelor, clopidogrel, prasugrel, ticagrelor(unlicensed).
Aspirin used indefinitely
24
Q
How long is aspirin used post-PCI
A
Indefinitely
25
How is clopidogrel used with bare metal stent
With Bare metal stent, clopidogrel used for at least a month
26
How long is clopidogrel used with a drug eluting stent
For drug eluting stent, clopidogrel used for at least 6 months ( typically 12 months)
Risk of re-endotheliasation if clopidogrel stopped prematurely in those with drug
27
Glucoprotein iib/iia inhibitors drugs
Abciximab, eptifibatide, tirofiban.
28
Glucoprotein iib/iia inhibitors use
Prevent platelet aggregation by blocking the binding of fibrinogen to receptors on platelets
Used to prevent ischemic complications , MI prevention
29
How is AF managed
controlling rate or rhythm control
30
When is electrocardioversion used
Life threatening insurances
31
When is rate control treatment preferred
If onset is more than 48 hours or there is uncertainty
32
What is preferred if there is structural heart disease in AF
Amiodarone
33
What drugs are used as urgent rate control
Beta blocker, verapamil
34
What form of AF treatment is preferred first
Rate
35
Rate control drugs
beta blockers(not sotalol), rate limiting CCB (diltiazem which is unlicensed, verapamil).
36
When is digoxin useful in AF treatment
Sedentary patients, and CHF
37
What happens if monotherapy treatment for AF fails
Combination of two drugs (beta blocker, digoxin and diltiazem) given, if this doesn’t work then rhythm-control is considered.
38
Rhythm control treatment
Beta blocker if not then antiarrhythmic e.g.sotalol, flecainide, propafenone, amiodarone, dronedarone
39
Amiodarone and cardioversion
Started 4 weeks before cardioversion and up to 12 months afterwards to maintain sinus rhythm
40
When are flecainide and propafenone contraindicated
If known ischaemic or structural heart disease and in paroxysmal AF
41
CHADSVASC and HAS-BLED are used to …
evaluate stroke and bleeding risk
42
CHADVASC risk factors
prior ischaemic stroke, transient ischaemic attacks, or thromboembolic events, heart failure, left ventricular systolic dysfunction, vascular disease, diabetes, hypertension, females, and patients over 65 years
43
When is oral anticoagulation offered in AF
In confirmed diagnosis in whom sinus rhythm has not been restored within 48 hours of onset or at high risk of AF recurrence e.g. structural heart disease, previous history of AF/cardioversion and when stroke risk outweighs bleeding risk
44
Atrial flutter treatment
Responds less well to drug treatment than AF
Direct current cardioversion is used and catheter ablation.
Flecainide and propafenone can be used
45
Paroxysmal supraventricular tachycardia treatment
With adenosine or verapamil, cardioversion, catheter ablation and prevented by usual suspects e.g. diltiazem beta blockers including sotalol
46
Treating bradycardia
IV dose of atropine. If risk of asystole give atropine/adrenalin
47
How to restore sinus rhythm
Direct current cardioversion given to restore sinus rhythm
48
Treating sustained ventricular tachycardia
Amiodarone if haemodynamically stable
49
Cause of torsade de pointes
Often drug induced or caused by hypokalemia, severe bradycardia and genetics.
50
Result of torsade de pointes
self limiting but can result in impairment and loss of consciousness
51
Drugs that act on supraventricular arrhythmias:
Verapamil (adenosine can be used against paroxymal SVT due to its short action)
52
Drugs acting on supraventricular and ventricular:
Amiodarone, beta blockers, flecainide, propafenone
53
What arrhythmia can lidocaine potentially treat
Ventricular
54
Digoxin and ventricular
Digoxin lows ventricular response in AF and atrial flutter
55
Amiodarone characteristics
It has a very long half-life. Weeks or months needed to achieve steady state.
56
Sotalol is used in what arrhythmias
Sotalol used in management of ventricular arrhythmias
57
Nitrates and tolerance and what to do
Many patients on long-acting or transdermal nitrates rapidly develop tolerance (with reduced therapeutic effects). Reduction of blood-nitrate concentrations to low levels for 4 to 12 hours each day usually maintains effectiveness in such patients.
58
Statins and pregnancy
Statins should be avoided in pregnancy (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.
59
Statin Mechanism of Action
Inhibit HMG COA reductase
60
When do GTN tablets expire
8 weeks
61
Nicorandil class
Potassium channel activator
62
Nicorandil indication
Prevention and long term treatment of angina
63
Notable nicorandil side effects
ulceration
64
Ivabadrine effect and indication
lowers heart rate used in angina and CHF
65
Where do beta blockers act
Heart, peripheral vasculature, bronchi, pancreas and liver
66
What is intrinsic sympathomimetic activity (ISA/Partial agonist activity)
Capacity of beta-blockers to stimulate and block adrenergic activity
67
What beta blockers have ISA
Celiprolol, pindolol, acebutolol and oxprenolol (CAPO)
68
What is the advantage of ISA activity
Less bradycardia and coldness of extremities
69
Advantage of water soluble beta blockers
Less likely to enter brain and cause sleep disturbance/nightmare
70
Name water soluble beta blockers
Sotalol, Atenolol, Nadolol and Celiprolol - SANC
71
Disadvantage of water soluble beta blockers
Excreted by kidneys so dose reduction may be needed in renal impairment
72
What beta-blockers have OD regimen/ long duration of action
Atenolol, bisoprolol, celiprolol, nadolol - BANC
73
Who are beta-blockers contraindicated in
2nd/3rd degree heart block, unstable heart failure, Asthma, COPD
74
What beta blockers have arteriolar vasodilating action
Labetalol, celiprolol, carvedilol and nebivolol
75
Stance on beta blockers in asthma/COPD
Cause bronchospasm so try to avoid but use if necessary in well-controlled asthma or COPD for heart failure or post MI. use cardioselective blockers
76
Cardioselective beta blockers
```
Acebutolol
Atenolol.
Betaxolol.
Bisoprolol.
Celiprolol
Metoprolol.
Nebivolol.
Esmolol.
```
77
Notable uses of beta blockers
Anxiety, tremor, migraine prophylaxis and glaucoma
78
Dihydropyridine calcium-channel blockers
Amlodipine, felodipine, lacidipine, lercanidipine hydrochloride, nicardipine hydrochloride, nifedipine, and nimodipine
79
What CCB can be used in heart failure
Amlodipine
80
Why can’t CCBs be used in heart failure
They further depress cardiac function and exacerbate symptoms
81
Verapamil indications
Angina, hypertension, arrhythmias (SVT), unstable angina when beta blockers can’t be used
82
How does verapamil work
Reduces cardiac output, slows heart rate, impairs atrioventricular conduction
83
Verapamil cautions
Precipitates heart failure, worsens conduction disorders, don’t use with beta blockers, constipation
84
What is verapamil
Negatively inotropic
85
Nifedipine mechanism of action
Relaxes vascular smooth muscle, dilates arteries
86
What drugs resemble nifedipine and what are they used for
Nicardipine, amlodipine, felodipine.
| Treat angina/ hypertension
87
Side effects of dihydropyridines
Borne from vasodilation e.g. flushing, headache (gets better after a few days), ankle swelling
88
What is diltiazem used for
Angina, hypertension (long acting) when beta blockers can’t be used
89
What CCB is used for life threatening hypertension
IV nicardipine
90
Initial acute ischaemic stroke treatment
Alteplase if within 4.5 hours of symptoms by medical staff.
| If intracranial excluded treat with aspirin asap within 24 hours +PPI if needed
91
How to treat stroke in those with AF
Give aspirin for two weeks then consider anticoagulant
92
What to do for patients already taking anticoagulant who have a stroke
Stop and substitute for aspirin for 7 days
93
Hypertension treatment and stroke management
stop hypertension treatment in acute phase of stroke unless considered for thrombolysis
94
Long term TIA / ischaemic attack treatment
Clopidogrel/ dipyridamole MR +aspirin/dipyradimole MR/aspirin (in preference order)
And
High intensity statin regardless of cholesterol level 48 hours after onset
95
When do you give long term treatment for strokes
Atrial fibrillation or other indications (such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection
96
Blood pressure target post stroke
<130/80 mmHg
97
Intracerebral haemorrage initial treatment
Surgery to remove haematoma , blood pressure lowering therapy within 6 hours, stop and reverse anticoagulant treatment
98
Digoxin cautions
Hypokalaemia, renal function, elderly (STOPP), hypercalcaemia, hypomagnesaemia, hypoxia, thyroid disease
99
Initial endocarditis treatment
Amoxicillin maybe add gentamicin, give vancomycin if penicillin allergy, if severe sepsis riskfactors and gram negative give vancomycin and meropenem
100
Endocarditis caused by staphylococci treatment
Flucloxacillin for 4 weeks, if penicillin allergy/MRSA give vancomycin+rifampicin
101
Streptococci endocarditis treatment
Benzylpenicillin sodium
102
Endocarditis caused by enterococci treatment
Amoxicillin+gent/benzylpenicillin
103
HACEK endocarditis treatment
Amoxicillin
104
Heart failure effect/symptoms
Reduced cardiac output, SOB, coughing, wheezing, ankle swelling, fatigue, reduced exercise tolerance, pulmonary oedema/crackles, jugular venous pressure higher, pink frothy sputum
105
Reduced heart failure is
Left ventricle loses its ability to contract normally and therefore presents with an ejection fraction of less than 40%
106
Preserved heart failure
Left ventricle loses its ability to relax normally therefore the ejection fraction is normal or only mildly reduced
107
Heart failure non-pharmacological treatment
smoking stop, less alcohol, more exercise, weight control, healthy diet, report weight gain of more than 1.5kg in 2 days, salt restricted if intake already high9 less than 6 g of salt a day)
108
Why are diuretics recommended for treatment of reduced heart failure
Relieve breathlessness and oedema for those with fluid retention
109
Reduced Ejection fraction heart failure treatment
Beta blocker+ ACEi
Loop diuretic
Aldosterone antagonist - eplerenone
110
What to check when initiating ACE/ARB
serum potassium and sodium, renal function, and blood pressure
111
Thiazide use in HF
To relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure.
112
Loop diuretic use in HF
Pulmonary oedema due to left ventricular failure and in patients with chronic heart failure or in resistant hypertension
113
Thiazide mechanism
Inhibit sodium reabsorption at the beginning of the distal convoluted tubule
114
Thiazide mechanism
Inhibit sodium reabsorption at the beginning of the distal convoluted tubule
115
When do thiazide diuretics work and how long for
Within 1-2 hours for 12-24 hours
116
Furosemide and bumetanide action and duration timings
Act in one hour and complete diuresis within 6 hours
117
Spironolactone indications
Cirrhosis, primary hyperaldosteronism, heart failure,oedema
118
Mannitol diuretic type
osmotic
119
dorzalamide/brinzolamide indication
Inhibit formation of aqueous humour and used in glaucoma
120
What to look out for when initiating ACE
First dose hypotension with heart failure patients taking loop diuretic, so may temporarily remove loop, this may need specialist supervision
121
What do fibrates do e.g. fenofibrate
Reduce triglyceride concentration
122
Risk of concomitant use of statin and fibrate
Muscle related side effects
123
High intensity statins and dose
atorva 20mg = rosuva 10mg = simvastatin 80mg
124
Low intensity statins
Simvastatin 10mg=prava 40mg=fluva 40mg
125
When should alteplase/streptokinase be given for MI
6-12 hours of MI, ideally within an hour
126
Hypertension lifestyle treatment
Clinic BP between 140/90 and 160/100 or >135/85 at home
127
When to consider treatment for patients of >80YO with hypertension
If >150/90
128
When to consider treatment for under 60 years old with hypertension
Stage 1 and estimated 10 year cv risk >10%
129
When to consider hypertension treatment under age of 80
established cardiovascular disease, renal disease, diabetes, or a 10 year cardiovascular risk ≥10%.
130
SIGN guidance on antihypertension treatment eligibility
Treatment offered if >140/90 regardless of age or stroke even if normal BP
131
Stage 2 hypertension
Clinic BP160/100 - 180/120 mmHg or 150/95 at home
132
When to refer hypertension patients on the same day
>180/120, consider starting antihypertensive treatment immediately
133
Aspirin and hypertension caution
BP must be controlled before giving aspirin
134
BP target if under 80
140/90
135
BP target in over 80yo
<150/90
136
SIGN BP target
140/90
137
Strategy for: Hypertension with type 2 diabetes in all patients (any age or origin), or hypertension without type 2 diabetes in those aged 55 years or below and not of black African or African-Caribbean origin
1. ACE/ARB
2. CCB/thiazide like diuretic +ACE/ARB
3. ACE/ARB+ CCB and a thiazide-like diuretic
4. Seek advice
138
Hypdertension without type 2 diabetes in patients age 55 and over, or all ages of black African or African-Caribbean origin patients without type 2 diabetes
1. CCB
2. CCB+ACE/ARB/Thiazide
3. ACE/ARB+CCB+Thiazide
4. Seek advice + confirm
139
T1DM hypertension aim
135/85 mmHg
140
Antihypertensives with the potential of causing hypoglycaemia
Beta blockers
141
Antihypertensives with the potential of causing hyperglycaemia
Thiazide, CCB
142
Hypertension in pregnancy
intravenous labetalol hydrochloride, intravenous hydralazine hydrochloride, or oral nifedipine modified-release to achieve a target blood pressure of 135/85 mmHg or less.
143
First line pre-eclampsia/ hypertension pregnancy treatment if >140/90
Labetalol (nifedipine mr if unsuitable then methyldopa)
144
First line pre-eclampsia/ hypertension pregnancy treatment if 160/90
Labetalol if not then nifedipine, methyldopa
145
Severe hypertension and pregnancy
Magnesium in critical care setting
146
Methyldopa and pregnancy discontinuation
2 days before birth and switch
147
Hypertension medicines used in breastfeeding
Enalapril first line or nifedipine/amlodipine in afro-Caribbean
148
Nitrates action
Flushing, headache, and postural hypotension
149
Length of GTN effect
20-30 minutes
150
Nitrate indication
Angina prophylaxis, CHF adjunct
151
When is isosorbide dinitrate used
Infrequent and prophylaxis
152
Isosobide mononitrate use
Prophylaxis
153
Anticoagulant use reason
Prevent thrombus formation/extension in the slower venous side
154
Why are anticoagulants not that effective against artery thrombus prevention
Not that effective in preventing thrombus formation in arteries as they are faster flowing and the platelets have less fibrin
155
Vitamin k antagonists
Warfarin, acenocoumarol, phenindione
156
What anticoagulant is preferred before surgery
LMWH or heparin (can continue warfarin if already on it and at high risk of VTE)
157
INR 2.5 is for
```
DVT treatment
Treatment pulmonary embolism
AF
MI
Cardioversion (achieve at least 3 weeks before and 4 weeks after with higher targets may be used just to prevent cancellation)
```
158
When is an INR of 3.5 recommended
Recurrent DVT/PE in patients already receiving anticoagulation with an INR >2
Mechanical prosthetic heart valves
159
How to stop major bleeding from warfarin
Stop warfarin
| Give phytomenadione IV , dried prothrombin complex or fresh frozen plasma (less effective) restart INR when <5.0
160
When to stop warfarin before elective operations (days)
Stop 5 days before elective surgery
161
At what INR do you still need to give phytomenadione if warfarin is stopped before surgery
Dose given the day before a procedure If INR greater than >1.5
Can bridge with LMWH
162
When to bridge warfarin
High risk of thromboembolism
163
Who is at high risk of thromboembolism
VTE in last 3 months
AF with previous stroke/TIA
Mechanical valve
164
Antiplatelet +anticoagulant indication
ACS
| PCI
165
Why are LWMH preferred to heparin in VTE prevention
Equally effective and lower risk of HIT (heparin-induced thrombocytopenia)
166
Fondaparinux action
Synthetic pentasaccharide that inhibits activated factor X
167
Raynauds treatment
Smoking cessation
| Aspirin
168
QRISK factors
```
Smoking status:
non-smoker
Diabetes status:
none
Angina or heart attack in a 1st degree relative < 60
Chronic kidney disease (stage 3, 4 or 5)
Atrial fibrillation
On blood pressure treatment
Do you have migraines
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Severe mental illness
(this includes schizophrenia, bipolar disorder and moderate/severe depression)
On atypical antipsychotic medication
Are you on regular steroid tablets
A diagnosis of or treatment for erectile disfunction
Ethnicity
Age
BMI
Cholesterol
```
169
When is heparin preferred to LMWH
Renal impairment
170
Who is at risk of hospital acquired blood clots
post-surgery, immobility, malignancy, obesity, acquired/inherited hypercoaguable states, pregnancy and postpartum, hormonal therapy,
171
Who should stockings be given to
acute stroke, thrombocytopenia, bleeding disorders
172
What to use in general or orthopaedic surgery when the risk of VTE outweighs the risk of bleeding
LWMH( first line) , fondaparinux, aspirin+ stockings /rivaroxaban/apixa/dabigatran
173
Who is at risk of hospital acquired blood clots
Post-surgery, immobility, malignancy, obesity, acquired/inherited hypercoaguable states, pregnancy and postpartum, hormonal therapy,
174
First line confirmed proximal DVT/PE
Apixaban / rivaroxaban if contraindicated then LMWH for 5 days then dabigatran/edoxaban or LMWH with vitamin K antagonist until INR is at least 2.0
175
Heparin antidote and downfalls
Protamine sulfate is a specific antidote to heparin (and LMWH but only partially reverse its effects)
176
Stable angina is characterized by
Predictable chest pain/pressure often due to physical exertion/stress increasing hearts oxygen demand.
177
Acute attack of angina
Treated with GTN, can also be used as a preventer, used just before activities known to result in attack.
178
How does angina pain radiate
Starts at front of chest and may go to neck, shoulders, jaws or arms
179
When are statin doses lowered
Lowered if side effects, low dose if CKD, high dose simvastatin avoided due to myopathy risk, maximum dose of 20mg when given with amlodipine
180
When and what statin alternatives are used
Ezetimbe and bile acid sequestrants when elevated CVD risk and statin contraindicated
181
Aim for reduction in non-HDL-cholesterol concentration with statins
>40%
182
Who should be offered low dose atorvastatin
T1DM patients who are over 40 or have other risk factors , patients over 85
183
CVD risk greatest in>
South asian, men, family history, over 50 years,
184
Resus
CPR - adrenaline every 3-5 minutes chest compressions , can be given (lidocaine is an alternative) amiodarone
185
Long term angina prevention
beta-blocker first line
CCB if beta contraindicated
combine CCB and beta if monotherapy fails, try long acting nitrate monotherapy
