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BNF Chapters > Cardiology > Flashcards

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

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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

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3
Q

What beta blockers should be used if Left ventricular dysfunction

A

bisoprolol, carvedilol, metoprolol

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4
Q

What CCB to use if beta blockers are contraindicated in those with left ventricular dysfunction

A

Diltiazem and verapamil

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5
Q

What diuretic is used for left ventricular dysfunction heart failure

A

Epleronone

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6
Q

How to manage Von Willebrand Disease haemophilia

A

Desmopressin

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7
Q

what fibrinolytic (plasminogen activator) treats DVT

A

Streptokinase

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8
Q

What drug inhibits fibrinolysis

A

Tranexamic acid

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9
Q

what fibrinolytic (plasminogen activator) treats PE

A

Alteplase

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10
Q

Role of hydralazine

A

adjunct to other antihypertensives for resistant HT, hypertensive crisis, heart failure

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11
Q

Concerns with Thiazides in renal impairment

A

Not to be used below 30mL/minute/1.73 m2 (Metolazone can still be used)

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12
Q

Thiazide use in pregnancy and breastfeeding

A

Not to be used in pregnancy but alright in breastfeeding women

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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

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14
Q

What is methyldopa

A

a centrally acting antihypertensive, can be used in pregnancy

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15
Q

What is clonidine

A

a centrally acting antihypertensive

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16
Q

Aspirin’s cardiovascular uses

A 
MI,
CVD secondary prevention,
AF, 
post CABG, 
strokes, and stent placement
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17
Q

Common clopidogrel side effects

A

Diarrhoea; gastrointestinal discomfort; haemorrhage; skin reactions

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18
Q

Long Term STEMI treatment

A

Dual antiplatelet therapy, Beta blocker, ACE, Statin

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19
Q

Length of clopidogrel treatment for NSTEMI

A

Initially 300 mg, then 75 mg daily for up to 12 months

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20
Q

Length of clopidogrel treatment for STEMI

A

Initially 300 mg, then 75 mg for at least 4 weeks. (if >75yo then 75mg)

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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

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22
Q

When is DAPT needed

A

After PCI

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23
Q

DAPT combinations

A

Aspirin +cangrelor, clopidogrel, prasugrel, ticagrelor(unlicensed).
Aspirin used indefinitely

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24
Q

How long is aspirin used post-PCI

A

Indefinitely

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25
Q

How is clopidogrel used with bare metal stent

A

With Bare metal stent, clopidogrel used for at least a month

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26
Q

How long is clopidogrel used with a drug eluting stent

A

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

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27
Q

Glucoprotein iib/iia inhibitors drugs

A

Abciximab, eptifibatide, tirofiban.

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28
Q

Glucoprotein iib/iia inhibitors use

A

Prevent platelet aggregation by blocking the binding of fibrinogen to receptors on platelets
Used to prevent ischemic complications , MI prevention

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29
Q

How is AF managed

A

controlling rate or rhythm control

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30
Q

When is electrocardioversion used

A

Life threatening insurances

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31
Q

When is rate control treatment preferred

A

If onset is more than 48 hours or there is uncertainty

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32
Q

What is preferred if there is structural heart disease in AF

A

Amiodarone

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33
Q

What drugs are used as urgent rate control

A

Beta blocker, verapamil

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34
Q

What form of AF treatment is preferred first

A

Rate

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35
Q

Rate control drugs

A

beta blockers(not sotalol), rate limiting CCB (diltiazem which is unlicensed, verapamil).

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36
Q

When is digoxin useful in AF treatment

A

Sedentary patients, and CHF

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37
Q

What happens if monotherapy treatment for AF fails

A

Combination of two drugs (beta blocker, digoxin and diltiazem) given, if this doesn’t work then rhythm-control is considered.

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38
Q

Rhythm control treatment

A

Beta blocker if not then antiarrhythmic e.g.sotalol, flecainide, propafenone, amiodarone, dronedarone

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39
Q

Amiodarone and cardioversion

A

Started 4 weeks before cardioversion and up to 12 months afterwards to maintain sinus rhythm

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40
Q

When are flecainide and propafenone contraindicated

A

If known ischaemic or structural heart disease and in paroxysmal AF

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41
Q

CHADSVASC and HAS-BLED are used to …

A

evaluate stroke and bleeding risk

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42
Q

CHADVASC risk factors

A

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

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43
Q

When is oral anticoagulation offered in AF

A

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

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44
Q

Atrial flutter treatment

A

Responds less well to drug treatment than AF
Direct current cardioversion is used and catheter ablation.
Flecainide and propafenone can be used

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45
Q

Paroxysmal supraventricular tachycardia treatment

A

With adenosine or verapamil, cardioversion, catheter ablation and prevented by usual suspects e.g. diltiazem beta blockers including sotalol

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46
Q

Treating bradycardia

A

IV dose of atropine. If risk of asystole give atropine/adrenalin

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47
Q

How to restore sinus rhythm

A

Direct current cardioversion given to restore sinus rhythm

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48
Q

Treating sustained ventricular tachycardia

A

Amiodarone if haemodynamically stable

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49
Q

Cause of torsade de pointes

A

Often drug induced or caused by hypokalemia, severe bradycardia and genetics.

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50
Q

Result of torsade de pointes

A

self limiting but can result in impairment and loss of consciousness

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51
Q

Drugs that act on supraventricular arrhythmias:

A

Verapamil (adenosine can be used against paroxymal SVT due to its short action)

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52
Q

Drugs acting on supraventricular and ventricular:

A

Amiodarone, beta blockers, flecainide, propafenone

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53
Q

What arrhythmia can lidocaine potentially treat

A

Ventricular

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54
Q

Digoxin and ventricular

A

Digoxin lows ventricular response in AF and atrial flutter

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55
Q

Amiodarone characteristics

A

It has a very long half-life. Weeks or months needed to achieve steady state.

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56
Q

Sotalol is used in what arrhythmias

A

Sotalol used in management of ventricular arrhythmias

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57
Q

Nitrates and tolerance and what to do

A

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.

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58
Q

Statins and pregnancy

A

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.

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59
Q

Statin Mechanism of Action

A

Inhibit HMG COA reductase

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60
Q

When do GTN tablets expire

A

8 weeks

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61
Q

Nicorandil class

A

Potassium channel activator

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62
Q

Nicorandil indication

A

Prevention and long term treatment of angina

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63
Q

Notable nicorandil side effects

A

ulceration

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64
Q

Ivabadrine effect and indication

A

lowers heart rate used in angina and CHF

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65
Q

Where do beta blockers act

A

Heart, peripheral vasculature, bronchi, pancreas and liver

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66
Q

What is intrinsic sympathomimetic activity (ISA/Partial agonist activity)

A

Capacity of beta-blockers to stimulate and block adrenergic activity

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67
Q

What beta blockers have ISA

A

Celiprolol, pindolol, acebutolol and oxprenolol (CAPO)

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68
Q

What is the advantage of ISA activity

A

Less bradycardia and coldness of extremities

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69
Q

Advantage of water soluble beta blockers

A

Less likely to enter brain and cause sleep disturbance/nightmare

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70
Q

Name water soluble beta blockers

A

Sotalol, Atenolol, Nadolol and Celiprolol - SANC

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71
Q

Disadvantage of water soluble beta blockers

A

Excreted by kidneys so dose reduction may be needed in renal impairment

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72
Q

What beta-blockers have OD regimen/ long duration of action

A

Atenolol, bisoprolol, celiprolol, nadolol - BANC

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73
Q

Who are beta-blockers contraindicated in

A

2nd/3rd degree heart block, unstable heart failure, Asthma, COPD

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74
Q

What beta blockers have arteriolar vasodilating action

A

Labetalol, celiprolol, carvedilol and nebivolol

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75
Q

Stance on beta blockers in asthma/COPD

A

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
Q

Cardioselective beta blockers

A 
Acebutolol 
Atenolol.
Betaxolol.
Bisoprolol.
Celiprolol 
Metoprolol.
Nebivolol.
Esmolol.
77
Q

Notable uses of beta blockers

A

Anxiety, tremor, migraine prophylaxis and glaucoma

78
Q

Dihydropyridine calcium-channel blockers

A

Amlodipine, felodipine, lacidipine, lercanidipine hydrochloride, nicardipine hydrochloride, nifedipine, and nimodipine

79
Q

What CCB can be used in heart failure

A

Amlodipine

80
Q

Why can’t CCBs be used in heart failure

A

They further depress cardiac function and exacerbate symptoms

81
Q

Verapamil indications

A

Angina, hypertension, arrhythmias (SVT), unstable angina when beta blockers can’t be used

82
Q

How does verapamil work

A

Reduces cardiac output, slows heart rate, impairs atrioventricular conduction

83
Q

Verapamil cautions

A

Precipitates heart failure, worsens conduction disorders, don’t use with beta blockers, constipation

84
Q

What is verapamil

A

Negatively inotropic

85
Q

Nifedipine mechanism of action

A

Relaxes vascular smooth muscle, dilates arteries

86
Q

What drugs resemble nifedipine and what are they used for

A

Nicardipine, amlodipine, felodipine.

Treat angina/ hypertension

87
Q

Side effects of dihydropyridines

A

Borne from vasodilation e.g. flushing, headache (gets better after a few days), ankle swelling

88
Q

What is diltiazem used for

A

Angina, hypertension (long acting) when beta blockers can’t be used

89
Q

What CCB is used for life threatening hypertension

A

IV nicardipine

90
Q

Initial acute ischaemic stroke treatment

A

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
Q

How to treat stroke in those with AF

A

Give aspirin for two weeks then consider anticoagulant

92
Q

What to do for patients already taking anticoagulant who have a stroke

A

Stop and substitute for aspirin for 7 days

93
Q

Hypertension treatment and stroke management

A

stop hypertension treatment in acute phase of stroke unless considered for thrombolysis

94
Q

Long term TIA / ischaemic attack treatment

A

Clopidogrel/ dipyridamole MR +aspirin/dipyradimole MR/aspirin (in preference order)
And
High intensity statin regardless of cholesterol level 48 hours after onset

95
Q

When do you give long term treatment for strokes

A

Atrial fibrillation or other indications (such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection

96
Q

Blood pressure target post stroke

A

<130/80 mmHg

97
Q

Intracerebral haemorrage initial treatment

A

Surgery to remove haematoma , blood pressure lowering therapy within 6 hours, stop and reverse anticoagulant treatment

98
Q

Digoxin cautions

A

Hypokalaemia, renal function, elderly (STOPP), hypercalcaemia, hypomagnesaemia, hypoxia, thyroid disease

99
Q

Initial endocarditis treatment

A

Amoxicillin maybe add gentamicin, give vancomycin if penicillin allergy, if severe sepsis riskfactors and gram negative give vancomycin and meropenem

100
Q

Endocarditis caused by staphylococci treatment

A

Flucloxacillin for 4 weeks, if penicillin allergy/MRSA give vancomycin+rifampicin

101
Q

Streptococci endocarditis treatment

A

Benzylpenicillin sodium

102
Q

Endocarditis caused by enterococci treatment

A

Amoxicillin+gent/benzylpenicillin

103
Q

HACEK endocarditis treatment

A

Amoxicillin

104
Q

Heart failure effect/symptoms

A

Reduced cardiac output, SOB, coughing, wheezing, ankle swelling, fatigue, reduced exercise tolerance, pulmonary oedema/crackles, jugular venous pressure higher, pink frothy sputum

105
Q

Reduced heart failure is

A

Left ventricle loses its ability to contract normally and therefore presents with an ejection fraction of less than 40%

106
Q

Preserved heart failure

A

Left ventricle loses its ability to relax normally therefore the ejection fraction is normal or only mildly reduced

107
Q

Heart failure non-pharmacological treatment

A

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
Q

Why are diuretics recommended for treatment of reduced heart failure

A

Relieve breathlessness and oedema for those with fluid retention

109
Q

Reduced Ejection fraction heart failure treatment

A

Beta blocker+ ACEi
Loop diuretic
Aldosterone antagonist - eplerenone

110
Q

What to check when initiating ACE/ARB

A

serum potassium and sodium, renal function, and blood pressure

111
Q

Thiazide use in HF

A

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

112
Q

Loop diuretic use in HF

A

Pulmonary oedema due to left ventricular failure and in patients with chronic heart failure or in resistant hypertension

113
Q

Thiazide mechanism

A

Inhibit sodium reabsorption at the beginning of the distal convoluted tubule

114
Q

Thiazide mechanism

A

Inhibit sodium reabsorption at the beginning of the distal convoluted tubule

115
Q

When do thiazide diuretics work and how long for

A

Within 1-2 hours for 12-24 hours

116
Q

Furosemide and bumetanide action and duration timings

A

Act in one hour and complete diuresis within 6 hours

117
Q

Spironolactone indications

A

Cirrhosis, primary hyperaldosteronism, heart failure,oedema

118
Q

Mannitol diuretic type

119
Q

dorzalamide/brinzolamide indication

A

Inhibit formation of aqueous humour and used in glaucoma

120
Q

What to look out for when initiating ACE

A

First dose hypotension with heart failure patients taking loop diuretic, so may temporarily remove loop, this may need specialist supervision

121
Q

What do fibrates do e.g. fenofibrate

A

Reduce triglyceride concentration

122
Q

Risk of concomitant use of statin and fibrate

A

Muscle related side effects

123
Q

High intensity statins and dose

A

atorva 20mg = rosuva 10mg = simvastatin 80mg

124
Q

Low intensity statins

A

Simvastatin 10mg=prava 40mg=fluva 40mg

125
Q

When should alteplase/streptokinase be given for MI

A

6-12 hours of MI, ideally within an hour

126
Q

Hypertension lifestyle treatment

A

Clinic BP between 140/90 and 160/100 or >135/85 at home

127
Q

When to consider treatment for patients of >80YO with hypertension

A

If >150/90

128
Q

When to consider treatment for under 60 years old with hypertension

A

Stage 1 and estimated 10 year cv risk >10%

129
Q

When to consider hypertension treatment under age of 80

A

established cardiovascular disease, renal disease, diabetes, or a 10 year cardiovascular risk ≥10%.

130
Q

SIGN guidance on antihypertension treatment eligibility

A

Treatment offered if >140/90 regardless of age or stroke even if normal BP

131
Q

Stage 2 hypertension

A

Clinic BP160/100 - 180/120 mmHg or 150/95 at home

132
Q

When to refer hypertension patients on the same day

A

> 180/120, consider starting antihypertensive treatment immediately

133
Q

Aspirin and hypertension caution

A

BP must be controlled before giving aspirin

134
Q

BP target if under 80

135
Q

BP target in over 80yo

136
Q

SIGN BP target

137
Q

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

A
  1. ACE/ARB
  2. CCB/thiazide like diuretic +ACE/ARB
  3. ACE/ARB+ CCB and a thiazide-like diuretic
  4. Seek advice
138
Q

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

A
  1. CCB
  2. CCB+ACE/ARB/Thiazide
  3. ACE/ARB+CCB+Thiazide
  4. Seek advice + confirm
139
Q

T1DM hypertension aim

A

135/85 mmHg

140
Q

Antihypertensives with the potential of causing hypoglycaemia

A

Beta blockers

141
Q

Antihypertensives with the potential of causing hyperglycaemia

A

Thiazide, CCB

142
Q

Hypertension in pregnancy

A

intravenous labetalol hydrochloride, intravenous hydralazine hydrochloride, or oral nifedipine modified-release to achieve a target blood pressure of 135/85 mmHg or less.

143
Q

First line pre-eclampsia/ hypertension pregnancy treatment if >140/90

A

Labetalol (nifedipine mr if unsuitable then methyldopa)

144
Q

First line pre-eclampsia/ hypertension pregnancy treatment if 160/90

A

Labetalol if not then nifedipine, methyldopa

145
Q

Severe hypertension and pregnancy

A

Magnesium in critical care setting

146
Q

Methyldopa and pregnancy discontinuation

A

2 days before birth and switch

147
Q

Hypertension medicines used in breastfeeding

A

Enalapril first line or nifedipine/amlodipine in afro-Caribbean

148
Q

Nitrates action

A

Flushing, headache, and postural hypotension

149
Q

Length of GTN effect

A

20-30 minutes

150
Q

Nitrate indication

A

Angina prophylaxis, CHF adjunct

151
Q

When is isosorbide dinitrate used

A

Infrequent and prophylaxis

152
Q

Isosobide mononitrate use

A

Prophylaxis

153
Q

Anticoagulant use reason

A

Prevent thrombus formation/extension in the slower venous side

154
Q

Why are anticoagulants not that effective against artery thrombus prevention

A

Not that effective in preventing thrombus formation in arteries as they are faster flowing and the platelets have less fibrin

155
Q

Vitamin k antagonists

A

Warfarin, acenocoumarol, phenindione

156
Q

What anticoagulant is preferred before surgery

A

LMWH or heparin (can continue warfarin if already on it and at high risk of VTE)

157
Q

INR 2.5 is for

A 
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
Q

When is an INR of 3.5 recommended

A

Recurrent DVT/PE in patients already receiving anticoagulation with an INR >2
Mechanical prosthetic heart valves

159
Q

How to stop major bleeding from warfarin

A

Stop warfarin

Give phytomenadione IV , dried prothrombin complex or fresh frozen plasma (less effective) restart INR when <5.0

160
Q

When to stop warfarin before elective operations (days)

A

Stop 5 days before elective surgery

161
Q

At what INR do you still need to give phytomenadione if warfarin is stopped before surgery

A

Dose given the day before a procedure If INR greater than >1.5
Can bridge with LMWH

162
Q

When to bridge warfarin

A

High risk of thromboembolism

163
Q

Who is at high risk of thromboembolism

A

VTE in last 3 months
AF with previous stroke/TIA
Mechanical valve

164
Q

Antiplatelet +anticoagulant indication

165
Q

Why are LWMH preferred to heparin in VTE prevention

A

Equally effective and lower risk of HIT (heparin-induced thrombocytopenia)

166
Q

Fondaparinux action

A

Synthetic pentasaccharide that inhibits activated factor X

167
Q

Raynauds treatment

A

Smoking cessation

Aspirin

168
Q

QRISK factors

A 
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
Q

When is heparin preferred to LMWH

A

Renal impairment

170
Q

Who is at risk of hospital acquired blood clots

A

post-surgery, immobility, malignancy, obesity, acquired/inherited hypercoaguable states, pregnancy and postpartum, hormonal therapy,

171
Q

Who should stockings be given to

A

acute stroke, thrombocytopenia, bleeding disorders

172
Q

What to use in general or orthopaedic surgery when the risk of VTE outweighs the risk of bleeding

A

LWMH( first line) , fondaparinux, aspirin+ stockings /rivaroxaban/apixa/dabigatran

173
Q

Who is at risk of hospital acquired blood clots

A

Post-surgery, immobility, malignancy, obesity, acquired/inherited hypercoaguable states, pregnancy and postpartum, hormonal therapy,

174
Q

First line confirmed proximal DVT/PE

A

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
Q

Heparin antidote and downfalls

A

Protamine sulfate is a specific antidote to heparin (and LMWH but only partially reverse its effects)

176
Q

Stable angina is characterized by

A

Predictable chest pain/pressure often due to physical exertion/stress increasing hearts oxygen demand.

177
Q

Acute attack of angina

A

Treated with GTN, can also be used as a preventer, used just before activities known to result in attack.

178
Q

How does angina pain radiate

A

Starts at front of chest and may go to neck, shoulders, jaws or arms

179
Q

When are statin doses lowered

A

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
Q

When and what statin alternatives are used

A

Ezetimbe and bile acid sequestrants when elevated CVD risk and statin contraindicated

181
Q

Aim for reduction in non-HDL-cholesterol concentration with statins

182
Q

Who should be offered low dose atorvastatin

A

T1DM patients who are over 40 or have other risk factors , patients over 85

183
Q

CVD risk greatest in>

A

South asian, men, family history, over 50 years,

184
Q

Resus

A

CPR - adrenaline every 3-5 minutes chest compressions , can be given (lidocaine is an alternative) amiodarone

185
Q

Long term angina prevention

A

beta-blocker first line
CCB if beta contraindicated
combine CCB and beta if monotherapy fails, try long acting nitrate monotherapy

BNF Chapters (11 decks)

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