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Cardiology - High Flashcards

1
Q

What are the most commonly prescribed statins?

A

Atorvastatin
Simvastatin
Pravastatin
Rosuvastatin

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2
Q

What are the clinical indications for the use of statins?

A
  1. Primary preventionof cardiovascular events (MI / stroke)
  2. Secondary prevention of cardiovascular events in patients with established cardiovascular disease
  3. Primary hyperlipidaemia
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3
Q

What are the important adverse effects associated with the use of statins?

A
  • Muscle pain and myopathy
  • GI upset
  • Rhabdomyolysis
  • Drug-induced hepatitis
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4
Q

Why is simvastatin taken at night?

A

Because simvastatin has a relatively short half-life and cholesterol is primarily synthesised in the early hours of the morning.

Other statins (atorvastatin) can be taken at any time during the day

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5
Q

When should the use of statins be avoided?

A

In pregnancy and breastfeeding

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6
Q

When should statins be used with caution?

A

Hepatic impairment
Dose should be reduced in renal impairment

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7
Q

Which drugs interact with statins and to what effect?

A
  • CYP enzyme inhibitors (metronidazole, amiodarone, irtaconazole, macrolides, etc)
  • Amlodipine - reduces the metabolism of statins
  • Grapefruit juice
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8
Q

What action should be taken if a patient established on a statin is started on treatment with either amlodipine or a CYP inhibiting drug?

A

Dose of statin will likely need to be reduced.
If the course of the other drug is only short term then the statin can be held for the duration.

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9
Q

What is a typical dose of simvastatin for primary prevention?

A

40mg OD

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10
Q

What is a typical dose of atorvastatin for primary prevention?

A

20mg OD

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11
Q

What % reduction in non-HDL cholesterol levels is the target 3 months after initiation of a statin?

A

40%

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12
Q

What are the key points when counselling a patient on the use of statins?

A
  • Seek medical attention if you experience muscle symptoms such as pain or weakness
  • Blood tests are required 3 and 12 months after initiation
  • Minimise alcohol intake
  • Avoid grapefruit juice
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13
Q

Which statins do not interact with grapefruit juice?

A

Pravastatin
Rosuvastatin

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14
Q

Which condition can cause hyperlipidaemia and should be resolved before considering starting a patient on statins?

A

Hypothyroidism

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15
Q

What monitoring requirements are there during the use of statins?

A
  • Lipid profile at initiation and 3 months after
  • LFTs at baseline, 3 months and 12 months after initiation
  • Cholesterol levels for efficacy at any interval

(A rise in ALT to 3x the upper limit may be acceptable, but above this statins must be discontinued)

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16
Q

What is the target blood pressure in individuals 80 years and older?

A

< 150/90

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17
Q

What kind of calcium channel blocker is verapamil?

A

Non-dihydropyridine (Rate-limiting)

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18
Q

What can be given when urgent rate control is required?

A

IV beta-blocker
Verapamil

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19
Q

Which drugs can be used for pharmacological cardioversion?

A

Flecainide
Amiodarone

Flecaininde cannot be used if there is structural or ischaemic heart disease present

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20
Q

Is rate- or rythm-control preferred when arrythmias have been present for more than 48 hours?

A

Rate-control

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21
Q

If the onset was over 48 hours ago, is electric cardioversion or pharmacological cardioversion preferred in atrial fibrillation?

A

Electric cardioversion

But, the patient must have been anticoagulated for at least 3 weeks

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22
Q

What is the preferred first line therapy for atrial fibrillation?

A

Rate-controlwith beta-blocker or rate-limiting calcium channel blocker (diltiazem or verapamil)

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23
Q

Which beta-blocker cannot be used as rate-control?

A

Sotalol hydrochloride

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24
Q

When is the use of digoxin monotherapy appropriate for rate control?

A

In patients with non-paroxysmal AF, who are sedentary, or in those where the use of other rate-limiting medications is unsuitable

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25
Q

What is the preferred therapy for a patient whose ventricular function is impaired (LVEF <40%)?

A

Bisoprolol + Digoxin

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26
Q

When monotherapy fails in initial rate-control for AF, which drugs are available for use in combination therapy?

A

Bisoprolol
Digoxin
Diltiazem

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27
Q

If drug treatment is required to maintain sinus rhythm post-cardioversion, what are the first- and second-line treatment options?

A

First-line - standard beta-blocker
Second-line - amiodarone or flecainide

Dronedarone can also be considered 2nd line in the treatment of paroxsymal AF

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28
Q

What is the “Pill-in-the-pocket” approach to treatment of AF?

A

For paroxysmal AF where the patient has infrequent episodes. They are able to take an anti-arrhythmic drug to treat an epsiode of AF when it occurs.

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29
Q

Which anticoagulants are recommended for non-valvular AF?

A

DOACs

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30
Q

What should be offered to patients with new-onset AF while a decision is made regarding their ongoing anticoagulation?

A

Parenteral anticoagulant (Heparin)

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31
Q

What is the difference between atrial fibrillation and atrial flutter?

A

Atrial fibrillation - atria beat irregularly
Atrial flutter - atria beat regularly, but faster than usual, and often faster than the ventricles

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32
Q

How long should anticoagulation be continued post-cardioversion?

A

At least 4 weeks

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33
Q

Which drugs are used for pharmacological cardioversion of atrial flutter?

A

Flecainide or Propafenone
(in conjunction with either beta-blocker, diltiazem, or verapamil)

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34
Q

When is catheter ablation preferred for cardioversion?

A

Recurrent atrial flutter

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35
Q

When does the dose of digoxin have to be halved?

A

When use concurrently with:
Amiodarone
Dronedarone
Quinine

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36
Q

What should be used to treat bradycaria post-myocardial infarction?

A

A dose of IV atropine

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37
Q

What is the preferred anti-arrhythmic drug for the treatment of ventricular tachycardia?

A

Amiodarone

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38
Q

What is Torsade de pointes and how can it be treated?

A

A usually self-limiting ventricular tachycrdia associated with QT prolongation.
It can be treated with a beta-blocker, but not anti-arrhythmics as these further prolong the QT interval.

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39
Q

Which electrolyte disorder enhances the pro-arrhythmic effects of anti-arrhythmic drugs?

A

Hypokalaemia

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40
Q

What class of anti-arrhythmic drug is flecainide?

A

Class I

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41
Q

What class of anti-arrhythmic drug are beta-blockers?

A

Class II

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42
Q

What class of anti-arrhytymic drug is amiodarone?

A

Class III

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43
Q

What class of anti-arrhythmic drug is verapamil?

A

Class IV

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44
Q

What class of anti-arrhythmic drug is dronedarone?

A

Class III

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45
Q

What class of anti-arrhythmic drug is licodcaine?

A

Class I

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46
Q

Which class of drugs does digoxin belong to?

A

Cardiac glycoside

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47
Q

What is the drug of choice for treating paroxsymal supraventricular tachycardia?

A

Adenosine

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48
Q

Is digoxin effective at rapid control in atrial flutter and atrial fibrillation?

A

No, may take several hours to take effect

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49
Q

Which drugs are effective at treating both ventricular and supraventricular arrhythmias?

A

Amiodarone
Beta-blockers
Flecainide
Propafenone
Disopyramide

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50
Q

Does amiodarone have a long or a short half-life?

A

Long (several weeks)

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51
Q

What are the downsides of using disopyramide intravenously and orally, respectively?

A

IV - decreases cardiac contractility
PO - has antimuscarinic effects

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52
Q

What is dispyarmide indicated for?

A

Prevention and treatment of ventricular and supraventricular arrhythmias, including after MI

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53
Q

What is the antidote for digoxin overdose?

A

Digifab

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54
Q

Which electrolyte disorders can increase the risk of digoxin toxicity?

A

Hypokalaemia
Hypomagnesaemia
Hypercalcaemia

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55
Q

Which drugs are used for the treatment of supraventricular arrhythmias?

A

Digoxin
Adenosine
Verapamil

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56
Q

What is Tranexamic acid used for?

A

Fibrinolysis and prevention and treatment of haemorrhage in trauma

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57
Q

Which drug is available for the treatment of subarachnoid haemorrhage?

A

Nimodipine

POM

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58
Q

List some risk factors for VTE

A
  • Surgery
  • Trauma
  • Pregnancy and postpartum
  • Hormonal therapy
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59
Q

What type of anticoagulant is preferred for general and orthopaedic surgery?

A

Low molecular weight heparin

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60
Q

When is the use of unfractionated heparin preferrable to other heparins for surgical VTE?

A

Renal impairment

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61
Q

How long should VTE prophylaxis be continued for post-surgery?

A

7 days, or until the patient recovers all of their mobility

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62
Q

How should patients undergoing elective hip relacement be anticoagulated?

A

LMW heparin for 10 days, followed by 28 days of low dose aspirin

DOACs are also a suitable option

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63
Q

How should patients undergoing elective knee replacement be anticoagulated?

A

Low dose aspirin for 14 days

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64
Q

What kind of anticoagulation is most appropriate for a pregnant inpatient?

A

LMW heparin

Until VTE is no longer a risk of they are discharged

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65
Q

Patients who have given birth, had a miscarriage, or termination of pregnancy within 6 weeks should be treated with what kind of VTE prophylaxis and for how long?

A

LMW heparin 4 - 8 hours after the event, and continued for at least 7 days

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66
Q

What are the first line treatment options for proximal VT or PE?

A

Apixaban
OR
Rivaroxaban

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67
Q

Which DOACs require 5 days of parenteral anticoagulation prior to their initiation?

A

Edoxaban
Dabigatran

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68
Q

How long should anticoagulation be continued for the treatment of DVT or PE?

A

3 months

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69
Q

How long should anticoagulation be continued for the treatment of AF?

A

Life-long

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70
Q

What kind of anticoagulation should a pregnant patient, or who has just given birth in the last 6 weeks receive for the treatment of VTE (DVT or PE)?

A

LMW heparin as soon as VTE suspected and then continued as maintenance unless diagnosis of DVT or PE excluded

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71
Q

Can the DOACs be used in pregnancy and breastfeeding?

A

No

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72
Q

When is alteplase no longer appropriate for the treatment of acute ischaemic stroke?

A

4.5 hours after onset of stroke

(It is also inappropriate in intracranial bleeding)

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73
Q

What is the first line treatment for ischaemic stroke, regardless of whether the patient has received alteplase?

A

300mg aspirin for 14 days
(Needs to be started 24 hours after thrombolysis / ASAP within 48 hours of symptom onset in those not receiving thrombolysis)

Consider PPI in addition

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74
Q

How should treatment be managed in patients receiving anticoagulation for a prosthetic heart valve who then suffer a disabling ischaemic stroke?

A

Anticoagulation should be stopped and replaced with aspirin 300mg OD for 7 days

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75
Q

What needs to be started within 48 hours of stroke onset, excluding anticoagulation or antiplatelet drugs?

A

High intensity statin such as atorvastatin

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76
Q

What drug should be used for long-term management following ischaemic stroke or TIA?

A

Clopidogrel

Dipyridamole with aspirin when clopidogrel is contraindicated or not tolerated

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77
Q

Can beta-blockers be used for hypertension following a stroke?

A

No

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78
Q

What is the target blood pressure range post-stroke?

A

< 130/80mmHg

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79
Q

What is the initial management of intracerebral haemorrhage within 6 hours of symptom onset?

A

Blood lowering medication if systolic BP is 150 - 220 down to target BP of 130 - 140 maintained for 7 days

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80
Q

Which drug class should ideally be avoided after intracerebral haemorrhage?

A

Statins

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81
Q

How long does it take for warfarin to produce its anticoagualnt effect after initiation?

A

48 - 72 hours

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82
Q

What is the typical target INR during warfarin therapy?

A

2.5

0.5 units within the target is acceptable

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83
Q

For which indications is the target INR 3.5 during warfarin therapy?

A

Recurrent DVT or PE in patients currently receiving anticoagulation

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84
Q

How many days before elective surgery should warfarin be stopped?

A

5 days

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85
Q

Which kind of anticoagulants are used to “bridge” warfarin therapy in those undergoing elective surgery who are at a highrisk of thromboembolism?

A

LMWH which should be stopped 24 hours before surgery

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86
Q

Reversal agents are not available for which of the DOACs?

A

Edoxaban

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87
Q

What reversal agents are available for DOAc overdose?

A

Andaxanet - Rivaroxaban and Apixaban
Idarucizumab - Dabigatran

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88
Q

Which has a shorter onset and duration of action, heparin (unfractionated) or low molecular weight heparins?

A

Heparin (unfractionated)

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89
Q

Which has a lower incidence of heparin-inducedthrombocytopenia, heparin (unfractionated) or low molecular weight heparins?

A

LMWH

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90
Q

Can aspirin be used in primary prevention of cardiovascular disease?

A

No, long-term use of low dose aspirin is only recommended for secondary prevention

a.k.a in established cardiovascular disease

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91
Q

How long prior to surgery do DOACs need to stopped?

A

24 hours

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92
Q

What is the dose of edoxaban in an adult weighing < 61kg

A

30mg

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93
Q

What is the dose of edoxaban in an adult weighing > 61kg

A

60mg

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94
Q

When is a dose adjustment of edoxaban required and when should it be avoided?

A

CrCl 15ml/min - 50ml/min - reduce to 30mg OD
Avoid if CrCl <15ml/min

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95
Q

What is the typical dosing regimen of apixaban for the treatment of VDT or PE?

A

10mg BD for 7 days
Then
5mg BD

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96
Q

When is a dose reduction of apixaban necessary?

A

When used for prophylaxis of stroke and systemic embolism in non-valvular AF in patients in patients >80yrs, < 60kg, or with CrCl 15 -29ml/min

Dose reduced to 2.5mg BD

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97
Q

What are the MHRA warnings associated with the use of the DOACs?

A
  • Increased risk of recurrent thrombotic eventsin patients with antiphospholipidsyndrome (June 2019)
  • Reminder of bleeding risk, including availability of reversal agents (June 2020)
  • Warfarin and other anticoagulants: Monitoring of patients during the Covid-19 pandemic (Octoer 2020)
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98
Q

What are the main contraindications for the use of the DOACs?

A
  • Antiphospholipid syndrome
  • Prosthetic heart valve
  • Almost any condition with increased blled risk or recent surgery
  • Concurrent use of any other anticoagulant
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99
Q

What is the MHRA warning specifically associated with the use of warfarin?

A

Reports of calciphylaxis (July 2016)

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100
Q

What are the common clinical indications for the use of calcium channel blockers?

A
  1. Amlodipine and nifedipine can be used as first- and second-line treatment of hypertension
  2. All calcium channel blockers are used to control symptoms of stable angina
  3. Diltiazem and verapamil are used as cardiac rate control in supraventricular arrhythmias (AF, atrial flutter, etc)
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101
Q

What are the important adverse effects associated with the use of amlodipine and nifedipine?

A
  • Ankle swelling
  • Flushing
  • Headaches
  • Palpitations
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102
Q

What are the important adverse effects associated with the use of diltiazem and verapamil?

A
  • Bradycardia
  • Constipation
  • Heart block
  • Heart failure

Diltiazem has mixed vascualr and cardiac actions and causes any/all of the adverse effects associated with the use of CCBs

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103
Q

When is the use of amlodipine and nifedipine contraindicated?

A
  • Unstable angina
  • Severe aortic stenosis
  • Cardiogenic shock
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104
Q

When is the use of verapamil and diltiazem contraindicated?

A
  • Severe impairment of left venticular function
  • Bradycardia
  • Heart failure
  • Hypotension
  • Heart block
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105
Q

Which drugs cannot be given alongside non-dihydropyridine calcium channel blockers unless under specialist supervision and why?

A

Beta-blocker, because they are both negatively inotropic and chronotropic, and together may cause heart failure

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106
Q

Which calcium channel blocker has the longest half-life and duration of action?

A

Amlodipine

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107
Q

What is a typical dose of amlodipine for hypertension?

A

5 - 10mg OD

108
Q

What is a typical dose of diltiazem for angina?

A

MR 90mg BD

109
Q

What is a typical dose of verapamil for supraventricular arrhythmias?

A

40 - 120mg TD

110
Q

What are the key pointswhen counselling a patient on the use of calcium channel blockers?

A
  • Measures to reduce cardiac risk
  • Side effects such as ankle oedema
111
Q

Modified release preparations of which calcium channel blockers are not bioequivalent and as such should be ordered by brand?

A

Diltiazem
Nifedipine

112
Q

What are the clinical indications for the use of amiodarone?

A
  1. Supraventricular arrythmias (AF, atrial flutter, supraventricular tachycardia)
  2. Ventricular tachycardia

Generally only used when other therapeutic options have been ineffective

113
Q

When is the use of amiodarone contraindicated?

A
  • Thyroid dysfunction
  • Heart block
  • Severe conduction disturbances

Amiodarone shouldalso be used with caution in those with severe hypotension

114
Q

What are the most notable interactions with amiodarone?

A
  • Grapefruit juice
  • Digoxin
  • Non-hydropyridine CCBs
  • Drugs that prolong the QT
  • Phenytoin
  • Atorvastatin
  • Warfarin
  • Nitrofurantoin
115
Q

What are the key points when counselling a patient on the use of amiodarone?

A
  • Grey skin and photosensitivity (UV protection)
  • ## Microdeposits in the eye
116
Q

How do heparins affect potassium levels?

117
Q

What are the common clinical indications for the use of ADP receptor antagonist antiplatelets?

A
  1. Treatment of ACS, usually in combination with aspirin
  2. Prevention of occlusion of coronary artery stents, usually with aspirin
  3. Long-term secondary prevention of thrombotic events in patients with cardiovascular, cerebrovascualr and peripheral arterial disease
118
Q

How long before elective surgery should clopidogrel be stopped?

119
Q

What are the some adverse effects associated with the use of antiplatelets?

A
  • Haemorrhage
  • GI upset
  • Thrombocytopenia (rare)
120
Q

When is the use of antiplatelets contraindicated?

A

Active bleeding

121
Q

Which drugs interact with clopidogrel and to what extent?

A
  • Omeprazole - decreases efficacy of clopidogrel
  • CYP inhibitors (erythromycin, SSRIs, metronidazole, etc)
122
Q

What is the typical dosing regimen of clopidogrel for the treatment of ACS?

A

Loading of 300mg once only
Maintenance 75mg OD

123
Q

What is the typical NSAID dose of aspirin for mild to moderate pain?

A

300 - 900mg QD (Max 4g)

124
Q

What is the typical dose for the treatment of migraine?

A

900mg as a single dose at onset of symptoms

125
Q

What are the indications for the use of aspirin?

A
  1. Treatment of ACS and acute ischaemic stroke
  2. Long-term secondary prevention of thrombotic events in patients with cardiovascular, cerebrovascualr and peripheral aterial disease
  3. Mild to moderate pain and fever
126
Q

What are the important adverse effects associated with the use of aspirin?

A
  • GI irritation and ulceration
  • Bronchospasm
  • Haemorrhage
  • Tinnitus

Overdose is characterised by hearing changes, hyperventilation, metabolic acidosis, confusion, followed by convulsions, cardiovascualr and respiratory arrest

127
Q

What is the minimum age a patient can be to receive aspirin?

A

16 - risk of Reye’s syndrome in children <16

128
Q

When is the use of aspirin contraindicated?

A
  • <16yrs
  • Bleeding disorders
  • Peptic ulceration
  • Severe cardiac failure
129
Q

Which drugs interact with aspirin and to what extent?

A

Antiplatelets - increased risk of bleeds
Anticoagulants - increased risk of bleeds

130
Q

What is the typical dose and duration of aspirin for the treatment of ischaemic stroke?

A

300mg OD for 2 weeks

131
Q

What are the beta-blockers indicated for?

A
  1. Ischaemic heart disease toimprove symptoms and prognosis of ACS
  2. Heart failure
  3. Reduce ventricular rate and maintain sinus rythm in AF
  4. Restore sinus rhythm is supraventricular tachycardia
  5. Hypertension when ACEIs, ARBs, CCBs, and diuretics are insufficient
132
Q

When is the use of beta-blockers contraindicated?

A
  • Asthma
  • Uncontrolled heart failure
  • Heart block
  • Concurrent use with non-dihydropyrine CCBs unless under specialist supervision
133
Q

Which beta-blockers are cardioselective?

A

Atenolol
Bisoprolol
Metoprolol

134
Q

What are some important adverse effects associated with the use of beta-blockers?

A
  • Peripheral coldness
  • Headache
  • GI upset
  • Sleep disturbances
  • Impotence
135
Q

Which beta-blockers are non-cardioselective?

A

Propranolol
Labetolol
Carvedilol
Sotalol

136
Q

Can beta-blockers be use in asthma and COPD?

A

Asthma - No
COPD - Use is not contraindicatd but it is prudent to use amore cardioselective option such as bisoprolol to minimise risk of bronchospasm

137
Q

When do beta-blockers require dose reduction?

A

In hepatic impairment

138
Q

How should beta-blockers be dosed in heart failure?

A

They should be started at a low dose and up-titrated slowly as they can initially impair cardiac function

139
Q

Which drugs interact with beta-blockers and to what effect?

A
  • Non-dihydropyridine CCBs - increased risk of bradycardia, heart failure, and asystole
140
Q

Which is usualy the beta-blocker of choice when starting acute treatment for ACS and other indications, and how is it dosed?

A

Metoprolol
25mg 8hrly

More responsive to dose adjustment in acute treatment - can be switched to OD preparations for long-term maintenance

141
Q

What are the common indications for the use of digoxin?

A
  1. In AF and atrial flutter to reduce ventricular rate (However beta-blockers or CCBs are usually more effective)
  2. Severe heart failure in patients who are already taking an ACE, beta-blocker and either an aldosterone antagonist or ARB
142
Q

When is the use of digoxin contraindicated?

A
  • Constrictive pericarditis
  • Myocarditis
  • Ventricular tachycardia or fibrillation
143
Q

Which drugs interact with digoxin and to what effect?

A
  • Loop and thiazide diuretics - increase risk of hypokalaemia and thus digoxin toxicity
  • Amiodarone - increase serum concentration of digoxin
  • CCBs - increase serum concentration of digoxin
  • Spironolactone - increase serum concentration of digoxin
  • Dronedarone - increase serum concentration of digoxin
  • Quinine - increase serum concentration of digoxin
144
Q

What is a typical maintenance dose of digoxin for atrial fibrillation or atrial flutter?

A

125 - 250 micrograms OD

145
Q

What needs to monitored during treatment with digoxin?

A
  • Symptoms
  • Heart rate
  • Electrolytes
  • Renal function
145
Q

What is a typical maintenance dose of digoxin for heart failure?

A

62.5 - 125 micrograms OD

146
Q

Treatment with which medication can cause ST segment elevation?

147
Q

When should heparins be used with caution?

A
  • Uncontrolled hypertension
  • Clotting disorders
  • Recent surgery or trauma
  • Renal impairment (dose reduction)
148
Q

What should be monitored in long term therapy with heparins?

A
  • Potassium levels
  • Platelet count
  • Antifactor Xa activity
149
Q

What are the threshold blood pressure readings indicative of Stage 1 hypertension?

A

Clinical BP between 140/90 and 160/90
(ambulatory home BP of >135/85)

150
Q

What are the threshold blood pressure readings indicative of Stage 2 hypertension?

A

Clinical BP between 160/90 and 180/90
(ambulatory home BP of >150/95)

151
Q

What are the threshold blood pressure readings indicative of severe hypertension?

A

Systolic >180
Diastolic >120

152
Q

What is a target blood pressure during treatment of hypertension in a patient younger than 80yrs?

A

<140/90
(ambulatory home BP <135/85)

153
Q

What is a target blood pressure during treatment of hypertension in a patient older than 80yrs?

A

<150/90
(ambulatory home BP <145/85)

154
Q

What are the steps for the treatment of hypertension in patients over 55yrs or of black african or African-Caribbean origin (without type 2 diabetes)?

A

Step 1. CCB
Step 2. CCB + ACEI / ARB / thiazide-like diuretic
Step 3. CCB + ACEI/ARB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker

155
Q

What are the steps for the treatment of hypertension in patients younger than 55yrs and not of black african or African-Caribbean origin?

A

Step 1. ACEi / ARB
Step 2. ACEi / ARB + CCB / thiazide-like diuretic
Step 3. ACEi / ARB + CCB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker

156
Q

What are the steps for treatment of hypertension in patients with type 2 diabetes?

A

Step 1. ACE / ARB (always ARB in African/Caribbean origin)
Step 2. ACE / ARB + CCB / thiazide-like diuretic
Step 3. ACE / ARB + CCB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker

157
Q

What is the target blood pressure for a patient with type 1 diabetes being treated for hypertension?

158
Q

What is the antihypertensive drug of choice in pregnancy

159
Q

Woemn if at moderate and high risk of hypertension during pregnancy are advised to take whatfrom week 12 until birth?

A

Aspirin

Unlicensed use

160
Q

Which antihypertensives should be stopped on discovery of pregnancy?

A
  • ACEis
  • ARBs
  • Thiazide and thiazide-like diuretics

Due to risk of congenital abnormalities

161
Q

What are the second- and third-line choices for antihypertensives in pregnancy?

A

2nd - MR nifedipine
3rd - methyldopa

162
Q

What action should be taken regarding methyldopa post pregnancy for the treatment for hypertension?

A

Methyldopa should be stopped within 2 days of birth and switched to an alternative antihypertensive

163
Q

What are the first line choices of antihypertensives post-pregnancy in women who decide to breastfeed?

A
  • Enalapril
  • (African/Caribbean) nifedipine or amlodipine
164
Q

Which drug class does methyldopa belong to?

A

Centrally acting antihypertensive

165
Q

Which class of cardiac medications can mask the symptoms of hypoglycaemia?

A

Beta-blockers

Not contraindicated but cardioselective beta-blockers are preferred

167
Q

Which calcium channel blocker can be used in heart failure?

A

Amlodipine

168
Q

Which combination of drugs is sold under the brand name Entresto?

A

Sacubitril and valsartan

169
Q

What is a typical dose of amlodipine for the treatment of angina or hypertension?

A

5 - 10mg OD

170
Q

Which drug can be given in hypotensive crises?

A

Sodium itroprusside

171
Q

How is heart failure characterised?

A
  • Breathlessness
  • Swelling of the ankles
  • Reduced exercise tolerance
  • Fatigue
  • Elevated jugular venous pressure
  • Pulmonary crackles
  • Pulmonary oedema
172
Q

What is the ejection fraction of the left ventricle in heart failure with reduced ejection fraction?

173
Q

Which calcium chaneel blockers should be avoided in heart failure with a reduced ejection fration?

A
  • Rate limiting CCBs (verapamil + diltiazem)
  • Short acting hydropyridines (nifedipine + nicardipine)

These drugs reduce cardiac contractility

174
Q

Which class of diuretics is the class of choice for the relief of breathlessness and oedema in patients with heart failure?

A

Loop diuretics

175
Q

What is the first line therapy for heart failure irrespective of other comorbidities?

A

ACEi and beta-blocker

ARB if ACEi not tolerated or contraindicated

176
Q

What is the second-line therapy option in worsening heart failure?

A

Consider adding aldosterone antagonist such as spironolactone to existing therapy

177
Q

What is the third-line therapy option in worsening heart failure despite optimal treatment?

A

Specialist advice should be sought regarding the use of amiodarone, digoxin, Entresto, empaglaflizon, and dapagliflozin.

178
Q

What are the 4 pillars of heart failure?

a.k.a most commonly prescribed combination for heart failure

A

ACEi
Beta-blocker
Aldosterone antagonist
SGLT2 inhibitor

Entresto replaces ACEi in this combination if prescribed

179
Q

When is digoxin used in heart failure?

A

For those in sinus rhythm with worsening symptoms or severe heart failure

180
Q

What are the monitoring requirements for treating heart failure?

A
  • Serum potassium
  • Serum sodium
  • Renal function
  • Blood pressure
  • Heart rate
    (all of these measured monthly for 3 months, then every 6 months)
181
Q

When is the use of spironolactone contraindicated?

A
  • Hyperkalaemia
  • Anuria
  • Addison’s disease
182
Q

How should Entresto be initiated in a patient already established on an ACEi?

A

Must wait at least 36 hours atfer last dose of ACEi before first dose of Entresto

Risk of angioedema

183
Q

What can be used for the treatment of severe hypercholesterolaemia or hypertriglyceridaemia that is not adequately controlled by maximal dose of a statin?

184
Q

Which statin is associated with the highest risk of myopathy?

A

Simvastatin

185
Q

What is used to treat acute attacks of stable angina?

186
Q

What are the first line options for the loing term prevention of chest pain in stable angina?

A

Beta-blocker (bisoprolol)
(rate-limiting CCB if BB not appropriate)

187
Q

What si the second line option for the prevention of chest pain in stable angina when monotherapy is ineffective?

A

Combined use of a beta-blocker and CCB
(if this is not possible a long-acting nitrate can be used such as ivabradine, nicorandil, or ranolazine)

188
Q

What should patients with stable angina be given for secondary prevention of cardiovascular events?

A
  • Low dose aspirin
  • Statin
  • ACEi (particularly in diabetes)
189
Q

What is the initial management for all acute coronary syndromes?

A
  • Pain relief with GTN sublingual or buccal
  • Loading dose of aspirin (300mg ONCE)
190
Q

What is the initial management for STEMI?

A
  • Loading dose of aspirin (300mg ONCE)
  • Dual anti-platelet therapy (aspirin + clopidogrel/ticagrelor/prasugrel)
191
Q

Which antiplatelet is preferred in patients receiving percutaneious coronary intervention following STEMI?

192
Q

What is the initial management of NSTEMI or unstable angina?

A
  • Loading dose of aspirin (3oomg ONCE)
  • Dual antiplatelet therapy
  • Possibly antithrombin therapy with fondaparinux
193
Q

For secondary prevention following STEMI and NSTEMI what should be offered to the patient?

A
  • ACEi
  • Beta-blocker
  • Dual antiplatelet therapy
  • Statin
194
Q

How does secondary prevention differ following NSTEMi and STEMI in those with and without reduced left ventricular ejection fraction?

A

In those with reduced LVEF - beta-blocker continued indefinitely
In those without reduced LVEF - consider stopping beta-blocker after 12 months

195
Q

When can calcium channel blockers such as verapamil and diltiazem be used as an alternative to beta-blockers for secondary prevention following NSTEMI and STEMI?

A

In patients without pulmonary congestion or without reduced LVEF

196
Q

How long should dual antiplatelet therapy be continued following NSTEMI and STEMI?

A

Aspirin - indefinitely
Clopidogrel - consider stopping after 12 months

197
Q

What are the first line diuretics for the treatment of hypertension?

A

Indapamide
Chlortalidone

198
Q

What are the most commonly prescribed alpha-blockers?

A

Doxazosin
Tamsulosin
Alfuzosin

199
Q

What are the common indications for the use of alpha-blockers?

A
  1. Treatment of benign prostatic hyperplasia
  2. Add-on treatment in resistant hypertension when other medicines are insufficient
200
Q

What are the important adverse effects associated with the use of alpha-blockers?

A
  • Hypotension
  • Dizziness
  • Syncope

Especially when used alongside other antihypertensives

201
Q

When is the use of alpha-blockers contraindicated?

A
  • Postural hypotension
202
Q

What is a typical dose of tamsulosin?

203
Q

Which alpha-blocker is actually licensed for the treatment of hypertension?

204
Q

What is a typical dose of doxazosin?

A

4mg OD
(Max 8mg for BPH / Max 16mg for hypertension)

205
Q

How should treatment with alpha-blockers be started?

A

Ideally, omit doses of other antihypertensives on the day the alpha blocker is started to avoid pronounced first-dose hypotension

206
Q

What are the commonly prescribed aldosterone antagonists?

A

SPironolactone
Eplerenone

207
Q

What are the common clinical indications for the use of aldosterone antagonists?

A
  1. Ascites and oedema due to liver cirrhosis
  2. Chronic heart failure
  3. Primary hyperaldosteronism
208
Q

What are the important adverse effects associated with the use ofaldosterone antagonists?

A
  • Hyperkalaemia
  • Gynaecomastia
209
Q

Between spironolactone and eplerenone, which is less likely to cause endocrine side effects?

A

Eplerenone

210
Q

Can aldosterone antagonists be used in pregnancy and breastfeeding?

211
Q

When is the use of aldosterone antagonists contraindicated?

A
  • Hyperkalaemia
  • Severe renal impairment
  • Addison’s disease
212
Q

Which drugs interact with aldosterone antagonists and to what effect?

A

Drugs that raise serum potassium (trimethoprim, ACEi/ARBs, heparin, NSAIDs, beta-blockers)

213
Q

Which aldosterone antagonist is only licensed for the treatment of heart failure?

A

Eplerenone

214
Q

What is a typical dose of spironolactone for the treatment of oedema/ascites in cirrhosis?

215
Q

What is a typical dose of spironolactone in heart failure?

216
Q

Describe the action of spironolactone as a diuretic

A

Spironolactone is relatively weak diuretic and is often given alongside a thiazide or loop diuretic, where it counteracts the potassium wasting effect and potentiates the diuretic effect.

Used together with furosemide at a ratio of 5:1 (Spiro 200mg / furosemide 40mg)

217
Q

What are the most commonly prescribed ACE inhibitors?

A

Ramipril
Lisinopril
Perindopril

218
Q

What are the common indications for the use of ACE inhibitors?

A
  1. Hypertension
  2. Chronic heart failure
  3. Ischaemic heart disease
  4. Chronic kidney disease and diabetic nephropathy
219
Q

What are some important adverse effects associated with the use of ACE inhibitors?

A
  • Hyperkalaemia
  • Persistent dry cough
  • Hypotension
  • Renal failure
  • Angioedema
  • Anaphylactoid reactions
220
Q

Can ACE inhibitors be used in pregnancy and breastfeeding?

221
Q

When is the use of ACE inhibitors contraindicated?

A
  • Renal impairment (eGFR <60)
  • Angioedema
222
Q

When must ACE inhibitors be used with caution?

A
  • Renal artery stenosis
  • AKI
  • Low sodium diet
  • African/Caribbean origin
  • Dialysis
223
Q

Which drugs interact with ACE inhibitors and to what effect?

A
  • Drugs that elevate serum potassium (trimethoprim, heparin, NSAIDs, k-spring diuretics, beta-blockers, etc)
  • Diuretics - Hypotension
  • NSAIDs - ioncreased risk of nephrotoxicity
224
Q

Is the starting dose of ramipril in heart failure typically higher or lower of that in other indications?

225
Q

What is a typical starting dose of ramipril for heart failure or nephropathy?

A

1.25mg OD

(Can be uptitrated to 10mg OD)

226
Q

What is atypical starting dose of ramipril for the treatment of hypertension?

A

2.5mg OD

(Can be uptitrated to 10mg OD)

227
Q

What action should be taken when serum potassium rises above 5mmol/L in a patient taking ramipril?

A

Stop all other potassium elevating drugs
If despite this potassium rises above 6mmol/L then ramipil must be stopped

228
Q

What are the most commonly prescribed angiotensin receptor blockers?

A

Losartan
Candesartan
Irbesartan

229
Q

What are the common indications for the use of ARBs?

A

Generally used when ACEis are not tolerated or as alternative fisrt-line in certain demographics - indications are the same as ACEis:
1. Hypertension
2. Chronic heart failure
3. Ischaemic heart disease
4. Chronic kidney disease and diabetic nephropathy

230
Q

What are some important adverse effects associated with the use of ARBs?

A
  • Hypotension
  • Renal impairment
  • Hyperkalaemia

Less likely to cause dry cough or angioedema than ACEis

231
Q

Can ARBs be used in pregnancy and breastfeeding?

232
Q

When should ARBs be used with caution?

A
  • Renal artery stenosis
  • AKI
  • CKD
233
Q

Which drugs interact with ARBs and to what effect?

A
  • Drugs that elevate serum potassium (trimethoprim, heparin, NSAIDs, k-sparing diuretics, beta-blockers etc)
  • Diuretics - hypotension
  • NSAIDs - nephrotoxicity
234
Q

What is a typical starting dose of losartan for hypertension?

A

50mg OD (25mg >76yrs)

Increased up to 100mg if necessary

235
Q

What is atypical starting dose of losartan for heart failure?

A

12.5mg OD

Increased up to 100mg if necessary

236
Q

What are the most commonly prescribed loop diuretics?

A

Furosemide
Bumetanide

237
Q

What are the common indications for loop diuretics?

A
  1. Relief of breathlesness in acute pulmonary oedema
  2. Symptomatic relief of fluid overload in chronic heart failure
  3. Symptomatic relief of fluid overload in other oedematous states
238
Q

What are some important adverse effects associated with the use of loop diuretics?

A
  • Dehydration
  • Hypotension
  • Electrolyte depletion
  • Hearing loss
  • Tinnitus
239
Q

When is the use of loop diuretics contraindicated?

A
  • Hypovalaemia and dehydration
  • Severe hyponatraemia
  • Severe hypokalaemia
  • Anuria
  • Drug-induced renal failure
240
Q

When should loop diuretics be used with caution?

A
  • Gout - chronic use can worsen symptoms
  • Hepatic encephalopathy
241
Q

Which drugs interact with loop diuretics and to what effect?

A
  • Other drugs that lower serum electrolyte levels
  • Digoxin - risk of toxicity increased due to associated hypokalaemia
  • Aminoglycosides - increasedrisk of nephrotoxicity and ototoxicity
242
Q

1mg of bumetanide is equivalent to what dose of furosemide?

243
Q

What are th most ommonly prescribed thiazide and thiazide-like diuretics?

A

Bendroflumethiazide
Indapamide
Chlortalidone

244
Q

What are the common indications for the use of thiazide and thiazide-like diuretics?

A
  1. As an alternative first-line treatment for hypertension where a CCB would normally be used
  2. Add-on treatment for hypertension
245
Q

What are some common adverse effects associated with the use of thiazide diuretics?

A
  • Hyponatraemia
  • Hypokalaemia
  • Arrhythmias
  • Preciptations of attacks of gout
246
Q

When is the use of thiazide diuretics contraindicated?

A
  • Electrolyte depletion
  • Addison’s disease
247
Q

Which drugs interact with thiazide diuretics and to what effect?

A
  • NSAIDs - reduce the effectiveness of thiazides
  • Other diuretics - increase the risk of electrolyte and fluid depletion
248
Q

What are the most commonly prescribed nitrates?

A

Isosorbide mononitrate
Glyceryl trinitrate

249
Q

What are the common indications for the use of nitrates?

A
  1. Short acting nitrates (GTN) are used for the management of chest pain in acute angina and acute ACS
  2. Long acting nitrates (isosorbide) are used for angina prophylaxis where beta-blockers and/or CCBs have been insufficient
  3. IV nitrates are used in the treatment of pulmonary oedema (usually in combination with furosemide and oxygen)
250
Q

What are the main adverse effects associated with the use of nitrates?

A
  • Flushing
  • Headaches
  • Light-headedness
  • Tolerance in sustained use
251
Q

When is the use of nitrates contraindicated?

A
  • Aortic stenosis
  • Hypotension
  • Hypovolaemia
  • Cardiac tamponade
  • Marked anaemia
252
Q

Which drugs interact with nitrates and to what effect?

A
  • Phosphodiesterase inhibitors (sildenafil) - prolong the hypotensive effects of nitrates
  • Antihypertensive medications
253
Q

What is a typical dose of isosorbide mononitrate for angina prophylaxis?

A

30 - 120mg BD/TDS

254
Q

What information should be given to a patient regarding the administration of GTN?

A
  • Can be taken before tasks that normally bring on angina
  • Nitrates are better at preventing than terminating angina
  • Sit down for up to 5 minutes before and after administration to avoid postural hypotension
  • Should have a nitrate free period of roughly 18 hours for long term use nitrates (BD dosing of morning and afternoon)
255
Q

What are the common clinical indications for the use of warfarin?

A
  1. VTE (concurrent heparin loading is required at initiation)
  2. Embolism prophylaxis in patients with AF or prostheric heart valve

Lifelong treatment in those with mechanical heart valves

256
Q

What is the main adverse effect associated with the use of warfarin?

257
Q

When is the use of warfarin contraindicated?

A
  • 48 hours postpartum
  • Haemorrhagic stroke
  • Acute bleeding risk
258
Q

Can warfarin be used in pregnancy and breastfeeding?

A

It should ideally beavoided in pregnancy especially in the 1st and 3rd trimesters.
It is not present in breastmilk and appears safe.

259
Q

Which drugs interact with warfarin and to what effect?

A
  • Grapefruit juice
  • CYP inducers - decrease serum warfarin levels and increase risk of clots
  • CYP inhibitors - increase serum warfarin levels and increase the risk of bleeding
  • Broad-spectrum antibiotics - kill gut flora that synthesise vitamin K, increasing bleeding risk
260
Q

Which drugs interact with grapefruit juice?

A
  • Warfarin
  • Amiodarone
  • Statins
  • Antiplatelets
  • Calcium channel blockers
  • Immunosuppressants
261
Q

Which statins are considered high-intensity?

A

Atorvastatin 20 - 40mg
Rosuvastatin 10 - 40mg
Simvastatin 80mg

Ordered highest to lowest intensity

262
Q

When is the use of adenosine contraindicated?

A
  • Asthma
  • COPD
  • Hypotension
  • Decompensated heart failure
  • Coronary ischaemia
263
Q

Which cardiac medication requires the patient to receive a chest x-ray before its initiation?

A

Amiodarone

Pre-Registration Pharmacy (20 decks)

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