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pre reg Thammis cards > Cardiovascualr > Flashcards

Cardiovascualr Flashcards

1
Q

what are the complications of AF and why

A

stroke and thromboembolism

due to AF causing stasis of the blood which can form a thrombi

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2
Q

what are the symptoms of AF

A

heart palpitations, SOB, chest pain, tiredness….

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3
Q

what are the three different types of AF

A

paroxysmal: symptoms stop within 48 hours of starting treatment
persistent: symptoms lasting longer than 7 days
permanent: constant symptoms

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4
Q

1st line treatment for AF

A

preferred 1st line rate control (beta blockers except sotalol)
OR
rate limiting CCB: verapamil and diltiazem

1st used as monotherapy them 2nd line use as combination

digoxin is used for sedentary patients, with HF, non-paroxysmal AF, in combo with Beta blocker if LVEF <40%

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5
Q

2nd line treatment for AF

A

rhythm control - cardioversion

pharmacological cardioversion: flecainide OR amiodarone

electrical cardioversion: DC cardioversion - preferred
must be anticoagulated 3 weeks prior and 4 weeks after

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6
Q

post cardioversion treatment

A

1st line: beta blocker

2nd line: sotalol, propafenone, amiodarone, flecainide (SPAF)

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7
Q

CI of propafenone and dronedarone

A

propafenone: IHD, LVF, HF
dronedarone: HF

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8
Q

management of paroxysmal AF

A

1st line: beta blocker

2nd line: sotalol, propafenone, amiodarone or flecainide

pill in pocket for PRN: flecainide or propafenone

assess stroke risk

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9
Q

management of atrial flutter

A

1st line: rate control - beta blocker or rate limiting CCB

2nd line: rhythm control (3 options)

  • DC cardioversion
  • pharmacological cardioversion: SPAF
  • catheter ablation

flutters longer than 48 hours require 3 week anticoagulation prior and 4 weeks post

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10
Q

management of paroxysmal supraventricular tachycardia

A

usually terminates spontaneously

1st line: reflex vagal stimulation: valsalva maneuver, submerge face in ice water, sinus carotid massage (all whilst connected to ECG)

2nd line: IV adenosine

3rd line: IV verapamil

maintenance/ prophylaxis: beta blocker OR rate limiting CCB

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11
Q

management of ventricular tachycardia (stable and unstable)

A

pulseless ventricular tachycardia OR ventricular fibrillation = RESUS

unstable sustained ventricular tachycardia

  • 1st line: DC cardioversion
  • 2nd line: IV amiodarone
  • 3rd line: repeat DC cardioversion

stable ventricular tachycardia

  • 1st line: IV amiodarone
  • 2nd line: DC cardioversion

non-sustained stable ventricular tachycardia:
- beta blockers

high risk patients = risk of cardiac arrest so must be maintained on:

  • implant cardiovertable defibrillator
  • can add beta blocker OR beta blocker plus amiodarone
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12
Q

management of high risk patients with ventricular tachycardia

A

risk of cardiac arrest so must be managed with:

implantable cardioverter defibrillator

may add beta blocker OR beta blocker PLUS amiodarone

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13
Q

management of torsades des pointes (prolonged QT interval)

A 
IV magnesium sulphate 
beta blocker (Except sotalol) and atrial/ ventricular pacing can be considered

antiarrhythmic drugs should be avoided as they cause bradycardia which may prolong QT interval

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14
Q

causes of QT prolongation (torsades des pointes)

A

macrolides, quinolones, drugs that cause hypokalemia, TCAs, SSRIs, amiodarone, sotalol, haloperidol, antifungals

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15
Q

what are the antiarrhythmic drugs and the classes

A 
class I: membrane stabilising - flecainide and lidocaine
class II:  beta blockers 
class III: sotalol and amiodarone
class IV: rate limiting CCB's - diltiazem and verapamil
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16
Q

what is the loading regimen for amiodarone

A

200MG TDS 1 week then
200MG BD for 1 week then
200MG OD maintenance

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17
Q

what are the side effects and monitoring parameters for amiodarone

A

side effects:
corneal microdeposits: may cause blurred vision, stop if vision impairment
thyroid dysfunction: hypo or hyperthyroid due to iodine content
pulmonary toxicity: report on new/ progressive SOB, coughing
hepatotoxicity: stop on signs of liver impairment
photosensitivity: avoid sunlight and put on suncream for months after

monitoring: 
TFTs: before treatment and 6 months 
LFTs: before treatment and 6 months
chest x ray: before treatment 
ECG and transaminase if using IV amiodarone
annual eye examination
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18
Q

interactions of amiodarone

A

drugs that cause hypokalaemia: diuretics, gentamicin, theophylline, corticosteroids…
drugs that prolong QT interval: macrolides, quinolones, SSRI, TCAs, haloperidol…
CYP450 substrates: warfarin, COC, statins
CYP450 inducers: decrease concentration
CYP450 inhibitors: increase concentration
drugs that cause bradycardia: beta blockers and rate limiting CCB
digoxin: use with amiodarone - need to half digoxin dose

Patients who stopped amiodarone within last few months need to have close monitoring with the following drugs due to risk of heart block
- Sofosovir, daclatasivir, simeprevir, ledipasvir

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19
Q

therapeutic and toxicity range for digoxin

and when are levels taken and what is monitored

A

therapeutic: 0.7-2ng/ml
toxicity: 1.5-3ng/ml

taken 6-12 hours after dose

electrolytes and renal function

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20
Q

signs of digoxin toxicity and how to reverse this

A

bradycardia
Nausea and vomiting
confusion, dizziness
blurred/ yellow vision

reversal: digoxin specific antibody

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21
Q

interactions of digoxin

A

beta blockers: increase risk of AV block and increase plasma concentrations
Antidepressants: can cause arrythmia
drugs that cause hypokalaemia: increase risk of toxicity
CYP450 inducers: decreases concentration
CYP450 inhibitors: increases concentration

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22
Q

what are the indications for tranexamic acid and desmopressin in helping with clotting (reduce bleeding)

A

tranexamic acid: menorrhagia, surgeries and dental extraction

desmopressin: mild to moderate haemophilia and von willebrands disease

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23
Q

symptoms of VTE and PE

A

VTE: swelling, painful to touch, hot leg (usually one calf)

PE: SOB, coughing, chest pain

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24
Q

2 types of prophylaxis for thromboembolism

A

mechanical: compression stockings

pharmacological: anticoagulants
- usually started within 14 hours of hospital admission
- assess risk of bleeding
- use if risk of VTE outweighs risk of bleed

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25
Q

differences and similarities between LMWH and unfractionated heparin

A

unfractionated heparin:

  • quick onset and DOA - more suitable for those with high risk of bleed
  • monitor APTT
  • preferred in renal impairment
  • can cause hyperkalamia
  • protamine sulphate used if bleed/ haemorrhage (reversal)

LMWH:

  • suitable for all surgery
  • longer acting
  • preferred in pregnancy
  • less associated with thrombocytopenia
  • can cause hyperkalaemia
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26
Q

reversal for unfractionated heparin

A

protamine sulphate

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27
Q

when is fondaparinux used for VTE prophylaxis

A

lower limb immobility

pelvis fragility fractures

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28
Q

VTE prophylaxis regimen for elective hip replacement

A
  • 10 days LMWH then aspirin OR
  • 28 days LMWH + compression stockings until D/C OR
  • rivaroxaban
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29
Q

VTE prophlyaxis regimen for knee replacement

A
  • 14 days 75mg Aspirin OR
  • 14 days LMWH + compression stockings OR
  • rivaroxaban
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30
Q

how long after is VTE prophylaxis started for a women who has given birth/ miscarriage/ termination in last 6 weeks?

A

4-8 hours

continued for minimum of 7 days

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31
Q

how long VTE prophylaxis continued for after surgery

A

7 days
28 days for abdomen cancer surgery
30 days for spinal surgeries

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32
Q

treatment for confirm proximal DVT or PE

A

1st line: Apixaban or rivaroxaban
2nd line:
- LMWH for 5 days then dabigatran or edoxaban OR
- LMWH + warfarin for at least 5 days OR until INR >2 for 2 readings followed by warfarin alone

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33
Q

what are the treatment durations for the different types of VTE

A 
distal DVT (calf) = 6 weeks
proximal DVT/ PE = 3 months at least (3-6 months if active cancer)
provoked DVT / PE (removable cause) = 3 months if provoked factor resolved
unprovoked DVT/ PE = 3 months plus
recurrent DVT/ PE = lifelong
AF = lifelong
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34
Q

treatment for renally impaired patients with proximal DVT or PE (Crcl 15-50)

A

apixaban OR
Rivaroxaban OR
LMWH for 5 days then dabigatran (if Crcl >30) or edoxaban
LMWH or UF heparin + warfarin for at least 5 days until 2 INR readings >2

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35
Q

INR targets for warfarin use

A

> 2.5: MI, AF, VTE, cardioversion, cardiomyopathy

>3.5: recurrent VTE or mechanical heart valve

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36
Q

how to manage bleeds if on warfarin and high INR

A

major bleed: stop warfarin + IV phytomenadione + prothrombin complex
minor bleed + INR>8: stop warfarin + IV phytomenadione
minor bleed + INR 5-8: Stop warfarin + IV phytomenadione
No bleed + INR>8: stop warfarin + oral phytomenadione
no bleed + INR 5-8: withhold 1-2 doses of warfarin

warfarin can be restarted once INR <5

37
Q

3 warnings of warfarin (one = MHRA warning)

A
  • MHRA: calciphylaxis and skin necrosis
  • haemorrhage: antidote = phytomenadione
  • pregnancy: use contraception in 1st and 3rd trimester
38
Q

interactions of warfarin

A

vitamin K rich foods: leafy greens - reduced warfarin efficacy
CYP450 inducers:
CYP450 inhibitors:
cranberry and pomegranate juice - increases INR
miconazole = increases INR - bleed risk

39
Q

management of warfarin in surgery with minor bleed risk

A

stop warfarin
perform surgery if INR <2.5
restart warfarin 24 hours within procedure

40
Q

management of warfarin in surgery with major bleed risk and explain bridging management

A

stop warfarin 3-5 days before
give vitamin K if INR > 1.5 day before surgery
if high risk of thromboembolism = bridging management

bridging management:

  • stop warfarin 3-5 days before surgery and start LMWH
  • stop LMWH 24 hours before surgery
  • restart LMWH for 48 hours after surgery
41
Q

management of warfarin for emergency surgery

A

if surgery can be delayed for 6-12 hours, give IV vitamin k

If surgery can NOT be delayed: IV vitamin K + dried prothrombin complex

42
Q

dose of apixaban for treatment of thromboembolism

A

10mg BD for 7 days then 5mg BD maintenance

43
Q

dose of rivaroxaban treatment for thromboembolism and counselling point

A

15mg BD for 3 weeks then 20mg OD

to be taken with food

44
Q

treatment with dabigatran dose for thromboembolism

A

18-74: 150mg BD
75-79: 110-150mg BD
80+: 110mg BD

to be started 5 days after LMWH

45
Q

treatment dose of thromboembolism for edoxaban

A

60mg OD
under 61kg: 30mg OD

to be started after 5 days of LMWH

46
Q

management of haemorrhagic stroke

A

management blood pressure

add high intensity statin

47
Q

initial management of ischaemic stroke and TIA

A

TIA: aspirin 300mg daily until official diagnosis

ischaemic: alteplase within 4.5 hours then aspirin 300mg for 14 days

48
Q

long term management of ischaemic stroke

A
  1. antiplatelet:
    1st line: clopidogrel 75mg OD
    2nd line: MR dipyridamole + aspirin 75mg OD
    3rd line: MR dipyridamole OR aspirin 75mg OD
  2. High intensity statin after 48 hours
  3. antihypertensive (not beta blocker)
    - target <130/80mmHg
49
Q

what is the diagnosis blood pressure in clinic and ambulatory for stage 1, 2 and 3

A

stage 1: initiate treatment if < 80 + co-morbidities/ 10% risk, elderly with BP >150/90mmHg, < 60 with <10% risk

clinic: 140/90mmHg- 160/90mmHg
ambulatory: 135/90mmHg - 150/90mmHg

stage 2: initiate treatment in all patients

clinic: 160/100mmHg - 180/100mmHg
ambulatory: > 150mmHg

stage 3: MEDICAL EMERGENCY
>180/200mmHg

50
Q

when do you initiate treatment in stage 1 hypertension

A

under 80 years old with co-morbidities/ 10% CV risk

> 80 with BP >150/90mmHg

< 60 with <10% CV risk

51
Q

hypertension step by step management for over 55 or Afro-Caribbean

A

step 1: CCB

step 2: CCB + ACEI/ARB

Step 3: CCB + ARB/ACEI + Thiazide diuretic

Step 4/ resistant : CCB + ARB/ACEI + thiazide +

spironolactone if K <4.5mmol/l
beta blocker OR alpha if K >4.5mmol/l

52
Q

hypertension management for someone with diabetes or under 55

A

step 1: ACEI/ARB

Step 2: ACEI/ARB + CCB

Step 3: ACEI/ARB + CCB + thiazide diuretic

Step 4/ resistant: ACEI/ARB + CCB + thiazide diuretic +

low dose spironolactone if K < 4.5mmol/l
beta blocker OR alpha blocker if K > 4.5mmol/l

53
Q

side effects of ACE inhibitors and ARBs

A 
dry cough - give ARB instead 
angioedema 
hyperkalaemia
renal impairment
hepatic failure
dizziness 
headaches

ARBs have the same side effects but do not have dry cough or angioedema

54
Q

what drugs do ACE inhibitors interact with

A

increased risk of renal failure with:
- NSAIDs, ARBs, potassium sparing diuretic

increased risk of hyperkalaemia with:
- NSAIDs, ARBs, heparins, potassium sparing diuretics, beta blockers

increased risk of volume depletion:
- diuretics

lithium: can exacerbate lithium toxicity (increase lithium levels)

55
Q

what antihypertensive drug interacts with lithium

A

ACE inhibitors = increases lithium concentration

56
Q

what beta blockers are cardioselective and what are the advantages of these

A

BAtMAN

bisoprolol
Atenolol
metoprolol
Acebutolol
Nebevilol

preferred beta blocker for asthmatics

57
Q

what beta blockers are water soluble and what are the advantages of these

A

watering CANS

Celiprolol
Atenolol
Nadolol
Sotalol

water soluble so less likely to cross BBB and cause nightmares

58
Q

what beta blockers are intrinsic sympathomimetics and what are the advantages of these

A

POACHh

Pindolol
Oxprenalol
Acebutolol
Celiprolol

less likely to cause cold extremities

59
Q

what beta blocker is used in gestational hypertension and what other antihypertensive can be used in pregnancy

what is the target BP for pregnant women

A

laebtalol - 1st line

nifedipine or methyldopa - 2nd line

target: 135/80mmHg

60
Q

side effects of beta blockers

A 
hyperkalaemia
bradycardia
mask symptoms of hypoglycaemia
hyperglycaemia
bronchospasm - cardioselective should be used in asthma if needed
coldness of extremeties
nightmares
61
Q

interactions of beta blockers

A

amiodarone/ digoxin -> may cause heart block

hypotensive drugs

62
Q

side effects of CCB

A

gingival hyperplasia
vasodilatory effects: swollen ankles, flushing, headaches
dizziness
RL-CCB: complete AV block

63
Q

what is the BP target for type 1 diabetes

A

135/85mmHg

64
Q

what patients should be offered lipid lowering agents

A 
under 85 + CVD risk> 10 %
type 2 diabetes + CVD risk>10%
type 1 diabetes + over 40/ diabetic for 10 years/ nephropathy
CKD
familial hypercholesterolaemia
65
Q

what statins can be taken at any time of day

A

atorvastatin

rosuvastatin

66
Q

what co-morbidity must be correct before a statin is initiated

A

hypothyroidism

67
Q

how often should patients with a high risk of diabetes and on statins have BG and HbA1c checked?

A

every 3 months

68
Q

what are the monitoring parameters for statins

A 
before initiation 
LFTs (liver profile)
renal function 
TFTs (thyroid profile)
full lipid profile

liver function tests also performed at 3 months and 12 months

creatinine kinase monitored in patients who previously had muscle ache with statins

69
Q

when should statins be discontinued

A

when serum transaminases are >3 x the upper limit

CK is measured in patients with muscle ache:
when CK is more than 5 x higher than the upper limit:
- Don’t start statin yet and remeasure in 7 days
- If still higher than 5 x the upper limit = do not initiate statin
- If still raised but less than 5 x the upper limit = initiate at lower dose

70
Q

side effects of statins

A

rhabdomyolysis
-muscle toxicity: tenderness, weakness, pain - seek medical advice

interstitial lung disease
- seek medical advice if SOB, coughing, weight loss

teratogenic: should be discontinue 3 months before conception

71
Q

interactions of statins

A

CYP450 inducers: CRAP GP
- reduces statin

CYP450 inhibitors: macrolide, grapefruit juice - risk of rhabdomyolysis

  • increases statin
  • can temporarily stop statin whilst on macrolide

oral fusidic acid: stop statin whilst on this and restart 7 days after last dose

simvastatin + amlodipine = max simvastatin 20mg
simvastatin + amiodarone = max simvastatin 20mg
simvastatin + diltiazem/ verapamil = max simvastatin 20mg
simvastatin + ticagrelor = max simvastatin 40mg
atorvastatin + ciclosporin = max atorvastatin 10mg
atorvastatin + tipranivir = max atorvastatin dose 10mg

statins + fibrate/ ezetimibe = risk of rhabdomyolysis

72
Q

monitoring and caution for fibrates

A

monitor LFTs every 3 months

in patients with renal impairment - may cause myotoxicity (muscle toxicity)

73
Q

acute/ initial treatment for stable angina

A

GTN spray/ S/L tablets every 5 minutes

if after 3rd dose pain persists. = 999

74
Q

long term management of stable angina

A

1st line: Beta blocker OR RL-CCB if beta blocker CI
2nd line: beta blocker + CCB
3rd line: addition of long acting nitrate, ranolazine, nicrorandil or ivabradine
- these can also be used in monotherapy if beta blocker/ CCB CI

can also implement 75mg Aspirin + low intensity statin

75
Q

side effect of nicorandil

A

may cause GI or mouth ucleration

76
Q

how long can an opened pack of S/L nitrates be used for

A

8 weeks

77
Q

how to take nitrates

A

need a nitrate free period to avoid tolerance
take nitrate tablets 8 hours apart in BD regimen (not 12 hours) to allow nitrate free period

transdermal patch should also be removed for 8-12 hours/day

78
Q

side effects of nitrates

A

dizziness
flushing
headaches
caution in elderly due to falls risk

79
Q

initial management of ACS

A

pain relief: GTN or IV morphine
loading dose of aspirin 300mg
oxygen monitored but not routinely given

STEMI required PCI within 2 hours which requires heparin and 2ndry antiplatelet usually prasugrel

80
Q

structural difference between STEMI, NSTEMI, unstable angina

A

STEMI: myocardial necrosis, ST elevation, complete blockage

NSTEMI: myocardial necrosis, no ST elevation, partial blockage

unstable angina: partial blockage of artery

81
Q

secondary management of ACS patients

A

DAPT: aspirin 75mg lifelong + clopidogrel 75mg/ ticagrelor/ prasugrel (preferred) for 12 months
ACEI: or ARB if CI
beta blocker: may be discontinued after 12 mnths in patients with LVEF
high intensity statin: atorvastatin 80mg

other:
metformin should be avoided for 48 hours post MI/ angio
PPI for gastro protection from DAPT may be needed

82
Q

symptom and acute management of heart failure

A

symptoms: SOB, coughing, oedema, fatigue, reduced exercise tolerance

management:
loop diuretic - used in pulmonary oedema
- lasts 6 hours so can give BD preparation

83
Q

management of chronic HF

A

1st line: beta blocker + ACEI/ ARB

  • start low go slow
  • hydralazine + nitrate if not tolerated

2nd line: add aldosterone antagonist: spironolactone/ epleronone

3rd line: add amiodarone/ digoxin OR ivabradine OR entresto OR dapagliflozin

use digoxin if worsening HF with sinus rhythm

use lower doses of ACEI/ ARB/ aldosterone antagonist in CKD

84
Q

what drugs should be avoided in patients with reduced ejection fraction HF

A

RL CCB or short acting CCB (nifedipine)

85
Q

monitoring drug treatment for HF

A

ACEI/ ARB/ aldosterone antagonist
- monitor serum potassium, sodium, blood pressure and renal function before starting and 1-2 weeks after and at each dose increment

beta blockers:
Heart rate and symptom control should be monitored before starting and at each dose change

86
Q

side effects of potassium sparing diuretics and when should medication be stopped

A

may cause blue urine (amiloride/ triamterene)

stop aldosterone anatagonist if: dehydration, V/D

hyperkalaemia

change in libido

breast tenderness

87
Q

interactions of diuretics

A

potassium sparing:

  • do not take potassium supplements
  • avoid hyperkalaemia inducing drugs

loop/ thiazide:
- avoid hypokalaemia inducing drugs

loop + aminoglycoside = nephrotoxicity/ ototoxicity

spironolactone/ loop + lithium = lithium toxicity risk

88
Q

side effects of loop/ thiazide diuretics

A

hypotension
hypokalaemia
exacerbation of diabetes/ gout (loop only)

89
Q

what are the 2 types of vascular disease and how are these managed

A
  1. OCCLUSIVE PERIPHERAL VASCULAR DISEASE
    - caused by atherosclerosis
    - manage: healthy lifestyle, statins, antiplatelets
  2. RAYNAUDS SYNDROME (VASOSPASTIC PERIPHERAL VASCULAR DISEASE)
    - avoid exposure to cold
    - quit smoking
    - if drug treatment needed: nifedipine

pre reg Thammis cards (8 decks)

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