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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
differences and similarities between LMWH and unfractionated heparin
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
26
reversal for unfractionated heparin
protamine sulphate
27
when is fondaparinux used for VTE prophylaxis
lower limb immobility | pelvis fragility fractures
28
VTE prophylaxis regimen for elective hip replacement
- 10 days LMWH then aspirin OR - 28 days LMWH + compression stockings until D/C OR - rivaroxaban
29
VTE prophlyaxis regimen for knee replacement
- 14 days 75mg Aspirin OR - 14 days LMWH + compression stockings OR - rivaroxaban
30
how long after is VTE prophylaxis started for a women who has given birth/ miscarriage/ termination in last 6 weeks?
4-8 hours | continued for minimum of 7 days
31
how long VTE prophylaxis continued for after surgery
7 days 28 days for abdomen cancer surgery 30 days for spinal surgeries
32
treatment for confirm proximal DVT or PE
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
33
what are the treatment durations for the different types of VTE
``` 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 ```
34
treatment for renally impaired patients with proximal DVT or PE (Crcl 15-50)
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
35
INR targets for warfarin use
>2.5: MI, AF, VTE, cardioversion, cardiomyopathy | >3.5: recurrent VTE or mechanical heart valve
36
how to manage bleeds if on warfarin and high INR
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
3 warnings of warfarin (one = MHRA warning)
- MHRA: calciphylaxis and skin necrosis - haemorrhage: antidote = phytomenadione - pregnancy: use contraception in 1st and 3rd trimester
38
interactions of warfarin
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
management of warfarin in surgery with minor bleed risk
stop warfarin perform surgery if INR <2.5 restart warfarin 24 hours within procedure
40
management of warfarin in surgery with major bleed risk and explain bridging management
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
management of warfarin for emergency surgery
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
dose of apixaban for treatment of thromboembolism
10mg BD for 7 days then 5mg BD maintenance
43
dose of rivaroxaban treatment for thromboembolism and counselling point
15mg BD for 3 weeks then 20mg OD | to be taken with food
44
treatment with dabigatran dose for thromboembolism
18-74: 150mg BD 75-79: 110-150mg BD 80+: 110mg BD to be started 5 days after LMWH
45
treatment dose of thromboembolism for edoxaban
60mg OD under 61kg: 30mg OD to be started after 5 days of LMWH
46
management of haemorrhagic stroke
management blood pressure | add high intensity statin
47
initial management of ischaemic stroke and TIA
TIA: aspirin 300mg daily until official diagnosis ischaemic: alteplase within 4.5 hours then aspirin 300mg for 14 days
48
long term management of ischaemic stroke
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
what is the diagnosis blood pressure in clinic and ambulatory for stage 1, 2 and 3
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
when do you initiate treatment in stage 1 hypertension
under 80 years old with co-morbidities/ 10% CV risk > 80 with BP >150/90mmHg < 60 with <10% CV risk
51
hypertension step by step management for over 55 or Afro-Caribbean
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
hypertension management for someone with diabetes or under 55
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
side effects of ACE inhibitors and ARBs
``` 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
what drugs do ACE inhibitors interact with
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
what antihypertensive drug interacts with lithium
ACE inhibitors = increases lithium concentration
56
what beta blockers are cardioselective and what are the advantages of these
BAtMAN ``` bisoprolol Atenolol metoprolol Acebutolol Nebevilol ``` preferred beta blocker for asthmatics
57
what beta blockers are water soluble and what are the advantages of these
watering CANS Celiprolol Atenolol Nadolol Sotalol water soluble so less likely to cross BBB and cause nightmares
58
what beta blockers are intrinsic sympathomimetics and what are the advantages of these
POACHh Pindolol Oxprenalol Acebutolol Celiprolol less likely to cause cold extremities
59
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
laebtalol - 1st line nifedipine or methyldopa - 2nd line target: 135/80mmHg
60
side effects of beta blockers
``` hyperkalaemia bradycardia mask symptoms of hypoglycaemia hyperglycaemia bronchospasm - cardioselective should be used in asthma if needed coldness of extremeties nightmares ```
61
interactions of beta blockers
amiodarone/ digoxin -> may cause heart block | hypotensive drugs
62
side effects of CCB
gingival hyperplasia vasodilatory effects: swollen ankles, flushing, headaches dizziness RL-CCB: complete AV block
63
what is the BP target for type 1 diabetes
135/85mmHg
64
what patients should be offered lipid lowering agents
``` 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
what statins can be taken at any time of day
atorvastatin | rosuvastatin
66
what co-morbidity must be correct before a statin is initiated
hypothyroidism
67
how often should patients with a high risk of diabetes and on statins have BG and HbA1c checked?
every 3 months
68
what are the monitoring parameters for statins
``` 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
when should statins be discontinued
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
side effects of statins
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
interactions of statins
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
monitoring and caution for fibrates
monitor LFTs every 3 months in patients with renal impairment - may cause myotoxicity (muscle toxicity)
73
acute/ initial treatment for stable angina
GTN spray/ S/L tablets every 5 minutes if after 3rd dose pain persists. = 999
74
long term management of stable angina
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
side effect of nicorandil
may cause GI or mouth ucleration
76
how long can an opened pack of S/L nitrates be used for
8 weeks
77
how to take nitrates
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
side effects of nitrates
dizziness flushing headaches caution in elderly due to falls risk
79
initial management of ACS
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
structural difference between STEMI, NSTEMI, unstable angina
STEMI: myocardial necrosis, ST elevation, complete blockage NSTEMI: myocardial necrosis, no ST elevation, partial blockage unstable angina: partial blockage of artery
81
secondary management of ACS patients
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
symptom and acute management of heart failure
symptoms: SOB, coughing, oedema, fatigue, reduced exercise tolerance management: loop diuretic - used in pulmonary oedema - lasts 6 hours so can give BD preparation
83
management of chronic HF
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
what drugs should be avoided in patients with reduced ejection fraction HF
RL CCB or short acting CCB (nifedipine)
85
monitoring drug treatment for HF
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
side effects of potassium sparing diuretics and when should medication be stopped
may cause blue urine (amiloride/ triamterene) stop aldosterone anatagonist if: dehydration, V/D hyperkalaemia change in libido breast tenderness
87
interactions of diuretics
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
side effects of loop/ thiazide diuretics
hypotension hypokalaemia exacerbation of diabetes/ gout (loop only)
89
what are the 2 types of vascular disease and how are these managed
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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