Cardiovascular Flashcards
What is the treatment for paroxysmal supraventricular tachycardia?
First line: Reflex vagal nerve stimulation e.g. Valsalva manoeuvre
Second line: IV adenosine
Third line: IV verapamil
What is adenosine CI in ?
Asthma and COPD
What is the first line maintenance drug treatment for arrhythmia rate control?
Rate control
- beta blockers except sotalol
- Rate limiting CCB
- Digoxin
What is the second line maintenance drug treatment for arrhythmia rhythm control?
- beta blockers
2. oral anti-arrhythmic drugs
What are Class I anti-arrhythmic and what is their MOA?
Sodium channel blockers
- Disopyramide
- Lidocaine
- Flecainide acetate
- Propafenone hydrochloride
What are Class II anti-arrhythmic and what is their MOA?
Beta blockers Propranolol Metoprolol Atenolol Timolol
What are Class III anti-arrhythmic and what is their MOA?
Potassium channel blockers
- Sotalol
- Dronedarone
- Amiodarone
What is amiodarone MOA?
Potassium channel blockers but also blocks beta receptors, sodium and calcium channels
What is the recommended dose of amiodarone?
200mg TDS for 1/52, then 200mg BD for 1/52 then a maintenance dose of 200mg OD
How many days is amiodarone half life?
50 days
What are the monitoring requirements of amiodarone?
Thyroid function before and every 6 months
Annual eye test
Liver function before and every six month
Potassium - as can result in hypokalaemia
What action is taken if a patient has hypothyroidism due to amiodarone?
Treat with levothyroxine without withdrawing amiodarone
What action is taken if a patient has hyperthyroidism due to amiodarone?
Withdraw amiodarone and give carbimazole
What are the warning signs of amiodarone?
- sSigns and symptoms of hypo/hyper thyroidism
- Impaired vision i.e. optic neuritis/optic neuropathy
- Photophobia / dazzled by headlights
- Progressive SOB/ Cough
- Neurological effects such as tremor, peripheral neuropathy
- Phototoxic skin reactions
- Slate grey skin discoloration
- Bradycardia
- Taste disturbance
- Nausea/ Vomiting
When is it recommended for amiodarone to be withdrawn?
- Hepatotoxicity i.e. jaundice
- Peripheral neuropathy
- Pulmonary toxicity
What are the signs of hepatotoxicity?
Jaundice Nausea Vomiting Malaise Itching Burning Abdominal pain Decreased liver function
What are the signs of pulmonary toxicity?
New or progressive SOB or dry cough
What are the signs of peripheral neuropathy?
Numbness
Tingling hands and feet
Tremors
What juice does amiodarone interact with and what does it result in?
Grape fruit juice (enzyme inhibitor) and it results in increased plasma amiodarone concentration
What is the treatment dose for AF with digoxin and what is the maintenance dose?
Treatment is 0.75mg to 1.5mg
Maintenance is 125-250mcg
What is the maintenance dose of digoxin in HF?
62.5-125mcg
What class is digoxin?
Cardiac glycoside
What is digoxin therapeutic target?
1-2mcg/L measured after 6 hours of taking first dose
What are the monitoring requirements of digoxin?
- Potassium
- Liver and kidney function
- Heart rate
- Plasma concentration
What are the warning signs of digoxin?
- Blurred/yellow vision
- Cardiac e.g. arrhythmia / heart block
- neurological
- GI- anorexia, nausea, vomiting, diarrhoea, abdominal pain
- Hyperkalaemia
What is unfractionated heparin “standard heparin” MOA?
Activates anti-thrombin
What is LMWH MOA and what does it include?
Tinzeparin, enoxaprin, dalteparin
inactivates factor Xa
What are the benefits of standard heparin?
good in renal impairment and high risk of bleeding as its easily reversible
What is used to reverse heparin?
Protamine
What are the benefits of LWMH?
Pregnancy and osteoporosis
What are the colours of warfarin tablets?
0.5 mg- white
1mg- brown
3mg - blue
5mg- pink
What is the MOA of warfarin?
Antagonises vitamin K
What is the duration of treatment and conditions with warfarin?
Isolated calf DVT- 6 weeks
Provoked DVT- 3months
Unprovoked DVT- 3months to long term
What are the target INR?
- 5 for VTE, AF, MI, cardioversion, bio-prosthetic mitral valve
- 5- recurrent VTE
- 0- mechanical valve
Can vary -/+0.5
What is the target BP for over 80 and under 80 with no further complications?
over 80- <150/90
under 80- <140/90
What is the target BP for under 80 with further complications?
<130/80
What is the target BP during pregnancy?
150/100 chronic hypertension
<140/90 for chronic hypertension with organ damage or giving birth
What are the treatment for gestational hypertension? and what is first line
Labetalol- first time
Methyldopa stopped after 2 days of birth
MR nifedipine - unlicensed use
What are the side effects of ACE inhibitors?
- persistent dry cough
- hyperkalaemia so also hypoglycaemia
- nephrotoxic so avoid the DAMN drugs - diuretics, ACE, ARB, metformin, NSAIDs
- cholestatic jaundice, hepatic failure
- avoid in pregnancy
Which beta blockers have intrinsic sympathomimetic activity and less cold extremities / less bradycardia SE?
ice PACO
Pindolol
Acebutolol
Celiprolol
Oxprenolol
Which beta blockers don’t cross the BBB and has less sleep disturbance and nightmares SE?
water CANS
Celiprolol
Atenolol
Nadolol
Sotalol
Which beta blockers have cardio-selective properties therefore cause less bronchospasm?
Be A MAN
Bisoprolol Atenolol Metoprolol Acebutolol Nebivolol
Which beta blockers have a long duration of action therefore are taken once daily?
BACoN
Bisoprolol
Atenolol
Celiprolol
Nadolol
What are dihydropyridine calcium channel blockers? and what do they include?
- amlodipine
- felodipine
- lacidipine
- lercanidipine
- nifedipine - maintain on same MR Brand
they have vasodilating effects
What are dihydropyridine calcium channel blockers side effects?
Ankle swelling
flushing
headaches
What are Amlodipine and nifedipine CI in?
unstable angina
What are rate limiting calcium channel blockers? and what do they include?
More selective for the heart; lowers HR and force contraction
- Verapamil
- Diltiazem maintain on same brand when dose over 60mg
What are rate-limiting CCB CI in?
heart failure
What is a BNP test and what does it indicate?
A BNP test is a blood test that measured the level of BNP protein.
When BNP levels are high it means you have heart failure
What is first line treatment for heart failure?
ACEi/ARB + B blocker
ARB- candesartan/valsartan
mild-mod stable HF/70+= nebivolol
All grades of LVSD= Bisoprolol/Carvedilol
What is second line treatment for heart failure?
Spironolactone/ eplerenone after acute MI with LVSD or mild HF
What are the alternative second line treatment for HF?
Hydralazine+ Isosorbide dinitrate (esp. in African/ Caribbean)
ARB (on top of ACE)
Entresto
What is third line treatment for heart failure?
Ivabradine (added if patient in sinus rhythm/ HR >75bpm)
or
Digoxin in worsening or severe HF
Pregnancy and statins
Statins are teratogenic
use effective contraception during and 1 month after stopping
How long before conceiving do you stop statins and when do you restart them?
3 month before conceiving and restart after finishing breast feeding
What is the max dose of statin with fibrates?
10mg
what is the max dose of statin with amiodarone, amlodipine, diltiazem, and verapamil?
20mg
What is the max dose of atorvastatin with ciclosporin?
10mg
What is the max dose of Rosuvastatin with clopidogrel?
20mg
What is GTN converted into and what does it do?
GTN is converted into nitric oxide and its a vasodilator
How long does the effects of GTN last?
20-30minutes
What is the dose instructions for GTN? and what is the dose equivalence for tablets and spray?
1 dose = 1 tablets or 1-2 sprays
Maximum of 3 doses with 5 minutes interval between each
After the third dose if the symptoms are not relieved call 999
What is the first line treatment for long term prophylaxis of stable angina?
Beta blocker or CCB
What is the second line treatment for long term prophylaxis of stable angina?
Beta blocker + CCB
What can be used for the prophylaxis of stable angina if beta blockers or CCB are CI?
Vasodilators such as isosorbide mononitrate
Ivabradine
Nicorandil
What actions are taken if tolerance is suspected
- leave patches off for 8-12 hours overnight
2. take second dose after 8 hours not 12 hours for the isosorbide mononitrate/dinitrate
What are the side effects of nitrates?
- flushing of the face
- throbbing headache
- dizziness
- postural hypotension
What is the long-term management plan for STEMi/ NSTEMi?
- statin
- treat blood pressure i.e ACE/ARB….
- Aspirin + Clopidogrel for short term use
- beta blockers
What is used to access stroke risk?
CHA₂DS₂-VASc
What is is used to access bleeding risk?
HASBLED
Which diuretic is to be avoided with gout?
furosemide
which diuretic causes musculoskeletal pain?
Torasemide
What the onset of action and duration of action of loops? and how many times can they be taken a day?
they can be taken BD with last one at 4pm
onset of action is 1 hr
duration of action is 6 hrs
What are the side effects of loop diuretics ?
- ototoxicity at high doses
- Acute urinary retention= too rapid diuresis
- Hyperglycaemia
- hyperuricaemia
- Hypo K+, Na+, Cl-, Mg2+, Ca2+
Which thiazide like diuretic is used in severe renal impairment?
Metolazone
Which thiazide like diuretic is less aggravating to diabetes and is used for hypertension and HF?
Indapamide
What the onset of action and duration of action of thiazide?
1-2hr onset of action
12-24 hr duration of action
What is the dose of Bendroflumethiazide for HF and hypertension?
HF= 5mg OM Hypertension= 2.5mg OM
What are the SE of spironolactone?
- Gynaecomastia
- hypertrichosis
- Change in libido
- Hyperkalaemia, Hyperuricemia, Hyponatraemia
What includes osmotic diuretics and what is it used for ?
Mannitol and cerebral oedema
