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PRE-REG own > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

When would you initiate statins fo primary prevention of CVD?

A
  • T1DM
  • Only in type 2 if QRISK ?10%
  • CKD /albuminuria
  • familial hypercholesterolaemia
  • > 85 y/o
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2
Q

When would you initiate statins for secondary prevention?

A

Established CVD e.g. angina, MI, stroke/TIA, PAD

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3
Q

When is QRISK score not suitable to use?

A

Score would be underestimated in high risk pts eg.

  • T1DM
  • established CVD
  • > 85
  • CKD
  • familial hypercholestereolaemia
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4
Q

What is the cholesterol level that diagnoses hyperlipidaemia?

A

6mmol/L

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5
Q

What is the treatment pathway for primary and familial hypercholesterolaemia?

A

High intensity statin e.g. atorvastatin
If C/I or not tolerated= ezetimibe

Moderate triglyceridaemia if statin not tolerated/Ci = fibrate

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6
Q

What are the doses of atorvastatin for primary and secondary prevention

A

Primary: 20mg OD
Secondary: 80mg OD

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7
Q

What is the MHRA alert fo simvastatin 80mg?

A

High risk of myopathy - only give if risk of CV complications and treatment goals not achieved at lower dose

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8
Q

What are the 3 common side effects of statins and counselling point?

A

Myopathy
Myositis
rhabdomyolysis

To report any tender, weak and painful muscles

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9
Q

What monitoring is involved with statins

A

Baseline lipids
Renal function
Thyroid function
HbA1c
Creatine kinase - discontinue if 5x upper limit
Liver function- discontinue if 3x upper limit

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10
Q

Can statins be used in pregnancy?

A

No - teratogenic

  • need effective contraception during and1 month after stopping
  • stop taking 3 months before conception and restart after finishing breastfeeding
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11
Q

What increases the risk of muscle toxicity with statins?

A
  • personal/family history of muscle disorder
  • alcohol
  • renal impairment
  • hypothyroidism
  • concomitant ezetimibe/fibrates esp gemfibrozil
  • concomittant fusidic acid
  • interaction with clarithromcyin and atorvastatin
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12
Q

What is the interaction between clarithromycin & atorvastatin?

A

Increases atorvastatin levels - adjust or avoid - monitor for rhabdo

would generally hold statin for abx course

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13
Q

What is the interaction of statins with Fusidic acid?

A

Increased statin levels - hold statin and re-start 7 days after last oral fusidic acid dose

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14
Q

Which drugs concomittantly require a maximum dose of simvastatin 20mg?

A
  • Amlodipine
  • amiodarone
  • diltiazem
  • verapamil
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15
Q

What is the max dose of atorvastatin with ciclosporin?

A

10mg

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16
Q

What is the max dose of rosuvastatin with clopidogrel?

A

20mg

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17
Q

What is ezetimibe?

A

Reduces cholesterol by inhibiting the absorption of cholesterol by the small intestine

Can be used as alternative or if statins not tolerated

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18
Q

What is the general treatment pathway of lipid lowering therapies?

A

Statins
Ezetimibe
Fibrates
Bile acid sequestrates / nicotinic acid

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19
Q

if myalgia is a risk then would you add ezetimibe?

A

No - consider other drugs e.g
fibrates if triglycerides are high
or bile acid sequestrants

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20
Q

What fibrate can you NOT use with statins due to risk of myopathy?

A

Gemfibrozil

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21
Q

When are fibrates used?

A

Severe hypetriglyceridaemia when >10mmol/L or cannot tolerate statin (specialist)

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22
Q

What is an advisory label for colestyramine (bile acid sequestrant)?

A

Take other medicines one hour before or 4 hours after

4 hours before colesevelam

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23
Q

What is the limitation of using nicotinic acid?

A

Flushing - prostaglandin mediated reaction - within 1 hour of dosing and lasts for 30mins esp with initial doses

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24
Q

What is a contraindication if nicotinic acid

A

peptic ulcer disease

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25
Q

What is the treatment for an acute angina attack

A

Short acting nitrate
- GTN - 2 sprays, wait 5 min, 2 sprays
OR isosorbide dinitrate SL

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26
Q

How long do the effects of GTN last for

A

20-30 mins

if using 2-3x a week then need long term prophylaxis

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27
Q

What is counselling for GTN spray

A

Take when sitting down (dizziness)
1s dose under tongue, wait 5 min
2nd dose and wait 5 min if pain not subsided
3rd dose wait 5 mins

Still present = 999
Max 3 doses

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28
Q

What is the special container for GTN sublingual tabs

A

expiry 8 weeks after opening - foil-lined container with no cotton wadding

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29
Q

What is the treatment fo long term prophylaxis of angina?

A
  • Beta blocker or CCB e.g. diltiazem OR
  • Beta blockere + dihydropyridine CCB (Amlodipine, nifedipine MR, felodipine) - max 2 dugs

Vasodilator–> long acting nitrate e.g. MR isosobide mononitrate

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30
Q

What is the MHRA alert regarding Nicorandil?

A

Now given 2nd line due to risk of ulcer complications in mouth, skin, eye, GIT

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31
Q

What are common S/E of nitrates

A 
Flushing
throbbing headache
postural hypotension
heartburn
dizziness
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32
Q

What is needed for nitrates to stop tolerance developing?

A

Occurs with long acting + transdermal

  • need to reduce the [nitrate] fo 4-12 hours a day
  • patch = leave off ovenight
  • tabs = take 2nd dose after 8 hours not 12 hours
  • MR isosorbide mononitrate taken OD so no tolerance
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33
Q

Long term management of ACS?

A

NSTEMI: DAPT 12 months then aspirin lifelong for secondary prevention
Statin - high dose/intensity e.g. Atorvastatin 80mg or Rosuvastatin 20mg
ACEi - within 24hrs
Beta blocker- within 24hrs - cardioselective e.g. bisoprolol, metoprolol, atenolol,nebivolol

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34
Q

Symptoms of ACS?

A 
Chest pain radiating to left arm
dizziness, fatigue
indigestion
Radiation to back and jaw
lasting >15min
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35
Q

Treatment of cardiac arrest (adult)

A

CPR 30 compressions: 2 breaths

IV adrenaline 1 in 1000 every 3-5min

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36
Q

What is the mechanism of thiazide diuetics?

A

Inhibit Na/Cl transporter in distal convoluted tubule

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37
Q

What thiazide diuretics are perferred in hypertension?

A

Chortalidone (given on alternate days due to long duration of action)
Indapamide (less metabolic disturbance/glucose)

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38
Q

What is the risk of using thiazides

A

Changes in uric acid, glucose and lipids causing
- Hyperglycaemia
- Hyperuricaemia
precipitating diabetes and gout

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39
Q

What thiazide diuretic can be used in severe renal failure?

A

metolazone

but monitor for profound diuresis

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40
Q

What is the mechanism of loops diuretics

A

Inhibit Na/K/Cl transporte in ascending loop of henle, onset in 1 hou

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41
Q

What are adverse effects of loop diuretics

A
  • ototoxicity - tinnitus, deafness
  • acute urinary retention–> caution in BPH
  • Hyperglycaemia
  • Hyperuricaemia
  • Hypoakalaemia, Hyponatraemia, HypoCl, Hypomagnesaemia
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42
Q

What is the mechanism of potassium sparing diuretics and name some

A 
Promotes urination (diuresis) without the loss of potassium by inhibiting sodium channels in the distal convoluted tubule 
e.g. triameterine, amiloride
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43
Q

What is the mechanism of aldosterone antagonists?

A

Inhibit aldosterone which is responsible for causing sodium reabsorption via the Na/K/H co-transporter

Less K+ and hydrogen ions exchanged for sodium so less lost in urine

sodium not reabsorbed or water

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44
Q

What is an MHRA alert of aldosterone antagonists?

A

Use of Aldosterone antagonists in conjunction with ACE/ARB in heart failure - risk of potentially fatal/severe hyperkalaemia - monitor electrolytes

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44
Q

What are common side effects of spironolactone?

A
  • gynaecomasstia / benign breast tumour / menstrual disturbances
  • hypertrichosis (excessive hair growth on body)
  • changed libido
  • hyperkalaemia, hyperuricaemia, hyponatraemia
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44
Q

What are common side effects of spironolactone?

A
  • gynaecomasstia / benign breast tumour / menstrual disturbances
  • hypertrichosis (excessive hair growth on body)
  • changed libido
  • hyperkalaemia, hyperuricaemia, hyponatraemia
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45
Q

What are treatment options in simple gravitational oedema in the elderly?

A

Aim to try alternatives first e.g stockings, raise legs, movement
Can use low dose diuretic but not long term

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46
Q

What are treatments for occlusive peripheral vascula disease

A

(intermittent claudication caused by atherosclerosis)

  • aspirin 75mg daily
  • statin secondary prevention
  • lifestyle advice
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47
Q

What is the therapeutic range of digoxin

A

1-2 micrograms/L (1.5-3)

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48
Q

What is the dosing for digoxin based on?

A

Renal function

Loading dose needed as it has a long half life to get to steady state

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49
Q

What are risk factors for digoxin toxicity

A 
Hypokalaemia 
Renal impaiment
Elderly
Hypomagnesaemia
Hypercalcaemia
Hypoxia
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50
Q

What are symptoms of digoxin toxicity

A 
Bradycadia
Nausea, vomiting
Diarrhoea
abdominal pain
confusion
YELLOW vision/blurred ivsion
confusion
rash
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51
Q

What are the interactions of digoxin? (think CRASED)

A

Calcium channel blockers e.g. verapamil - inhibitor
Rifampicin - reduced digoxin as it is an inducer
Amiodarone - inhibitor - need to half dig dose
st johns wort - inducer
Erythromycin/macrolides - inhibitors
Diuretics - risk hypokalaemia

(also other drugs that cause hypokalaemia will interact e.g. b2 agonists, steroids, theophylline)

NSAIDS and ACEi/ARB can reduce renal excretion which is also a risk for toxicity

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52
Q

In pt taking digoxin, if K+ is <4.5 mmol/L what is done?

A

K+ supps or K+ sparing diuretic (preferred)

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53
Q

Common symptoms of atrial fibrillation

A 
Palpitations
SOB
Dizziness,fainting
ches tpain
abnormally fast,slow,irregular pulse
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54
Q

What tool is used to assess stroke risk in Af patients?

A

CHADS2VASC
Congestive heart failure
Hypertension >140/90 or current anti-hypertensives
Age >75 (2 points) or 65-74 (1 point)
Diabetes - glucose >7mmol/L or treatment
Stroke/Tia/thromboembolism - 2 points
Vascular disease e.g. previous MI/PAD/aortic plaque
Sex - feemale (2), male (1)

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55
Q

What is classed as no risk/ no need for anticoagulation in CHADASVASC?

A

If a male is 0, female 1 = no need
Score of 1: low to moderate - consider antiplatelet/anticoag
2 or more: moderate/high - definite need

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56
Q

What tool is used to assess bleed risk with anticoagulation?

A 
ORBIT
Old age >75
Reduced Hb (<130 in Males, <120 females) = score of 2 
Bleeding history
Insufficient renal function eGFR <60
Antiplatelets
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57
Q

How is New onset AF managed? (not maintenance but initial)

A

Haemodynamic instability onset <48hrs and unstable = urgent= electrical CV and heparin prior, anticoagulate

Haemodynamically stable:
<48hrs=electrical CV preference, can also use rate control (dilt/verap)
>48hrs=pharmacological - amiodarone or flecainide
If structural heat disease use amiodarone

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58
Q

What is 1st line maintenance therapy for AF?

A

Rate control e.g. beta blocker (not sotalol)

OR a rate limiting CCB e.g. Verap or dilt [unlicensed]

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59
Q

What situation would you give digoxin for AF?

A

Sedentary pts with non paroxysmal AF

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60
Q

What is 2nd line for mainenance AF?

A

Rhythm control e.g. sotalol, amiodarone, flecinide

maintaining sinus rhythm post CV

61
Q

When can amiodarone be started in AF?

A

4 weeks before and continue up to 2 months after electrical cardioversion to maintain sinus rhythm in paroxysmal or persistent Af but not for long term rate control

62
Q

What drugs would you NOT use for AF in ischaemic or structual heart disease?
What drug would you use and how long?

A

Flecainide or propafenone rhyhm control

Use amidoarone - if persistent AF use for >7days, if permenant = all time

63
Q

When would you do cardiovesion?

A

Wait until fully anticoagulated for 3 weeks before and continue 4 weeks after

64
Q

when would you NOT offer stoke prevention with anticoagulation in AF pts?

A
  • <65 with AF and no other risk factors other than sex

BUT do not withhold anticoag solely based on age or falls risk

65
Q

What is unique about dabigatran DOAC?

A

It has a diffeent MoA to the others - it is reversible inhibitor of free thrombin, fibrin bound thrombin and thrombin induced platelet aggregation

66
Q

What is the MHRA advice on DOACs?

A

Caution in pts at risk of bleed (elderly, renal imp, low BW)
Monitor interactions & do not take with strong enzyme inhibitors or p-glycoprotein
Dose dependent on renal function

67
Q

Which DOAC is contraindicated in eGFR <30ml/min?

A

Dabigatran

68
Q

What is the renal function cut off for apixaban?

A

<15ml/min

69
Q

In renal impairment, how would you know how often to monitor a patient on DOACs?

A

CrCl/10 gives how often to monitor renal

70
Q

What circumstance would you dose reduce apixaban to 2.5mg BD for AF?

A

Age >80
weight <60kg
Cr >133 micromol/L

If 2 or more =reduce

71
Q

What DOAC interacts with verapamil?

A

Dabigatran - need to reduce the dose of Dabi to 110mg BD as opposed to 150mg BD.

72
Q

What is the target INR in AF patients?

A

2.5

73
Q

Which DOAC is taken with food?

A

Rivaroxaban

Can also be crushed and mixed with apple puree/put through NG tube

74
Q

What is the onset of action of DOACs?

A

1-4 hrs - around 2-4hours to peak

Dabigatran fastest 0.5-2hrs

75
Q

Which DOACs should not be used in severe liver disease due to hepatic metabolism?

A

Apixaban

Rivaroxaban

76
Q

Which DOAC has the warning label - swallow whole, do not chew or crush

A

Dabigatran (increased bleed risk)

77
Q

Which DOAC cannot be put in a compliance aid? WHY?

A

Dabigatran

Moistue sensitivie

78
Q

If a dose of a DOAC is missed is this a risk?

A

Yes- shorter half life so missed dose means no anticoagulation
If miss, take it ASAP(within 6hrs if Dabigatran)

Warfarin less of an issue - just skip the dose

79
Q

If a patient has type 2 diabetes with hypetension - what is 1st line after lifestyle?

A

ACE or ARB

80
Q

What is the first line for stage 1 hypertension? (140/90)

What situation would you treat stage 1 HTN?

A

Lifestyle advice

Only treat if >80, or if <80 and risk factors such as CKD, retinopathy, QRISK 20% or more, diabetes

81
Q

What is classed as stage 2 HTN?

A

160/100

always treat

82
Q

If a person is <55 and not of african/caribbean origin and their BP isnt controlled by ACEi, what is next line step 2 management?

A

CCB or thiazide like diuretic (use thiazide if high risk heart failure)

83
Q

If a patient is >55 or african/caribbean origin - what drug treatment is indicated as step 1?

A

CCB

Wouldnt use ACE first line due to low plasma renin activity

84
Q

Which dug is used in hypertensive emergency?

A

IV hydralazine - reduce slowly due to risk of reduced organ perfusion and organ damage

85
Q 
What are the clinic BP targets for
<80 
>80 
renal disease 
diabetic
A

<80 = <140/90
>80 = <150/90
Renal: <140/90 but <130/80 if CKD, diabetes, proteinuria
Diabetic: <140/80 but <130/80 if diabetic complications

86
Q

What are the target BP in pregnancy and which anti-hypertensives are used?

A

<150/100 chronic HTN
<140/90 for chronic HTN if target organ damage or given birth
- labetalol 1st choice
- Alternatives methyldopa [stop 2 days post birth] or MR nifedipine [unlicensed]

87
Q

What is a risk with labetalol?

A

hepatotoxicity

88
Q

Which ACE inhibitor is BD

A

Captopril

Rest are OD

89
Q

What are the common side effects of ACEi

A 
=persistent dry cough
= hyperkalaemia
= angioedema 
= nephrotoxic in AKI, avoided in renovascular disease
= cholestatic jaundice and hepatic failure
= oral ulcers
= taste disturbance
= hypoglycaemia
90
Q

What counselling advice would you give for ACEi first time?

A

Take first dose at bedtime to avoid first dose hypotension

91
Q

What warning label for perindopril?

A

Take 30-60min before food

92
Q

What are key interactions of ACEI

A

Inceased risk hyperkalaemia = K+ sparing diuretics, aldosteone antagonists, ARBs, aliskeren

Nephrotoxicity/reduced eGFR = NSAIDS

Hypotension= diuretics (volume depletion)

Avoid concomitant ACE/ARB therapy/drugs affecting RAAs system

93
Q

What is a common issue with methyldopa for hypertension? (centrally acting antihypertensive not as common)

A

Drowsiness

Fever,hepatic disordes=stop

94
Q

What is a side effect of clonidine? (centrally acting antihypertensive less ocmmon)

A

Flushing

95
Q

What are side effects of hydralazine and when is it used

A

Fluid retention
tachycardia

used in hypertensive emergency / heart failure with long acting nitrate under specialist / severe HTN

96
Q

Before initiation of hydralazine what is measured?

A

Poteinuria
antinuclear factor
acetylator status

97
Q

What is a side effect of sotalol

A

Torsades de pointes - prolong QT

98
Q

What are the cardioselective BB

A 
Bisoprolol
atenlol
metoprolol
acebutalol
nebivolol

Less bronchospasm

99
Q

Can cardioselective BB be used in asthmatics

A

Yes if well controlled asthma under specialist if no other choice

100
Q

Which beta blockers have less bradycardia and less cold extremities and why?

A

ice PACO

Pindolol
Acebutalol
celiprolol
oxprenolol

These have less intrinsic sympathomimetic activity

101
Q

Which beta blockers have less nightmares and why?

A 
WATER CANS 
Celiprolol
atenolol
nadelol
sotalol

Why? because they are water soluble, cannot cross BBB and less likely to cause nightmares, sleep disturbances

102
Q

What is the caution of water soluble beta blockers

A

excreted renally so caution in renal impairment

103
Q

what beta blockers have ONCE daily dosing?

A 
BACoN
Bisopolol
atenolol
Celiprolol
Nadolol

Instrinsically longer duration of action

104
Q

What are contraindications of beta blockers?

A
  • asthma including eye drops (non selective bind to beta2 receptors in lungs so bronchospasm risk)
  • worsening unstable heart failure (reduced CO )
  • 2/3 degree AV block
  • severe hypotension and bradycardia (will worsen)
105
Q

Common side effects of Beta blockers?

A
  • bradycardia - reduced CO
  • fatigue
  • cold extremities
  • hypotension
  • hyper or hypoglycaemia due to disturbing carbohydrate metabolism
  • masking symptoms of hypo e.g. tachy due to brady
106
Q

What are 2 main interactions of beta blockers?

A

Verapamil injection = causes Asystole and hypotension (even risk with oral verap)

Thiazide like diuetics due to risk of hyperglycaemia = would avoid in diabetes/high isk

107
Q

Which CCBs are more selective fo the vasculature?

A

Dihydopyridines e.g. amlodipine etc

108
Q

Which dihydopyridine CCB needs to be maintained with same MR brand?

A

Nifedipine

109
Q

What are common S/E of dihydropyridine CCBs

A

ankle swelling
flushing
headaches

110
Q

When would you need to maintain brand of diltiazem

A

When doses >60mg

111
Q

What condition should rate limiting CCBs be avoided

A

Heart failure-can precipitate worsening due to the fact they reduce HR and force of contraction

112
Q

What is a common interaction for CCBs

A

enzyme inhibitors = increase CCB concs e.g. grapefruit juice

113
Q

What factors increased risk of VTE

A
  • immobility
  • obesity >30BMI
  • cancer
  • +60y/o
  • personal history or first degree relative
  • clotting disorders (thrombophilia)
  • HRT or combined contraceptives
  • varicose veins w/phlebitis
  • pregnancy
  • critical care
  • significant co-morbditiies
114
Q

What factors are increased risk of bleeding

A
  • Thrombocytopenia - low platelets <150x109 g/dL
  • acute stroke
  • bleeding disorders e.g. liver failure, haemophilia, WBD
  • anticoagulation
  • systolic hypertension
115
Q

What is the treatment of VTE

A

LNWH or UFH (renal) at least 5 days until INR 2 or more for at least 24hrs
start oral anticoagulant at the same time e.g. warfarin o DOAC

116
Q

What pharmacological VTE prophylaxis is used? and duration?

A

LMWH or UFH if eGFR >30 or fondaparinux in ACS

General surgery: 5-7 days or until sufficiently mobile
Major cancer surgery/abdomen/pelvis: 28 days
Knee/hip surgery: extended duration

117
Q

What medication is used for VTE in pregnancy and why?

A

LMWH - less risk of osteoporosis and heparin induced thrombocytopenia
- stop when labour starts

118
Q

What are the 4 common side effects of heparins

A
  1. Haemorrhage - withdraw. If antidote: Protamine
  2. Hyperkalaemia - monitor before and if >7 days
  3. Osteoporosis
  4. Heparin induced thrombocytopenia which can occur 5-10 day safter
119
Q

How is heparin induced thrombocytopenia identified and when does it occur?

A

5-10 days after heparins

  • 30% reduction in platelets
  • skin allergy
  • thrombosis

Keep monitoring plt if >4 days
Use heparinoid instead if HIT

120
Q

When is UFH preferred to LMWH?

A
  • If there is Higher risk of bleeding due to short half life
  • Renal impairment
121
Q

What is an essential monitoring parameter with UFH

A

APTT - activated partial thromboplastin time

122
Q

Why is bridging needed when initiating warfarin

A

Takes 48-72hours to work

123
Q

What are the durations of treatment for
isolated calf DVT
Provoked VTE
Unprovoked DVT

A

isolated calf DVT: 6 weeks
Provoked VTE: 3 months
Unprovoked VTE: at least 3M = long term

124
Q

What is the target warfarin INR for

VTE, AF, MI, cardioversion, biprosthetic mitral valve?

A

2.5

within 0.5units

125
Q

What is the target warfarin INR for recurrent VTE in patients already receiving an anticoagulant and INR>2?

A

3.5

126
Q

Provide counselling points for warfarin

A 
Yellow treatment book/alert card
Signs of bleeding - blood in stools/urine, nose bleeds, easily bruising
Report painful skin rash 
Do not do drastic diet changes e.g. coumarins, leafy greens 
Reduce alcohol / no binge drinking 
Inform dentist of any procedures
Care with teeth/shaving - gentle 
not drink pomegranate juice
127
Q

What is the MHRA alert regarding warfarin and a major side effect?

A

RISK OF CALCIPHYLAXIS
pts to report painful skin rashes and stop

Risk factor is end stage renal disease

128
Q

What are the side effects of warfarin

A

bleeding –> nose bleeds <10min, gums, bruising

Calciphylaxis / painful skin rash

129
Q

What are 2 key interactions of warfarin that have an MHRA warning?

A
  1. With miconazole (otc miconazole daktarin oral gel) - increased bleeding as miconazole enzyme inhibitor
  2. Direct acting antivirals to treat Hep C- monitor INR

Other interactions= enzyme inhibitors

130
Q

For elective surgery what is the protocol for warfarin

A

Stop 5 days before
If INR >1.5 the day before then give phytomenadione PO
Re-start warfarin evening or next day

If high risk of VTE (e.g. VTE in last 3M, AF with previous stroke/TIA, mechanical valve: bridge with treatment dose LMWH and stop 24hrs prior to surgery

131
Q

If there is emergency surgery what changes are needed to warfarin

A

Delay 6-12hrs

If no delay - IV phytomenadione and dried prothrombin complex

132
Q

What is treatment if there is major bleeding with warfarin

A

STOP

IV phytomenadione

Dried prothrombin complex or fresh frozen plasma

133
Q

if a patients INR comes back at e.g. 5.6 (or within 5-8 range) with no bleeding - what is the protocol

A
  • withhold 1-2 doses
  • reduce maintenance
  • measure INR in 2-3 days
134
Q

If INR is beteween 5-8 with minor bleeding what is the protocol

A
  • omit warfarin
  • IV phytomenadione
  • repeat if INR still high in 24hrs
  • re-start when INR >5
135
Q

If INR >8 but no bleeding?

A

Omit warfarin
Oral phytomenadione
Repeat if INR still high after 24hrs
Re start when IN <5

136
Q

If INR >8 with minor bleeding?

A

Omit wafarin
IV phytomenadione
repeat if still high in 24hrs
start when INR <5

137
Q

What is the special storage/packaging for Dabigatran?

A

It is a special container - with a 4month expiry

138
Q

What are contraindications of DOACs

A
  • GI ulceration
  • malignancy
  • recent brain/spinal surgery or haemorrhage
  • varices in oesphagus
  • vascular aneurisms
  • Arteriovenous malformations
139
Q

What is the cut off for use of apixaban in renal impairment

A

<15 ml/min

140
Q

What are the treatments for HF with reduced EF?

A
  • always offer diuretics for congestive symptoms/fluid retention

1st line: ACEi and BB
add in mineralocoticoid receptor antagonist if symptoms continue e.g. spiro/epl

Consider hydralazine and nitrate if intolerant of ACE and ARB

persistent symptoms - replace ACE/ARB with sacubitril/valsasrtan if EF <35%
Add ivabradine for sinus rhythm with HF >75 and EF <35%
Add hydralazine and nitrate esp if ACS decent

Digoxin for HF with sinus rhythm

141
Q

At what LVEF is entresto used?

A

LVEF <35%

142
Q

What is the dose titration for beta blockers in HF

A

Start low and go slow

assess HR and BP after each dose increase

143
Q

What is used for fluid overload symptoms in HF

A

Loop diuretic - potent.

If monotherapy doesnt work = add in thiazide diuretic (thiazides not in <30ml/min)

If still uncontrolled: metolazone and thiazide like diuretic added

144
Q

If HF with preserved EF, what dosage of furosemide is used

A

low to medium dose loop e.g. <80mg furosemide daily

145
Q

What is some lifestyle advice for HF patients

A

Vaccinations + annual flu and pneumococcal
Dont routinely advise to restrict salt/fluids but ask about consumption - if its high then do

Avoid salt substitutss containing K+
smoking + alcohol
Driving and air travel

146
Q

Which ACEi can cause stomatitis/mouth ulcers/sores

A

Ramipril

147
Q

What is the use of sodium nitroprusside

A

Hypertensive emergency

148
Q

Which anti-platelet drug can cause throbbing headache S/E

A

Dipyridamole

149
Q

What is the max daily dose of furosemide

A

120mg in divided doses

150
Q

What medication is ONLY indicated for hypertension

A

Lercanidipine

151
Q

Which CCB is the only one used in heart failure patients?

A

amlodipine

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