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GPhC BNF > CARDIOVASCULAR > Flashcards

CARDIOVASCULAR Flashcards

1
Q

ATRIAL FIBRILLATION

AF vs ECTOPIC BEATS? Management?

A

ECTOPIC BEATS- spontaneous, b-blocker if treatment needed
AF- can lead to stroke (blood doesn’t fully eject–> clot)
Use ventricular rate control or sinus rhythm control

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2
Q

Treatment- patient with life-threatening haemodynamic instability caused by AF?

A

Emergency electrical cardioversion without delay to achieve anticoagulation!

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3
Q

Patients without life-threatening haemodynamic instability
Onset of AF <48 hours?
Onset of AF >48 hours?

A

Onset of AF <48 hours? Rate or Rhythm control

Onset of AF >48 hours? Rate control

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4
Q

2 Types of (Cardioversion) Rhythm Control to restore sinus rhythm?

A

Pharmacological- flecainide or amiodarone

Electrical- start IV anticoagulation (heparin) and rule out a left atrial thrombus

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5
Q

3 Types of Rate Control Monotherapy?

A
  • beta-blocker (not sotalol)
  • Rate-limiting CCB- verapamil/diltiazem
  • Digoxin (mainly sedentary patients with non-paroxysmal AF)
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6
Q

Monotherapy to control ventricular rate, an L? Use Rate Control Dual Therapy?

A

Combine any 2: beta blocker/digoxin/diltiazem

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7
Q

Clinic BP 149/91
Home BP 143/86
Hypertension Stage?

A

Stage 1

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8
Q 
Stroke Prevention, CHA2-DS2-VASC SCORE?
C
H
A2
D
S2
V
A
Sc

When is thromboprophylaxis NOT needed?

A 
C congestive HF
Hypertension
Age 75+ (2)
Diabetic
Stroke/TIA (2)
Vascular disease- dvt, aneurysm, etc
Age 65-74
Sex- female

When is thromboprophylaxis NOT needed?
Men= 0
Women= 1

Thromboprophylaxis: Warfarin OR NOACs in non-valvular AF

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9
Q

ANTI-ARRYTHMIC DRUGS

AMIODARONE? AVOID+SIDE EFFECTS?

BCTPHP

A

Bradycardia & heart block

Corneal microdeposits (reversible when treatment ends, impaired vision? STOP)

Thyroid disorder (hypo/hyperthyroidism, depends on iodine content)

Photosensitivity (avoid sunlight exposure+sunscreen for months after treatment ends)

Hepatoxicity (clay stools N+V,)

Pulmonary toxicity (SOB, cough)

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10
Q

AMIODARONE INTERACTIONS? LONG TINGGGGGG

HQCB

Digoxin dose?

A

Very long half life

hypokalaemia- diuretics (loop/thiazide), insulin, laxative

QT prolongation- antihistamines, antidepressants, antibioics

CYP450 enzyme substrate (amiodarone= inhibitor)- grapefruit inhibitor, warfarin/contraceptive/statin
Inducer? Phenytoin, phenobarbital

Bradycardia- b-blocker/R-L CCB

Digoxin dose? HALF

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11
Q

AMIODARONE MONITORING?

TLP-XE

A

Thyroid test: before treatment+ every 6 months

Liver test: before treatment+ every 6 months

Serum potassium conc: before treatment

Chest x-ray: before treatment

Annual eye examination

IV USE: ECG+liver transaminase

Amiodarone stopped recently, need to start sofosbuvir and daclatasvir, simeprevir and sofosbuvir, or sofosbuvir and ledipasvir? Close monitoring, risk of heart block, fatal!

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12
Q

AMIODARONE LOADING DOSE?

A

200mg TDS 7 days
200mg BD 7 days
200mg OD maintenance

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13
Q

DIGOXIN? SICK&SLOW!

Therapeutic range?

Toxicity risk? Treatment?

Signs of toxicity?

WHEN DO YOU TAKE BLOOD SAMPLES?

AF loading dose?

A

Therapeutic range?
0.7-2.0 ng/mL

Toxicity risk?
Increased from 1.5-3.0 ng/mL.
Treated with digoxin-specific antibody

Signs of toxicity?
SA/AV block+bradycardia
D&V
Dizziness/confusion/depression
Blurred/yellow vision

WHEN DO YOU TAKE BLOOD SAMPLES? TAKE BLOOD SAMPLES AT LEAST 6HRS POST-DOSE
MONITOR ELECTROLYTES+RENAL FUNCTION

AF loading dose? 125-250mcg OD

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14
Q

DIGOXIN INTERACTIONS?

BTHC

A

B-BLOCKER- AV block risk

TCAS- arrythmias

Drugs that cause hypokalaemia- risk of toxicity

CYP450 enzyme inducer: reduces plasma conc

CYP450 enzyme inhibitor: increase plasma conc

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15
Q

BLEEDING DISORDERS

TRANEXAMIX ACID?

DESMOPRESSIN?

A

TRANEXAMIX ACID?

  • Surgeries, dental extraction/menorrhagia
  • GI side effects: N&V

DESMOPRESSIN?
-Mild-moderate haemophilia +von Willebrand’s disease (difficulty clotting)

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16
Q

THROMBOEMBOLISM

VTE?
DVT?
PE?

Risk factors?
ST(sI)MOPC

A

VTE? Blood clot in a vein- blocks blood flow

DVT? Legs/pelvis- unilateral localised pain/swelling

PE? Lungs- chest pain/SOB

Risk factors?
Surgery
Trauma
Significant immobility
Malignancy
Obesity
Pregnancy
CHC/HRT

D-dimer test for diagnosis

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17
Q

VENOUS THROMBOEBOLISM PROPHYLAXIS

2 METHODS?

A

MECHANICAL? graduated compression stockings, wear until patient is mobile

PHARMACOLOGICAL? anticoagulants, start within 14hrs of admission
Patients with RF for bleeding (stroke, thrombocytopenia..)- ONLY receive prophylaxis when their risk of VTE outweighs risk of bleeding.

Risk of bleeding tool- ORBIT/HASBLED

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18
Q

VTE PROPHYLAXIS- SURGERY

MECHANICAL?

PHARMACOLOGICAL?

post-surgery?
major cancer?
spinal?

A

MECHANICAL?
-Continued until mobility/discharge

PHARMACOLOGICAL?

  • LWMH common
  • Unfractionated heparin preferred in renal impairment
  • Fondaparinux, lower limb immob

Continue for at least 7 days post-surgery/till mobility
However,
28 days after major cancer surgery in abdomen
30 days in spinal surgery

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19
Q

VTE PROPHYLAXIS- SURGERY

ELECTIVE HIP REPLACEMENT?

ELECTIVE KNEE REPLACEMENT?

A

ELECTIVE HIP REPLACEMENT?

  • LMWH for 10 days AND THEN 75mg aspirin for 28 days
  • LMWH for 28 days+stockings till discharge
  • Rivaroxaban- 10mg OD, 5 weeks

ELECTIVE KNEE REPLACEMENT?

  • 75mg aspirin for 14 days
  • LMWH for 14 days+stockings till discharge
  • Rivaroxaban- 10mg OD, 2 weeks

General medical patients, high risk of VTE- pharmacological prophylaxis for at least 7 days OR mechanical till mobile

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20
Q

VTE PROPHYLAXIS- PREGNANCY

Risk of VTE?

Birth/miscarriage/termination during past 6 weeks?

Additional mechanical prophy?

A

Risk of VTE>?
-LMWH, hospital, till no VTE risk/discharge

-Birth/miscarriage/termination during past 6 weeks? start LMWH 4-8hrs after event+continue for 7 days

Additional mechanical prophy? till discharge/mobile

Treatment of VTE: LMWH, unfractionated if patient at high risk of haemorrhage

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21
Q

VTE TREATMENT

Confirmed proximal DVT/PE?

If unsuitable?

Durations of Treatments?
Distal DVT?
Proximal DVT/PE?
Provoked DVT/PE?
Unprovoked DVT/PE?
Recurrent DVT/PE?
A

Confirmed proximal DVT/PE?
Apixaban/Rivaroxaban

If unsuitable?

  • LMWH for at least 5 days, followed by dabigatran/edoxaban
  • LMWH+warfarin for at least 5 days/till INR at least 2, 2 readings, followed by warfarin alone.

Durations of Treatments?

Distal DVT? 6 weeks
Proximal DVT/PE? At least 3 months (3-6m for active cancer)
Provoked DVT/PE? Stop at 3 months if the provoking factor resolved
Unprovoked DVT/PE? 3 months+
Recurrent DVT/PE? Long-term

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22
Q

WARFARIN- MONITORING INRs, higher INR= runnier blood

VTE/AF/Cardioversion/MI/Cardiomyopathy?

Recurrent VTE/Mechanical heart valves?

WARFARIN ACTIONS
Major bleed?

INR>8, minor bleeding?

INR>8, no bleeding?

INR 5-8, minor bleeding?

INR 5-8, no bleeding?

INR should be monitored every 1-2 days in early treatment and then /12 weeks

A

VTE/AF/Cardioversion/MI/Cardiomyopathy? 2.5

Recurrent VTE/Mechanical heart valves? 3.5

WARFARIN ACTIONS
Major bleed? Stop warfarin-> IV phytomenadione (vitamin K)+dried protrhombin

INR>8, minor bleeding? Stop warfarin->IV phytomenadiaone

INR>8, no bleeding? Stop warfarin-> oral phytomenadione

INR 5-8, minor bleeding? Stop warfarin-> IV phytomenadione

INR 5-8, no bleeding? Withhold 1-2 doses of warfarin+reduce subsequent dose

Restart warfarin when INR<5

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23
Q

WARFARIN SIDE-EFFECTS?

A

SKIN NECROSIS+CALCIPHYLAXIS- painful skin rash

HAEMORRHAGE- prolonged bleeding, vitamin K1 (phytomenadione) antidote

PREGNANCY- avoid in 1st and 3rd trimester- use contraception

BLUE TOE SYNDROME!

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24
Q

WARFARIN- INTERACTIONS?

A

VITAMIN K RICH FOODS- avoid major diet changes, leafy greens, reduces efficacy of warfarin

POMEGRANATE+CRANBERRY JUICE- increases patient INR

MICONAZOLE (OTC Daktarin oral gel)- increases patient INR

CYP450 enzyme inhibitor/inducer- increase/decrease warfarin conc.

CYP inhibitor- fluconazole, macrolides
CYP inducer- phenytoin, carbamazepine, rifampicin
Other antibiotics, kill gut flora that make vitamin K, increases warfarin effect

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25
Q

WARFARIN- SURGERY

MINOR PROCEDURES, LOW RISK OF BLEEDING?
INR LESS THAN
, restart within..

PROCEDURES RISK OF SEVERE BLEEDING?
Stop warfarin…
INR GREATER THAN
Thromboembolism risk…

EMERGENCY SURGERY?
Can be delayed…
Can’t be delayed..

A

MINOR PROCEDURES, LOW RISK OF BLEEDING?
INR<2.5
Restart within 24hrs of op

PROCEDURES RISK OF SEVERE BLEEDING?
Stop warfarin 5 days before
INR equal to/>1.5? Give vitamin K day before surgery
High risk of thromboembolism? Bridge with LMWH, stop LMWH 24hrs before surgery, restart LMWH 48hrs after

EMERGENCY SURGERY?
Can be delayed by 6-12 hrs? Give IV vitamin K
CAN’T be delayed by 6-12hrs? IV vitamin K+dried prothrombin complex

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26
Q

DOACs- apixaban/dabigatran/edoxaban/rivaroxaban

thromboembolism treatment ONLY

APIXABAN?

RIVAROXABAN?

DABIGATRAN?

EDOXABAN?

A

APIXABAN?
10mg BD for 7 days-> 5mg BD

RIVAROXABAN?
15mg BD for 3 weeks-> 20mg OD, should be taken with food

DABIGATRAN?
150mg BD aged 18-74
110-150mg BD, aged 75-79
110mg BD, aged 80+

EDOXABAN?
60mg OD, 30mg OD if <61kg

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27
Q

Parenteral Anticoagulants- HEPARIN vs LMWH?

ALL HEPARINS?

UNFRACTIONATED HEPARIN?

LMWH?

A

ALL HEPARINS?
Avoid in heparin-induced thrombocytopenia
Can cause hyperkalaemia
Haemorrhage- treat with PROTAMINE SULPHATE (used for unfractionated heparin)

UNFRACTIONATED HEPARIN?
Quick initiation+elimination- ideal in high bleeding risk (monitor APTT)
Higher risk of heparin-induced thrombocytopenia than LMWH
Preferred in renal impairment

LMWH?
Preferred in pregnancy

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28
Q

STROKE?

HAEMORRHAGIC?

ISCHAEMIC?

Long-term Management?

A

HAEMORRHAGIC?
Manage bp+avoid statins

ISCHAEMIC? TIA/ACTUAL STROKE

Initial Management w/ Aspirin

Long-term Management?

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29
Q

STROKE

HAEMORRHAGIC?

ISCHAEMAIC
TIA VS ACTUAL STROKE?

Long-term Management?

A

HAEMORRHAGIC?
Manage bp+avoid statins

ISCHAEMIC? TIA/ACTUAL STROKE
Initial management w/ aspirin
TIA: 300mg OD till diagnosis established
Ischaemic: 300mg OD for 14 days, then alteplase (given in 4.5hrs)

Long-term Management?
1st line: Clopidogrel 75mg OD
2nd line: MR Dipyridamole+Aspirin
3rd line: MR Dipyramidole alone (or Aspirin alone)

START HIGH-INTENSITY STATIN 48HRS AFTER STROKE
MANAGE HYPERTENSION TO ACHIEVE <130/80
AVOID BETA-BLOCKERS

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30
Q

HYPERTENSION

STAGE 1?

STAGE 2?

STAGE 3?

A

STAGE 1? 140/90-160/100mmHg (clinic) AND 135/85-149/94mmHg (ambulatory)
<80 with kd, diabetes, CVD, >10%risk CVD 10 years? drug treatment
<60 w/ <10% risk of CVD in 10 years? consider drug treatment+lifestyle advice
>80 with bp>150/90mmHg? drug treatment+lifestyle

STAGE 2? 160/100-180/120mmHg (clinic) AND >150/95mmHg (ambulatory)
Treat all patients

STAGE 3? >180/120mmHg
Medical emergency

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31
Q

HYPERTENSION TREATMENT

PATIENTS <55/TYPE 2 DM?

Step 1?
Step 2?
Step 3?
Step 4?

*type 2 diabetes+afro-caribbean?

A

PATIENTS <55/TYPE 2 DM?

Step 1?
ACE-I OR ARB*

Step 2?
ACE-I/ARB+ CCB OR TLD

Step 3?
ACE-I/ARB+ CCB + TLD

Step 4?
Potassium <4.5mmol/L= low dose spironolactone
Potassium >4.5mmol/L= alpha/beta-blocker

*type 2 diabetes+afro-caribbean?
ARB>ACE-i preferred

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32
Q

HYPERTENSION TREATMENT

PATIENTS >55/AFRO-CARIBBEAN?

Step 1?
Step 2?
Step 3?
Step 4?

A

Step 1?
CCB

Step 2?
CCB+ ACEi/ARB

Step 3? same same
ACE-I/ARB+ CCB + TLD

Step 4?
Potassium <4.5mmol/L= low dose spironolactone
Potassium >4.5mmol/L= alpha/beta-blocker

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33
Q

ACE-INHIBITORS- ramipril, enalapril, lisinopril and perindopril

SIDE EFFECTS?
CHHAReD

ARBs?

A 
Cough (ARB instead)
Hyperkalaemia
Hepatic failure
Angioedema
Renal impairment
Dizziness & headaches

ARB: Candesartan/Irbesartan/Losaratan
Same S-Es as ACE-i, except cough and angioedema!

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34
Q

ACE-INHIBITOR INTERACTIONS?

A

INCREASED..

Risk of renal failure- ARBs, K-sparing diuretics, NSAIDs

Hyperkalaemia- Heparin, ARBs, NSAIds, K-sparing diuretics, b-blockers

Volume depletion- Diuretics

Plasma levels of lithium

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35
Q

BETA-BLOCKERS

CARDIO-SELECTIVE?

WATER-SOLUBLE?

INTRINSIN SYMPATHOMIMETIC B-BLOCKERS?

A

CARDIO-SELECTIVE? less likely to cause bronchospasms
BAtMAN
Bisoprolol, Atenolol, Metoprolol, Acebutolol & Nebivolol

WATER-SOLUBLE? less likely to cross BBB-> less nightmares
Water CANS
Celiprolol, Atenolol, Nadolol & Sotalol

INTRINSIN SYMPATHOMIMETIC B-BLOCKERS? less likely to cause cold extremities
Ice PACO
Pindolol, Acebutolol, Celiprolol & Oxprenolol

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36
Q

BETA-BLOCKERS SIDE-EFFECTS? INTERACTIONS?

A

BRADYCARDIA/HF (avoid amiodarone/digoxin)
MASKS EFFECTS OF HYPOGLYCAEMIA
‘Can induce diabetes’ hypergly?
BRONCHOSPASMS-> contraindicated in asthmatic patients

INTERACTIONS- digoxin, heart block+ any hypotensive drug!

ANY HEART DRUG, BRADYCARDIA RISK?

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37
Q

CALCIUM CHANNEL BLOCKERS SIDE-EFFECTS
Dihydropyridine?

Rate-limiting?

SIDE-EFFECTS?

A

Dihydropyridine?
Amlodipine, Felodipine, Lacidipine, Lercanidipine & Nifedipine

Rate-limiting?
Diltiazem & Verapamil

SIDE-EFFECTS?
Dizziness
Gingival Hyperplasia- enlarged gums
flushing/headaches/ankle swelling: more so in dihydro
Complete AV block- more so in R-L
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38
Q

HYPERTENSION- PREGNANCY

High risk of developing pre-eclampsia?

Blood pressure> 140/90mmHg?

A

High risk of developing pre-eclampsia?
Kidney disaese/diabetes/autoimmune disease/hypertension

TAKE ASPIRIN FROM WEEK 12 TILL BIRTH

Blood pressure> 140/90mmHg?
Labetalol, L? Nifedipine MR, L? Methyldopa

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39
Q

HYPERTENSION TARGETS- CLINICAL AND AMBULATORY
clinical and ambulatory difference? C 5 more

<80years?

> 80years?

Renal Disease?

Pregnancy?

Type 1 Diabetes?

A
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40
Q

HYPERTENSION TARGETS- CLINICAL AND AMBULATORY
clinical and ambulatory difference? C-A= 5

<80years?

> 80years?

Type 2?

Renal Disease?

Pregnancy/Type 1 Diabetes?

A

<80years?
140/90mmHg (clinical) | 135/85 (ambulatory)

> 80years?
150/90mmHg (clinical) | 145/85 (ambulatory)

Type 2? Clinical same as above

Renal Disease?
140/90mmHg (clinical)

Pregnancy/Type 1 Diabetes?
135/85mmHg (clinical)

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41
Q

HYPERLIPIDAEMIA

Total cholesterol?

HDL (good cholesterol)?

LDL (bad cholesterol)?

Non-HDL (bad cholesterol)?

Triglycerides?

A

Total cholesterol?
5 or below

HDL (good cholesterol)?
1 or greater

LDL (bad cholesterol)?
3 or below

Non-HDL (bad cholesterol)?
4 or below

Triglycerides?
2.3 or below

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42
Q

DYSLIPIDAEMIA- statins, fibrates/ezetimibe

When to offer lipid-lowering agents?

A 
When to offer lipid-lowering agents?
<85 w/ >10% 10-year CVD risk
Type 2 diabetes w/ >10% 10-year CVD risk
ALL Type 1 diabetes:
>40years
Diabetes>10 years
Established nephropathy
CKD
Familial Hypercholesterolaemia
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43
Q

STATINS- ATORVASTATIN/SIMVASTATIN/FLUVASTATIN/PRAVASTATIN

Time of day?

Atorvastatin strongest dose?

Hypothyroidism?

High risk of diabetes?

A

Time of day?
Atorvastatin/Rosuvastatin-any time of day
Other 3- ON, cholesterol produced at night, highest

Atorvastatin strongest dose?
Atorvastatin 80mg- used in secondary prevention (e.g. had a heart attack)

Hypothyroidism?
Manage BEFORE starting statin

High risk of diabetes?
Measure FBG/HbA1C BEFORE starting statin
Repeat after 3 months

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44
Q

STATINS- SIDE-EFFECTS

A

MYOPATHY+RHABDOMYOLYSIS-> muscle toxicity- seek medical advice if they develop muscle symptoms (pain/tenderness/weakness)

INTERSTITIAL LUNG DISEASE-> seek medical attention if patients develop dyspnoea/cough/weight loss

TERATOGENIC-> statins should be avoided in pregnancy (discontinue 3 months before conceiving)

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45
Q

STATINS- INTERACTIONS

CYP450 enzyme inducer?

CYP450 enzyme inhibitor?

Fusidic acid (oral)?

A

CYP450 enzyme inducer? (rifampin, phenytoin, phenobarbital)
-Reduces conc. of statin

CYP450 enzyme inhibitor? (erythromycin, ketoconazole, diltiazem, colchicine)

  • Increases conc of statin-> increased risk of rhabdomyolysis
  • Patients prescribed macrolides-> stop taking statin during treatment
  • Avoid drinking grapefruit juice
Fusidic acid (oral, X cream)?
-Stop statin during treatment-> restart 7 days after last dose
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46
Q

STATINS- MAXIMUM DOSES

AMIODARONE+SIMVASTATIN?

AMLODIPINE+SIMVASTATIN?

DILTIAZEM/VERAPAMIL+SIMVASTATIN?

TICAGRELOR+SIMVASTATIN?

CICLOSPORIN+ATORVASTATIN?

TIPRANAVIR+ATORVASTATIN?

BUT SIMVA AND FIBRATES?

A

AMIODARONE+SIMVASTATIN? 20mg

AMLODIPINE+SIMVASTATIN? 20mg

DILTIAZEM/VERAPAMIL+SIMVASTATIN? 20mg

TICAGRELOR+SIMVASTATIN? 40mg

CICLOSPORIN+ATORVASTATIN? 10mg

TIPRANAVIR+ATORVASTATIN? 10mg

SIMVA+FIBRATES 10MG

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47
Q

OTHER LIPID-LOWERING AGENTS- SIDE-EFFECTS?
????

EZETIMIBE?

FIBRATES?

A

EZETIMIBE?
Statins+fibrates= increased risk of rhabdomyolysis

FIBRATES?
Bezofibrate/Ciprofibrate/Fenofibrate/Gemfibrozil
Myotoxicity in renal impairment
LFTs/3 months for the first year
Statins+fibrates= increased risk of muscle related side-effects

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48
Q

MYOCARDIAL ISCHAEMIA

?

A

? Build up of atherosclerotic plaques which restrict arteries, reducing blood supply and oxygen to the heart

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49
Q

STABLE ANGINA- predictable chest pain/pressure, physical exertion/emotional

INITIAL TREATMENT?

LONG-TERM PREVENTION?

A

INITIAL TREATMENT?

  • Can be taken prophylactically/when symptoms arise
  • GTN dose to be taken at 5mins intervals
  • If symptoms haven’t resolved after third dose: medical emergency

LONG-TERM PREVENTION?
1st line: beta-blocker (R-L ccb if contra)
2nd line: b-blocker +normalCCB (amlodipine, lacidipine, etc)
NEVER B-B+R-L CCB
3rd line: long-acting nitrate- nicorandil/ivabradine/ranolazine
Nicorandil can cause GI+mucosal ulceration

Angina further advice?
Healthy lifestyle measures
75mg aspirin
low dose statin
(not secondary prevention)
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50
Q

NITRATES

GTN SUBLINGUAL TABLETS DISCARD?

TOLERANCE?

SIDE-EFFECTS?

A

SUBLINGUAL TABLETS DISCARD?
-Discard 8 weeks after opening bottle

TOLERANCE?

  • Patients should have nitrate free period to prevent tolerance
  • Second dose of nitrate, give 8hrs after first dose (not 12), 16hrs nitrate-free blood (8am, 4pm…)
  • Transdermal use: leave patch off for 8-12hrs

SIDE-EFFECTS?

  • Dizziness
  • Flushing
  • Headaches

-Elderly, caution!

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51
Q

ACUTE CORONARY SYNDROME

MAJOR RISK FACTORS?

A 
MAJOR RISK FACTORS?
Family history
Hypertension
Hypercholesterolaemia
Diabetes
Smoking

All syndromes- similar in initial/secondary treatment

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52
Q

Real-life scenario, ECG/biomarkers, STEMI determined, action?

A

STEMI- Primary PCI (coronary reperfusion therapy) should be delivered ASAP within 2hrs

P.S . All 3 syndromes started on secondary prevention

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53
Q

ACS INITIAL MANAGEMENT, 3 THINGS?

NSTEMI/UNSTABLE ANGINA/STEMI DIFFERENCE?

A

LOADING DOSE ASPIRIN 300mg
PAIN RELIEF: GTN/IV morphine
O2 if needed
Monitor all patients for hyperglycaemia, >11mmol/L? Insulin!-> dose-adjusted infusion

NSTEMI/UNSTABLE ANGINA/STEMI DIFFERENCE?
-UNSTABLE ANGINA-
PARTIAL blockage of artery

-NSTEMI- PARTIAL blockage of artery+myocardial necrosis (dead cardiomyocytes->elevated cardiac troponin values)
ST zone of ECG is not elevated

-STEMI- COMPLETE blockage of artery causing myocardial necrosis
ST zone of ECG is elevated

non-ST vs st-elevated myocardial infarction!

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54
Q

STEMI requiring PCI (percutaneous coronary intervention) within 2 hours?

A

Give heparin if PCI is done through radial access

Long-term management? Prasugrel- secondary anti-platelet

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55
Q

x4 SECONDARY PREVENTION? FOR ALL ACS!*

DABS

A

DUAL, ACE, B-B & S

DUAL ANTIPLATELET THERAPY?
lifelong aspirin 75mg
12 months: clopidogrel, prasugrel (preferred if PCI), ticagrelor

ACE-i?
ARB if ACE-i is contraindicated

B-BLOCKER?
Discontinue after 12months in patients with LVEF

STATIN?
Atorvastatin 80mg, high strength

*only difference is STEMI needs PCI!
Patients with NSTEMI might consider PCI to prevent future MI

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56
Q

HEART FAILURE SYMPTOMS?

SPARF

A 
SOB
Persistent cough/wheezing
Ankle swelling
Reduced exercise tolerance
Fatigue
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57
Q

CHRONIC HEART FAILURE

1st LINE?

SYMPTOMS PERSIST?

SYMPTOMS PERSIST 2?

LOOP DIURETICS PURPOSE?

DIGOXIN HF LOADING DOSE?

A

1st LINE? ACEi+B-blocker
Start at low dose+titrate up slowly to max.
ARB instead if ACE-I an L (licensed only- candesartan/losartan/valsartan)

Hydralazine+nitrate if both ACE-i & ARB an L (common in African/Caribbean origin)

SPIRO AFTER HYDRALAZINE+NITRATE!

SYMPTOMS PERSIST?
Add aldosterone antagonist- spironolactone/eplerenone (previous MI/HF?)

SYMPTOMS PERSIST 2?
Add amiodarone/digoxin/sacubitril w/ valsartan/ivabradine/dapagliflozin
Dapagliflozin has water loss side-effect, chronic HF excess fluid
Digoxin for patients in sinus rhythm in worsening/severe HF

LOOP DIURETICS PURPOSE?
Relieve breathlessness/oedema in fluid retention, furosemide/bumetanide/torasemide

DIGOXIN HF LOADING DOSE?
62.5-125mcg OD

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58
Q

2 TYPES OF OEDEMA?

A

Water retention in the system
Pulmonary- lungs
Peripheral- rest of the body (ankle swelling)

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59
Q

TYPES OF DIURETICS? (1)

A

THIAZIDE? BIt- Bendroflumethiazide, Indapamide
Inhibits sodium reabsorption at the beginning of the distal convoluted tubule
Lasts up to 24hrs- needs to be given AM to avoid sleep L

LOOP? FBT- Furosemide, Bumetanide, Torasemide
Inhibits reabsorption from the ascending limb of the loop of Henle
Used in pulmonary oedema due to left ventricular failure
Lasts 6hrs, can give BD, no L on sleep

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60
Q

TYPES OF DIURETICS? (2)

A

POTASSIUM-SPARING DIURETICS? AT- Amiloride, Triamterene (blue urine)
Prevents sodium reabsorption in the distal tubule collecting duct

ALDOSTERONE ANTAGONISTS (P-S A)? Spironolactone, Epleronone
Inhibits potassium secretion in the distal tubule collecting duct
Stopped if person becomes dehydrated- vomiting/diarrhoea

MUST NOT TAKE WITH K+ supplements

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61
Q

DIURETICS SIDE-EFFECTS

ALL?

LOOP+THIAZIDE?

K+-SPARING?

A

ALL?
Induce hyponatraemia+hypomagnesaemia

LOOP+THIAZIDE?
Hypokalaemia
Exacerbates diabetes+exacerbates gout (both loop only)
Hypotension

K+-SPARING?
Hyperkalaemia
Change in libido
Breast pain/tenderness

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62
Q

DIURETICS- INTERACTIONS

Loop+Thiazide?

Thiazide?

K+sparing?

Loop+Aminoglycosides?

Spironolactone/Loop+Lithium?

A

Loop+Thiazide? hypokalaemia inducing drugs

Thiazide? avoid NSAIDs, but low-dose aspirin calm

K+sparing? hyperkalaemia inducing drugs

Loop+Aminoglycosides? nephrotoxicity/ototoxicity (gent)

Spironolactone/Loop+Lithium? reduces lihtium secretion (renal)

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63
Q

2 TYPES OF PERIPHERAL VASCULAR DISEASE?

A

OCCLUSIVE VASCULAR DISEASE?

  • Normally caused by atherosclerosis
  • Reduced risk with health lifestyle, statins & antiplatelets

VASOSPASTIC VASCULAR DISEASE? (Raynaud’s)

  • Avoid exposure to cold+smoking cessation
  • Further treatment? NIFEDIPINE!
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64
Q

x3 Apixaban dose reduction criteria?

A

At least 2 of:
>/=80years
>/=133 Cr
= 60kg

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65
Q

EDOXABAN PE pre-treatment?

A

Parenteral anticoag for 5 days

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66
Q

LVEF<40%?

A

B-blocker+Digoxin is key!

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67
Q

FLECAINIDE/PROPAFENONE should be avoided in?d

A

Patients with heart disease/heart failure

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68
Q

digoxin & amiloride?

A

reduces risk of toxicity

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69
Q

what drug
Thyroid function tests, including T3, T4 and TSH, should be performed before treatment with this drug, and then every 6 months. In addition, liver function tests are required before treatment and then every 6 months

A

amiodarone

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70
Q

WARFARIN ANTICOAG EFFECT TAKES..?RU

A

48-72 HOURS!

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71
Q

DOACS, DABIGATRAN, ONLY 1 WITH ANTIDOTE?

A

TRUE

idarucizumab

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72
Q

BLOOD PRESSURE TARGETS

UNDER 80?

OVER 80?

A

UNDER 80? 140/90 clinical, 135/85 amb

OVER 80? 150/90 clinical, 145/85 amb

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73
Q

METHOTREXATE SIDE-EFFECTS? (D)USSBM

A 
DARK URINE/ABDOMINAL DISCOMFORT
SOB
SORE THROAT
BRUISING
MOUTH ULCERS
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74
Q

Rosuvastatin dose
Initial?
Max. with Clopidogrel?

A

5mg

20mg

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75
Q

Osmotic diuretic?

A

Mannitol
cerebral oedema
high intracranial pressure

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76
Q

WARFARIN

INCREASES ANTICAOG EFFECT?

A

CRANBERRY JUICE

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77
Q

WARFARIN

REDUCES ANTICOAGULANT EFFECT OF WARFARIN?

A

SPINACH & KALE CONTAINING VITAMIN K

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78
Q

Dual therapy L-> Use RHYTHM CONTROL

A

Sinus rhythm? Use electrical or pharmacological.

Pharmacological- Flecainide or amiodarone

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79
Q

AF> 48 hours in a non-acute presentation?

A

AF> 48 hours?
Electrical cardioversion’s preferred.
- Patient must be fully anticoagulated for at least 3 weeks
- Give oral anticoagulation- +4weeks at least after cardioversion

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80
Q

Drug treatment post-cardioversion? (rhythm control)

A

Drug treatment post-cardioversion? (rhythm control)

  • Standard beta blocker (1st line) (NOT SOTALOL)
  • SPAF (Sotalol, Propafenone, Amiodarone or Flecainide)
  • Amiodarone, can be started 4 weeks before and continued up to 12 months after electrical cardioversion, increase success of procedure
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81
Q

PAROXYSMAL ATRIAL FIBRILLATION

Ventricular rhythm/rate-control?

A

Ventricular rhythm? (rate-control)

Standad beta-blocker

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82
Q

PAROXYSMAL ATRIAL FIBRILLATION

Symptoms persist/standard B-B not appropriate?

A

Symptoms persist/standard B-B not appropriate?

SPAF (Sotalol, Propafenone, Amiodarone or Flecainide)

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83
Q

PAROXYSMAL ATRIAL FIBRILLATION

Symptomatic paroxysmal AF?

A

Symptomatic paroxysmal AF?

‘Pill-in-the-pocket’- Flecainide/Propafenone PRN

84
Q

ATRIAL FLUTTER

RATE?

A

RATE?

B-blocker/R-L CCB, temporary

85
Q

ATRIAL FLUTTER

RHYTHM CONTROL RESTORATION?

A

RESTORATION?
Direct current cardioversion- rapid control needed
Pharmacological cardioversion
Catheter ablation- recurrent atrial flutter

86
Q

ATRIAL FLUTTER

STILL NEED TO ENSURE?

A

STILL NEED TO ENSURE?
Patient has been anticoagulated for 3 weeks if flutter has lasted longer >48hrs
Assess stroke risk

87
Q

VTE PROPHYLAXIS- SURGERY

ELECTIVE HIP REPLACEMENT?fv

A

ELECTIVE HIP REPLACEMENT?

  • LMWH for 10 days AND THEN 75mg aspirin for 28 days
  • LMWH for 28 days+stockings till discharge
  • Rivaroxaban- 10mg OD 5 weeks
88
Q

VTE PROPHYLAXIS- SURGERY

ELECTIVE KNEE REPLACEMENT?

A

ELECTIVE KNEE REPLACEMENT?

  • 75mg aspirin for 14 days
  • LMWH for 14 days+stockings till discharge
  • Rivaroxaban

General medical patients, high risk of VTE- pharmacological prophylaxis for at least 7 days OR mechanical till mobile

89
Q

VTE PROPHYLAXIS- SURGERY

PHARMACOLOGICAL?

A

MECHANICAL?
-Continued until mobility/discharge

PHARMACOLOGICAL?

  • LWMH common
  • Unfractionated heparin preferred in renal impairment
  • Fondaparinux, lower limb immob

Continue for at least 7 days post-surgery/till mobility
However,
28 days after major cancer surgery in abdomen
30 days in spinal surgery

90
Q

VTE PROPHYLAXIS- SURGERY

PHARMACOLOGICAL?

A

PHARMACOLOGICAL?

  • LWMH common
  • Unfractionated heparin preferred in renal impairment
  • Fondaparinux, lower limb immob

Continue for at least 7 days post-surgery/till mobility
However,
28 days after major cancer surgery in abdomen
30 days in spinal surgery

91
Q

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA?

Spontaneous?

A

Spontaneous?

Terminate ekhla

92
Q

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA?

Reflex vagal stimulation?

A

Reflex vagal stimulation?

Valsalva manouevre/face-in-cold water (ECG monitoring though)

93
Q

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA?

Reflex Vagal L?

A

L? IV Adenosine, L? IV Verapamil (but avoid in patients, recent b-blockers, risk of brady/hypotension)

94
Q

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA?

Recurrent symptoms?

A

Recurrent symptoms? Catheter ablation (terminate faulty electrical pathways from sections of heart)

95
Q

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA?

Preventing future episodes?

A

Preventing future episodes? B-blocker/R-L CCB

96
Q

VENTRICULAR TACHYCARDIA? (abnormal heart rhythm/arrythmia)

Pulseless ventricular tachycardia OR ventricular fibrillation?

Unstable ventricular tachycardia?

Stable ventricular tachycardia?

Patients high risk of cardiac arrest?

A

Pulseless ventricular tachycardia OR ventricular fibrillation?
RESUSCITATION

97
Q

VENTRICULAR TACHYCARDIA? (abnormal heart rhythm/arrythmia)

Unstable ventricular tachycardia?

A

Unstable sustained ventricular tachycardia?

Direct current cardioversion. L? Give IV amiodarone. L? Repeat current cardioversion

98
Q

VENTRICULAR TACHYCARDIA? (abnormal heart rhythm/arrythmia)

Stable ventricular tachycardia?

A

Stable ventricular tachycardia?
IV amiodarone, L? Direct current cardioversion
Non-sustained ventricular tachycardia- b-blocker

99
Q

VENTRICULAR TACHYCARDIA? (abnormal heart rhythm/arrythmia)

Patients high risk of cardiac arrest?

A

Patients high risk of cardiac arrest?
Implantable cardioverter defib
Add b-blockers/amiodarone (combined with standard b-blocker)

100
Q

Torsade de Pointes, QT PROLONGATION? Extended interval between heart contracting/relaxing

Can be drug induced/caused by severe hypokalaemia/severe bradycardia?

A

Can be drug induced/caused by severe hypokalaemia/severe bradycardia?
Amiodarone, sotalol, macrolide, haloperidol, SSRI, TCA, antifungals

101
Q

Torsade de Pointes, QT PROLONGATION? Extended interval between heart contracting/relaxing

Can be drug induced/caused by severe hypokalaemia/severe bradycardia?

Self-limiting, but if recurrent?

A

Self-limiting, but if recurrent?

Can lead to impaired consciousness

102
Q

Torsade de Pointes, QT PROLONGATION? Extended interval between heart contracting/relaxing

No control?

A

No control?

Ventricular fibrillation–> death

103
Q

Torsade de Pointes, QT PROLONGATION? Extended interval between heart contracting/relaxing

TREATMENT?

A

TREATMENT?
IV magnesium sulphate
B-blocker (NOT sotalol) and atrial/ventricular pacing may be considered

104
Q

Torsade de Pointes, QT PROLONGATION? Extended interval between heart contracting/relaxing

AVOID?

A

AVOID– anti-arrythmics- prolong QT interval- worsens condition

105
Q

B-BLOCKER LICENSED FOR HEART FAILURE?

A

BISOPROLOL
CARVEDILOL
NEBIVOLOL

106
Q

HF MONITORING?

A

K+
NA+
BP
RENAL

before treatment
1-2 weeks after starting
at each dose increment.

Target hit/maximum tolerated dose is achieved, monitor monthly for 3 months and then at least every 6 months, and if the patient becomes acutely unwell.

107
Q

WARFARIN- SURGERY

MINOR PROCEDURES, LOW RISK OF BLEEDING?
INR LESS THAN X?
Restart within…

PROCEDURES RISK OF SEVERE BLEEDING?
Stop warfarin…
INR GREATER THAN X?
HIGH RISK OF THROMBOEMBOLISM?

EMERGENCY SURGERY?
Can be delayed…
Can’t be delayed..

A

MINOR PROCEDURES, LOW RISK OF BLEEDING?
INR<2.5
Restart within 24hrs of op

PROCEDURES RISK OF SEVERE BLEEDING?
Stop warfarin 3-5 days before
INR equal to/>1.5? Give vitamin K day before surgery
High risk of thromboembolism? Bridge with LMWH, stop LMWH 24hrs before surgery, restart LMWH 48hrs after

EMERGENCY SURGERY?
Can be delayed by 6-12 hrs? Give IV vitamin K
CAN’T be delayed by 6-12hrs? IV vitamin K+dried prothrombin complex

108
Q

SIMVASTATIN, HYPERCHOLESTEROLAEMIA DLOWWW?

A

Advice from the MHRA: there is an increased risk of myopathy associated with high-dose (80 mg) simvastatin. The 80 mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.

109
Q

WE DO NOT USE ACE IN ANGINA!!!!!

ANGINGA MANAGEMENT MUCH SHORTER THAN HF BTW

A
110
Q

WARFARIN IS NOT GRAPEFRUIT!

A

BUT POMEGRANATE AND CRANBERRY :) INHIBITOR

111
Q

HEART FAILURE

AVOID RATE-LIMITING CCBs+ALL OTHER CCBs

except AMLODIPINE

A
112
Q

STEMI

CLOPI WITH ASPIRIN OR ASPIRIN ALONE?

A

HIGH BLEEDING RISK

113
Q

ORBIT TOOL?

A 
Old age (74+)
Reduced haemoglobin- +2 (<13 mg/dL in men and <12 mg/dL in women)
Bleeding history- +2
Insufficient kidney function (eGFR<60)
Tx w/ antiplatelets

REDUCED HAEMOGLOBIN/BLEEDING GET +2 EACH

114
Q

APIXABAN REVERSAL AGENT?

A

ANDAXANET ALFA

115
Q

DABIGATRAN REVERSAL AGENT?

A

IDARUCIZUMAB

116
Q

Sotalol dosing?

A

Initially 80 mg daily in 1–2 divided doses, then increased to 160–320 mg daily in 2 divided doses, dose to be increased gradually at intervals of 2–3 days.

117
Q

citalopram+rivaroxaban/doac?

A

bleed

118
Q

AFRO CARIB+DIABETIC, GIVE?

A

ARB!

119
Q

rivaroxaban+binge alcohol= bleed

A
120
Q

NOSEBLEED A&E WHEN?

A

nosebleed lasts longer than 10 to 15 minutes

121
Q

Treatment of pulmonary embolism in uncomplicated patients with low risk of recurrence

A

1.5 mg/kg every 24 hours until adequate oral anticoagulation established.

122
Q

HYDROCHLORTHIAZIDE MHRA WARNING?

A

MHRA/CHM advice: Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use (November 2018)

123
Q
A

A?

124
Q

BLACK TRIANGLE?

A

The black triangle symbol identifies newly licensed medicines that require additional monitoring by the European Medicines Agency. Such medicines include new active substances, biosimilar medicines, and medicines that the European Medicines Agency consider require additional monitoring. The black triangle symbol also appears in the Patient Information Leaflets for relevant medicines, with a brief explanation of what it means. Products usually retain a black triangle for 5 years, but this can be extended if required.

Spontaneous reporting is particularly valuable for recognising possible new hazards rapidly. For medicines showing the black triangle symbol, the MHRA asks that all suspected reactions (including those considered not to be serious) are reported through the Yellow Card Scheme. An adverse reaction should be reported even if it is not certain that the drug has caused it, or if the reaction is well recognised, or if other drugs have been given at the same time.

surveillance lol

125
Q

GTNCHEST APPLICATION?

A

One ‘5’ patch to be applied to chest or upper arm; replace every 24 hours, siting replacement patch on different area, dose to be adjusted according to response.

126
Q

BMI RANGES?

A
127
Q

DON’T GIVE DOACS IN METALLIC HEART VALVES, WARFARIN INSTEAD!

A
128
Q

METALLIC HEART VALVE ANTICOAG

A

GIVE WARFARIN

129
Q

POINT OF LOOP/THIAZIDE?

A

RELIEVES OEDEMA, SWELLING

SO ELDERLY, SWELLING CAN’T TAKE CCB? GIVE THIAZIDE!

130
Q 
Durations of Treatments?
Distal DVT?
Proximal DVT/PE?
Provoked DVT/PE?
Unprovoked DVT/PE?
Recurrent DVT/PE?
A

Distal DVT? 6 weeks
Proximal DVT/PE? At least 3 months (3-6m for active cancer)
Provoked DVT/PE? Stop at 3 months if the provoking factor resolved
Unprovoked DVT/PE? 3 months+
Recurrent DVT/PE? Long-term

131
Q

B-BLOCKERS WITH LONG DURATION OF ACTION? ABCN

A

ATENOLOL
BISOPROLOL
CELIPROLOL
NADOLOL

132
Q

bendroflumethiazide, thiazide

indapamide/metolazone, thiazide-like

A
133
Q

RIVAROXABAN, DURATION

VTE PROPHYLAXIS

FOLLOWING KNEE SURGERY?

FOLLOWING HIP SURGERY?

A

FOLLOWING KNEE SURGERY? 2 WEEKS

FOLLOWING HIP SURGERY? 5 WEEKS

134
Q

Normal BP?

A

<120/80

135
Q

You are discussing with the nursing team the number of patients who are coming into the
surgery to get their INR tested due to being on warfarin. As part of a measure to try and
reduce this you identify a cohort of patients who are eligible and willing to switch over to a
DOAC.
One of the nurses asks what a patients INR should ideally be if they are to switch over
to Apixaban from Warfarin straight away?

A

INR<2

136
Q

what drug, stable angina
can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative?

A

NICORANDIL

137
Q

PERINDOPRIL LABELLING?

A

30-60MINS BEFORE FOOD

138
Q

SYMPTOMS OF REYE SYNDROME?

A

VOMITING
TIRED
RAPID BREATHING SEIZURES
LFT/WCC raised

NOT muscle aches

WCC raised? body fighting infection! :(

139
Q

So only Reduce Digoxin to HALF the dose with the following drugs:

A

Amiodarone
Quinine
Dronedarone

Dilt
Verap?

140
Q

what can potentiate digoxin toxicity?

A

hypokalaemia
hypomagnesaemia
hypercalcaemia
hypoxia

141
Q

. Post-operatively, Mr C is returned to the ward with an epidural catheter in situ for his pain
relief. In the evening, as Mr C is eating and drinking, he is prescribed all of his usual
medications, as well as the post-operative medications, as per below.
Which ONE of the following drugs should be omitted in order to have the greatest
reduction in risk of complications associated with the insertion of an epidural
catheter?

A

Dabigatran, NOACs have a risk!

142
Q

Which of the following is the most appropriate use of aspirin?

A

Prevention of cardiovascular events in a COPD patient who has previously had a
myocardial infarction

143
Q

Mr INR is a 62-year-old man who has been prescribed warfarin to treat myocardial infarction.
He has been admitted into hospital with an INR of 10.4 with minor bleeding.
Which of the following is the most appropriate course of action?

A

Stop warfarin; give phytomenadione (vitamin K1) by slow IV injection; repeat dose of
phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0

144
Q

warfarin

INR>8 minor bleeding?

INR>8 no bleeding?

A

INR >8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin sodium when INR <5.0
INR >8.0, no bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0

145
Q

Mr DVT has been experiencing recurrent deep-vein thrombosis. He has been taking warfarin
for several months. His last three INR readings have been stable at 2.4.
What should his INR target be?

A

3.5

RECURRENT DVT/PE, has score above 2
mechanical prosthetic heart valve

146
Q

You explain that sometimes patients require a particular brand. Which one of the
following does this apply to?

A

The standard formulations containing 60mg diltiazem hydrochloride are licensed as generics and
there is no requirement for brand name dispensing. Different versions of modified-release
preparations containing more than 60mg diltiazem hydrochloride may not have the same clinical
effect. To avoid confusion between these different formulations of diltiazem, prescribers should
specify the brand to be dispensed.

147
Q

Heparin administartion?

A

IV OR SC

NEVER IM

148
Q

NIFEDIPINE MR?

A

PRESCRIBE BY BRAND

149
Q

ototoxicity likelihood?

A

aminoglycosides/glycopeptides»» linezolid

150
Q

Only give prasugrel to people with a history of stroke/TIA? Hmmm

A
151
Q

STATINS+interactions?

A

ciclosporin
macrloides
grapefruit juice

NOT? azithromycin (macrolide, but no interaction)

152
Q

ANGINA,

it’s b-locker OR rate-limiting ccb, never these two specifically together

A
153
Q
A
154
Q

DOACS R NOT USED IN HEART VALES

WE USE WARFARIN!

A
155
Q
A
156
Q
A
157
Q

Patient, has a vascular spasm, haemorrhagic stroke

medication?

A

Nimodipine, smooth muscle relaxant effect, use confined to following haemorrhage

158
Q

methyldopa?

A

stop 2 days before birth, risk of depression

159
Q

SENNA, shops/supermarkets?

A

18+

but pharmacist supervision? 12+

160
Q

MACROLIDES- QT PROLONGATION YH

A
161
Q

DOAC INTERACTIONS?

CC DAWNS

A 
corticosteroids
carbocisteine
doacs
antiplatelets
warfarin
nsaid
ssris
162
Q

vte post-surgery?

A

usually 7
28 days cancer
30 days spinal

163
Q

Cardiac arrest drugs?

A

amiodarone
adrenaline
lidocaine
epinephrine

164
Q

Patient with prinzmetal angina or decompensated heart failure?

A

B-blockers are contraindicated
Give diltiazem or verapamil!

amlodipine might be decent

165
Q

Mr AK has come to your heart failure clinic for a medication review. He has been stable on
the maximum dose of ACE inhibitor and beta-blocker for 8 weeks. However, you notice Mr
AK’s ankles are still swollen indicating his heart failure symptoms have not been adequately
controlled. You decide to refer Mr AK to his specialist for a review of his symptoms, where a
few days later a letter from the heart failure consultant has recommended you initiate the
next phase of heart failure treatment. The consultant has mentioned that Mr AK’s ejection
fraction is <35% and he is at class III of the New York Heart Association classification for
heart failure. Which of the following medications would be the most appropriate to initiate
MR AK’s as step regimen for managing his heart failure symptoms?

A

Sacubitril/Valsartan

166
Q

salt intake/day?

A

6g max

167
Q

HF weight gain?

A

Patients should be encouraged to weigh themselves daily at a set time of day and to report any weight gain of more than 1.5–2.0 kg in 2 days to their GP or heart failure specialist.

168
Q

Driving, X drug, no offence?

A

buprenorphine

169
Q 
Atorvastatin 20mg- high intensity 
Fluvastatin 80mg- medium intensity 
Pravastatin 20mg - low intensity 
Rosuvastatin 5mg - medium intensity 
Simvastatin 40mg - medium intensity
A
170
Q
  1. A 56-year-old female patient attends her GP surgery after developing a cough, having chest pain, and losing her appetite. The GP performs an examination and uses the CRBGS score to diagnose low-severity
    community-acquired pneumonia. A course of antibiotics is prescribed

Which of the following treatment options would be appropriate for this patient?

A. A 3-day course of a single antibiotic.
B. A 5-day course of a single antibiotic.
C. A 5-day course of two antibiotics.
D. A 7-day course of a single antibiotic.
E. A 7-day course of two antibiotics.

A

Answer: B (A 5-day course of a single antibiotic.)

Adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.

Pneumonia is usually caused by bacteria and should be treated with antibiotic therapy. A 5-day course of a single antibiotic is usually an effective treatment for diagnosed low-severity community-acquired pneumonia unless symptoms do not improve. Prescribing a 5-day course will ensure that antibiotic therapy is not given for longer than necessary, and will contribute to effective antimicrobial stewardship. Healthcare professionals should give people advice on seeking further help if their symptoms do not show signs of improving after 3 days of antibiotic therapy.

171
Q

STROKE, WARFARIN TO RIVAROXABAN SWITCH
50. Following the procedure, the patient has been considered suitable for a switch to rivaroxaban. The patient’s latest CrCI was calculated to be 78ml/min.
Which of the following doses would you expect the patient to be switched to?

A

Answer: D {20mg once a day)

  • CrCI >50ml/min: 20mg
  • Manufacturer advises reduce dose to 15 mg once daily if creatinine clearance 15-49 ml/minute.
172
Q

BREAST CANCER INCREASES WITH CHC, otheres decrease

A

IMIPRAMIEN MOST ANTIMUSCARINIC

173
Q
  1. An 88-year-old woman has been identified as suitable candidate for a direct oral anticoagulant for the prophylaxis of recurrent pulmonary embolism. To aid compliance, she would prefer the medication to be taken once a day without the need for concomitant food consumption.
A

EDOXABAN

  • Rivaroxaban: The MHRA has received a small number of reports suggesting a lack of efficacy (thromboembolic events) in patients taking 15 mg or 20 mg rivaroxaban tablets on an empty stomach. Healthcare professionals are advised to remind patients to take rivaroxaban 15 mg or 20 mg tablets with food.
  • Apixaban dosing is twice a day and may affect compliance
174
Q

Sotalol?

A

Sotalol may prolong the QT interval, and it occasionally causes life threatening ventricular arrhythmias (important: manufacturer advises particular care is required to avoid hypokalaemia in patients taking sotalol—electrolyte disturbances, particularly hypokalaemia and hypomagnesaemia should be corrected before sotalol started and during use).

175
Q
A
176
Q

AVOID B-BLOCKER+VERAPAMIL

BRADYCARDIA RISK!

A
177
Q

AMIODARONE
ENZYME INHIBITOR
RAISED INR

A
178
Q

HF TEST

A

Brain natriuretic peptide

179
Q

IBS/IBD TEST?

A

Faecal calprotectin

180
Q

DOAC, crush+mix with water+apple?

A

Rivaroxaban

181
Q

rivaroxaban 15-49mL/min?

A

15mg DO

182
Q

QT PROLONGATION DRUGS

Long hearts make vets cut animals

A

Lithium /Haloperidol /Macrolides /Venlafaxine /Citalopram /Amiadorone

183
Q

Apixaban

DVT/PE general treatment?

A

10mg BD 7 days, 5mg BD maintain

184
Q

SITALGLIPTIN INTERSTITIAL LUGN DISEASE? OKEE

A
185
Q

NOT A SIDE-EFFECT OF NICOTINE PATCH?

A

SLEEPINESS! insomnia can coccur yikes

186
Q

WARFARIN+ST JOHN WORT?

A

ST JOHN WORT, INDUCER, LESS WARFARIN, CLOT, LETSS EFFECTIV!

187
Q

GTN TABS?

A

HYPOTENSION
TACHYCARDIA
HEADACHE
DIZZINESS

188
Q

METHOTREXATE+AMOX?

A

TOXICITY!

189
Q

METHADONE+DOMPERI?

A

QT TACHY?

190
Q

verapamil+dabigatran?

A

dose reduce DB?

191
Q

tramadol+dabigatran

A

no interaction

192
Q

BEST FIRST LIEN RATE CONTROL?

A

BISOPROLOL BOYO

193
Q

SIMVASTATIN+FIBRATE?

A

MAX 10MG!

194
Q

SIMVASTATIN MAX DOSING?

A

Manufacturer advises max. 10 mg daily with concurrent use of bezafibrate or ciprofibrate.

Manufacturer advises max. 20 mg daily with concurrent use of amiodarone, amlodipine, or ranolazine.

Manufacturer advises reduce dose with concurrent use of some moderate inhibitors of CYP3A4 (max. 20 mg daily with verapamil and diltiazem).

Manufacturer advises max. 40 mg daily with concurrent use of lomitapide or ticagrelor.

Manufacturer advises max. 20 mg daily with concurrent use of elbasvir with grazoprevir.

Manufacturer advises usual max. 20 mg daily with concurrent use of bempedoic acid or bempedoic acid with ezetimibe; max. dose 40 mg daily in patients with severe hypercholesterolaemia and at high risk of cardiovascular complications.

195
Q

pseudoephederine+phenelzine?

A

hypertensive crisis, 14 days MAOI gap, etc

196
Q

oxycodone?

A

cd 2

197
Q
A

B, 2.5mg

198
Q

FLOZIN, REDUCED RENAL?

A

CONSIDER ADDITIONAL DRUG

GLIPTIN BEST

199
Q

3 drugs to half digoxin dose with?

A

DAQ
Droanderone
Amiodarone
Quinine

200
Q

WHEN DO YOU TAKE DIGOXIN LEVEL???

A

6 HOURS AFTER!!!!

201
Q

rivaroxaban dose in surgery post?

A

10mg od

202
Q

GRAPEFRUIT JUICE DOES NOT INTERACT WITH?

A

WARFARIN!!

203
Q

HIGH INTENSITY STATINS?

A

ATORVASTATIN- 20MG, 40MG, 80MG

ROSUVASTATIN- 10MG, 20MG, 40MG

SIMVASTATIN- 80MG

204
Q

ALL DIURETICS CAUSE?

A

HYPONATARAMIEA+HYPOMAGNESAEMIA

205
Q

In type 1 diabetes, aim for a clinic blood pressure of 135/85 mmHg or less unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg or less

A

GPhC BNF (48 decks)

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