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GPhC Exam > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Ectopic beats treatment

A
  • ectopic beats are spontaneous - rarely need treatment
  • if treatment required - b-blockers
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2
Q

Atrial fibrillation treatment summary

A
  • stroke risk
  • ventricular rate or sinus rhythm control
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3
Q

Life threatening AF treatment

A
  • haemodynamic instability = emergency electrical cardioversion ASAP for anticoagulation
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4
Q

AF onset < 48 hours - acute treatment

A

rate OR rhythm control

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5
Q

AF onset > 48 hours - acute treatment

A

rate control

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6
Q

What is used for urgent rate control

A
  • IV b-blocker OR
  • verapamil LVEF > > 40 %
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7
Q

If cardioversion (rhythm control) agreed:

A
  • pharmacological = flecainide or amiodarone
  • electrical = IV anticoagulation to rule out left atrial thrombus
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8
Q

AF maintenance treatment

A
  1. rate control monotherapy - b-blocker (not sotalol) or RLCCB (digoxin - sedentary in non-paroxysmal)
  2. rate control dual therapy
  3. rhythm control - electrical or pharmacological cardioversion
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9
Q

AF > 48 hours - maintenance treatment

A
  • electrical preferred = risk of clotting so fully anticoagulated for at least 3 wks before and 4 wks after
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10
Q

Drug treatment post cardioversion

A

b-blocker OR 1 of:
Sotalol
Propafenone
Amiodarone
Flecainide

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11
Q

What is used with electrical cardioversion to improve success of procedure

A

amiodarone 4 wks before and up to 12 months after

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12
Q

Paroxysmal AF treatment

A
  1. ventricular rhythm control = b-blocker
  2. SPAF
    - episodes of symptomatic paroxysmal AF = ‘pill-in-pocket’ - felcainide/propafenone PRN on symptoms
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13
Q

CHA2DS2VASc score

A
  • congestive HF - 1
  • hypertension - 1
  • age 75+ - 2
  • diabetes - 1
  • stroke/tia - 2
  • vascular disease - 1
  • age 65-74 - 1
  • sex = female = 1
  • men > >1, women > >2 = thromboprophylaxis
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14
Q

Stroke risk treatment AF

A

DOAC in non-valvular AF or warfarin

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15
Q

Atrial flutter treatment

A
  • rate or rhythm control but less effective
  • rate control temporary until sinus rhythm restored = b-blocker or RLCCBS
  • rhythm control = direct current cardioversion for rapid control. pharmacological, catheter ablation for recurrent flutter
  • assess for stroke risk
  • anticoagulant for 3 weeks if flutter lasted > 48 hours
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16
Q

Paroxysmal supraventricular tachycardia treatment

A
  1. terminate spontaneously/alone - no tx
  2. reflex vagal stimulation - valsalva manoeuvre with ECG monitoring - face in ice cold water/carotid sinus massage
  3. IV adenosine
  4. IV verapamil
    - recurrent = catheter ablation, prophylaxis = b-blockers or RLCCBs
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17
Q

Ventricular tachycardia treatment

A
  • pulseless VT or VFib = resuscitation (ECG = random)
  • unstable sustained VT = direct current cardioversion - IV amiodarone - repeat current cardioversion
  • stable VT = IV amiodarone - direct current cardioversion not sustained VT = b-blocker
  • high risk cardiac arrest = maintenance = implantable cardioverter defibrillator, can add b-blocker alone or with amiodarone
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18
Q

Torsade de pointes (QT prolongation) treatment

A
  • drug induced or caused by hypokalaemia and severe bradycardia = amiodarone, sotalol, macrolides, haloperidol, SSRIs, TCAs, antifungals
  • self limiting but can be recurrent - impaired consciousness
  • if not controlled = Vfib = death
  • treat with IV magnesium sulfate
  • b-blocker (not sotalol) and atrial/ventricular pacing considered
  • no anti-arrhythmias = prolongs QT interval = worsens condition
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19
Q

Anti-arrhythmic drugs

A
  • classified into acting on: supraventricular arrhythmias, ventricular arrhythmias or both
  • also according to electrical behaviour:
    1. membrane stabilising drugs (lidocaine, flecainide)
    2. b-blockers
    3. amiodarone, sotalol
    4. RLCCBs ONLY - not ‘pines’
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20
Q

Warfarin and INR limits

A
  • INR 2.5 = VTEs, AF, cardioversion, MI, cardiomyopathy
  • INR 3.5 = recurrent VTEs or mechanical heart valves
  • major bleed = stop warfarin - IV phytomenadione & dried prothrombin
  • INR > 8, minor bleed - stop warfarin & IV vit K
  • INR > 8, no bleeding - stop warfarin & oral vit K
  • INR 5-8, minor bleed - stop warfarin & IV vit K
  • INR 5-8, no bleed - withhold 1-2 doses of warfarin
  • start warfarin when INR < 5
  • monitor INR every 1-2 days in early tx, then very 12 weeks
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21
Q

Warfarin MHRA warning

A

skin necrosis & calciphylaxis (painful skin rash)

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22
Q

Warfarin side effects

A
  • haemorrhage - vit K
  • teratogenic - avoid in 1st and 3rd trimester - use contraception
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23
Q

Warfarin interactions

A
  • vit K foods (leafy greens) - reverses warfarin
  • pomegranate and cranberry juice - increase INR
  • miconazole (OTC daktarin gel) - increases INR
  • CYP 450 inhibitors/inducers - increase/decrease warfarin conc
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24
Q

Warfarin and surgery

A
  • minor, low bleeding risk = INR < 2.5, warfarin restarted within 24 hours
  • risk of bleeding = stop warfarin 3-5 days before, INR <1.5 day before surgery (vit K to reduce), if high risk VTE bridge with LMWH - stop LMWH 24 hours before restart LMWH 48 hours after
  • emergency surgery = IV vit K and prothrombin complex, if can be delayed 6-12 hours - IV vit K alone
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25
Apixaban VTE dose
10mg BD for 7 days then 5mg BD
26
Apixaban AF dose
- 5mg BD - 2.5mg BD of 2 of: 80 yrs +, < < 60kg, CrCl > > 133 mol/L
27
Rivaroxaban VTE dose
15mg BD for 3 weeks then 20mg OD - with food
28
Rivaroxaban AF dose
20mg OD - with food
29
Dabigatran VTE dose
- 150mg BD aged 18-74 - 110-150mg BD aged 75-79 - 110mg BD aged 80+
30
Dabigatran AF dose
- 150mg BD aged 18-74 - 110-150mg BD aged 75-79 - 110mg BD aged 80+
31
Edoxaban VTE dose
- 60mg OD - 30mg OD if weigh <61kg
32
Edoxaban AF dose
- 60mg OD - 30mg OD if weigh <61kg
33
Amiodarone loading dose
200mg TDS for 7 days then BD for 7 days then OD maintenance
34
Amiodarone side effects
- reduce HR so avoid in bradycardia and heart block - corneal microdeposits - reversible - blurred/dazzled headlights - thyroid disorders - hypo/hyper due to iodine content - photosensitivity reactions - avoid sun, use sunscreen for months after tx ends - long t1/2 - hepatotoxicity - stop if jaundice, dark urine, abdo pain, NV, pale stools - pulmonary toxicity - SOB, cough
35
Amiodarone interactions
- long t1/2 = potential for months after ending - drugs that cause hypokalaemia, QT prolongation, bradycardia - b-blockers, RLCCBs - CYP substrates (amiodarone = inhibitor) - grapefruit (inhibitor) - warfarin, contraceptives, statins - 1/2 digoxin dose with amiodarone - digoxin = enzyme inhibitor
36
Amiodarone monitoring
- LFTs, TFTs - before tx, then 6 monthly - CXR - before tx, serum conc of K+ - before tx - annual eye examinations - IV use = ECG and liver transaminase - sofosbuvir, daclatasvir, simeprevir, ledipasvir = extreme monitoring, risk of severe heart block = fatal
37
Digoxin AF loading dose
- 125-250mcg OD - different formulations = different bioavailability
38
Digoxin therapeutic range
- 0.7 - 2.0 ng/ml - toxicity from 1.5 - 3.0 ng/ml - tx with digoxin-specific antibody (digifab) - levels 6 - 12 hours after dose, monitor electrolytes & renal function
39
Digoxin toxicity
bradycardia, SA/AV block, DV, dizziness, confusion, depression, blurred or yellow vision. Sick and slow
40
Digoxin interactions
- b-blockers = increased risk of AV block and increases in plasma concs - TCAs - can induce arrhythmias - drugs that cause hypokalaemia - increased risk of digoxin toxicity - CYP 450 inducers - reduces plasma concs - CYP 450 inhibitors - increases plasma concs
41
What is VTE
clot in vein - obstructs bloods flow
42
What is DVT
in legs or pelvis - unilateral localised pain or swelling
43
What is PE
in lungs - chest pain or SOB
44
Risk factors of VTE
surgery, trauma, immobility, malignancy, obesity, pregnant, COC, HRT
45
Diagnostic test for VTE
d-dimer
46
VTE prophylaxis
mechanical (stockings), or pharmacological (anticoags) - start within 14 hours of admission, VTE > bleed, ORBIT or HASBLED
47
VTE prophylaxis - surgery
- mechanical until mobile/discharged - pharmacological when VTE > bleed - LMWH suitable in all general and ortho surgeries - UFH in renal impairment - lower t1/2 than LMWH - fondaparinux for lower limb immobilisation or pelvis fragility fractures - at least 7 days post op, or until sufficient mobility - 28 days after cancer surgery in abdomen - 30 days after spinal surgery
48
VTE prophylaxis in elective hip replacement
- LMWH 10 days then 75mg aspirin 28 days OR - LMWH 28 days + stockings until discharge OR - rivaroxaban 10mg OD for 35 days
49
VTE prophylaxis elective knee replacement
- 75mg aspirin for 14 days OR - LMWH 14 days + stockings until discharge OR - rivaroxaban 10mg OD for 35 days
50
General medicine patients with increased risk of VTE
pharmacological prophylaxis for at least 7 days or mechanical until mobile
51
VTE prophylaxis in pregnancy
- if VTE > bleeding - LMWH during admission until no risk of VTE or discharged - birth/miscarriage/abortion in past 6 wks = LMWH 4-8 hours after event, min 7 days + mechanical if immobilised until mobile/discharged - Tx of VTE = LMWH; UFH if increased risk of haemorrhage
52
Proximal DVT or PE treatment
- apix or rivarox - 3 months min (3-6 months if active cancer) - if unsuitable = LMWH 5 days min then dabigatran or edoxaban OR LMWH + warfarin 5 days min or until INR > > 2 x 2 in a row then warfarin alone
53
Distal DVT treatment
- 6 weeks tx
54
Provoked DVT/PE treatment
- e.g. immobile/COC - stop at 3 months if provoking factor resolved
55
Unprovoked DVT/PE treatment
3 months +
56
Recurrent DVT/PE treatment
longterm
57
All heparins information
- avoid in heparin-induced thrombocytopenia - can cause hyperkalaemia - haemorrhage = tx with protamine sulfate - only effective for UFH
58
UFH information
- quick initiation & elimination - good for increased bleeding risk (monitor APTT) - increased risk of heparin induce thrombocytopenia - preferred in renal impairment
59
LMWH information
preferred in pregnancy
60
Bleeding disorders information
- bleeding disorder = cant stop blood from running (doesn't clot) - tx help formation of clots - tranexamic acid for surgeries, dental extraction, menorrhagia = GI, NV - desmopressin for mild-mod haemophilia and von willebrands disease
61
Haemorrhagic stroke management
- manage BP (will be very high) - avoid statins
62
Ischaemic stroke initial management
- initial = 300mg aspirin - TIA = 300mg daily until diagnosis established - ischaemic = 300mg for 14 days following alteplase within 4.5 hours
63
Ischaemic stroke long-term management
1. clopidogrel 75mg OD 2. dipyridamole MR and aspirin 75mg 3. dipyridamole MR or aspirin 75mg - start high intensity statin 48 hours after as troke - manage hypertension to achieve < 130/80 - DONT use b-blockers
64
Stage 1 hypertension targets
- 140/90 - 159/99 - clinic - 135/85 - 149/94 - ambulatory - tx if < 80 yrs with kidney disease, diabetes, CVD, or QRISK > 10 % - drug tx and lifestyle if < 60 yrs with QRISK < 10% - drug tx if > 80 yrs with BP over 150/90
65
Stage 2 HTN targets
- 160/100 - 180/120 - clinic - > 150/95 - ambulatory - tx all
66
Stage 3 HTN targets
- > 180/120 - medical emergency
67
HTN treatment <55 yrs or T2DM
1. ACEi or ARB 2. & CCB or TLD 3. ACEi/ARB + CCB + TLD 4. K+ < 4.5 = spiro, K+ > 4.5 = a or b-blocker
68
HTN treatment > 55 year or afro-carribbean
1. CCB 2. & ACEi or ARB 3. ACi/ARB + CCB + TLD 4. K+ < 4.5 = spiro, K+ > 4.5 = a or b-blocker - ARB in black, ACEi in diabetes, black and diabetes = ARB
69
HTN in pregnancy treatment
- high risk of pre-elampsia if kidney disease, diabetes, autoimmune disease - aspirin from week 12 until birth - if BP > 140/90: 1. labetolol - avoid in asthma 2. nifedipine - avoid in HF 3. methyldopa - stop 48 hours after birth - BP target = 135/85 - clinical
70
BP Targets
- age < 80 = 140/90 (clinical) - age > 80 = 150/90 (clinical) - renal disease = 140/90 (clinical) - pregnancy = 135/85 (clinical) - diabetes = 140/90 - diabetes + > 80 years = 150/90 - diabetes + kidney disease = 130/80
71
ACEi side effects
- Cough (ARB instead) - Hyperkalaemia - Hepatic impairment - Angioedema - Renal impairment - Dizziness & headaches CHHARD
72
ARB side effects
same side effects as ACEi (CHHARD) except cough and angioedema
73
ACEi/ARB interactions
- increased risk of renal failure - ARBs, K+ sparing diuretics, NSAIDs - hyperkalaemia - heparins, NSAIDs, Ksparing diuretics, b-blockers - risk of volume depletion - diuretics - increased plasma levels of lithium
74
Cardioselective b-blockers
- less likely to cause bronchospasms (better in asthma) - Bisoprolol - Atenolol - Metoprolol - Acebutolol - Nebivolol - BAtMAN
75
Water soluble b-blockers
- less likely to cross BBB = less nightmares - Celiprolol - Atenolol - Nadolol - Sotalol - water CANS
76
Intrinsic sympathomimetic b-blockers
- less likely to cause cold extremities - Pindolol - Acebutolol - Celiprolol - Oxprenolol - Ice PACO
77
b-blockers side effects
- bradycardia or HF - blunts effects of hypoglycaemia (palpitations, tremors, sweating) - can cause hyperglycaemia - bronchospasm - contraindicated in asthma
78
b-blockers interactions
- digoxin, Amiodarone - heart block/bradycardia - any other hypotensive drugs
79
Dihydropyridine CCBs
amlodipine, felodipine, lacidopine, lercanidipine, nifedipine
80
Rate limiting CCBs
diltiazem, verapamil
81
CCBs side effects
- dizziness - gingival hyperplasia - vasodilatory effects (flushing, headaches, ankle oedema) - more in dihydropyridines - complete AV block - more in RLCCBs
82
Cholesterol level ranges
- total cholesterol = 5 or below - HDL (good) = 1 or above - LDL (bad) = 3 or below - non-HDL (bad) = 4 or below - triglycerides = 2.3 or below
83
Lipid lowering agents offered in:
- under 85 with QRISK > 10% - T2DM with QRISK > 10% - T1DM with age > 40, diabetes for > 10 years, established nephropathy - CKD - familial hypercholesterolaemia
84
Statins names and administration time
- atorvastatin, rosuvastatin = anytime - simvastatin, fluvastatin, pravastatin = at night - cholesterol produced at night - atorvastatin 80mg = strongest = 2ndary prevention
85
Statins monitoring
- rule out thyroid disorders - if hypo = manage before statin initiation - high risk of diabetes = FBG or HbA1c before statin initiation - repeat after 3 months - before initiation = LFTs, TFTs, renal, full lipid profile - LFTs before, 3 months, 12 months - stop if 3x UL - CK if muscle pain - 5xUL = remeasure in 7 days, if still 5xUL = don't start, if raised but not 5xUL = statin at lower dose
86
Statins interactions
- CYP 450 inducers - reduce concentration of statins - CYP 450 inhibitors - increase conc of statins = rhabdomyolysis - macrolides = hold statin - grapefruit juice - oral fusidic acid = hold statin and restart 7 days after last dose
87
CYP 450 enzyme inducers
- Carbamazepine - Rifampicin - Alcohol - Phenytoin - Griseofulvin - Phenobarbital - St Johns Wort
88
CYP 450 enzyme inhibitors
- Sodium valproate - Isoniazid - Cimetidine - Ketoconazole - Fluconazole - Alcohol - Chloramphenicol - Eryhtro/clarithromycin - Sulfonamides - Ciprofloxacin - Omeprazole - Metronidazole - Grapefruit - Amiodarone - Verapamil - Itraconazole - Diltiazem
89
Statins side effects
- myopathy and rhabdomyolysis = muscle toxicity = medical advice - interstitial lung disease = med attention if dyspnoea, cough, weight loss - teratogenic = stop 3 months before conceiving
90
Max doses of statins
- amiodarone/amlodipine/RLCCBs + simvastatin = 20mg - ticagrelor + simvastatin = 40mg - ciclosporin + atorvastatin = 10mg - tipranavir + atorvastatin = 10mg
91
Other lipid lowering agents
- ezetimibe or fibrates (bezafibrate, ciprofibrate, fenofibrate, gemfibrozil) - dont give either with statin - risk of rhabdomyolysis - fibrates = myotoxicity in renal impairment - fibrates = LFTs every 3 months for first year
92
What is myocardial ischaemia
- build up of atherosclerotic plaques = restrict arteries = lowers blood and oxygen to the heart - stable angina - ACS (unstable angina, NSTEMI, STEMI)
93
Stable angina initial treatment
- predictable chest pain or pressure due to physical exertion or emotion - prophylactically or when symptoms arise - GTN dose at 5 minute intervals - 999 after 3rd dose
94
Stable angina long term prevention
1. b-blocker (RLCCBs if bb contraindicated - never together) 2. b-blocker + CCB ('pines') 3. long acting nitrate, nicorandil, ivabradine or ranolazine - nicorandil = GI and mucosal ulceration - implement healthy life style and introduce 75mg aspirin and low dose statin
95
Nitrates key information
- GTN sublingual tabs = discard 8 wks after opening bottle - nitrate free period to prevent tolerance - 2nd dose after 8 hours not 12 - transdermal = leave off for 8-12 hours a day - side effects = dizziness, flushing, headaches, risk of falls
96
ACS risk factors
- family history - hypertension - hypercholesterolaemia - diabetes - smoking
97
ACS initial Management
- aspirin 300mg stat, pain relief - GTN +/- IV morphine, oxygen if needed - test result to determine type of ACS - PCI for STEMI within 2 hours - heparin if done through radial access
98
What is unstable angina and NSTEMI
- partial blockage of artery (myocardial necrosis in NSTEMI) - NSTEMI = ST not elevated
99
What is STEMI
- complete blockage of artery = myocardial necrosis - ST elevated
100
Secondary prevention for all ACS
- DAPT - lifelong aspirin, 12 months of either clopi, prasugrel, ticagrelor. Prasugrel preffered for STEMI - ACEi - ARB if contraindicated - Statin - atorvastatin 80mg - B-blocker - stopped after 12 months if reduced LV ejection fraction - if NSTEMI - consider PCI to prevent future MI - assess risk of HF
101
Heart failure symptoms
SOB, persistent coughing, wheezing, ankle swelling, reduced exercise, fatigue, multiple pillows
102
Heart failure treatment
1. ACEi (ARB if CI) + b-blocker - titrate both up alt: hydralazine + nitrate if not tolerated 2. & aldosterone antagonist - spiro/eplerenone 3. & amiodarone, digoxin, sac+val, ivabradine or dapagliflozin (dapa = water loss) - digoxin if sinus rhythm worsening or severe HF - digoxin loading dose in HF = 62.5 - 125 mcg OD - loop diuretics to relieve SOB and oedema in fluid retention
103
What is oedema
water retention in system = pulmonary (lungs) or peripheral (rest of body e.g. ankle) oedema
104
Thiazide diuretics key information
- bendroflumethiazide, indapamide - inhibits sodium reabsorption at beginning of distal convoluted tubule - long half life - give early to avoid sleep disturbance
105
Loop diuretics key information
- furosemide, bumetanide, toresamide - preferred over thiazide if prone to urinating through night - inhibits reabsorption from ascending limb of loop of henle - in pulmonary oedema due to left ventricular failure - last 6 hours so can be given BD w/o interfering sleep
106
Potassium sparing diuretics key information
- amiloride, triamterene (blue urine) - prevents sodium reabsorption in the distal convoluted tubule collecting duct - hyperkalaemia - dont take K+ supplements - aldosterone antagonists ( a type of K+ sparing diuretics) = spiro/eplerenone. Inhibit potassium secretion in distal tubule collecting duct. Stop if dehydrated due to vomit and/or diarrhoea
107
All diuretics side effects
- hyponatraemia - hypomagnesaemia
108
Loop and thiazide diuretics side effects
- hypokalaemia - exacerbate diabetes - loop only - exacerbates gout - hypotension
109
Potassium sparing diuretics side effects
- hyperkalaemia - change in libido - breast pain or tenderness
110
Diuretics side effects
- loop and thiazide = hypokalaemia inducing drugs - K+ sparing = hyperkalaemia inducing drugs - Loop and aminoglycosides = nephro and oto - toxicity - spiro/loop + lithium = reduced lithium secretion = lithium toxicity
111
Occlusive peripheral vascular disease key information
- normally caused by atherosclerosis - reduced risk with healthier lifestyle , statins and antiplatelets
112
Vasospastic peripheral vascular disease (Raynaud's) key information
- bad circulation to extremities - avoid exposure to cold - smoking cessation - further tx = nifedipine
113
Which beta-blocker has a long duration of action
nadolol
114
What drug class is metolazone
thiazide-like diuretic
115
Rivaroxaban administration post hip replacement
10mg OD for 35 days
116
INR level if switching from warfarin to apixaban
<2
117
Which drugs increase the risk of QT interval prolongation when given with sotalol
- haloperidol - citalopram
118
Perindopril administration directions
30 - 60 minutes before food
119
Reye's syndrome symptoms
- vomiting - seizures - increased white cell count - increased LFTs - delirium - lack of energy - irritability - aggression - coma
120
Lifestyle measure to reduce BP
- restrict salt intake to 6g per day - 30 minutes exercise 5x week - healthy diet including 5 fruit or veg per day
121
Max dose of ramipril when eGFR 30-60
5mg
122
What is ticagrelor not licensed with
- aspirin AND low dose rivaroxaban together - licensed with aspirin alone
123
Which PPI is the least suitable with clopidogrel
- omeprazole and esomeprazole
124
How long should ramipril be taken before the response is determined
4 weeks
125
Which drugs increase the risk of gout
diuretics
126
Dipyridamole MR capsules key information
- keep in original container - discard 6 weeks after opening
127
Is warfarin okay to use whilst breastfeeding
yes
128
Which diuretic can be given BD without risking interfering with sleep
furosemide
129
Which drugs can cause secondary hypertension
- ciclosporin - leflunomide - NSAIDs
130
Which drug is not known to cause secondary hypertension
progesterone only pill

GPhC Exam (22 decks)

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