Cardiovascular Flashcards
what are the symptoms of AF?
papitations
pounding/ fluttering
dizziness
SOB
tiredness
what are the three types of AF?
paroxysmal AF - episodes stop within 48 hours
persistent AF - episodes last > 7 days
permanent AF
what is the treatment for life threatening haemodynamic instability in AF?
electrical cardioversion
what treatment should be offered to patients who present with acute AF within the first 48 hours?
rate (beta blocker or rate limiting CCB)
AND
rhythm control (flecanide or amiodarone)
what treatment should be offered to patients who present with acute AF after 48 hours?
rate control
what are the treatment options for rate control?
beta-blocker (not sotalol)
rate limiting CCB (diltiazem or verapamil)
digoxin (non paroxysmal AF who are sedentary) (AF with congestive HF)
what are the treatment options for rhythm control?
beta blocker (not sotalol)
amiodarone, flecainide, propafenone, sotalol
what is the pill in the pocket approach and when can it be used?
used for patients with symptomatic paroxysmal AF
flecainide or propafenone
what is the treatment step process to managing AF?
rate control - monotherapy
rate control - dual therapy
rhythm control
what two tools are used to guide stroke prevention in AF?
CHA2DS2-VASc
ORBIT
what CHA2DS2-VASc score is required to offer stroke prevention?
All patients with a score of 2
Men with a score of 1
what drugs can be offered to patients who need stroke prevention in AF?
DOAC - non-valvular AF
Warfarin - valvular or DOAC not appropriate
what are the treatment options for paroxysmal supraventricular tachycardia?
1st spontaneous termination or reflex vagal nerve stimulation
2nd IV adenosine
3rd IV verapamil
Prevention: beta blockers or rate limiting CCBs
how do you treat torsade de pointes?
IV magnesium sulfate
beta blocker (not sotalol)
what are the causes of torsade de pointes?
sotalol and other drugs causing QT prolongation
hypokalaemia
bradycardia
what are the classes of anti-arrhythmics?
Class I: membrane stabilising (lidocaine, flecainide)
Class II: beta blockers (not sotalol)
Class III: Amiodarone, sotalol
Class IIII: CCBs (verapamil and diltiazem)
what is the loading dose for amiodarone?
200mg TDS for 7 days
200mg BD for 7 days
200mg OD thereafter
what are the side effects of amiodarone?
corneal microdeposits - night time glares when driving
optic neuropathy - STOP if vision impaired
phototoxicity - skin burns (use high SPF)
slate grey skin
peripheral neuropathy
pulmonary fibrosis
hepatotoxicity
thyroid (hyper and hypo)
what monitoring is required for amiodarone?
eye tests annually
chest x ray before treatment
LFTs 6 monthly
TFTs before and 6 monthly
BP and ECG
Serum potassium
which of the following does not interact with amiodarone?
grapefruit juice
warfarin
morphine
simvastatin
clarithromycin
morphine
grapefruit juice - enzyme inhibitor
warfarin - amiodarone is enzyme inhibitor
simvastatin - risk of myopathy
clarithromycin - QT prolongation
what is the therapeutic target level of digoxin?
1-2 mcg/L
what digoxin level is associated with an increased risk of toxicity?
1.5-3 mcg/L
what are the symptoms of digoxin toxicity?
hypokalaemia
hypercalcaemia
bradycardia/ heart block
nausea, vomiting, diarrhoea, abdo pain
blurred/ yellow vision
confusion
rash
what is the treatment for digoxin toxicity?
digoxin specific antibody
what effect do enzyme inhibitors have on digoxin?
increase plasma concentration, leading to toxicity
what effect do enzyme inducers have on digoxin?
reduce plasma concentrations, leading to subtherapeutic doses
what test can be used to diagnose a thromboembolism?
D-dimer
what are the DOACs?
edoxaban, rivaroxaban, apixaban, dabigatran
what are the reversal agents for the DOACs?
andexanet alfa - for apixaban and rivaroxaban
idarucizumab - for dabigatran
edoxaban has no reversal agent
which of the DOACs require an initial loading dose of a LMWH before treatment for confirmed PE/DVT?
dabigatran and edoxaban
which DOAC must be taken with food?
rivaroxaban (15mg and 20mg)
how long does warfarin take to act?
48-72 hours
what is the monitoring requirements for warfarin?
INR every 3 months once stable
what is the MHRA alert for warfarin?
calciphylaxis - painful skin rash
what are the warfarin targets?
2-3 - AF, VTE, MI
3-4 - recurrent VTE, valvular AF
what should be done if a patient presents with an INR of 5-8 and no bleeding?
withhold 1-2 doses
reduce maintenance dose
measure INR after 2-3 days
what should be done if a patient presents with an INR > 8 and no bleeding?
omit warfarin
oral phytomenadione
repeat if INR still high after 24 hours
restart warfarin when INR < 5
what should be done if a patient presents with an INR > 5 with bleeding?
omit warfarin
IV phytomenadione
repeat if INR still high after 24 hours
restart warfarin when INR < 5
what treatment options are available for stable angina?
Acute angina attacks:
Short acting nitrates - (1st GTN, 2nd isosorbide dinitrate)
Long term prophylaxis:
1st beta-blockers (atenolol, bisoprolol, metoprolol, propranolol)
2nd BB + CCBs (verapamil, diltiazem)
3rd Ivabradine, Ranolazine, Nicorandil, MR isosorbide dinitrate, isosorbide mononitrate
what formulations does GTN come as?
sublingual spray and tablets
(tablets must be discarded after 8 weeks)
how and when should you take GTN, and when should you escalate care?
when required OR before angina-inducing activities
take sitting down as dizziness can occur, under tongue, 1 dose is 1 tablet or 1-2 sprays
1st dose and wait 5 MINS,
2nd dose and wait 5 MINS,
3rd dose and wait 5 MINS,
if pain still present, CALL 999
what is the risk with nicorandil?
ulcers (mouth, skin, eyes, GI)
what is the risk with long acting nitrates which requires specific administration timings?
risk of tolerance
leave patches off for 8-12 hours
take second dose after 8 hours not 12 hours (MR isosorbide dinitrate and isosorbide mononitrate)
MR isosorbide mononitrate is take OD
what is the side effects of nitrates?
flushing, throbbing headache, dizziness, postural hypotension, tachycardia, dyspepsia, heartburn
what three things come under ACS and how do you differentiate between them?
unstable angina - symptoms
NSTEMI - increased troponin but no ST elevation
STEMI - increased troponin and ST elevation
how should ACS be initially managed?
aspirin 300mg
GTN with/ without morphine
oxygen if needed
if a patient has a STEMI, what treatment should be offered?
PCI within 2 hours
*PCI can be considered in NSTEMI
what secondary prevention medications would be appropriate following an NSTEMI/ STEMI?
DAPT - Aspirin lifelong with clopidogrel, prasugrel, ticagrelor for 12 months
ACE/ ARB
BB (12 months if reduced LVEF)
Statin
GTN
how should you manage a stroke?
alteplase within 4.5 hours
aspirin 300mg daily for 14 days
how should you manage a TIA?
aspirin 300mg daily
what is the long term treatment of stroke?
1st clopidogrel
2nd MR dipyridamole + aspirin
3rd MR dipyridamole OR aspirin
patients presenting to clinic with a BP over what need to perform ABPM?
> 140/90
what is stage 1 hypertension?
140/90 - 160/100 (clinic)
135/85 - 150/95 (ABPM)
what is stage 2 hypertension?
160/100 - 180/120 (clinic)
> 150/95 (ABPM)
what is stage 3/ severe hypertension?
180/120
when would you treat patients with stage 1 hypertension?
if <80 with CKD, diabetes, CVD or 10% CVD risk in 10 years
what is the target BP for patients under 80?
140/90 (clinic)
135/85 (ABPM)
what is the target BP for patients over 80?
150/90 (clinic)
145/ 85 (ABPM)
what is the target BP if a patient is pregnant?
135/85
what is the target BP if a patient has a high risk of CVD or target organ damage?
135/85
what is the treatment step pathway for patients with hypertension who are < 55 years and/ or T2DM?
1st ACE/ARB
2nd + CCB/ TLD
3rd ACE/ARB + CCB + TLD
4th spironolactone (K<4.5) OR alpha/ beta blocker (K>4.5)
what is the treatment step pathway for patients with hypertension who are < 55 years and/ or afro-carribean?
1st CCB
2nd + ACE/ ARB OR TLD
3rd ACE/ARB + CCB + TLD
4th spironolactone (K<4.5) OR alpha/ beta blocker (K>4.5)
is an ACE or ARB preferred in afro-carribean patients?
ARB
If a CCB is not tolerated due to oedema, what should be offered instead?
TLD
If starting on a diuretic for hypertension, which is preferred?
thiazide like diuretic (indapamide) as opposed to a thiazide type diuretic
which conditions increase a woman’s risk of pre-eclampsia during pregnancy?
diabetes
hypertension
CKD
what treatment should be offered to women who are at increased risk of developing pre-eclampsia?
aspirin from week 12
what treatment options are available for treating hypertension in pregnancy?
1st labetalol
2nd nifedipine
what time should you take your first dose of an ACE?
bedtime
which of the ACE is taken BD?
captopril
which of the ACE needs to be taken 30-60 minutes before food?
perindopril
what are the side effects of ACEs?
dry cough
hyperkalaemia
angioedema
hepatic effect (cholestatic jaundice, hepatic failure)
renal impairment
which of the beta blockers have intrinsic sympathomimetic activity, and what benefit does this have?
Acebutolol
Pindolol
Celiprolol
these BBs cause less bradycardia and less coldness of extremities
Acebutolol Prevents Coldness
which of the beta blockers are water soluble, and what benefit does this have?
Atenolol
Celiprolol
Sotalol
Nadolol
these BBs are less likely to cross the BBB and therefore less likely to cause nightmares and sleep disturbances
these BB are renally cleared, and may need dose reductions in renal impairment
Atenolol Can Stop Nightmares
which of the beta blockers are cardioselective, and what benefit does this have?
Bisoprolol
Atenolol
Metoprolol
Acebutolol
Nebivolol
these BBs cause less bronchospasm and can be used in asthmatics if no other choice
B A MAN
which of the beta blockers have intrinsically longer duration of action?
Bisoprolol
Atenolol
Celiprolol
Nadolol
these BBs have once daily dosing
BACoN
which of the CCB requires the same brand prescribed?
nifedipine (modified release)
diltiazem (doses > 60mg)
what are the side effects of CCBs?
gingival hyperplasia
ankle swelling
flushing
headache
what treatments are available for hypotension and shock?
noradrenaline
phenylephrine (longer acting)
which CCBs should be avoided in HF?
verapamil and ditiazem
which BBs are licensed for HF?
bisoprolol, carvedilol, nebivolol
which ARBS are licensed for HF?
candesartan, losartan, valsartan
which diuretics are first line for patients with HF who have breathlessness and/or oedema?
loop diuretics
what is the treatment pathway for HF?
ACE + BB (titrate low and slow) *
aldosterone antagonist (spironolactone/ eplerenone)
amiodarone, digoxin, entresto, ivabradine, dapagliflozin
*ARB if ACE not tolerated
*hydralazine + nitrate if ACE/ARB not tolerated
what is the monitoring requirements for HF patients?
initiating ACE/ARB/MRNA:
potassium and sodium, renal function, and BP before, 1-2 weeks after starting and after each dose increase, monthly for 3 months, then 6 monthly thereafter
initiating BB:
HR and BP before and after dose increases
define hyperlipidaemia?
> 6 mmol/L total cholesterol
what are the lipid targets for hyperlipidaemia?
Total cholesterol < 5
Non - HDL < 4
LDL < 3
Triglycerides < 2
HLD > 1
which statins do not need to be taken at night?
atorvastatin
rosuvastatin
which of the statins are high intensity statins?
Atorvastatin: 20mg, 40mg, 80mg
Rosuvastatin: 10mg, 20mg, 40mg
Simvastatin: 80mg
what is the MHRA alert for simvastatin?
high dose simvastatin (80mg) has increased risk of myopathy
what are the side effects of the statins?
myopathy, myositis, rhabdomyolysis, interstitial lung disease, diabetes
why should hypothyroidism be resolved prior to commencing a statin?
increased risk of muscle toxicity
what are the monitoring requirements of statin treatment?
baseline lipids
renal function
TFTs
HbA1c
what is first line for hyperlipidaemia?
statins
what is second line for hyperlipidaemia?
ezetimibe
what other options are available for hyperlipidaemia?
fibrates (fenofibrate)
bile acid sequestrants (colestyramine)
what are the two types of vascular disease?
occlusive peripheral - statins + antiplatelets
vasospastic peripheral (raynauds) - nifedipine
