Cardiovascular Flashcards
When do thiazide and related diuretics lose effectiveness?
When CrCl is less than 30ml/min
How long should anticoagulation be continued after a provoked and unprovoked DVT or PE?
provoked = 3 months (3 to 6 months for those with active cancer)
unprovoked = beyond 3 months (beyond 6 months for those with active cancer)
What is the CrCl value in which you should AVOID each DOAC?
Apixaban, edoxaban and rivaroxaban - CrCl less than 15ml/min
Dabigatran - CrCl less than 30ml/min
What is the dosage adjustment of edoxaban if CrCl between 15-50ml/min
30mg OD
Missed dose advice with dabigatran
If a dose is more than 6 hours late, the missed dose should not be taken and the next dose should be taken at the normal time.
What patient characteristics could warrant the use of reduced dose of apixaban?
Age 80 years and over
body weight 60kg or less
Serum creatinine 133micromol/L or over
What are common interactions of warfarin?
Cranberry juice
Pomegranate juice (increases INR)
Direct acting antivirals
Alcohol (decreases anticoagulant effect)
SSRIs and NSAIDs (severe, increased risk of bleeding)
Miconazole
What are common interaction with statins?
Grapefruit juice
Amlodipine (increased risk of myopathy, max dose of 20mg simvastatin)
Clarithromycin
Which statin is used with caution in Asians?
What adjustments can be made?
Rosuvastatin
use 5-20mg only, dose to be increased gradually
What are the key side effects of nitrates?
flushing, headache, and postural hypotension
How to avoid building tolerance to nitrates?
Transdermal patches they should be left off for 8–12 hours (usually overnight) in each 24 hours
Modified release and conventional preparations - second dose should be given after 8 hours (instead of 12).
These aim to increase the nitrate free interval.
Counselling advice with short acting nitrates such as GTN?
to repeat the dose after 5 minutes if the pain has not gone
to call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose
When using GTN spray sit down as dizziness can occur, spray under tongue and mouth should be closed immediately after
What medications can be prescribed for someone with stable angina?
Short acting nitrates to manage acute attacks
Drugs for secondary prevention of CVD (aspirin 75mg daily, ACEi, statins)
For long term prevention of chest pains in angina: beta-blocker or CCB (rate-limiting or dihydropyridines)
What medication can be prescribed for treatment of stable angina if first-line meds not tolerated?
Long-acting nitrate, ivabradine, nicorandil or ranolazine.
When should ivabradine be discontinued?
Resting heart rate below 50bpm
(monitor for bradycardia)
What is normal heart rate?
60-100 beats per min
What are common side-effects of calcium channel blockers?
Flushing
Peripheral oedema
Headaches
Dizziness
Gingival hyperplasia (uncommon)
What is a key side-effect of nicorandil?
Can cause serious skin, mucosal and eye ulceration.
Can cause GI ulcers.
Stop treatment if ulceration occurs.
What are the dose adjustments of ramipril in renal impairment?
Max daily dose 5mg if CrCl 30-60ml/min
Max initial dose is 1.25mg if CrCl is less than 30ml/min
What are the 4 pillars of heart failure with reduced ejection fraction?
ACEi/ARB (max tolerate dose, titrate quick)
Beta-blocker (‘start low, go slow’)
MRAs e.g. spironolactone or eplerenone
SGLT2i
+Loop diuretics for sympotamtic relief (oedema)
Which beta-blockers are licensed for heart failure?
Bisoprolol
Carvedilol
Nebivolol
Which calcium channel blockers can be used if HF with reduced ejection fraction?
amlodipine
What dosage adjustments need to be made if amiodarone and eplerenone are used together?
Amiodarone and inhibitors of CYP enzymes increase the exposure to Eplerenone, so the max dose will be 25mg OD
What medications should be used as part of DAPT when patient has STEMI with primary PCI
Aspirin + prasugrel
Aspirin + clopidogrel if patient already taking oral anticoagulant
What medication should be used for STEMI not treated with PCI?
Aspirin + ticagrelor
Aspirin + clopidogrel (if bleeding risk high)
What medications should be offered for secondary prevention following MI?
ACEi/ARB
DAPT
Beta-blocker (rate-limiting CCBs can be used instead if not tolerated or no reduction in LVEF)
Statin
What are the recommended doses of prasugrel?
5mg OD
10mg OD if body weight 60kg or more and the patient is under 75
What are the recommended doses of ticagrelor?
90mg BD for upto 12 months
Reduced to 60mg BD if treatment extended beyond 12 months
After a stroke or TIA, what antiplatelet treatment can be given when DAPT is not appropriate?
clopidogrel is given alone, 300 mg as an initial dose then 75 mg daily
When do you use a max dose of simvastatin 20mg daily?
concurrent use of amiodarone, amlodipine, or ranolazine, verapamil and diltiazem
What should you do with simvastatin if patient is also taking bezafibrate or ciprofibrate.
Manufacturer advises max. 10 mg daily
What is a caution of all systemic beta-blockers?
Cautioned in diabetes, can mask the symptoms of hypoglycaemia
Which class of diuretics can cause marked changed in plasma glucose and aggravate diabetes?
Thiazides and related diuretics.
Indapamide aggravates diabetes the least.
Loop diuretics can exacerbate diabates but to a much less degree.
What type of diuretic is amioloride and triameterene?
potassium sparing - these are weak diuretics given alongside thiazide or loop diuretics
