Cardiovascular

Question 1

When do thiazide and related diuretics lose effectiveness?

Answer 1

When CrCl is less than 30ml/min

Question 2

How long should anticoagulation be continued after a provoked and unprovoked DVT or PE?

Answer 2

provoked = 3 months (3 to 6 months for those with active cancer)

unprovoked = beyond 3 months (beyond 6 months for those with active cancer)

Question 3

What is the CrCl value in which you should AVOID each DOAC?

Answer 3

Apixaban, edoxaban and rivaroxaban - CrCl less than 15ml/min

Dabigatran - CrCl less than 30ml/min

Question 4

What is the dosage adjustment of edoxaban if CrCl between 15-50ml/min

Answer 4

30mg OD

Question 5

Missed dose advice with dabigatran

Answer 5

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.

Question 6

What patient characteristics could warrant the use of reduced dose of apixaban?

Answer 6

Age 80 years and over
body weight 60kg or less
Serum creatinine 133micromol/L or over

Question 7

What are common interactions of warfarin?

Answer 7

Cranberry juice
Pomegranate juice (increases INR)
Direct acting antivirals
Alcohol (decreases anticoagulant effect)
SSRIs and NSAIDs (severe, increased risk of bleeding)
Miconazole

Question 8

What are common interaction with statins?

Answer 8

Grapefruit juice
Amlodipine (increased risk of myopathy, max dose of 20mg simvastatin)
Clarithromycin

Question 9

Which statin is used with caution in Asians?
What adjustments can be made?

Answer 9

Rosuvastatin
use 5-20mg only, dose to be increased gradually

Question 10

What are the key side effects of nitrates?

Answer 10

flushing, headache, and postural hypotension

Question 11

How to avoid building tolerance to nitrates?

Answer 11

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.

Question 12

Counselling advice with short acting nitrates such as GTN?

Answer 12

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

Question 13

What medications can be prescribed for someone with stable angina?

Answer 13

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)

Question 14

What medication can be prescribed for treatment of stable angina if first-line meds not tolerated?

Answer 14

Long-acting nitrate, ivabradine, nicorandil or ranolazine.

Question 15

When should ivabradine be discontinued?

Answer 15

Resting heart rate below 50bpm
(monitor for bradycardia)

Question 16

What is normal heart rate?

Answer 16

60-100 beats per min

Question 17

What are common side-effects of calcium channel blockers?

Answer 17

Flushing
Peripheral oedema
Headaches
Dizziness
Gingival hyperplasia (uncommon)

Question 18

What is a key side-effect of nicorandil?

Answer 18

Can cause serious skin, mucosal and eye ulceration.

Can cause GI ulcers.

Stop treatment if ulceration occurs.

Question 19

What are the dose adjustments of ramipril in renal impairment?

Answer 19

Max daily dose 5mg if CrCl 30-60ml/min

Max initial dose is 1.25mg if CrCl is less than 30ml/min

Question 20

What are the 4 pillars of heart failure with reduced ejection fraction?

Answer 20

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)

Question 21

Which beta-blockers are licensed for heart failure?

Answer 21

Bisoprolol
Carvedilol
Nebivolol

Question 22

Which calcium channel blockers can be used if HF with reduced ejection fraction?

Answer 22

amlodipine

Question 23

What dosage adjustments need to be made if amiodarone and eplerenone are used together?

Answer 23

Amiodarone and inhibitors of CYP enzymes increase the exposure to Eplerenone, so the max dose will be 25mg OD

Question 24

What medications should be used as part of DAPT when patient has STEMI with primary PCI

Answer 24

Aspirin + prasugrel

Aspirin + clopidogrel if patient already taking oral anticoagulant

Question 25

What medication should be used for STEMI not treated with PCI?

Answer 25

Aspirin + ticagrelor

Aspirin + clopidogrel (if bleeding risk high)

Question 26

What medications should be offered for secondary prevention following MI?

Answer 26

ACEi/ARB
DAPT
Beta-blocker (rate-limiting CCBs can be used instead if not tolerated or no reduction in LVEF)
Statin

Question 27

What are the recommended doses of prasugrel?

Answer 27

5mg OD

10mg OD if body weight 60kg or more and the patient is under 75

Question 28

What are the recommended doses of ticagrelor?

Answer 28

90mg BD for upto 12 months

Reduced to 60mg BD if treatment extended beyond 12 months

Question 29

After a stroke or TIA, what antiplatelet treatment can be given when DAPT is not appropriate?

Answer 29

clopidogrel is given alone, 300 mg as an initial dose then 75 mg daily

Question 30

When do you use a max dose of simvastatin 20mg daily?

Answer 30

concurrent use of amiodarone, amlodipine, or ranolazine, verapamil and diltiazem

Question 31

What should you do with simvastatin if patient is also taking bezafibrate or ciprofibrate.

Answer 31

Manufacturer advises max. 10 mg daily

Question 32

What is a caution of all systemic beta-blockers?

Answer 32

Cautioned in diabetes, can mask the symptoms of hypoglycaemia

Question 33

Which class of diuretics can cause marked changed in plasma glucose and aggravate diabetes?

Answer 33

Thiazides and related diuretics.
Indapamide aggravates diabetes the least.

Loop diuretics can exacerbate diabates but to a much less degree.

Question 34

What type of diuretic is amioloride and triameterene?

Answer 34

potassium sparing - these are weak diuretics given alongside thiazide or loop diuretics