Cardiovascular Flashcards
Treatment for ectopic beats
Nothing generally, as they are spontaneous beats. If particularly troublesome, patient can have a beta blocker
What are the three types of AF?
Paroxysmal (episodes stop within 48h of treatment),
Persistent (episodes >7 days),
Permanent (present all the time)
When managing patients on rate control treatment for AF, which rate are we controlling? Atrial or ventricular
Ventricular
How often do you review the stroke and bleeding risk for AF patients?
Annually
How do you manage a patient with new onset AF (haemodynamic instability i.e. rapid pulse BP dizziness unconscious etc)) within 48h?
Electrical cardioversion
How do you manage a patient with AF where they don’t have haemodynamic instability (i.e., non urgent) in primary care?
Rate controlled preferred (beta blocker other than sotalol or a rate limiting calcium channel blocker)
Who is digoxin preferred in? This is also a reason why we don’t use it in most people
Sedentary patients as it can only control the ventricular rate at rest
Give examples of rate limiting CCBs
Verapamil and diltiazem
Give examples of non DHP CCBs
Verapamil and diltiazem also (dihydropyridines are amlodipine and nifedIPINE think PINE) so non DHP= rate limiting
What drugs do you give for non-electrical cardioversion?
Antiarrhythmics like flecainide, propafenone, amiodarone
What happens with driving when you have been diagnosed with AF?
group 1 (cars, moroecycles) - controlled for 4 weeks,
group 2 (lorries, buses) - controlled for 3 months
How long is the wait for a follow up after initiation of rate control?
1 week- patients should be monitored for symptoms, how they tolerate the drug, HR and BP
If you have had AF onset for >48 hours and are going to have a cardioversion, is electrical or pharmacological preferred?
Electrical CV is preferred over pharmacological when it has been <48h
How long should a patient be anticoagulated for before a cardioversion?
Three weeks, if this is not possible parenteral anticoagulation should be commenced and left atrial thrombus ruled out immediately
How long should a patient have oral anticoagulation post cardioversion?
4 weeks
What treatment do you give for rate control?
A standard beta blocker (but not sotalol)
What happens when monotherapy fails to control the ventricular rate?
Add another therapy such as: beta blocker, diltiazem or digoxin.
What happens if this dual therapy fails to control VR?
If this does not control it then a rhythm control method should be considered
Digoxin is also used when a patient has ……… co-morbidity
Congestive heart failure
Post cardioversion, if a drug is required to maintain sinus rhythm that is used?
Normally a standard beta blocker, but if not appropriate or effective consider an oral anti-arrhythmic such as sotalol, flecainide, propafenone, amiodarone, dronedarone
Sometimes, amiodarone is given post cardioversion to help the success of it, if used for this indication how long should it be prescribed for?
4 weeks before and continued for 12 months after as it increases success of procedure
Which two drugs cannot be given in known structural or ischaemic heart disease?
Flecainide or propafenone
What is the MHRA alert with sotalol?
Prolongs QT interval and causes life threatening ventricular arrhythmias- also be careful of hypokalemia
What class of antiarrhythmic is sotalol?
Class 2 and 3
When is dose adjustment recommended regarding renal function for sotalol?
60ml/min
What are the different classes of antiarrhythmics?
1- membrane stabilising =lidocaine, flecainide, propafenone
2- beta blockers =propranolol, sotalol
3- potassium channel blockers =sotalol, amiodarone, dronedarone
4- Non DHP CCBS =verapamil, diltiazem
For ‘pill in the pocket’ what drugs can be given for paroxysmal AF?
Flecainide or propafenone NB: cannot take >2 doses in 24h
What does CHADSVASC stand for?
Chronic heart failure
Hypertension
Age 75+ (2 points)
Diabetes
Stroke/TIA/VTE Hx (2 points)
Vascular disease
Age 65-74 years
Sex category (1 point for female)
When would we consider anticoagulation with CHADSVASc?
Men with 1 point or females with 2
What drug would you give alongside CPR and defib with ventricular tachycardia?
IV amiodarone
List the three drugs which are antiarrhythmics which cover atrial, ventricular and both
Ventricular = lidocaine (L for lower),
Amiodarone= ventricular and atrial,
Verapamil= atrial
What is Torsade de Pointes?
A form of ventricular tachycardia with QT prolongation. NB: if not treated this can move to ventricular fibrillation and death
Which electrolyte can cause torsade de pointes?
Hypokalaemia
How do you treat torsade de pointes?
IV magnesium
Which drug do you avoid in this condition (torsade de pointes)?
Antiarrhythmics as prolongs the QT interval further
List some drugs which cause QT prolongation
Tramadol, opioids, macrolides, SSRIs, antiarrhythmics, quinolones, antimuscarinics, ondansetron, lithium, sildenafil
What is the MHRA alert with amiodarone?
When taken with sofosbuvir and combination of other antivirals- risk of severe bradycardia and heart block when taken with amiodarone
What is the loading dose for amiodarone?
200mg TDS 7/7
200mg BD 7/7
200mg OD continued
Amiodarone side effects
EYES: corneal microdeposits AND optic neuropathy
SKIN: phototoxicity AND slate grey skin (use SPF for months after stopping)
NERVES: peripheral neuropathy
LUNGS: pneumonitis AND pulmonary fibrosis
LIVER: hepatotoxicity
THYROID: both hypo and hyperthyroidism
EXTRA: heart block, bradycardia, nausea and vomiting, taste disturbances
What monitoring is done with amiodarone and how often?
Before treatment: serum K+, ECG and BP, CXR
Before treatment and every 6 months: TFTs, LFTs
Before treatment and annually: eye test
How long is the half-life of amiodarone?
Around 50 days (25-100 days)- so interactions can occur up to three months after stopping
What is the interaction between grapefruit juice and amiodarone?
Enzyme inhibitor - Increased amiodarone concentration – toxicity
Which three (high risk) drugs do you have to give half the dose if they are given concomitantly with amiodarone?
Warfarin, phenytoin, digoxin (as amiodarone inhibits their metabolism)
What would be the interaction between amiodarone and quinolones?
Prolonged QT interval
What is the digoxin level for TDM?
1-2 mcg/L
What is the bioavailability for digoxin tablets, elixir and IV?
Tabs- 90%, elixir- 75%, IV- 100%
You stop digoxin if the heart rate goes below what BPM?
60 bpm
What are the signs of digoxin toxicity?
Cardiac arrhythmias, heart block, bradycardia, nausea, vomiting, abdominal pain, confusion, delirium, psychosis, rash, yellow vision, blurred vision
How would you treat digoxin toxicity?
Withdraw digoxin, correct electrolytes, digoxin specific antibody if unresponsive to atropine
Why is potassium disturbance important when considering digoxin?
Digoxin competes with potassium to bind to the Na+/K+/ATPase pump. When serum potassium levels are low, competition is reduced and the effects of digoxin are enhanced
What would be the interaction between quinine and digoxin?
They would increase plasma concentration of digoxin and therefore risk of toxicity (same with amiodarone, spironolactone)
What would be the interactions between ibuprofen and digoxin?
(reduced renal excretion)- toxicity as digoxin is renally excreted
What would be the interactions between digoxin and st john’s wort?
Subtherapeutic- cv events?
What would be the interactions between digoxin and erythromycin?
Enzyme inhibitor - Digoxin toxicity
What would be the interactions between digoxin and colchicine?
Myopathy
What does HASBLED stand for?
Hypertension
Abnormal liver function/ renal function / alcohol >8 units a week
Stroke
Bleeding
Labile INRs
Elderly (>65)
Drugs (antiplatelets/NSAIDs)
What score on HASBLED would you consider a non-pharmacological alternative?
> 3
What class of drug is tranexamic acid?
Antifibrinolytic- it inhibits fibrin dissolution (stops bleeding)
What other drug can be used in the treatment of mild to moderate haemophilia and von Willebrand’s disease?
Desmopressin
What drug schedule (GSL, P, POM) is tranexamic acid?
P
What drug is used in subarachnoid haemorrhage? What class in this drug?
Nimodipine (dihydropyridine calcium channel blocker)
What is the initial management of a TIA?
Aspirin 300mg or
Clopidogrel 75mg
and PPI
What is the long term treatment for a TIA?
Clopidogrel 75mg or dipyridamole with aspirin is contraindicated AND a statin (check BP, if >130/80 start antiHTN med
What is the acute management for an ischaemic stroke (ACT FAST)?
Alteplase within 4.5 hours, aspirin 300mg or clopidogrel
Long term management for ischaemic stroke?
Clopidogrel 75 (or dipyridamole and aspirin if c/i) and statin, manage HTN if >130/80
VTE prophylaxis duration for general surgery?
7 days
VTE prophylaxis duration for abdominal/pelvis cancer surgery?
28 days
VTE prophylaxis duration for spinal surgery?
30 days
Elective hip VTE prophylaxis duration?
10 days LWMH then 75mg aspirin for further 28 day
VTE prophylaxis duration for elective knee operation?
14 days of aspirin or LWMH WITH anti embolism stockings or rivaroxaban
What generally should be used to treat DVT?
Apixaban or rivaroxaban, if unsuitable: LMWH for at least 5 days followed by dabigatran or edoxaban OR 3rd line is to administer LWMH concomitantly with warfarin for at least 5 days or until the INR is below 2 for 2 consecutive readings
Do heparins cross the placenta?
Does not cross the placenta
What factor do LMWHs inhibit in the clotting cascade?
Facror Xa
What is the duration of warfarin for DVT or PE
a) isolated
b) DVT provoked
c) unprovoked?
6 weeks for isolated DVT, 3 months provoked, 3 months and potentially longer for unprovoked
What does heparin do to potassium levels?
Cause hyperkalemia
Heparin induced thrombocytopenia can take how many days to occur after administration?
5-10 days after
You monitor platelets when patients are on heparins for a duration of longer than how many days?
4 or more days
When initiating a patient on warfarin, what dose do you start on?
5mg OD, monitor every 1-2 days
What is the target INR for a patient who has had a cardioversion?
2.5
What is the target INR for a patient who has recurrent VTEs when already receiving anticoagulation and INR was >2?
3.5
What is the target INR for a patient who has a bioprosthetic valve?
2.5
What is the target INR for a patient who has a mechanical valve?
3.5
What would you monitor for warfarin patients?
INR, FBC, renal, liver, BP, thyroid
What are the MHRA warnings for warfarin?
A) Changes in liver function due to hep C treated with antivirals- monitor INR
B) skin rash (calciphylaxis – consult doctor if painful rash)
C) miconazole gel, CI in patients taking warfarin, increases anticoag effect
D) warfarin and other anticoagulants, monitoring of patients during covid 19 as virla infection can exacerbate anticoag treatment
What are the enzyme inducers and inhibitors for CYP450?
- Inhibitors
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol (binge)
Chloramphenicol
Erythromycin
Sulphonamides
.
Ciprofloxacin
Omeprazole
Metronidazole
(GRAPEFRUIT JUICE) - Inducer
Carbamazepine
Rifampicin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
For high-risk bleeders, when would you stop warfarin before surgery?
5 days or more
If stopped for surgery and INR is still >1.5, what do you do?
Give vitamin K 1 day prior to surgery
What do you do if a patient has INR of 7 and no bleeding?
Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose
What do you do if a patient has INR of 7 and bleeding?
Stop warfarin and give IV phytomenadione, restart the warfarin when INR <5
What do you do if a patient has INR 9 and bleeding?
Stop warfarin and give IV phytomenadione slow, repeat vit K dose if INR still to high, restart warfarin when patients INR is <5
What do you do if a patient has INR 9 and not bleeding?
Stop warfarin and give ORAL vit k, repeat if necessary and restart warfarin when <5
What do you do if there is major bleeding for a warfarin patient?
Give IV phytomenadione and dried prothrombin complex
What would you do if there is a high-risk patient (VTE risk wise- in the last three months, or stroke and AF, or mechanical valve) who was on warfarin, what would you do when stopping the warfarin 5 days before surgery?
Bridge with LMWH until 24 hours before the surgery
What would you do if the patient is high risk of bleeding and having surgery, when do you recommence?
2 days after surgery
Which anticoagulant is a direct thrombin inhibitor and what is its expiry?
Dabigatran and four months after opening (special container)
What is the reversal agent of LMWH?
Protamine sulfate (same for heparins)
What other drugs do we use in a SAH (subarachnoid haemorrhage as well as nimodipine?
Laxatives- to prevent straining
Antiplatelets inhibit platelet coagulation in venous or arterial blood supply?
Arterial – because of faster flowing vessels, thrombi are composed of mainly platelets and little fibrin
How would you counsel a patient to take dipyramidole?
30-60 mins before food
What is the expiry on dipyramidole?
6 weeks - special container
How long is clopidogrel given for with aspirin after a STEMI?
Aspirin- life long and clopidogrel 12 months (DAPT)
What is the recommended exercise amount?
30 mins 5x a week of cardio and 2 x a week for weight training
ABPM is offered to patients for patients with blood pressure of …… to confirm hypertension
140/90
How long should you wait to allow a response for antihypertensives?
4 weeks
What are the values for stage 1 hypertension?
140/90mmHg- 159/99mmHg or ABPM 135/85mmHg
What are the values for stage 2 hypertension?
160/100mmHg – 179/119 or ABPM 150/95
What is the value for severe hypertension?
180/120mmHg and above
What is the blood pressure target for over 80s with no comorbidities?
150/90
What are the blood pressure targets for diabetics under 80?
140/90
What are the blood pressure targets for type 2 diabetics over 80 years old?
Type 1- 135/85 OR 130/80 if albuminuria or 2 or more features of metabolic syndrome.
Type 2- 140/90
What is the blood pressure target for someone with renal disease?
140/90
What is the blood pressure target for someone with renal disease and diabetes?
130/80
In HTN treatment, if an ACE and ARB is not tolerated which do you use?
CCB
In HTN treatment, if a CCB is not tolerated, which do you use?
ACE/ Thiazide like diuretic
Where in the kidneys do ACE inhibitors work?
In the efferent arteriole (which reduces intraglomerular pressure and slows progression of CKD)
Which ACE inhibitor do you have to take 30-60 mins before food?
Perindopril
Do ACE inhibitors cause hypokalaemia or hyperkalaemia?
Hyperkalaemia
What would be the interaction between NSAIDs and ACE inhibitors?
Nephrotoxicity/reduced eGFR
What would be the interaction between spironolactone and ramipril?
Hyperkalaemia
Where are beta 1 and beta 2 receptors mainly located in the body?
Beta 1- in the heart, beta-2 in the lungs
Which beta blockers are taken once daily?
BACoN – bisoprolol, atenolol, celiprolol, nadolol
Which beta blockers are water soluble?
WATER CANS- celiprolol, atenolol, nadolol, sotalol
Which beta blockers are cardio specific?
BeAMANe- bisoprolol, atenolol, metoprolol, acebutolol, nebivolol
Which class of calcium channel blocker is more specific for the vasculature?
Vasculature- dihydropyridines (amlodipine, nifedipine)
Which class of calcium channel blocker is more specific for the heart?
Heart- non DHP: diltiazem, verapamil
Why can thiazide like diuretics unmask diabetes?
It causes hyperglycemia
As well as exacerbating diabetes in pt with diuretics, what other conditions can it exacerbate?
Gout and lupus
What are the symptoms of pre-eclampsia?
Severe headache, BP >140/90mmHg, sudden swelling of hands and feet, proteinuria, severe pain below the ribs, vision problems and vomiting
When do you recommend starting to take aspirin if a lady has pre-eclampsia?
From week 12 of pregnancy until baby is born (in practice do 36 weeks)
What is first line for gestational hypertension?
Labetalol (ensure over 8 weeks pregnant), if not then nifedipine MR, then methyldopa
What is the BP target for gestational hypertension?
135/85mmHg
What is the first line antihypertensive in females who are breast feeding?
Enalapril (do not give ACE during pregnancy)
How do you treat shock?
Volume replacement to correct hypovolaemia, sympathomimetics i.e. adrenaline, dopamine. If these don’t work then use noradrenaline (vasoconstrictor)
What percentage is the ejection fraction if you have reduced EF HF?
Lower than 40%
What vaccinations should HF patients have?
Pneumococcal and annual influenza
What meds should patients NOT have with reduced EF?
avoid CCBs and dihydropyridines as they reduce cardiac contractility (although amlodipine is fine in reduced EF)
What meds should patients have with reduced EF?
Loop diuretics for relief of breathlessness and oedema if has fluid retention but LT: BETA BLOCKER AND ACE
if already on BB, then switch to a BB licensed for HF, start low and up titrate
** if the above has not worked: used an aldosterone antagonist, i.e, spironolactone, eplerenone.
Next line is specialist ie amiodarone digoxin etc
How often do you monitor patients when initiated on ACE, ARB and aldosterone antagonists?
K+, Na+, renal function, BP BEFORE treatment AND 1-2 weeks AFTER, AND after each dose change, MONTHLY for 3 months then every 6 months and if patient becomes unwell
In hyperlipidaemia, statins are effective at reducing cholesterol. What are fibrates effective at reducing?
Triglyceride concentration
A high intensity statin reduces LDL cholesterol by how much?
40% or more
What can you give to patients with a contraindication to statins?
Ezetimibe
What is the most potent statin to the least potent statin?
Rosuvastatin (most) - atorvastatin - simvastatin - pravastatin, Fluvastatin (least)
What is the MHRA alert with simvastatin?
80mg of simvastatin should only be considered patients with severe hypercholesteremia and high risk of CV complications
What is measured with QRISK?
Age, lipid profile, systolic BP, gender, ethnicity etc
Is aspirin recommended for primary prevention of CV disease?
No, only secondary
What are the targets for patient lipid levels?
Total cholesterol <5, LDL cholesterol <3, HDL cholesterol >1, serum triglyceride concentration <1.7
Name a bile acid sequestrant
Ezetimibe, Colestyramine, colesevelam
How do statins work?
Inhibition of HMG CoA reductase- thereby reducing cholesterol production (indirectly reduces TGs and increases HDL cholesterol and reduces LDL)
Give some examples of drugs which cause hyperlipidaemia
Corticosteroids, antipsychotics, immunosuppressants, ARVs
Statins can interact with Fusidic acid, when would you restart the statin?
7 days after last dose (interaction= increased risk of rhabdomyolysis)
What do you monitor with statins?
Baseline lipid profile+ 3 months, renal function, thyroid function before, HbA1c if risk of developing diabetes, creatinine kinase (discontinue if 5x upper limit), liver function (discontinue if 3x upper limit)
When do you check LFTs?
At baseline, 3 and 12 months
Contraception is required during statin treatment for the duration of treatment and for how long after?
1 month after cessation of treatment
If a patient wants to become pregnant, when should she stop taking statins?
3 months before conceiving
How do bile acid sequestrants work?
Binds to bile acid, prevents reabsorption, promotes hepatic conversion of cholesterol into bile, increased LDL receptor activity, increased LDL cholesterol clearance from plasma (i.e., cholestyramine)
Do statins raise or reduce HbA1c?
Raise HbA1c
What vitamins do bile acid sequestrants interfere with?
Fat soluble vitamins (ADEK)
How long should you wait to take other medicines after taking a bile acid sequestrant (i.e., cholestyramine)
4-6 hours
Rhabdomyolysis can occur as a side effect of bile acid sequestrants, in which type of patient (co-morbidity) does it more commonly occur in?
Renal disease
What is the long-term prevention for stable angina?
Beta blocker first line, rate limiting CCB as alternative.
If inadequate- add another agent. So beta blocker + dhp CCB. Then add if needed after: LA nitrate/ivabradine/nicorandil/ranolazine (assess response to treatment every 2-4 weeks following initiation or change of therapy + increase to max tolerated dose)
When would a dr consider prophylactic nitrates in angina patients?
If they are using GTN sprays more than TWICE a week. (NB cannot use nitrates in aortic stenosis)
What is the expiry for nitrate sublingual tablets?
8 weeks
What is the MHRA alert for nicorandil (potassium channel activator)
Now given second line- risk of ulcer complications in mouth, skin, eye, GI
When do we dose isosorbide mononitrate? (timing)
Generally, 8am and 4pm due to tolerance, but needs to be 12 hours of nitrate free period
How do you initially treat unstable angina and NSTEMI?
Oxygen, nitrates, aspirin 300mg, diamorphine for pain, clopidogrel, UFH/LMWH, beta blockers
What do you give long term for NSTEMI and UA?
AAABC (ace, aspirin, atorvastatin, beta blocker, clopi or ticagrelor?) If a high risk of death use glycoprotein IIa/IIIb inhibitor (eptifibatide)
What antiplatelets are given post PCI with a bare metal stent and drug eluting stent with stable angina?
Aspirin indefinitely and clopidogrel (ticagrelor is unlicensed but can be used) 1-month bare metal stent, at least 6 months for drug eluting stent
What drug is given to patients having a STEMI LT proph which is not generally given in unstable angina and NSTEMI?
ACEi
How would you resuscitate someone in the community? How many compressions/breaths?
30 compressions, 2 breaths
How many compressions a minute?
100-120 compressions/min
How much do you press down on their chest during compressions?
5-6 mins
You use IV adrenaline (1 in 1000) every 3-5 mins during cardiogenic shock, what do you use if there is ventricular fibrillation present?
IV amiodarone
Which is the most potent loop diuretic?
Bumetanide
What drug is used to treat Raynaud’s syndrome?
First lifestyle: stop smoking and avoid the cold, then use nifedipine
What is the MHRA alert with aldosterone antagonists?
Concomitant use with ACEi/ARB= potential risk of fatal hyperkalemia- monitoring is essential
Potency and example of thiazide and
Moderately potent
Ex: indapamide and bendrofluthiazide
Examples of loop diuretics and side effects
Ex: furosemide, bumetanide and torsemide
SE: exacerbate diabetes & gout, cause urinary retention and potassium loss
Examples of potassium sparing diuretics & its treatment
Ex: amiloride
Minerealcorticoid receptor antagonist: eplerrnone and spiralactone
treatment - oedema and ascites caused by cirrhosis of liver
