Cardiovascular Flashcards
What is the pill in pocket approach?
In selected patients with infrequent episodes of symptomatic paroxsymal atrial fibrillation, sinus rhythm can be restored using the ‘pill in pocket approach’. This involves the patient taking oral flecinide or propafenone to self-treat an episode of AF.
What does CHA2DSVASc stand for?
Congestive heart failure Hypertension Age - >65 = 1 Diabetes Stroke or TIA = 2 Vascular disease Age >75 = 2 Sex category - if women 1 point
What does HASBLED stand for?
Hypertension Abnormal liver or renal function Stroke Bleeding tendency or predisposition Labile INR Eldery Drugs e.g. aspirin, alcohol, warfarin
How should amiodarone induced hypothyroidism be managed?
Hypothyroidism can be treated with replacement without withdrawing amiodarone if it is essential
How should amiodarone induced hyperthyroidism be managed?
Thyrotoxicosis may be very refractory and amiodarone should usually be withdrawn at least temporarily to help achieve control. Treatment with carbimazole may be required
How should amiodarone corneal microdeposits be managed?
Most patients taking amiodarone develop corneal microdeposits; these rarely interfere with vision, bu drivers may be dazzled by headlights at night. However if vision is impaired then amiodarone must be stopped to prevent blindness.
A patient on amiodarone develops a cough and is SOB, what might be wrong with them?
Pulmonary toxicity can occur with amiodarone - pneumonitis should always be suscepted if new or progressive shortness of breath or cough develops in patients taking amiodarone
For the management of AF, the maintenance dose of digoxin can usually be determined by the ventricular rate at rest, which should not usually be allowed to fall below what?
60 beat per min
Digoxin and amiodarone interaction
Need to reduce digoxin dose by half
Digoxin and quinine interaction
Need to half digoxin dose
Digoxin monitoring requirements
Monitor serum electrolytes and renal function.
Management of VTE in pregnancy
LMWH - eliminated more rapidly in pregnancy, requiring BD dosing
A patient has been diagnose as having a stroke. The cause has been identified as AF, should anticoagulation be started?
Patients presenting with AF following ischaemic stroke should receive aspirin before being considered for anticoagulant treatment.
A patient with already diagnosed AF, has be admitted to hospital following ischaemic stroke. They usually take rivaroxaban 20mg OD for stroke prevention. What should happen to their anticoagulant treatment now?
Patients is at significant risk of haemorrhagic transformation, and should have their anticoagulant treatment stopped for 7 days and substituted with aspirin.
Treatment of hypertension in ischaemic stroke should only occur when?
Treatment of hypertension in the acute phase of stroke can result in reduced cerebral perfusion and should therefore only be instituted in the event of a hypertensive emergency or in those patients considered for thrombolysis
What long term management should patients receive following a stroke or TIA?
Clopidogrel
Anticoagulants are not routinely recommended, except in AF
A statin should be initiated 48 hours after stroke symptom onset irrespective of their cholesterol concentration
Antihypertensives to achieve BP of 130/80
What is a patients BP target following a stroke?
<130/80
Long term management following a intracerebral haemorrhage?
Aspirin therapy should only be given to patients at high risk of a cardiac ischaemic event.
Blood pressure should be measured and treatment initatied where appropriate, taking care to avoid hypoperfusion. Statins should be avoided following intracerbral haemorrhage, however they can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage.
How many days before surgery should warfarin be stopped?
5 days. Phytomenadione should be given on the day of surgery if INR is >1.5
LMWH should be stopped when before surgery?
24 hours before
How long after surgery can warfarin be started? at what dose?
If haemostasis is adequate, warfarin can be resumed at the normal maintenance dose the evening of surgery or the next day
How long after surgery can LMWH be restarted?
LMWH should not be restarted until at least 48 hours after surgery
What is Praxbind?
Idaruizumab - reversal agent for dabigatran
What should patients be loaded with before PCI?
Clopidogrel 300mg and aspirin 300mg.
How long should dual AP therapy be continued following the placement of a bare metal stent?
1 month
How long should dual AP therapy be continued following the placement of a drug eluting stent?
12 months
Clopidogrel should NOT be discontinued prematurely in patients with a drug-eluting stent. There is an increased risk of stent thrombosis as a result of the eluted drug slowing the re-endothelialisation process.
What is abciximab? What is it used for ?
Glycoprotein IIb/IIIa inhibitor - it is licensed as an adjunct to UFH and aspirin for the prevention of ischaemic complications in high risk patients undergoing PCI.
How long should aspirin be given for in ischaemic stroke?
300mg OD for 14 days - to be initiated 24 hours after thrombolysis or as soon as possible within 48 hours of symptoms onset
Aspirin dose for pain/pyrexia?
300-900mg every 4-6 hours. Max 4g each day.
Clopidogrel should be discontinued how many days before surgery?
7 days
Can dipyridamole capsules be dispensed in a MDS tray?
NO - m/r capsules should be dispensed in original container and any capsules remaining should be discarded 6 weeks after opening.
Apixaban dose for VTE prophylaxis following knee surgery
2.5mg BD for 10-14 days
Apixabdan dose for VTE prophylaxis following hip surgery
2.5mg BD for 32-38 days
Apixaban dose for the treatment of DVT/PE
10mg BD for 7 days, then 5mg BD
Apixaban dose for stroke prevention in AF
5mg BD
reduce dose to 2.5 mg if two of the following: over 80years, <60kg or serum creatine >133
How long after using GTN spray should a patient take a second dose if the pain has not eased?
Repeat after 5 minutes
What is the first line treatment for stable angina?
Beta-blocker or CCB
What secondary prevention treatment should be considered in patients with stable angina?
Consider aspirin 75mg in all people with stable angina. Offer atorvastatin 80mg.
What are the water soluble beta blockers?
Atenolol, sotalol, nadolol and celiprolol
Common beta blocker side effects
Fatigue, coldness of extremities, and sleep disturbances. Can affect carbohydrate metabolism causing both hypo and hyperglycemia in patients with our without diabetes.
Time of day that first dose of ramipril should be given?
For hypertension the first dose should preferably be given at bedtime
A 50 year old Caucasian lady who has been taking ramipril and amlodipine for the past 4 weeks at maximum dosing. The patient has a blood pressure reading of 170/105 mmHg that was taken in the surgery. What further antihypertensive treatment do you suggest?
A thiazide like diuretic - Chlortalidone and indapamide are the preferred diuretics in the management of hypertension.
BP target in pregnancy?
150/90 (unless the patient has target organ damage as a result of chronic HTN, then 140/90)
Which antihypertensive is generally first line in pregnancy?
Labetolol (but methyldopa or nifedipine [unlicensed] are also options
Methyldopa should be discontinued within how many days of giving birth?
2 days
What can be given to reduce BP quickly in an hypertensive crisis?
IV sodium nitroprusside, nicardipine labetolol are all options
Outline the management of phaeochromocytoma?
Long term management involves surgery
Give an alpha blocker for short term management of hypertensive episodes
Why are ARBs a suitable alternative for someone experiencing a cough with an ACEi?
ARBs do not inhibit the breakdown of bradykinin
What kind of drug is aliskren?
Renin inhibitor
What is the recommendation about combining ACEi/ARB or aliskren?
Combination is not advised due to increased risk of hyperkalemia, hypotension and renal impairment
What is meant by instrinsic sympathomimetic activity (ISA) in terms of beta blockers?
Capacity of a BB to stimulate as well as block receptors
What is the advantage of BB that have less intrinsic sympathomimetic activity?
Tend to cause less bradycardia and less coldness of the extremeties
What are the water soluble beta blockers? (hint: SCAN)
Sotalol
Carvedilol
Atenolol
Nadolol
Why might a water soluble BB be beneficial?
Less able to cross the BBB and cause sleep disturbances
What are the cardioselective beta blockers?
Atenolol
Bisoprolol
Metoprolol
Nebivolol
Why should BB be avoided in combination with a thiazide diuretic in patients with diabetes?
BB can cause both hyper and hypo glycemia
BB can mask the symptoms of hypos
Thiazides can cause hyperglycemia and therefore exacerbate diabetes
How is a beta blocker overdose treated?
Atropine (to reverse bradycardia)
if ineffective can give glucagon
Which beta blockers are worse in breast feeding?
Water soluble beta blockers are present in breast milk in greater amounts that other BB
When using beta blockers in heart failure, what must you ensure before adding in a beta blocker or increasing the dose?
Ensuring the heart failure is stable and not worsening.
Ramipril in hepatic impairment
Ramipril is a prodrug so requires good renal function. Max 2.5mg in hepatic impairment
What agents can be used to manage hypotension and shock?
Correct volume and can use sympathomimetic inotropes such as adrenaline, epinephrine and dobutamine
What is the indication of eplenerone?
Can be used in patients with LVSD following an MI
What patient groups require primary prevention of CVD with a statin?
Diabetics, CKD, FHx of hypercholesterolaemia and if QRISK >10%
Hypothyroidism can increase plasma lipid levels. What action should be taken in this case?
Patients with hypothyroidism should receive levothyroxine as this may correct lipid levels before assessing the need for a statin.
Also - untreated hypothyroidism increases the risk of myositis with statins.
Statin monitoring
Baseline total cholesterol, HDL-cholesterol and non-HDHL after 3 months. Aim for a 40% reduction in non-HDL.
LFTs baseline, 3 months and after 12 months.
CK baseline
If diabetic - HbA1c baseline
1st line treatment for stable angina
CCB or a BB
2nd line treatment for stable angina
CCB and a BB
3rd line treatment for stable angina?
Consider a long acting nitrate, ivabradine, nicorandil or ranolazine
Ivabradine is contraindicated with what 3 drugs?
Diltiazem, erythromycin and verapamil
Ivabraidine monitoring
Monitor regularly for the presence of AF and for bradycardia. If HR is persistently <50bpm discontinue
