Cardiovascular Flashcards
Name 2 cardiovascular prostaglandins
Epoprostenol and iloprost
What drugs are alpha and beta blockers?
Carvedilol and labetolol
Which beta blockers are less likely to cause sleep disturbance and why.
Water soluble. Sotalol, nadolol, atenolol, celiprolol
Which beta blockers also partially stimulate the receptors? What is their advantage?
Acebutolol, celiprolol, oxprenolol, pindolol.
Less bradycardia and cold extremities.
In what cases will cardioselective beta blockers be preferred? Which are these?
Common hypoglycemic attacks. Asthma.
Acebutolol, atenolol, bisorolol, celiprolol, esmolol, metoprolol, nebivolol
Allocate the antiarrhythmic drugs to their classes
Class 1a: disopyramide
Class 1b: lidocaine
Class 1c: flecainide and propafenone
Class III: amiodarone and dronedarone
Adenosine (other)
When are class 1c antiarrhythmics used, and not used?
“pill in the pocket” for paroxysmal AF. not in structural heart disease
How will sympathomimetics act upon the cardiovascular system? Give examples.
Increase blood pressure/vasoconstriction.
Ionotropic: dopamine, dobutamine.
Metarominol, midodrine, noradrenaline, adrenaline, phenylephrine
What is hydralazine indicated for?
Heart failure and hypertension
Minoxidil is an antihypertensive - what else can it be used for?
Alopecia
What drugs are used for hypertension in phaeochromocytoma? Which has more problems?
Alpha blockers - phenoxybenzamine and phentolamine. Phenoxybenzamine causes sensitisation on handling and troublesome side effects such as dizziness, fatigue, nasal congestion and reflex tachycardia.
Moxisylyte, naftidrofuryl oxalate and pentoxyfylline are what drugs for what conditions?
Peripheral vasodilator for vascular disease and raynauds syndrome.
How does guanethidine work?
Peripheral antiadrenergic. Prevents NA release. No effect on supine blood pressure but can cause postural hypotension (for resistant hypertension)
What should be monitored with milrinone?
ECG, HR, BP, fluid and electrolytes, renal function, platelets
What is tranexamic acid used for?
Haemorrhage. Anti fibrinolytic.
Name the antihaemorrhagic monoclonal antibody
Emicizumab
What 3 products can be used in major bleeding with warfarin
Phytomenadione. Then dried prothrombin complex or fresh frozen plasma.
What different coagulation proteins are available?
VIIa, VIII, IX, XIII (and with inhibitor bypassing fraction), fibrinogen, protein c complex
Which calcium channel blocker is used for a different indication than the rest and for what?
Nimodipine is used for ischemic neurological defects in subarrachnoid haemorrhage
Which calcium channel blockers can be used in angina?
Nicardipine and nifedipine
How do NOACs exert their action?
FACTOR XA inhibitors. Prevent prothrombin to thrombin and increase clotting time.
What is bivalirudin and when is it used.
Thrombin inhibitor. In heparin induced thrombocytopenia.
Name the 2 tissue plasminogen activators?
Alteplase and tenecteplase
What should be monitored with cangrelor and ticagrelor?
Renal impairment with ACS
When should a person having elective surgery stop their clopidogrel?
7 days before
What do centrally acting antihypertensives have in common?
Drowsiness, slow withdrawal.
When are potassium sparing diuretics used and when is their risk highest?
Oedema or to preserve potassium with loop/thiazides. Hyperkalaemia high risk with renal impairment.
Which diuretic can colour your urine?
Triamterene
What class is indapamide?
Thiazide like
What classes of antihypertensives should not be used together and why? Which are sometimes combined?
ACEIs/ARBs/renin inhibitor due to high potassium, low BP and renal impairment. Sometimes an ACEI will be given with valsarta and candesartan. Don’t give any with k sparing.
What tests should be done with endothelin receptor antagonists?
Haemoglobin at 1 month and 6m. Liver function.
How does colestyramine interact with drugs?
Should not be given 1h before or 4-6 hours after
What 5 classes of drugs are used in hyperlipidaemia.
Bile acid sequestrants, cholesterol absorption inhibitors, fibrates, nicotinic acid derivatives, statins
What is ranolazine used in
Angina
In what instance should nicorandil be stopped?
Skin/mucosal/eye ulceration
What cardiovascular drug can also be used for anal fissure?
Glyceryl trinitrate
What should be reviewed in AF patients and how often?
Anticoagulation, Stoke and bleeding risk annually
What control technique is preferred if onset of arrythmias are more than 48 hours?
Rate
What drugs are used in pharmacological cardioversion and when are they preferred?
IV amiodarone (preferred if structural heart disease) or flecainide
When is electrical cardioversion given?
If present for over 48 hours and patient should be anticoagulated for t least 3 weeks
What drugs can be used in rate control and when are they preferred?
Beta blockers - not sotalol
Diltiazem
Verapamil - only monotherapy
Digoxin - sedentary (HR should not fall below 60bpm), congestive heart failure, C/I with accessory conductive pathway disorders
B blockers and digoxin if diminished ventricular function
What drugs can be used post cardioversion for rhythm control?
B blocker
Sotalol
Felcainide/Propafenone - not if ischemic or structural heart disease, pill in the pocket if infrequent symptomatic paroxysmal
Aminodarone - 4w before and 12m after, left ventricular impairment or HF
Dronedarone - paroxysmal or persistent
What does CHA2-DS2-VASc measure?
Risk of stroke using risk factors; prior ischemic stroke, TIA, thromboembolic event, heart failure, left ventricular systolic dysfunction, vascular disease, diabetes, hypertension, female, over 65. Score of 0 in men or 1 in women do not require anticoagulation.
When can NOACs be used for AF anticoagulation?
Non valvular
What should flecainide and propefanone be prescribed with for atrial flutter?
Beta blocker, Verapamil or diltiazem
What should flecainide and propefanone be prescribed with for atrial flutter?
Beta blocker, Verapamil or diltiazem
What are the treatment stages for paroxysmal supra ventricular tachycardia?
Vagal stimulation
Adenosine - below maybe preferred in asthma
IV Verapamil - avoid in recent beta blocker
What can cause torsade de points?
Drugs, hypokaleamia, severe bradycardia, genetics
What drugs shouldn’t be used in torsade de points?
Anti arrythmic and Sotalol
When is disopyramide used in arrythmias?
After MI. But impairs contractility and has antimuscarinic effect (no glaucoma or prostatic hyperplasia.)
What should be adjusted with concurrent use with amiodarone?
Flecainide - reduce dose by half
Digoxin - reduce dose by half (also with Dronedarone and quinine)
What serious adverse effects are caused by amiodarone and Dronedarone?
Corneal micro deposits
Thyroid disorder
Hepatitoxicity - advise to recognise abdominal pain, anorexia, jaundice, nausea, fever, malaise, itching, dark urine
Pulmonary toxicity - SOB/cough (also with Dronedarone)
Photosensitivity - sheild from sun even several months after
Bradycardia and heart block with antivirals
Liver injury and heart failure (odoema, dyspnoea) also in dronedarone
What monitoring is done for amiodarone?
Thyroid function before and 6m. Raised t3 and t4 with very low tsh suggests thyrotoxicosis
Liver function before and 6m.
Serum potassium and xray before.
What monitoring is done with Dronedarone?
ECG every 6m.
Serum creatinine before and 7d. Again if raised andstop if continues.
Liver function before, 1w, monthly for 6m, 3m
What electrolyte imbalances should be corrected before sotalol use
Prolong qt interval and causes life threatening ventricular arrythmias so correct hypokaleamia and hypomagnesemia
What measures are used in suspected digoxin toxicity?
Atropine
Correction of electrolytes
Digoxin specific antibody - if lifethreatening associated with ventricular arrythmias or Brady arrythmias unresponsive to the above
At what plasma concentration is digitalis toxicity most likely?
1.5 - 3 mcg/L
What is the mechanism of action of digoxin
Increases the force of myocardial contraction and reduces conductivity within the AV node
Digoxin levels should be monitored - true or false
False. Only if problems suspected or renal impairment. Take at least 6 hours after dose.
In what side effects should tranexanic acid be discontinued?
Colour vision changes and visual impairment
What are the risk factors considered in hospital for VTE?
Anticipated to have substantial reduction in mobility, obese, malignant disease, history of VTE, thrombophillic disorder, over 60 years.
What prophylaxis of VTE is considered for surgical patients.
Mechanical. Pharmacological if general or ortho.
When are the different anticoagulants preferred?
LMWH suitable for all types of surgery.
Unfractionated heparin if renal failures.
Fondaparinux for hip/knee replacement, hip fracture, bariatric, and day surgery.
Oral following hip /knee replacement
How long should pharmacological prophylaxis continue following general surgery compared to major cancer surgery?
5 - 7 days in general. 28 in major cancer.
How is VTE treated?
LMWH or Unfractionated. Warfarin started at the same time and heparin continued for at least 5 days and until INR above 2 for 24 hours.
Which heparin is preferred in pregnancy and what must be considered?
LMWH have lower risk of osteoporosis and thrombocytopenia but are eliminated more rapidly so dosage must be altered for dalteparin , enoxaparin and tinzaparin
What should be done if haemorrhage occurs on parenteral anticoagulants?
Usually sufficient to just withdraw but protamine can be used for rapid reversal
What should be given in suspected TIA?
Aspirin. Or clopidogrel.
What should be given acutely following ischemic stroke?
Alteplase if within 4.5 hours for thrombolysis. Aspirin following this within 24 hours. Or within 48 hours if not receiving thrombolysis (or clopidogrel).
When are anticoagulants recommended following stroke?
Parenteral if symptomatic or high risk of VTE. After cardio embolic stroke with AF. Substitute with aspriirn for 7 days when experiencing disabling stroke.
What long term treatment is given following stroke?
Clopidogrel or
MR dipyridamole +aspirin or
MR dipyridamole or
Aspirin
Review warfarin/anticoagulant if AF
Statin 48 hours after onset
Antihypertensives for target under 130/80 (not beta blockers)
Describe the different mechanisms of action of anticoagulants and antiplatelets in relation to venous speed of target vessels and fibrin content
Anticoagulants act in slower moving venous side with high fibrin content
Antiplatelets act in faster moving arteries within little fibrin
Most INR targets are 2.5, when might it be 3.5?
Recurrent VTE and mechanical heart valves
What are the different recommended durations for warfarin use following VTE?
6 weeks if isolated calf vein DVT
3 months if provoked
At least 3 months if unprovoked
What should be done if major bleeding occurs on warfarin?
Stop, giev phytomenadione and dried prothrombin complex or fresh frozen plasma
What should be done if INR found over 8?
Stop warfarin. Give phytomenadione (injection if bleeding). Repeat if still high after 24 hours and restart when below 5.
Do you give phytomenadione if INR is found to be over 5?
Yes if minor bleeding. Just withold 1 or 2 doses if not.
What should be done in regards to warfarin and surgery.
Stop 5 days before. Give phytomenadione if INR above 1.5 the day before surgery. Bridge if high risk of VTE and don’t restart until 48 hours after if surgery carries high risk of bleeding. Can give prothrombin complex in addition to heparin in emergency surgery that cannot be delayed.
The risk of bleeding with clopidogrel and warfarin is lower than with aspirin and warfarin. True or false
False
What is the difference between LMWH and Unfractionated?
Unfractionated is rapid and short lived. So preferred if higher risk of bleeding. LMWH have lower risk of thrombocytopenia
What other parenteral anticoagulants exist other than heparins and when are they used?
Heparinoids - DVT, thrombocytopenia
Hirudins - ACS with urgent/early intervention
Epoprostenol - dialysis
Fondaparinux
A patient is in need of primary cardiovascular disease prevention and has diabetes, is aspirin suitable?
No, only benefit in established (secondary prevention)
What duration is clopidogrel given with low dose aspirin following STEMI and NSTEMI
Up to 12 months without elevation and at least 4 weeks with it.
What antiplatelet considerations are there for patients selected for percutaneous coronary intervention with placement of coronary stent?
Aspirin I definately. With either cangrelor, clopidogrel (1m or 12m if drug eluting or ACS) , prasugrel or ticagrelor.
What is the danger of using abciximab
Only used once to avoid additional risk of thrombocytopenia
How are glycoprotein inhibitors used in ACS?
In combination with anticoagulants and antiplatelets
What are the main features of salicylate poisoning?
Hyperventilating, tinnitus, deafness, vasodilation, and sweating. Coma if severe.
What is aspirins effects in pregnancy and breastfeeding?
Caution antiplatelet dose in third trimester as impairs platelet function and so risk of haemorrhage. Can also delay onset and increase duration of labour. Avoid analgesic dose in last few weeks as hig doses may be related to growth restriction, teratogenicity, closure of fetal ductus arteriosus.
Reyes risk if breastfeeding and hypothrombinaemia.
What anti arrythmic and anti infective drugs limit the dosing of edoxaban and to what dose?
30 mg with ciclosporin, Dronedarone, erythromycin or ketoconazole
What are the signs of heparin induced thrombocytopenia
30% reduction of platelet count, thrombosis or skin allergy
Describe the mechanism of heparins causing a common electrolyte imbalance?
Inhibit aldosterone secretion =hyperkalaemia. Higher risk if diabetes, chronic renal failure, acidosis.
What is the safety profile of vitamin k antagonists in pregnancy?
Not in first trimester. Risk of congenital abnormalities and haemorrhage, especially in last few weeks and delivery. So also avoid in third if possible. Stopping before the 6th week may largely avoid abnormalities.
How often should inr measurements be taken?
Daily or alternate days in early treatment then gradually longer and then up to 12 weekly.
When should people be treated for stage 1 hypertension?
Under 80yo and target organ damage (left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy), cvd, renal disease, diabetes or 1 year cvd risk over 20%. Review annually otherwise.
What are the stages of antihypertensive treatment?
ACE inhibitor (or ARB if not tolerated) - beta blocker if neither tolerated. Calcium channel blocker if over 55 or afrocarribean or thiazide related if not tolerated)
Combine ccb and acei
Ccb, acei and thiazide related..
Add low dose spironolactone (or high dose thiazide related if k above 4.5)
Alpha or beta blocker
When should beta blockers be avoided in routine antihypertensive treatment
Diabetes patients or high risk of development, especially with thiazide diuretics
When is a thiazide related diuretic used over a calcium channel blocker in antihypertensive therapy?
Evidence or high risk of heart failure
What is the target clinic blood pressure for over 80 year old?
150/90
A patient has a blood pressure of 160/60,should they be treated?
Yes. Common over 60. Treat as if both were raised.
What antihypertensive has the most specific role for diabetes?
Ace inhibitor
What considerations are there regarding antihypertensive therapy in renal disease?
Ace inhibitor if proteinuria but caution in renal impairment thiazides may be ineffective and high doses of loop may be needed
What 3 drugs may be used for hypertension in pregnancy?
Lavetolol, methyldopa and modified release nifedipine
How should pregnant women on antihypertensive therapy be treated after birth?
Review 2 weeks following unless methyldopa which should be stopped/switched to original within 2 days.
What should women at risk of pre eclampsia be given?
Aspirin from week 12 if ckd, diabetic, autoimmune disease, chronic hypertension or in previous pregnancy. Also if they have more than one moderate risk factor (first pregnancy, over 4o years old, over 10 year pregnancy interval, bmi over 35 at first visit, multiple pregnancy or family history)
What is the difference between hypertensive urgency and emergency and how are they both handled?
Severe hypertension (>180/110)
With acute damage to target organs (ACS, aortic dissection, pulmonary oedema, encephalopathy, haemorrhage, eclampsia, renal failure). Reduce BP by 20 to 25% within 2 hours.
Without damage is urgency and it should be reduced over 24 to 48 hours.
How is phaeochromocytoma treated?
Surgery after adequate blockade of alpha and beta adrenoreceptors. Often by phenoxybenzamine and a cardioselective beta blocker.
What can vasodilators cause and how is this prevented in the treatment of hypertension?
Tachycardia and fluid retention.
Minoxidil also increased cardiac output. Beta blocker and diuretic mandatory. Hypertrichosis renders unsuitable for females
Why should alpha blocking drugs eg prazosin be introduced with caution?
Rapidly reduce blood pressure after first dose
Ramipril 10mg Bisoprolol 2.5mg Spironlolactone 100mg Naproxen 500mg Verapamil What is wrong with this combination?
Increased risk of hyperkalaemia with acei and spironolactone. It may be used at low dose in heart failure with them. Concomitant NSAIDs increases risk of renal damage with ACEIs. Verapamil should not be used with beta blockers (bradycardia)
What is the issue with starting Ramipril in someone taking furosemide 80mg daily.
First dose hypotension. May be needed to initiated by specialist.
When should acei be introduced with caution and under specialist with careful monitoring?
Hugh dose/multiple diuretics ARB Hypovalaemia Hyponatreamia Hypotension Unstable heart failure High dose vasodilator Renovascular disease
Why would ACEIs be replaced with an ARB?
Do not inhibit breakdown of bradykinin so less likely to cause persistent dry cough
What group of patients should particularly not be given concomitant drugs affecting the renin angiotensin system?
Those with diabetic neuropathy.
ACEIs with candesartan or valsartan may be used in heart failure, but definitely not with aldosterone antagonist or potassium sparing diuretic
What advice is given with methyldopa and clonidine?
Not to be given with history of depression
Can cause depression, dry mouth, sleep disorders and may affect performing skilled tasks.
Which beta blockers are given once daily and why?
Longer duration of action. Atenolol, Bisoprolol, celiprolol and nadolol.
Wyy are beta blockers cautioned in diabetes?
Effect carbohydrate metabolism and the respo ses to hypoglycaemia so may mask tachycardia. Can also develop diabetes especially with thiazide diuretics
What can result from beta blockade without concurrent alpha blockade in phaeochromocytoma?
Hypertensive crisis
Which beta blockers are have evidence relating to use after MI?
Atenolol, metoprolol, (acute phase), acebutolol, metoprolol timolol and propranolol (after early convalescent phase)
Which beta blockers are have evidence relating to use after MI?
Atenolol, metoprolol, (acute phase), acebutolol, metoprolol timolol and propranolol (after early convalescent phase)
What beta blockers are used in arrythmias?
Sotalol and esmolol
What beta blockers are used in heart failure?
Bisoprolol, carvedilol
Nebivilol (stable mild ot moderate in over 70yo)
What are the signs of beta blocker overdose?
Lightheaded, dizzy, possible syncope. Heart failure may be precipitated or exacerbated.
What are beta blocker issues with pregnancy and breastfeeding?
Intrauterine growth restriction, neonatal hypoglycaemia and bradycardia.
Toxicity in infants unlikely in bf but monitor and be aware that water soluble beta blockers are present in greater amounts
Which beta blocker has monitoring requirements for liver damage?
Labetolol.
Which calcium channel blockers are not used in heart failure and why?
Diltiazem and Verapamil. Depress cardiac function
Wgat are common side effects of calcium channel blocker?
Flushing headache and ankle swelling
What electrolyte imbalances do thiazide diuretics cause?
Hypokaleamia - dangerous in cardiac conditions and glycosides. Can precipitate encephalopathy, particularly in alcoholic cirrhosis. Elderly susceptible so lower dose initially and not for gravitational oedema
Hypomagnesemia in alcoholic cirrhosis
What advice is given with ACEIs treatment?
Discontinue if marked elevation of hepatic enzymes or jaundice.
Take first dose at night.May cause dry cough
What hormone syndrome have some ACEIs reported as a side effect?
SIADH
What advice is given for endothelian receptor antagonists use in pregnancy?
Teratogenic in animal studies so exclude before treatment and use effective contraception throughout and one month after stopping. Monthly testing advised.
What advice is given with riociguat treatment?
Smoking cessation as response may be reduced. Effective contraception should be used and monthly tests advised.
What action is taken with shock?
Treat underlying causes such as haemorrhage, sepsis, myocardial insufficiency with fluids. Ionotropic suport
What is the danger of using vasoconstricting sympathomimetic s?
Although they raise blood pressure in emergencies they also reduce perfusion of vital organs such as kidney
Which sympathomimetics have a longer duration of action than noradrenaline?
Metaraminol and phenylephrine so may cause prolonged rise in blood pressure
What should be monitored with midodrine?
Hepatic and renal function. Supine and standing blood pressure. Report symptoms of chest pain palpitations, shortness of breath, headache and blurred vision. Risk of supine hypertension reduced by raising head of bed.
What is the treatment for heart failure associated with reduced left ventricular ejection fraction?
ACEIs and beta blocker. Can have sacubitril (nsprilysin inhibitor) and valsartan if already stabilised on acei or ARB.
Aldosterone antagonist if remain symptomatic (low dose spironolactone or eplernine if cannot use)
Isosorbide dinitrate with hydralazine if can’t have acei or ARB or remain symptomatic.
Digoxin if worsening or still symptomatic.
What are the considerations when choosing a diuretic for fluid overload in heart failure?
Thiazide - mild. Ineffective if egfr less than 30. So loop if poor renal function.
Who is at high risk of developing cardiovascular disease?
Diabetes, CKD (egfr <60),albuminuria, familial. Risk increases with age os 85 yo and over most risk especially if smoking or hypertension.
10 year risk of 10% of more with benefit most from drug treatment.
What do Qrisk and JBS3 calculators base risk on?
Lipid profile, systolic blood pressure, gender, age, ethnicity, smoking status, bmi, CKD, diabetes, AF, hypertension, rheumatoid arthritis
What considerations should be given to a hypothyroidism patient when assessing cardiovascular treatment?
They should recurve adequate Thyroid replacement before assessing as correcting it may resolve lipid abnormalities. Untreated hypothyroidism can also increase the risk of myositis with lipid regulating drugs.
Which drug is considered first line for primary and secondary prevention of cvd ?
Atorvastatin.
How often are non hdl cholesterol levels taken and what reduction is aimed for?
Greater than 40% reduction. And below 2.5mmol/l. Check 3 months after starting
Reduction of of greater than 50% in familial.
What drugs are considered after a statin in hyperlipidaemia
Ezetimibe may be given additionally or as an alternative.
Fenofibrate if triglycerides remain high.
Nicotinic acid (triglyceride or ldl lowering further)
Bile acid sequestrant (if ldl severely raised as can aggregate hypertriglyceridaemia) , nicotinic acid (side effects especially vasodilation) or fibrate (if triglycerides over 10mmol/l) by specialist.
What combination therapy is not used due to dangerous risk of rhabdomyolysis?
Gemfiibrozil and statins.
What supplements may patients on bile acid sequestrants need to take?
ADK folic acid if prolonged treatment
What monitoring is done with colesevalam treatment?
Blood ciclosporin concentrations
Colestyramine can be mixed with fruit juice. True or false.
True.
What advise is given to patients taking colestyramine.
Don’t take other drugs at the same time.
Which groups of people have increased risk of muscle toxicity?
Personal/family history of toxicity/muscle disorder, increased alcohol intake, renal impairment and hypothyroidism
Don’t start statin if baseline cr kinase is more than 5 times upper limit
What monitoring is required in fibrate use?
Liver function on every 3 months for first 12. Maybe monitor Serum creatinine in first 3 months
When are fibrate contraindicated?
Gall bladder disease
What side effect is common in early nicotinic acid treatment and how is it solved?
Prostoglandin mediated flushing. Taking after meal or aspirin minimises.
What symptoms should statin patients look out for?
Unexplained muscle pain, tenderness or weakness. Dyspnoea, cough and weight loss.
Are statins safe in pregnancy?
No. They should be discontinued 3 months before attempting to conceive. And contraception should b eused during and for 1 month afterwards.
What monitoring is done with statins?
Lipid profile, Thyroid hormone, renal function before (non fasting).
Liver enzymes before, within 3 months and 12 months. Serum transaminasses more than 3 times upper limit should discontinue.
Creatinine kinase before and again at 7 days if more than 5 times upper limit. If below after 7 days start at lower dose, if above do not start.
If high risk for diabetes, fasting blood glucose or hba1c before and repeated after 3 months.
What drugs effect the maximum dosage of atorvastatin that can be given?
Max 10mg with ciclosporin
Max 20mg with ellbasvir with grazoprevir
Max 4omg with anion exchange resin
Rosuvastatin 10mg
Bezafibrate 200mg
Clopidogrel 75mg
New prescription - what is the problem?
Advised 5mg initially with these drugs. Max 20mg with clopidogrel and 40mg c/I with fibrate. Also interacts with antivirals and teriflunomide
What drugs effect the maximum simvastatin dose?
10mg with beza/ciprofibrate
20mg with amiodarone, amlodipine, ranolazine, Verapamil, diltiazem, ellbasvir with grazoprevir (reduce with use with cyp3a4 inhibitors)
40mg with lomitapine or ticagrelor.
How should statin doses be introduced?
Adjusted in intervals of at least 4 weeks
Which statins need to be taken at night?
Simvastatin, pravastatin, fluvastatin
What drug therapy is given for stable angina?
Glyceryl trinitrate for immediately before activity that brings on an attack. Regular therapy if attacks occur more than twice weekly; beta blocker or calcium channel blocker, then combine, or add long acting nitrate, ivabridine, nicorandil or ranolazine.
Assess response every 2 to 4 weeks.
What monitoring is required with ivabridine?
Monitor for AF and bradycardia (discontinue if resting heart rate below 50bpm)
What drugs effect the maximum dose of ivabridine?
2.5mg BD with cyp3a4 inhibitor (except diltiazem, erythromycin and Verapamil which are contraindicated)
What advice is given with nicorandil?
Can cause serious skin, mucosa and eye ulceration. Do not drive or operate heavy machinery. Can use lower initial dose if susceptible to headache side effect.
What extent of myocardial necrosis is found in the different ACS?
No evidence with unstable angina. Then NSTEMI
What does management of NSTEMI or unstable angina involved?
Oxygen if hypoxia, pulmonary oedema or continuing ischaemia .
Nitrates - sublingual gtn or IV/buccal gtn or I’ve Isosorbide dinitrate
Or morphine/diamorphine with metoclopramide
Aspirin and clopidogrel /prasugrel/ticagrelor
Heparin LMWH or Fondaparinux
Beta blockers or dilyiazem/Verapamil (if no lv dysfunction)
Glycoprotein IIB /IIIA inhibitor if high risk of MI or death
What differences and additions are given for STEMI compared to other ACS?
Straight to morphine for pain in addition to Nitrates.
Thrombolytic drug or pci
ACEIs or ARB
Insulin if raised blood glucose
More long term management with anticoagulants
Which beta blockers are more suitable for STEMI patients with left ventricular dysfunction?
Carvedilol, Bisoprolol or long acting metoprolol.
How soon after symptom onset can the different fibrinolytics be used following MI?
Ideally all within 1 hour.
Alteplase;6-12 hours
Reteplase/streptokinase; 12h
Tenecteplase; 6h
What side effects of Nitrates often limit therapy?
Flushing headache and postural hypotension
Which Nitrates may cause a tolerance and how is it tackled?
Long acting or transdermal. Reduce blood concentration for 4-12 hours each day. Transdermal can be left off for 8-12 hours (overnight) if tolerance suspected and give 2nd of tablet doses after 8h rather than 12.
What drugs can be given in cardiac arrest?
Adrenaline IV injection every 3-5 minutes. IV Amiodarone if refractory to defibrillation. Or lidocaine.
What is the advantage of Indapamide in hypertension over other diuretics?
Less effect on metabolism so less agrevating for diabetes.
Are thiazides or loop diuretics better suited in pulmonary oedema?
Loop
What are the cautions associated with loop diuretics?
May exacerbate gout and diabetes.
Lower initial doses in elderly
Hypokaleamia can result in encephalopathy particularly in alcoholic cirrhosis
Enlarged prostate may result in urinary retention
Hypomagnesemia in alcoholic cirrhosis leading to arrhythmia.
What are the 2 types of peripheral vascular disease?
Occlusive (intermittent claudication) and vasopastic (Raynauds)
When should patients on medication for peripheral vascular disease be reviewed?
Should see improvement with naftidrofueyl within 3 to 6 months. Should review cilostazol every 3 months.
What lifestyle advice is given to Raynauds patients?
Avoid exposure to cold and stop smoking.
