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Pre-reg exam > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

What is the mechanism of action of digoxin?

A

Slows heart rate and increases force of contraction of myocardium
Reduces conductivity of AV node

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2
Q

What are the 2 main indications of digoxin?

A

Atrial fibrillation

Heart failure

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3
Q

Why is digoxin once daily dosing?

A

Long half life

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4
Q

How frequently is digoxin taken?

A

Once daily

Long half life

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5
Q

Why can digoxin toxicity be difficult to identify?

A

Similar symptoms to deterioration of heart disease

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6
Q

Name 1 thing that can predispose a patient to digoxin toxicity?

A

Hypokalaemia

e.g. furosemide, bendroflumethazide

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7
Q

Name a class of drugs that can increase the risk of digoxin toxicity

A

Diuretics that do not conserve potassium
= Hypokalaemia
Furosemide, bendroflumethazide

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8
Q

Name a condition that digoxin should NOT be used in

A

Heart block

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9
Q

List 3 side effects of digoxin

A

Nausea
Vomiting
Blurred vision

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10
Q

Name the main indication of thiazide diuretics

A

Relieve oedema

  • In CHF
  • For hypertension (+BB)
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11
Q

How should thiazides be dosed when prescribed for hypertension?

A

Low doses

No additional benefit of high doses

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12
Q

Which thiazide diuretic is preferred in hypertension?

A

Indapamide

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13
Q

For which indication is indapamide preferred for vs other thiazide diuretics?

A

Hypertension

+ Beta blocker

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14
Q

Which thiazide diuretic is preferred in CHF?

A

Bendroflumethiazide

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15
Q

For which indication is bendroflumethiazde preferred vs other thiazide diuretics?

A

CHF

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16
Q

How can thiazide diuretics affect electrolytes?

A 
Low potassium
Low sodium
Low magnesium
High calcium
High glucose

Monitor electrolytes when on thiazide diuretics

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17
Q

Why should thiazide diuretics not be used in diabetes?

A

Can cause high glucose

Exacerbate diabetes

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18
Q

What condition can thiazides cause?

A

Gout

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19
Q

Name 2 drugs that should not be given with thiazide diuretics

A

Digoxin

Lithium - sodium depletion increases risk of toxicity

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20
Q

Why should lithium + thiazide diuretics not be given?

A

Thiazides can cause sodium depletion = increased risk of lithium toxicity

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21
Q

2 main indications of loop diuretics

A

Pulmonary oedema

CHF

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22
Q

When should loop diuretics be given?

A

In the morning

Work within an hour, finished acting in 6 hours

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23
Q

Why should loop diuretics be given in the morning?

A

Work within an hour

Finish acting in 6 hours

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24
Q

2 adverse effects of giving loop diuretics via rapid IV

A

Tinnitus

Deafness

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25
Q

Which class of drug should loop diuretics not be given with

A

Aminoglycosides - vancomycin, gentamicin

Ototoxicity risk

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26
Q

Are thiazides or loop diuretics more likely to cause hyperglycaemia?

A

Thiazides cause hyperglycaemia

Loops can cause hyperglycaemia but less likely to exacerbate diabetes

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27
Q

How do loop diuretics affect lithium?

A

Reduce excretion of lithium

To a lesser extent than thiazides

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28
Q

Which diuretic class is preferred in diabetes?

A

Loop > thiazides

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29
Q

Which diuretic class is preferred if patient is also on lithium?

A

Loop > thiazides

Loop reduces the excretion of lithium to a lesser extent than thiazides

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30
Q

What is the purpose of potassium-sparing diuretics/aldosterone antagonists?

A

Given with thiazide or loop diuretics
For retention of potassium
Instead of potassium supplements

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31
Q

How are potassium sparing diuretics also known?

A

Aldosterone antagonists

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32
Q

Name 2 drugs that potassium sparing diuretics should NOT be given with

A

ACEi’s
ARBs
Can lead to hyperkalaemia

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33
Q

What is the effect of potassium sparing diuretic + ACEi/ARB?

A

Hyperkalaemia

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34
Q

Name an adverse effect of spironolactone

A

Hepatotoxicity

So take with food

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35
Q

Why should spironolactone always be taken with food

A

Can cause hepatotoxicity

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36
Q

What are the 2 ways that atrial fibrillation can be managed?

A

Rate control

Rhythm control

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37
Q

Why is atrial fibrillation treated?

A

Prevent complications - stroke, VTE

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38
Q

What is the preferred method of managing atrial fibrillation?

A

Rate control

Over rhythm control

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39
Q

Which drugs are used to control rate in atrial fibrillation

A

Beta blocker
CCB - rate controlling - diltiazem, verapamil
Digoxin - if single drug fails to control AF

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40
Q

Which calcium channel blockers are used in atrial fibrillation?

A

Diltiazem
Verapamil

Both rate-controllers

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41
Q

How do diltiazem and verapamil help to treat AF?

A

Both are rate controllers

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42
Q

Which drugs are used to control rhythm in atrial fibrillation?

A

Beta blocker + Amiodarone

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43
Q

Which drug is used to treat ventricular tachycardia?

A

Amiodarone

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44
Q

List 2 indications of amiodarone

A

Rhythm control in AF

Ventricular tachycardia

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45
Q

When can amiodarone be started?

A

Under specialist supervision

In hospital setting

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46
Q

How quickly does amiodarone start acting?

A

Long half life
May not need loading dose
IV amiodarone acts rapidly

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47
Q

List the 2 adverse effects of amiodarone that relate to the eyes

A

Development of corneal deposits - most patients - rarely interfere with vision, can cause dazzling at night
Phototoxicity

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48
Q

How does amiodarone affect the thyroid

A

Amiodarone contains iodine
Can cause hypothyroidism + hyperthyroidism
Monitor thyroid function even 6 months

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49
Q

Why should thyroid function be monitored on amiodarone

A

Amiodarone contains iodine
Can cause hypo- + hyper thyroidism

Monitor thyroid function every 6 months

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50
Q

How often should thyroid function be monitored when on amiodarone?

A

Every 6 months

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51
Q

List 3 symptoms of hyperthyroidism associated with amiodarone use

A

Weight loss
Palpitations
Insomnia

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52
Q

How can amiodarone affect the skin?

A

Cause blue-grey discolouration
This is an acceptable side effect
Cover skin and use wide spectrum suncream

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53
Q

How does amiodarone affect the liver

A

Can cause hepatotoxicity
LFTs every 6 months

Stop amiodarone if hepatotoxicity occurs

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54
Q

How often should LFTs be performed on amiodarone

A

Every 6 months

Stop amiodarone if hepatotoxicity occurs

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55
Q

Why should LFTs be performed every 6 months when on amiodarone?

A

Amiodarone can cause hepatotoxicity

Stop amiodarone

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56
Q

How can amiodarone affect the nerves?

A

Amiodarone can cause peripheral neuropathy

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57
Q

List 9 possible side effects/adverse effects of amiodarone

A 
Corneal micro-deposits
Dazzling at night
Phototoxicity
Hypothyroidism
Hyperthyroidism
Grey skin
Hepatotoxicity
Peripheral neuropathy
Taste disturbances
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58
Q

Which drugs does amiodarone affect the levels of?

A

Warfarin
Digoxin
Phenytoin

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59
Q

Why does amiodarone X simvastatin?

A

Increased risk of myopathy

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60
Q

Why does amiodarone X Lithium

A

Increased risk of arrhythmias

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61
Q

How do beta blockers have their effect?

A

Act on beta-adrenoceptors in heart and peripheral vasculature
Also receptors in liver, bronchi and pancreas

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62
Q

Name 4 beta blockers that are least likely to cross the blood-brain barrier

A

Atenolol
Sotalol
Nadolol
Celiprolol

Most water-soluble beta blockers
Less likely to cross BBB
So reduced sleep disturbance and nightmares

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63
Q

Name 4 beta blockers that are the least likely to cause sleep disturbance and nightmares

A

Atenolol
Sotalol
Nadolol
Celiprolol

Most water soluble beta blockers
Less likely to cross BBB
Reduced sleep disturbance and nightmares

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64
Q

Why are some beta blockers less likely to cause sleep disturbance and nightmares?

A

Water soluble
Less likely to cross BBB
Atenolol, sotalol, nadolol, celiprolol

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65
Q

Why should beta blockers be avoided in asthmatics?

A

Beta-adrenoceptors in bronchi

Can cause bronchospasm

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66
Q

How do beta blockers affect the lungs?

A

Beta adrenoceptors in lungs
Can cause bronchospasm

Avoid in asthmatics

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67
Q

What should be used if beta blockers are necessary in asthma?

A

Use more cardio selective beta blocker

Atenolol, Bisoprolol

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68
Q

How do beta blockers affect the liver and pancreas?

A

Affect carbohydrate emetabolism

= Hyper or Hypo glycaemia

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69
Q

How can beta blockers cause hypo or hyperglycaemia?

A

Affect carbohydrate metabolsim

By effects on liver and pancreas

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70
Q

How can beta blockers affect sugar levels?

A

Can cause hypo or hyper glycaemia

By interacting with liver & pancreas so affecting carbohydrate metabolism

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71
Q

What should be considered in diabetic patients being prescribed a beta blocker?

A

Beta blockers can affect sugar control in diabetics
Caution with BBs in diabetes

BBs affect liver & pancreas = carbohydrate metabolism
So can cause hypo or hyper glycaemia

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72
Q

When should beta blockers not be recommended in diabetes?

A

When in combination with thiazide diuretic for hypertension

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73
Q

How do beta blockers help to manage angina?

A

Reduce workload of heart

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74
Q

How can beta blockers be of use post MI

A

May prevent recurrence of MI

Reduces workload of the heart

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75
Q

Name 2 beta blockers that can reduce the mortality of heart failure

A

Bisoprolol

Carvedilol

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76
Q

List 5 indications of beta blockers

A 
Hypertension
Angina
Post MI - reduce recurrence
Heart failure - reduce mortality
Anxiety
Migraine prophylaxis
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77
Q

What is an important consideration when stopping a beta blocker?

A

Beta blockers should not be stopped suddenly

Especially in ischaemic heart disease - following an MI

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78
Q

What is the purpose of treating hypertension?

A

Reduce risk of stroke, coronary events, heart failure and renal impairment

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79
Q

What is stage 1 hypertension?

A

140/90mmHg or above

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80
Q

When should stage 1 hypertension be treated?

A

If damage to an organ - heart, kidney, eye disease, diabetes
or
If QRISK score >20%

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81
Q

What is stage 2 hypertension?

A

160/100 mmHg or above

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82
Q

When should stage 2 hypertension be treated?

A

All patients with stage 2 hypertension should be treated

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83
Q

Describe stage 1 hypertension

A

140/90mmHg or above

Treat only if target organ damage - heart, kidney, eye, diabetes or if QRISK score >20%

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84
Q

Describe stage 2 hypertension

A

160/100 mmHg or above

All patients with stage 2 hypertension should be treated

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85
Q

What is severe hypertension?

A

Systolic >180 mmHg

Diastolic >100 mmHg

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86
Q

How should drugs be added in hypertension?

A

Usually more than 1 drug required
Added step-wise
Gap of 4 weeks between each drug

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87
Q

What is the 1st line treatment for hypertension in under 55s?

A

ACE inhibitor
ARB if ACEi not tolerated
Beta blocker if ACEi and ARB not suitable

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88
Q

What is the 2nd line treatment for hypertension in under 55s?

A

ACEi or ARB + CCB

If have HF or risk of HF - thiazide (indapamide) > CCB

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89
Q

What are the treatment options for hypertension in those who are under 55 years old?

A

1) ACEi (–> ARB –> BB)

2) ACEi or ARB + CCB (thiazide > CCB if HF or risk of HF)

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90
Q

Which diuretic is used for hypertension if patient also has heart failure or is at risk of heart failure?

A

Indapamide

= Thiazide diuretic

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91
Q

What is the 1st line treatment for hypertension in black patients?

A

Calcium channel blocker

Or thiazide diuretic (indapamide) if risk of heart failure

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92
Q

What is the 1st line treatment for hypertension in the over 55s?

A

Calcium channel blocker

Or thiazide diuretic (indapamide) if risk of heart failure

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93
Q

What is the 2nd line treatment for hypertension in over 55s?

A

CCB (or thiazide) + ACEi or ARB

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94
Q

What is the 2nd line treatment for hypertension in black patients?

A

CCB (or thiazide) + ARB or ACEi

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95
Q

What are the treatment options for hypertension in over 55s?

A

1) CCB

2) CCB + ARB or ACEi

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96
Q

What are the treatment options for hypertension in black patients?

A

1) CCB

2) CCB + ARB or ACEi

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97
Q

What is the 3rd line treatment for hypertension in all patients?

A

ACEi or ARB + CCB + thiazide

+ spironolactone, alpha or beta blockers

+ aspirin, statins if patient at high risk

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98
Q

What is the choice of antihypertensive in pregnancy?

A

Methyldopa

Not losaratan or ramipril - lower baby’s blood pressure and inhibit growth

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99
Q

Why should ramipril or losartan now be used in pregnancy

A

Lower baby’s blood pressure = inhibits growth

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100
Q

Which 2 antihypertensives should not be given in pregnancy?

A

Losaratan and ramipril

Lower baby’s blood pressure = inhibits growth

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101
Q

At what age may hypertension medication not be considered necessary?

A

Newly diagnosed hypertension at around 80 years old

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102
Q

How should just raised systolic BP be treated?

A

Treat as regular hypertension

Raised systolic still = cardiovascular disease risk

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103
Q

How should patients with hypertension and renal disease?

A

ACEi - with caution

Thiazides may not work - loop diuretics may be needed instead

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104
Q

Name 3 vasodilators

A

Hydralazine
Minoxidil
Sildenafil

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105
Q

What is hydralazine used for?

A

Resistant hypertension

Rarely used on its own

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106
Q

What is sildenafil licensed for? (other than ED)

A

Pulmonary arterial hypertension

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107
Q

How does methyldopa work?

A

Centrally acting antihypertensive

Causes the CNS to reduce sympathetic tone

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108
Q

When is methyldopa used?

A

Hypertension in pregnancy

Centrally acting hypertensive - CNS reduces sympathetic tone

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109
Q

What should be monitored with methyldopa?

A

FBC + LFTs

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110
Q

What is a possible adverse effect with methyldopa?

A

Can cause drowsiness - driving

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111
Q

What is a key counselling point with methyldopa?

A

Can cause drowsiness - driving

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112
Q

What is doxazosin used for?

A

Resistant hypertension with other drugs

Alpha blocker

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113
Q

What kind of drug is doxazosin?

A

Alpha blocker?

114
Q

What is a key counselling point with doxazosin?

A

Can cause profound 1st dose hypotension - start carefully

115
Q

What are the aims of treating heart failure?

A

Relieve symptoms
Reduce exacerbations
Reduce mortality

116
Q

Which 2 drugs form the basis of heart failure treatment?

A

ACEi + beta blocker

Titrate both up gradually

ARB can be used instead of ACEi - but high dose needed

117
Q

Which are the 2 common beta blockers used in heart failure?

A

Bisoprolol

Carvedilol

118
Q

How should ACEis and BBs be dosed in heart failure?

A

Both should be gradually titrated up

119
Q

When should spironolactone be used in heart failure?

A

Low dose spironolactone added if symptoms not controlled

Monitor eGFR and potassium

120
Q

What should be monitored with spironolactone in heart failure?

A

Renal function

Potassium

121
Q

What can be added to ACEi + BB in heart failure if symptoms still not controlled?

A

Spironolactone - low dose

Isosorbide denitrate + hydralazine

122
Q

What is an alternative to low dose spironolactone for resistant heart failure?

A

Isosorbide denitrate + hydralazine

Poorly tolerated

123
Q

What is the purpose of digoxin in heart failure?

A

Reducing symptoms and exacerbations
Does not reduce mortality
Usually only added as last resort

124
Q

What can be added in patients with heart failure and fluid overload?

A

Loop or thiazide diuretic

125
Q

When can loop or thiazide diuretics be added in heart failure?

A

If heart failure + fluid overload

126
Q

List 4 indications of ACE inhibitors

A

Heart failure
Hypertension
Diabetic nephropathy
Prophylaxis of cardiovascular events - post MI

127
Q

When should initiation of ACEi take place under specialist supervision?

A 
Severe or unstable heart failure
Taking diuretics
Hypovolaemia
Hyponatraemia
Hypotension
High dose vasodilators
Renovascular disease
128
Q

What effect will ACEi + potassium sparing diuretic have?

A

Increased risk of hyperkalaemia

Low dose spironolactone + ACEi can be used in heart failure

129
Q

Why should only low doses of spironolactone be used in heart failure?

A

Increased risk of hyperkalaemia from ACEi+ potassium-sparing diuretic

130
Q

What should be checked before and during treatment with ACE inhibitors?

A

eGFR

Electrolytes

131
Q

What effect can ACEi + NSAID have?

A

Increases risk of renal damage

132
Q

List 8 side effects of ACE inhibitors

A 
Dry cough
Rash
Diarrhoea or constipation
Hyperkalaemia
Hypoglycaemia
Blood disorders
133
Q

How do ACE inhibitors affect lithium excretion?

A

ACEi’s reduce excretion of lithium

134
Q

Why ACEis X lithium?

A

ACEi’s reduce the excretion of lithium

135
Q

How do ARBs differ from ACEi’s?

A

ARBs do not inhibit breakdown of bradykinin

So less likely to cause persistent dry cough

136
Q

How do nitrates work on the cardiovascular system?

A

Nitrates = potent coronary vasodilators

137
Q

What are nitrates used for?

A

Angina

Potent coronary vasodilators

138
Q

List 3 side effects of nitrates that limits their use

A

Headaches
Flushing
Postural hypotension

139
Q

What is an important consideration with nitrates?

A

Can develop tolerance

Nitrate free period of 4-12 every 24 hours

140
Q

How should GTN tablets be taken?

A

Immediately after chest pain
Take sitting down
Facial flushing may occur

141
Q

What storage considerations should be made with GTN sublingual tablets?

A

Should not be stored in a different container

Discarded after 8 weeks

142
Q

How long should GTN sublingual tablets be kept after opening?

A

Discard after 8 weeks

143
Q

Which adverse effect may occur after taking GTN sublingual tablets?

A

Facial flushing

144
Q

How should isosorbide mononitrate be prescribed?

A

By brand - saves money

145
Q

How should ISMN be dosed?

A

If twice daily - 2nd dose after 8 hours not 12
Nitrate free period

MR preps = once daily

146
Q

Which complaint would make nitrates contraindicated?

A

Patients with recurrent headaches

147
Q

Name 2 calcium channel blockers which should be avoided in heart failure

A

Diltiazem

Verapamil

148
Q

Name 3 side effects of calcium channel blockers

A

Amlodipine, felodipine, verapamil:
Headache
Flushing
Oedema and swelling of ankles

Due to vasodilation properties

149
Q

What is a common interaction involving calcium channel blockers?

A

CCB X simvastatin

Increased risk of myopathy

150
Q

What is diltiazem?

A

Calcium channel blocker

151
Q

How should MR preparations of diltiazem be prescribed?

A

By brand
Adizem
Tildiem

152
Q

What is nifedipine

A

Calcium channel blocker

153
Q

What is nifedipine indicated for?

A

Angina

Hypertension

154
Q

How does nifedipine differ from verapamil?

A

Nifedipine has no anti-arrhythmic activity

155
Q

How should MR preparations of nifedipine be prescribed?

A

By brand

Adalat

156
Q

What is verapamil?

A

Calcium channel blocker

157
Q

What is verapamil indicated for?

A

Angina
Hypertension
Arrhythmias

158
Q

How does verapamil have its effects on the cardiovascular system?

A

Slows heart
Reduces cardiac output
Impairs AV conduction

159
Q

What is a common side effect of verapamil?

A

Constipation

160
Q

2 common drugs should not be given with verapamil

A

Beta blockers

Statins

161
Q

What is nicorandil?

A

Potassium channel activator

Vasodilating properties

162
Q

What is the purpose of using anticoagulants?

A

Preventing thrombus formation in VEINS

Venus thrombi = mostly fibrin - respond to anticoagulation

163
Q

What do anticoagulants only prevent thrombus formation in veins?

A

Venus thrombi = mostly fibrin
So respond to anticoagulation
Arterial thrombi = mostly platelets

164
Q

Why do anticoagulants NOT prevent thrombus formation in the arteries?

A

Arterial thrombi = platelets

Venous thrombi = fibrin

165
Q

What is a venous thromboembolism?

A

Vein becomes completely blocked by a thrombus

DVT, PE

166
Q

What does warfarin antagonise the effect of?

A

Vitamin K

167
Q

How does warfarin have its anticoagulation effects?

A

Antagonises the effect of vitamin K

168
Q

How long can it take warfarin to have an effect?

A

48-72 hours

Quicker effect = heparin

169
Q

What should be used for quick onset of anticoagulation?

A

Heparin

Warfarin = 48-72 hours

170
Q

List 4 indications of warfarin

A

Treatment of VTE
Prophylaxis of VTE
Atrial fibrillation in those at risk of stroke
Prosthetic heart valves

171
Q

What 7 risk factors increase the risk of stroke in atrial fibrillation?

A 
History of TIA
Heart failure
Vascular disease
Diabetes
Hypertension 
Women
Aged over 65
172
Q

When should warfarin be taken?

A

Once daily

Same time each day

173
Q

What are the normal starting and maintenance doses of warfarin?

A

Starting dose = 10mg

Maintenance dose = 3-9mg

174
Q

What is the usual target INR for those on warfarin?

A

2-3

Except in recurrent DVT, a PE in patient already taking anticoagulation therapy, prosthetic heart valves

175
Q

For what conditions is long term treatment with warfarin indicated?

A

1) Atrial fibrillation
→ Warfarin should continue unless risk of bleeding is higher than risk of stroke

2) PE - where risk factors cannot be removed

176
Q

How long is the warfarin treatment plan for those with PE where risk factor is identified and resolved?

A

3 months

177
Q

In what cases are patients given a 3 month warfarin treatment plan?

A

PE where risk factors are identified and resolved

Proximal DVT = upper leg

178
Q

How long is warfarin given for proximal (upper leg) DVT?

A

3 months of warfarin for proximal DVT

179
Q

List 4 risk factors for DVT/PE

A

Oral contraceptive pill
Pregnancy
Plaster cast
Recent surgery

180
Q

How long is warfarin given for distal (lower leg) DVT?

A

6 weeks of warfarin for distal DVT

181
Q

In what cases are patients treated with warfarin for 6 weeks?

A

Distal (lower leg) DVT

182
Q

How often should INR be monitored?

A

Daily or on alternate days initially
Gradually increased
Up to 12 weeks apart

Change to condition or lifestyle = more frequent INR
(Liver, meds, diet, smoking, alcohol)

183
Q

List 5 lifestyle factors which may affect INR control and require more frequent INR testing

A 
Decreased liver function
Change of medication
Diet
Smoking 
Alcohol intake
184
Q

List 4 acute factors which can affect INR control

A

Loss of weight
Acute illness
Diarrhoea
Vomiting

185
Q

What is the main adverse effect of warfarin?

A

Haemorrhage

Any increase in INR should be investigated

186
Q

What should happen if INR increases at any point?

A

The cause should be investigated - increased risk of haemorrhage

187
Q

What should be happen if there are signs of bleeding while on warfarin?

A

Stop warfarin immediately
Start vitamin K

Major bleeding = prothrombin complex

188
Q

What should happen if there is major bleeding while on warfarin?

A

Prothrombin complex

Stop warfarin, start vitamin K

189
Q

What should happen if INR >8 but no signs of bleeding?

A

Stop warfarin

Oral Vitamin K

190
Q

What should happen if INR >5 but no signs of bleeding?

A

Suspend warfarin for 1-2 days

191
Q

How should warfarin be handled with regards to surgery with risk of bleeding?

A

Stop 3 days before
Restart immediately afterwards

Bridging if risk of VTE

192
Q

How should a warfarin patient be handled in surgery if at high risk of VTE?

A

Stop warfarin
Bridging - with dalteparin/tinzaparin
Stop bridging 24 hours before surgery and start 48 hours after

193
Q

How should a patient on warfarin be handled for emergency surgery?

A

Vitamin K + Prothrombin complex

194
Q

What should be considered with regards to warfarin X antiplatelets?

A

Should not overlap
Hold 1 while course of other finishes if possible
If not - assess for bleeding risk
Warfarin + aspirin is better than warfarin + clopidogrel

195
Q

If it is unavoidable that a patient be on an anti platelet while on warfarin - which is the preferred antiplatelet

A

Aspirin is preferred to clopidogrel

196
Q

What should be considered with warfarin in renal impairment?

A

Warfarin can be used in renal impairment

More frequent INR testing in severe renal impairment

197
Q

What should be considered with warfarin in pregnancy?

A

AVOID warfarin in pregnancy

198
Q

What should be issued to patients with warfarin?

A

Anticoagulant treatment book

199
Q

What should be considered regarding diet by patients on warfarin?

A 
Avoid:
Cranberry juice
Liver
Sprouts
Broccoli
Leafy green vegetables
200
Q

List 4 drugs that may increase risk of bleeding through pharmacodynamic interactions

A

Clopidogrel
Ibuprofen
Aspirin
SSRIs

201
Q

List 8 drugs which increase the risk of bleeding via pharmacokinetic interactions

A 
Enzyme INHIBITORS:
Allopurinol
Fluconazole
Omeprazole
Amiodarone
Statins
Erythromycin
Metronidazole
Acute high levels of alcohol
202
Q

List 8 drugs which decrease the effect of warfarin via pharmacokinetic interactions

A 
Enzyme INDUCERS:
Phenobarbital
Carbamazepine
Phenytoin
Rifampicin
Azathioprine
Oral contraceptives
St John's Wort
Chronic alcohol intake
203
Q

Name 2 drugs that can cause unpredictable pharmacokinetic interactions with warfarin

A

Ritonavir

Corticosteroids

204
Q

How can broad spectrum antibiotics increase the risk of bleeding?

A

Killing off bacteria in gut which makes vitamin K

205
Q

Which nutritional supplements should patients avoid taking?

A

Glucosamine

Vitamin E

206
Q

How is warfarin metabolised?

A

In liver

By CYP enzymes

207
Q

How do enzyme inducers affect INR control?

A

Decrease effect of warfarin
Decreased INR
Increased risk of clotting

208
Q

How do enzyme inhibitors affect INR control?

A

Enhance effects of warfarin
Increased INR
Increased risk of bleeding

209
Q

How does dabigatran work as an anticoagulant?

A

Thrombin inhibitor

210
Q

How do apixaban and rivaroxaban work as anticoagulants?

A

Inhibit activated factor X

211
Q

Which 2 DOACs can be affect by enzyme inducers/inhibitors?

A

Apixaban

Rivaroxaban

212
Q

Why may rivaroxaban be the preferred DOAC?

A

Once daily dosing (others are BD)

Cheapest DOAC

213
Q

How often are DOACs taken?

A

Rivaroxaban = once daily

Other DOACs = twice daily dosing

214
Q

Name 3 low molecular weight heparins

A

Enoxaparin
Dalteparin
Tinzaparin

215
Q

How often are LMWH’s given?

A

Once daily

Do not need anticoagulation monitoring

216
Q

What is the dosing for dalteparin?

A 
Prophylactic = 5,000U OD
Treatment = 10,000-15,000 U OD - depending on body weight
217
Q

What is the purpose of anti-platelet drugs?

A

Antiplatelet drugs prevent thrombus formation in faster-flowing arterial circulation

Arterial thrombi = platelets

218
Q

What is 75mg aspirin OD useful for?

A

Secondary prevention of cardiovascular events - already have CVD

No proven benefit of use in primary prevention

219
Q

What is clopidogrel used for?

A

Antiplatelet for preventing thrombotic events in patients with history of ischeamic disease

220
Q

Which 2 cases is clopidogrel + aspirin used?

A

STEMI

AF when warfarin not suitable

221
Q

How should an ischaemic stroke or TIA be treated?

A

Alteplase = thrombolytic - within 4.5 hours of symptom onset
300mg aspirin OD for 2 weeks
Anticoagulant after if necessary (AF)

222
Q

How is stroke managed after the acute period?

A

Clopidogrel 75mg OD

Statin - regardless of cholesterol levels

223
Q

List 4 cautions for aspirin

A

Asthma
Uncontrolled hypertension
History of peptic ulcers
Elderly

224
Q

List 3 contraindications for aspirin

A

Under 16 years old
Haemophilia
Active peptic ulceration

225
Q

How should aspirin be taken?

A

Aspirin should be taken with food

226
Q

What is stable angina caused by?

A

Atherosclerosis in coronary arteries

227
Q

How are acute angina attacks managed?

A

GTN

228
Q

What regular meds are used in angina?

A

Beta blocker
or
Calcium channel blocker - not rate limiting - amlodipine, felodipine, nifedipine

Long acting nitrate (nicorandil) added if needed

229
Q

List 6 factors which increase the risk of developing cardiovascular disease

A 
Diabetes
Chronic kidney disease
Familiar hypercholesterolaemia
Old age
Smokers
Hypertension
230
Q

When should lipid-regulating drugs be given as primary prevention?

A

Prevention of CVD if at high risk

→ risk factors or QRISK >10%

231
Q

At what QRISK score are lipid-regulating drugs given for primary prevention?

A

10%

232
Q

What should normal cholesterol levels be?

A

5 mmol/L

233
Q

Which tests should be carried out when starting lipid-regulating drugs?

A

LFTs

234
Q

What is the 1st line treatment for primary and secondary prevention of cardiovascular disease/events?

A

Statins

235
Q

What tests should be carried out before initiating statins?

A 
Full lipid profile
HbA1c
TSH
eGFR
LFTs
236
Q

Which is the preferred statin for primary and secondary prevention of CVD/events?

A

Atorvostatin

237
Q

How do statins regulate lipids?

A

Statins inhibit HMG CoA reductase

= enzyme involved in cholesterol synthesis

238
Q

What is the difference between statins and fibrates?

A

Statins are better at lowering LDL cholesterol

Fibrates are better at reducing triglyceride levels

239
Q

What should be considered with statins in pregnancy?

A

Avoid statins in pregnancy

Congenital abnormalities

240
Q

List 6 factors which increase the risk of myopathy on statins

A 
Higher dose of statin
History of muscle pain
Alcoholism 
Renal impairment
Hypothyroidism
Age
241
Q

How can statins affect the liver?

A 
Statins are linked with altered liver function
Hepatitis
Jaundice
Pancreatitis
Liver failure
242
Q

List 3 interactions of atorvastatin

A

Increase plasma concentration of atorvastatin = rhabdomyolysis:

Clarithromycin
Verapamil
Fibrates

243
Q

List 8 interactions of simvastatin

A 
Bezafibrate
Amiodarone
Verapamil
Diltiazem
Amlodipine
Clarithromycin
Carbamazepine
Grapefruit juice
244
Q

How does ezetimibe reduce cholesterol levels?

A

Ezetimibe inhibits the intestinal absorption of cholesterol

Can be used alone or in combination with statin - though increased risk of myopathy

245
Q

What is cardioversion?

A

Tachycardia or arrhythmia converted to normal rhythm using drugs or electricity

246
Q

What should occur prior and post electrocardioversion?

A

Patient should be anticoagulated 3 weeks before and 4 weeks afterwards

247
Q

How does amiodarone work?

A

Alters sinus rhythm to restore normal heart beat

248
Q

List 5 monitoring tests that should be done with amiodarone

A 
Thyroid function test - before and every 6 months
LFTs - before and every 6 months
Serum K - before 
Chest x ray - before
ECG (with IV use)
249
Q

What should be considered with amiodarone in pregnancy?

A

Risk of neonatal goitre

Use only if no alternative

250
Q

What should be considered with amiodarone in breastfeeding?

A

Avoid amiodarone in breastfeeding
Present in significant amounts in milk
Risk of neonatal hypothyroidism from release of iodine

251
Q

How long after stopping treatment can amiodaorne interaction occur?

A

Amiodarone has a long half life

Interactions can occur several weeks after stopping

252
Q

What is sotalol used for?

A

Beta blocker

To reduce heart rate in arrhythmias

253
Q

What is a significant caution to be aware of with sotalol?

A

Can cause QT interval prolongation

Can lead to life-threatening ventricular arrhythmias

254
Q

What are some red flags for digoxin?

A

Haemorrhage - reverse by phytomenadione

  • Nosebleeds
  • Bleeding from wounds
  • Bruising

DVT/PE

  • Pain/swelling/red/tenderness in calf
  • Chest pain/SOB

Haemorrhagic stroke

  • Headaches
  • Confusion

Rash, skin necrosis purple toes

Diarrhoea and vomiting - may lead to poor absorption

255
Q

What are the ranges of digoxin in overdose?

A

1.5-3 mcg/L

256
Q

What should be monitored while on digoxin?

A

Serum electrolytes - K, Mg, Ca
Renal function - excretion
Plasma-digoxin
Heart rate - should be >60 bpm

257
Q

Why should serum electrolytes be monitored in digoxin treatment?

A

K, Mg, Ca

Digoxin toxicity increased by hypoK, hypoMg, hyperCa

258
Q

Why is renal function monitored in digoxin treatment?

A

Digoxin is renally excreted

Reduce dose of digoxin in renal impairment to reduce accumulation of metabolite

259
Q

Why should serum electrolytes be monitored in digoxin treatment?

A

K, Mg, Ca

Digoxin toxicity increased by hypoK, hypoMg, hyperCa

260
Q

Why is renal function monitored in digoxin treatment?

A

Digoxin is renally

261
Q

When should bloods be taken to monitor plasma-digoxin?

A

At least 6 hours after dose

262
Q

What is the minimum heart rate for treatment with digoxin?

A

Above 60 bpm

263
Q

Which anticoagulant should a patient receive if they have renal impairment?

A

Unfractionated heparin

264
Q

How is a DVT or PE treated?

A

LMWH/UFH IV infusion
Warfarin started at same time
→ continue for 5+ days and until the INR >2 for at least 24 hours

265
Q

Why are heparins used in pregnancy?

A

They do not cross the placenta

LMWH preferred = lower risk of osteoporosis and HIT

266
Q

When should heparins be stopped in pregnancy?

A

At the onset of labour

267
Q

Why may LMWH be preferred to UFH?

A

Longer duration of action
= less frequent dosing
Monitoring not required as often
= more convenient

268
Q

How does LMWH differ from UFH?

A 
UFH = rapid anticoagulation, short duration
LMWH = longer duration of action
269
Q

Why may LMWH be preferred to UFH

A

Longer duration of action
= less frequent dosing
Monitoring not required as often

270
Q

Why may UFH be preferred to LMWH?

A

Effects can be terminated rapidly by stopping infusion
→ short half life
Good if at high risk of bleeding

271
Q

How can heparins lead to hyperkalaemia?

A

Heparins inhibit aldosterone secretion

272
Q

Which electrolyte can heparins affect?

A

Potassium

Hyperkalaemia

273
Q

List 5 groups of patients that are at an increased risk of hyperkalaemia from heparins

A 
Diabetes mellitus
Chronic renal failure
Acidosis
Raised plasma potassium
Potassium-sparing drugs

→potassium monitored before and during treatment

274
Q

How should ischaemic stroke be managed in the long term?

A

Clopidogrel
(If contraindicated - MR dipyridamole + aspirin)

Statin 48 hours after symptom onset
Treat hypertension - not beta blockers unless for other condition
Lifestyle modifications

275
Q

How should a TIA be managed in the long term?

A

MR dipyridamole in combination with aspirin

MR dipyridamole alone if contra-indicated to aspirin

Clopidogrel alone if contraindicated to both

276
Q

How should stroke associated with AF be managed in the long term?

A

Long term treatment with warfarin

277
Q

What is the target INR range for healthy people?

A

1.1 or below

278
Q

What is the target INR for DVT or PE?

A

3.5

279
Q

What is the target INR for DVT or PE?

A

3.5

280
Q

What should be considered with warfarin in breastfeeding?

A

Significant amounts of warfarin is not present in breastmilk

But increased risk of haemorrhage, especially in vitamin K deficiency

Pre-reg exam (2 decks)

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