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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
Which class of drug should loop diuretics not be given with
Aminoglycosides - vancomycin, gentamicin | Ototoxicity risk
26
Are thiazides or loop diuretics more likely to cause hyperglycaemia?
Thiazides cause hyperglycaemia | Loops can cause hyperglycaemia but less likely to exacerbate diabetes
27
How do loop diuretics affect lithium?
Reduce excretion of lithium | To a lesser extent than thiazides
28
Which diuretic class is preferred in diabetes?
Loop > thiazides
29
Which diuretic class is preferred if patient is also on lithium?
Loop > thiazides | Loop reduces the excretion of lithium to a lesser extent than thiazides
30
What is the purpose of potassium-sparing diuretics/aldosterone antagonists?
Given with thiazide or loop diuretics For retention of potassium Instead of potassium supplements
31
How are potassium sparing diuretics also known?
Aldosterone antagonists
32
Name 2 drugs that potassium sparing diuretics should NOT be given with
ACEi's ARBs Can lead to hyperkalaemia
33
What is the effect of potassium sparing diuretic + ACEi/ARB?
Hyperkalaemia
34
Name an adverse effect of spironolactone
Hepatotoxicity | So take with food
35
Why should spironolactone always be taken with food
Can cause hepatotoxicity
36
What are the 2 ways that atrial fibrillation can be managed?
Rate control | Rhythm control
37
Why is atrial fibrillation treated?
Prevent complications - stroke, VTE
38
What is the preferred method of managing atrial fibrillation?
Rate control | Over rhythm control
39
Which drugs are used to control rate in atrial fibrillation
Beta blocker CCB - rate controlling - diltiazem, verapamil Digoxin - if single drug fails to control AF
40
Which calcium channel blockers are used in atrial fibrillation?
Diltiazem Verapamil Both rate-controllers
41
How do diltiazem and verapamil help to treat AF?
Both are rate controllers
42
Which drugs are used to control rhythm in atrial fibrillation?
Beta blocker + Amiodarone
43
Which drug is used to treat ventricular tachycardia?
Amiodarone
44
List 2 indications of amiodarone
Rhythm control in AF | Ventricular tachycardia
45
When can amiodarone be started?
Under specialist supervision | In hospital setting
46
How quickly does amiodarone start acting?
Long half life May not need loading dose IV amiodarone acts rapidly
47
List the 2 adverse effects of amiodarone that relate to the eyes
Development of corneal deposits - most patients - rarely interfere with vision, can cause dazzling at night Phototoxicity
48
How does amiodarone affect the thyroid
Amiodarone contains iodine Can cause hypothyroidism + hyperthyroidism Monitor thyroid function even 6 months
49
Why should thyroid function be monitored on amiodarone
Amiodarone contains iodine Can cause hypo- + hyper thyroidism Monitor thyroid function every 6 months
50
How often should thyroid function be monitored when on amiodarone?
Every 6 months
51
List 3 symptoms of hyperthyroidism associated with amiodarone use
Weight loss Palpitations Insomnia
52
How can amiodarone affect the skin?
Cause blue-grey discolouration This is an acceptable side effect Cover skin and use wide spectrum suncream
53
How does amiodarone affect the liver
Can cause hepatotoxicity LFTs every 6 months Stop amiodarone if hepatotoxicity occurs
54
How often should LFTs be performed on amiodarone
Every 6 months Stop amiodarone if hepatotoxicity occurs
55
Why should LFTs be performed every 6 months when on amiodarone?
Amiodarone can cause hepatotoxicity Stop amiodarone
56
How can amiodarone affect the nerves?
Amiodarone can cause peripheral neuropathy
57
List 9 possible side effects/adverse effects of amiodarone
``` Corneal micro-deposits Dazzling at night Phototoxicity Hypothyroidism Hyperthyroidism Grey skin Hepatotoxicity Peripheral neuropathy Taste disturbances ```
58
Which drugs does amiodarone affect the levels of?
Warfarin Digoxin Phenytoin
59
Why does amiodarone X simvastatin?
Increased risk of myopathy
60
Why does amiodarone X Lithium
Increased risk of arrhythmias
61
How do beta blockers have their effect?
Act on beta-adrenoceptors in heart and peripheral vasculature Also receptors in liver, bronchi and pancreas
62
Name 4 beta blockers that are least likely to cross the blood-brain barrier
Atenolol Sotalol Nadolol Celiprolol Most water-soluble beta blockers Less likely to cross BBB So reduced sleep disturbance and nightmares
63
Name 4 beta blockers that are the least likely to cause sleep disturbance and nightmares
Atenolol Sotalol Nadolol Celiprolol Most water soluble beta blockers Less likely to cross BBB Reduced sleep disturbance and nightmares
64
Why are some beta blockers less likely to cause sleep disturbance and nightmares?
Water soluble Less likely to cross BBB Atenolol, sotalol, nadolol, celiprolol
65
Why should beta blockers be avoided in asthmatics?
Beta-adrenoceptors in bronchi | Can cause bronchospasm
66
How do beta blockers affect the lungs?
Beta adrenoceptors in lungs Can cause bronchospasm Avoid in asthmatics
67
What should be used if beta blockers are necessary in asthma?
Use more cardio selective beta blocker | Atenolol, Bisoprolol
68
How do beta blockers affect the liver and pancreas?
Affect carbohydrate emetabolism | = Hyper or Hypo glycaemia
69
How can beta blockers cause hypo or hyperglycaemia?
Affect carbohydrate metabolsim | By effects on liver and pancreas
70
How can beta blockers affect sugar levels?
Can cause hypo or hyper glycaemia | By interacting with liver & pancreas so affecting carbohydrate metabolism
71
What should be considered in diabetic patients being prescribed a beta blocker?
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
72
When should beta blockers not be recommended in diabetes?
When in combination with thiazide diuretic for hypertension
73
How do beta blockers help to manage angina?
Reduce workload of heart
74
How can beta blockers be of use post MI
May prevent recurrence of MI | Reduces workload of the heart
75
Name 2 beta blockers that can reduce the mortality of heart failure
Bisoprolol | Carvedilol
76
List 5 indications of beta blockers
``` Hypertension Angina Post MI - reduce recurrence Heart failure - reduce mortality Anxiety Migraine prophylaxis ```
77
What is an important consideration when stopping a beta blocker?
Beta blockers should not be stopped suddenly | Especially in ischaemic heart disease - following an MI
78
What is the purpose of treating hypertension?
Reduce risk of stroke, coronary events, heart failure and renal impairment
79
What is stage 1 hypertension?
140/90mmHg or above
80
When should stage 1 hypertension be treated?
If damage to an organ - heart, kidney, eye disease, diabetes or If QRISK score >20%
81
What is stage 2 hypertension?
160/100 mmHg or above
82
When should stage 2 hypertension be treated?
All patients with stage 2 hypertension should be treated
83
Describe stage 1 hypertension
140/90mmHg or above | Treat only if target organ damage - heart, kidney, eye, diabetes or if QRISK score >20%
84
Describe stage 2 hypertension
160/100 mmHg or above | All patients with stage 2 hypertension should be treated
85
What is severe hypertension?
Systolic >180 mmHg | Diastolic >100 mmHg
86
How should drugs be added in hypertension?
Usually more than 1 drug required Added step-wise Gap of 4 weeks between each drug
87
What is the 1st line treatment for hypertension in under 55s?
ACE inhibitor ARB if ACEi not tolerated Beta blocker if ACEi and ARB not suitable
88
What is the 2nd line treatment for hypertension in under 55s?
ACEi or ARB + CCB If have HF or risk of HF - thiazide (indapamide) > CCB
89
What are the treatment options for hypertension in those who are under 55 years old?
1) ACEi (--> ARB --> BB) | 2) ACEi or ARB + CCB (thiazide > CCB if HF or risk of HF)
90
Which diuretic is used for hypertension if patient also has heart failure or is at risk of heart failure?
Indapamide | = Thiazide diuretic
91
What is the 1st line treatment for hypertension in black patients?
Calcium channel blocker | Or thiazide diuretic (indapamide) if risk of heart failure
92
What is the 1st line treatment for hypertension in the over 55s?
Calcium channel blocker | Or thiazide diuretic (indapamide) if risk of heart failure
93
What is the 2nd line treatment for hypertension in over 55s?
CCB (or thiazide) + ACEi or ARB
94
What is the 2nd line treatment for hypertension in black patients?
CCB (or thiazide) + ARB or ACEi
95
What are the treatment options for hypertension in over 55s?
1) CCB | 2) CCB + ARB or ACEi
96
What are the treatment options for hypertension in black patients?
1) CCB | 2) CCB + ARB or ACEi
97
What is the 3rd line treatment for hypertension in all patients?
ACEi or ARB + CCB + thiazide + spironolactone, alpha or beta blockers + aspirin, statins if patient at high risk
98
What is the choice of antihypertensive in pregnancy?
Methyldopa | Not losaratan or ramipril - lower baby's blood pressure and inhibit growth
99
Why should ramipril or losartan now be used in pregnancy
Lower baby's blood pressure = inhibits growth
100
Which 2 antihypertensives should not be given in pregnancy?
Losaratan and ramipril | Lower baby's blood pressure = inhibits growth
101
At what age may hypertension medication not be considered necessary?
Newly diagnosed hypertension at around 80 years old
102
How should just raised systolic BP be treated?
Treat as regular hypertension | Raised systolic still = cardiovascular disease risk
103
How should patients with hypertension and renal disease?
ACEi - with caution | Thiazides may not work - loop diuretics may be needed instead
104
Name 3 vasodilators
Hydralazine Minoxidil Sildenafil
105
What is hydralazine used for?
Resistant hypertension | Rarely used on its own
106
What is sildenafil licensed for? (other than ED)
Pulmonary arterial hypertension
107
How does methyldopa work?
Centrally acting antihypertensive | Causes the CNS to reduce sympathetic tone
108
When is methyldopa used?
Hypertension in pregnancy Centrally acting hypertensive - CNS reduces sympathetic tone
109
What should be monitored with methyldopa?
FBC + LFTs
110
What is a possible adverse effect with methyldopa?
Can cause drowsiness - driving
111
What is a key counselling point with methyldopa?
Can cause drowsiness - driving
112
What is doxazosin used for?
Resistant hypertension with other drugs | Alpha blocker
113
What kind of drug is doxazosin?
Alpha blocker?
114
What is a key counselling point with doxazosin?
Can cause profound 1st dose hypotension - start carefully
115
What are the aims of treating heart failure?
Relieve symptoms Reduce exacerbations Reduce mortality
116
Which 2 drugs form the basis of heart failure treatment?
ACEi + beta blocker Titrate both up gradually ARB can be used instead of ACEi - but high dose needed
117
Which are the 2 common beta blockers used in heart failure?
Bisoprolol | Carvedilol
118
How should ACEis and BBs be dosed in heart failure?
Both should be gradually titrated up
119
When should spironolactone be used in heart failure?
Low dose spironolactone added if symptoms not controlled | Monitor eGFR and potassium
120
What should be monitored with spironolactone in heart failure?
Renal function | Potassium
121
What can be added to ACEi + BB in heart failure if symptoms still not controlled?
Spironolactone - low dose | Isosorbide denitrate + hydralazine
122
What is an alternative to low dose spironolactone for resistant heart failure?
Isosorbide denitrate + hydralazine | Poorly tolerated
123
What is the purpose of digoxin in heart failure?
Reducing symptoms and exacerbations Does not reduce mortality Usually only added as last resort
124
What can be added in patients with heart failure and fluid overload?
Loop or thiazide diuretic
125
When can loop or thiazide diuretics be added in heart failure?
If heart failure + fluid overload
126
List 4 indications of ACE inhibitors
Heart failure Hypertension Diabetic nephropathy Prophylaxis of cardiovascular events - post MI
127
When should initiation of ACEi take place under specialist supervision?
``` Severe or unstable heart failure Taking diuretics Hypovolaemia Hyponatraemia Hypotension High dose vasodilators Renovascular disease ```
128
What effect will ACEi + potassium sparing diuretic have?
Increased risk of hyperkalaemia | Low dose spironolactone + ACEi can be used in heart failure
129
Why should only low doses of spironolactone be used in heart failure?
Increased risk of hyperkalaemia from ACEi+ potassium-sparing diuretic
130
What should be checked before and during treatment with ACE inhibitors?
eGFR | Electrolytes
131
What effect can ACEi + NSAID have?
Increases risk of renal damage
132
List 8 side effects of ACE inhibitors
``` Dry cough Rash Diarrhoea or constipation Hyperkalaemia Hypoglycaemia Blood disorders ```
133
How do ACE inhibitors affect lithium excretion?
ACEi's reduce excretion of lithium
134
Why ACEis X lithium?
ACEi's reduce the excretion of lithium
135
How do ARBs differ from ACEi's?
ARBs do not inhibit breakdown of bradykinin | So less likely to cause persistent dry cough
136
How do nitrates work on the cardiovascular system?
Nitrates = potent coronary vasodilators
137
What are nitrates used for?
Angina | Potent coronary vasodilators
138
List 3 side effects of nitrates that limits their use
Headaches Flushing Postural hypotension
139
What is an important consideration with nitrates?
Can develop tolerance | Nitrate free period of 4-12 every 24 hours
140
How should GTN tablets be taken?
Immediately after chest pain Take sitting down Facial flushing may occur
141
What storage considerations should be made with GTN sublingual tablets?
Should not be stored in a different container | Discarded after 8 weeks
142
How long should GTN sublingual tablets be kept after opening?
Discard after 8 weeks
143
Which adverse effect may occur after taking GTN sublingual tablets?
Facial flushing
144
How should isosorbide mononitrate be prescribed?
By brand - saves money
145
How should ISMN be dosed?
If twice daily - 2nd dose after 8 hours not 12 Nitrate free period MR preps = once daily
146
Which complaint would make nitrates contraindicated?
Patients with recurrent headaches
147
Name 2 calcium channel blockers which should be avoided in heart failure
Diltiazem | Verapamil
148
Name 3 side effects of calcium channel blockers
Amlodipine, felodipine, verapamil: Headache Flushing Oedema and swelling of ankles Due to vasodilation properties
149
What is a common interaction involving calcium channel blockers?
CCB X simvastatin | Increased risk of myopathy
150
What is diltiazem?
Calcium channel blocker
151
How should MR preparations of diltiazem be prescribed?
By brand Adizem Tildiem
152
What is nifedipine
Calcium channel blocker
153
What is nifedipine indicated for?
Angina | Hypertension
154
How does nifedipine differ from verapamil?
Nifedipine has no anti-arrhythmic activity
155
How should MR preparations of nifedipine be prescribed?
By brand | Adalat
156
What is verapamil?
Calcium channel blocker
157
What is verapamil indicated for?
Angina Hypertension Arrhythmias
158
How does verapamil have its effects on the cardiovascular system?
Slows heart Reduces cardiac output Impairs AV conduction
159
What is a common side effect of verapamil?
Constipation
160
2 common drugs should not be given with verapamil
Beta blockers | Statins
161
What is nicorandil?
Potassium channel activator | Vasodilating properties
162
What is the purpose of using anticoagulants?
Preventing thrombus formation in VEINS | Venus thrombi = mostly fibrin - respond to anticoagulation
163
What do anticoagulants only prevent thrombus formation in veins?
Venus thrombi = mostly fibrin So respond to anticoagulation Arterial thrombi = mostly platelets
164
Why do anticoagulants NOT prevent thrombus formation in the arteries?
Arterial thrombi = platelets | Venous thrombi = fibrin
165
What is a venous thromboembolism?
Vein becomes completely blocked by a thrombus | DVT, PE
166
What does warfarin antagonise the effect of?
Vitamin K
167
How does warfarin have its anticoagulation effects?
Antagonises the effect of vitamin K
168
How long can it take warfarin to have an effect?
48-72 hours Quicker effect = heparin
169
What should be used for quick onset of anticoagulation?
Heparin | Warfarin = 48-72 hours
170
List 4 indications of warfarin
Treatment of VTE Prophylaxis of VTE Atrial fibrillation in those at risk of stroke Prosthetic heart valves
171
What 7 risk factors increase the risk of stroke in atrial fibrillation?
``` History of TIA Heart failure Vascular disease Diabetes Hypertension Women Aged over 65 ```
172
When should warfarin be taken?
Once daily | Same time each day
173
What are the normal starting and maintenance doses of warfarin?
Starting dose = 10mg | Maintenance dose = 3-9mg
174
What is the usual target INR for those on warfarin?
2-3 Except in recurrent DVT, a PE in patient already taking anticoagulation therapy, prosthetic heart valves
175
For what conditions is long term treatment with warfarin indicated?
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
How long is the warfarin treatment plan for those with PE where risk factor is identified and resolved?
3 months
177
In what cases are patients given a 3 month warfarin treatment plan?
PE where risk factors are identified and resolved | Proximal DVT = upper leg
178
How long is warfarin given for proximal (upper leg) DVT?
3 months of warfarin for proximal DVT
179
List 4 risk factors for DVT/PE
Oral contraceptive pill Pregnancy Plaster cast Recent surgery
180
How long is warfarin given for distal (lower leg) DVT?
6 weeks of warfarin for distal DVT
181
In what cases are patients treated with warfarin for 6 weeks?
Distal (lower leg) DVT
182
How often should INR be monitored?
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
List 5 lifestyle factors which may affect INR control and require more frequent INR testing
``` Decreased liver function Change of medication Diet Smoking Alcohol intake ```
184
List 4 acute factors which can affect INR control
Loss of weight Acute illness Diarrhoea Vomiting
185
What is the main adverse effect of warfarin?
Haemorrhage Any increase in INR should be investigated
186
What should happen if INR increases at any point?
The cause should be investigated - increased risk of haemorrhage
187
What should be happen if there are signs of bleeding while on warfarin?
Stop warfarin immediately Start vitamin K Major bleeding = prothrombin complex
188
What should happen if there is major bleeding while on warfarin?
Prothrombin complex Stop warfarin, start vitamin K
189
What should happen if INR >8 but no signs of bleeding?
Stop warfarin | Oral Vitamin K
190
What should happen if INR >5 but no signs of bleeding?
Suspend warfarin for 1-2 days
191
How should warfarin be handled with regards to surgery with risk of bleeding?
Stop 3 days before Restart immediately afterwards Bridging if risk of VTE
192
How should a warfarin patient be handled in surgery if at high risk of VTE?
Stop warfarin Bridging - with dalteparin/tinzaparin Stop bridging 24 hours before surgery and start 48 hours after
193
How should a patient on warfarin be handled for emergency surgery?
Vitamin K + Prothrombin complex
194
What should be considered with regards to warfarin X antiplatelets?
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
If it is unavoidable that a patient be on an anti platelet while on warfarin - which is the preferred antiplatelet
Aspirin is preferred to clopidogrel
196
What should be considered with warfarin in renal impairment?
Warfarin can be used in renal impairment | More frequent INR testing in severe renal impairment
197
What should be considered with warfarin in pregnancy?
AVOID warfarin in pregnancy
198
What should be issued to patients with warfarin?
Anticoagulant treatment book
199
What should be considered regarding diet by patients on warfarin?
``` Avoid: Cranberry juice Liver Sprouts Broccoli Leafy green vegetables ```
200
List 4 drugs that may increase risk of bleeding through pharmacodynamic interactions
Clopidogrel Ibuprofen Aspirin SSRIs
201
List 8 drugs which increase the risk of bleeding via pharmacokinetic interactions
``` Enzyme INHIBITORS: Allopurinol Fluconazole Omeprazole Amiodarone Statins Erythromycin Metronidazole Acute high levels of alcohol ```
202
List 8 drugs which decrease the effect of warfarin via pharmacokinetic interactions
``` Enzyme INDUCERS: Phenobarbital Carbamazepine Phenytoin Rifampicin Azathioprine Oral contraceptives St John's Wort Chronic alcohol intake ```
203
Name 2 drugs that can cause unpredictable pharmacokinetic interactions with warfarin
Ritonavir | Corticosteroids
204
How can broad spectrum antibiotics increase the risk of bleeding?
Killing off bacteria in gut which makes vitamin K
205
Which nutritional supplements should patients avoid taking?
Glucosamine | Vitamin E
206
How is warfarin metabolised?
In liver | By CYP enzymes
207
How do enzyme inducers affect INR control?
Decrease effect of warfarin Decreased INR Increased risk of clotting
208
How do enzyme inhibitors affect INR control?
Enhance effects of warfarin Increased INR Increased risk of bleeding
209
How does dabigatran work as an anticoagulant?
Thrombin inhibitor
210
How do apixaban and rivaroxaban work as anticoagulants?
Inhibit activated factor X
211
Which 2 DOACs can be affect by enzyme inducers/inhibitors?
Apixaban | Rivaroxaban
212
Why may rivaroxaban be the preferred DOAC?
Once daily dosing (others are BD) | Cheapest DOAC
213
How often are DOACs taken?
Rivaroxaban = once daily | Other DOACs = twice daily dosing
214
Name 3 low molecular weight heparins
Enoxaparin Dalteparin Tinzaparin
215
How often are LMWH's given?
Once daily | Do not need anticoagulation monitoring
216
What is the dosing for dalteparin?
``` Prophylactic = 5,000U OD Treatment = 10,000-15,000 U OD - depending on body weight ```
217
What is the purpose of anti-platelet drugs?
Antiplatelet drugs prevent thrombus formation in faster-flowing arterial circulation Arterial thrombi = platelets
218
What is 75mg aspirin OD useful for?
Secondary prevention of cardiovascular events - already have CVD No proven benefit of use in primary prevention
219
What is clopidogrel used for?
Antiplatelet for preventing thrombotic events in patients with history of ischeamic disease
220
Which 2 cases is clopidogrel + aspirin used?
STEMI | AF when warfarin not suitable
221
How should an ischaemic stroke or TIA be treated?
Alteplase = thrombolytic - within 4.5 hours of symptom onset 300mg aspirin OD for 2 weeks Anticoagulant after if necessary (AF)
222
How is stroke managed after the acute period?
Clopidogrel 75mg OD | Statin - regardless of cholesterol levels
223
List 4 cautions for aspirin
Asthma Uncontrolled hypertension History of peptic ulcers Elderly
224
List 3 contraindications for aspirin
Under 16 years old Haemophilia Active peptic ulceration
225
How should aspirin be taken?
Aspirin should be taken with food
226
What is stable angina caused by?
Atherosclerosis in coronary arteries
227
How are acute angina attacks managed?
GTN
228
What regular meds are used in angina?
Beta blocker or Calcium channel blocker - not rate limiting - amlodipine, felodipine, nifedipine Long acting nitrate (nicorandil) added if needed
229
List 6 factors which increase the risk of developing cardiovascular disease
``` Diabetes Chronic kidney disease Familiar hypercholesterolaemia Old age Smokers Hypertension ```
230
When should lipid-regulating drugs be given as primary prevention?
Prevention of CVD if at high risk | → risk factors or QRISK >10%
231
At what QRISK score are lipid-regulating drugs given for primary prevention?
10%
232
What should normal cholesterol levels be?
5 mmol/L
233
Which tests should be carried out when starting lipid-regulating drugs?
LFTs
234
What is the 1st line treatment for primary and secondary prevention of cardiovascular disease/events?
Statins
235
What tests should be carried out before initiating statins?
``` Full lipid profile HbA1c TSH eGFR LFTs ```
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Which is the preferred statin for primary and secondary prevention of CVD/events?
Atorvostatin
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How do statins regulate lipids?
Statins inhibit HMG CoA reductase | = enzyme involved in cholesterol synthesis
238
What is the difference between statins and fibrates?
Statins are better at lowering LDL cholesterol | Fibrates are better at reducing triglyceride levels
239
What should be considered with statins in pregnancy?
Avoid statins in pregnancy | Congenital abnormalities
240
List 6 factors which increase the risk of myopathy on statins
``` Higher dose of statin History of muscle pain Alcoholism Renal impairment Hypothyroidism Age ```
241
How can statins affect the liver?
``` Statins are linked with altered liver function Hepatitis Jaundice Pancreatitis Liver failure ```
242
List 3 interactions of atorvastatin
Increase plasma concentration of atorvastatin = rhabdomyolysis: Clarithromycin Verapamil Fibrates
243
List 8 interactions of simvastatin
``` Bezafibrate Amiodarone Verapamil Diltiazem Amlodipine Clarithromycin Carbamazepine Grapefruit juice ```
244
How does ezetimibe reduce cholesterol levels?
Ezetimibe inhibits the intestinal absorption of cholesterol | Can be used alone or in combination with statin - though increased risk of myopathy
245
What is cardioversion?
Tachycardia or arrhythmia converted to normal rhythm using drugs or electricity
246
What should occur prior and post electrocardioversion?
Patient should be anticoagulated 3 weeks before and 4 weeks afterwards
247
How does amiodarone work?
Alters sinus rhythm to restore normal heart beat
248
List 5 monitoring tests that should be done with amiodarone
``` 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
What should be considered with amiodarone in pregnancy?
Risk of neonatal goitre | Use only if no alternative
250
What should be considered with amiodarone in breastfeeding?
Avoid amiodarone in breastfeeding Present in significant amounts in milk Risk of neonatal hypothyroidism from release of iodine
251
How long after stopping treatment can amiodaorne interaction occur?
Amiodarone has a long half life | Interactions can occur several weeks after stopping
252
What is sotalol used for?
Beta blocker | To reduce heart rate in arrhythmias
253
What is a significant caution to be aware of with sotalol?
Can cause QT interval prolongation | Can lead to life-threatening ventricular arrhythmias
254
What are some red flags for digoxin?
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
What are the ranges of digoxin in overdose?
1.5-3 mcg/L
256
What should be monitored while on digoxin?
Serum electrolytes - K, Mg, Ca Renal function - excretion Plasma-digoxin Heart rate - should be >60 bpm
257
Why should serum electrolytes be monitored in digoxin treatment?
K, Mg, Ca | Digoxin toxicity increased by hypoK, hypoMg, hyperCa
258
Why is renal function monitored in digoxin treatment?
Digoxin is renally excreted | Reduce dose of digoxin in renal impairment to reduce accumulation of metabolite
259
Why should serum electrolytes be monitored in digoxin treatment?
K, Mg, Ca | Digoxin toxicity increased by hypoK, hypoMg, hyperCa
260
Why is renal function monitored in digoxin treatment?
Digoxin is renally
261
When should bloods be taken to monitor plasma-digoxin?
At least 6 hours after dose
262
What is the minimum heart rate for treatment with digoxin?
Above 60 bpm
263
Which anticoagulant should a patient receive if they have renal impairment?
Unfractionated heparin
264
How is a DVT or PE treated?
LMWH/UFH IV infusion Warfarin started at same time → continue for 5+ days and until the INR >2 for at least 24 hours
265
Why are heparins used in pregnancy?
They do not cross the placenta | LMWH preferred = lower risk of osteoporosis and HIT
266
When should heparins be stopped in pregnancy?
At the onset of labour
267
Why may LMWH be preferred to UFH?
Longer duration of action = less frequent dosing Monitoring not required as often = more convenient
268
How does LMWH differ from UFH?
``` UFH = rapid anticoagulation, short duration LMWH = longer duration of action ```
269
Why may LMWH be preferred to UFH
Longer duration of action = less frequent dosing Monitoring not required as often
270
Why may UFH be preferred to LMWH?
Effects can be terminated rapidly by stopping infusion → short half life Good if at high risk of bleeding
271
How can heparins lead to hyperkalaemia?
Heparins inhibit aldosterone secretion
272
Which electrolyte can heparins affect?
Potassium | Hyperkalaemia
273
List 5 groups of patients that are at an increased risk of hyperkalaemia from heparins
``` Diabetes mellitus Chronic renal failure Acidosis Raised plasma potassium Potassium-sparing drugs ``` →potassium monitored before and during treatment
274
How should ischaemic stroke be managed in the long term?
Clopidogrel (If contraindicated - MR dipyridamole + aspirin) Statin 48 hours after symptom onset Treat hypertension - not beta blockers unless for other condition Lifestyle modifications
275
How should a TIA be managed in the long term?
MR dipyridamole in combination with aspirin MR dipyridamole alone if contra-indicated to aspirin Clopidogrel alone if contraindicated to both
276
How should stroke associated with AF be managed in the long term?
Long term treatment with warfarin
277
What is the target INR range for healthy people?
1.1 or below
278
What is the target INR for DVT or PE?
3.5
279
What is the target INR for DVT or PE?
3.5
280
What should be considered with warfarin in breastfeeding?
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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