Cardiovascular Part 8

Question 1

What is the interaction between statins and amiodarone?

Answer 1

Risk of rhabdomyolysis

Question 2

What is the interaction between thiazide diuretics and PPIs?

Answer 2

Hyponatraemia

Question 3

What is the interaction between thiazide diuretics and lithium?

Answer 3

Increased lithium toxicity

Question 4

What is the initial ACS treatment?

Answer 4

Sublingual/ buccal GTN for pain releief
IV morphine also for pain relief especially in MI
Aspirin loading dose
Dual antiplatelet (prasugrel, ticagrelor (180mg) & clopidogrel - prasugrel preferred if undergoing primary PCI

Question 5

What is the secondary prevention of cardiovascular events?

Answer 5

• ACEi/ARB
• BB (continue indefinitely in reduced left ventricular ejection fraction otherwise discontinue after 12 months)
  Consider diltiazem or verapamil as an alternative to BB in pt’s who do not have pulmonary congestion or reduced LVEF
• Dual antiplatelet therapy (aspirin indefinitely, 2nd antiplatelet for 12 months)
  if aspirin contraindicated = clopidogrel monotherapy
  Another option: rivaroxaban with either aspirin alone or aspirin and clopidogrel (this option is recommended for elevated cardiac biomarkers)
• Statin

Question 6

What thrombolytic drugs are used to treat MI?

Answer 6

Streptokinase and alteplase - found to reduce mortality
For acute MI: reteplase and tenecteplase
- Alteplase: given within 6-12 hours of symptom onset
- Reteplase and streptokinase: within 12 hours of symptom onset
- Tenecteplase: usually within 6 hours
Ideally all should be given within an hour

Question 7

What is the digoxin dose for heart failure?

Answer 7

62.5mcg-125mcg

Question 8

What is the digoxin dose for AF?

Answer 8

125mcg-250mcg

Question 9

What drugs do you need to half the dose of digoxin dose with?

Answer 9

Amiodarone
Dronedarone
Quinine
If digoxin or another cardiac glycoside has been given in the preceding 2 weeks
In elderly

Question 10

When would you increase digoxin dose?

Answer 10

When switching from IV to oral - increase dose by 20-33% to maintain the same plasma digoxin concentration

Question 11

Which drugs increase plasma digoxin levels?

Answer 11

Amiodarone
Rate limiting CCB
Macrolides
Ciclosporin

Question 12

Which drugs decrease plasma digoxin levels?

Answer 12

St John’s Wort
Rifampicin

Question 12

What drug class is angioedema more likely to happen in?

Answer 12

ACEi - common
Uncommon - CCB

Question 13

Which drugs can cause hypokalaemia?

Answer 13

Diuretics
B2 agonists
Steroids
Theophylline

(These drugs predispose digoxin)

Question 14

Which drugs decrease renal excretion?

Answer 14

NSAIDs
ACEi/ARB

(reduce digoxin dose when taking these as digoxin is also renally excreted)

Question 15

What are the common side effects of Nicorandil?

Answer 15

• Skin, mucosal and eye ulcers (including GI) - stop treatment if ulcers occur (e.g. anal ulcers)
• Headache: common on initiation
• Flushing
• Asthenia
• Hyperkalaemia
• Abdominal pain
• N/V
• Diplopia (double vision)

Question 16

What is the treatment of stable angina?

Answer 16

1st line: BB (atenolol, bisoprolol, metoprolol, propranolol)/ rate limiting CCB (if BB contraindicated)
2nd line: BB + rate limiting CCB
3rd line: long-acting nitrate
- Ivabradine
- Nicorandil
Ranolazine

(secondary prevention = Aspirin + statin)

Question 17

What are the contraindications for BBs for stable angina?

Answer 17

Prinzmetals angina
Decompensated HF

Question 18

What drugs would you consider in prinzmetals angina?

Answer 18

Dihydropyridine derivatives
- Amlodipine

Question 19

What are the adverse effects of diuretics?

Answer 19

Hypotension
Ototoxicity
HYPO-Na/K/Mg/Ca
Hyperglycaemia (more common with thiazides)
Metabolic acidosis
Renal impairment from dehydration
Gout