Cardiovascular System Flashcards
1
Q
What is ectopic beats?
A
Ectopic heartbeats are changes in a heartbeat that is otherwise normal. These changes lead to extra or skipped heartbeats. There is often not a clear cause for these changes. They are common.
2
Q
What is the tx for ectopic beats?
A
Beta blockers
3
Q
What is atrial fibrillation?
A
Atrial fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate. Can be higher than 100bpm
4
Q
What can AF lead to?
A
Stroke - blood may not be fully ejected so can cause clot
5
Q
How do you manage AF?
A
Ventricular rate control or sinus rhythm control
6
Q
What is ventricular rate control?
A
Using medications
7
Q
What is sinus rhythm control?
A
Using cardioversion
8
Q
What do you do if pt presents with life-threatening haemodynamic instablilty?
A
Emergency electrical cardioversion w/o delaying to achieve anticoagulation
9
Q
What do you do if pt presents w/o life-threatening haemodynamic instablilty within <48hr
A
Rate or rhythm control
10
Q
What do you do if pt presents w/o life-threatening haemodynamic instablilty within >48hr
A
Rate control
11
Q
What is pharmacological cardioversion?
A
Flecainide or amiodarone
12
Q
What is electrical cardioversion?
A
start IV anticoagulation + rule out left atrial thrombus
13
Q
What is AF maintenance?
A
1) rate control monotherapy - standard BBlocker (x sotalol) OR RL CCB or digoxin (predominantly sedentary pt with non-paroxysmal AF)
2) rate control with dual therapy (bblocker +__)
3) rhythm control - if >48hr risk of clotting so electrical cardioversion. Pt needs to be anticoagulated for at least 3 weeks and given oral anticoagulation for 4 wks after.
14
Q
What drugs are used for post cardioversion tx?
A
Standard Bblockers - SPAF (sotalol, propafenone, amiodarone (4wk before and continue for 12MT) or flecainide).
15
Q
What is paroxysmal AF?
A
Intermittent episodes of atrial fibrillation that terminate within seven days either spontaneously or with intervention.
16
Q
How to tx paroxysmal AF?
A
Standard bblockers if x work then SPAF.
Episodes; pill in pocket - flecainide/propafenone PRN
17
Q
How does stroke prevention work?
A
Assess risk of stroke + need for thromboprphylaxis (warfarin) using CHA2DSC2-VASc.
X needed if men = 0 women =1
18
Q
what is CHA2DSC2-VASc?
A
C = congestive heart failure- 1
H = hypertension - 1
A2 = 75+ - 2
D = diabetes - 1
S2 = stroke/TIA - 2
V = vascular disease - 1
A = 66-74 - 1
Sc = sex (female) - 1
19
Q
How do you tx atrial flutter?
A
rhythm or rate control.
More effective with cardioversion. If meds = Bblockers or RL CCB.
20
Q
What is atrial flutter?
A
Atrial flutter is an abnormal heart rhythm (arrhythmia) which causes the upper chambers of your heart (atria) to beat too quickly. This can lead to symptoms such as palpitations and feeling light-headed.
21
Q
How is rhythm control used in atrial flutter?
A
1) Direct current cardioversion
2) Pharmacological cardioversion
3) catheter ablation (recurrent tx)
22
Q
What do you do if atrial flutter has lasted >48hr?
A
anticoagulation for 3wk
23
Q
What is paroxysmal supraventricular tachycardia?
A
It occurs when a short circuit rhythm develops in the upper chamber of the heart. This results in a regular but rapid heartbeat that starts and stops abruptly. Normally tx not needed
24
Q
What is the tx for paroxysmal supraventricular tachycardia?
A
1) should terminate spontaneously on its own
2) reflux vagal stimulation
3) IV adenosine
4) IV verapamil
if recurrent - catheter ablation
prevent future - bblockers or RL CcB
25
What is ventricular tachycardia?
Ventricular tachycardia (VT or V-tach) is a type of abnormal heart rhythm, or arrhythmia. It occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood.
26
How do you tx pulseless ventricular tachycardia or ventricular fibrillation?
resuscitation
27
How do you tx unstable sustained ventricular tachycardia?
direct current cardioversion or IV amiodarone and repeat current cardioversion of others x work
28
How do you tx stable ventricular tachycardia?
1) IV amiodarone * direct current cardioversion
2) if x sustained bblocker
29
What is the maintenance therapy for pt who are at high risk of cardiac arrest
1) implantable cardioverter defibrillator
2) + bblocker or amiodarone (in combination with bblocker)
30
What is QT prolongation?
QT prolongation is the medical term for an extended interval between the heart contracting and relaxing. This condition increases risk of experiencing abnormal heart rhythms and sudden cardiac arrest. QT prolongation can be present from birth, or it may develop later in life.
Usually self-limiting but can be recurrent. Can lead to impaired consciousness if not controlled - VF - DEATH.
31
What causes QT prolongation?
Can be drug-induced (amiodarone, sotalol, macrolides, SSRI, TCA, antifungals, haloperidol) or caused by hypokalaemia + severe bradycardia
32
What is tx for QT prolongation?
IV magnesium sulphate.
Blocker x sotalol
Consider atrial/ventricular pacing
33
What is anti-arrhythmic drugs classified into?
Supraventricular arrythmias, ventricular arrythmias or both
34
What is the electrical classification of anti-arrhythmic drugs?
*less clinical*
1) membrane stabilising drugs (flecainide/lidocaine)
2) bblockers
3) amiodarone, sotalol
4) CCB (verapamil, diltiazem)
35
What is the dose of amiodarone ?
200mg TDS 7DY* 200mg BD 7DY* 200mg OD DIR
36
When do you avoid amiodarone?
in bradycardia and heartblock
37
What is the S/E of amiodarone?
- corneal microdeposits (reversible if tx stopped)
- thyroid disorders - hyper/hypo due to iodine
- photosensitivity - avoid sunlight
- hepatoxicity - liver disease
- pulmonary toxicity - SoB, cough
- vision impaired - blurry
38
Interactions of amiodarone?
- drugs that cause hyperkalaemia
- drugs that cause QT prolongation
- CYP450 enzyme inhibitors/inducers
- drugs that cause bradycarrdia
39
Monitoring for amiodarone?
- Thyroid functions before * 6MT
- LFT " "
- Chest x-ray before tx
-annual eye exams
- IV : ECG + liver transaminase
40
Which drugs need to monitored after stopping amiodarone?
*for heartblock*
Sofosburvir, daciatosuvir, simeprevir, sofosbuvir, lediapruvir
41
What is loading dose for digoxin?
125-250mcg.
Different bioavailabilites for diff formulations
42
what is therapeutic range for digoxin
0.7 to 2.0ng/ml
43
What is the toxicity range for digoxin
1.5 - 3.0ng/ml
44
What are the signs of toxicity for digoxin?
- SA/AV block + bradycardia
- diarrhoea + vomiting
- dizziness, confusion, depression
- blurred/yellow vision
45
Monitoring for digoxin?
serum electrolytes + renal function
take blood samples 6-12hr after each dose
46
Digoxin interactions?
- bblockers - inc risk of AV block + inc plasma conc
- tricyclic antidepressants - induce arrythmias
- drugs that cause hypokalaemia (inc digoxin toxicity)
- cyp450 inducers (dec) + inhibtors (inc)
47
When is tranexamic acid used?
*Helps with formulation of blood clots*
- Surgeries. dental extractions, menorrhagia
s/e - GI (N+V)
48
When is desmopressin used?
For mild to moderate haemophilia and von Willebrand's disease.
49
What is VTE?
Venous thromboembolism.
Blood clot in vein which obstructs blood flow.
50
What is DVT?
Deep vein thrombosis.
In legs or pelvis. Unilateral localised pain +/or swelling
Use compression socks to prevent
51
What is PE?
Pulmonary embolism.
In lungs - chest pain or SoB
52
Risk factors for thromboembolism?
Surgery, trauma, significant immobility, malignancy, obesity, pregnancy, hormonal therapy (COC/HRT)
53
What is mechanical prophylaxis for VTE?
graduated compression stockings wear till mobile
54
When do you start pharmacological prophylaxis for VTE?
start within 14HR of admission.
If risk factors only use if risk of VTE outweight risk of bleeding
55
prophylatic surgery
1) LMWH = suitable in all types of general + orthopaedic syrgery
+ pregn
2) unfractionated heparin = renal impairment (lower half life so if need to stop fluidity of blood quickly)
3) fondaparinux sodium = lower limb immobilisation or pelvis fragility fractures
4) continue for at least 7 days post surgery or until suf mobility (28DY after major cancer surgery in abdomen or 30DY in spinal surgery)
56
tx for elective hip replacement?
1) LMWH 10DY * 75mg aspirin 28DY
2) LMWH 28DY + stockings until discharge
3) rivaroxaban = common
57
tx for elective knee replacement?
1) 75mg aspirin 14DY
2)LMWH 14DY+ stockings until discharge
3)rivaroxaban
58
if pt has as high risk of VTE what should you give for prophylaxis?
Mechanical until mobile.
Pharmacological for 7DY at least
59
what is the VTE prophylaxis in pregn?
3) if given birth/miscarriage/termination in past 6WK start LMWH 4-8hr after event and continue for min 7DY
TX of VTE = LMWH; unfractionated if pt at high risk of haemorrhage
60
What is VTE tx?
- confirmed proximal DVTE/PE; apixaban or rivaroxaban
-if x suitable then LMWH for 5DY*dabigatran/edoxaban or LMWH + warfarin for 5DY till INR 2.0 for 2x readings then warfarin alone
61
What is the duration of VTE tx?
- distal DVT (CALF) - 6WK
- proximal DVT/PE = 3MT (3-6MT in active cancer)
- provoked DVT/PE = stop at 3MT if factors stopped
- unprovoked DVT/PE = 3MT+
- Recurrent DVT/PE = long term
62
When do you need to maintain and INR of 2.5 (+/-0.5)?
VTEs, AF, cardioversion, MI, cardiomyopathy
63
When do you need to maintain and INR of 3.5
recurrent VTE or mechanical heart valves
64
What do you do in a major bleed?
stop warfarin + give IV vit K (phytomenadione) + dried prothrombin
65
What do you give if INR >8 and is minor bleed?
stop warfarin and give IV vit K
66
What do you give if INR >8 and no bleed?
stop warfarin and give oral vit K
67
What do you give if INR 5-8 and is minor bleed?
stop warfarin and give IV vit K
68
What do you give if INR 5-8 and no bleed?
withhold 1-2 doses of warfarin and restart when INR is <5
69
What are the side effects of warfarin?
-MHRA = skin necrosis and calciphylaxis (pale skin rash)
- haemorrhage; prolonged bleed give vit K antidote
- pregn = avoid in 1st + 3rd trimester (use contraception
70
Interactions of warfarin
-vit k rich foods (reduce efficacy)
-pomegranate + cranberry juice (inc INR)
-miconazole (inc INR)
-CYP450 inhibitors/inducers (inc/dec conc of warfarin)
71
if it is minor procedure with low risk of bleeding what do you do (warfarin surgery)
only perform if INR less than 2.5 - restart warfarin within 24 hr of surgery
72
What do you do in procedures where there is severe risk of bleeding?
1) stop warfarin 3-5DYs before
2) vit K if INR is > or = to 1.5 the day before surgery
3) pt = high risk of thromb stop LMWH 24hr before + restart 48hr after
73
if it a emergency surgery do you do in regards with warfarin
if it can be delayed by 6-12 give IV vit K if not then give IV vit k + dried prothrombin complex
74
What are the doses for DOAC?
-apixaban - 10mg BD 7DY* 5mg BD
-rivaroxaban - 15mg BD 3WK* 20mg OD
-dabigatran - ( 18-74) 150mg BD, (75-79) 110-115 bd, ( 80+) 110mg BD
-edoxaban - 60mg OD if under 6kg then 30mg
75
which DOACs are given after 5DYs of heparin?
edoxaban and dabigatran
76
What do all heparins do?
- avoid in heparin induced thrombocytopenia
- can cause hyperkalaemia
- haemorrhage tx protamine sulphate (unfractionated)
77
what do unfractionated heparins do?
- quick initation + elimiation ideal for high bleeding risk
- high risk of heparin induced thrombocytopenia
78
which heparin is preferred in renal impairment?
Heparin unfractionated
79
what do you do in haemorrhagic strokes?
Manage BP and stop statins
80
what do you do in ischaemic strokes?
-apsirin 300mg 14DY following altepase (within 4.5 hr)
1)1st line - clopidogrel 75mg OD
2) 2nd line - MR dipyridamole + aspirin
3) 3rd line - MR dipyridamole or aspirin
start high intensity statin 48HR after stroke.
manage BP to <130/80 with no bblocker
81
what do you do in TIA?
give 300mg daily till diagnosis
82
what is stage 1 of hypertension
- clinic = 140-90 - 159/99
-ambulatory = 135/85 - 149/94
83
what is stage 2 of hypertension
-clinic = 160/100 - 180/120
-ambulatory = > 150/95
84
what is stage 3 of hypertension
>180/120
85
how do you tx stage 1 of hypertension
- < 80 drug tx in ckd, diabetes, CVD or 10% risk of CVD in 10yr
- <60 drug tx + lifestyle advice with 10% risk of CVD in 10 yr
86
how do you tx stage 2 of hypertension
tx all pt
87
how do you tx stage 3 of hypertension
medical emergency - hypotensive crisis
88
tx of hypertension pt < 55yr
- TY2D
1) ACEi/ARB
2) ACEi/ARB + CBB or TLD
3) ACEi/ARB + CCB + TLD
4) k+ < 4.5mmol/l = low dose spironolactone
k+ > 4.5 = a/bblocker
if afro-carribbean = ARB instead of ACEi
89
tx of hypertension > 55yr
- afro-carribbean
1) CCB
2) CBB + ACEi/ARB
3) ACEi/ARB + CCB + TLD
4) k+ < 4.5mmol/l = low dose spironolactone
k+ > 4.5 = a/bblocker
90
S/E of ACEi?
*CHHARD*
-C = cough
-H = hyperkalaemia
-H = hepatic failure
-A = angiodema
-R = renal failure
-D = dizziness + headaches
91
S/E of ARB
-H = hyperkalaemia
-H = hepatic failure
-R = renal failure
-D = dizziness + headaches
92
ACEi interactions
- high risk of renal failure = ARBs, K sparing diuretics, NSAIDs
- high hypercalcaemia = heparin, ARBs, NSAIDs, k sparing diuretics, bblockers
-high risk of vol depletion - diuretics
- high plasma lvls of lithium
93
which bblocker is given in gestational pregn
labetalol
94
which bblockers are cardio selective? less likely to cause bronchospasms
*BArMAN*
- bisoprolol
- atenolol
- metoprolol
-acebutolol
-nebivolol
95
which bblockers are water soluble - less likely to cross BBB less nightmares
*CANS*
-celiprolol
-atenolol
-nadolol
-sotalol
96
which bblockers are intrinsic sympathomimetic less cause of cold extremities
*PACO*
-pindolol
-acebutolol
-celiporolol
-oxprenolol
97
what are the s/e of bblocker
-bradycardia or HF
- blunt effects of hypoglycaemia
-causes hypercalcemia
-bronchospasm
98
interactions of bblocker
-digoxin - heart block
- hypotensive drugs
99
which CCB are dihydropyridine?
amlodipine, felodipine, lacidipine, lercanidipine, nifedipine
100
which CCB are rate-limiting
diltiazem, verapamil
101
s/e of CCB
- dizzy
- gingival hyperplasia - enlarged gums
- vasodilatory effects (flushing, headaches, ankle swelling) higher in dihydropyridine
- complete atrioventricular block - higher in RL CCB
102
what are pregnant pt at risk of in hypetension
- high risk of developing pre-eclampsia in
--> CKD, diabetes, autoimmune disease, hypotension .. take aspirin form WK12 of pregn till birth
103
hypertension pregn tx
BP < 140/90
1) labetalol
2) nifedipine or methyldopa
target of 135/85
104
what are the target ranges of hypertension?o
- <80yr - 140/90
- >80yr - 150/90
- renal - 140/90
- pregn - 135/85
- TY1D - 135/85
105
What are the healthy levels in hyperlipidaemia?
- total cholesterol - 5+ less
- HDL (good) 1 / more
- LDL (bad) - 3 / less
- non-HDL (bad) - 4 / less
- triglycerides - 2.3 / less
106
when should lipid lowering agents be offered?
- pt < 85 with 10yr risk of CVD > 10%
- pt TY2D 10yr risk CVD >10%
- TY1D - 40+, 10yr of diabetes, established nephropathy
- pt with CKD
- familial hypercholesterolaemia
107
when should statins be taken and why
night - high prod of cholesterol at night but atorvastatin and rovostatin anytime
108
what strength of atorvastatin is strongest for secondary prevention?
80mg
109
what should be managed with statins
hypothyroidism
110
statins and diabetes?
pt are at risk of diabetes so fasting blood glucose conc/ HbA1c checked before statins and repeat 3MT
111
monitoring of statins
- before starting - full lipid, thyroid function, renal function + liver function
- LFT: 3MT to 12MT STOP if serum transaminase more than 3x limit
- creatinine kinase - pt previously persistent muscle aches
- if 5x than upper limit remeasure in 7DY if x lower than x give statins but if lvls are high but x 5x limit can give statins
112
s/e statins
-myopathy and rhabdomyolysis
--> muscle toxicity gv medical advice for pain, tenderness, weakness
- interstitial lung disease - medical advice if dyspnoea, cough, weight loss
- x gv in pregn (x gv 3mt before conceiving)teratogenic
113
statins interactions
-cyp450 inducers = lower conc of statins
- cyp450 inhibitors = inc conc of statins so inc risk of rhabdomyolysis
-fusidic acid - stop and restart after 7dy last dose
114
max doses of statins
- amiodarone + simvastatin = 20mg
- amlodipine + simvastatin = 20mg
- dilitazem/verapamil +simvastatin = 20mg
- ticagrelor + simvastatin = 40mg
- ciclosporin + atorvastatin = 10mg
- tipranavir + atorvastatin = 10mg
115
what are the other lipid lowering drugs
- ezetimibe (+ statins inc rhabomyolysis)
- fibrates (aprofibrates, fenofibrates, gemfibozil
-> renal impairment. lft every 3mt 1st yr, statin + fibrates inc muscle s/e
116
what is myocardial ischaemia?
build up of atherosclerotic plaques which restrict arteries dec supply of blood + o2 to heart
117
stable angina + tx
- predictable chest pain or pressure due to physical or emotional
- initial tx ; prophylactically or when symptoms : GTN spray every 5 mins if 3rd dose no improve - emergency
- prevention:
-> 1st line : BBlocker (RL-CCB if CI)
-> BB + +CCB (amlodipine/lacidipine)
-> long-acting nitrate, nicrorandil (can cause GI + muscle ulceration). ivarbradine, ranolazine
75mg aspirin + low dose statin
118
when do you discard GTN sublingual tablets
8 weeks after opening
119
how to stop nitrate tolerance?
-nitrate free period
-2nd dose given 12hr after
-transdermal patch - leave off 8-12hr
120
s/e of nitrates
dizziness, flushing, headaches, caution in elderly = falls
121
major risks in acute coronary syndrome
FH, hypertension, hypercholesterolaemia, diabetes, smoking
122
initial tx of acute coronary syndrome
loading dose of aspirin 300mg, pain relief = GTN +/- IV morphine
02 if needed
123
What is partial blockage of artery?
myocardial necrosis in NSTEMI
124
What is complete blockage of artery?
myocardial necrosis STEMI
125
types of ACS?
NSTEMI + unstable angina: partial blockage of artery
STEMI : complete blockage of artery
- NSTEMI : ST zone of ECG X elevated
- STEMI : ST zone of ECG elevated
126
What does STEMI require?
STEM requires percutaneous coronary intervention (PCI) within 2nd
- pt given heparin If PCI = done through radial access
- preferred secondary anti-platelet = prasugrel = long term
127
what is secondary prevention of ACS
- Dual antipatelet theapy:
->Life long 10ng aspirin
->12MT: clopidogrel, prasugrel or ticagrelor
->ACEi Or ARB if CI
-BB - discontinue after 12 months in pt with LvEF
-statin : inc strength of atrov to 80mg
-pt = NSTEMI = PCI to prevent MI>
128
symptoms of HF?
- SoB, persistent coughing, wheezing, ankle swelling, dec exercise tolerance + fatique.
129
TX of CHF?
ACEi + BB 1st line
-low dose + inc max tolerated dose
- give ARB if ACEi CI/ x tolerated
- give hydralazine + nirate if both ACEi+ BB x tolerated
-+aldosterone antagonist if symptoms persist ( spirolactone/eplerone)
- + amlodipine, digoxin, sac + val, ivaberadine, dapagfliozin if symp still persist
- loop diuretics - breathlessness or oedema in fluid retention
130
what is odema
water retention in system carrying pulmonary or perpheral odema
131
what are thiazide diuretics?
Bendroflumethiazide, indapamide
-inhibit Na reabsorption at beginning of distal convoluted tubule
- last up to 24hr needs to be taken morning
132
what are loop diuretics?
furosemide, bumetanide, torasemide
- inhibit reabsorption from ascending limb of loop of henle
-pulmonary odema to left ventricular failure
-lasts 6hr can be BD
133
what are k sparing diuretics?
amiloride, triamterene (blue urine)
- prevent Na rebasorption from distal tubule collecting duct
134
what are aldosterone antagonist diuretics?
spironolactone, eplerenone
-inhibit k secretion distal tubule collecting duct
- x dehydration due to vomiting and or diarrhoea
x give K+ supplements
135
s/e of what are diuretics?
induce hyponatreaemia and hypomagnesaemia
136
s/e of loop and thiazide diuretics
hypokalaemia
excerbate diabetes and gout (loop)
hyoptension
137
s/e of k+ sparing diuretics
hypokalaemia
change in libido (sex drive)
breast pain or tenderness
138
interactions of diuretics
-hypokalaemia inducing drugs (thiazdie + loop)
-hyperkalaema (k sparing)
- nephrotoxicity + ototoxitiy = loop diureitcs + amnioglycosides
- dec lithium secretion = spironolactone/loop + lithium
139
what is peripheral vascular disease
occulsive peripheral vascular disease normally caused by atherosclerosis lower risk with healthier lifestyle, statins, anti-platelets
140
vasoplastic peripheral vascular disease (raynauds)
avoid exposure to cold and smoking cessation if tx ; nifedipine
