Cardiovascular System Flashcards
1
Q
What is atrial fibrillation?
A
Irregular electrical signals in the heart
2
Q
Which wave is absent on an ECG during AF?
A
P wave
3
Q
What is the difference between rate and rhythm control in AF?
A
Rate control: controls ventricular rate
Rhythm control: controls/maintains sinus rhythm of the heart
4
Q
What is the immediate management of a haemodynamically unstable patient with AF?
A
Immediate electrical cardioversion
5
Q
What determines whether you treat a patient for rate or rhythm control in an acute AF presentation (if <48h)?
A
Rhythm control needed if patient is symptomatic/has reversible AF and can include cardioversion or pharmacological
Rate control preferred if rhythm not appropriate
6
Q
What drugs are involved in rate controlling AF (>48h)?
A
B-blockers (not sotalol)
Rate limiting CCBs
Digoxin (esp. in HF patients)
7
Q
Which type of control is preferred if AF has been present for more than 48h?
A
Rate control
8
Q
What are the pharmacological drugs used if a patient presents with AF <48h and cardioversion is not suitable?
A
Flecainide (no IHD)
Amiodarone (with IHD)
9
Q
Why are b-blockers and rate-limiting CCBs never given together?
A
Because there is a risk of severe bradycardia and death
10
Q
In which type of patients is digoxin recommended in?
A
Patients living sedentary lifestyles, or if they have heart failure
11
Q
Which drugs are used as self-treatment if a patient has infrequent episodes of AF (also known as ‘pill in picket’)?
A
Flecainide
Propafenone
12
Q
What must be done if a patient presents with AF for >48h, and requires rhythm control?
A
3 weeks of anticoagulation, then electrocardioversion, then anticoagulation for a further 4 weeks after
13
Q
What does the CHA2DS2VASc tool measure? When should treatment be initiated?
A
It is a tool to measure the risk of stroke in a patient
1 or 0 = aspirin/no therapy needed
>2 = warfarin/DOAC
14
Q
Which tool measures the risk of bleeding?
A
HAS-BLED (or ORBIT)
15
Q
What is the treatment for pulseless/unstable ventricular tachycardia?
A
Pulseless: resuscitation/CPR
Unstable: IV amiodarone or cardioversion
16
Q
What is the treatment for stable ventricular tachycardia?
A
IV amiodarone, but can also use flecainide/propafenone
17
Q
What is the maintenance treatment for patients with high risk of cardiac arrest?
A
Cardioverter defibrillator implant
B-blocker
18
Q
What is the treatment for torsade de pointes?
A
Magnesium sulphate
19
Q
What is the treatment for paroxysmal supraventricular tachycardia?
A
Iv adenosine 6mg
Alternatively IV verapamil
20
Q
Why is amiodarone only given once daily?
A
Because it gas a very long half life that can extend to several weeks
21
Q
What specific side effects can amiodarone cause?
A
Reversible corneal micro-deposits
Optic neuropathy
Photoxicity
Slate-grey skin
22
Q
What symptoms should patients taking amiodarone report?
A
Night glares
Impaired vision/blindness
Burning skin/erythema
23
Q
What can SOB/coughing with amiodarone use implicate?
A
Pulmonary toxicity (usually reversible)
24
Q
Since amiodarone contains iodine, what can this cause?
A
Hypo or hyperthyroidism
25
What monitoring is required with amiodarone?
Annual eye test
Chest X-ray
LFTs every 6 months
TSH
BP, ECG
Serum potassium
26
Which specific fruit juice should be avoided with amiodarone?
Grapefruit juice as this is enzyme inhibiting which can cause amiodarone toxicity
27
What type of drug is digoxin?
It is a cardiac glycoside by increasing the hearts contraction and reducing conductivity in AV node
28
What are the therapeutic levels of digoxin and when should samples be taken?
1-2mcg/L, 6h after dose
29
Why do patients need to be given a loading dose of digoxin initially?
Because it has a long half-life
30
What determines the dose of digoxin?
Renal function of patient since digoxin is renally cleared
31
Which specific electrolyte must be corrected before starting a patient on digoxin?
Potassium, since hypokalaemia can predispose the patient to digoxin toxicity
32
What are the signs of digoxin toxicity?
SLOW AND SICK
Bradycardia
N+V
Blurred or yellow vision
Confusion
Rash
33
Which antifibrinolytic is used in menorrhagia?
Tranexamic acid
34
What is the dose of tranexamic acid? What is the max. daily dose?
1g TDS for up to 4 days
Max. 4g a day
35
What are the symptoms of a DVT?
Swelling, tenderness of leg
Skin changes
Vein distention
36
What are the symptoms of a PE?
SOB
Chest pain
Coughing blood
37
When is mechanical VTE prophylaxis given?
If patient has undergone major trauma, or undergoing minor surgery
38
When is pharmacological VTE prophylaxis given?
If patient is undergoing general or orthopaedic surgery
39
Which parenteral anticoagulants are given for pharmacological prophylaxis?
Unfractionated heparin if renally impaired
Heparin
Fondaparinux
40
When are DOACs given as VTE prophylaxis?
After knee/hip replacement surgery
Treatment/prevention of recurrent VTE (mainly edoxaban used)
41
What is given (and for how long) for patients undergoing elective hip surgery requiring VTE prophylaxis?
LMWH for 10 days
Aspirin for 28 days
ALTERNATIVELY
LMWH for 28 days + stockings until discharge
42
What is given (and for how long) for patients undergoing elective knee surgery requiring VTE prophylaxis?
Aspirin for 14 days
ALTERNATIVELY
LMWH for 14 days + stockings till discharge
43
What is the treatment of a confirmed DVT?
DOAC + LMWH or unfractionated heparin if renally impaired for at least 5 days and INR being 2 for at least 24h
44
Which DOACs are usually given in a renally impaired patient?
Apixaban
Rivaroxiban
45
Which anticoagulant is recommended in pregnancy related VTE?
LMWH, e.g. dalteparin, enoxaparin, tinzaparin
46
Which type of heparin has the longest duaryion of action?
LMWH
47
Why are unfractionated heparins the preferred choice for those at high risk of bleeding?
Because it has a short duration of action, so its effects can be reversed by just stopping the infusion
48
What are some examples of LMWH? What route are these given?
Tinzaparin
Enoxaparin
Dalteparin
They are given as subcutaneous injections
49
Which specific electrolyte should you monitor if a patient is receiving a heparin for >7 days?
Potassium (risk of hyperkalaemia)
50
How long does warfarin take to exert its effects?
48-72h
51
What are the colours of warfarin tablets and what are their strengths?
White = 0.5
Brown = 1mg
Blue = 3mg
Pink = 5mg
(Remember WBBP)
52
What are the target INRs for VTE, and for recurrent VTE?
2.5 = treatment
3.5 = recurrent
53
What is painful itchy skin associated with warfarin a sign of?
Calciphylaxis - must report
54
What should you do if a patient has a major bleed and are taking warfarin?
Stop warfarin
Give IV phytomenadione
55
What is the INR target to restart warfarin after having a bleed?
<5
56
What should you do if the patients INR if 5-8, with no bleeding?
Omit 1-2 doses of warfarin and reduce maintenance dose.
Measure INR after 2-3 days
57
What should the patient do if they are taking warfarin and are due for an elective surgery?
Stop warfarin 5 days before elective surgery
58
Which specific NOAC is in a special container? What is its expiry date once opened?
Dabigatran - 4 month expiry
59
What is the difference between an ischaemic and haemorrhagic stroke?
Ischaemic: loss of oxygen to brain due to a blood clot
Haemorrhagic: a weak vessel in the brain bursting
60
What are the symptoms of a stroke?
Remember FAST
Facial drooping
Arms dropping
Slurred speech
Time
61
What is the long term management of stroke?
Lifestyle advice
High intensity statin
Clopidogrel 75mg OD
OR MR dipyridamole 200mg + aspirin 75mg
Anticoagulant therapy 14 days after acute event
62
What are examples of antiplatelets?
Clopidogrel
Aspirin
Prasugrel
DOACs
Ticagrelor
63
What is given in an acute ischaemic event?
Alteplase or tenectaplase within 4.5h
64
What is given in an acute haemorrhagic event?
Surgery
Vitamin K/fresh frozen plasma to reverse bleeding
65
What is the hypertension pathway for a Caucasian person who is <55yrs old, or has T2DM?
Step 1: ACEi or ARB
Step 2: ACEi or ARB + CCB or thiazide
Step 3: ACEi or ARB + CCB + thiazide
Step 4: Low dose spironolactone, or a/b blockers
66
What is the hypertension pathway for a black patient, or >55yrs old, or without T2DM?
Step 1: CCB
Step 2: CCB + ACEi or ARB or thiazide
Step 3: CCB + ACEi or ARB + thiazide
Step 4: low dose spironolactone, or a/b blockers
67
What is the cut off point for potassium levels to initiate spironolactone in hypertension?
Only give if K+ levels are <4.5mmol/L
68
What is the recommended daily salt intake?
<6g a day (or 100mmol)
69
What is the normal BP target for an adult in a clinical setting?
<140/90mmHg
70
When should you offer ABPM or HBPM in a clinical setting?
If the patient has a BP reading of 140/90mmHg - 179/119mmHg
71
What is classified as stage 1 hypertension?
If their ABPM/HBPM is 135/85mmHg-149/94mmHg
72
When should you refer a patient to a same-day clinic who has come in for a BP reading?
If their BP is >180/120mmHg
73
What is classified as stage 2 hypertension?
If their ABPM/HBPM is >150/95mmHg
74
What are the BP targets for a T1DM and T2DM patient?
T1DM: <135/85mmHg
T2DM: <140/90mmHg
75
What is the target BP for a patient >80 years old?
<150/90mmHg
76
Why is the first dose of an ACEi taken a night?
To avoid first dose hypotension
77
What should you do if a patient develops a dry cough whilst on an ACEi?
Switch to an ARB
78
Which specific side effect is more common in black people taking an ACEi?
Angiodema
79
Which specific electrolyte should be monitored whilst on an ACEi?
K+, because ACEi can cause risk of hyperkalaemia
80
Which drugs if given with an ACEi can increase the risk of an AKI?
Remember DAMN drugs
Diuretics
ACEi/ARB
Metformin
NSAIDs
81
Which hepatic effects can be caused by ACEi, and hence must stop its use?
Cholestatic jaundice
If liver transaminases are x3 normal of baseline
82
What are some other side effects o ACEi?
Hypoglycaemia
Mouth ulcers
Taste disturbances
83
Which specific drug is unlicensed for the use of gestational hypertension?
Methyldopa
84
Which drug is given in severe resistant hypertension?
Hydralazine
85
What are some examples of alpha-blockers which can be give as a last step in hypertension if K+ levels are >4.5mmol/L?
Doxazosin
Prazosin
86
Where are B1 and B2 receptors found in the body?
B1: heart, kidney, fat cells
B2: lungs, arteries of skeletal muscles
87
Which type of b-blockers have less side effects of bradycardia/coldness of extremities?
ISA B-blockers
88
Which b-blockers can cause less sleep disturbances and nightmares?
Remember ANS
Atenolol
Nadolol
Sotalol
89
Which b-blockers are cardio-selective, and hence cause less bronchospasms?
Remember Be A MAN
Bisoprolol
Atenolol
Metorpolol
Acebutalol
Nebivolol
90
Which b-blockers are taken once daily due to their long duration of action?
Remember BACoN
Bisoprolol
Atenolol
Celiprolol
Nadolol
91
What are some side effects of b-blockers?
Bradycardia
Hypotension
Hyperglycaemia
Masking symptoms of hypoglycaemia
92
What are some common side effects of dihydropyridine CCBs?
Ankle swelling
Flushing
Headaches
93
Which 2 CCBs are known as rate-limiting?
Verapamil
Diltiazem
94
Why should diltiazem always be prescribed by brand if it is >60mg?
Because different MR preparations may not have the same clinical effect
95
Which specific fruit juice should you avoid with CCBs?
Grapefruit juice, because it is enzyme inhibiting so can cause increased CCB concentrations
96
What is given during a hypertensive crisis?
IV sodium nitroprusside
97
Which drugs are used to treat pulmonary hypertension?
Sildenafil
Tadalafil
Oliprost
98
Which vasoconstricting sympathomimetics are used in shock/hypotension?
Atropine
Noradrenaline
Phenylephrine
99
What are symptoms of heart failure?
SOB
Persistent coughing/wheezing
Reduced exercise tolerance
Fatigue
Weight gain due to fluid build up
100
What is the difference between reduced ejection fraction and preserved ejection fraction?
Reduced ejection fraction: when left ventricle loses its ability to contract, so ejection is only 40%
Preserved ejection fraction: left ventricle cannot relax normally so output is normal/slightly reduced
101
Which types of CCBs should always be avoided in HF patients?
Rate-limiting CCBs - verapamil, diltiazem
Short acting CCBs - nifedipine
102
What are the 2 first line treatment drugs which are used in HF?
B-blockers and ACEi/ARB
103
Which b-blockers are license din HF patients?
Bisoprolol
Carvedilol
Nebivolol
104
What others drugs can be added if 1st line treatment in HF is not suitable, or symptoms worsen?
Eplerenone
Spironolactone
Ivabradine
Digoxin
Amiodarone
105
What drugs can be used for HF patients to help with oedema related symptoms?
Loop diuretics, e.g. furosemide, bumetanide
106
What monitoring is required for HF patients?
K+, Na+
Renal function
BP
Weight
HR
Symptom control
107
When is primary CVD prevention offered in patients?
If their QRISK2 score is >10%
108
What is the diagnosis for hyperlipidaemia?
If total cholesterol is >6mmol/L, or triglycerides are >1.7mmol/L
109
When are fenofibrates used to reduce cholesterol levels?
If triglyceride levels remain high even after LDL levels reduced
110
What should be added if cholesterol levels are still high despite being on the highest dose of statin?
Add ezetimibe
111
Which enzyme do statins inhibit?
HMG-CoA
112
Why are statins taken at night?
Because cholesterol synthesis is greater at night, so treatment will be more effective
113
Which specific side effects should patients taking statins report?
Muscle weakness, pain or tenderness
114
What monitoring is required for a patient taking a statin?
LFTs
TFTs
Renal function
Baseline lipid profile
HbA1c
115
When should a statin be discontinued?
If creatine kinase is x5 normal level, or liver transaminases are x3 normal level
116
Which class of antibiotic would require the patient to stop taking their statin during treatment?
Macrolides
117
What should a patient do if they are prescribed fusidic acid if they are taking a statin?
Must stop taking their statin during treatment and restarted 7 days after last dose
118
What is the max dose of rosuvastatin if taken with clopidogrel?
20mg
119
Which vitamins may not be absorbed if a patient takes a bile sequestrant?
Fat-soluble vitamins (ADEK), and folic acid
120
What are some example of bile sequestrants?
Colesevelam
Colestyramine
121
What is the dose of bempedoic acid?
180mg OD
122
What can precipitate stable angina?
Physical exercise
Emotional stress
123
What is used to relieve acute angina attacks?
GTN spray
124
How is GTN spray/tablets taken?
When required or before angina-inducing activity
125
How long after the first GTN dose can a patient repeat another dose?
5 minutes (max. 3 times in 1 sitting)
126
What is the expiry of GTN sublingual tablets?
8 weeks (special container)
127
What drugs can be given for stable angina prophylaxis?
MR Isosorbide dinitrate
Isosorbide mononitrate
B-blockers
CCB
Ivabradine
Ranolazine
Nicorandil
128
Which drug has the risk of causing mucosal ulceration?
Nicorandil, stop drug if this occurs
129
What can be done to reduce tolerance of long-acting transdermal nitrate preparations?
Avoid wearing the patch overnight
2nd dose can be taken 8h after 1st dose
Take isosorbide mononitrate OD
130
What are some side effects of nitrate preparations for angina?
Worsening angina (if abruptly stopped)
Flushing
Throbbing headache
Heartburn
131
Which type of ACS requires a PCI or reperfusion intervention?
A STEMI (heart attack)
132
What is given during an acute ACS event (I.E. in ambulance)?
Remember MONA
Morphine 5mg IV
Oxygen
Nitrates
Aspirin 300mg loading dose
133
What is given for the long term treatment of an ACS event?
Remember ABAS
Dual antiplatelet therapy (aspirin lifelong + clopidogrel 75mg 12 months)
B-blocker
ACEi
Statin (high dose)
+ PPI as GI protection
134
Which antiplatelet is given within 12h of onset for a STEMI?
Prasugrel 60mg as loading dose
135
How many compressions/min are given during cardiac arrest?
100 compressions per minute
136
Which loop diuretic is the most potent?
Bumetanide
137
Why are diuretics taken in the morning?
To avoid sleep disruption/night time waking to go toilet
138
Which diuretic can colour urine blue?
Triamterene
139
How do diuretics work?
They inhibit sodium/water reabsorption, so more is urinated out and which relieved oedema
140
Why can loop diuretics be given twice a day?
Because they have a shorter duration of action (6h)
141
Why should you avoid loop diuretics in patients with BPH?
Because loops can cause acute urinary retention
142
Which type of diuretic should you avoid if a patient has hypercalcaemia?
Thiazides
143
Which type of diuretic is given if a patient is experiencing hypokalaemia?
Potassium sparing diuretics, e.g. spironolactone
144
What is an example of an osmotic diuretic?
Mannitol
145
