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Pre-reg Exam > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

How do you manage acute non life- threatening AF?

A

If <48 hours,
Rate or rhythm control can be used.

If >48 hours/ uncertain,
Rate control only

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2
Q

What drugs are used for pharmacological cardio version?

A

IV amiodarone or flecainide

Do not give flecainide in structural heart disease

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3
Q

What drugs are used for rate control in AF?

Distinguish first line and second line options.

A 
First line:
Beta blocker (not sotalol) or Rate- limiting calcium channel blocker (diltiazem or verapamil) monotherapy 
Second line:
Digoxin monotherapy (if non-paroxymal AF+sedentary)

Third line:
Combination therapy with 2 of: a beta blocker, diltiazem, digoxin
DO NOT offer amiodarone for long term rate control.

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4
Q

How is stroke risk assessed in patients with AF?

A

CHA2DS2-VASc score tells you stroke risk.
HAS-BLED score tells you risk of bleeding.

Offer stroke prevention if
CHADSVASc is 1 or more for men or 2 or more for women, taking bleeding risk into account.

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5
Q

What medicines are used to prevent stroke in patients with AF?

Under what circumstances can you start treatment?

A

Anticoagulants:
Wafarin, apixaban, dabigatran, rivaroxaban, edoxaban

Non-valvular AF with at least one of:
congestive HF, HTN, previous stroke or TIA, DM, age 75 or over.

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6
Q

What is torsade de pointes and how is it treated?

A

A form of ventricular tachycardia with an elongated QT. This is very serious and can lead to death.
STOP any anti-arrhythmic drugs - further prolong QT and exacerbate the condition

Treatment: IV magnesium infusion or beta blockers (not sotalol)

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7
Q

What are the Vaughan- williams classes of anti-arrhthmic drugs?

Include examples

A

Class Ia- affect sodium channels ( e.g disopyramide)
Class Ib- lidocaine
Class Ic- flecainide
Class II- beta blockers
Class III- affect potassium channels e.g amiodarone, dronedarone
Class IV- affect calcium channels- diltiazem and verapamil
Class V- adenosine, digixin, magnesium

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8
Q

Which anti-arhythmic drugs can only be used in supraventricular arrhythmias?

A

Class IV + V antiarrhythmics:

Adenosine 1st line ( can be used after a b-blocker unlike verapamil)
Verapamil (preferable to adenosine in asthma)
Digoxin

NOTE: verapamil is only effective for supra ventricular arrhythmias.

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9
Q

Which anti-arhythmic drugs can only be used in ventricular arrhythmias?

A

Class Ib - IV lidocaine

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10
Q

What is a subarachnoid haemorrhage and how can it be managed?

A

Life-threatening type of stroke caused by bleeding into the space surrounding the brain.
It can be caused by ruptured aneurysms or head injury.

Nimodine ( a CCB) can be used for preventing ischaemic neurological defects following the bleed.

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11
Q

How are blood clots in catheters and lines managed?

A

UH, urokinase, epoprosterol (a prostaglandin)

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12
Q

What is the preferred treatment of VTE in pregnancy?

A

Heparins as they do not cross the placenta

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13
Q

What is the initial management for a suspected and confirmed TIA?

A

Aspirin 300mg stat (clopidogrel 75mg is altenative)

Following diagnosis, offer secondary prevention (anticoagulant)

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14
Q

How is acute ischemic stroke managed?

A

**Intracerebral haemorrhage must be excluded first.

Acute:
If within 4.5 hours of onset, give alteplase.
If after 4.5 hours or cant give alteplase, give 300mg aspirin ( clopidogrel 75mg is alternative. Then aspirin 300mg OD for 2 weeks (24 hours after alteplase)

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15
Q

What is the long term treatment post stroke or TIA?

A

Maintenance:
Clopidogrel 75mg OD (aspirin or dipyridamole if C/I)
Anticoagulants are not recommended if no AF
Warfarin should NOT be started in acute phase.

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16
Q

How long do coumarins and phenindione take to work?

A

48-72 hours

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17
Q

What is the INR target in AF, singular DVT/PE, MI, cardioversion?

A

2.5 but within 0.5 of target is okay, (2-3)

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18
Q

In what circumstances is the INR target not 2.5 (or 2-3) and what is the target?

A

Recurrent DVT+ PE and mechanical/prosthetic heart valves. INR target is 3.5 (3-4) as higher risk of a clot.

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19
Q

What action should be taken if a patient on warfarin has a MAJOR bleed?

A

STOP warfarin
give phytomenadione 5mg stat - slow IV (vitamin K)
give octaplex (prothrombin complex)

if octaplex unavailable give fresh frozen plasma octaplasLG (not as effective)

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20
Q

What action should be taken if a patient on warfarin has a MINOR bleed (INR >8)?

When can warfarin then be restarted?

A

STOP warfarin
give phytomenadione 5mg stat - slow IV (vitamin K). Repeat after 24 hours of INR still high.

Restart warfarin when INR <5

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21
Q

What action should be taken if a patient on warfarin presents with an INR >8 NO bleed?

A

STOP warfarin
give phytomenadione 5mg stat - ORAL (vitamin K). Repeat after 24 hours of INR still high.

Restart warfarin when INR <5

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22
Q

What action should be taken if a patient on warfarin presents with an INR 5-8 MINOR bleed?

A

STOP warfarin
give phytomenadione 5mg stat - Slow IV (vitamin K).

Restart warfarin when INR <5

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23
Q

What action should be taken if a patient on warfarin presents with an INR 5-8 NO bleeding?

A

Withhold 1-2 doses of warfarin and reduce subsequent maintenance dose.

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24
Q

What should you do if a patient on warfarin is due to have surgery electively?

What about emergency surgery?

A

Stop warfarin 5 days before.
If high risk of bleed, start a LMWH (bridging) and stop this 24 hours before surgery.
If INR >/= 1.5, give phytomenadione day before surgery.
Restart warfarin night of surgery if all OK.

If emergency surgery can be delayed by 6-12 hours give phytomenadione and check INR.
If it can’t be delayed give phytomenadione and prothrombin complex and check INR

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25
Which parenteral anticoagulant is preferred in renal impairment?
Unfractionated heparin (UFH)
26
Which parenteral anticoagulants have a lower risk of HIT: heparin or the LMWHs?
LMWHs- hence they are preferred.
27
Which parenteral anticoagulant is used in patients with history of HIT?
Danaparioid
28
What is the partial reversal agent for LMWHs?
Protamine
29
What is epoprostenol?
A prostacyclin: Inhibits platelet aggregation during renal dialysis when heparins are contraindicated Also licensed for pulmonary hypertension.
30
What meds do patients who have had a percutaneous coronary intervention (PCI) or stent need to be on?
Dual anti platelet therapy with: Aspirin (lifelong) Clopidogrel/ ticagrelor/ prasugrel (12 months)
31
What are glycoprotein IIb/ IIIa inhibitors? What are some examples and what are they used for?
They inhibit platelet aggregation- specialist use only. Abciximab ( used for PCI/UA) Eptifibatide (used with aspirin + UFH for UA/NSTEMI) Tirofiban (used with aspirin, clopidogrel + UFH for UA/STEMI/NSTEMI)
32
What is a major contraindication of aspirin? Can it be used in pregnancy?
Children under 16 (except in Kawasaki disease) due to risk of Reye's syndrome. Reye's involves swelling of the liver and brain and can lead to permanent brain damage. It can be used but in third trimester, at high doses, can cause: intrauterine growth restriction, closure of fetal ductus arteriosus in utero and possibly persistent pulmonary hypertension of newborn.
33
What are the restrictions on aspirin sale?
Packs of maximum 32 can be sold to the public. Pharmacists can sell multiple packs up to 100 tabs/caps.
34
What is the dose of apixaban for stroke prophylaxis in AF? Are there any dose adjustments? What is the dose for treatment of DVT/PE?
5mg BD. AVOID if crcl <15ml/min Reduce to 2.5mg BD if: Age 80 and over, body weight less than 61kg, creatinine > 133micromol/, or if Crcl 15-29ml/min For DVT/PE: Initially: 10mg BD for 7 days Then: 5mg BD maintenance for 6 months
35
What is the dose of apixaban for prophylaxis of VTE? What is the length of treatment for the different surgeries?
2.5mg BD 10-14 days for knee surgery (2 weeks) 32-38 days following hip replacement surgery (5 weeks)
36
What is the dose of edoxaban for stroke prophylaxis in AF? What is the dose for treatment of DVT/PE? Are there any dose adjustments?
Body weight up to 61kg: 30mg OD Body weight 61kg and above: 60mg OD Same dose for DVT/PE(following 5 days parenteral anticoagulant treatment) Avoid if crcl <15ml/min Reduce dose to 30mg OD if crcl= 15-50ml/min Max. dose 30mg OD with concurrent use of DECK- ciclosporin, dronedarone, erythromycin, ketoconazole.
37
What is the dose of rivaroxaban for stroke prophylaxis in AF? Are there any dose adjustments? What is the dose for treatment of DVT/PE?
20mg OD Reduce dose to 15mg OD if crcl= 15-49ml/min Avoid id crcl<15ml/min For DVT/PE: Initially: 15mg BD for 21 days Then: 20mg OD
38
What is the dose of dabigatran for stroke prophylaxis in AF? What is the dose for treatment of DVT/PE? Are there any dose adjustments?
150mg BD Same dose for DVT/PE(following 5 days parenteral anticoagulant treatment) Reduce to 110mg BD if: concurrent use with amiodarone or verapamil, age over 80 or if crcl 30-50ml/min. Avoid if crcl<30ml/min
39
What are side effects of heparins?
HIT- usually develops after 5-10 days and described a 30% reduction in platelets/thrombosis. Stop heparin and give alternative such as danaparoid Hyperkalaemia- due to aldosterone inhibition
40
What are enoxaparin doses for treatment and prophylaxis of DVT? Are there any dose adjustments?
Prophylaxis in medical patients: 40mg OD Reduce to 20mg OD if crcl<30ml/min Avoid if crcl<15ml/min Treatment: 1.5mg/kg OD if low risk of reccurence 1mg/kg BD if high risk (obesity, cancer, recurrent VT)
41
What are dalteparin doses for treatment and prophylaxis of DVT? Are there any dose adjustments?
Prophylaxis: 5,000 units OD In renal failure reduce based on factor xa levels Treatment: weight banded- approx 200units/kg OD (max 18,000units per dose)
42
What is the MHRA warning for vitamin K antagonists/ (warfarin, phenindione, aceocoumarol)?
Direct acting antivirals to treat hepatitis C can cause changes in liver function which may affect efficacy of Vitamin K antagonists. Monitor INR closely.
43
Can you use warfarin in pregnancy or postpartum?
No- teratogenic - congenital malformations Contraindicated 48 hours postpartum Delay warfarin until 5-7 days postpartum.
44
What is the MHRA warning associated with warfarin?
Rare risk of calciphylaxis (skin ulcers) | Report any painful skin rashes
45
What is the BP threshold for clinic settings that would require ambulatory BP monitoring to confirm diagnosis?
140/90mmHg
46
What is stage 1 hypertension? When do you start treatment?
Clinic BP ≥140/90 mmHg AND ambulatory or home BP ≥135/85 mmHg. Treat if <80 and target organ damage ( CKD, diabetes etc/ 10 year CV risk 20 or more) If <40, refer to specialist for further investigations
47
What is stage 2 hypertension? When do you start treatment?
Clinic BP ≥ 160/100 mmHg and ambulatory or home BP 150/95 ≥mmHg Treat all patients
48
What is severe hypertension?
Clinic systolic ≥ 180mmHg clinic diastolic ≥ 110mmHg | Treat immediately
49
What is a hypertensive crisis and how is it treated? How does it differ from hypertensive urgency? What is the treatment for both?
Severe hypertension with acute damage to target organs (e.g heart, eyes, kidneys). Dangerous if BP reduced too quickly- reduced organ perfusion. BP should be reduced by 20-25% within 2 hours. IV antihypertensives often required: sodium nitroprusside, labetalol, nicardipine, hydralazine. Hypertensive urgency: Severe hypertension without target organ damage. BP reduced gradually over 24-48 hours. Use oral drugs: labetalol, amlodipine, felodipine.
50
How is hypertension treated in patients under 55?
Step 1: ACE/ARB. (if not tolerated beta blocker [not in diabetes]) Step 2: ACE/ARB + CCB (if CCB not tolerated or if HF, thiazide. If beta blocker use in step 1, choose CCB) Step 3: ACE/ARB + CCB + thiazide Step 4: ACE/ARB + CCB + thiazide + spironolactone/ alpha blocker/ beta blocker Last line options include hydralazine, minoxidil (vasodilators), methyldopa, moxonidine, clonidine (centrally active) aliskiren (renin inhibitor)
51
How is hypertension treated in patients over 55 (or at any age of African/ Caribbean descent)
Step 1: CCB (if not tolerated/ HF, thiazide) Step 2: CCB/thiazide + ACE/ARB (ARB preferred in African/ carribean patients) Step 3: ACE/ARB + CCB + thiazide Step 4: ACE/ARB + CCB + thiazide + spironolactone/ alpha blocker/ beta blocker Last line options include hydralazine, minoxidil (vasodilators), methyldopa, moxonidine, clonidine (centrally active) aliskiren (renin inhibitor)
52
When are thiazide diuretics ineffective? What is the exception to this?
In renal failure egfr <30ml/min Metolazone is the exception (but associated with excessive diuresis)
53
How is hypertension managed in pregnancy? Are there any other special considerations?
Labetalol, methylodpa or MR nifedipine STOP methyldopa (contraindicated in depression) and switch to an alternative 2 days after birth. Review HTN meds after 2 weeks. Women with comorbidities are at higher risk of pre-eclampsia- aspirin from week 12 until birth. In women with pre-eclampsia, where birth is likely within 7 days, give bethamethasone for foetal lung maturation.
54
What is the target blood pressure? When does it differ?
Patients < 80 = 140/90mmHg clinic, 135/85mmHg ambulatory or home Patients ≥ 80 = 150/90mmHg clinic, 145/85mmHg ambulatory or home Pregnant patients = 150/100mmHg Patients with diabetes = 140/80mmHg (130/80mmHg if kidney, eye, cerebrovascular disease)
55
What is phaeochromocytoma? How is it managed?
It is a tumour of the medulla in the adrenal glands which leads to high BP. Long term management is by surgery but alpha and beta blockage must be accomplished first. Alpha blockers- phenoxybenzamine (lots of s/es) Beta blockers- atenolol/ bisoprolol
56
What side effects can hydralazine and minoxidil cause?
Tachycardia and fluid retention. With minoxidil it MUST be used with a beta blocker and a diuretic. Minoxidil also used for male alopecia so may cause excessive hair growth in patients.
57
What drugs are indicated for pulmonary hypertension?
Sildenafil, tadalafil, bosentan, iloprost, epoprostenol.
58
If a patient is on both a beta blocker and moxonidine, which should be stoped first?
The beta blocker. Avoid abrupt withdrawal of moxonidine
59
How do ACE inhibitors (pril) work? What are some side effects of ACE inhibitors? What is a specific contraindication?
Prevent angiotensin I to angiotensin II conversion. Major first dose hypotension (especially if on diuretics) Dry cough Angiodema (can be delayed) Hyperkalaemia (stop potassium sparing diuretics) Renal impairment Hepatic failure (STOP if deranged LFTs/ jaundice) The use of an ACE + aliskiren is contraindicated in patients with diabetes or if egfr <60ml/min (higher risk of hyperkalaemia)
60
Which beta blockers are less likely to cause bad dreams/ sleep disturbances and why?
SNAC- sotalol, nadolol, atenolol, celiprolol They are water soluble and do not readily cross the BBB
61
Which beta blockers are less likely to cause bradycardia and cold extremities?
PACO- pindolol, acebutolol, celiprolol, oxprenolol
62
When are beta blockers contraindicated and why? What is a specific caution of beta blockers?
Heart block, unstable HF- They slow the heart and depress the myocardium Asthma- they worsen bronchospasm Caution in diabetes- mask symptoms of hypoglycaemia such as tachycardia.
63
Which CCBs should be prescribed by brand?
MR diltiazem and nifedipine. NOTE: preparations with L in the name are once daily (e.g LA, XL) Those without (e.g retard) twice daily dosing.
64
How are hypotension and shock managed?
Volume replacement | Vasoconstrictors: adrenaline, dopamine (inotrope), noradrenaline, metaraminol, phenylephrine, midodrine
65
How is heart failure managed? Distiguish differences of treatment between reduced ejection fraction (HF- REF) and preserved ejection fraction (HF-PEF)
HF-PEF No established treatment- just diuretics. HF-REF Use loop and/ or thiazide diuretics as needed throughout 1st line- beta blocker + ACE/ARB 2nd line- ADD spironolactone/ eplerenone (NOTE these are AKA: aldosterone antagonists/ potassium sparing diuretics/ mineralocorticoid receptor antagonist) 3rd line- ADD ivabradine/ digoxin/ isosorbide with hydralazine/ entresto (sacubitril /valsartan)
66
Which are the only two ARBs licensed for heart failure?
Candesartan and losartan
67
Which are the beta blockers licensed in HF?
bisoprolol, nebivolol, carvedilol
68
How is stable angina managed?
Symptomatic GTN spray or s/l tablets throughout 1st line- beta blocker OR CCB 2nd line- switch to the other or use both. Not rate limiting CCB if using both. 3rd line- if pt can't have beta blocker or CCB, MONOTHERAPY with: long acting nitrate/ ivabradine/ ranolazine/ nicorandil 4th line- beta blocker OR CCB with long acting nitrate/ ivabradine/ ranolazine/ nicorandil DO NOT offer a third drug. Only if: symptoms aren't controlled AND they're awaiting revascularisation/ revascularisation not possible for the patient)
69
What is a side effect of nicorandil that requires treatment cessation?
GI ulcers - it can also cause serious skin, mucosal and eye irritation.
70
What is the difference between the different ACS - UA, NSTEMI, STEMI?
UA- no myocardial necrosis NSTEMI- some myocardial necrosis STEMI- significant myocardial necrosis
71
How are UA and NSTEMI managed?
BLOMAN Beta blockers- (if C/I verapamil or diltiazem) LMWH or heparin or fondaparinux Oxygen if hypoxia Morphine- 5-10mg slow IV (1-2mg/min) Aspirin 300mg + clopidogrel Nitrates- SL GTN/ IV or buccal GTN/ IV isosorbide If extreme: glycoprotein IIb/IIIa inhibitors (e.g abciximab) or revascularisation (e.g PPCI)
72
How is STEMI managed?
BLOMAN- TAG ``` Beta blockers LMWH or heparin or fondaparinux Oxygen if hypoxia Morphine- 5-10mg slow IV (1-2mg/min) Aspirin 300mg + clopidogrel Nitrates- SL GTN/ IV or buccal GTN/ IV isosorbide ``` Thrombolytic drug (e.g alteplase/ streptokinase within 12 hours) or PPCI. ACE inhibitor Glycoprotein IIb/IIIa inhibitors (e.g tirofiban)
73
What medicines should be initiated post STEMI (MI) ?
BADS Beta blocker ACE Dual antiplatelets- aspirin + Clopidogrel 12 months Statin - Atorva 80mg
74
When is alteplase contraindicated?
Hypersensitivity to gentamycin.
75
What is the MHRA alert associated with adrenaline pens?
2 pens should be prescribed + carried with the patient at all times. Note: if after 1st injection no improvement, a second injection can be used 5-15 minutes later.
76
What is the MHRA alert associated with hydrochlorothiazide?
Risk of non- melanoma skin cancer especially with long term use. Limit exposure to sunlight, have all skin lesions investigated.
77
What conditions can be exacerbated by diuretics?
Diabetes- can cause hyperglycaemia Gout Encephalopathy - in liver failure, the hypokalaemia caused by diuretics can worsen encephalopathy especially in alcoholic cirrhosis.
78
What are QRISK2 and JBS3? When are they unsuitable for use?
Assessment of 10 year cardiovascular risk. Those with a risk of 10% or more may benefit from drug treatment. They are unsuitable for assessing risk in patients over 85 or patients with type 1 diabetes.
79
What condition can cause lipid abnormalities?
Hypothyroidism- always treat this first before initiating any lipid modifying drugs.
80
What is recommended for primary prevention of cardiovascular disease? When would medications be indicated?
10 year cardiovascular risk ≥10% or patient over 85. Patients with type 1 diabetes and: over 40, other risk factors, diabetes >10 years, nephropathy. Lifestyle modification first step. Atorvastatin 20mg OD
81
What is recommended for secondary prevention of cardiovascular disease?
Atorvastatin 80mg OD
82
What is the follow-up after initiating a statin and what are the treatment aims?
Monitor total cholesterol, HDL and non HDL cholesterol within 3 months of starting. Aims: NICE say non- HDL cholesterol reduction by over 40% JBS3 say non- HDL cholesterol conc. below 2.5mmol/L
83
How is familial hypercholesterolemia managed?
High intensity statin to reduce LDL by over 50% | If intolerant to statin, they can have ezetimibe.
84
Which are the high intensity statins? What is the MHRA advice specific to simvastatin 80mg?
Atorvastatin 20-80mg simvastatin 80mg rosuvastatin 10-40mg Increased risk of myopathy with simva 80mg
85
Which are the medium intensity statins?
atorvastatin 10mg simvastatin 20-40mg fluvastatin 80mg rosuvastatin 5mg
86
Which are the low intensity statins?
pravastatin 10-40mg simvastatin 10mg fluvastatin 20-40mg
87
What are some side effects of statins? Can they be taken during pregnancy?
- Myopathy - do not initiate statins if creatinine kinase 5x upper limit of normal. - Interstitial lung disease- report dyspnoea, cough - Diabetes in patients at risk - Liver disease- avoid in active liver disease and stop statin if serum transaminases >3x upper limit. No- adequate contraception during and for 1 month after treatment. Stop statins 3 months before attempting to conceive- congenital abnormalities.
88
Are there any dose adjustments with atorvastatin therapy?
Maximum dose is 10mg if concurrent use with ciclosporin. Maximum dose is 20mg when used with elbasvir or grazoprevir.
89
Are there any dose adjustments with simvastatin therapy?
Maximum dose is 10mg if concurrent use with bezafibrate or ciprofibrate. Maximum 20mg with amlodipine, amiodarone, verapamil, diltiazem, elbasvir, grazoprevir. Maximum 40mg with ticagrelor
90
What are bile acid sequestrates? Do they require any special considerations?
They bind to bile acids and prevent their reabsorption leading to increased clearance of LDLs. Examples are colesevelam, colestyramine. Take 4 hours before or after other drugs. They interfere with the absorption of fat soluble vitamins (ADEK) so may need supplementation.
91
What are fibrates better at reducing then statins?
Triglycerides.
92
What is Raynaud's syndrome and how is it managed?
Its a condition where parts of the fingers can turn pale/ blue due to unknown causes cutting off blood supply. Managed by: avoiding cold and stop smoking. If severe, a vasodilator can be used. Nifedipine can also be used. Naftidrofuryl oxalate also helps. Oxerutins can be used for relief of oedema symptoms- not really used anymore.
93
What is the initial and usual dose of warfarin?
Initially 5-10mg | Maintenance 3-9mg (dependant on INR)
94
Which drugs are contraindicated in peripheral artery disease?
Beta blockers- don't stop abruptly- taper. Symptoms: pain, achiness, fatigue, pain in the extremities such as feet.
95
Which antihypertensive should an afro-carribean patient with diabetes be initiated on?
ACE+ CCB (or diuretic)

Pre-reg Exam (15 decks)

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