CH2: CARDIO CLINICAL Flashcards
1
Q
if ectopic beats are troublesome or persist how would you treat them?
A
offer beta-blockers
2
Q
what is atrial fibrillation (AF)
A
- irregular rapid heart beak caused by abnormal disorganised electrical signals in the atrium
- classified by HR> 100 beats/min
3
Q
what are the complications of AF and what are the risk assessments tools used?
A
complications of AF
- all AF pts are assessed for risk of stroke & thromboembolism
Risk assessment tools
1. CHAD2DS2-VASc
2. HASBLED
4
Q
diagnosis of AF
A
ECG
5
Q
symptoms of AF
A
- Heart pounding
- SOB
- Chest pain
- Heart palpilations
- Dizzinesses
- Tiredness
6
Q
Briefly describe the 3 types of AF
A
- Paroxysmal AF = episodes last within 48 hours of treatment.
- Persistent AF = episodes last more than 7 days of treatment
- Permanent AF = present all the time
7
Q
describe acute AF management for pts with life-threatening haemodynamic instability
A
- emergency electrical cardioversions ASAP
8
Q
describe acute AF management for pts without life-threatening haemodynamic instability, with the onset of AF < 48 hours
A
- offer rate control and rhythm control medications
9
Q
describe acute AF management for pts without life-threatening haemodynamic instability, with the onset of AF > 48 hours
A
- offer rate control medicaions
10
Q
describe the pharmacological interventions for cardioversion.
A
-flecainide
-amiodarone
11
Q
describe the electrical interventions for cardioversion in pts with acute AF
A
- start IV anticoagulants (heparins) and rule out left atrial thrombus
12
Q
Briefly state the treatment for AF management (rate control); 1st line, alternative and if both are unsuitable for pts.
A
‘rate control’
1st line = beta-blockers (except for sotalol)
alternative = non-dihydropyridines CCB e.g. verapamil and diltiazem
if the above is unsuitable - digoxin
13
Q
state the 2nd line treatment for AF management if symptoms are not controlled with 2 rate control drugs
A
2nd line - Cardioversion
(pharmacological or electrical cardioversions)
14
Q
electrical cardioversions
A
- the preferred type of cardioversion for 2nd line AF treatment
Preferred in pts;
- the onset of AF > 48 hours
- patient must be anticoagulated for at least 3 weeks
- Give PO anti-coagulation for at least 4 weeks after cardioversion
- Offer amiodarone for at least 4 weeks before cardioversion and 12 months after cardioversion
15
Q
pharmacological cardioversion
A
Anti-arrhythmic drugs
- Flecainide
OR - Amiodarone
16
Q
State the 1st and 2nd line treatment if sinus rhythm is still not maintained post cardioversion.
A
1st line: Beta-blockers
2nd line: SPAF
Sotalol, Propafenone, Amiodarone and Flecanide.
17
Q
What pts conditions are to be avoided to taking flecainide and propafenone?
A
- Heart failure
- Left ventricular disease
- Ischemic heart disease
18
Q
what medication as a 2nd line sinus rhythm control is to be offered to pts with ventricular impairment and heart failure?
A
Amiodarone
19
Q
what can dronedarone be used for?
A
- 2nd line treatment for persistent paroxysmal AF
20
Q
contraindication for dronedarone?
A
- pts with heart failure
21
Q
what is atrial flutter (AFL)
A
when the atria beats regularly but faster
(tachycardia effect)
22
Q
state treatment options for atrial flutter
A
- can treat with rate/rhythm control
- electrical cardioversion is more effective/ responds better
- assess the patient’s risk of stroke
23
Q
state the 2nd line treatment for atrial flutter
A
’ rhythm control’
- Direct current cardioversion = when rapid control of sinus rhythm is needed
- Pharmacological cardioversion = amiodarone or flecainide.
- Catheter ablation = recurrent atrial flutter
24
Q
what would you offer to a pt whose atrial flutter lasts longer than 48 hours?
A
3 weeks of anticoagulation
25
1st line treatment for paroxysmal AF
beta blockers
26
if symptoms are persistent or 1st line treatment for paroxysmal AF is unsuitable what are other options (2nd line)?
SPAF
Sotalol
Propafenone
Amiodarone
Flecainide
27
State what approaches is suitable for pts experiencing infrequent episodes of paroxysmal AF
1. Pill-in-the-pocket approach = the pt has PO antiarrhythmic drug to self-treat during episodes of AF if occurs
2. Can also offer flecainide or propafenone as PRN for symptom control
28
what is paroxysmal super-ventricular tachycardia (PSVT)?
- a type of arrhythmia/ abnormal heart beat that is regular but too fast.
- a PSVT episode occurs very fast and ends abruptly
29
1st line treatment for paroxysmal super-ventricular tachycardia (PSVT)?
- reflex vagal stimulation (carotid sinus massage, immersing face into cold water and Valsalva manoeurve)
30
2nd line treatment for paroxysmal super-ventricular tachycardia (PSVT)?
- IV adenosine
31
3rd line treatment for paroxysmal super-ventricular tachycardia (PSVT)?
- IV verapamil
32
state the maintenance/prophylaxis for paroxysmal super-ventricular tachycardia (PSVT)?
'rate control' medications
1st line- beta blockers
or
non-dihydropyridines CCB (diltiazem or verapamil)
33
what medication can you give patients with super-ventricular arrhythmias and NOT with ventricular arrhythmias?
verapamil
34
what is ventricular tachycardia (VT)
- is a type of arrhythmia, a fast heart rate arising from the ventricles
- where the HR > 120 beats/min
35
Briefly state the treatment for unstable sustained ventricular tachycardia
(1st line, 2nd line and 3rd line treatment options)
1st line: Direct current cardioversion
2nd line: IV amiodarone
3rd line: Repeat direct current cardioversion
36
Briefly state the treatment for stable ventricular tachycardia
(1st-line and 2nd-line treatment options)
1st line: IV amiodarone
2nd line: Direct current cardioversion
37
Briefly state the treatment for unsustained stable ventricular tachycardia
beta-blockers
38
state the maintenance for pts with ventricular tachycardia
high-risk patients= have a high risk of cardiac arrest
therefore, pts must be maintained on;
1. Implanted cardioverter defibrillator
2. May add on: Beta-blockers (inc sotalol) or Amiodarone (+/- beta blockers)
39
causes of QT prolongation (Torsade de pointes)
- drug-induced
- hypokalemia
- severe bradycardia
40
management for QT prolongation (Torsade de pointes)
- usually self-limiting but recurrent may cause impaired consciousness
- IV magnesium sulphate
- Beta-blocker (NOT sotalol)
- Atrial/ventricular pacing
41
what class of drugs should be AVOIDED in the management of QT prolongation?
< besides the drugs causing QT prolongation>
anti-arrhythmic drugs as it prolongs QT intervals = worsens the condition
42
Name the different types of strokes.
Transient Ischaemic stroke (T.I.A)
Acute ischemic stroke
Haemorrhagic strokes
43
What is a hemorrhagic stroke?
- an artery in the brain leaks blood or ruptures.
- can lead to high BP and aneuryms
44
What is Transient Ischemic Attack (T.I.A)?
- a blockage of a blood vessel.
- mini stroke
- Usually lasts for a short time (~5 mins) and resolved with 24 hours
45
what is the underlying cause of ischemic stroke
due to the development of fatty deposits lining the vessel walls and this is called atherosclerosis.
46
What are the symptoms of a stroke?
FAST
- facial weakness (one-side)
- arm weakness (one-side)
- speech slurred
-time (time to dial 999)
47
State the initial management for a patient diagnosed with T.I.A
- 1st line: Aspirin 300 mg immediately OD or if sensitive,
- 2nd line: Clopidogrel 75mg OD
Offer PPIs e.g. omeprazole to protect the stomach lining from the use of aspirin
48
state the initial management of Ischemic stroke
- IV Alteplase within 4.5 hours of symptom onset.
- Then Aspirin 300mg OD or Clopidogrel 75mg OD for 14 days to prevent incidences of stroke in patients at high risk of atherosclerosis.
49
State the long term management of a pt for stroke without AF (1st line, 2nd line and 3rd line)
- 1st line: Clopidogrel 75mg OD
- 2nd line: (dual therapy) Dipyridamole MR 200mg OD + Aspirin 300mg OD
- 3rd line: Dipyridamole MR 200mg OD
OR
Aspirin 300mg OD
50
State the long-term management of a pt for stroke associated WITH AF.
Warfarin or other anticoagulants for pts with AF ONLY
51
State the three factors part of the long-term management of TIA/stroke
(1) Statin (if not taking already)
e.g. Atorvastatin 80mg OD should be initiated 48hrs after stroke symptoms.
(2) Monitor BP
- target <130/80 mmHg
- AVOID use of beta blockers
(3) Lifestyle advice/signposting - reducing smoking, alcohol intake, and salt. Increasing physical activity, fibre/balanced diet meals.
52
MoA of antifibrinolytic drugs
e.g. tranexamic acid
helps with the formation of blood clots and reducing bleeding
53
treatment option for mild to moderate haemophilia & von Willebrand's disease
desmopressin
54
describe the 2 main types of thromboembolism (VTE) & its symptoms
1. Pulmonary embolism (PE)
- a blood clot that travels to the lungs
- Symptoms: chest pain and SOB
2. Deep vein thromboembolism (DVT)
- a blood clot in a deep vein usually in the calf (one leg/pelvis)
- symptoms: swelling, hot to touch, painful (one leg or pelvis)
55
state the risk factors of VTE
- Immobility
- Surgery
- Trauma
- Pregnancy
- Obesity
- Malignancy
- Hormonal therapy: HRT/COC
56
state the diagnosis for VTE
D-dimer test
57
what are the 2 types of prophylaxis for VTE
1. Mechanical
2. Pharmacological
58
state the mechanical prophylaxis for VTE
- compression stockings
- to be worn when immobile until sufficiently mobile
59
state the pharmacological prophylaxis for VTE
- Anticoagulants
- start within 14 hours of admission
- assess pts risk of bleeding using ORBIT or HAS-BLED tools
- patient's risk factors for bleeding should only receive pharmacological prophylaxis if the risk of VTE outweighs the risk of bleeding.
60
state the mechanical surgical prophylaxis for VTE
- compression stockings
- continued until fully mobile or discharged
61
state the types of pharmacological surgical prophylaxis for VTE
1. Low molecular weight heparins (LWMH)
2. Unfractioned heparins
3. Fondaparinux
62
describe the use of LMWH for surgical VTE prophylaxis
- suitable for all general or orthopaedic surgeries
- longer-acting anticoagulant effect compared to unfractionated heparins
63
describe the use of unfractionated heparins (UFH) for surgical VTE prophylaxis
e.g. heparin
- preferred in renal impairment
- pts who have a high risk of bleeding as UFH have a shorter half-life - when stopped its anticoagulant effect stops rapidly.
64
describe in what surgeries is fondaparinux suitable for surgical VTE prophylaxis
- pts with lower limb immobility
OR
- pts with pelvis fragility fractures
65
describe the type of surgical VTE prophylaxis used in cancer surgeries & for how long?
- pharmacological VTE prophylaxis
- for general cancer surgeries = usually 7 days post-surgeries or until fully mobilised
66
describe the type of surgical VTE prophylaxis used in spinal cancer surgery & for how long?
- extend pharmacological VTE prophylaxis for 30 days
67
describe the type of surgical VTE prophylaxis used in abdomen cancer surgery & for how long?
- extend pharmacological VTE prophylaxis for 28 days
68
describe the type of surgical VTE prophylaxis used in pts with renal impairment or bleeding risk
- pharmacological VTE prophylaxis: Unfractioned heparins (e.g. heparin)
69
describe the type of surgical VTE prophylaxis used in hip replacement & for how long?
- 10 days of LMWH then 28 days of Aspirin 75mg
OR
- 28 days of LMWH + compression stockings until D/C
OR
- Rivaroxaban for 35 days
70
describe the type of surgical VTE prophylaxis used in knee replacement & for how long?
- 14 days of Aspirin 75mg
OR
- 14 days of LMWH + compression stockings until D/C
OR
- Rivaroxaban for 14 days
71
describe the type of surgical VTE prophylaxis used in general/orthopaedic minor surgeries & for how long?
- pharmacological or mechanic VTE prophylaxis
- fondaparinux = pts with lower limb immobility
or
- LMWH
generally for 5-7 days or until stable
72
describe the procedures in pregnancy VTE prophylaxis
- Pharmacological VTE proph = if VTE outweighs the risk of bleeding
- Mechanical (compression stocks) if pt is immobile
- LMWH = during hospital admission until no further use or D/C
- In events of birth, miscarriage or termination within the past 6 weeks of pregnancy
Start prophylaxis 4-8 hours after the event
Continue a minimum of 7 days
73
state the treatment for confirmed proximal DVT/ PE?
(1st line & 2nd line)
1st line: Rivaroxaban or Apixaban
2nd line:
- LMWH for at least 5 days then give edoxaban or dabigatran
OR
- LMWH + warfarin for at least 5 days or until INR>2 for at least 2 consecutive readings, followed by taking only warfarin.
74
how long would you treat for distal DVT (calf)?
6 weeks
75
how long would you treat for proximal DVT/PE?
3 months
6 months if pt has active cancer
76
how long would you treat for provoked DVT/PE (resolved cause)?
3 months
77
how long would you treat for unprovoked DVT/PE?
3 months +
usually, 6 months if pts has cancer
78
how long would you treat for recurrent DVT/ PE?
long term
79
how long would you treat for VTE for a pt with AF?
long term
80
how long would you treat for a prosthetic heart valve?
long term
81
how long does it take for warfarin to have an effect?
48 to 72 hours
82
name the conditions that have a target INR of 2.5.
- VTE
- Cardioversion
- Cardiomyopathy
- MI
83
name the conditions that have a target INR of 3.5.
- mechanical heart valve
- recurrent VTE
84
bleed management if a pt has a major bleed?
- stop warfarin
- give IV Phytomenadione & dried prothrombin
85
bleed management if a pt has INR > 8 with minor bleeds?
- stop warfarin
- give IV phytomenadione
86
Bleed management if a pt has INR 5-8 with minor bleeds?
- stop warfarin
- give IV phytomenadione
87
bleed management if a pt has INR > 8 with NO bleeds?
- stop warfarin
- give PO phytomenadione
88
bleed management if a pt has INR 5- 8 with NO bleeds?
- withhold 1-2 doses of warfarin
- can restart after INR <5
89
when should INR be monitored in early management?
1-2 days
90
when should INR be monitored after early management?
every 12 weeks
91
side effects of warfarin
1. MHRA warning: calciphylaxis and skin necrosis (blue toe syndrome)
2. Painful skin reactions
3. Haemorrhage= prolonged bleeding - use antidote (Phytomenadione)
4. Pregnancy = avoid use in 1st trimester (1 to 12 weeks) and 3rd trimester (28 to 40 weeks)
92
describe the management for pt taking warfarin in a minor low-risk surgery
- Stop warfarin
- Surgery can be performed if INR <2.5
- Restart warfarin within 24 hours of the procedure
93
describe the management for pt taking warfarin in a major severe risk surgery
- Stop warfarin 3 to 5 days before surgery
-Day of surgery check pts INR, if INR is >1.5 = give Vitamin K
94
describe the management for a pt with a high risk of thromboembolism who is taking warfarin and about to undergo a major severe-risk surgery
If the patient is at high risk of thromboembolism, we can do a bridging effect
- Stop warfarin 3-5 days before surgery and start taking LMWH
- Stop LMWH 24 hours before surgery
- Restart LMWH after 48 hours of surgery
95
differentiate the use of parental anticoagulants of unfractionated heparins vs LMWH
unfractionated heparin
- preferred in pts with renal impairment
- has a short half-life, DOA and quick action
- high risk of heparin-induced thrombocytopenia (takes 5-20days)
- ideal for pts with a high risk of bleeding
- can cause hyperkalemia
- monitor APTT (prothrombin time - liver)
- the risk of haemorrhage = give protamine sulphate
LMWH
- preferred in pregnancy
- longer acting than UFH
- less risk of heparin-induced thrombocytopenia
- can cause hyperkalemia
96
state the antidote of UFH
protamine sulphate
97
diagnosis of hypertension; stage 1, state the clinic and ambulatory BP
clinic BP: 140/90 to 159/99 mmHg
Ambulatory BP: 135/85 -149/94 mmHg
98
for stage 1 (diagnosis of hypertension) state the factors that would determine whether a patient would require treatment or not
- patient < 80 years with 1 OR more co-morbidities (organ damage: kidney disease, CVD or 10%> Qrisk)
- patient <60 y/o with <10% Qrisk
- patient with > 80 years with BP >150/90 mmHg
99
diagnosis of hypertension; stage 2, state the clinic and ambulatory BP
clinic BP: 160/100 to 180/120 mmHg
Ambulatory BP: >150/ 95 mmHg
100
for stage 2 (diagnosis of hypertension) state the factors that would determine whether a patient would require treatment or not
treat all patients
101
diagnosis of hypertension; stage 3, state the clinic and ambulatory BP
> 180/120 mmhg
102
for stage 3 (diagnosis of hypertension) state the factors that would determine whether a patient would require treatment or not
medical emergency
103
briefly describe step 1 of hypertension management for a pt is 55 years or more and pts of afro Caribbean descent
CCB
104
briefly describe step 2 of hypertension management for a pt is 55 years or more and pts of afro Caribbean descent
CCB + ACEi/ARBs
**afro-Caribbean descent prefer ARBs!
105
briefly describe step 3 of hypertension management for a pt is 55 years or more and pts of afro Caribbean descent
CCB + ACEi/ARBs + thiazide like diuretics
106
briefly describe step 4 of hypertension management for a pt is 55 years or more and pts of afro Caribbean descent
K+ > 4.5mmol/L - alpha or beta blocker
K+ <4.5 mmol/L - low dose spironolactone (25mg)
107
briefly describe step 1 of hypertension management for a pt under 55 years and pts with diabetes
ACEi/ARBs
108
briefly describe step 2 of hypertension management for a pt under 55 years and pts with diabetes
ACEi/ARBs + thiazide like diuretics
109
briefly describe step 3 of hypertension management for a pt under 55 years and pts with diabetes
ACEi/ARBs + CCB + Thiazide-like diuretics
110
briefly describe step 4 of hypertension management for a pt under 55 years and pts with diabetes
K+ > 4.5mmol/L - alpha/beta blocker
K+ <4.5 mmol/L - low dose spironolactone (25mg)
111
name a beta blocker that can be used for gestational hypertension
labetalol
112
state the treatment options for a pregnant woman with hypertension (1st, 2nd and 3rd line)
if BP>140/90mmHg treat with;
1st line= labetalol
2nd line = nifedipine (unlicensed)
3rd line = methyldopa (unlicensed)
113
state the treatment pts who are at high risk of pre-eclampsia must take
aspirin at 12 weeks of pregnancy to birth
114
what pts are at risk of pre-eclampsia?
- autoimmune disease
- kidney disease
- diabetes
- hypertension
115
what is the target BP for pregnancy hypertension?
135/80 mmhg
116
what are the symptoms of heat failure?
- SOB
- Persistent coughing or wheezing
- reduced exercise tolerability
- fatigue
- ankle swelling
117
1st line treatment for chronic heart failure management
1st line = beta blocker and ACEi/ARBs
*ACEi = ramipril
*ARBs = losartan or candesartan < more preferred for afro-carribean>
*BB = all grades of LVSD (Bisoprolol or Carvedilol), Mild to moderate, aged 70+ (Nebivolol)
118
If B-blockers and ACEi/ARBs are CI as 1st line treatment for chronic HF management, what would you suggest?
Consult a specialist to initiate
Hydralazine + Isosorbide Dinitrate
119
2nd line treatment for chronic heart failure management, if symptoms persist...
Add on therapy
Spironolactone or Epleronone
120
HF pt with hyperkalaemia and poor renal function is still experiencing symptoms post 2nd line treatment for chronic HF, what alternatives would you suggest?
- Hydralazine + Isosorbide Dinitrate
- Sacubitril/Valsartan (LVEF <35% and taking a stable dose of ACEis/ARBs)
- ACEi + ARBs (last resort)
121
3rd line treatment for chronic heart failure management, if symptoms persist...
Add on therapy
Ivabradine = is has sinus rhythm + HR >75bpm
OR
Digoxin = if has sinus rhythm, and worsening of symptoms
122
State the treatment options for managing fluid retention in pts with HF (mild, mod and severe HF)?
Mild HF = Thiazide-like diuretics, CI if eGFR is <30ml/min
Moderate/severe HF = Loop diuretic
123
what drug class should be avoided in heart failure?
- rate-limiting CCB as it can cause cardiac contractility
124
what are the symptoms of oedema?
1. pulmonary = SOB, chest pain
2. peripheral = ankle swelling
125
state the types of diuretics
- K+ sparing diuretics
- loop diuretics
- thiazide like diuretics
126
Give examples of K+ sparing diuretics
examples; amiloride, triamterene
- inhibit Na+ reabsorption in the distal collecting duct
aldosterone antagonist - spironolactone - inhibits K+ secretion
127
what type of drugs would you avoid taking with K+ sparing diuretics?
K+ supplements as it would reduce the loss of K+ (Moa of aldosterone antagonists)
128
examples of loop diuretics, and duration of action?
examples; furosemide, bumetanide
- inhibits Na+ reabsorption in the ascending loop of Henle.
- up to 6 hours, can take BD without causing any sleep disruptions.
129
examples of thiazide like diuretics (TLD) and duration of action?
example; bendroflumethiazide, chlortalidone and indapamide
- long-acting; lasts up to 24 hours should be taken in the early days- as it may disrupt sleep
- inhibits Na+ absorption in the distal convoluting tubule.
130
side effects of diuretics
- electrolyte imbalances = hyponatraemia and hypomagnesia
- loop/thiazide = hypotension, hypokaelemia and loop exacerbates gout and diabetes
- K+ sparing = hyperkalemia, breast pain and tenderness, change in libido
131
state the drug-interaction effect of spironolactone and loop diuretics with lithium
increases lithium plasma concentration
132
state the drug-interaction effect of loop diuretics and gentamicin
& aminoglycosides
increases risk of nephrotoxocity or ototoxicity
133
describe the 2 types of vascular diseases
1. Occlusive peripheral vascular disease
- Caused by atherosclerosis
- Reduced risk by a healthy lifestyle, statins and antiplatelets
2. Reynaud’s syndrome (vasospastic peripheral vascular disease)
- Avoid exposure to cold
- Treat with nifedipine
134
state the healthy level of total cholesterol
< 5 mmol/l
135
state the healthy level of HDL
- good cholesterol
- > 1mmol/L
136
state the healthy level of LDL
- bad cholesterol
- < 3 mmol/l
137
state the healthy level of non-HDL
- bad cholesterol
- < 4 mmol/l
138
state the healthy level of non-triglycerides
- most dangerous
- < 2.3 mmol/l
139
state the healthy level of TC: HDL ratio
- <6 mmol/L
140
what type of patients would you offer lipid lowering agents?
* Patients under 85 years old with a CVD risk > 10%
* Patient with type 2 diabetes with a CVD risk > 10%
* Type 1 diabetes with:
- Age over 40
- Diabetes for over 10 years
- Established nephropathy
* Patients with CKD
* Patients with familial hypercholesterolaemia
141
examples of lipid lowering agents
Atorvastatin, simvastatin, rosuvastatin, pravastatin, Fluvastatin
142
state the statins that can be taken anytime of the day?
- Atorvastatin
- Rosuvastatin
143
state the statins that must be taken at night and why?
- simvastatin
- pravastatin
- fluvastatin
better response of reducing LDL levels at night
144
state the monitoring parameters for statins
Before initiation
* Full lipid profile
* Thyroid function = risk of hypothyroidism = should be corrected before initiation
* Renal function = impairment would increase the risk of myotoxicity
* Liver function
* Hba1c (& every 3 months)
145
state the liver function monitoring for statins
* LFT's
- Before treatment
- 3 months
- 12 months
* Discontinue if: serum transaminases are more than 3 x the upper limit
146
why is creatinine kinase measured?
Measured in patients who have had persistent muscle aches previously
147
what would you do if the measurement of creatinine kinase is 5x higher than upper limit?
- Don’t start statin yet and remeasure in 7 days
- If still higher than 5 x the upper limit = do not initiate statin
- If still raised but less than 5 x the upper limit = initiate at lower dose
148
side effects of statins
1. Myopathy and rhabdomyolysis
- Muscle toxicity: muscle pain, tenderness, weakness
- Seek medical advice if muscle symptoms occur
2. Interstitial lung disease
- Seek medical advice if: breathing difficulty, cough, weight loss
3. headaches
4. GI distrubances -- N/V, constipation
149
state the drug interactions of statins as a P450 substrate
1. CYP450 inducers:
- reduces statin concentration
- CRAP GPS: carbamazepine, rifampicin, alcohol, phenytoin, griseofulvin, phenobarbital, st johns wort
2. CYP450 inhibitors:
- Increases statin concentration
- Macrolides and grapefruit juice = increased risk of rhabdomyolysis (mostly with simvastatin)
- Can temporarily stop statin whilst on macrolide
150
state the drug-interaction of statins with fibrates
examples; bezafibrate, ciprofibrate, fenofibrate, gemfibrozil
*interactions: statin + fibrate = increased risk of muscle related SE (rhabdomyolysis…)
151
state the drug-interaction of statins with ezetimibe (and its max dose of statins)
Statin + ezetimibe = increased risk of rhabdomyolysis max 10mg statin dose
*Ezetimibe is a lipid-modifying agent
152
state the max dose of simvastatin with amiodarone?
20mg
153
state the max dose of simvastatin with amlopidine?
20mg
154
state the max dose of simvastatin with diltiazem/verapimil/ranolazine?
20mg
155
state the max dose of simvastatin with tricagrelor?
40mg
156
state the max dose of atorvastatin with ciclosporin?
10mg
157
state the max dose of atorvastatin with tipranavir?
10mg
158
what are myocardial ischaemia (IHD) and its complications?
the build-up of atherosclerotic plaques that restrict arteries which reduce blood flow and oxygen to the heart can lead to complications like a heart attack.
159
describe stable angina
predictable: chest pain caused by physical excretion or emotional stress.
160
describe the initial treatment of stable angina
- take GTN (spray or S/L) every 5 minutes
- if after the 3rd dose symptoms still persist call 999
161
1st line long-term prevention for stable angina
beta blocker
if CI, use rate limiting CCB (diltiazem or verapamil)
162
2nd line long-term prevention for stable angina
beta blocker + CCB
163
if a pt is suffering from prizmetal angina or decompensated heart failure, what treatment would you offer?
CCB such as amlodpine
164
3rd line long-term prevention for stable angina
long-acting nitrates (RIN) = nicorandil, ivabradine and ranolazine
165
what other management to offer for long-term prevention for stable angina?
- Healthy lifestyle
- Aspirin 75mg OD
- low-intensity statin
166
what are the major risk factors of ACS?
- family history
- hypertension
- diabetes
- smoking
- hypercholesterolaemia
167
What is ACS?
Acute coronary syndrome that encompasses myocardial infraction with or without ST-segment elevation (STEMI, NSTEMI or unstable angina)
168
Diagnostic tests for ACS
Test for ECG and biomarkers to differentiate between unstable angina, NSTEMI and STEMI
169
State the initial treatment for confirmed ACS
- Loading dose of aspirin 300mg
- Pain relief = GTN and/or IV morphine
- Offer oxygen if needed
170
describe STEMI and its biomarkers
- Complete blockage of an artery
- Myocardial neurosis
- ST elevation
PCI needed within 2 hours
With antithrombin agents – heparin and prasugrel (preferred antiplatelet)
*PCI = percutaneous coronary intervention
171
describe NSTEMI and its biomarkers
- Partial/intermediate blockage of artery
- Myocardial neurosis
- No ST elevation
If PCI is needed, consider heparin for anti-thrombin agent
172
describe Unstable angina and its biomarker
- Partial/intermediate blockage of artery
- No myocardial neurosis
- No ST elevation
173
State the five new medications a patient would be initiated after confirmed ACS
1. Dual antiplatelet therapy
Aspirin 75mg (lifelong)
Clopidogrel, prasugrel or ticagrelor = for 12 months
*offer PPI for gastroprotection
2. Beta-blocker
Maybe discont. after 12 months in pts with LVEF
3. ACEi, use ARBS if CI
4. High-intensity statin (atorvastatin 80mg OD)
*may offer eplerenone if there is LVD and evidence of HF
174
A T2DM pt taking a regular dose of metformin was admitted to the hospital with a heart attack, state what medication intervention you would make?
Withholding metformin for 48 hours as it is CI post MI or angiogram procedure.
175
Pt is taking clopidogrel together with aspirin as a dual anticoagulant therapy for ACS management, what PPI would you advice to prescribe, and what PPI would you avoid and why?
Advice to prescribe -
Lansoprazole
AVOID
Omeprazole + Clopidogrel = Severe interaction = increases the risk of bleeding.
176
Can a pregnant woman take statins?
No, it should be avoided in pregnancy as it is teratogenic and should be stopped 3 months before conception.
177
State pts who are at high risk of myopathy or rhabdomyolysis
- pt who has alcoholism
- consuming a high dose of statin
- history of muscle pain
- have renal impairment
- hypothyroidism
- older ager
- severe liver disease
178
state the drug interaction of statins + fusidic acid?
Fusidic acid (oral):
- stop statin during treatment
- restart statin 7 days after the last dose of fusidic acid
179
state the drug interaction of statins + fluconazole?
- withhold statin until the fluconazole course is completed
180
state the drug interaction of statin + warfarin, and what statin has this effect?
- monitor INR levels
-ONLY pravastatin = increasing the risk fo bleeding
181
state the drug interaction of statin and ciclosporin, and what statin is contraindicated to take with ciclosporin?
- Rosuvastatin + ciclosporin = contraindicated
- max use of simvastatin/ator- with ciclosporin is 10mg OD
182
What are the key signs of myopathy?
Symptoms may or may not occur with raised creatine kinase concentrations
- Muscle pain
- Dark coloured urine
- Tenderness
- Weakness
- Rhabdomyolysis (severe skeletal muscle damage): creatine kinase> 10 times the upper limit of normal
183
What medications to avoid in pre-eclampsia?
- ACEi
- ARBs
- TLD
* risk of congenital deformities
184
State the patients who would have a blood pressure target of less or equal to 130/85mmHg.
- have diabetes and in presence of kidney, eye or cerebrovascular disease.
- have chronic renal disease and diabetes if urine albumin (ACR) is >70
- have established atherosclerotic CVD
185
What is the best antihypertensive treatment for a black African 60-year-old man who has been shown to have evidence of heart failure in having left ventricular hypertrophy?
Thiazide-like diuretic such as indapamide or
chlortalidone
In line with the NICE guidelines, black African people should be offered calcium channel blockers first line. However, that is slightly different if there is evidence of heart failure. Where there is evidence of heart failure, it is recommended to give a thiazide diuretic.
186
I have a 60 year old Caucasian woman with me and we found her clinic BP to be 161/101 mmHg. I would like to know what the best hypertension management should be for her baring in mind she has no end stage organ failure and her QRIISK is 6%.
Start a calcium channel blocker
Her reading is line with stage 2 hypertension which warrants initiation of antihypertensive drug- regardless of whether there is end organ damage or what their CVD risk is.
In line with the NICE guidelines, people 55 and over should be started with a calcium channel blocker such as amlodipine
187
I have 50 year old Caucasian man who has a type 2 diabetes. He has a clinic BP of 142/90mmHf and home blood pressure of 135/85mmHg. I’d like to know how best I can manage his blood pressure? With drugs or is lifestyle sufficient at the moment?
Start an ACEI such as ramipril
His reading is line with stage 1 hypertension.
This stage does not always warrant the use of antihypertensive drugs, however in line with the guidelines, if a patient with stage 1 hypertension also has either of the following:
End stage organ damage Diabetes
Renal disease Established CVD
They should be started on an antihypertensive. As she is under 55, give her an ACEI.
188
I have a 60-year Caribbean woman with me here who I’d like to move onto step 2 of the antihypertensive regimen. She has currently been taking amlodipine 10mg for 4 weeks.
Which is the best drug for me to give her?
Add on an angiotensin-II-receptor blocker
such as losartan
The next step would be to add an ACEI or ARB. But in line with the guidelines, as she is of black African/Caribbean background, instead of an ACEI, they are recommended to have an ARB like losartan.
189
I’m a 50-year-old black African man with recently diagnosed high blood pressure. I don’t have diabetes. Which drug do I start with?
CCB such as amlodipine
190
I am a 55-year-old white female with recently diagnosed high blood pressure. Which drug do I start with?
CCB- amlodipine
191
I have type 2 diabetes and I was also recently diagnosed with high blood pressure. Which drug do I start with?
ACEi or ARBs
192
A black African who has diabetes and also recently got diagnosed with high blood pressure. Which drug do I start with?
ARBs, more prefered than ACEi
193
I’m a Caucasian mother. I’ve decided to breastfeed, I had pre- eclampsia and I’d like to know which drug is best for me now I have given birth?
First line: enalapril
Be sure to monitor maternal renal function & serum potassium
194
Advise a patient who was treated with anti-hypertensives during their pregnancy review.
6-8 weeks post-birth by GP/ specialist
195
Advise a patient who was treated with anti-hypertensives and wondering when they can continue taking their anti-hypertensives post-birth review.
2 weeks post-birth
196
Which of the following is not licensed in the management of hypertension
a) Indapamide MR 2.5mg
b) Ramipril 2.5mg
c) Amlodipine 5mg
d) Spironolactone 50mg
e) Chlortalidone 12.5mg
D, Spironolactone 50mg
Step 4 is a low-dose spironolactone therefore should be 25mg
197
Mr. Brown is a 79-year-old pensioner. He has recently been experiencing headaches and feels increasingly lethargic. He has tried paracetamol for his headaches and occasionally ibuprofen but no improvement. He was recently told by his neighbours that frequent headaches may be a sign of HTN.
Which of the situations below would not require a Px for an antihypertensive medication?
a) BP is 165/100 with no organ damage or any other complication
b) has a clinical BP of 155/90 with a 10 year CV risk equivalent to 5% and no organ damage
c) has a clinical 145/90 with mild retinopathy
d) ambulatory BP of 175/90 with no organ damage
e) clinic BP of 140/90 with renal disease
B, has a clinical BP of 155/90 with a 10 year CV risk equivalent to 5% and no organ damage
198
A 25-year-old lady with pre-eclampsia is 20 weeks pregnant. She has no other conditions
Methyldopa
199
A 45-year-old Caucasian male with T2DM and ankle oedema who has had ramipril and his BP is still high and the GP wants to add a new medication
G, Chlortalidone
200
A 35-year-old man who is experiencing swollen breast tissue, pain and tenderness and thinks it may be due to one of his medications
B, Spironolactone
