Chapter 2- Cardiovascular Flashcards
High weighted drugs
Which anticoagulant is preferred in renal impairment?
Heparin (unfractionated)
Low molecular weight heparin is suitable in all types of general and orthopaedic surgery
Which anticoagulant is used for venous thromboembolism in pregnancy?
Heparins (do not cross placenta)
Low molecular weight heparins are preferred(low risk osteoporosis and HIT). They are eliminated more rapidly in pregnancy
What drug is used for rapid reversal of effects of heparin?
Protamine (but only partially reverses the effects of lmw heparins)
Which anticoagulant should not be commenced in acute phase of ischaemic stroke?
Warfarin
(anticoagulants nor recommened as alternative to antiplatelets in Acute ischaemic stroke in pateints who are in sinus rhythm
What drugs are used in long term management of TIA or ischaemic stroke?
1st Clopidogrel
2nd MR dipyridamole and aspirin (either alone or in combi)
Stroke with af: warfarin
Statin within 48 hrs
Blood pressure meds(not b blocker) with target bp <130/80
Name vitamin K antagonists
Warfarin, phenindione, acenocoumarol
How long till onset of vit k antagonists
48 to 72 hrs.
Unfractionated or lmw heparin is given if immediate effect is required
Should initial dose of anticoagulants be given after base line PT time is determined?
No. Initial dose should not be delayed
INR 5-8 no bleeding
Omit 1 or 2 doses of warfarin and reduce maintenance dose
Inr 5-8 minor bleeding
Stop warfarin. Phytomenadione by slow iv infusion. Restart warfarin if INR <5
Inr >8 no bleeding
Stop warfarin. Phytomenadione p.o.
Repeat phytomenadione dose if INR still high after 24 hrs. Restart warfarin when Inr <5
Inr >8 minor bleeding
Stop warfarin, phytomenadione by slow IV.
Repeat phytomenadione if INR is high after 24 hrs. Restart warfarin inr <5
Heparin vs lmw heparin
Unfractionated heparin has short duration of action compared to lmw heparin.
The former is also preferred in high risk of bleeding since its effect can be terminated rapidly by stopping the infusion
Which heparin is preferred in prevention of venous thromboembolism and treatment of dvt and pe?
Lmw heparins e.g enoxaparin, dalteparin, tinzaparin
They are as effective and have lower risk of heparin induced thrombocytopaenia.
Duration of action is longer(once daily subcutaneous admin is possible)
When is aspirin used for prevention of cardiovascular disease?
Secondary prevention
It is not recommended in primary prevention of cvd in patients with or eithout diabetes or hypertension
What is the dose of aspirin for secondary prevention of cvd
75 mg
Why is aspirin c/i in children under 16 years?
It hass an association with Reye’s syndrome
When no strength is stated in a prescription for aspirin, what strength should be dispensed?
300 mg.
Aspirin exception to legal category
32 pack up to 100 pack
What should you keep in mind when dispensing MR dipyridamole
It should be dispensed in its original container and any capsules remaining should be discarded 6 weeks after opening
Give examples of factor Xa inhibitors
Apixaban. Edoxaban. Fondaparinux. Rivaroxaban
How can rivaroxiban be administered?
With food
May be crushed and mixed with water or apple puree
What concomitant drugs require edoxaban dose to be adjusted?
Max 30.od with ciclosporin, ketoconazole, erythromycin, dronedarone
What are signs of heparin induced thrombocytopaenia?
30% reduction of platelet count
Skin allergy
Thrombosis
What monitoring requirements are needed for heparins
HIT: plasma counts
Hyperkalaemia: plasma K conc. Aldosterone secretion is inhibited thus causing hyperkalaemia. More susceptible in diabetes mellitus, chronic renal failure, acidosis, k sparing drugs
Which heparin is a biological medicine and should be prescribed and dispensed by brand name?
Enoxaparin sodium
Arovi, Inhixa, Clexane
What is the direction for administration when taking dabigatran with amiodarone or verapamil?
They should be taken at the same time.
Why are vit k antagonists avoided in pregnancy?
Can cross placenta with risk of congenital malformations and placental, feral or neonatal haemorrhage esp during lask weeks of pregnancy and at delivery.
Stopping before 6th wk of gestation may laregly avoid the risk of fetal abnormality.
What is an important safety information by MHRA/CHM regarding warfarin?
Can cause calciphylaxis. Advice patients to consult doctor if they develop painful skin rash.
What is stage 1 hypertension and when does it need oharmacological treatment?
Clinic bp 140/90, ABPM 135/85
Treat in <80 with target organ damage, cvd, diabetes, 10 yr cv risk >20%
What is stage 2 hypertension?
Clinic bp 160/100, ABPM 150/95
What is 1st line treatment for hypertension in diabetes? Target bp?
Ace inhibitors.
<140/80. If with kidney, eye or cerebrovascular disease: 130/80
What medications can be given for hypertension in pregnancy?
LABETALOL
METHYLDOPA
NIFEDIPINE MR(unlicensed)
What medication is needed to prevent pre eclampsia in at risk pregnant patients?
Aspirin once daily from wk 12 of pregnancy until baby is born
What side effect of minoxidil requires use of b blocker and a diuretic?
Tachycardia and fluid retention due to vasodilatation
What are indications for acei
Heart failure usually with B blocker.
Hypertension in <55(caucasian)
HT in type 1 with diabetic nephropathy.
2ndary prevention of MI/cardiovascular events
NSAID +ACEi
Increased risk of renal impairment
K sparing diuretic + acei
Hyperkalaemia
Which beta blockers are water soluble?
remember: Water CANS Celiprolol Atenolol Nadolol Sotalol
How are water soluble b blockers excreted?
Renally- reduction in impairment
Long acting b blockers that allows it to be taken once daily
Atenolol
Bisoprolol
Celiprolol
Nadolol
Cardioselective beta blockers
Be A MaN Bisoprolol Atenolol Metoprolol Nebivolol
Common side effects of beta blockers
Cold extremities
Fatigue
Sleep disturbance with nightmares
Why is beta blocker not advised for diabetes?
It interferes with carbohydrate metabolism causing hypo or hyperglycaemia. Not contraindicated in diabetes although cardiospecific are preferred.
Should be avoided in frequent hypoglycaemia and uncomplicated HT in patients with diabetes or at high risk
What does combination of b blocker and verapamil do in established ischaemic heart disease?
Precipitating of heart failure
Can beta blockers be used in unstable heart failure?
No. Only in stable HF.
Bisoprolol and carvedilol.
Nebivolol in >70 with stable mild.or.moderate HF
Which beta blocker can be used for thyrotoxicosis?
Propranolol which can reverse clinical symptoms within 4 days
Which type of CCB has less effect on myocardium and therefore rarely precipitates heart failure?
Dihydropyridines
E.g nifedipine, amlodipine, felodipine, nicardipine
Ddo prescribers need to specify the specific brand when prescribing diltiazem?
Only for MR formulations containing >60 mg.
Which CCBs should be prescribed by brand?
Diltiazem and nifedipine
At what eGFR are thiazide and related diuretics ineffective?
Can thiazide and related diuretics be used for gestational hypertension?
No. Can cause a lot of s/e
Important safety info with hydrochlorothiazide
Increased risk of non melanoma skin cancer particularly in long term use
Limit exposure to sunlight and uv rays
Examine suspicious moles or skin lesions
Acei and aliskiren is contraindicated in these conditions
Diabetes mellitus and eGFR <60 ml/min/1.73m2
When should acei be discontinued?
Marked elevation of hepatic enzymes or jaundice occur- reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis, hepatic failure
Patients with heart failure and angina may be safely treated with this
Amlodipine
Rate limiting ccbs and short acting dihydropyridines should be avoided in reduced ejectipn fraction since it reduces cardiac contractility
Name a bile acid sequestrant and what may the patient require when treatment is prolonged?
Colesevelam/colestyramine/colestipol.
Interference with absorption of fat soluble vitamins may require supplements of A, D, K and folic acid
Waht should be managed adequately before statin treatment?
Hypothyroidism
Statin + fusidic acid interaction
Temporarily discontinue statin and restart after 7 days after last fusidic acid dose
