Chapter 2: Cardiovascular system Flashcards
Which NOAC has twice daily dosing? Which has once daily dosing?
Twice daily: Apixaban (5mg BD), Dabigatran (150mg BD)
Once daily: Rivaroxiban (20mg OD), Edoxaban (30-60mg OD)
Which NOAC requires loading?
Apixaban 10mg twice daily for 7 days followed by 5mg BD maintenance (loading not required for prophylaxis)
Which DOAC interacts with verapamil and subsequently requires a dose reduction? What other medication has the same interaction?
Dabigatran
Verapamil increases dabigatran levels, so patients also on verapamil need to take a reduced dose of dabigatran (110mg BD as opposed to 150mg BD)
Same with amiodarone- use max dose of 110mg dabigatran with amiodarone
Which one of the NOACs is a DIRECT THROMBIN inhibitor?
Dabigatran is a direct thrombin inhibitor
An INR within ____ units of the target range is generally satisfactory
0.5 units
A target INR of ____ is used for most things! Eg treatment of DVT/PE, AF patients, electrical cardioversion, myocardial infarction…
2.5
Do the NOACS have any food interactions?
No But remember to take Rivaroxiban with food to increase absorption
Which NOAC may be crushed an mixed with apple purée/ put through an NG tube before administration?
Rivaroxaban
Which CCBs need to be avoided in Heart failure?
Verapamil and diltiazem
When should a target INR of 3.5 be used? What is the target for most other conditions?
If the patient has a VTE whilst on treatment with warfarin (with an INR above 2).
Mechanical heart valve
Warfarin’s time to peak effect ranges from 3-5 days, so it is not good if immediate effects are needed. NOACs have a much faster onset to action, what is this? Which is the fastest?
1 - 4 hours
Dabigatran fastest: peak action 0.5-2 hours after oral admin
Edoxaban: 1-2 hours onset of action
Apixaban and rivaroxaban take around 2-4 hours to peak
What is the difference between Phytomenadione and Phenindinone?
Phytomenadione (vit k) is the reversal agent for warfarin overdose
Phenindinone is another oral anticoagulant (coumarin) like warfarin!
What baseline tests do patients need before commencing on a NOAC? Which NOAC is least likely to be chosen with renal impairment ?
Baseline renal function - dose reduction required in renal impairment
Dabigatran has most caution with renal function: it is CI if CrCl is under 30 ml/min
Which NOACs should not be used in severe liver disease?
All
We know that warfarin interacts with a lot of the CYP enzyme inhibitors and inducers, Which NOACs also have a similar problem? Can you think of any interactions?
All
CYP3A4 inhibitors (sickfaces.com) effect these: ketoconazole, itraconazole, Inducers effect these: carbamazepine, rifampicin, phenytoin, St. John’s wort
Which NOAC cannot be put in a compliance aid?
Dabigatran
Which DOAC needs the warning label “swallow whole, do not chew or crush”
Dabigatran
Which is more problematic if a dose is missed, warfarin or the NOACs?
NOACs - shorter half life so if dose is missed there is more time without coagulation If miss a dose of a NOAC
What is the reversal agent for LMWHs?
Protamine sulfate
Name me three LMWHs
Dalteparin Enoxaparin Tinzaparin
When in pregnancy should warfarin be avoided?
First trimester
Crosses the placenta especially in the third trimester
Safe in breast feeding
When used for the prophylaxis of stroke in AF what are the 3 characteristics which are used to identify if a dose reduction is required.
age 80+
body weight 60kg or less
Serum creatinine of 133 or greater
Which NOAC causes the most GI side effects?
Rivaroxaban: constipation, diarrhoea, abdo pain, nausea, vomiting
Also causes: pain in extremities, Pruritis (itching), Rash
What is heparin induced thrombocytopenia and which heparins is it more common with?
Development of very low platelet count
It is an immune mediated reaction that can develop after 5-10 days
More common with UFH than LMWHs
Management: stop the heparin, use something else like Heparinoids
Which anticoagulant is indicated in patients with a history of heparin-induced thrombocytopenia?
Danaparoid
This is a Heparinoid so won’t cause the Same reaction
What heparin should we choose in patients with renal impairment?
UFH (unfractionated heparins).
This is because the LMWHs Dalteparin, enoxaparin and tinzaparin have their risk of causing bleeds increased in renal impairment
Dalteparin vs dabigatran?
Dalteparin is LMWH
Dabigatran is a NOAC
What is the treatment for a VTE (DVT or PE)?
Warfarin and bridge with LMWH for at least 5 days or until the INR has been over 2 for 24 hours
Apixaban: 10mg BD for 7 days, then 5mg BD
Edoxaban: 30-60mg OD (lower dose for weight <61kg)
Rivaroxaban: 15mg BD for 21 days then 20mg OD with food
Dabigatran: 150mg BD following at least 5 days of treatment with parenteral anticoagulant
What can be used for VTE treatment in pregnant women?
Heparins are Safe in pregnancy as they do not cross the placenta.
LMWHs usually preferred as they carry a lower risk of osteoporosis and heparin induced thrombocytopenia. LMWHs unlicensed in pregnancy for the treatment of VTE
What do we need to monitor with heparins?
Weight- dose based on weight
Renal function
Platelet count
What is Bivalirudin and when is it used?
It’s a thrombin inhibitor, and it used as an anticoagulant for those undergoing PCI and in NSTE-ACS
What is the anticoagulant used in NSTEMI/ unstable angina episode if angiography is NOT planned within the next 24 hours? What kind of drug is this?
Fondaparinux
Synthetic pentasaccharide
If angiography is planned: use LMWH as they have a shorter half life
Which beta blocker has been associated with severe liver damage?
Labetalol
Sotalol is a beta blocker commonly used in ventricular arrhythmias, different tachycardias and as Rhythm control following cardioversion in AF. There is an important safety warning that comes with Sotalol, do you know what it is?
QT prolongation! May cause life threatening ventricular arrhythmias!! Electrolyte disturbance- especially Hypokaleamia and hypomagnesaemia- need to be sure these are corrected before starting Sotalol or there will be even more risk of arrhythmias
What are the nitrates (GTN, isosorbide dinitrate, isosorbide mononitrate) used in?
Principle role in ANGINA- they reduce venous return so reduce left ventricular work of the heart
What are some of the undesirable effects of the nitrates? (3)
Flushing
Throbbing Headache
Postural hypotension
dizziness
GTN is one of the most effective drugs at providing rapid symptom relief from angina, it’s effects only last for ______
20-30 minutes
You know GTN has a short duration of action, what about isosorbide mononitrate/ dinitrate?
Much longer- MR has duration of 12 hours, but not as rapid onset so not as effective for rapid symptomatic relief of angina
BD dosing of nitrates should account for a nitrate free period. Therefore give OM and LU
NITRATES can lead to TOLERANCE and reduced therapeutic effects if long-acting preparations used/ transdermal preps used. What can be done to overcome this?
Need to reduce blood nitrate concentration for 4-12 hours each day to avoid tolerance. Eg. If transdermal: leave the patch off overnight If MR isosorbide dinitrate: give the second dose after 8 hours rather than 12 hours
What if patients on Statin therapy develop symptoms of Dysponea, cough and weight loss, what should be done?
Seek medical attention ASAP as this could indicate interstitial lung disease
Why is brand specific prescribing required with Nifedipine preparations?
Different versions of the the MR preparations may not have the same clinical effects
NB: ADALAT - LA and VALNI- XL are both not appropriate in hepatic impairment
Why should adequate urinary output be established before initiating therapy with a Loop diuretic?
Because loops can result in urinary retention if there if an enlarged prostate/ other disruption of urinary flow…Loops usually stimulate more urine production!
If a loop diuretic (eg. Bumetanide, furosemide, co-amilofruse) is needed twice daily, when should the doses be taken?
One in the morning and one before 4pm- no later than this otherwise the patient might have a disturbed sleep (waking up to go to the toilet)
When are ACE inhibitors contra-indicated
History of angioedema
What is sodium nitroprusside prescribed for?
Hypertensive emergencies
Rapidly reduces blood pressure
What anti-platelet drug can cause a throbbing headache as a side effect?
Dipyridamole
What does a positive D-dimer test indicate?
High level of cross-linked fibrin by-products, i.e. a clot has formed - DVT/ PE
What is the early management for STEMI
Immediate: Aspirin 300mg
If having PCI:
Prasugrel and Aspirin (if not on anticoagulant)
Clopidogrel and Aspirin (if on anticoagulant)
If within 12 hours of onset but PCI cannot be performed within 120 minutes of fibrinolysis:
Fibrinolysis and anti-thrombolytic together
If PCI can not be done:
Ticagrelor + Aspirin if no bleeding risk
Clopidogrel + Aspirin if bleeding risk present
Following admission to hospital when should a VTE risk assessment be carried out?
Within 24 hours
What does mechanical prophylaxis involve with VTE prevention?
Stockings, IPC sleeve
Can you think of any risk factors for VTE?
NB: Classed as HIGH risk if one or more of these are present!
Active cancer/cancer treatment Aged > 60 Dehydration History of DVT/VTE Obesity: BMI over 30 Comorbidites- Heart disease, endocrine, inflammatory condition COC's/Tamoxifen/HRT Varicose veins Pregnancy
Can you think of any risk factors for bleeding?
HASBLED Hypertension Abnormal liver/renal function Stroke Bleeding tendency labile INR Elderly (Age >65) Drugs/alcohol
For patients treated for DVT, PE and prevention of their re-occurence, who want to switch from warfarin to the NOAC rivaroxiban, at what INR can they do so?
Once INR is less than or equal to 2.5
As HIT develops the platelet count typically begins to fall _____ days after starting Heparin.
5-10 days
Patients who receive any type of heparin should have a baseline platelet count, but after this platelet monitoring is not usually needed.
Colestyramine is a Bile acid sequesterant used in hypercholesteremia when a statin and ezetimibe have failed. When should patients be advised to take other medicines with this?
Take other medicines at least 1 hour before or 4 hours after Colestyramine as it can effect their absorption considering it tampers with bile acid
What medication should be added if a patient has a particularly high level of TRIGLYCERIDES?
Fenofibrate
A patient has suffered muscle pain with three different statins now, and the consultant asks you where to go next. Their Triglycerides are within range. Your options are: Fenofibrate Ezetimibe Nicotinic acid Colestyramine
Usual guidance: Statin»_space; Ezetimibe»_space; Fibrate if TGL is high/ bile aid sequesterant/ nicotinic acid. Ezetimibe may also cause Myalgia so rule this out. Patients TGL’s are normal so rule out Fibrates.
Best option if pt has myalgia with ezetimibe: Colestyramine (bile acid sequesterant)
What is the reversal agent for Dabigatran?
Idarucizumab- a monoclonal Antibody
Which is more potent Loop: Bumetanide or Furosemide?
Bumetanide
Why don’t Afro-carribean patients respond as well to ACE inhibitors/ ARBs?
Because these work on the renin-angiotensin system and it has been established that black people have low circulating renin
What kind of drug is Amiloride?
Potassium sparing diuretic - hyperkaleamia risk !!
What are the three types of acute coronary syndromes (ACS)
STEMI
NSTEMI
UNSTABLE ANGINA
You are a pharmacist on a very busy ward and Mr Jones is suffering from hypertension. The duty doctor wants to give him a medication, but he only wants to prescribe one which is indicated for hypertension only. He is unsure which medication to give. He asks you which medication below would be most suitable for Mr jones?A. AmlodipolineB. FelodiponeC. VerapamilD. Lercanidipine
D. Lercanidipine
Is treatment usually required for ectopic beats?
No, but can use beta blockers if needed
What two things can you try and control in a patient with AF?
Rate and rhythm control
In patients without life-threatening haemodynamic instability, if a patient has onset of AF less than 48 hours ago, what can be offered to the patient?A- rate controlB- rhythm controlC- both
C- both
If a patient presents with AF and the onset is more than 48 hours ago or uncertain, is it preferable to control rate or rhythm?
Rate
What beta blocker should you not use in rate control for AF?
Sotalol because it is known to be proarrhythmic with an increased risk for TdP.
- How can ventricular rate be controlled in AF?
2. If this does not work, what can be used?
- Monotherapy:Standard beta blocker (not sotalol), Rate limiting CCB e.g. verapamil, Diltiazem is used but unlicensed, Digoxin
- Combination of beta blocker, digoxin or diltiazem
What group of patients should digoxin monotherapy be used for ventricular control in AF?
Only effective for controlling the ventricular rate at rest, so should only be used as monotherapy in sednetary (inactive) patients with non-paroxysmal atrial fibrillation.
What is meant by paroxysmal AF?
Episodes come and goEpisodes last from a few seconds - days. In between episodes heart has normal (sinus) rhythm. Most eps convert within 48 hrs
If dual ventricular rate therapy does not control symptoms in AF, what can then be considered?
Rhythm control
In patients with AF and diminished ventricular function, what should be used to control rate?
Beta blockers that are licensed for use in heart failure and digoxin
Post cardioversion in AF, what is used to maintain sinus rhythm?
Beta blocker
What is 1st line for long term rhythm control in AF?
Beta blocker (not sotalol)
If amiodarone is needed in an electrical cardioversion patient, how long before and after the procedure can they be on it for?
4 weeks before and up to 12 months after
For rhythm control in AF, what group of patients would flecainide acetetate or propafenone NOT be suitable for?
Known ischaemic or structural heart disease
When would dronedarone be used in rhythm control for AF?
As an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:- whose atrial fibrillation is not controlled by first‑line therapy (usually including beta‑blockers), that is, as a second‑line treatment option and after alternative options have been considered and who have at least 1 of the following cardiovascular risk factors:-hypertension requiring drugs of at least 2 different classes- diabetes mellitus- previous transient ischaemic attack, stroke or systemic embolism- left atrial diameter of 50 mm or greater or- age 70 years or older andAnd:who do not have left ventricular systolic dysfunction andwho do not have a history of, or current, heart failure.(consider amiodarone in these patients)
What group of patients would you consider amiodarone for rhythm control
Left ventricular impairment or heart failure
What 2 drugs can be used for the “pill in the pocket” approach for AF?
Flecainide or propafenone
What tool do you use to assess for stroke risk in AF patients?
CHADVASC
Congestive heart failure Hypertension Age >75 Diabetes Vascular disease Stroke/TIA previous Sex (female)
What tool do you use to assess for bleeding risk?
HASBLED
Hypertension Abnormal liver/renal Stroke Bleeding tendency Labile INR Elderly (>65) Drugs and alcohol
At what CHADVASC score in men would you consider anticoagulation in AF?At what score should you offer (taking into account bleeding risk)?
more than or equal to 1
At what CHADVASC score in females would you consider anticoagulation to in AF?
2
Is aspirin monotherapy recommended for stroke prevention in AF?
No
What is the MHRA warning associated with amiodarone and hepatitis C antivirals?
Increased risk of bradycardia and heart block Needs very close monitoring if used together but ideally use alternatives
What are the key side effects of amiodarone?
- Corneal microdeposits (reversible upon withdrawal of treatment but can cause blindness)
- Thyroid function- amiodarone contains iodine and can cause hyper and hypothyroidism (thyrotoxicosis)
- Hepatotoxicity
- Pulmonary toxicity- pneumonitis should always be suspected is new or worsening SOB occurs
- phototoxicity
- Grey skin discolouration
What does amiodarone contain that could cause thryoid problems?
Iodine
What is the patient advice regarding amiodarone and the sun?
Patients should be instructed to avoid exposure to sun and to use protective measures during therapy as patients taking Amiodarone tablets can become unduly sensitive to sunlight, which may persist after several months of discontinuation of Amiodarone tablets. In most cases symptoms are limited to tingling, burning and erythema of sun-exposed skin but severe phototoxic reactions with blistering may be seen.Patients need to shield their skin from light during treatment and for several months after discontinuing treatment as it has a very long half life
What is the main side effects with dronedarone?
Can cause/worsen heart failure so patients should seek help if symptoms of SOB, oedema, weight gainHepatic failure - Seek prompt medical attention if symptoms such as abdominal pain, anorexia, nausea, vomiting, fever occurPulmonary toxicity
What is the important safety information regarding sotalol and what it should be used for?
QT prolongation
Need to correct any hypokalaemia before starting
The use of sotalol should be limited to the treatment of ventricular arrhythmias orprophylaxis of supraventricular arrhythmias.
It should no longer be used for angina, hypertension, thyrotoxicosis or for secondary prevention after myocardial infaction
If digoxin is being used alongside amiodarone, dronedarone or quinine, what do you do to the dose of digoxin?
Half it
When switching from IV to oral digoxin, how should you convert the dose?
Increase by approx 33%
True or false: Hypocalcaemia increases risk of digoxin toxicity
False
Hypercalcaemia increases this risk
True or false: Hyperkalaemia increases risk of digoxin toxicity
False: Hypokalaemia increases this risk
True or false:Hypomagnesaemia increases risk of digoxin toxicity
TRUE
Digoxin toxicity- what colour can your vision go?
Yellow
What is nimodipine used for?
Used in subarachnoid haemorrhage
What should patients immediately receive if they have a suspected TIA?
If within 4.5 hours of symptom onset, what should be given?
300mg Aspirin (2 weeks)
Alteplase
Within how many hours of symptom onset for TIA can a patient receive alteplase?
Within 4.5 hours
If a patient has been thromobylsed with alteplase for TIA, when should aspirin be given?
24 hours after
Can warfarin be started in the acute phase of TIA?
If they are experiencing symptoms or at high risk of VTE or PE, what should the management be?
No
Parenteral anticoagulants can be used - risk vs benefit
Anticoagulation should be considered post stroke if the patient has AF. When should you consider aspirin before considering anticoagulation treatment?
If it is a disabling ischaemic stroke, give aspirin 300mg for 2 weeks
Then, consider the value of anticoagulation for prevention of stroke in AF
If a patient experiences a disabling ischaemic stroke but has a prosthetic heart valve (and is on anticoagulation), what should happen to their anticoagulation treatment?
Stopped for 7 days and substituted with aspirin
Treatment of hypertension in the acute phase of TIA can result in what?
In what situations would you want to lower the blood pressure?
Reduced cerebral perfusion
Only lower the blood pressure if:- Hypertensive emergency (>180/110mmHg)- In patients considered for thrombolysis
Following an ischaemic stroke (not associated with AF), what long term treatment is recommended?
Clopidogrel + Statin started 48 hours after stroke symptom onset
Long term management post ischaemic stroke:If clopidogrel is contraindicated or not tolerated, what can patients have instead?
Modified-release dipyridamole in combination with aspirin
Is long term aspirin monotherapy recommended post ischaemic stroke?
No - only in combination with dipyridamole
Is long term MR dipyridamole monotherapy recommended post ischaemic stroke?
No - only in combination with aspirin
When should long term anticoagulation be considered post ischaemic stroke?
ONLY if the patient has AF
Should not be used for the general long-term prevention of recurrent stroke
When should a statin be started post ischaemic stroke?
What about if their cholesterol levels are in range?
48 hours after symptom onset regardless of their cholesterol levels,
How long should a patient be on high dose aspirin post ischaemic stroke?
300mg 2 weeks
How do you manage someone in the acute phase of haemorrhagic stroke?
Supportive measures e.g. blood pressure, fluids
If a patient has had a haemorrhagic stroke, at what systolic BP would you initiate antihypertensive treatment?
Over 200 mmHg
What are the 3 vitamin K antagonists?
Warfarin
Acenocoumarol
Phenindione
When would you have a target INR of 3.5?
Recurrent DVT/PE in patients receiving anticoagulation and with an INR > 2
Mechanical prosthetic heart valves
How long should a patient be anticoagulated for following an isolated calf DVT?
6 weeks
How long should a patient be anticoagulated for following a VTE provoked by a risk factor e.g. surgery, oral contraceptive?
3 months
What is the reversal agent for warfarin?
Phytomenadione (vitamin K)
If a patient is on warfarin and needs surgery straight away, what should be given?
Phytomenadione and dried prothrombin complex
Is aspirin recommended in primary prevention of cardiovascular disease?
No
When is aspirin indicated as cardiovascular disease prevention?
Secondary preventionNot primary
What is the cut off point for CrCl in apixaban?
Avoid if CrCl < 15 mL/min
When do you reduce dose in apixaban in terms of CrCl?
15-29 mL/min - reduce dose to 2.5 mg BD for stroke prophylaxis in AF
When do you reduce dose of apixaban in terms of weight?
<60 kg - reduce dose to 2.5 mg BD for stroke prophylaxis in AF
If a patient on warfarin has a major bleed, what do you do?
Stop warfarin and give phytomenadione by slow IVGive dried prothrombin complexCan give fresh frozen plasma but this is less effective
Warfarin patient:If their INR > 8 and has minor bleeding, what do you do?When would you restart warfarin?
Give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours
Restart warfarin when INR <5.0
Warfarin patient:If their INR > 8 but no bleeding, what do you do?When would you restart warfarin?
Give phytomenadione (vitamin K1) by mouth (using injection solution- unlicensed) Repeat dose of phytomenadione if INR still too high after 24 hours
Restart warfarin when INR <5.0
Warfarin patient:If their INR is 5-8 and has minor bleeding, what do you do?
Stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injectionRestart warfarin sodium when INR <5.0
Warfarin patient:If their INR is 5-8 and has no bleeding, what do you do?
Withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
How many days before is warfarin usually stopped before elective surgery?If they are at high risk of clot e.g. VTE in last 3 months, AF with previous stroke, what would you do?
5 days Bridge with LMWH and stop this 24 hours before surgery
If a patient who carries high risk of thromboembolism is on LMWH and is having surgery that carries high risk of bleeding, when should the LMWH be restarted?
At least 48 hours after
Does unfractionated or low molecular weight heparin have a shorter duration of action?
Unfractionated
What is the only DOAC that has a reversal agent?
Dabigatran
Are DOACs recommended in patients with prosthetic heart valves?
No- efficacy has not been established
Can apixaban be crushed?
Yes- mix with water or apple juice/puree
Is apixaban once or twice daily dosing?
Twice daily
Is edoxaban once or twice daily dosing?
Once daily
If a patient is taking one of the following drugs:- ciclosporin- dronedarone- erythromycin- ketoconazole And needs to be on edoxaban, what is the maximum daily dose?
30mg OD
What DOACs are black triangle drugs?
Rivaroxaban and edoxaban
When would you reduce the dose of edoxaban in renal impairments?
15-50 mL/min
Max 30mg OD
What is the cut off point for renal impairment for edoxaban?
Avoid if < 15mL/min
When do you reduce dose of edoxaban in terms of weight?
<61 kg reduce to 30mg OD
What is the cut off point for renal impairment for rivaroxaban?
Avoid if < 15mL/min
Can rivaroxaban be crushed?
Yes in water/apple juice or puree
What can rivaroxaban be used for in ACS patients?
Prophylaxis of atherothrombotic events following an ACS with elevated cardiac biomarkersCombined with aspirin alone or with clopidogrel too
Which DOAC should be taken with food?
Rivaroxaban
Which DOAC cannot be put in a blister pack?
Dabigatran
What is the cut off point for renal impairment for dabigatran?
Avoid if < 30 mL/min
When would you reduce dose of dabigatran in renal impairment?
30-50 mL/min
What is the advice around a patient on dabigatran who is taking one of the following:- Verapamil- Amiodarone
Reduce dabigatran dose
What are the main side effects of heparins?
Thrombocytopenia
Haemorrhage
Hyperkalaemia
When do you take anti factor Xa levels?
3-4 hours after dose
Are multidose or single vials of dalteparin and enoxaparin recommended in pregnancy and why?
Single vials
Multidose vials contain benzyl alcohol so not recommended
What is the MHRA warning associated with Vit K antagonists and hepatitis C antivirals?
Changes in liver function (secondary to antivirals for hep C) may effect efficiacy of Vit K antagonists so INR should be closely monitored
In what trimesters of pregnancy are Vit K antagonists particularly dangerous?
1st and 3rd
What is the MHRA warning associated with warfarin?
Calciphylaxis - patient should consult doctor if they develop a painful skin rash. (Calcification of the small blood vessels located within the fatty tissue and deeper layers of the skin)Particularly in those with end stage renal failure
Are DOACs licensed in cancer patients?
No
Are DOACs licensed in antiphospholipid syndrome?
No
When would a warfarin patient need to seek medical help with a nose bleed?
> 10 mins or heavy bleeding
When would a warfarin patient need to seek medical help with a cut?
Bleeding > 30 mins or heavy bleeding
If a warfarin patient is experiencing heavier periods than usual, what should they do?
Seek medical help
If a warfarin patient has hit their head/ had an accident but seem fine, what should they do?
Seek medical help, always get it checked out to rule out bleed on brain
Do DOACs interact with alcohol?
No
Which DOAC has the least risk of GI bleed?
Apixaban
Do DOACs or warfarin carry higher GI bleed risk?
DOACs (apart from apixaban which has same risk as warfarin)
What juice interacts with warfarin and should therefore be avoided?
Cranberry
What is the max time a warfarin patient should go without having their INR checked?
12 weeks
What sort of AF are DOACs licensed in?
Non valvular
What is valvular AF?
AF + artificial heart valve, Mitral stenosis
What would you use for prophylaxis of stroke in valvular patients?
Warfarin
Why is missing a DOAC dose more dangerous than missing a warfarin dose?
DOACs have a shorter half life
What is classed as stage 1 hypertension? When would you treat?
Clinic 140/90 mmHg or higher
daytime average of 135/85 mmHg or higher
Treat when:
under 80 with: Target organ damage, CKD, retinopathy, QRISK 10% or more, Renal disease
or Diabetes
What is classed as stage 2 hypertension?
Would this need treatment?
Clinic 160/100 mmHg or higher and daytime average of 150/95 mmHg or higher
Treat all
What is classed as severe hypertension?
Would this need treatment and how?
Clinic systolic of at least 180 mmHg or clinic diastolic of at least 110 mmHg
Yes:Hypertensive emergency (acute target organ damage) - IV drugs to reduce BP slowly (otherwise risk of hypoperfusion)
Hypertensive urgency (without organ damage) Oral BP meds to reduce slowly over 24-48 hours
What is the target blood pressure for patients under 80 years including diabetes with no additional disease?
Clinic of below 140/90 mmHg Average home of 135/85 mmHg
What is the target blood pressure in those with established atherosclerotic cardiovascular disease/diabetes (with related disease e.g. kidney, eye)?
Clinic blood pressure of 135/85