Chapter 2: Cardiovascular system Flashcards
Which DOAC has twice daily dosing? Which has once daily dosing?
READ- R E (OD) AD (BD)
Once daily: Rivaroxiban (20mg OD), Edoxaban (30-60mg OD)
Twice daily: Apixaban (5mg BD), Dabigatran (150mg BD)
Which DOAC requires loading?
Treatment of deep-vein thrombosis
Treatment of pulmonary embolism
Apixaban 10mg BD x 7 days
followed by 5mg BD maintenance (loading dose 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 reduce 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 DOACs 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
Which DOAC needs to be taken with food and at what strength ?
Rivaroxiban 15mg and 20mg needs to be taken with food to increase absorption
Cautionary and advisory labels
Label 10:
Warning: Read the additional information given with this medicine
Label 21 (15 and 20 mg tablets):
Take with or just after food, or a meal
Which DOAC 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 and nifedipine, or nicardipine hydrochloride should be avoided in patients who have HF with reduced ejection fraction as these drugs reduce cardiac contractility. Patients with heart failure and angina may safely be treated with amlodipine.
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. DOACs 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
*Think phyto fights warfarin
Phenindinone is another oral anticoagulant (coumarin) like warfarin!
*Think phenin is a friend of warfarin
What baseline tests do patients need before commencing on a DOAC? Which DOAC is least likely to be chosen with renal impairment ?
Renal function before treatment in all patients and at least annually thereafter. Dose reduction required in renal impairment
Dabigatran has most caution with renal function: it is CI if CrCl is under 30 ml/min
Which DOACs should not be used in severe liver disease?
Avoid all DOACs in severe liver impairment
We know that warfarin interacts with a lot of the CYP enzyme inhibitors and inducers, Which DOACs 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 DOAC 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 DOACs?
DOACs - shorter half life so if dose is missed there is more time without coagulation If dose of DOAC is missed
What is the reversal agent for LMWHs/UH?
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 DOAC 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?
HIT= very low platelet count (platelets help blood to clot)
It is an immune mediated reaction that can develop after 5-10 days
More common with UFH than LMWHs
Management: stop the heparin, use 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
Which drug class do the following belong to?
Dalteparin
Dabigatran
Dalteparin is LMWH
Dabigatran is a DOAC
**What is the treatment for a VTE (DVT or PE)?
RAPE = treatment of PE
Rivaroxaban: 15mg BD for 21 days then 20mg OD with food
Apixaban: 10mg BD for 7 days, then 5mg BD
Warfarin and bridge with LMWH for at least 5 days or until the INR has been over 2 for 24 hours
Edoxaban: 30-60mg OD (use lower dose for weight <61kg)
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
1) lower risk of osteoporosis
2) reduced heparin induced thrombocytopenia.
LMWHs unlicensed in pregnancy for the treatment of VTE
What do we need to monitor with heparins?
Platelet count
Hyperkalaemia (Plasma-potassium concentration)
Weight- dose based on weight
Renal function
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?
Sotalol may prolong QT interval, and it occasionally causes life threatening ventricular arrhythmias (important: manufacturer advises particular care is required to avoid hypokalaemia in patients taking sotalol—electrolyte disturbances, particularly HYPOkalaemia and HYPOmagnesemia should be corrected before sotalol started and during use).
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?
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
GTN has a short duration of action, what about isosorbide mononitrate/ dinitrate?
Much longer- MR has duration of action upto 12 hours.
No rapid onset so not as effective for rapid symptomatic relief of angina
BD dosing of dinitrates should account for a nitrate free period. Therefore give doses 8 hours apart (not 12h)
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?
Interstitial lung disease
If patients develop symptoms such as dyspnoea, cough, and weight loss, they should seek medical attention.
Why is brand specific prescribing required with Nifedipine MR (CCB) preparations?
Different versions of modified-release preparations may not have the same clinical effect. To avoid confusion between these different formulations of nifedipine, prescribers should specify the brand to be dispensed.
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?
Loooops make you peeeee
Because loops can result in urinary retention if there is 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
ACE inhibitor + aliskiren is contra-indicated in patients with an eGFR less than 60 mL/minute/1.73 m2;
ACE inhibitor + aliskiren is contra-indicated in patients with diabetes mellitus
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 ( no anticoagulant)
Clopidogrel and Aspirin ( 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 DOAC 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?
Bile acid sequesterents- Colesevelam, Colestipol
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 (Bezafibrate, Ciprofibrate, Gemfibrozil)
Fibrates are mainly used in those whose serum-triglyceride concentration is greater than 10 mmol/litre or in those who cannot tolerate a statin (specialist use).
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 !!
Contra-indications
Addison’s disease; anuria; hyperkalaemia
What are the three types of acute coronary syndromes (ACS)
1) STEMI (SeriousTEMI) complete and persistent blockage of the artery resulting in myocardial necrosis
2) NSTEMI
3) UNSTABLE ANGINA
partial or intermittent blockage of the artery occurs, which usually results in myocardial necrosis in NSTEMI but not in 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 (skipped or extra heart 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?
- 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 sedentary(inactive) patients with non-paroxysmal atrial fibrillation.
What is meant by paroxysmal AF?
Episodes come and go
Episodes 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?
What tool do you use to assess for bleeding risk?
Orbit
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
If taking amiodarone with concurrent sofosbuvir-containing regimens, patients and their carers should be told how to recognise signs and symptoms of bradycardia and heart block and advised to seek immediate medical attention if symptoms such as shortness of breath, light-headedness, palpitations, fainting, unusual tiredness or chest pain develop.
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?
Liver injury including life-threatening acute liver failure reported rarely; discontinue treatment if 2 consecutive alanine aminotransferase concentrations exceed 3 times upper limit of normal.
Heart failure New onset or worsening heart failure reported. If heart failure or left ventricular systolic dysfunction develops, discontinue treatment.
Pulmonary toxicity Interstitial lung disease, pneumonitis and pulmonary fibrosis reported. Investigate if symptoms such as dyspnoea or dry cough develop and discontinue if confirmed.
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 or prophylaxis of supraventricular arrhythmias.
It should no longer be used for angina, hypertension, thyrotoxicosis or for secondary prevention after myocardial infaction
Digoxin + Dronedarone
Digoxin +Amiodarone,
Digixon + Quinine (malaria)
Digoxin DAiQuiri
what do you do if the above combinations are prescribed?
Half dose of digoxin
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 halos around objects - xanthopsia / blurred vision
What is nimodipine used for?
Used in subarachnoid haemorrhage
Subarachnoid hemorrhage is bleeding into the subarachnoid space
What should patients immediately receive if they have a suspected TIA?
300mg Aspirin (2 weeks)
Alteplase within 4.5 hours
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 within 4.5 hours, aspirin can be given ___?
24 hours after
Provided that intracranial haemorrhage has been excluded, treatment with aspirin should be initiated as soon as possible within 24 hours of symptom onset
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?
Warfarin sodium should not be given in the acute phase of an ischaemic stroke.
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?
Patients with a disabling ischaemic stroke and atrial fibrillation should receive aspirin for 2 weeks before being considered for anticoagulant treatment.
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
Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore only be instituted in the event of a hypertensive emergency, or in those 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?
MR dipyridamole 200 mg BD, to be taken preferably with food + Aspirin 75mg OD
Is long term aspirin monotherapy recommended post ischaemic stroke?
If both modified-release dipyridamole and clopidogrel are contra-indicated or not tolerated, then aspirin alone is recommended.
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?
A high-intensity statin (such as atorvastatin), should be initiated 48 hours after stroke symptom onset in patients not already taking a statin, irrespective of the patient’s serum-cholesterol concentration.
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?
Stop all medications
Supportive measures e.g. Treat high blood pressure only, 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)
Your patient is on warfarin and needs emergency surgery straight away, what can you give them?
Phytomenadione and dried prothrombin complex
Is aspirin recommended in primary prevention of cardiovascular disease?
Aspirin is not recommended in primary prevention of CVD
When is aspirin indicated in cardiovascular disease prevention?
Secondary prevention
Not primary
At what CrCl should you avoid using apixaban?
Avoid if CrCl < 15 mL/min
When do you reduce dose of apixaban in stroke prophylaxis in AF 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 to 2.5mg BD 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 IV
Give dried prothrombin complex
Can 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
Which DOAC does not have a reversal agent?
Edoxaban
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
Lixiana = edoxaban
Dronedarone + edoxaban
Erythromycin + edoxaban
Ciclosporin + edoxaban
Ketoconazole + edoxaban
What should you do if the above combinations are prescribed?
Reduce dose of Edoxaban- 30mg OD
What DOACs are black triangle drugs?
Rivaroxaban and edoxaban
When would you reduce the dose of edoxaban in renal impairment?
15-50 mL/min
Max 30mg OD
When is Edoxaban contraindicated in renal impairment?
Avoid if < 15mL/min
When do you reduce dose of edoxaban in terms of weight?
<61 kg reduce to 30mg OD
When do you avoid rivaroxaban in renal impairment?
Avoid if < 15mL/min
Can rivaroxaban be crushed?
Yes in water/apple juice or puree
What can rivaroxaban be used for in ACS patients?
2.5 mg twice daily usual duration 12 months
Prophylaxis of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers (in combination with aspirin alone or aspirin and clopidogrel)
Which DOAC should be taken with food?
Rivaroxaban
Which DOAC cannot be put in a blister pack?
Dabigatran
When is dabigatran contraindicated in renal impairment?
Avoid if < 30 mL/min
Risk of bleeding
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 (low platelet count)
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)
The MHRA has advised that calciphylaxis is most commonly observed in patients with known risk factors such as end-stage renal disease, however cases have also been reported in patients with normal renal function.
Are DOACs licensed in cancer patients?
No
Are DOACs licensed in antiphospholipid syndrome?
No CONTRAINDICATED!!!!!!
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 carry a higher GI bleeding risk (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 = DOAC
Valvular AF = warfarin
Vv =warfarin
What is valvular AF?
AF + artificial heart valve, Mitral stenosis :narrowing of the heart’s mitral valve
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?
Stage 1 hypertension is a clinic blood pressure 140/90 mmHg
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?
Clinic 160/100 mmHg
Treat all patients who have stage 2 hypertension, regardless of age.
What is classed as severe hypertension?
Would this need treatment and how?
Severe hypertension is a clinic systolic blood pressure of 180 mmHg or higher, or a clinic diastolic blood pressure of 120 mmHg or higher.
Treat severe hypertension promptly
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
What is step 1 in a patient under 55 years with hypertension?
If these are not tolerated or contraindicated, what would be an alternative?
ACEi if not tolerated ARB
What is step 2 in a patient under 55 years with hypertension?
A + CCB or thiazide diuretic
In addition to an ACE inhibitor or ARB, add in a calcium channel blocker or thiazide-like diuretic (indapamide) Offer a thiazide-like diuretic if there is evidence of heart failure.
What is step 3 in a patient under 55 years with hypertension?
A+C+D
Step 3: Offer an ACE inhibitor or ARB, a calcium channel blocker and a thiazide-like diuretic.
What is step 4 (resistant) in a patient under 55 years with hypertension?
Add low-dose spironolactone (potassium sparing diuretic) if potassium is < 4.5 mmol/litre
or an alpha blocker (prazosin, terazosin, indoramin) or a beta blocker if potassium is > 4.5 mmol/litre.
What is step 1 in a patient over 55 years/Black or Carribbean with hypertension?
CCB
What is step 2 in a patient over 55 years/Black or Carribbean with hypertension?
A+C or D
CCB and ACEi/ARB or Thiazide diuretic
What is step 3 and 4 in a patient over 55 years/Black or Carribbean with hypertension?
Same as under 55 years
ACEi/ARB combined with CCB and thiazide like diuretic
What antihypertensive drugs are safe to use in pregnancy?
Target blood pressure of less than 135/85 mmHg
1) Labetalol oral - To be taken with food
Initially 100 mg twice daily, dose to be increased at intervals of 14 days; usual dose 200 mg twice daily
max 2.4g daily
2) MR nifedipine (unlicensed)
3) Methyldopa -discontinue treatment within 2 days of the birth and switch to an alternative antihypertensive.
If a woman (who previously had hypertension) was switched to methyldopa during pregnancy, when should she resume her original antihypertensive treatment?
Within 2 days of birth
What is a hypertensive emergency?
Severe hypertension with acute organ damage
****How do you treat a hypertensive emergency?
IV nicardipine, labetolol
When can minoxidil be used in hypertension?
What is the problem with this and what other drugs must the patient be on?
Resistant- when other drugs have failed
Tachycardia and fluid retention
Addition of beta blocker to counteract tachycardia and duretic (usually furosemide in high dosage) to help with fluid and electrolyte balance = mandatory
Systemic minoxidil used in severe hypertension, is unsuitable for what gender and why?
Females as it causes XS hair growth (hypertrichosis)
What are the 3 centrally acting antihypertensive drugs?
Drowsiness may affect performance of skilled tasks (e.g. driving); effects of alcohol may be enhanced.
1) Methyldopa- stop methyldopa 2 days AFTER birth and continue regular hypertension treatment
2) Clonidine-In hypertension, must be withdrawn gradually to avoid severe rebound hypertension
3) Moxonidine- Avoid abrupt withdrawal (if concomitant treatment with beta-blocker has to be stopped, discontinue beta-blocker first, then moxonidine after a few days).
What kind of drug is prazosin and what are its side effects?
Alpha blocker and vasodilator
Can reduce BP rapidly after the first dose (therefore should be taken on retiring to bed). Patients should be warned to lie down if symptoms such as dizziness, fatigue or sweating develop, and to remain lying down until they abate completely.
Driving and skilled tasks
May affect performance of skilled tasks e.g. driving.
What should you monitor if patient is on ACEi/ARB and potassium sparing diuretic (spironolactone /Eplerenone)?
Potassium levels- increased risk of hyperkalaemia
Are ACEis recommended in people with renal artery stenosis?
No
What should you monitor if patient is on ACEi + loop diuretic (furosemide/ bumetanide/ torasemide?
Blood pressure - hypotension
ACEi can cause a rapid fall in BP, and so can loops if high dose
Under specialist supervision, what two ARBs are licensed alongside ACEi and what for?
Candesartan and valsartan for management of heart failure when other treatments are unsuitable
When are beta blockers contraindicated?
2nd or 3rd degree heart block
Asthma
avoid in patients with a history of asthma, bronchospasm or a history of obstructive airways disease. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution
Prinzmetal’s angina
uncontrolled HF
Severe hypotension or bradycardia
If a beta blocker is needed in asthma, what type of beta blocker should be used?
Cardioselective
BB avoid in patients with a history of asthma, bronchospasm or a history of obstructive airways disease. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution
What are the cardioselective beta blockers?
B a Man
Imagine nervous guy not wanting to give his heart away, tell him to be a man, this guys so nervous he’s on nebs =nebivolol
B isoprolol
A tenolol
Metoprolol
Acetabutol
Nebivolol
What is the advantage of water soluble beta blockers over lipid soluble ones?
Does not cross BBB so less likely to cause sleep disturbances and nightmares
Silly man not paying attention to sona, too busy drinking water
Celi ——-nada———-atenolol
C eliprolol
A tenolol
N adolol
S otalol
What are the side effects of beta blockers?
Constipation
Fatigue
Coldness of extremities (Raynaud’s phenomenon)
Sleep disturbances (if lipid soluble) Bradycardia
Bronchospasm
Symptoms of hypoglycaemia can be masked
Rash reversible on discontinuation
which beta blocker is used for thyrotoxicosis
Propranolol 10-40mg TDS-QDS
What beta blockers have additional vasodilatory effects?
Labetlol Nebivolol Celiprolol Carvedilol Can lower peripheral resistance
What is the advice surrounding treatment cessation of beta blockers?
Patients are advised to not stop abruptly Can cause rebound myocardial ischaemia Gradual reduction is recommended
Is carvedilol a cardioselective beta blocker?
No
What is the main organ (and related function tests) that should be monitored if on labetalol therapy?
Liver
Can cause severe liver injury even after short term treatment
What is a disadvantage of water soluble beta blockers in renal impairment?
Excreted via the kidneys so requires dose reduction in renal impairment
Verapamil and diltiazem are contraindicated in ____ and should not be prescribed with ——?
Contraindicated in HF and should not be given with BBs
BB in combination with verapamil or diltiazem (risk of heart block)
What group of cardiac drugs commonly causes peripheral oedema?
CCBs
Hypokalaemia is associated with what types of diuretics?
Loop and thiazide
In hepatic failure, hypokalaemia caused by diuretics can result in what?
HF + Hypokalaemia =?
Encephalopathy -damage or disease that affects the brain
Thiazide diuretics can exacerbate what conditions?
Diabetes
Gout
Systemic lupus erythematosus
What is the cut off point regarding renal impairment in thiazides and why?
Below 30 mL/min as they are no longer effective
need good kidney function for them to be effective
What are the main side effects of ACEis?
Angioedema
Hyperkalaemia
Hypotension
renal impairment
Dry cough
For ACEis, when should the first dose be given?
Bedtime
Aliskren is what type of drug and what is it licensed for?
Renin inhibitor- inhibit renin directly; renin converts angiotensinogen to angiotensinⅠ
Essential hypertension- occurs when you have abnormally high blood pressure that’s not the result of a medical condition
What is essential hypertension?
Otherwise known as primary hypertension
When there is no clear cause behind the hypertension
When is aliskren contraindicated in combination with ACEi/ARB?
Concomitant treatment of Aliskiren + ACE/ARB contraindicated
eGFR less than 60
diabetes mellitus
hereditary/idiopathic angioedema
What kind of drug is hydralazine?
Vasodilator
What drugs are used in pulmonary hypertension?
Epoprostenol
Sildenafil
Tadalafil
SelexipagIloprost
Ambrisentan
Bosentan
Macitentan
What is the MHRA warning regarding riociguat for pulmonary hypertension?
Idiopathic interstitial pneumonias
What is first line for heart failure?
ACEi and beta blocker
(ARB if ACEi not tolerated)
Loop diuretics to treat fluid overload
If a heart failure patient remains symptomatic on ACEi and beta blocker, what can be added?
However if showing signs of breathlessness and fluid overload, loop diuretics should be used If symptomatic despite optimal first line treatment, an aldosterone antagonist e.g. spironolactone can be added
When would eplerenone be used over spironolactone?
In males getting oestrogen-like side effects Or in chronic heart failure after acute myocardial infarction
When can you add in ivabradine to heart failure treatment?
After ACEi, beta blocker and aldosterone antagonist (on this for at least 4 weeks)
In sinus rhythm with heart rate of 75 bpm or more
When can you add in digoxin to heart failure treatment?
If it is worsening heart failure and other combinations have not worked
Patient needs to be in sinus rhythm
Routine monitoring of serum levels is not recommended in patients with heart failure
For heart failure patients who are fluid overloaded, what can be added?
Loop or thiazide
Is sacubitril valsartan a black triangle drug?
Yes
When should you use sacubitril valsartan?
Chronic heart failure that LEVF <35% (can already be taking stable dose of ACE or ARB) However, need to stop any ACEis or ARBs
Are there established guidelines for preserved (right sided) heart failure?
No- existing guidelines are for left sided (reduced ejection fraction) heart failure
What vaccines are recommended in heart failure patients?
Flu vaccine annually
Pneumococcal (once only)
What assessment tool is used for determining if someone needs to go on a statin for primary prevention?
QRISK3 Measures 10 year risk of cardiovascular disease
What QRISK2 % would indicate someone should go on a statin?
10%
What are the high intensity statins and what doses?
Atorvastatin 20mg OD or higher
Rosuvastatin 10mg OD or higher
Simvastatin 80mg OD
What is the highest intensity statin (and dose)?
Atorvastatin 80mg OD
What statin recommended for primary prevention of cardiovascular disease?
Atorvastatin 20mg OD (unlicensed at this starting dose)Dose can be increased if necessary
What statin recommended for secondary prevention of cardiovascular disease?
Atorvastatin (unlicensed)
***True or false:All patients with diabetes should be considered for a statin
Should be considered in all type 1 diabetics. Based on other risk factors will be started
If a patient still has high cholesterol after max dose of statin, what should be added?
Another lipid regulating drug e.g. ezetimibe
Which of the following are most effective at reducing triglycerides:
Fibrates
Statins
Ezetimibe
Fibrates
Bezafibrate
Gemfibrozil
Fenofibrate
Ciprofibrate
Take with or just after food, or a meal
What group of lipid regulating drugs are the most effective at reducing LDL cholesterol?
Statins
When would you add a fibrate Bezafibrate
Gemfibrozil
Fenofibrate
Ciprofibrate
to statin therapy?
If triglycerides remain high even after the LDL-cholesterol concentration has been reduced adequately.
What is the MHRA advice regarding high dose (80mg) simvastatin?
Increased risk of myopathy
What is 1st line for familial hypercholesterolaemia?
High intensity statin
Patients with primary heterozygous familial hypercholesterolaemia who have contra-indications to, or are intolerant of statins, can be considered for treatment with what?
Ezetimibe as monotherapy
The combination of a statin and fibrate carries the risk of what?
Muscle related side effects
bile acid sequestrants (colestyramine, colestipol, colesevelam) lower cholesterol, however what else do they do?
Even though they effectively reduce LDL, they can aggravate hypertriglyceridaemia
What type of drug is colesevelam and colestipol?
Bile acid sequesterant
What is the advice surrounding bile acid sequesterants (colestyramine, colestipol, colesevelam) if a patient is on other medication?
Avoid taking other drugs at the same time
What is the caution surrounding statins and thyroid function?
Hypothyroidism needs to be appropriately managed before starting Hypothyroidism may cause high cholesterol and treating this will lower cholesterol without the need for statins
What are the side effects of statins?
Muscle myopathy
Interstitial lung disease
If patients develop symptoms such as dyspnoea, cough, and weight loss, they should seek medical attention.
Hepatic disorders- LFTs needed before starting treatment
Can cause diabetes in those at risk- but should not be discontinued if blood glucose is high as benefit outweighs risk
What creatine kinase level is concerning in a statin patient?
If it is 5 x upper limit of normal
if the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
What is the max dose of atorvastatin if a patient is on ciclosporin?
10mg OD
What kind of stroke is atorvastatin cautioned in?
Haemorrhagic Higher incidence of this type of stroke
simvastatin + bezafibrate / ciprofibrate?
10mg OD
Manufacturer advises max. 10 mg daily with concurrent use of bezafibrate or ciprofibrate.
What is the max dose of simvastatin if combined with amiodarone?
20mg OD
Manufacturer advises max. 20 mg simvastatin daily w concurrent use of
amiodarone,
amlodipine
ranolazine.
verapamil
diltiazem
Ezetimibe
grazoprevir
10 mg daily with concurrent use of bezafibrate or ciprofibrate
What is the max dose of SIMVASTATIN if combined with AMLODIPINE?
20mg OD
What is the max dose of simvastatin if combined with diltiazem/verapamil?
20mg OD
What is the max dose of simvastatin if combined with ticagrelor?
40mg OD
Manufacturer advises max. 40 mg daily with concurrent use of lomitapide or ticagrelor.
What kind of juice should be avoided in patients on a statin?
Grapefruit
Acute attacks of stable angina should be managed with what?
Sublingual GTN
If a patient is on GTN for attacks of stable angina, when is regular drug therapy indicated?
If attacks occur more than twice a week
????After GTN, how is stable angina managed?
Beta blocker OR CCB. Diltiazem or verapamil are more effective than other CCBs ??????
In stable angina, if a beta blocker or CCB monotherapy fails to control symptoms, what should you do?
Combination of beta blocker and dihydropyridine CCB e.g. amlodipine (Not diltiazem or verapamil due to increased risk of hypotension and bradycardia with beta blocker)
When is a long acting nitrate indicated in stable angina?What can alternatively be added?
If the following steps have not controlled symptoms:
1. GTN
2. Add in beta blocker/CCB
3. Combine beta blocker and CCB therapy
Other options:Ivabradine, nicorandil, ranolazine can be added in OR monotherapy if beta blockers and CCBs are not tolerated/contraindicated
True or false:Stable angina medication should be titrated according to symptom control to the maximum tolerated dose
TRUE
How often should response to stable angina treatment be monitored?
Every 2-4 weeks
What are the requirements for an individual starting on ivabradine for stable angina?
Needs to be in normal sinus rhythm and heart rate of 70 bpm or over
What interacts with ivabradine?
CYP3A4 inhibitors
What drugs cause bradycardia alongside ivabradine?
Diltiazem, verapamil
Does ranolazine prolong QT interval?
Yes
Does ivabradine prolong QT interval?
Yes
What is the MHRA alert with nicorandil (Prophylaxis and treatment of stable angina (second-line) ?
Can cause skin/mucosal/eye ulceration including GI ulcers. Stop if this occurs and consider alternative
What is the difference between stable and unstable angina?
Stable angina (more common) – attacks have a trigger (such as stress or exercise) and stop within a few minutes of resting
Unstable angina (more serious) – attacks are more unpredictable (they may not have a trigger) and can continue despite resting
ACS is an umbrella term for what 3 conditions?
Unstable angina
NSTEMI
STEMI
What is the difference between STEMI and NSTEMI?
STEMI results in irreversible damage of the heart muscleNSTEMI can progress to STEMI
Are lower or higher doses of thiazide diuretics preferable in hypertension?
Lower doses produce maximal/near maximal BP lowering effect
Higher doses =biochemical disturbances
What are the preferred thiazide like diuretics in hypertension?
Indapamide and chlortalidone
Some patients still take bendro although this is no longer considered first line
Should potassium supplements be given with potassium sparing diuretics and aldosterone antagonists?
No - hyperkalaemia
What type of diuretic is mannitol and when is it used?
Osmotic that can be used to treat cerebral oedema and raised intra-ocular pressure
What group of patients are particularly susceptible to side effects of diuretics?
Elderly so lower initial doses used
If a patient has an enlarged prostate and taking a loop diuretic, what can occur?
Urinary retention
Diuretics increase the risk of what in alcoholic cirrhosis?
Hypomagnesaemia and therefore arrhythmias
Can beta blockers be used with verapamil and diltiazem?
No- severe interaction
Bradycardia and hypotension risk
How does atorvastatin interact with diltiazem and verapamil?
Increases exposure of atorvastatin so increased risk of myopathy
What is the MHRA advice surrounding ivabradine?
- Monitor for symptoms of bradycardia and do not prescribe with other medicines that cause bradycardia, eg, verapamil or diltiazem-If heart rate reduces to less than 50 bpm, a dose reduction can be considered or drug stopped if this persists- Monitor regularly for signs of atrial fibrillation- Consider stopping if no improvement in three months
Does ranolazine interact with simvastatin? If so, what should be done?
Increases exposure of simvastatin, so statin dose should be adjusted to simvastatin 20mg Or Change to atorvastatin (although interaction is still present, manufacturer does not give dose adjustment advice)
What is the target blood pressure in a pregnant lady with uncomplicated chronic hypertension?
<135/85
What is 1st line for gestational hypertension What are alternatives?
Labetalol
LABETALOL DOSE PREGNANCY [GPhC EXAM QUEST]
ADULT DOSE: Initially 100mg twice daily, dose to be increased at intervals of 14 days
USUAL DOSE: 200mg twice daily: increased if necessary to up to 800mg daily in 2 divided doses
● To be taken with food
● Higher doses to be given in 3-4 divided doses
● Maximum 2.4g per day
2) MR nifedipine
3) Methyldopa
Although labetalol is used in pregnancy for hypertension, in what group of patients should it not be used in if it can be helped?
Asthmatics
Aspirin is often given to pregnant women who are at a high risk of pre-eclampsia after week 12 of pregnancy. Is this a licensed indication?
No
What is the difference between hypertensive emergency and hypertensive urgency?
A hypertensive emergency is defined as severe hypertension (>180/110mmHg) with acute organ damage
A hypertensive urgency is defined as severe hypertension with NO acute organ damage.
Sudden withdrawal of clonidine can result in what?
Rebound hypertension
What type of drug is chlortalidone?
Thiazide like diuretic
For step 2 treatment in hypertension in Afro and Caribbean patients, is an ACEi or an ARB preferred?
ARB
What is the risk of starting a patient on ACEi and diuretic?
Electrolyte imbalances
May cause a very quick fall in BP
What are examples of water soluble beta blockers? (CANS acronym)
Celiprolol, Atenolol, Nadolol, Sotalol
What is the most cardioselective CCB?
Verapamil
What two CCBs should not be used in unstable angina?
Amlodipine and nifedipine
What CCB should you take 30-60 minutes before food?
Lercanidipine
What kind of drug is indapamide?
Thiazide like diureticUsually used in preference for earlier stages of hypertension over a thiazide diuretic e.g. bendro
What kind of drug is metolazone?
Thiazide like diuretic
What age is nebivolol licensed for in heart failure?
70 years and over
Thiazides are ineffective in an EGFR of what?What is the exception to this?
< 30 Metolazone but this is associated with excessive risk of diuresis
Aldosterone antagonists are contraindicated in what condition?
Addison’s Disease
Should spironolactone be taken with food?
Yes- with or just after food
What diuretic can cause urine to look blue under certain lights?
Triamterene
True or false:Statins should be considered for all Type 1 diabetic patients, especially if over 40 years
TRUE
What is the aim of treatment for statin use in primary and secondary prevention for cholesterol levels?
The aim of treatment is to reach a non-HDL concentration of greater than 40% or target non-HDL cholesterol concentration below 2.5 mmol/litre
Increase statin dose if this is not achieved
Are fibrates recommended in primary and secondary prevention?
No
What cholesterol lowering drug class is first line for high cholesterol?
Statins
What cholesterol lowering drug class is first line for primary and secondary prevention?
Statins
What is the problem with using gemfibrozil and a statin together?
Severe interaction- avoidRisk of rhabdo
What is the aim of treatment for statin use in familial hypercholesterolaemia for cholesterol levels?
The dose of the statin should be titrated to achieve a reduction in LDL-cholesterol concentration of greater than 50% from baseline.
What dose of simvastatin is classed as high intensity?
80mg daily
What dose of atorvastatin is classed as high intensity?
20mg daily
What dose of rosuvastatin is classed as high intensity?
10mg daily or more
If a patient was prescribed systemic (oral) fusidic acid and was regularly on a statin, what would you do?
Suspend statinStatin therapy may be re-introduced seven days after the last dose of fusidic acid.
If a patient was prescribed macrolides and was regularly on a statin, what would you do?
Suspend statin during antibiotic treatment
What is the max dose of simvastatin you can have if taken with amlodipine?
20mg daily
What is the recommendation with statins during pregnancy or if the patient is wishing to conceive?
Statins should be avoided in pregnancy (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported
What is a main side effect of nitrates?
Headaches and postural hypotension
True or false:You can develop tolerance with nitrate use
TrueReducing the nitrate concentration in the blood for 4 to 8hours each day usually maintains effectiveness e.g. by giving twice dailypreparations after 8 hours then after 16 hours.
On an aspirin prescription, if no strength is stated what does the BP direct to do?
Dispense the 300mg
What is the antidote for overdose of unfractionated heparin and LMWH?
Protamine sulphate
When would verapamil be preferred over adenosine in supraventricular arrhythmias?
In asthmatics
What is the storage requirements for GTN tablets?
GTN tablets should be supplied in glass containers of not more than 100 tablets, closed with a foil-lined cap, and containing no cotton wool wadding (i.e. the original container). They should be discarded after 8weeks.
What is the the advice regarding how to take GTN spray and when to seek medical attention?
400–800 micrograms (1-2 sprays), to be administered under the tongue and then close mouth, dose may be repeated at 5 minute intervals if required; if symptoms have not resolved after 3 doses, medical attention should be sought.
What is the oral loading dose regimen for amiodarone in arrhythmias?
200mg TDS for 1 weekThen 200mg BD for 1 weekThen 200mg OD maintenance
What is the CHADVASC score along with its associated points?
Congestive heart failure - 1Hypertension - 1Age (75 years and above) - 2Diabetes - 1Stroke/Thromboembolism - 2Vascular disease - MI, peripheral artery disease - 1Age 65-74 years - 1Sex (female) - 1
What does HAS BLAD stand for?
Each has 1 point:HypertensionAbnormal renal/liver functionStrokeBleeding tendencyLabile INRAge > 65 Drugs that could cause bleeding or alcohol
When should digoxin levels be taken?
6 hours or more post dose
What is the MHRA warning on hydrochlorothiazide?
Risk of non-melanoma skin cancer, particularly in long-term use
In what situations would you reassess using warfarin for anticoagulation (INR ranges)?
2 INR values higher than 5 in the last 6 months or
1 INR value higher than 8 in the last 6 months
Time in therapeutic range < 65%
Amiodarone IV should be put in what fluid and why?
Glucose It is incompatible with sodium chloride
Warfarin is stopped 5 days before elective surgery. At what INR would you administer phytomenadione the day before?
If INR is 1.5 or above, give phytomenadione
Post surgery, if a warfarin patient is haemodynamically stable, when can their warfarin be restarted?
Evening of surgery or day after
When should ACEi and ARBs be stopped before surgery?Why is it recommended that they are stopped?
24 hours before - don’t give the morning of Can be associated with severe hypotension after induction of anaesthesia
When should potassium sparing diuretics be stopped before surgery and why?
The morning of surgery Hyperkalaemia may develop if renal perfusion is impaired or if there is tissue damage
When should loop diuretics be stopped before surgery?
Don’t give the morning of
If a patient is on LMWH and required epidural, how should this be managed?
i) prophylactic dose
ii) treatment dose
i) Prophylactic dose - stop at least 12 hours before
ii) Treatment dose- stop at least 24 hours before
due to the risk of neuraxial haematoma
In pregnant women with target-organ damage as a result of chronic hypertension, and in women with chronic hypertension who have given birth, what is their target BP?
<140/90 mmHg
Which cardio drug class can cause gingival hyperplasia (gum overgrowth)?
CCBs
True or false:Routine digoxin monitoring is recommended in heart failure patients
FALSE
What monitoring requirements are needed with amiodarone and when?What additional precautions are needed for IV administration?
- Thyroid function tests before treatment and then every 6 months NB- clinical assessment of thyroid function is unreliable (T4, T3 and TSH should all be measured) 2. LFTs before treatment and then every 6 months 3. Potassium concentration before treatment - hypokalaemia monitoring4. Chest X-Ray before treatment IV use - requires ECG monitoring and resuscitation facilities need to be available
How does warfarin and amiodarone interact?
Amiodarone inhibits warfarin metabolism - enhanced anticoagulation
How does amiodarone interact with beta blockers?
Increased risk of bradycardia, AV block and myocardial depression
How does amiodarone interact with lithium?
Risk of ventricular arrhythmias
How does amiodarone interact with digoxin?
Plasma concentration of digoxin increased by amiodarone
Is digoxin a positive or negative ionotrope?
Positive - increases the force of myocardial contraction and reduces conductivity within the AV node
What is the desired digoxin level?
1-2mcg/L
How does digoxin interact with eythromycin?
Digoxin concentration increased as erythromycin is an enzyme inhibitor
How does digoxin interact with rifampicin?
Digoxin concentration decreased as rifampicin is an enzyme inducer
How does digoxin interact with St John’s Wort?
Digoxin concentration decreased as St John’s Wort is an enzyme inducer
How does digoxin interact with loop and thiazide diuretics?
Increased toxicity risk - hypokalaemia
How does digoxin interact with CCBs?
Digoxin concentration increased by CCBs
True or false:Warfarin is highly protein bound
TRUE
Can you use warfarin in severe renal impairment?
Yes but need to monitor INR more frequently
How does warfarin interact with NSAIDs?
Increased anticoagulation effect
How does warfarin interact with fluconazole?
Increased anticoagulation effect
How does warfarin interact with statins?
Increased anticoagulation effect
How does warfarin interact with ciprofloxacin, metronidazole, erythromycin?
Increased anticoagulation effect
How does warfarin interact with griseofulvin?
Decreased anticoagulation effect
How does warfarin interact with St John’s Wort?
Decreased anticoagulation effect
How does warfarin interact with antiepileptics?
Decreased anticoagulation effect
How does warfarin interact with cranberry juice?
Anticoagulant effect enhanced by cranberry juice
Which of these drugs is not associated with ototoxicity?Loop diureticsAminoglycosidesAspirinCalcium channel blockers
CCBs
In what condition is spironolactone contraindicated in?
Addisons it is an aldosterone antagonist
Which of these drug classes carries the risk of hypoglycaemia unawareness?Alpha blockersACEisBeta blockers
Beta blockersThey can mask the symptoms of hypoglycaemia that would otherwise be detected by the patient
What is the MOA of class 1 antiarrythmics?
Sodium channel blockers
What is the MOA of class 2 antiarrythmics?
Beta blockers
What is the MOA of class 3 antiarrythmics?
Potassium channel blockers
What is the MOA of class 4 antiarrythmics?
Calcium channel blockers
What is the target blood pressure for patients 80 years and older?
Clinic - 150/90Home- 145/85 mmHg for people aged 80 years and over.
If AF has been present for more than 48 hours, what procedure is preferred?What anticoagulation length is recommended?
Electrical cardioversionNeeds to be orally anticoagulated 3 weeks before and then 4 weeks after cardioversion
Before an electrical cardioversion for AF, it is recommended that the patient is orally anticoagulated 3 weeks before and then 4 weeks after the procedure. If this is not possible, what is an alternative?
Parenteral anticoagulation Left arterial thrombus needs to be ruled out immediately before the procedure Oral anticoagulation for 4 weeks after
What are the two types of cardioversion?
Electrical Pharmacological
If pharmacological cardioversion is required, what can be used?
IV amidarone (preferred if patient has heart disease)Or IV Flecainide
Is digoxin rate or rhythm control?
Rate
What are the class 1 antiarrhythmics?
Membrane stabilising drugs - lidocaine, flecainide
What are the class 2 antiarrhythmics?
Beta blockers
What are the class 3 antiarrhythmics?
Amiodarone, sotalol Sotalol is also class 2
What are the class 4 antiarrhythmics?
Non-dihydropyridine CCBs e.g. verapamil
What group of patients is adenosine contraindicated in?
Asthmatics COPD
Can amiodarone cause:a) Hypothyroidismb) Hyperthyroidismc) Both
Both
What is the effect of amiodarone on potassium levels?
Can cause hypokalaemia
Does amiodarone have a long or short half life?
Long
Does digoxin have a long or short half life?
Long
What are the digoxin interactions? (CRASED) acronym
Calcium channel blockers (verapamil)
Rifampicin
Amiodarone
St Johns Wort
Erythromycin
Diuretics - hypokalaemia risk
Is systolic hypertension a bleeding or a VTE risk?
Bleeding risk
Is fondaparinux a LMWH?
NoIt is a synthetic and selective inhibitor of activated Factor X (Xa)
What is the safest class of medicine to use for a VTE in pregnancy?
LMWH
Does unfractionated heparin or LMWH carry a lower risk of osteoporosis?
LMWH
Does unfractionated heparin or LMWH carry a lower risk of HIT?
LMWH
What do you need to monitor regularly if a patient is on unfractionated heparin?
APTT (activated partial thromboplastin time)
What is the antidote for heparin?
Protamine
What effect can heparins have on potassium levels?
Can cause hyperkalaemia
What is the treatment dose of dalteparin for VTE or PE?What is the max dose a day?
200 units/kg ODMax 18,000 units OD
What is the treatment dose of enoxaparin for VTE or PE in low risk patients?
1.5mg/kg OD
What is the treatment dose of enoxaparin for VTE or PE in high risk patients?What would be classed as high risk?
1mg/kg BDObesityCancerRecurrent VTEProximal thrombosis - above the knee
What is a proximal thrombosis?
Above the knee
What is a distal thrombosis?
Below the knee
White warfarin tablets are what strength?
0.5mg
Brown warfarin tablets are what strength?
1mg
Blue warfarin tablets are what strength?
3mg
Pink warfarin tablets are what strength?
5mg
If a patient has had a major bleed on warfarin, in addition to IV phytomenadione, is dried prothrombin complex or fresh frozen plasma preferable?
Dried prothrombin complex
If a warfarin patient is due for surgery but their INR is still too high, what can be given?
Oral phytomenadione the day before if INR is 1.5 or above
What is the treatment dose of tinzaparin for VTE or PE?
175 units/kg ODSame dose in pregnancy and for high risk patients e.g. cancer
What is the expiry date of dabigatran capsules in a bottle once opened?
4 months (if usual blister packaging, expiry is 4 months)
After the acute phase of an ischaemic stroke, what should the blood pressure target be?
130/80 max
Can beta blockers be used in the management of hypertension following a stroke?
No - unless already on for an existing condition
What drugs would you avoid in a haemorrhagic stroke that you would normally use in an ischaemic stroke?
Avoid aspirin, statins and anticoagulants in a patient with haemorrhagic strokeOnly give if essential eg very high risk of ischaemic event
If a hypertensive emergency (acute organ damage), why would you want to reduce the BP slowly?
To reduce the risk of reduced organ perfusion
When would you treat Stage 1 hypertension (140/90)?
If under 80 with:Target organ damage, CKD, retinopathyQRISK 10% or moreRenal diseaseDiabetes
When would you refer in Stage 1 hypertension?
Patients under 40 years with no overt target organ damage/risk factors To find out if there is a secondary cause of hypertension
Which ACEi is a pro drug and conversion to its active drug is reduced by food?
Perindopril Better to take 30-60 mins before food
Do ARBs cause a dry cough?
No (it does not inhibit the breakdown of bradykinin)
What are the beta blockers that have intrinsic sympathomimetic activity?What are the advantages of these?
PACO
Pindolol
Acebutol
Celiprolol
Oxprenolol
Less bradycardia and less coldness of the extremities
What are the once daily dosing beta blockers?
BACoN
Bisoprolol
Atenolol
Celiprolol
Nadalol
What CCB commonly causes constipation?
Verapamil
What are the main side effects of CCBs?
What beta blockers are licensed in heart failure?
For all grades of HF:BisoprololCarvedilolFor mild-moderate HF and in 70 years + :Nebivolol
When can you use nebivolol for HF?
For mild-moderate HF and in 70 years +
How does sacubitril work?
Inhibits breakdown of BNP
What role does a combination of hydrazaline and isosorbide dinitrate play in heart failure?
Useful if the patient is on an ACEi and BB and remains symptomatic Especially if the patient is Black/Caribbean
If a patient on a statin reports feeling short of breath, having a cough and weight loss, what should you do?
ReferInterstitial lung disease is a side effect of statins
If a patient is on a statin, at what LFT level would you stop the statin?
If it is 3 x the upper limit of normal
If a patient is on a statin, at what creatine kinase level would you stop the statin?
If it is 5 x the upper limit of normal
When taking a nitrate, is it recommended the patient stands up or sits down?
Sits down - can cause dizziness
As patients can develop tolerance with nitrates, what is the recommendation is off a nitrate patch?
Leave patch off for 8-12 hours (overnight)
Can loop diuretics exacerbate diabetes and gout?
Yes
Which drug used in heart failure and resistant hypertension can cause menstrual disturbances, such as post menopausal bleeding?
Spironolactone
In what 3 groups of patients would you offer lipid modification therapy for primary prevention without the need for a formal assessment?
- Type 1 diabetics
- CKD eGFR <60
- Familial hypercholesterolaemia
CONSIDER lipid modification therapy for 85 years and older (as QRISK score is not applicable to this age group)
The QRISK tool has an upper age limit of what?
84 years
True or false:All pravastatin strengths are low intensity
TRUE
What is the target for total cholesterol?
< 5 mmol/L
What is the target for LDL?
< 3 mmol/L
What is the target for HDL?
> 1.0 mmol/L
What is the target for triglycerides?
< 1.7 mmol/L
Is amiodarone an enzyme inducer or inhibitor?
Enzyme inhibitor
What is licensed for the following:Potassium conservation when used as an adjunct to thiazide or loop diuretics for hypertension or congestive heart failure
Amiloride
When is ACEi and Aliskiren (used in essential HTN) contraindicated?
eGFR less than 60
diabetes mellitus
If a patient taking dabigatran develops dyspepsia during treatment, what would you advise the patient?
Patients and their carers should be advised to contact their doctor if gastrointestinal symptoms such as dyspepsia develop during treatment.
Patients and their carers should be provided with an alert card and advised to keep it with them at all times.
How is a patient switched from warfarin to dabigatran?
warfarin treatment should be stopped before dabigatran treatment is started to reduce the risk of over-anticoagulation and bleeding.
What is the MHRA warning regarding DOAC prescribing in those with antiphospholipid syndrome?
Increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin, in patients with antiphospholipid syndrome and a history of thrombosis. There may be a similar risk associated with other DOACs. Healthcare professionals are advised that DOACs are not recommended in patients with antiphospholipid syndrome.
Switching to a vitamin K antagonist such as warfarin should be considered.
Which diuretic lowers BP with less effects on electrolyte balance and less aggravation of diabetes
Indapamide
Which thiazide has a long duration of action and may be given on alternate days to control oedema
Chlorthalidone
Which thiazide is used for mild or moderate HF or hypertension [no longer 1st line]
Bendroflumethazide
What eGFR is bendroflumethazide (thiazides) ineffective?
Thiazides & related diuretics are INEFFECTIVE if eGFR < 30ml/min/1.73m and should be avoided
Thiazide diuretics- bendroflumethaiazide, chlortalidone, indapamide, metolazone, xipamide
Thiazides are used to relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure.
Act within 1 to 2 hours of oral administration and most have a duration of action of 12 to 24 hours; they are usually administered early in the day so that the diuresis does not interfere with sleep.
HYPOkalaemia
HYPOmagnesaemia
HYPERcalcaemia
Hyperuricaemia- gout
Hyperglycaemia- diabetes
Unmask type 2 diabetes
Increases LDL and triglycerides
Contra-indications Addison’s disease
Impotence in men
Loop diuretics are used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure. Stronger diuretics than thiazides and can be used for resistant oedema- furosemide, bumetanide, torasemide
Diabetes, hyperglycaemia is less likely than with thiazides
Gout
All electrolytes HYPO -Na, K, Cl, Ca, Mg
Enlarged prostate =urinary retention [less likely if small doses and less potent diuretics are used initially]
Furosemide and bumetanide- both act within 1 hour of oral administration and diuresis is complete within 6 hours so can be given BD without interfering with sleep
High doses or rapid IV administration of loop diuretics may cause tinnitus and
deafness
K sparing diuretics- Amiloride and triamterene given with thiazide or loop diuretics as a more effective alternative to potassium supplements
Too weak diuretics to be given on their own. They cause retention of potassium HYPERkalaemia therefore given with thiazide or loop diuretics as a more effective alternative to potassium supplements
Potassium supplements must not be given with potassium- sparing diuretics
Do not give amiloride / triamterine with ACEI or ARBs
Contra-indications
Addison’s disease
Aldosterone antagonist- spironolactone and eplerenone used in moderate to severe heart failure and resistant hypertension
Potassium supplements must not be given with aldosterone antagonists.
Side effects- gynaecomastia, hyperkalaemia (discontinue)
Which diuretics can cause auditory disorders (more common with rapid intravenous administration, and in renal impairment)
Loop diuretics - Furosemide and bumetanide, torasemide
Which diuretics cause hypokalaemia ?
Thiazide and loops
Thiazides- Chlortalidone, indapamide, bendroflumethiazide
Loops- Furosemide, bumetanide, torasemide
Which diuretics cause gynacomastia?
Aldosterone antagonists -
Spironolactone
Eplerenone
Bendroflumethiazide + NSAID (ibuprofen)
Bendroflumethiazide + Ibuprofen
Ibuprofen increases the risk of acute renal failure when given with Bendroflumethiazide.
Both Bendroflumethiazide and Ibuprofen can increase the risk of hyponatraemia.
Bendroflumethiazide + Digoxin
Bendroflumethiazide + Digoxin
Bendroflumethiazide is predicted to increase the risk of Digoxin toxicity when given with digoxin (HYPERcalaemia)
Beta blockers label
Warning: Do not stop taking this medicine unless your doctor tells you to stop
When should one full lipid profile, TSH, renal function for statins be measured?
Before starting treatment with statins
How long does a patient need to be on contraception when using statins
Adequate contraception is required during treatment and for 1 month afterwards.
Your patient tells you she wants to start trying for a baby, she is currently taking statins
Statins should be avoided in pregnancy (discontinue 3 months before attempting to conceive) as congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development.
Simvastatin + clarithromycin
Severe interaction
Clarithromycin is predicted to increase the exposure to Simvastatin.
What is the treatment for raynauds syndrome?
Raynaud’s syndrome affects your blood circulation. When you’re cold, anxious or stressed, your fingers and toes may change colour.
immediate-release
NIFEDIPINE Initially 5 mg 3 times a day, then adjusted according to response to 20 mg 3 times a day.
What is orbit ?
Can DOACs increase the risk of GI bleeding ?
If your patient has hypertension and type 2 diabetes and is Afro Caribbean, what is step 1 treatment?
ARB
Which beta blockers are less likely to cause bradycardia / cold extremities ?
ICE PACO
In preclampsia which pregnant females are advised to take aspirin from week 12 of pregnancy?
Pregnant females are at high risk of developing pre-eclampsia if they have chronic kidney disease, diabetes mellitus, autoimmune disease, chronic hypertension, or if they have had hypertension during a previous pregnancy; these females are advised to take aspirin [unlicensed indication] from week 12 of pregnancy until the baby is born. Females with more than one moderate risk factor for developing pre-eclampsia (first pregnancy, greater than 40 years of age, pregnancy interval of greater than 10 years, BMI above 35 kg/m² at first visit, multiple pregnancy, or family history of pre-eclampsia) are also advised to take aspirin [unlicensed indication] from week 12 of pregnancy until the baby is born.
Hypertension and breastfeeding, what do you offer mother?
Enalapril
Before starting treatment with a statin, we measure LFTS, thyroid, U&Es and HbA1C. Why are thyroid measurements and HBA1C measurements taken?
Hypothyroidism can cause high cholesterol so therefore if hypothyroidism is treated then this will diminish the need for Statins.
Statins cause Hyperglycaemia
Can simvastatin be sold otc?
Simvastatin 10 mg tablets can be sold to the public to reduce risk of first coronary event in individuals at moderate risk of coronary heart disease (approx. 10–15 % risk of major event in 10 years), max. daily dose 10 mg and pack size of 28 tablets; treatment should form part of a programme to reduce risk of coronary heart disease.
