Chapter 2: Cardiovascular system Flashcards
Is treatment usually required for ectopic beats?
No, but can use beta blockers if needed.
Ectopic beatsare early (premature) or extraheartbeats, which can cause you to have palpitations. ‘Ectopic’ means out of place.
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 hrs ago, what can be offered to the patient?
A- rate control
B- rhythm control
C- 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?
A. Paroxysmal AF
B. Non paroxysmal AF
C. Sedentary lifestyle patients with paroxysmal AF
D. Sedentary lifestyle patients with non paroxysmal AF
Digixin is only effective for controlling the ventricular rate at REST, so it 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? What could be the side effects?
Beta blocker
SE
tiredness, cold hands and feet, low blood pressure, nightmares and impotence
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, when what group of patients would flecainide acetetate or propafenone NOT be suitable for?
Patients with known ischaemic or structural heart disease
When would dronedarone be used in rhythm control for AF?
Maintenance of sinus rhythm after successful cardioversion in paroxysmal or persistent AF:
- AF not controlled by 1st‑line therapy (usually including BB), that is, as a 2nd‑line tx option and after alternative options have been considered and who have at least 1 of the following CV risk factors:
- HTN 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 and
And:
- DO NOT have left ventricular systolic dysfunction and
- DO NOT have a history of HF.
(consider amiodarone in these patients)
What group of patients would you consider amiodarone for in rhythm control for AF?
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?
CHA2DVAS2C
□ Congestive HF signs/symptoms
□ Hypertension, resting BP > 140/90 mmHg on at least 2 occasionsoron current antihypertensive meds
□ Age > 75 yrs [2 points]
□ Diabetes mellitus, Fasting glucose > 125 mg/dL or treatment with oral hypoglycemic agent and/or insulin
□ Stroke,TIA, orTE, Includes any history of cerebral ischemia [2 points]
□ Vascular disease, priorMI, peripheral arterial disease, or aortic plaque
□ Age 65 - 74 years
□ Sexcategory (female), higher risk
What tool do you use to assess for bleeding risk?
HAS BLED
■ Hypertension- Uncontrolled, >160 mmHg systolic
■ Abnormal
Renal disease- Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L
Liver disease- Cirrhosis or bilirubin >2x normal with AST/ALT/AP >3x normal
■ Stroke history
■ Bleeding major/predisposition
■ Labile INR- Unstable/high INRs, time in therapeutic range <60%
■ Elderly >65 yo
■ DUGS Medication usage predisposing to bleeding: Aspirin, clopidogrel, NSAIDs OR Alcohol use- ≥8 drinks/week
At what CHADVASC score in men would you consider anticoagulation in AF?
At what score should you offer (taking into account bleeding risk)?
At what CHADVASC score in females would you consider anticoagulation to in AF?
1
2
2
You are discussing with the nursing team the number of patients who are coming into the surgery to get their INR tested due to being on Warfarin.
As part of a measure to try and reduce this you identify a cohort of patients who are eligible and willing to switch over to a DOAC.
One of the nurses asks what a patients INR should ideally be if they are to switch to Apixaban from Warfarin straightaway?
A. <2
B. < 2.5
C. 2 - 3
D. > 2.5
E. 3 - 4
A
After stopping Warfarin: < 2 》start DOAC immediately 2 - 2.9 》start DOAC following day 3 - 3.5 》start DOAC in 2 days >3.5 》recheck INR in 2-3 days
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 - 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 😤
- “Dazzled in light” phototoxicity 💥
- Grey skin discolouration ☑
- Altered taste 👅
- Sleep disorders 😴
- Peripheral neuropathy 💅
Some beta blockers are cardioselective. They act on B1 receptors in the heart. Which of the following is not a cardioselective beta blocker? A. Atenolol B. Metoprolol C. Nebivolol D. Propranolol
D. Propranolol
The cardio-selective beta-1-blockers include atenolol, betaxolol, bisoprolol, esmolol, acebutolol, metoprolol, and nebivolol.
Also
What is the patient advice regarding amiodarone and the sun?
Avoid exposure to sun and to use protective measures during therapy; sensitive to sunlight, and it may persist after several months of discontinuation. Symptoms are tingling, burning and erythema of sun-exposed skin but severe phototoxic rxns 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 ~142 days
What is the main side effects with dronedarone?
LIVER: injury + life-threatening acute liver failure (rare); discontinue tx if 2 consecutive alanine aminotransferase conc >3 times upper limit of normal.
- HEART failure New onset or worsening HF. If HF or left ventricular systolic dysfunction develops, discontinue tx.
- PULMONARY toxicity Interstitial lung disease, pneumonitis & pulmonary fibrosis. Investigate symptoms; dyspnoea or dry cough => 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, HTN, thyrotoxicosis or for 2ndary 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 20-33%
True or false:
Hypocalcaemia increases risk of digoxin toxicity
False
Hypercalcaemia increases this risk as well as
Hypokalaemia
Hypomagneasemia
Therapeutic range digoxin?
A. 0.7 - 2.0 ng/mL
B. 10 - 20 mg/L
C. 0.4 - 1mmol/L
D. 5- 10 mg/L
A
A. 0.7 - 2.0 ng/mL digoxin
B. 10 - 20 mg/L phenytoin
C. 0.4 - 1mmol/L lithium
D. 5- 10 mg/L gentamicin peak multiple daily
True or false:
St John’s Wort decreases Digoxin concentration
True
Digoxin toxicity- what colour can your vision go?
Yellow
Also bradycardia and GI disorders
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
However, if the patient is not being thrombolysed- aspirin should be started immediately within 48 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?
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 the 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 combo with aspirin
Is long term aspirin monotherapy recommended post ischaemic stroke?
Is long term MR dipyridamole monotherapy recommended post ischaemic stroke?
No - only in combination with dipyridamole
No - only in combination with aspirin
Dipyridamole is an antiplatelet medication. Which of the following statements is FALSE
A. M/R caps should only be dispensed in the original container and discarded after 6 weeks of opening
B. Alcohol may ^ rate of release of M/R capsules
C. Inhibits platelet function by ^ platelet cAMP and inhibits adenosine uptake by erythrocytes and platelets as well as causing vasodilation
D. Cautioned in MS, Hypotension and HF
E. Used in primary prevention of ischaemic stroke
F. Dose 200mg bd taken preferably with food
E
Secondary prevention of ischaemic stroke
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 / prophylaxis
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, a statin should be initiated
How long should a patient be on high dose aspirin post ischaemic stroke?
300mg for 2 weeks
How do you manage someone in the acute phase of haemorrhagic stroke?
Supportive measures e.g. blood pressure, fluids
hemorrhagic strokehappens when a blood vessel bursts, causingbleedingin the brain
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 (sinthrome)
Phenindione
- take 48 - 72 hrs for anticoagulant effect to develop fully;
- warfarinis the drug of choice.
- If an immediate effect is required, unfractionated or low molecular weight heparin must be given concomitantly.
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
P.s. An INR within 0.5 units of the target value is generally satisfactory; larger deviations require dosage adjustment.
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 prevention
Not 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?
<61 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
if prothrombin complex unavailable 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?
Stop 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?
Stop 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 injection
Restart 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
Heparin initiates anticoagulation rapidly but has a short duration of action. It is often referred to as‘standard’orheparin (unfractionated)to distinguish it from thelow molecular weight heparins, which have a longer duration of action. Although a LMWH is generally preferred for routine use,heparincan be used in those at high risk of bleeding because its effect can be terminated rapidly by stopping the infusion.
What is the only DOAC that has a reversal agent?
What is the reversal agent for dabigatran?
Dabigatran
Idarucizumab
Calcium channel blocker adverse effects
▪︎palpitations
▪︎flushing
▪︎peripheral oedema
▪︎gingival hyperplasia
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?
Is edoxaban once or twice daily dosing?
Twice daily apixaban
Once daily edoxaban
What are the interactions between calcium channel blockers and the following: □ grapefruit juice □ macrolides □ simvastatin □ mefloquine
Ccb x
□ grapefruit juice > increase plasma concentration CCB
□ macrolides > reduce CCB metabolism so ^SE
□ simvastatin > max 20mg simv. with amlodipine. Can also change to noninteracting statin eg rosuvastatin
□ mefloquine > ^risk bradycardia
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
The black triangle denotes that anewly licenced medicinesubject to additional monitoring. It is a mechanism to strengthen monitoring and to actively encourage patients andHCPsto report any possible adverse reactions observed with thesemedicines
When would you reduce the dose of edoxaban in renal impairments?
CrCl 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 biomarkers
Combined with aspirin alone or with clopidogrel too
P.s. acute coronary syndrome(ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non—ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).
Which DOAC should be taken with food?
Rivaroxaban with food
Apixaban and edoxaban can be taken with or without food
Dabigatran: take with food to minimise indigestion; capsules must NOT be opened or chewed and must NOT be removed from original packaging (i.e. do not transfer to dosette box)
Low molecular weight heparins (dalteparin sodium,enoxaparin sodium, andtinzaparin sodium) are usually preferred overheparin (unfractionated)in thepreventionof venous thromboembolism because they are as effective and they have a lower risk of heparin-induced
A. Neutroprnia B. Haemolysis C. Thrombocytopenia D. Hyperkalaemia E. Hypokalaemia
C.
Clinically important heparin-induced thrombocytopenia is immune-mediated and can be complicated by thrombosis. Signs of heparin-induced thrombocytopenia include a 30% reduction of platelet count, thrombosis, or skin allergy. If it is strongly suspected or confirmed, the heparin should be stopped and an alternative anticoagulant, such as danaparoid, should be given. Ensure platelet counts return to normal range in those who require warfarin.
Rare Hyperkalaemia
Inhibition of aldosterone secretion by unfractionated or LMWH can result in hyperkalaemia; patients with DB, chronic renal failure, acidosis, raised plasma potassium or those taking K-sparing drugs seem to be more susceptible. The risk appears to increase with duration of therapy.
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
Take doses at the same time
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
What is the MHRA warning associated with Vit K antagonists and hepatitis C antivirals?
Changes in liver function (2ndary to antivirals for hep C) may affect efficacy of Vit K antagonists so INR should be closely monitored
In what trimesters of pregnancy are Vit K antagonists particularly dangerous?
1st and 3rd
Warfarin, acenocoumarol, and phenindione cross the placenta with risk of congenital malformations, and placental, fetal, or neonatal haemorrhage, esp. during the last few weeks of pregnancy and at delivery. Therefore, if at all possible, they should be avoided in pregnancy, especially in the 1st and 3rd trimesters (difficult decisions may have to be made, particularly in women with prosthetic heart valves, atrial fibrillation, or with a history of recurrent venous thrombosis or pulmonary embolism).
Stopping these drugs before the 6th week of gestation may largely avoid the risk of fetal abnormality.
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?
Are DOACs licensed in antiphospholipid syndrome?
No x2
Dose of warfarin tablets package colours match to dosage: White Brown Blue Pink
White 0.5mg
Brown 1mg
Blue 3mg
Pink 5mg
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 in brain
Do DOACs interact with alcohol?
No
While alcohol is not expected to affect DOAC levels per se. Excess alcohol consumption and binge drinking not advised, due to risks of alcohol associated acute injuries (e.g. head injuries) and chronic liver disease (which may affect coagulation). Also at higher risk of GI bleeding
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
Treated with Vit K antagonists
What would you use for prophylaxis of stroke in valvular AF patients?
Vit K antagonists
Not DOACs
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
and daytime average of 135/85 mmHg or higher
If < 80 yrs with: Target organ damage, CKD, retinopathy QRISK 20% or more Renal disease 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?
Under 80 yrs DB:
Clinic of below 140/90 mmHg
Average home of below 135/85 mmHg
Over 80 yrs DB:
Clinic of below 150/90 mmHg
Average home of below 145/85 mmHg
What is the target blood pressure in those with established atherosclerotic cardiovascular disease/diabetes (with related disease e.g. kidney, eye)?
130/80 mmHg
Adults starting step1 antihypertensive treatment who:
□have type 2 DB, any age or family originor
are aged under 55 but not of black African or □African–Caribbean family origin.
What drug would you give as per NICE guidelines?
If these are not tolerated or contraindicated, what would be an alternative?
What if Step 1 treatment is insufficient, what is Step 2?
ACEi
if not tolerated ARB
Do not combine an ACE inhibitor with an ARB to treat hypertension
Step 2
If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step1 treatment:
a CCBor
a thiazide-like diuretic
Adults starting step1 antihypertensive treatment who:
are aged 55 or over and do not have type 2 DBor
are of black African or African–Caribbean family origin and do not have type2 diabetes (of any age).
Drug class to give as per NICE guidelines?
What if CCB is not tolerated?
What is Step 2?
CCB
If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension
Step 2 If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step1 treatment: ▪︎an ACE inhibitoror ▪︎an ARBor ▪︎a thiazide-like diuretic.
If hypertension is not controlled in adults of black African or African–Caribbean family origin who do not have type2 DB taking step1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step1 treatment.
What is step 3 in a patient with hypertension?
ACEi/ARB combined with CCB and thiazide like diuretic
What is step 4 (resistant) in a patient under 55 years with hypertension?
- consider adding a 4th antihypertensive drug as step4 treatment or seeking specialist advice.
- Consider further diuretic therapy with low-dose spironolactonefor adults with resistant hypertension starting step4 treatment who have a blood K level of 4.5mmol/l or less.
Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood Na and K and renal function within 1month of starting treatment and repeat as needed thereafter. - Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step4 treatment who have a blood K level of more than 4.5mmol/l.
- If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4drugs, seek specialist advice
DOACs normal doses
- Rivaroxaban
- Edoxaban
- Dabigatran
- Apixaban
What factors would cause dose reduction?
DOACs normal doses
- Rivaroxaban 20 mg OD
CrCl 15- 49: reduce dose to 15mg OD - Edoxaban
Bodyweight >=61kg: 60mg OD
Bodyweight <61 kg: reduce to 30mg OD - Dabigatran
Age 18 - 74: 150mg BD
Age 75 - 79: 110 - 150mg BD
Age >= 80 | concomitant Tx with verapamil 110mg BD
- Apixaban 5mg Reduce dose to 2.5 mg BD if at least 2 characteristics □ Age >= 80yrs □ body weight >=61 kg □ serum creatinine >= 133 micromol/L
Which of the following is not a direct and reversible inhibitor of factor Xa A. Rivaroxaban B. Dabigatran C. Edoxaban D. Apixaban
B. Dabigatran is a reversible inhibitor of free thrombin, fibrin bound thrombin, and thrombin induced platelet aggregation
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
Add in beta blocker/alpha blocker/further diuretic
Spironolactone if potassium if fine, but if potassium is high (>4.5) use a high dose thiazide diuretic
What antihypertensive drugs are safe to use in pregnancy?
Labetalol
Methyldopa
MR nifedipine (unlicensed)
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 diuretic (usually furosemide in high dosage) to help with fluid and electrolyte balance = mandatory
Systemic minoxidil is unsuitable for what gender and why?
Females as it causes XS hair growth (hypertrichosis)
What are the 3 centrally acting antihypertensive drugs?
Methyldopa
Clonidine
Moxonidine
What kind of drug is prazosin and what is the associated problem with it after the first dose?
Alpha blocker and vasodilator
Can reduce BP rapidly after the first dose, so needs to be introduced with caution
What should you monitor if patient is on ACEi/ARB and potassium sparing diuretic?
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 and loop diuretic?
Blood pressure
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 and COPD (especially poorly controlled- if needed, use cardioselective one)
Worsening unstable heart failure
Severe hypotension or bradycardia
If a beta blocker is needed in asthma/COPD, what type of beta blocker should be used?
Cardioselective
Cardioselective beta-blockers, e.g. atenolol, acebutol, esmolol, nebivolol, bisoprolol and metoprolol, have a greater affinity forbeta1-adrenoceptors and are less likely to cause constriction of airways or peripheral vasculature and are preferred in patients with respiratory disease
What are the cardioselective beta blockers?
Bisoprolol Acetabutol Metoprolol Atenolol 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
What are the side effects of beta blockers?
Fatigue Coldness of extremities (Raynaud's phenomenon) Sleep disturbances (if lipid soluble) Bradycardia Bronchospasm Hypo/hyperglycaemia
Beta blockers are cautioned in diabetic patients. What kind of beta blockers are preferred in diabetic patients and why?
Cardioselective ones as beta blockers can alter glucose control
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
Water-soluble beta-blockers (such asatenolol,celiprololhydrochloride,nadolol, andsotalol hydrochloride) are less likely to enter the brain, and may therefore cause less sleep disturbance and nightmares.
What two CCBs are contraindicated in heart failure?
Verapamil and diltiazem
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?
Encephalopathy
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
What are the main side effects of ACEis?
Angioedema Hyperkalaemia Renal impairment Hypotension Hepatitis and hepatic failure Cholestatic jaundice 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
Essential hypertension
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?
If eGFR <60
Or in patients with diabetes
However, this combination is generally not recommended due to increased risk of hypotension, hyperkalaemia etc
What kind of drug is hydralazine?
Vasodilator
What drugs are used in pulmonary hypertension?
Epoprostenol Sildenafil Tadalafil Selexipag Iloprost 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
ACEi: perindopril,ramipril,captopril,enalapril maleate,lisinopril,quinaprilorfosinopril sodium
Beta blockers: bisoprolol fumarate,carvedilol, ornebivolol
(ARB if ACEi not tolerated)
ARB: candesartan cilexetil,losartan potassium, orvalsartan
Treatment with a beta-blocker should not be withheld because of age or the presence of diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, erectile dysfunction, or interstitial pulmonary disease.Patients who are already taking a beta-blocker for co-morbidities (e.g. angina or hypertension) and whose condition is stable should be switched to a beta-blocker licensed for heart failure.
If a heart failure patient remains symptomatic on ACEi and beta blocker, what can be added?
If symptomatic despite optimal first line treatment, an aldosterone antagonist e.g. spironolactone or eplerenone can be added
However if showing signs of breathlessness and fluid overload, loop diuretics should be used.
Hydralazine hydrochloridecombined with a nitrate can be considered under the advice of a heart failure specialist in patients who are intolerant of both ACEi and ARBs (particularly those of African or Caribbean origin with moderate to severe heart failure).
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
Although digoxin does not reduce mortality, it may decrease symptoms and hospitalisation due to acute exacerbations.
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 patient is on
Started by specialist
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?
What QRISK2 % would indicate someone should go on a statin?
QRISK2
Measures 10 year risk of cardiovascular disease
10%
Medications which can cause hypertension
Coc Ciclosporin NSAIDS Leflunomide Venlafaxine
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
True
20mg atorvastatin
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
What group of lipid regulating drugs are the most effective at reducing LDL cholesterol?
Statins
When would you add a fibrate 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
What is the problem with bile acid sequestrants in lowering cholesterol?
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 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 patient develops SOB, cough, weight loss, seek medical attention
Hepatic disorders- LFTs 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
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
What is the max dose of simvastatin if combined with bezafibrate or ciprofibrate?
10mg OD
What is the max dose of simvastatin if combined with amiodarone? Amlodipine? Ticagrelor? Diltiazem? Verapamil?
20mg OD
Hypertension with type 2 diabetes in all patients (any age or origin), or hypertension without type 2 diabetes in those aged 55 years or below and not of black African or African-Caribbean origin
Step 1 - 4
□ Step 1:Offer an ACE inhibitor or ARB.
□ Step 2:In addition to an ACE inhibitor or ARB, add in a CCB or thiazide-like diuretic. Offer a thiazide-like diuretic if there is evidence of heart failure.
□Step 3:Offer an ACE inhibitor or ARB, a calcium channel blocker and a thiazide-like diuretic.
□Step 4:Before considering further treatment for a person with resistant hypertension, confirm clinic BP measurements using ambulatory or home blood pressure recordings, assess for postural hypotension and discuss adherence. If further treatment is required, consider seeking specialist advice, or the addition of low dose spironolactone [unlicensed indication] if potassium is 4.5 mmol/litre or less; or an alpha blocker or a beta blocker if potassium is > 4.5 mmol/litre.
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium and renal function within 1 month of starting treatment and repeat as needed thereafter.
Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs.
Hypertension without type 2 diabetes in patients aged 55 and over, or all ages of black African or African-Caribbean origin patients without type 2 diabetes
Step 1 - 4
Step 1:Offer a calcium channel blocker.
Step 2:In addition to a calcium channel blocker offer an ACE inhibitor, ARB or a thiazide-like diuretic.
Step 3:Offer an ACE inhibitor or ARB, a calcium channel blocker and a thiazide-like diuretic.
Step 4:Before considering further treatment for a person with resistant hypertension, confirm elevated clinic BP measurements using ambulatory or home BP recordings, assess for postural hypotension and discuss adherence. If further treatment is required, consider seeking specialist advice, or consider low dose spironolactone [unlicensed indication] if potassium is 4.5 mmol/litre or less; or an alpha blocker or a beta blocker if potassium is greater than 4.5 mmol/litre.
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium, and renal function within 1 month of starting treatment and repeat as needed thereafter.
Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs.
Intype 1 diabetes, aim for a clinic blood pressure of [HTN]..
Intype 1 diabetes, aim for a clinic blood pressure of 135/85 mmHg or less unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg or less.
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:
- GTN
- Add in beta blocker/CCB
- 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
SICKFACES.COM
What drugs are contraindicated alongside ivabradine?
Diltiazem, clarithromycin, erythromycin, verapamil
Does ranolazine prolong QT interval?
Yes
Does ivabradine prolong QT interval?
Yes
What is the MHRA alert with nicorandil?
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 muscle
NSTEMI 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 have little advantage over BP lowering but causes more 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
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 is on 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
Adjust atorvastatin dose and monitor
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 < 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 or only limited improvement after three months
Does ranolazine interact with simvastatin? If so, what should be done?
Increases exposure of simvastatin, so statin dose should be adjusted.
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?
<150/90mmHg
What is 1st line for gestational hypertension
What are alternatives?
Labetalol
Methyldopa, MR nifedipine
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 in pregnancy to those 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 diuretic
Usually 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 kind of drug is amiloride?
Potassium sparing diuretic
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- avoid
Risk 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?
40mg daily
If a patient was prescribed systemic (oral) fusidic acid and was regularly on a statin, what would you do?
Suspend statin
Statin therapy may be re-introduced seven days after the last dose of fusidic acid.
Rhabdomyolysis
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
True
Reducing the nitrate concentration in the blood for 4 to 8
hours each day usually maintains effectiveness e.g. by giving twice daily
preparations 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 8 weeks.
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 week
Then 200mg BD for 1 week
Then 200mg OD maintenance
What is the CHADVASC score along with its associated points?
Congestive heart failure - 1 Hypertension - 1 Age (75 years and above) - 2 Diabetes - 1 Stroke/Thromboembolism - 2 Vascular disease - MI, peripheral artery disease - 1 Age 65-74 years - 1 Sex (female) - 1
What does HAS BLAD stand for?
Each has 1 point:
Hypertension Abnormal renal/liver function Stroke Bleeding tendency Labile INR Age > 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
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
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) - LFTs before treatment and then every 6 months
- Potassium concentration before treatment - hypokalaemia monitoring
- 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 diuretics
Aminoglycosides
Aspirin
Calcium channel blockers
CCBs
In what condition is spironolactone contraindicated in?
Addison’s
as it is an aldosterone antagonist
Which of these drug classes carries the risk of hypoglycaemia unawareness?
Alpha blockers
ACEis
Beta blockers
Beta blockers
They 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 - 150/90
Home- 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 cardioversion
Needs 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) Hypothyroidism
b) Hyperthyroidism
c) 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?
No
It 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 OD
Max 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 BD
Obesity
Cancer
Recurrent VTE
Proximal 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 OD
Same 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 stroke
Only 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, retinopathy QRISK 20% or more Renal disease Diabetes
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?
Ankle swelling
Flushing
Headaches
What beta blockers are licensed in heart failure?
For all grades of HF:
Bisoprolol
Carvedilol
For 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
Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume.
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?
Refer
Interstitial 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
Anti-arrhythmic drugs can be classified clinically into those that act on
● supraventricular arrhythmias
● both supraventricular and ventricular arrhythmias
● ventricular arrhythmias
Anti-arrhythmic drugs can be classified clinically into those that act on supraventricular arrhythmias (e.g.verapamil hydrochloride), those that act on both supraventricular and ventricular arrhythmias (e.g.amiodarone hydrochloride), and those that act on ventricular arrhythmias (e.g.lidocaine hydrochloride)
Anti-arrhythmic drugs can also be classified according to their effects on the electrical behaviour of myocardial cells during activity (the Vaughan Williams classification) although this classification is of less clinical significance:
Class I
Class II
Class III
Class IV
Anti-arrhythmic drugs can also be classified according to their effects on the electrical behaviour of myocardial cells during activity (the Vaughan Williams classification) although this classification is of less clinical significance:
Class I: membrane stabilising drugs (e.g. lidocaine, flecainide)
Class II: beta-blockers
Class III: amiodarone; sotalol (also Class II)
Class IV: calcium-channel blockers (includes verapamil but not dihydropyridines)
What does NICE recommend for people with stable angina who us a short-acting nitrate to prevent and treat episodes of angina?
A) Call an emergency ambulance if the pain has not gone in 5 minutes after taking dose
B) Repeat the dose after 5 minutes if the pain has not gone and call an emergency ambulance if the pain has not gone after the second dose
C) Repeat the dose at 5 minute intervals if the pain has not gone and call an emergency ambulance if the pain has not gone 5 minutes after the third dose
B) NICE CG126 Stable angina: management recommends that a short-acting nitrate is offered for preventing and treating episodes of angina. People with stable angina should be advised:
- how to administer the short-acting nitrate
- to use it immediately before any planned exercise or exertion
- that SE such as flushing, headache and light-headedness may occur
- to sit down or find something to hold on to if feeling light-headed
• When a short-acting nitrate is being used to treat episodes of angina, advise people:
to repeat the dose after 5 mins if the pain has not gone
to call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose.
According to NICE which of the following would be the most appropriate first-choice of treatments for stable angina?
A) BB and CCB
B) BB and long acting nitrate
C) CCB or long acting nitrate
NICE CG126 Stable angina:management recommends offering either a beta blocker or a calcium channel blocker as first-line treatment for stable angina. You should support the patient to decide which drug to use based on their comorbidities, contraindications and their preferences. If the patient cannot tolerate the beta blocker or calcium channel blocker you could consider switching to the other option (calcium channel blocker or beta blocker).
Which of the following best describes the aim of drug treatment for angina?
NICE CG126 Stable angina:management recommends that people are advised that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke. Secondary prevention of cardiovascular events is management by the use of antiplatelets (usually aspirin 75mg) and statins in line with Lipid modification (NICE clinical guideline 67).
All patients with suspected angina should be tested for:
haemoglobin levels,
thyroid function,
fasting blood glucose,
why?
All patients with suspected angina should be tested for:
haemoglobin levels, as anaemia can exacerbate ischaemic chest pain
thyroid function, as thyroid disease can exacerbate CAD
fasting blood glucose, as diabetics have a worse prognosis and need aggressive management
When a GP identifies a patient with stable angina, further assessment at a cardiology outpatient clinic is desirable7
Pros n cons of beta blockers in AF
Pros; well tolerated, good safety profile and beneficial in ventricular rate control with drinedarone, flecainide and amiodarone
Cons; only modestly effective in preventing AF recurrence
Flecainide AF pros and cons
Pros; better tolerated than amiodarone
Cons; cannot be initiated in pts w coronary artery disease or HF. Caution use with BBB bundle branch block. Concomitant AV node block BB/Vera/Dilt tx usually required to reduce risk of flecainide organising AF to atrial flutter and for this to be rapidly conducted to ventricles.
Ecgocardiograms to assess cardiac function should be taken prior to tx
Dronedarone AF pros n cons
Pros; amiodarone derivative without iodine, less lipophilic, better tolerated than amiodarone
efficacy in maintaining sinus rhythm < amiodaronr and likely < flecainide & sotalol
Cons; LFT monitoring, permanent AF postmarketing studies show ^ mortality, stroke and heart failure. Must only be used to maintain sinus rhythm. Contraindicated in AF >6months or unknown duration. Pt recently decompressed HF also ^mortality risk. Contraindicated in pt w left ventricular dysfunction
Amiodarone AF pros cons
Pros
- most effective drug
- gd therapeutic option in pt unsuitable for AF ablation with frequent symptomatic AF despite drug therapy
- concomitant BB use
- safely administered to pt with structural heart disease and/ HF
Cons
- poor safety profile
- regular 6 month minimum baseline monitoring LFT Thyroid
- photosensitivity
- long half life longer effects after cessation
Management acute ventricular tachycardia
- unstable
- stable
Unstable; pt unconscious, severely hypotensive, or very symptomatic. Direct cardioversion with administration of short acting IV anaesthetic or sedative if poss. Antiarrhythmic drugs mayb used to reduce incidence of VT ocurence
Stable; consider pharmacological tx for pt with sustained VT who are haemodynamically stable. IV Lidocaine, amiodarone or flecainide.
Flecainide CI in pt with VT Post MI and CAD
Amiodarone has poor efficacy in terminating sustained VT
Lidocaine often considered more effective treatment
