Chapter 2- Cardiovascular System Flashcards
Two types of treatment in AF
Rate control
Rhythm control
First line option in AF?
Rate control
What can hypokalaemia cause?
Torsade de pointes due to long QT interval
Treatment of torsade de points?
IV infusion of magnesium sulfate
Name two class 1 membrane stabilising drugs used in arrhythmias under the Vaughan Williams classification
Lidocaine
Flecainide
What class of drug is under the class two of the Vaughan Williams classification
Beta blockers
Class 3 of the Vaughan Williams classification
Amiodarone
Sotolol
Class 4 of Vaughan Williams classification
CCB (includes verapamil but not dihydropyridines)
Treatment of choice for terminating paroxysmal supraventricular tachycardia
Adenosine
True or false - adenosine is preferred over verampamil in asthma?
False
Name a cardiac glycoside
Digoxin
The likelihood of toxicity increases progressively through what range of digoxin level?
1.3 - 3 mcg/litre
True or false: hyperkalaemia exposes people to digitalis toxicity
False - hypokalaemia does
Reducing raised BP decreases the risk of what 4 things
Stroke
Coronary events
Heart failure
Renal impairment
What two drugs form the basis of treatment for heart failure due to left ventricular dysfunction
Ace inhibitor
Beta blocker
What’s in co-flumactone and what’s it used for
Hydroflumethiazide and spironolactone used for congestive heart failure
Drug action of sacubitril
A prodrug that inhibits the breakdown of natriuretic peptides resulting in varied effects including increased diuresis, natriuresis and vasodilation
What is enoximone
Is a phosphodiesterase type 3 inhibitor that exerts most effect on the myocardium; it has positive inotropic properties and vasodilator activity
Name two phosphodiesterase type 3 inhibitors used in heart failure
Enoximone
Milrinone
List 3 things that make someone at higher risk of developing cardiovascular disease
Diabetes
CKD
Familial hypercholesterolaemia
You can use gemfibrozil and a station together to lower cholesterol
NO- this combination greatly increases the risk of rhabdomyolysis
When are GI rates used in hyperlipidaemia?
Those whose serum-triglyceride concentration is greater than 10mol/litre
Name 5 classes of drug used in hyperlipidaemia
Statins Bike acid sequestrants Fibrates Lomitapide Nicotinic acid group
How do bile acid sequestrants work?
Bind bile acids Prevent reabsorption Promotes hepatic conversion of cholesterol to bile acids Increased LDL receptor activity Increased clearance of LDL cholesterol
How does ezetimibe work
It inhibits the intestinal absorption of cholesterol
MOA of fibrates
They act by decreasing serum triglycerides; they have variable effect on LDL-cholesterol
Name 4 fibrates that modify lipid levels
Bezafibrate
Ciprofibrate
Fenofibrate
Gemfibrozil
Name a cholesterol absorption inhibitor
Ezetimibe
Mode of action if statins
Competitively inhibit HMG CoA reductase
When should patients not be started on a statin?
If the baseline creatinine kinase concentration is more than 5 times the upper limit of normal
Which drugs increase the plasma statin concentration
Macrolide antibiotics
Imidazole antifungals
Triazole antifungals
Ciclosporin
MOA of lomitapide
An inhibitor of microsomal triglyceride transfer protein (MTP), reduces lipoprotein secretion and circulating concentrations of lipoprotein-borne lipids such as cholesterol and triglycerides
Patients with stable angina should be given what?
GTN for acute attacks
Beta-blocker or CCB
Name three long acting nitrates used in stable angina
Ivabradine
Nicorandil
Ranolazine
How does cangrelor work
Antiplatelet- is a direct P2Y12 platelet receptor antagonist that blocks adenosine diphosphate induced platelet activation and aggregation
MOA of fibrinolytics
Act as thrombolytics by activating plasminogen to form plasminogen, which degrades fibrin and so breaks up thrombi
Alteplase is contraindicated if a patient has a history of hypersensitivity to what?
Gentamicin
Name four fibrinolytics
Alteplase
Reteplase
Streptokinase
Tenecteplase
How do nitrates exert their benefits in angina
Potent coronary vasodilators, their principle benefit follows from a reduction in venous return which reduces left ventricular work
What is dobutamine and how does it work
It’s a inotropic sympathomimetic that’s a cardiac stimulant which acts on beta-1 receptors in the cardiac muscle and increases contractility with little effect on rate
What should you monitor with dobutamine
Serum potassium concentration
How do thiazides work
They inhibit sodium reabsorption at the beginning of the distal convoluted tubule
What is disppyramide
Class IA antiarrhythmia drug- used to prevent arrhythmia post MI - has antimuscarinic effects so caution in glaucoma
Name a class IB antiarrhythmia drug
Lidocaine
Name two class IC anti arrhythmia agents
Flecainide
Propafenone
Propafenone has what extra mild activity and why is this used with caution in obstructive airway disease
Beta blocking activity
Vasoconstriction of airways
Name two class III anti arrhythmia drugs
Amiodarone
Dronedarone
MHRA warning with amiodarone + sofosbuvir + daclatasvir + ledipasvir + simeprevir
Can cause severe bradycardia and heart block if used together
MHRA warning with sotalol
May prolong QT or life threatening ventricular arrhythmias - correct hypomagnesium + hypokalaemia before initiating
Tue or false: patient with heart failure in sinus rhythm needs a loading dose of digoxin
FALSE no loading required
True or false: digoxin has a long half life
TRUE DAT- once daily maintenance dosing as a result
Likelihood of Digoxin toxicity increases through what range of level?
1.5-3mcg/L
What electrolyte imbalances can predispose to digitalis toxicity
Hypercalcaemia
Hypokalaemia
Hypomagnesmia
Switching from IV to oral digoxin requires what dose increase?
20-33%
Pt on digoxin requires half the dose with concurrent use of what 3 drugs
Amiodarone
Dronedarone
Quinine
What type of drug is tranexamic acid
Antifibrinolytic
Name a haemostatic drug
Ethamsylate
Name a dihydropyridine CCB used to increase cerebral perfusion in subarachnoid haemorrhage
Nimodipine
True or false: nimodipine tablets are light sensitive
TRUEEE
What is epoprostenol?
Prostacyclin (prostaglandin) and potent vasodilator that inhibits platelet aggregation used for blocked catheters and lines in e.g renal dialysis
how many days VTE prophylaxis following hip replacement?
28-35 days
How many days VTE prophylaxis following knee replacement surgery?
10-14 days
VTE in pregnancy?
Heparins preferred as do not cross placenta - LMWH best as they reduce risk of osteoporosis and HIT
The coumarins and phenindione take how long for full effect?
48-72 hrs
Warfarin should be stopped how many days before elective surgery
Five days - give phytomenadione by mouth using IV prep day before surgery if INR > 1.5
Which has a longer duration of action:
UFH
LMWH
LMWH
What is argatroban
Anticoagulation in adult patients with heparin induced thrombocytopenia type 2
Name a hirudin and what is it used for
Bivalirudin- thrombin inhibitor for unstable angina or NSTEMI/STEMI undergoing PCI
What is epoprostenol
Prostacyclin that inhibits platelet aggregation during renal dialysis when heparins are unsuitable or contraindicated - also for primary pulmonary hypertension resistant to other treatment
Name the antidote/chelator of dabigatran
Idarucizumab
Age limit for aspirin and why?
16yrs
Risk of Reye’s syndrome
What is Reye’s syndrome
Swelling in liver and brain - in children/teens recovering from viral infection e.g flu or chicken pox
Max quantities to sell of aspirin OTC
32 - but pharmacists can sell multiple packs reaching a max of 100 in certain circumstances
Allergy and cross sensitivity info for clopidogrel
Caution in history of hypersensitivity reactions to thienopyridines (e.g prasugrel)
Dipyridamole taken with food?
YAHHH preferably
Mode of action of apixaban, edoxaban, fondaparinux and rivaroxaban
Inhibitors of factor X (factor Xa)
Dose and duration of apixaban for prophylaxis VTE following knee replacement?
2.5mg BD for 10-14 days to be started 12-24 hrs following surgery
Apixaban dose and duration for VTE prophylaxis in hip replacement surgery
2.5mg BD for 32-38 days to be started 12-24 hrs after surgery
Avoid apixaban if renal function < what?
< 15ml/min
When do you reduce the dose of apixaban in prevention of stroke in AF
When crcl < 30ml/min
Dose and duration of rivaroxaban for prophylaxis of VTE following knee replacement surgery
10mg OD for 2weeks to be started 6-10hrs after surgery
Dose and duration of rivaroxaban for prophylaxis of VTE following hip replacement surgery
10mg OD for 5 weeks to be started 6-10 hrs after surgery
Dose of apixaban for treatment of DVT/PE
Initially 10mg BD for 7 days then maintenance 5mg BD
Dose of rivaroxaban for treating DVT/PE
Initially 15mg BD for 21 days then 20mg OD
Main features of aspirin poisoning (salicylate poisoning)
Hyperventilation Tinnitus Deafness Vasodilatation Sweating
Name a heparinoid
Danaparoid
Antidote of heparin and partial antidote of LMWH
Protamine sulfate
How long after having heparin can HIT develop
5-10days
Signs of HIT
30% reduction of platelet count, thrombosis, skin allergy
Management of HIT
Stop heparin- switched to alternative anticoagulant such as danaparoid and ensure platelet count returns to normal range in those who require warfarin
How can heparin cause hyperkalaemia
Inhibition of aldosterone secretion
Does LMWH cross the placenta
No
True or false: argatroban can be used for anticoagulation in patients who’ve had HIT
True!
NICE recommendation on bivalirudin
Give in combination with aspirin and clopidogrel in STEMI in patients undergoing PCI
MOA of dabigatran
Direct thrombin inhibitor with a rapid onset of action
Name a tissue plasminogen activator
Urokinase
BP target in elderly (over 80)
150/90 clinic + 145/85 ambulatory/home
BP target in diabetes without secondary problems
140/80
BP target in diabetes with kidney, eye or cerebrovascular disease
130/80
Target BP in renal disease
Below 140/90 (130/80 is advised in patients with chronic kidney disease and diabetes, or if proteinuria exceeds 1g in 24hrs)
Three drugs used for hypertension in pregnancy
Labetolol
Methyldopa
MR nifedipine
Target BP for pregnant women with uncomplicated hypertension
<150/100
Target BP for pregnant women with hypertension with target organ damage and in women with chronic hypertension who have just given birth
<140/90
Women managed with methyldopa for hypertension during pregnancy should discontinue treatment and restart their original antihypertensive medication when?
Within 2 days of the birth
Pregnant women are at high risk of developing pre-eclampsia if they have what?
CKD Diabetes Autoimmune disease Chronic hypertension Hypertension during previous pregnancy
Pregnant women at high risk of pre-eclampsia are advised to take what?
Aspirin OD from week 12 of pregnancy until baby is born (unlicensed)
Alpha blocker used in phaeochromocytoma
Phenoxybenzamine
Phentolamine
Disadvantage of clonidine
Sudden withdrawal can cause severe rebound hypertension
Name three centrally acting antihypertensives
Clonidine
Methyldopa
Moxonidine
Why should alpha blockers be used with caution?
They can reduce BP rapidly after the first dose
Name 4 alpha blockers
Prazosin
Doxazosin
Indoramin
Terazosin
Other than hypertension, alpha blockers can we used in what?
Benign prostatic hyperplasia
Which two ARBs are licensed as adjuncts to ACEi under specialist supervision in the management of heart failure when other treatments are unsuitable?
Candesartan
Valsartan
Name a renin inhibitor licensed for hypertension?
Aliskiren
True or false- clonidine can be used for prevention of recurrent migraines
TRUE DAT
Name the more water soluble b-blockers and what are their benefits?
Atenolol
Celiprolol
Nadolol
Sotalol
-less likely to enter brain and may therefore cause less sleep disturbance and nightmares
Water soluble beta blockers are excreted by what?
Da kidneys
Name the more cardioselective beta- blockers
Atenolol Bisoprolol Metoprolol Nebivolol Acebutolol- lesser extent
Name three side effects of beta blockers
Fatigue
Coldness of extremities
Sleep disturbances
Why should you choose cardioselective beta blocker in diabetes
Beta blockers can affect carbohydrate metabolism resulting in either hypoglycaemia or hyperglycaemia
Administration of which beta blocker can reverse the clinical symptoms of thyrotoxicosis within 4 days
Propranolol
Name four beta blockers used topically in glaucoma
Betaxolol
Carteolol
Levobunolol
Timolol
Can beta blockers be used in the prophylaxis of migraine?
Yup
What symptoms of anxiety can beta blockers help to alleviate
Palpitations
Tremor
Tachycardia
Why caution of beta blockers in diabetes?
They can mask symptoms of hypoglycaemia
Can beta blockers reduce the responsiveness to adrenaline?
Yeh
Name the beta blockers used for hypertension in pregnancy
Labetolol
True or false - fat soluble beta blockers such as nadolol are more present in breast milk than other beta blockers
FALSE- water soluble such as nadolol are
What’s in the combination product ‘co-tenidone’
Chlortalidone and atenolol
Name two non-dihydropyridine CCBs
Verapamil
Diltiazem
Most common side effect of verapamil
Constipation
Verapamil is indicated for the treatment of what?
Angina
Hypertension
Arrhythmias
True or false - you can use verapamil with beta blockers
False!! Heart block
Which type of CCBs should be avoided in heart failure due to risk of cardiac depression?
The non-dihydropyridines (verapamil + diltiazem)
Name 7 dihydropyridines
Amlodipine Felodipine Lacidipine Lercanidipine Nicardipine Nifedipine Nimodipine
Nifedipine, nicardipine, amlodipine and felodipine are used for the treatment of what?
Hypertension
Angina
Side effects of CCBs
Flushing
Ankle swelling
Name the CCB that can be used IV for acute life threatening hypertension
IV nicardipine
Name the three CCB indicated for the treatment of hypertension only
Isradipine
Lacidipine
Lercanidipine
Which CCB is confined to prevention and treatment of vascular spasm following aneurysmal subarachnoid haemorrhage
Nimodipine
What is clevidipine
CCB used for hypertension in the peri-operative setting (specialist use only)
What is contained in co-amilozide
Amiloride and hydrochlorithiazide
Main issue of diuretics
Hypokalaemia
Thiazides and related diuretics can exacerbate what
Diabetes
Gout
Systemic lupus erythematosus
Name the four thiazides and related diuretics under the BNF section
Bendrofluemthiazide
Co-amiloride
Hydrochlorothiazide
Indapamide
True or false- indapamide is a thiazide like diuretic which at lower doses has a higher diuretic effect than antihypertensive
False- lower doses has more vasodilation/hypertensive effect, higher doses is where the diuretic effect increases
With regards to liver when should ACEi be discontinued
If marked elevations of hepatic enzymes or jaundice occur - as a result of reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis and hepatic failure
Name a guanylate Cyclase stimulator used in pulmonary hypertension
Riociguat
MHRA warning with riociguat
Efficacy and safety in patients with symptomatic PH-IIP1 Showed increased mortality and risk of serious adverse events with riociguat compared to placebo
Name three things that can cause shock
Haemorrhage
Sepsis
Myocardial insufficiency
Name three sympathomimetic inotropes used in shock
Adrenaline/ephedrine
Dobutamine
Dopamine
Mode of action of dopamine
Is a cardiac stimulant which acts on beta 1 receptors in the cardiac muscle, it increases contractility with little effect on rate
Name five drugs under the hypotension and shock BNF section
Dopamine Metaraminol Midodrine Noradrenaline Phenylephrine
Indication for midodrine
Severe orthostatic hypotension
What’s in the combination of co-flumactone
Hydroflumethiazide and spironolactone
Dose adjustment and interactions of eplerenone
Max dose 25mg daily with concurrent use of amiodarone or moderate inhibitors of CYP3A4
Name 3 potassium sparing diuretics used in heart failure
Co-flumactone
Eplerenone
Spironolactone
Caution with aldosterone antagonists/potassium sparing diuretics
HYPERKALAEMIA
Dose adjustments due to interactions for the endothelin receptor antagonist ‘Ambrisentan’ used in pulmonary hypertension
Max dose 5mg daily and close monitoring with concurrent use of ciclosporin
Midodrine is a pro-drug of what?
Desglymidodrine which is a sympathomimetic agent that acts on peripheral alpha adreneegic receptors to increase arterial resistance, resulting in an increase in BP
Can you combine statin and gemfibrozil
NO - huge risk of rhabdomyolysis
Define high intensity statin
One than produces a greater LDL cholesterol reduction that simvastatin 40mg
What drug is better than statins at reducing high triglyceride concentration
Fibrates
Name two monoclonal antibodies used in primary hypercholesterolaemia
Alirocumab
Evolocumab
Issue with bike acid sequestrants
They can aggravate hypertriglyceridaemia
When are fibrates used?
In those whose serum triglyceride conc is greater than 10mmol /litre or in those who cannot tolerate statin
Name three bile acid sequestrants
Colesevelam
Colestipol
Colestyramine
True or false: other drugs need to be taken 1 hour before or 4-6 hours after bile acid sequestrants
Trueeee
True or false: hypothyroidism should be corrected before initiating a statin
True!
Should statins be discontinued if there is an increase in the blood-glucose concentration or HbA1c
No- benefits still outweigh risks
Name 5 statins
Atorvastatin Fluvastatin Pravastatin Rosuvastatin Simvastatin
How does alirocumab and evolocumab work
They bind to a pro-protein involved in the regulation of LDL receptors on liver cells, receptor numbers are increased which results in increased uptake of LDL cholesterol from the blood
How does lomitapide work
Inhibitor of microsomal triglyceride transfer protein (MTP), reduces lipoprotein secretion and circulating concs of lipoprotein-borne lipids such as cholesterol and triglycerides
Management of stable angina
1) GTN acute attacks
2) beta blocker or CCB
3) beta blocker + CCB
4) beta blocker or CCB plus long acting nitrate
5) long acting nitrate if can’t tolerate beta or CCB
What is nicorandil
Potassium channel activator with a nitrate component licensed for long term angina management
Name three glycoproteins IIB/IIA inhibitors and what type of drug are they
Abciximab
Eptifibatide
Tirofiban
Timings for the four fibrinolytics for STEMI
Alteplase- 6-12 hrs
Streptokinase -12hrs
Reteplase -12hrs
Tenecteplase -6hrs
Sublingual GTN lasts how long?
20 to 30 mins
Caution for nitrates
Patients on long term long acting or transdermal nitrates rapidly develop tolerance
Common side effects of nitrates
Dizziness Postural hypotension Tachycardia Throbbing headache Flushing
Onset of action of thiazides and related diuretics
1-2 hrs after oral administration
Duration of action of thiazides and related diuretics
12-24hrs
MOA of thiazides and related diuretics
Inhibit sodium reabsorption at the beginning of the distal convoluted tubule
Furosemide and bumetanide oral take how long to work and last for how long?
1 hour
6hours
Can be given BD without affecting sleep
IV furosemide reaches peak affects after how long
30mins
Why do we give amiloride or trianterene with thiazide or loop diuresis?
Because they are weak diuretics on their own but cause potassium retention and are more effective than giving potassium supplements
True or false: hyperglycaemia is more likely with thiazides than loop diuretics?
True - it’s less likely than with thiazides
Plot twist - in what condition can loop diuretics cause urinary retention
Enlarged prostate
Name two drugs used with thiazides or loops for their potassium conservation effect
Triamterene
Amiloride
Name an osmotic diuretic and what’s it used for
Mannitol - to treat cerebral oedema and raised intra-ocular pressure
7 signs of digoxin toxicity
N&V Blurred yellow vision Weight loss Anorexia Palpitations Hallucinations Abdominal pain
When do you measure digoxin levels
Normally 6 hrs after dose
Side effect of furosemide if infused too quick
Deafness (if exceeds 4mg/min)
Side effect of bumetanide
Myalgia
Side effect of amiloride
Urine can look blue in some lighting
Four symptoms of hyperkalaemia
Fatigue
Palpitations
Nausea and vomiting
Chest pain
Name 4 beta blockers less likely to cause coldness of extremities or bradycardia
Oxyprenolol
Pindolol
Acebutol
Celiprolol
Name 4 water soluble beta blockers
Atenolol
Celiprolol
Nadolol
Sotalol
Name three beta blockers than are long acting and taken once daily
Atenolol
Bisoprolol
Nadolol
Name 5 cardioselective beta blockers
Atenolol Bisoprolol Metoprolol Nebivolol Acebutol
Name a non cardioselective beta blocker
Sotalol
Name three beta blockers which reduce mortality in MI
Atenolol
Metoprolol
Propranolol
Name 3 beta blockers that reduced morality in heart failure
Bisoprolol
Carvedilol
Nebivolol
Which beta blocker is used in anxiety?
Propranolol
Big side effect of nicorandil
Ulceration
Can you use pravastatin in preganancy and breastfeeding
NO
Name the two longer acting statins that can be taken any time of day as a result of this
Atorvastatin
Rosuvastatin
