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British National Formulary > Chapter 2- Cardiovascular System > Flashcards

Chapter 2- Cardiovascular System Flashcards

1
Q

Two types of treatment in AF

A

Rate control Rhythm control

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2
Q

First line option in AF?

A

Rate control

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3
Q

What can hypokalaemia cause?

A

Torsade de pointes due to long QT interval

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4
Q

Treatment of torsade de points?

A

IV infusion of magnesium sulfate

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5
Q

Name two class 1 membrane stabilising drugs used in arrhythmias under the Vaughan Williams classification

A

Lidocaine Flecainide

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6
Q

What class of drug is under the class two of the Vaughan Williams classification

A

Beta blockers

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7
Q

Class 3 of the Vaughan Williams classification

A

Amiodarone Sotolol

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8
Q

Class 4 of Vaughan Williams classification

A

CCB (includes verapamil but not dihydropyridines)

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9
Q

Treatment of choice for terminating paroxysmal supraventricular tachycardia

A

Adenosine

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10
Q

True or false - adenosine is preferred over verampamil in asthma?

A

False

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11
Q

Name a cardiac glycoside

A

Digoxin

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12
Q

The likelihood of toxicity increases progressively through what range of digoxin level?

A

1.3 - 3 mcg/litre

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13
Q

True or false: hyperkalaemia exposes people to digitalis toxicity

A

False - hypokalaemia does

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14
Q

Reducing raised BP decreases the risk of what 4 things

A

Stroke Coronary events Heart failure Renal impairment

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15
Q

What two drugs form the basis of treatment for heart failure due to left ventricular dysfunction

A

Ace inhibitor Beta blocker

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16
Q

What’s in co-flumactone and what’s it used for

A

Hydroflumethiazide and spironolactone used for congestive heart failure

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17
Q

Drug action of sacubitril

A

A prodrug that inhibits the breakdown of natriuretic peptides resulting in varied effects including increased diuresis, natriuresis and vasodilation

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18
Q

What is enoximone

A

Is a phosphodiesterase type 3 inhibitor that exerts most effect on the myocardium; it has positive inotropic properties and vasodilator activity

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19
Q

Name two phosphodiesterase type 3 inhibitors used in heart failure

A

Enoximone Milrinone

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20
Q

List 3 things that make someone at higher risk of developing cardiovascular disease

A

Diabetes CKD Familial hypercholesterolaemia

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21
Q

You can use gemfibrozil and a station together to lower cholesterol

A

NO- this combination greatly increases the risk of rhabdomyolysis

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22
Q

Name 5 classes of drug used in hyperlipidaemia

A

Statins Bike acid sequestrants Fibrates Lomitapide Nicotinic acid group

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23
Q

How do bile acid sequestrants work?

A

Bind bile acids Prevent reabsorption Promotes hepatic conversion of cholesterol to bile acids Increased LDL receptor activity Increased clearance of LDL cholesterol

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24
Q

How does ezetimibe work

A

It inhibits the intestinal absorption of cholesterol

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25
Q

MOA of fibrates

A

They act by decreasing serum triglycerides; they have variable effect on LDL-cholesterol

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26
Q

Name 4 fibrates that modify lipid levels

A

Bezafibrate Ciprofibrate Fenofibrate Gemfibrozil

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27
Q

Name a cholesterol absorption inhibitor

A

Ezetimibe

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28
Q

Mode of action if statins

A

Competitively inhibit HMG CoA reductase

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29
Q

When should patients not be started on a statin?

A

If the baseline creatinine kinase concentration is more than 5 times the upper limit of normal

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30
Q

Which drugs increase the plasma statin concentration

A

Macrolide antibiotics Imidazole antifungals Triazole antifungals Ciclosporin

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31
Q

MOA of lomitapide

A

An inhibitor of microsomal triglyceride transfer protein (MTP), reduces lipoprotein secretion and circulating concentrations of lipoprotein-borne lipids such as cholesterol and triglycerides

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32
Q

Patients with stable angina should be given what?

A

GTN for acute attacks Beta-blocker or CCB

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33
Q

Name three long acting nitrates used in stable angina

A

Ivabradine Nicorandil Ranolazine

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34
Q

How does cangrelor work

A

Antiplatelet- is a direct P2Y12 platelet receptor antagonist that blocks adenosine diphosphate induced platelet activation and aggregation

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35
Q

MOA of fibrinolytics

A

Act as thrombolytics by activating plasminogen to form plasminogen, which degrades fibrin and so breaks up thrombi

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36
Q

Alteplase is contraindicated if a patient has a history of hypersensitivity to what?

A

Gentamicin

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37
Q

Name four fibrinolytics

A

Alteplase Reteplase Streptokinase Tenecteplase

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38
Q

How do nitrates exert their benefits in angina

A

Potent coronary vasodilators, their principle benefit follows from a reduction in venous return which reduces left ventricular work

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39
Q

How do thiazides work

A

They inhibit sodium reabsorption at the beginning of the distal convoluted tubule

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40
Q

What is dispyramide

A

Class IA antiarrhythmia drug- used to prevent arrhythmia post MI - has antimuscarinic effects so caution in glaucoma

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41
Q

Name a class IB antiarrhythmia drug

A

Lidocaine

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42
Q

Name two class IC anti arrhythmia agents

A

Flecainide Propafenone

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43
Q

Propafenone has what extra mild activity and why is this used with caution in obstructive airway disease

A

can affect airway

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44
Q

Name two class III anti arrhythmia drugs

A

Amiodarone Dronedarone

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45
Q

MHRA warning with amiodarone + sofosbuvir + daclatasvir + ledipasvir + simeprevir

A

Can cause severe bradycardia and heart block if used together

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46
Q

MHRA warning with sotalol

A

May prolong QT or life threatening ventricular arrhythmias - correct hypomagnesium + hypokalaemia before initiating

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47
Q

Tue or false: patient with heart failure in sinus rhythm needs a loading dose of digoxin

A

FALSE no loading required

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48
Q

True or false: digoxin has a long half life

A

TRUE DAT- once daily maintenance dosing as a result

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49
Q

Likelihood of Digoxin toxicity increases through what range of level?

A

1.5-3mcg/L

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50
Q

What electrolyte imbalances can predispose to digitalis toxicity

A

Hypercalcaemia Hypokalaemia Hypomagnesmia

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51
Q

Switching from IV to oral digoxin requires what dose increase?

A

20-33%

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52
Q

Pt on digoxin requires half the dose with concurrent use of what 3 drugs

A

Amiodarone Dronedarone Quinine

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53
Q

What type of drug is tranexamic acid

A

Antifibrinolytic

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54
Q

Name a haemostatic drug

A

Ethamsylate

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55
Q

Name a dihydropyridine CCB used to increase cerebral perfusion in subarachnoid haemorrhage

A

Nimodipine

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56
Q

True or false: nimodipine tablets are light sensitive

A

TRUEEE

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57
Q

What is epoprostenol?

A

Prostacyclin (prostaglandin) and potent vasodilator that inhibits platelet aggregation used for blocked catheters and lines in e.g renal dialysis

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58
Q

how many days VTE prophylaxis following hip replacement?

A

28-35 days

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59
Q

How many days VTE prophylaxis following knee replacement surgery?

A

10-14 days

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60
Q

VTE in pregnancy?

A

Heparins preferred as do not cross placenta - LMWH best as they reduce risk of osteoporosis and HIT

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61
Q

The coumarins and phenindione take how long for full effect?

A

48-72 hrs

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62
Q

Warfarin should be stopped how many days before elective surgery

A

Five days - give phytomenadione by mouth using IV prep day before surgery if INR > 1.5

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63
Q

Which has a longer duration of action: UFH LMWH

A

LMWH

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64
Q

What is argatroban

A

Anticoagulation in adult patients with heparin induced thrombocytopenia type 2

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65
Q

Name a hirudin and what is it used for

A

Bivalirudin- thrombin inhibitor for unstable angina or NSTEMI/STEMI undergoing PCI

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66
Q

What is epoprostenol

A

Prostacyclin that inhibits platelet aggregation during renal dialysis when heparins are unsuitable or contraindicated - also for primary pulmonary hypertension resistant to other treatment

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67
Q

Name the antidote/chelator of dabigatran

A

Idarucizumab

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68
Q

Age limit for aspirin and why?

A

16yrs Risk of Reye’s syndrome

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69
Q

What is Reye’s syndrome

A

Swelling in liver and brain - in children/teens recovering from viral infection e.g flu or chicken pox

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70
Q

Max quantities to sell of aspirin OTC

A

32 - but pharmacists can sell multiple packs reaching a max of 100 in certain circumstances

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71
Q

Allergy and cross sensitivity info for clopidogrel

A

Caution in history of hypersensitivity reactions to thienopyridines (e.g prasugrel)

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72
Q

How do you take Dipyridamole

A

Dipyridamole given with food.

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73
Q

Mode of action of apixaban, edoxaban, fondaparinux and rivaroxaban

A

Inhibitors of factor X (factor Xa)

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74
Q

Dose and duration of apixaban for prophylaxis VTE following knee replacement?

A

2.5mg BD for 10-14 days to be started 12-24 hrs following surgery

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75
Q

Apixaban dose and duration for VTE prophylaxis in hip replacement surgery

A

2.5mg BD for 32-38 days to be started 12-24 hrs after surgery

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76
Q

Avoid apixaban if renal function < what?

A

< 15ml/min

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77
Q

When do you reduce the dose of apixaban in prevention of stroke in AF

A

When crcl < 30ml/min

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78
Q

Dose and duration of rivaroxaban for prophylaxis of VTE following knee replacement surgery

A

10mg OD for 2weeks to be started 6-10hrs after surgery

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79
Q

Dose and duration of rivaroxaban for prophylaxis of VTE following hip replacement surgery

A

10mg OD for 5 weeks to be started 6-10 hrs after surgery

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80
Q

Dose of apixaban for treatment of DVT/PE

A

Initially 10mg BD for 7 days then maintenance 5mg BD

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81
Q

Dose of rivaroxaban for treating DVT/PE

A

Initially 15mg BD for 21 days then 20mg OD

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82
Q

Main features of aspirin poisoning (salicylate poisoning)

A

Hyperventilation Tinnitus Deafness Vasodilatation Sweating

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83
Q

Name a heparinoid

A

Danaparoid

84
Q

Antidote of heparin and partial antidote of LMWH

A

Protamine sulfate

85
Q

How long after having heparin can HIT develop

A

5-10days

86
Q

Signs of Heparin induced thombocytopaenia?

A

30% reduction of platelet count, thrombosis, skin allergy

87
Q

Management of HIT

A

Stop heparin- switched to alternative anticoagulant such as danaparoid and ensure platelet count returns to normal range in those who require warfarin

88
Q

How can heparin cause hyperkalaemia

A

Inhibition of aldosterone secretion

89
Q

Does LMWH cross the placenta

A

No

90
Q

True or false: argatroban can be used for anticoagulation in patients who’ve had HIT

A

True!

91
Q

NICE recommendation on bivalirudin

A

Give in combination with aspirin and clopidogrel in STEMI in patients undergoing PCI

92
Q

MOA of dabigatran

A

Direct thrombin inhibitor with a rapid onset of action

93
Q

BP target in diabetes without secondary problems

A

140/80

94
Q

BP target in diabetes with kidney, eye or cerebrovascular disease

A

130/80

95
Q

Target BP in renal disease

A

Below 140/90 (130/80 is advised in patients with chronic kidney disease and diabetes, or if proteinuria exceeds 1g in 24hrs)

96
Q

Three drugs used for hypertension in pregnancy

A

Labetolol Methyldopa MR nifedipine

97
Q

Target BP for pregnant women with uncomplicated hypertension

A

<150/100

98
Q

Target BP for pregnant women with hypertension with target organ damage and in women with chronic hypertension who have just given birth

A

<140/90

99
Q

Women managed with methyldopa for hypertension during pregnancy should discontinue treatment and restart their original antihypertensive medication when?

A

Within 2 days of the birth

100
Q

Pregnant women are at high risk of developing pre-eclampsia if they have what?

A

CKD Diabetes Autoimmune disease Chronic hypertension Hypertension during previous pregnancy

101
Q

Pregnant women at high risk of pre-eclampsia are advised to take what?

A

Aspirin OD from week 12 of pregnancy until baby is born (unlicensed)

102
Q

Alpha blocker used in phaeochromocytoma

A

Phenoxybenzamine Phentolamine

103
Q

Disadvantage of clonidine

A

Sudden withdrawal can cause severe rebound hypertension

104
Q

Name three centrally acting antihypertensives

A

Clonidine Methyldopa Moxonidine

105
Q

Why should alpha blockers be used with caution?

A

They can reduce BP rapidly after the first dose

106
Q

Name 4 alpha blockers

A

Prazosin Doxazosin Indoramin Terazosin

107
Q

Other than hypertension, alpha blockers can we used in what?

A

Benign prostatic hyperplasia

108
Q

Which two ARBs are licensed as adjuncts to ACEi under specialist supervision in the management of heart failure when other treatments are unsuitable?

A

Candesartan Valsartan

109
Q

Name a renin inhibitor licensed for hypertension?

A

Aliskiren

110
Q

True or false- clonidine can be used for prevention of recurrent migraines

A

TRUE DAT

111
Q

Name the more water soluble b-blockers and what are their benefits?

A

Atenolol Celiprolol Nadolol Sotalol -less likely to enter brain and may therefore cause less sleep disturbance and nightmares

112
Q

Water soluble beta blockers are excreted by what?

A

Da kidneys

113
Q

Name the more cardioselective beta- blockers

A

Atenolol Bisoprolol Metoprolol Nebivolol Acebutolol- lesser extent

114
Q

Name three side effects of beta blockers

A

Fatigue Coldness of extremities Sleep disturbances

115
Q

Why should you choose cardioselective beta blocker in diabetes

A

Beta blockers can affect carbohydrate metabolism resulting in either hypoglycaemia or hyperglycaemia

116
Q

Administration of which beta blocker can reverse the clinical symptoms of thyrotoxicosis within 4 days

A

Propranolol

117
Q

Name four beta blockers used topically in glaucoma

A

Betaxolol Carteolol Levobunolol Timolol

118
Q

Can beta blockers be used in the prophylaxis of migraine?

A

Yup

119
Q

What symptoms of anxiety can beta blockers help to alleviate

A

Palpitations Tremor Tachycardia

120
Q

Why caution of beta blockers in diabetes?

A

They can mask symptoms of hypoglycaemia

121
Q

Can beta blockers reduce the responsiveness to adrenaline?

A

Yeh

122
Q

Name the beta blockers used for hypertension in pregnancy

A

Labetolol

123
Q

True or false - fat soluble beta blockers such as nadolol are more present in breast milk than other beta blockers

A

FALSE- water soluble such as nadolol are

124
Q

What’s in the combination product ‘co-tenidone’

A

Chlortalidone and atenolol

125
Q

Name two non-dihydropyridine CCBs

A

Verapamil Diltiazem

126
Q

Most common side effect of verapamil

A

Constipation

127
Q

Verapamil is indicated for the treatment of what?

A

Angina Hypertension Arrhythmias

128
Q

True or false - you can use verapamil with beta blockers

A

False!! Heart block

129
Q

Which type of CCBs should be avoided in heart failure due to risk of cardiac depression?

A

The non-dihydropyridines (verapamil + diltiazem)

130
Q

Name 7 dihydropyridines

A

Amlodipine Felodipine Lacidipine Lercanidipine Nicardipine Nifedipine Nimodipine

131
Q

Nifedipine, nicardipine, amlodipine and felodipine are used for the treatment of what?

A

Hypertension Angina

132
Q

Side effects of CCBs

A

Flushing Ankle swelling

133
Q

Name the CCB that can be used IV for acute life threatening hypertension

A

IV nicardipine

134
Q

Name the three CCB indicated for the treatment of hypertension only

A

Isradipine Lacidipine Lercanidipine

135
Q

Which CCB is confined to prevention and treatment of vascular spasm following aneurysmal subarachnoid haemorrhage

A

Nimodipine

136
Q

What is clevidipine

A

CCB used for hypertension in the peri-operative setting (specialist use only)

137
Q

What is contained in co-amilozide

A

Amiloride and hydrochlorithiazide

138
Q

Main issue of diuretics

A

Hypokalaemia

139
Q

Thiazides and related diuretics can exacerbate what

A

Diabetes Gout Systemic lupus erythematosus

140
Q

Name the four thiazides and related diuretics under the BNF section

A

Bendrofluemthiazide Co-amiloride Hydrochlorothiazide Indapamide

141
Q

True or false- indapamide is a thiazide like diuretic which at lower doses has a higher diuretic effect than antihypertensive

A

False- lower doses has more vasodilation/hypertensive effect, higher doses is where the diuretic effect increases

142
Q

With regards to liver when should ACEi be discontinued

A

If marked elevations of hepatic enzymes or jaundice occur - as a result of reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis and hepatic failure

143
Q

Name a guanylate Cyclase stimulator used in pulmonary hypertension

A

Riociguat

144
Q

MHRA warning with riociguat

A

Efficacy and safety in patients with symptomatic PH-IIP1 Showed increased mortality and risk of serious adverse events with riociguat compared to placebo

145
Q

Name three things that can cause shock

A

Haemorrhage Sepsis Myocardial insufficiency

146
Q

Name three sympathomimetic inotropes used in shock

A

Adrenaline/ephedrine Dobutamine Dopamine

147
Q

Mode of action of dopamine

A

Is a cardiac stimulant which acts on beta 1 receptors in the cardiac muscle, it increases contractility with little effect on rate

148
Q

Name five drugs under the hypotension and shock BNF section

A

Dopamine Metaraminol Midodrine Noradrenaline Phenylephrine

149
Q

Indication for midodrine

A

Severe orthostatic hypotension

150
Q

What’s in the combination of co-flumactone

A

Hydroflumethiazide and spironolactone

151
Q

Dose adjustment and interactions of eplerenone

A

Max dose 25mg daily with concurrent use of amiodarone or moderate inhibitors of CYP3A4

152
Q

Name 3 potassium sparing diuretics used in heart failure

A

Co-flumactone Eplerenone Spironolactone

153
Q

Caution with aldosterone antagonists/potassium sparing diuretics

A

HYPERKALAEMIA

154
Q

Dose adjustments due to interactions for the endothelin receptor antagonist ‘Ambrisentan’ used in pulmonary hypertension

A

Max dose 5mg daily and close monitoring with concurrent use of ciclosporin

155
Q

Midodrine is a pro-drug of what?

A

Desglymidodrine which is a sympathomimetic agent that acts on peripheral alpha adreneegic receptors to increase arterial resistance, resulting in an increase in BP

156
Q

Can you combine statin and gemfibrozil

A

NO - huge risk of rhabdomyolysis

157
Q

Define high intensity statin

A

One than produces a greater LDL cholesterol reduction that simvastatin 40mg

158
Q

What drug is better than statins at reducing high triglyceride concentration

A

Fibrates

159
Q

Name two monoclonal antibodies used in primary hypercholesterolaemia

A

Alirocumab Evolocumab

160
Q

Issue with bike acid sequestrants

A

They can aggravate hypertriglyceridaemia

161
Q

When are fibrates used?

A

In those whose serum triglyceride conc is greater than 10mmol /litre or in those who cannot tolerate statin

162
Q

Name three bile acid sequestrants

A

Colesevelam Colestipol Colestyramine

163
Q

True or false: other drugs need to be taken 1 hour before or 4-6 hours after bile acid sequestrants

A

Trueeee

164
Q

True or false: hypothyroidism should be corrected before initiating a statin

A

True!

165
Q

Should statins be discontinued if there is an increase in the blood-glucose concentration or HbA1c

A

No- benefits still outweigh risks

166
Q

Name 5 statins

A

Atorvastatin Fluvastatin Pravastatin Rosuvastatin Simvastatin

167
Q

How does alirocumab and evolocumab work

A

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

168
Q

How does lomitapide work

A

Inhibitor of microsomal triglyceride transfer protein (MTP), reduces lipoprotein secretion and circulating concs of lipoprotein-borne lipids such as cholesterol and triglycerides

169
Q

Management of stable angina

A

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

170
Q

What is nicorandil

A

Potassium channel activator with a nitrate component licensed for long term angina management

171
Q

Name three glycoproteins IIB/IIA inhibitors and what type of drug are they

A

Abciximab Eptifibatide Tirofiban

172
Q

Timings for the four fibrinolytics for STEMI

A

Alteplase- 6-12 hrs Streptokinase -12hrs Reteplase -12hrs Tenecteplase -6hrs

173
Q

Sublingual GTN lasts how long?

A

20 to 30 mins

174
Q

Caution for nitrates

A

Patients on long term long acting or transdermal nitrates rapidly develop tolerance

175
Q

Common side effects of nitrates

A

Dizziness Postural hypotension Tachycardia Throbbing headache Flushing

176
Q

Onset of action of thiazides and related diuretics

A

1-2 hrs after oral administration

177
Q

Duration of action of thiazides and related diuretics

A

12-24hrs

178
Q

MOA of thiazides and related diuretics

A

Inhibit sodium reabsorption at the beginning of the distal convoluted tubule

179
Q

Furosemide and bumetanide oral take how long to work and last for how long?

A

1 hour 6hours Can be given BD without affecting sleep

180
Q

IV furosemide reaches peak affects after how long

A

30mins

181
Q

Why do we give amiloride or trianterene with thiazide or loop diuresis?

A

Because they are weak diuretics on their own but cause potassium retention and are more effective than giving potassium supplements

182
Q

True or false: hyperglycaemia is more likely with thiazides than loop diuretics?

A

True: Thiazides are more likely to cause hyperglycemia

183
Q

Plot twist - in what condition can loop diuretics cause urinary retention

A

Enlarged prostate

184
Q

Name two drugs used with thiazides or loops for their potassium conservation effect

A

Triamterene Amiloride

185
Q

Name an osmotic diuretic and what’s it used for

A

Mannitol - to treat cerebral oedema and raised intra-ocular pressure

186
Q

7 signs of digoxin toxicity

A

N&V Blurred yellow vision Weight loss Anorexia Palpitations Hallucinations Abdominal pain

187
Q

When do you measure digoxin levels

A

Normally 6 hrs after dose

188
Q

Side effect of furosemide if infused too quick

A

Deafness (if exceeds 4mg/min)

189
Q

Side effect of bumetanide

A

Myalgia

190
Q

Side effect of amiloride

A

Urine can look blue in some lighting

191
Q

Four symptoms of hyperkalaemia

A

Fatigue Palpitations Nausea and vomiting Chest pain

192
Q

Name 4 beta blockers less likely to cause coldness of extremities or bradycardia

A

Oxyprenolol Pindolol Acebutol Celiprolol

193
Q

Name 4 water soluble beta blockers

A

Atenolol Celiprolol Nadolol Sotalol

194
Q

Name three beta blockers than are long acting and taken once daily

A

Atenolol Bisoprolol Nadolol

195
Q

Name 5 cardioselective beta blockers

A

Atenolol Bisoprolol Metoprolol Nebivolol Acebutol

196
Q

Name a non cardioselective beta blocker

A

Sotalol

197
Q

Name three beta blockers which reduce mortality in MI

A

Atenolol Metoprolol Propranolol

198
Q

Name 3 beta blockers that reduced morality in heart failure

A

Bisoprolol Carvedilol Nebivolol

199
Q

Which beta blocker is used in anxiety?

A

Propranolol

200
Q

Big side effect of nicorandil

A

Ulceration

201
Q

Can you use pravastatin in preganancy and breastfeeding

A

NO

202
Q

Name the two longer acting statins that can be taken any time of day as a result of this

A

Atorvastatin Rosuvastatin

203
Q

Alirocumab Evolocumab

A

two monoclonal antibodies used in primary hypercholesterolaemia

204
Q

What is Idarucizumab and side effects?

A

(NOAC) reversal agent that will only reverse the anticoagulant effects of dabigatran.

headache,

low blood potassium levels (hypokalemia),

delirium,

constipation,

fever,

pneumonia,

blood clots,

hypersensitivity,

205
Q
A
206
Q
A

British National Formulary (18 decks)

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