Chapter 2: Cardiovascular system Flashcards
Is treatment usually required for ectopic beats?
No, but can use beta blockers if needed
What two things can you try and control in a patient with AF?
Rate and rhythm control
In patients without life-threatening haemodynamic instability, if a patient has onset of AF less than 48 hours ago, what can be offered to the patient?
A- rate 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
- How can ventricular rate be controlled in AF?
2. If this does not work, what can be used?
- Monotherapy:
Standard beta blocker (not sotalol)
Rate limiting CCB e.g. verapamil
Diltiazem is used but unlicensed
Digoxin
- Combination of beta blocker, digoxin or diltiazem
What group of patients should digoxin monotherapy be used for ventricular control in AF?
Only effective for controlling the ventricular rate at rest, so should only be used as monotherapy in sednetary (inactive) patients with non-paroxysmal atrial fibrillation.
What is meant by paroxysmal AF?
Episodes come and go
If dual ventricular rate therapy does not control symptoms in AF, what can then be considered?
Rhythm control
In patients with AF and diminished ventricular function, what should be used to control rate?
Beta blockers that are licensed for use in heart failure and digoxin
Post cardioversion in AF, what is used to maintain sinus rhythm?
Beta blocker
What is 1st line for long term rhythm control in AF?
Beta blocker (not sotalol)
If amiodarone is needed in an electrical cardioversion patient, how long before and after the procedure can they be on it for?
4 weeks before and up to 12 months after
For rhythm control in AF, when what group of patients would flecainide acetetate or propafenone NOT be suitable for?
Known ischaemic or structural heart disease
When would dronedarone be used in rhythm control for AF?
As an option for the maintenance of sinus rhythm after successful cardioversion in people with paroxysmal or persistent atrial fibrillation:
- whose atrial fibrillation is not controlled by first‑line therapy (usually including beta‑blockers), that is, as a second‑line treatment option and after alternative options have been considered and who have at least 1 of the following cardiovascular risk factors:
- hypertension requiring drugs of at least 2 different classes
- diabetes mellitus
- previous transient ischaemic attack, stroke or systemic embolism
- left atrial diameter of 50 mm or greater or
- age 70 years or older and
And:
who do not have left ventricular systolic dysfunction and
who do not have a history of, or current, heart failure.
(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?
CHADVASC
What tool do you use to assess for bleeding risk?
HAS BLED
At what CHADVASC score in men would you consider anticoagulation in AF?
At what score should you offer (taking into account bleeding risk)?
1
2
At what CHADVASC score in females would you consider anticoagulation to in AF?
2
Is aspirin monotherapy recommended for stroke prevention in AF?
No
What is the MHRA warning associated with amiodarone and hepatitis C antivirals?
Increased risk of bradycardia and heart block
Needs very close monitoring if used together but ideally use alternatives
What are the key side effects of amiodarone?
- Corneal microdeposits (reversible upon withdrawal of treatment but can cause blindness)
- Thyroid function- amiodarone contains iodine and can cause hyper and hypothyroidism (thyrotoxicosis)
- Hepatotoxicity
- Pulmonary toxicity- pneumonitis should always be suspected is new or worsening SOB occurs
- “Dazzled in light” phototoxicity
- Grey skin discolouration
- Altered taste
- Sleep disorders
- Peripheral neuropathy
What does amiodarone contain that could cause thryoid problems?
Iodine
What is the patient advice regarding amiodarone and the sun?
Patients should be instructed to avoid exposure to sun and to use protective measures during therapy as patients taking Amiodarone tablets can become unduly sensitive to sunlight, which may persist after several months of discontinuation of Amiodarone tablets. In most cases symptoms are limited to tingling, burning and erythema of sun-exposed skin but severe phototoxic reactions with blistering may be seen.
Patients need to shield their skin from light during treatment and for several months after discontinuing treatment as it has a very long half life
What is the main side effects with dronedarone?
Can cause/worsen heart failure so patients should seek help if symptoms of SOB, oedema, weight gain
Hepatic failure - Seek prompt medical attention if symptoms such as abdominal pain, anorexia, nausea, vomiting, fever occur
Pulmonary toxicity
What is the important safety information regarding sotalol and what it should be used for?
QT prolongation
Need to correct any hypokalaemia before starting
The use of sotalol should be limited to the treatment of ventricular arrhythmias or
prophylaxis of supraventricular arrhythmias. It should no longer be used for angina, hypertension,
thyrotoxicosis or for secondary prevention after myocardial infaction
If digoxin is being used alongside amiodarone, dronedarone or quinine, what do you do to the dose of digoxin?
Half it
When switching from IV to oral digoxin, how should you convert the dose?
Increase by 20-33%
True or false:
Hypocalcaemia increases risk of digoxin toxicity
False
Hypercalcaemia increases this risk
True or false:
Hyperkalaemia increases risk of digoxin toxicity
False
Hypokalaemia increases this risk
True or false:
Hypomagnesaemia increases risk of digoxin toxicity
True
Digoxin toxicity- what colour can your vision go?
Yellow
What is nimodipine used for?
Used in subarachnoid haemorrhage
What should patients immediately receive if they have a suspected TIA?
If within 4.5 hours of symptom onset, what should be given?
300mg Aspirin (2 weeks)
Alteplase
Within how many hours of symptom onset for TIA can a patient receive alteplase?
Within 4.5 hours
If a patient has been thromobylsed with alteplase for TIA, when should aspirin be given?
24 hours after
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 combination with aspirin
Is long term aspirin monotherapy recommended post ischaemic stroke?
No - only in combination with dipyridamole
Is long term MR dipyridamole monotherapy recommended post ischaemic stroke?
No - only in combination with aspirin
When should long term anticoagulation be considered post ischaemic stroke?
ONLY if the patient has AF
Should not be used for the general long-term prevention of recurrent stroke
When should a statin be started post ischaemic stroke?
What about if their cholesterol levels are in range?
48 hours after symptom onset
Regardless of their cholesterol levels, a statin should be initiated
How long should a patient be on high dose aspirin post ischaemic stroke?
300mg 2 weeks
How do you manage someone in the acute phase of haemorrhagic stroke?
Supportive measures e.g. blood pressure, fluids
If a patient has had a haemorrhagic stroke, at what systolic BP would you initiate antihypertensive treatment?
Over 200 mmHg
What are the 3 vitamin K antagonists?
Warfarin
Acenocoumarol (sinthrome)
Phenindione
When would you have a target INR of 3.5?
Recurrent DVT/PE in patients receiving anticoagulation and with an INR > 2
Mechanical prosthetic heart valves
How long should a patient be anticoagulated for following an isolated calf DVT?
6 weeks
How long should a patient be anticoagulated for following a VTE provoked by a risk factor e.g. surgery, oral contraceptive?
3 months
What is the reversal agent for warfarin?
Phytomenadione (vitamin K)
If a patient is on warfarin and needs surgery straight away, what should be given?
Phytomenadione and dried prothrombin complex
Is aspirin recommended in primary prevention of cardiovascular disease?
No
When is aspirin indicated as cardiovascular disease prevention?
Secondary 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
Can give fresh frozen plasma but this is less effective
Warfarin patient:
If their INR > 8 and has minor bleeding, what do you do?
When would you restart warfarin?
Give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours
Restart warfarin when INR <5.0
Warfarin patient:
If their INR > 8 but no bleeding, what do you do?
When would you restart warfarin?
Give phytomenadione (vitamin K1) by mouth (using injection solution- unlicensed) Repeat dose of phytomenadione if INR still too high after 24 hours
Restart warfarin when INR <5.0
Warfarin patient:
If their INR is 5-8 and has minor bleeding, what do you do?
Stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous 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
What is the only DOAC that has a reversal agent?
Dabigatran
What is the reversal agent for dabigatran?
Idarucizumab
Are DOACs recommended in patients with prosthetic heart valves?
No- efficacy has not been established
Can apixaban be crushed?
Yes- mix with water or apple juice/puree
Is apixaban once or twice daily dosing?
Twice daily
Is edoxaban once or twice daily dosing?
Once daily
If a patient is taking one of the following drugs:
- ciclosporin
- dronedarone
- erythromycin
- ketoconazole
And needs to be on edoxaban, what is the maximum daily dose?
30mg OD
What DOACs are black triangle drugs?
Rivaroxaban and edoxaban
When would you reduce the dose of edoxaban in renal impairments?
15-50 mL/min
Max 30mg OD
What is the cut off point for renal impairment for edoxaban?
Avoid if < 15mL/min
When do you reduce dose of edoxaban in terms of weight?
<61 kg reduce to 30mg OD
What is the cut off point for renal impairment for rivaroxaban?
Avoid if < 15mL/min
Can rivaroxaban be crushed?
Yes in water/apple juice or puree
What can rivaroxaban be used for in ACS patients?
Prophylaxis of atherothrombotic events following an ACS with elevated cardiac biomarkers
Combined with aspirin alone or with clopidogrel too
Which DOAC should be taken with food?
Rivaroxaban
Which DOAC cannot be put in a blister pack?
Dabigatran
What is the cut off point for renal impairment for dabigatran?
Avoid if < 30 mL/min
When would you reduce dose of dabigatran in renal impairment?
30-50 mL/min
What is the advice around a patient on dabigatran who is taking one of the following:
- Verapamil
- Amiodarone
Reduce dabigatran dose
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 (secondary to antivirals for hep C) may effect efficiacy of Vit K antagonists so INR should be closely monitored
In what trimesters of pregnancy are Vit K antagonists particularly dangerous?
1st and 3rd
What is the MHRA warning associated with warfarin?
Calciphylaxis - patient should consult doctor if they develop a painful skin rash. (Calcification of the small blood vessels located within the fatty tissue and deeper layers of the skin)
Particularly in those with end stage renal failure
Are DOACs licensed in cancer patients?
No
Are DOACs licensed in antiphospholipid syndrome?
No
When would a warfarin patient need to seek medical help with a nose bleed?
> 10 mins or heavy bleeding
When would a warfarin patient need to seek medical help with a cut?
Bleeding > 30 mins or heavy bleeding
If a warfarin patient is experiencing heavier periods than usual, what should they do?
Seek medical help
If a warfarin patient has hit their head/ had an accident but seem fine, what should they do?
Seek medical help, always get it checked out to rule out bleed on brain
Do DOACs interact with alcohol?
No
Which DOAC has the least risk of GI bleed?
Apixaban
Do DOACs or warfarin carry higher GI bleed risk?
DOACs (apart from apixaban which has same risk as warfarin)
What juice interacts with warfarin and should therefore be avoided?
Cranberry
What is the max time a warfarin patient should go without having their INR checked?
12 weeks
What sort of AF are DOACs licensed in?
Non valvular
What is valvular AF?
AF + artificial heart valve
Mitral stenosis
What would you use for prophylaxis of stroke in valvular patients?
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 under 80 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?
Clinic of below 140/90 mmHg
Average home of 135/85 mmHg
What is the target blood pressure in those with established atherosclerotic cardiovascular disease/diabetes (with related disease e.g. kidney, eye)?
130/80 mmHg
What is step 1 in a patient under 55 years with hypertension?
If these are not tolerated or contraindicated, what would be an alternative?
ACEi
if not tolerated ARB
Beta blocker
What is step 2 in a patient under 55 years with hypertension?
ACEi/ARB and CCB
What is step 3 in a patient under 55 years with hypertension?
ACEi/ARB combined with CCB and thiazide like diuretic
What is step 4 (resistant) in a patient under 55 years with hypertension?
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 related diuretic
What is step 1 in a patient over 55 years/Black or Carribbean with hypertension?
If not tolerated, what can be used?
CCB
Thiazide like diuretic - indapamide
What is step 2 in a patient over 55 years/Black or Carribbean with hypertension?
CCB and ACEi/ARB
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 duretic (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
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
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