Chapter 2: CVS Flashcards
Arrythmias
Irregular heartbeat (due to change in rate or rhythm control)
>Conditions like Atrial fibrillation and atrial flutter can be caused by arrythmias.
>Arrythmias can cause coagulation
>We tend to RX with anticoagulants (MI=>Arryth=>AF=>increase coagulation=>DOAC)
>Rhythm control: amiodarone, dronadarone, felcanide, soltalol, propafenone
>Rate control: Beta blockers (no soltalol), rate-limiting CCB contraindicated in HF (diltiazem, verapamil), then digoxin (for sedentary)
> Pill in the pocket approach (only take when needed): 2 drugs: flicanide, propafenone
Which of the following advice is the most appropriate and specifically related to Amiodarone regarding Mrs. R. who has recently been started on Amiodarone 200mg tablets for the treatment of atrial fibrillation?
A. This medicine can cause yellow vision.
B. This medicine may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol.
C. Do not stop taking this medicine unless your doctor tells you to stop.
D. You may be dazzled by headlights especially at night.
E. Read the additional information given with this medicine.
D. You may be dazzled by headlights especially at night.
Blue-Grey Skin Tone
Amiodarone side effect, happens if patient goes under the sun or UV light exposure/photosensitivity
Ask patient to stop medication immediately and call 999, medical emergency
UPDATES
GTN Doses: 3-5 min for spray to take effect, after 1st and 2nd dose, no improvement, call 999
Stroke Management
3 types: heamorgagic stroke, TIA/minor ischeamic troke w/low risk of bleeding/no risk, ischemic stroke
>start statin as soon as able to swallow 80mg
Drugs: removed MR dipyridamole, added ticagrelor (TIA w/low risk of bleeding)
Blood Pressure:
Statins SE: can cause muscle breakdown (rhabdomylosis), can also cause myasthenia graves (infrequent)
Bromocriptine (Parkinson’s disease, Dopamine agonist can cause sudden onset of sleep, impulse control Disorders (gambling, sexual activity) : can cause CVS events
AMIODARONE
> Amiodarone has a very long half-life. Can stay in body for months even after last dose.
must continue to avoid direct sunlight, rx interactions, grapefruit juice at least 2 month after last dose
Amiodarone can be taken with or without food.
Amiodarone is photosensitive and can lead to a blue-gray tone.
Avoid grapefruit juice (inhibitor), more amiodarone
Corneal microdeposits (dazzling by headlights)
no red flags: book GP
red flags: visual impairment, discharge, blood, pain, send to A/E
Thyroid function (causes both)
Hepatotoxicity (jaundice, nausea, vomitting, fatigue)
Pulmonary toxicity, interstitial lung disease (statins also cause this)
Amiodarone Monitoring
Mneumonic: CHEST – L
>Thyroid function test (before treatment and then every 6 months)
>Liver function tests (before treatment and then every 6 months)
>Serum K+ (measured before treatment), can lead to hypokalaemia
>Chest x-ray (measured before treatment)
>IV use requires ECG (resuscitation facilities must be available)
DRUG INTERACTIONS – flecanaide, digoxin, warfarin, grapefruit juice
Soltalol
> (beta-blocker used to reduce heart rate in arrhythmias)
Sotalol is a water-soluble beta blocker.
Safety information
Sotalol can prolong the QT interval which can occasionally lead to life threatening ventricular arrhythmias
Soltalol Monitoring
Monitor Electrolytes
>ECG and measurement of corrected QT interval
>Serum electrolytes (K+ , Mg2+, Ca2+) (electrolyte disturbance i.e. hypokalaemia, hypomagnesaemia, should be corrected before starting sotalol.
DIGOXIN
> Digoxin is a cardiac glycoside that increases the force of myocardial contraction and reduces conductivity within the av node.
Different bioavailabilities depending on form: IV - 100%, Tablets 50-90%, Elixir 75%)
ANTI-DOTE: Digifab
Electrolyte imbalance leads to toxicity
Hypercalcaemia
Hypokalaemia (caused by diuretics, beta agonist, corticosteroids, theophylline, long term laxatives, insulin)
Hypomagnesaemia (caused by PPI)
hypoxia (low oxygen)
not IM route, only IV to prevent toxicity
Digoxin Toxicity
Advise patients to report to doctor immediately if presence of:
* Cardiac symptoms (arrhythmias and heart block)
* Neurological symptoms (weakness, lethargy, dizziness, headache, mental confusion and psychosis)
* Gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhoea, abdominal pain; avoided by dividing larger doses)
* Visual symptoms (blurred and/yellow vision)
GIVE DIGIFAB
Digoxin Monitoring
> Serum electrolytes (K+ , Mg2+, Ca2+) (toxicity increased by electrolyte disturbance i.e., hypokalaemia, hypomagnesaemia, and hypercalcaemia)
Renal function (renal excretion of drug; reduce dose in renal impairment to reduce accumulation of metabolite)
Plasma-digoxin (mainly in renal impairment, blood should be taken at least 6 hours after dose) (NSAIDs, ACE/ARB, methotrexate increases digoxin toxicity)
Heart rate (should be maintained above 60 beats/min)
Renal impairment: Reduce dose, monitor plasma concentration in renal impairment
Digoxin Interactions (Drugs, Mode of Interaction, Effects, Solution)
> Amiodarone , quinine, dronaderone (increase conc. of digoxin in system leading to toxicity, reduce digoxin to 50%)
Diuretics (hypocalamia leads to toxicity, change drug)
Nsaids
ACE inhibitor
St Johns wort (enzyme inducer, reduces digoxin then patient at increased risk, stop st. johns)
HAS-BLED TOOL
What is the use of HAS-BLED TOOL? measure the risk of bleeding for patients on anticoagulants who have history of A.fib
>HAS-BLED SCORE uses the following in calculation
>Age Eg over 65
>Hypertension
>Liver/kidney Disease
>Alcohol use, Stroke
ORBIT TOOL NEW – gender, age over 74, bleeding history, Egfr less 60ml/min and treatment with antiplatelets
Total score is 7 . Below 2 is low , 3 to 4 medium , 5 to 7 high
Which statement is NOT TRUE about warfarin?
A. Warfarin can cause Calciphylaxis
B. Warfarin can cause purple toes.
C. Warfarin is easier to reverse compared to NOAC drugs.
D. Warfarin can interact with carbamazepine and lead to an increase in INR.
E. An INR of 2.5 is target for patients taking warfarin with conditions like Mitrial Stenosis
D. Warfarin can interact with carbamazepine and lead to an increase in INR. (leads to a decrease in INR)
When INR goes up, bleeding goes up. Low INR, reduced bleeding.
WARFARIN
> Antagonises the effect of vitamin K.
Anticoagulant effect takes 48 to 72 hours to fully develop
Target within 0.5 nits of target value is satisfactory
Anticoagulant treatment yellow booklets and alert cards should be issued to all patients
Take at the same time of day, once a day with a full glass of water, if a dose is missed DO NOT double the dose the next day
Careful with green leafy vegetable (spinach, kale, broccoli, Brussel sprouts, collard greens, pumpkin leaves). Patient should notify their anticoagulation clinic of any changes to medication, lifestyle or diet
Brown tablets = 1mg Blue tablets = 3mg Pink tablets = 5mg white = 0.5mg
Ensure warfarin dose is expressed in milligrams and not the number of tablets
purple toes – bilateral, painful lesions on toes/feet that blanch with pressure.
INR TARGETS
INR 2.5 for:
>treatment of deep-vein thrombosis or pulmonary embolism (including those associated with antiphospholipid syndrome or for recurrence in patients no longer receiving warfarin sodium)
>atrial fibrillation
>cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR)
>dilated cardiomyopathy
>mitral stenosis or regurgitation in patients with either atrial fibrillation, a history of systemic embolism, a left atrial thrombus, or an enlarged left atrium
>bioprosthetic heart valves in the mitral position (treat for 3 months), or in patients with a history of systemic embolism (treat for at least 3 months), or with a left atrial thrombus at surgery (treat until clot resolves), or with other risk factors (e.g. atrial fibrillation or a low ventricular ejection fraction) [note: NICE guideline NG208 (Heart valve disease presenting in adults: investigation and management, November 2021) does not recommend anticoagulation after surgical biological heart valve replacement unless there is another indication for anticoagulation.]
>acute arterial embolism requiring embolectomy (consider long-term treatment)
>myocardial infarction
INR 3.5 for:
>recurrent deep-vein thrombosis or pulmonary embolism in patients currently receiving anticoagulation and with an INR above 2;
>Mechanical prosthetic heart valves:
the recommended target INR depends on the type and location of the valve, and patient-related risk factors
consider increasing the INR target or adding an antiplatelet drug, if an embolic event occurs whilst anticoagulated at the target INR.
***learn 3.5 conditions
Manage INR
High INR and Bleeding
>give vitamin K by injection/IV
> Major bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; give dried prothrombin complex (factors II, VII, IX, and X); if dried prothrombin complex unavailable, fresh frozen plasma can be given but is less effective; recombinant factor VIIa is not recommended for emergency anticoagulation reversal
INR >8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin sodium when INR <5.0
INR >8.0, no bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0
INR 5.0–8.0, minor bleeding—stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; restart warfarin sodium when INR <5.0
INR 5.0–8.0, no bleeding—withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
Unexpected bleeding at therapeutic levels—always investigate possibility of underlying cause e.g. unsuspected renal or gastro-intestinal tract pathology
ADVICE FOR PATIENTS ON WARFARIN
> They should always take their anticoagulant treatment booklet (‘Yellow book’) when they go to the warfarin clinic to have their INR checked.
They should take their warfarin at the same time each day.
They should not miss doses or take additional doses, without advice from a healthcare professional.
They must inform anticoagulant clinic staff if they think they have taken too much warfarin or have missed any doses.
If a dose is accidentally missed, they should continue with the regimen as prescribed, and never take a double dose (unless specifically advised).
Seek medical advice before undertaking any major changes in diet, especially if their diet is rich in vitamin K (such as broccoli, kale, or spinach) — this can potentially affect control of anticoagulation.
Limit alcohol intake to a maximum of one or two drinks a day, and never binge drink. (excessive alcohol leads to increase risk of bleeding)
Inform the anticoagulant clinic staff and other healthcare professional (their GP, dentist, pharmacist, and/or medical or nursing staff) of changes to their lifestyle, for example if they start, stop, or change the dose of other medicines.
Spontaneous bleeding occurs whilst on warfarin and the bleeding does not stop, or recurs. This includes bruising, bleeding gums, nosebleeds, prolonged bleeding from cuts, blood in the urine or stools, coughing up blood, a subconjunctival haemorrhage, and vaginal bleeding in a postmenopausal woman.
They get sudden severe back pain (which may indicate spontaneous retroperitoneal bleeding).
They experience difficulty breathing, increased breathing rate, or chest pain (which could be symptoms of pulmonary embolism).
Warfarin Interactions
> In pregnancy: No, causes congenital malfunctions, LMWH as alternative (must be given by brand: enoxaparin=clexin)***doesnt cross placenta
Travelling patients: wear compression stockings, increase mobility
Surgery: stop taking warfarin 5 days before elective (planned) surgery
INTERACTIONS
>Azoles (for thrush)– fluconazole, miconazole, clotrimazole (increase risk of INR, increases bleeding)
>Cranberry juice, pomegranate (both enzyme inhibitors, increases warfarin)
>Diet – green leafy veg
>SSRIs (GI irritation and GI bleeding)
>Metronidazole (can take 5-7 days max if INR is stable)
>NSAIDs (increase risk of bleeding)
>St John’s wort (reduces warfarin, increases clotting)
Scenario: Warfarin |Management | Anticoagulation - oral | CKS | NICE
DIRECT ORAL ANTICOAGULANTS (DOACS)
Mneumonic: READ, see an O (once a day: rivaroxaban, edoxaban)
> Direct-acting oral anticoagulants (DOACs) include apixaban, dabigatran etexilate, edoxaban, and rivaroxaban. Dabigatran etexilate is a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation. Apixaban, edoxaban, and rivaroxaban are reversible inhibitors of activated factor X (factor Xa) which prevents thrombin generation and thrombus development
> Types of DOAC:
rivaroxaban (brand names include Xarelto)
dabigatran (brand names include Pradaxa)
apixaban (brand names include Eliquis)
Edoxaban (brand names include Lixiana)
DOAC eGFR
REA: 15, D: 30 (dabigatran is different)
MHRA/CHM advice: Direct-acting oral anticoagulants (DOACs): reminder of dose adjustments in patients with renal impairment
(May 2023)
>Dabigatran – avoid if eGFR less than 30 ml/min/1.73 m² (risk of bleeding)
>Apixaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
>Rivaroxaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
>Edoxaban – avoid if eGFR less than 15 ml/min/1.73 m² (risk of bleeding)
CRITERIA – APIXABAN / EDOXABAN
> Antidote is Andexanet Alfa. Risk of bleeding, nose bleeds (stop taking medicine, seek medical attention) e.t.c
WHEN TO GIVE 2.5mg BD or 5mg BD dose ?? 2 of first 3 criteria to be on higher strength
AGE – LESS than 80 years
BODY WEIGHT – over 60kg
SERUM CREATININE–less than 133micromol/litre
creatinine clearance - 15–29 mL/minute.
Interactions – Nsaids, SSRIs, clarithromycin, st. johns’ wort, lopinavir
EDOXABAN (no antidote)
61kg or more – for 60mg Edoxaban
Interactions
ciclosporin , erythromycin , ketoconazole, dronaderone, amiodarone
CRITERIA – DABIGATRAN / RIVAROXABAN
> DABIGATRAN IS DIFFERENT
Dabigatran Antidote is idaricuzimab >Risk of bleeding , nose bleeds e.t.c
do not include in a dossette box (hygroscopic, attracts water)
avoid if eGFR less than 30 ml/min/1.73 m² (risk of bleeding)
Mode of action: direct thrombin inhibitor
Most expensive on annual basis
Rivaroxaban (factor Xa inhibitor)
which strengths to take with food? 15, 20 mg absorbed better
**DOAC summary
DIFFERENCES BETWEEN WARFARIN AND NOACS
> Cost: doac more expensive
Convenience /MONITORING: doac more convenient, no monitoring of INR
Duration of action: 12 (BD)-24(OD), Warfarin: 72 hrs
Diet: green leafy vegetables dont interact
Drug interactions: SSRI (increases bleeding), NSAIDs (increase bleeding), Aspirin/Antiplatelets (increase bleeding), amiodarone (increase conc. of doacs)
A 55-year-old man has just suffered from transient ischaemic stroke with low bleeding risk. His daughter calls 999 and paramedics arrived in an ambulance shortly after. The man has not been given any medication and there are no signs or symptoms of haemorrhage. NKDA
Which medication would you expect the patient to be administered when he initially presents in hospital?
A. Ticagrelor 90mg
B. Aspirin 300mg
C. Alteplase 900mcg
D. Aspirin 300mg plus clopidogrel 300mg
E. Clopidogrel 75mg
D. Aspirin 300mg plus clopidogrel 300mg (day 1), then reduce Aspirin 75mg and clopidogrel 75mg for 21 days
ASPIRIN
> Antiplatelet drug
Caution – anaemia, asthma, ulcer, uncontrolled hypertension
Contraindicated – bleeding disorders, severe cardiac failure, haemophaelia
Causes reyes syndrome in patients under 16yrs (except for Kawasaki disease)
Can pregnant women take aspirin? Yes, pre-eclampsia in 2nd and 3rd trimester (75/150mg OD dependent on BMI), OTC only if prescribed (check SCR)
Toxicity symptoms include – tinnitus, deafness, sweating , vasodilation , coma.
Antidote: sodium bicarbonate
CVD PREVENTION – PRIMARY VS SECONDARY
Drug interactions – warfarin, anti-platelet drugs, asthmatic patients
Aspirin | Drugs | BNF | NICE see link for doses of Aspirin in stroke
STROKE
WHAT ARE THE SYMPTOMS OF STROKE??? ACT FAST
face drooping, slurred speech, paralysis, numbness, confusion
>There are three types of strokes: TIA, Ischceamic stroke, haemorrhagic
>Initial management and long-term treatment
>Haemorrhagic stroke (deadly)
>Control blood pressure if high. Might need scan and medical procedures
>No statins, No aspirin or anticoagulant unless risk of DVT or PE
>Transient Ischaemic attack
>Immediately give Aspirin. Plus PPI if necessary
>Ischaemic stroke (70%)
>Give Alteplase within 4.5 hours of symptoms of acute ischaemic stroke. Not in intracranial haemorrhage. Give Aspirin within 24 hours if no haemorrhage . No warfarin in acute phase.
Stroke
> Transient ischaemic attack and minor ischaemic stroke
Patients suspected of having a transient ischaemic attack should immediately receive aspirin, unless contraindicated. Patients with aspirin hypersensitivity, or those intolerant of aspirin despite the addition of a proton pump inhibitor, should receive a suitable alternative antiplatelet.
Patients presenting within 24 hours of transient ischaemic attack or minor stroke who have a low risk of bleeding, should be considered for dual antiplatelet therapy with clopidogrel plus aspirin followed by clopidogrel monotherapy. Ticagrelor [unlicensed use] plus aspirin dual antiplatelet therapy followed by either ticagrelor [unlicensed use] or clopidogrel [unlicensed use] monotherapy is also an option. For patients who are not appropriate for dual antiplatelet therapy, clopidogrel monotherapy [unlicensed use] should be given.
A proton pump inhibitor should be considered for patients with a history of dyspepsia associated with aspirin, or for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.
ISCHAEMIC STROKE
> Initial management
**rule out any intracranial bleeding
Alteplase or tenecteplase [unlicensed use] are recommended in the treatment of acute ischaemic stroke if it can be administered within 4.5 hours of symptom onset and if intracranial haemorrhage has been excluded by appropriate imaging techniques. It should be given by medical staff experienced in the administration of thrombolytics and the treatment of acute stroke, within a specialist stroke centre. Some patients may also be eligible for surgical management. Provided that intracranial haemorrhage has been excluded, patients who received thrombolysis should be started on an antiplatelet after 24 hours, unless contraindicated.
Patients with disabling acute ischaemic stroke should be started on aspirin (unless contraindicated) as soon as possible within 24 hours and continued for 2 weeks after stroke onset, when long-term antithrombotic treatment should be started. Patients being transferred to care at home before 2 weeks should be started on long-term antithrombotic treatment earlier.
Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm (only in DVT/Pulmonary Embolism). However, anticoagulants may be indicated in patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism. Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis. Warfarin sodium should not be given in the acute phase of an ischaemic stroke. Patients already receiving anticoagulation for a prosthetic heart valve who experience a disabling ischaemic stroke and are at significant risk of haemorrhagic transformation, should have their anticoagulant treatment stopped for 7 days and substituted with aspirin.
Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore only be instituted in the event of a hypertensive emergency, or in those patients considered for thrombolysis.
HEMORRHAGIC STROKE
Avoid aspirin, antiplatelets, statins
>Surgical intervention may be required following intracerebral haemorrhage to remove the haematoma and relieve intracranial pressure.
>Rapid blood pressure lowering treatment should not be given to patients who have an underlying structural cause, have a score on the Glasgow Coma Scale of below 6, are going to have early neurosurgery to evacuate the haematoma, or who have a very large haematoma with a poor expected prognosis.
>Consider rapid blood pressure lowering for patients who present within 6 hours of symptom onset with a systolic blood pressure between 150 and 220 mmHg and who do not fit any exclusion criteria. Aim for a systolic blood pressure target of 130 to 139 mmHg within 1 hour and sustained for at least 7 days, ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment. Rapid blood pressure lowering should also be considered on a case-by-case basis for patients who present beyond 6 hours of symptom onset or who have a systolic blood pressure greater than 220 mmHg and who do not fit any exclusion criteria. Seek specialist paediatric advice if considering blood pressure lowering in patients aged 16 or 17 years who do not fit any exclusion criteria.
>Patients taking anticoagulants should have this treatment stopped and reversed. Anticoagulant therapy has, however, been used in patients with intracerebral haemorrhage who are symptomatic of deep vein thrombosis or pulmonary embolism; placement of a caval filter is an alternative in this situation.
>Patients with immobility after acute stroke should not be routinely given low molecular weight heparin or graduated compression stockings for the prevention of deep vein thrombosis.
LONG-TERM TREATMENT
Blood Pressure and Cholesterol
> Specialist advice should be sought for patients with atrial fibrillation and those at a high risk of ischaemic stroke or cardiac ischaemic events, as aspirin and anticoagulant therapy are not normally recommended following an intracerebral haemorrhage.
Blood pressure should be measured and treatment initiated where appropriate, taking care to avoid hypoperfusion. For guidance on blood pressure lowering therapy and treatment targets, see Hypertension.
After a stroke, don’t start beta blocker treatment for hypertension.
> Statins should be avoided following intracerebral haemorrhage, however they can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage. Patients should be assessed for lipid-lowering therapy on the basis of their overall cardiovascular risk and the underlying cause of the haemorrhage. For further information, see Cardiovascular disease risk assessment and prevention.
Put on Atorvastatin 80mg as soon as they can swallow
LONG-TERM PREVENTION OF STROKE
> Bloods - clopidogrel, ticagrelor , aspirin
BP control 130/80 - Anti-hypertensives but not beta-blockers
Cholesterol control – High intensity Statins
Give lifestyle advice such as stop smoking , physical activity , alcohol reduction, diet, weight loss
CHADS-VASC SCORE - STROKE
likelihood of patient developing a stroke
CONGESTIVE HEART FAILURE 1
HYPERTENSION 1
AGE 75 OR MORE 2
DIABETES 1
STROKE 2
-VASCULAR DISEASE 1
AGE 65 TO 74 1
SC SEX CATEGORY 1
Statin for primary prevention: Atorvastatin 20mg and BP
Higher the score, higher the risk.
Following admission to hospital a 68-year-old patient has their QRISK-3 score calculated. This score is taken into account before initiating suitable treatment.
What purpose does the QRISK-3 tool serve?
A. Calculates the likelihood of a patient having a major cardiovascular event over the following ten years.
B. Determines a patient’s probability of having a deep vein thrombosis.
C. Estimates the risk of bleeding in patients with atrial fibrillation who are being offered anticoagulation.
D. Estimates the risk of bleeding in patients with heart failure who are taking immunosuppressants.
E. Estimates the risk of stroke for a patient with non-valvular atrial fibrillation.
A. Calculates the likelihood of a patient having a major cardiovascular event over the following ten years.
Start, Stop criteria for elderly.
MYOCARDIAL INFARCTION (HEART ATTACK)
> Myocardial infarction or M is a serious medical emergency in which the supply of blood to the heart is suddenly blocked or reduced usually by atherosclerosis or blood clot.
STEMI
A STEMI or ST-elevation myocardial infarction is caused by a sudden complete (100 percent) blockage of a heart artery (coronary artery).
NSTEMI
A non-STEMI is usually caused by a severely narrowed artery but the artery is usually not completely blocked. The diagnosis is initially made by an electrocardiogram (ECG or EKG).
ACUTE CORONARY SYNDROME
Unstable Angina: rupture or artery causes chest pain, GTN
STEMI: complete blockage
NSTEMI: plaque narrows
ECG
QT interval
ST segment: if elevated (STEMI), if stays as is – or dips (NSTEMI)
TREATMENT
DRUG TREATMENT NSTEMI – MONA HB
Morphine, oxygen, Nitrates, Aspirin, Betablockers, heparin (low molecular weight)
DRUG TREATMENT STEMI – OBAMA SN
Morphine, Oxygen , Nitrates, Betablockers, Aspirin, Ace-inhibitors, statins.
ANGINA
> Stable angina
occurs predictably. It happens when you exert yourself physically or feel considerable stress. Stable angina doesn’t typically change in frequency, and it doesn’t worsen over time.
Unstable angina
is chest pain that occurs at rest or with exertion or stress.
DRUG TREATMENT - acute – nitrates – GTN. Instruct the person that if they experience chest pain they should:
Stop what they are doing and rest.
Use their glyceryl trinitrate spray or tablets as instructed.
Take a second dose after 5 minutes if the pain has not eased.
Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell
Long-term – betablocker, CCB, Long-acting nitrates, ivabradine, nicorandil (can’t break blisters, built in desiccant) or ranolazine.
HYPERTENSION
As a general guide:
>normal blood pressure is considered to be between 90/60mmHg and 130/80mmHg
>high normal: 13/81-139/89
>high blood pressure is considered to be 140/90mmHg or higher
>low blood pressure is considered to be 90/60mmHg or lower
> New NHS blood pressure monitoring service !!!!
Stage 1 hypertension: 140/90 – 160/100 mmHG
Stage 2 hypertension: 160/ 100 – 180/120 mmHg
Severe hypertension: More than 180/ 120 mmhg
Example: Stage 1 or 2=>lifestyle advice and ABPM for 24hrs or HBPM (monitor at home), then refer if still high
Send to A/E if severe hypertension
Hypertension in Pregnancy
HYPERTENSION IN PREGNANCY
>BP in pregnancy <140/90 on no BP meds
>In hypertension, on BP med, a target blood pressure of <135/85 mmHg is recommended.
>List three drugs used in Rx high BP in pregnancy.
1. labetolol (contraindicated in asmathics, contracts airways)
2. M/R nifedipine (afro carribean can take while breastfeeding or amlodipine, other ethnicities take enalapril as first line in breastfeeding)
3. Methyldopa (stop within 2 days after delivery, reduce risk of postpartum depression)
If already on ACE/ARB/Diuretic and planning to get pregnant, must stop and switched to something safer like amlodipine until they become pregnant changed to 1, 2 , 3.
SAME-DAY SPECIALIST REFERRAL
> Same-day specialist referral
Refer patients for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).
Patients should also be referred for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg or higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension), or life-threatening symptoms for example new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
Mr. V is a 65-year-old Type 2 diabetic patient who also suffers from renal disease. What is BP target for a patient like Mr. V as recommended by recent NICE guidelines?
<130/80 mmHg
<140/90 mmHg
<150/90 mmHg
<120/80 mmHg
<135/85 mmHg
<130/80 mmHg
Hypertension Targets
RENAL IMPAIRMENT : less than 140/90, comorbidity: less than 130/80
ELDERLY (over 80): less than 150/90
DIABETIC: type 1 (ACR less than 70mmol: less than 140/90, more than 70 mmol: 130/80), type 2 (less than 140/90)
PREGNANCY: no BP meds (140/90), with BP meds (135/85)
What about sympathomimetics (on cold and fly medicines, can increase BP) and High BP? Dont give psuedoephidrine
HYPERTENSION - DRUG TREATMENT
> UNDER 55 YRS NOT afro-carribeans or diabetic type 2
ACE inhibitor, ccb, thiazide-like, **only stop if not tolerated, add with not managed
*** after ccb, and patient develop ankle oedema=>give diuretic (indapamide, clotalidone)
ACE inhibitor or ARB, ccb OR thiazide-like,
ACE inhibitor, ccb, thiazide-like,
ACE or ARB plus CCB, thiazide-like, spirorolactone –check K +, alpha blocker
>OVER 55 YRS / afro-carribeans
CCB
CCB plus ACE inhibitor or ARB OR thiazide-like,
CCB plus ACE or ARB, thiazide-like,
CCB plus ACE or ARB, thiazide-like, spirorolactone –check K , alpha blocker
Abdi is a 54 year-old patient of Afro-Caribbean origin. He suffers from hypertension and diabetes and currently takes Amlodipine 10mg daily. Unfortunately , his blood pressure is not well controlled and his GP is thinking of adding another drug to his regime. Which drug is appropriate 2nd line treatment for Mr. Abdi given that his current BP is 155/95 mmHg and his Blood glucose level 90 minutes after a meal is 7mmol/L?
A. Atenolol
B. candesartan
C. Indapamide
D. Ramipril
E. Bendroflumethiazide
***swollen lips, angioedema (not only restricted to afro carribean decent)
Give ARB, not ACE
B. candesartan
BP DRUGS
ACE INHIBITORS
>First dose hypotension (make them feel sleepy/drowsy, first dose taken as close to bedtime as possible and take next dose in morning), (ARB/Alpha blockers/nitrates also cause first dose hypotension)
>desensitising vaccines (for those subject to serious allergic reactions, avoid giving vaccine to patients on ACE,BB, and asthmatics), jaundice (high bilirubin, liver biomarkers), diabetes
>Side-effects
>drug interactions
>Renal function (protects kidneys in diabetic patients but otherwise are nephrotoxic to other patients reducing eGFR)
>Electrolytes imbalance: causes increase in potassium
DIURETICS
> What is NICE guidelines first choice in hypertension treatment? indapamine/chlotalidone
Onset and duration of action of loop diuretics : onset 30 min, duration 6 hrs
Onset and duration of action of thiazide-related diuretics: onset 1-2hrs, duration 12-24hrs (bendro, hydro)
Loop and thiazide-related diuretics can exacerbate diabetes and gout. Can also affect digoxin due to hypokalaemia
Worsen gout and diabetes , cause skin cancer - hydrochlorothiazide (monitored by MHRA, stop taking and refer)
Drink adequate volume of fluid daily
Avoid potassium supplements and preparations when taking potassium sparing diuretics (aldosterone antagonists)
Increase potasssium levels: spironolactone, ACE/ARB, ciclosporin, heparins, trimethoprim, eplerenone)
NITRATES
> A woman takes isosorbide mononitrate tablets BD and complains of tolerance issues. What advise can you give to assist her with nitrate tolerance? reduce interval period from 12 to 8hrs (take within 8 hrs to reduce tolerance issues)
How long can nitrate tablets be kept after opening? nitrEIGHT (8 weeks max before discarded)
First dose hypotension with nitrates tablets. What advice would you give?
Side-effects – dizziness, drowsy, flushing, headache
● Postural hypotension - should sit down when using GTN spray.
● Tolerance
Name four drugs which increase risk of first dose hypotension
C.C.B
CALCIUM CHANNEL BLOCKERS
>Verapamil and diltiazem are non-dihydropyridine calcium channel blockers and exert their effect on cardiac muscle.
>Dihydropyridine CCBs (amlodipine, felodipine, lacidipine, lercanidipine, and nifedipine) cause relaxation of peripheral blood vessels. (amlodipine before pregnancy/while breastfeeding)
>What is the most common side-effect of CCBs ? Ankle swelling
>Diltiazem and verapamil should not be given to patients with heart failure!!!
>What is the most common side-effect of verapamil? constipation
>SIDE-EFFECTS
dizziness, headache, tachycardia, palpitations, abdominal pain, flushing
BETA BLOCKERS
> contraindications-
Cautionary labels: do not stop taking unless doctor has asked you to do so
side-effects - coldness of extremities, weigh gain, nausea, syncope (fainting), causes bradycardia (lower HR)
soluble (less likely to cross BBB and less cause to nightmares, CANS: celiprolol, atenolol, nadolol, soltalol)/ insoluble
Cardioselective (atenolol, bisoprolol) and non-cardioselective (timolol, propranolol=>more likely to interact with beta agonist)
Drug interaction: Beta Blockers and Beta agonists (salbutamol)
taking BB+CCB causes heart block
STATINS
> Statins HMG CoA reductase
Muscle effects can occur with all statins especially as dose increases. (rhabdomyosis)
NEW UPDATE: Myasthenia gravis
Interstitial lung disease
Use with caution in asian origin: rosuvastatin 5mg min-20mg max susceptible to muscle breakdown
Monitoring requirements
>Before treatment - At least one full lipid profile (Total less than 5, Trig less than 2.3, LDL less than 3, HDL more than 1)
>liver function test
>diabetes
>Creatinine kinase: if 5 times upper limit, red flag (indicates breakdown of muscle)
>Thyroid test: correct before starting
STATINS
> Pregnancy - Statins should be avoided in pregnancy and whilst trying to conceive.
Rosuvastatin should be used with caution in Asian patient
Statins Drug interactions
Macrolides – erythromycin , clarithromycin (stop 7 days and resume treatment on day 8)
Fusidic acid (stop statins, start 7 days after last dose before initiating statins again)
Colchicine (next 24 hrs)
Amlodipine, 20mg simvastatin max
Fibrates (monitor)
Amiodarone (20mg statin max with amiodarone)
Ms. J. a 55-year-old woman is prescribed indapamide 2.5mg tabs, one
tablet daily for treatment of hypertension. You decide to give her
counselling advice. Which of these is suitable advice to give Ms. J. as
regards cautionary label for this drug?
a) Take 30 to 60 minutes before food.
b) Take with or just after food, or a meal
c) Protect your skin from sunlight, even on a bright or cloudy day. Do not
use sunbeds.
d) Warning: Do not stop taking this medicine unless your doctor tells you
to stop
e) Swallow this medicine whole. Do not chew or crush
ohn is on holiday in Spain with his wife. One sunny afternoon, they decide to go to the beach. After about an hour, John’s wife began to notice yellow stains all over
John’s white T-shirt which were not there before they left the hotel. John’s wife decides to seek attention from a local pharmacy since John takes a ‘’cocktail of medicines’’. Which drug could most likely cause the symptom John is currently experiencing?
A. Propranolol
B. Digoxin
C. Amiodarone
D. Verapamil
E. Warfarin
Amiodarone is a narrow therapeutic index drug.
Which of the following statement is not true about
Amiodarone?
A. Amiodarone can affect thyroid function and cause both hypothyroidism and hyperthyroidism.
B. Amiodarone is a photosensitive drug. Patients must avoid direct sunlight.
C. Amiodarone has a long half-life. It can stay in the human body for months after
the last dose is taken.
D. There is a drug interaction if Amiodarone and Digoxin are taken concomitantly. In this event, it is routine to half the dose of Amiodarone.
E. Amiodarone can cause corneal microdeposits which could lead to blindness.
Which of the following can be used for the ‘’pill in the pocket’’ approach in the management of Arrythmias?
A. Digoxin
B. Sotalol
C. Propafenone
D. Flixotide
E. None of the above
Mr. James is about to be prescribed Amiodarone 200mg tabs for the management of atrial fibrillation. Mr. James has been told by the prescriber that he will require frequent monitoring whilst he is taking this medicine.
Which of the following tests is the least likely to be conducted as regards Mr. James taking AMIODARONE?
A. Chest X-ray
B. Liver function test
C. Renal function test
D. Serum electrolytes e.g potassium
E. Thyroid function test
Mary is 70-year-old patient on warfarin. One day, Mary began to notice minor nose bleeds. She contacts her warfarin clinic who check her INR and decide to adjust her treatment with warfarin. What is the best course of management for a patient whose INR is above 8 like Mary?
A. Withhold 1 or 2 doses of warfarin and reduce the next dose.
B. Stop warfarin and give phytomenadione orally since there is minor
bleeding. Restart when INR is <5.0.
C. Stop warfarin for 7 days
D. Stop warfarin and give dried prothrombin complex
E. Stop warfarin, give phytomenadione via slow IV, restart warfarin when INR<5.0
Which of the following is not usually used in the management of Arrythmias via rhythm control method ?
A. Dronedarone
B. Sotalol
C. Propafenone
D. Amiodarone
E. Diltiazem
Mr. Brown has been prescribed warfarin 5mg tablets for the management of atrial fibrillation. You dispense his prescription and decide to offer counselling points regarding his new medication. Mr. Brown comes to collect his first prescription and mentions that he has also been prescribed digoxin.
Which of the following is the least appropriate advice to give Mr. Brown?
A. Pomegranate juice should be avoided whilst taking warfarin
B. In most cases, warfarin does not need to be stopped before routine dental surgery.
C. There is no drug interaction between warfarin and digoxin to be concerned about.
D. The warfarin metabolism can be affected by thyroid status.
E. Weight loss could reduce the effects of warfarin and require a dose increase.
James is a 53-year-old male patient of Caucasian origin. He was recently prescribed ramipril 2.5mg capsules for the management of hypertension. You decide to offer him counselling advice regarding ‘’red flags’’ associated with taking his new medicine. Which of the following effects associated with ramipril is most likely to require stopping treatment and urgently referring the patient to the GP?
A. Rhabdomyolysis
B. Blood disorder symptoms
C. Dark urine
D. Lipodystrophy
E. Hypokalemia
You are an IP pharmacist, Mr. E. a-50-year-old male patient presents in your clinic for cardiovascular disease risk assessment. Mr. E’s total cholesterol level is found to be 4.6 mmol/Litre , he suffers from hypothyroidism, he lost his father to a stroke years ago and his average blood pressure reading is 150/75 mmHg. His Qrisk score is found to be 8.5% . In light of the information provided about Mr. E , which of the following is the next best line of action.
A. Offer him Atorvastatin 20mg only
B. Offer him lifestyle advice only
C. Offer him Atorvastatin 20mg + ramipril 5mg
D. Offer him Atorvastatin 20mg + ramipril 5mg + levothyroxine 25mg
E. Offer him Atorvastatin 20mg + Aspirin 75mg + levothyroxine 25mg
You work as a community pharmacist. Viagra connect is now available for sale over the counter from community pharmacies for the management of erectile dysfunction in men over the age of 18 years. There are a number of criteria that must be met before the sale of Viagra connect can take place. Which of the patients below would you sell Viagra connect to ?
A. A patient currently taking erythromycin for cellulitis.
B. A patient who had an ischaemic stroke 3 months ago.
C. A transgender man who has not had any surgical or hormonal changes.
D. A patient who suffers from hypertension who takes amlodipine 5mg.
E. A patient being treated for benign prostatic hyperplasia with Alfuzosin 10mg.
You are a GP pharmacist, miss. N. a-54-year-old female patient of south Asian origin presents in your clinic for cardiovascular disease risk assessment. Miss. Debs tells you that she is type 1 diabetic, and she has a family history of hypothyroidism and type 1 diabetes. You consider her risks for cardiovascular disease and decide to offer her life-style advice. Which of the following listed below can be classified as a modifiable risk factor for cardiovascular disease.
A. Family history
B. Type 1 diabetes
C. High blood pressure
D. South Asian ethnicity
E. Female gender
MATCH THE FOLLOWING MONITORING REQUIREMNETS TO THE APPROPRIATE DRUGS. Connect all three to various drugs. You may use one drug more than once.
CREATINEKINASE…………. ?
CHEST XRAY ……………….. ?
CALCIUM LEVELS ELECTROLYTE CHECK …………. ?
A. Ramipril
B. Atorvastatin
C. Amiodarone
D. Sotalol
E. Digoxin
Billy a 45-year-old male patient suffers from type 1 diabetes. He comes to your
pharmacy for a blood pressure check. Which of these is considered a target blood
pressure for a patient like Billy with type-1-diabetes whose ACR (albumin
creatinine ratio) is 65mg/mmol according to NICE guidelines?
Use resource provided.
A. <120/80mmHg
B. <140/90mmHg
C. <135/85mmHg
D. <130/80mmHg
E. <140/80mmHg
Hypertension | Treatment summaries | BNF | NICE
Mr. H. a 75-year-old male patient suffered an ischaemic stroke and has been
prescribed rivaroxaban for the prophylaxis of stroke and systemic embolism
given that he also developed non-valvular atrial fibrillation. Use the resource
provided to choose the most appropriate dose for Mr. H considering the
information provided ?
A. 10 mg once daily for 2 weeks
B. 15mgtwicedailywithfood
C. 2.5 mg twice daily usual duration 12 months. D. 20 mg once daily, to be taken with food
E. 2.5 mg once daily, to be taken with food
Rivaroxaban | Drugs | BNF | NICE
You are working in a maternity ward where you are presented with Ms. Debs a 35-year-old female of Afro-Caribbean origin. She developed gestational hypertension and was prescribed labetalol 200mg tablets during pregnancy. Ms. Debs has just delivered her baby in the ward and would like to speak to you about breast feeding. Which of the following options is the most appropriate line of action to take as a result of Ms. Debs’ decision to breastfeed ?
A. . Ms. Debs cannot take any anti-hypertensive whilst breastfeeding. B. Switch labetalol to Enalapril whilst breastfeeding.
C. Switch labetalol to Nifedipine M/R whilst breastfeeding.
D. Continue taking labetalol whilst breastfeeding .
E. Switch labetalol to losartan whilst breastfeeding.
Paula a 59-year-old woman started to take ramipril 5mg tablets prescribed by her GP one month ago for hypertension, alongside Amlodipine 10mg once daily and indapamide 2.5mg tablets which she has been taking for the past 2 years. When collecting her repeat prescription, she complains of a dry-irritating cough for the last 2 weeks. She wonders if her new tablet is to blame.
Which of the following is the most appropriate advice to give to this patient?
A. She is experiencing a side-effect of ramipril, and whilst safe to continue taking it,
she may wish to see her GP for an alternative.
B. Stop taking Ramipril and see your GP urgently.
C. She should see her GP as the dose of ramipril may need to be reduced.
D. stop taking Amlodipine straight away and see a doctor urgently.
E. Stop taking Indapamide and see your GP urgently.
You work as a hospital pharmacist when you are presented with Mr. Kay a 60- year-old patient with hypertension. You offer to check Mr. Kay’s blood pressure using an ambulatory blood pressure monitor and realised that his blood pressure has ‘’dropped’’ significantly from 130/ 85 previously to a systolic value of 100mmHg and diastolic of 58mmHg. In light of this result which of the following medication would you withhold temporarily ?
A. Losartan 50mg tablets
B. Tamsulosin 400mg m/r capsules C. Atorvastatin 40mg tablets
D. Bisoprolol 5mg tablets
E. Digoxin 125mcg tablets
Which of the following drugs would require a prescriber to reduce the dose of digoxin to 50% when taking concomitantly?
A. St. John’s wort
B. Indomethacin
C. Ciclosporin
D. Quinine
E. Furosemide
Mr. F a 60-year-old man who weighs 70kg takes edoxaban 60mg once daily for the treatment of DVT. His doctor has recently prescribed ciclosporin capsules for him to take. In light of this, what adjustment if any, would you expect to see being put in place. Use the resource provided.
A. reduce dose to 30mg
B. increase dose to 90mg
C. stop and switch to apixaban
D. reduce dose to 15mg
E. continue taking 60mg dose
Edoxaban | Drugs | BNF | NICE
Stella takes atorvastatin 20mg regularly. She presents with a prescription for clarithromycin 500mg tablets from her GP to treat a chest infection. What is the most suitable advice you would give Stella?
A . Stop atorvastatin whilst of clarithromycin and restart 2 days after the last dose of clarithromycin.
B. Take both medicines together as there is no interaction.
C. Stop atorvastatin whilst of clarithromycin and next after the last dose of clarithromycin
D. Hand the prescription back the stella and ask her to request an alternative antibiotic from her doctor.
E. Stop atorvastatin whilst of clarithromycin and on same day as the last dose of clarithromycin.
A female transgender patient is currently taking spironolactone 100mg tablets once daily. Which of the following are you most concerned about. Choose from the 5 options below the side-effect that will develop quicker?
A. Rhabdomyolysis
B. Hyperkalaemia
C. Breast cancer
D. Liver toxicity
E. Hypokalaemia
Mr. Tan takes warfarin regularly, but he is concerned about his current INR value. His target is 2 -3 but despite making lifestyle changes his INR value continue to fall around 1.7 – 1.9. You decide to conduct an MUR to see if any of his four current medicines can be contributing to the problem. Choose an option if you believe any of his current medicines is responsible for the fall in INR?
A. Contact his doctor and ask for sodium valproate to be reviewed.
B. Contact his doctor and ask for Gabapentin to be reviewed.
C. Contact his doctor and ask for Carbamazepine to be reviewed.
D. Contact his doctor and ask for Lorazepam to be reviewed.
E. Contact his doctor and ask for further investigation as none of his medicines can be responsible for the drop in INR value.
You work in a surgery and during a BP review appointment with Mary a 33-year-old female patient, she mentions that although her last pregnancy test showed negative, she is actively trying to conceive with her partner. She currently takes Ramipril 5mg daily and lansoprazole 30mg per day for stomach ulcer. What changes are required as a result of the information provided by Mary today?
A. Consider stopping Ramipril until she gets
pregnant.
B. Consider changing Ramipril to labetalol now and
continue Lansoprazole 30mg daily
C. Consider changing Ramipril now to Amlodipine
and continue Lansoprazole 30mg daily
D. Consider changing Ramipril to Amlodipine and
change Lansoprazole 30mg to omeprazole 20mg
per day
E. Consider changing Ramipril to methyldopa and
change Lansoprazole 30mg to omeprazole 20mg per day.
Digoxin is a narrow therapeutic index drug which has loads of drug interactions. Can you spot a drug below which could interact with digoxin via enzyme inhibition mechanism?
A. Quinine
B. Acarbose
C. Nitrofurantoin
D. Bisoprolol
E. Donepezil
Which of the following explanations best describes the role of NICE – National Institute for Health and
Care Excellence?
A. The UK regulator of all health and social care
organisations.
B. Reference source jointly published by the BMJ
group and pharmaceutical press.
C. An association founded for Doctors , pharmacists
and dentists for research purposes.
D. The UK regulator for suspected adverse effects
caused by drugs and medicinal products.
E. A non-departmental public body which provides
advice on health, medicines , medical technologies and social care matters.
NICE guidelines recommends that Rosuvastatin be used with caution in patients of Asian origin. What is the recommended dose range of Rosuvastatin for patients of Asian origin as stipulated in the most recent NICE guideline?
A.5mg -20mg
B. 2.5mg – 10mg
C. 5mg – 40mg
D. 2.5mg – 80mg
E. 2.5mg – 20mg
Which electrolyte imbalance could most likely lead to digoxin digitalis?
A. Hypermagnesia
B. Hyponatramia
C. Hypernatramia
D. Hypercalcaemia
E. Hyperkalaemia
Amy is a 31 year-old Caucasian patient who is currently 14 weeks pregnant. Amy suffers from mild hypertension, severe asthma, occasional spontaneous headaches and mild/moderate morning sickness. Which drug listed below would you not recommend for Amy during her pregnancy in light of her medical history?
A. Labetalol
B. Methyldopa
C. Nifedipine M/R
D. Paracetamol
E. promethazine
Mr. Choi a 69-year-old man takes the following medicines regularly
➢ simvastatin20 mg once daily
➢ dipyridamole m/r 200 mg twice daily ➢ omeprazole 40 mg per day
➢ metformin m/r 500 mg twice daily
➢ Lisinopril 2.5 mg once daily
He has type 2 diabetes and had a transient ischaemic attack two years ago. He has just been diagnosed with AF and is due to stop dipyridamole. Which of these medicines is an appropriate replacement for dipyridamole given his medical history?
A. Enoxaparin 40mg/ml injection OD B. Clopidogrel 75mg OD
C. Rivaroxaban 20mg OD
D. Losartan 50mg OD
E. Sotalol 40mg OD
What is the Blood pressure target for pregnant patients taking anti-hypertensive medication without any co-morbidity as recommended by NICE guidelines ?
A.<130/80 mmHg
B. <140/90 mmHg
C. <150/90 mmHg
D. <120/80 mmHg
E. <135/85 mmHg
A 64-year-old man started taking Amlodipine 5mg once daily about two months ago. He has also been taking linagliptin 5mg a day for one year. When collecting his repeat prescription, he complains of abdominal pain , fatigue , foul smelling stools which has lasted for the last two weeks. He wonders if his new tablet is to blame.
What is the most appropriate advice to give to this patient?
A. He is experiencing a side-effect of Amlodipine, and whilst safe to continue taking it, he may wish to see his GP for an alternative.
B. He should see his GP as the dose of Amlodipine may need to be increased.
C. He should see his GP as the dose of Linagliptin may need to be reduced.
D. Advise him to stop taking Amlodipine straight away and see his GP as soon as possible.
E. The symptoms described is a red flag symptom caused by linagliptin. Therefore, the patient needs to stop linagliptin and see his doctor for a review.
Abigailisa65-year-oldpatientwhousuallytakes Eplerenone 25mg tablets once daily. At a routine BP check, her doctor decides to change her dose to 50mg once a day. Which of the following checks should be initiated soon after this change is made? Choose most appropriate option below?
A. Liver function test should be initiated soon after
this change is made
B. Echocardiogram should be initiated before and
after this change is made
C. Serum sodium test should be initiated soon after
this change is made
D. Electrocardiogram should be initiated soon after
this change is made
E. Serum potassium test should be initiated before
and after this change is made.
Postpartum depression is a mental health illness that affects women after giving birth. With postpartum depression, feelings of sadness, loneliness, worthlessness, restlessness, and anxiety could last longer than a few weeks. Which of the following drugs can increase the risk of postpartum depression?
A. Erythromycin
B. Metformin
C. Ramipril
D. Nifedipine
E. Methyldopa
Michael is a 70-year old patient with a history of uncontrolled heart failure and at risk of QT interval prolongation. He currently takes
Ramipril 10mg OD
Digoxin 12mcg OD
Simvastatin 20mg ON Metformin 500mg BD
Which of the following medication would you consider safe for this patient and has the least adverse risk to his current treatment regimen and medical condition? A.Clarithromycin500mg BD
B. Verapamil 80mg OD C.Haloperidol 5mgOD D. Ranolazine 375mg OD E. Domperidone 50mg OD
A 54-year-old woman takes citalopram 40 mg daily for severe depression. She had a stroke 5 years ago and has recently been diagnosed with a new condition - non-valvular atrial fibrillation. She has been newly prescribed dabigatran etexilate 150 mg twice daily. Which side-effect are you mostly concerned about due to a potential drug interaction between both drugs?
A. Bleeding risk increased
B. bradycardia
C. Black hairy tongue effect
D. hypertensive crisis
E. myopathy
Mr. P. usually takes clopidogrel, bisoprolol, amlodipine and ramipril capsules on a regular basis. He presents with a prescription for omeprazole 20mg capsules. What is the main risk of taking omeprazole with his regular medication?
A. Increase risk of heart block
B. Increased risk of QT prolongation
C. Increased risk of myopathy
D. Increased risk of bleeding
E. Increased risk of blood clot formation
Mr.Abdula 43-year-old male is a patient of Black African origin. He has been diagnosed with stage 1 hypertension. His doctor would like to prescribe him a drug to manage his condition. He takes no other medication. Which of the following would you recommend?
A. Indapamide
B. Alfuzosin
C. Felodipine
D. Ramipril
E. Losartan
It is a Saturday night, and you are working in a pharmacy from 9am to 7pm. Ten minutes before the end of your shift, a worried woman comes into your pharmacy asking to speak to you; she has run out of her apixaban 5mg tablets. As it is a Saturday night, she will not be able to request a prescription before Monday. She is not a regular patient at your pharmacy. What would be your next line of action?
A. Tell her that she would have to miss a few doses until Monday, but this won’t affect her adversely.
B. Refer her to her usual pharmacy as she can obtain an emergency from there.
C. Offer to sell her aspirin tablets over the counter instead.
D. Refer her to A & E as that is the only way she can obtain the drug tonight.
E. Offer her an emergency supply for 3 days.
Mr. K is a 65-year-old patient who suffers chest pains whenever he rides his bicycle. He currently takes a beta- blocker and a calcium channel blocker. He sees his GP today who concludes that he should be on another medication for the management of stable angina. The doctor prescribes long- acting nitrate tablets. Unfortunately, Mr. K could not tolerate the new drug as he suffered headaches, flushing and dizziness continuously. What is a suitable replacement for nitrate tablets in this case?
A. Warfarin
B. Lomitapide
C. Dabigatran
D. Evolocumab
E. Ranolazine
Mr T’s potassium level is currently 6.1 mmol/L. Which of the following drugs can most likely increase the risk of hyperkalaemia?
A. Bisoprolol
B. Indapamide
C. Sacubitril/valsartan
D. Citalopram
E. Felodipine
Mr. J. suffers from stable angina and currently uses a GTN spray. His doctor would like to prescribe him a suitable long term drug to manage his condition. He currently also takes simvastatin 40mg, amitriptyline 10mg, salbutamol inhaler and co-codamol 30/500 PRN. Which drug is the most suitable for him?
A. Amlodipine
B. Bisoprolol
C. Losartan
D. Nicorandil
E. Propranolol
Mrs. B is a 54-year-old patient who had a recent non-ST elevation myocardial infarction. She is recovering well, and her doctor is happy about her progress so far. Currently, she takes
Rosuvastatin 20mg OD Amlodipine 5mg OD Clopidogrel 75mg OD Bisoprolol 5mg OD
What extra medication can be given to Mrs. B to significantly reduce her chances of suffering more cardiovascular events in the future given that she has no other medical conditions?
A. Digoxin
B. Apixaban
C. Ramipril
D. Indapamide
E. Glyceryl trinitrate
