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Pre-reg > Chapter 2- CVS > Flashcards

Chapter 2- CVS Flashcards

1
Q

How do you manage spontaneous etopic beats

A

If the patient has a normal heart treatment is rarely required. If they are particularly troublesome beta blockers are sometimes effective and the safest

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2
Q

What are the aims of treating atrial fibrillation?

A

Reduce symptoms

Prevent complication especially stroke

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3
Q

What should all atrial fibrillation patients be assessed for?

A

Risk of stroke (CHADVASC)
Bleeding risk (HASBLED)
And thromboembolism

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4
Q

What are the two ways that atrial fibrillation can be controlled?

A

Controlling the ventricular rate (rate control)
Or
Attempting to restore and maintain Sinus rhythm (rhythm control)

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5
Q

If drug treatment fails to control symptoms of AF what’s another option

A

Ablation strategies

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6
Q

How is cardioversion done

A

Electrical- direct current

Pharmacological- anti arrhythmic drug (eg amiodarone)

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7
Q

With patients presenting acutely with AF and life-threatening Haemo dynamic instability, what is offered

A

Electrical cardioversion- rhythm control

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8
Q

With patients presenting acutely with AF and without life-threatening Haemo dynamic instability, what is offered?

A

<48= rate or rhythm control

> 48= rate control (verapamil, BB)

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9
Q

What is given if urgent rate control is required in an atrial fibrillation patient

A

Beta blocker (not sotalol) or verapamil (rate limiting ca channel blocker) intravenously

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10
Q

What is electrical cardioversion and when is it used in atrial fibrillation?
How long should the patient be anti coagulated for?

A

A medical procedure where a fast heart or other cardiac arrhythmia is converted to a normal rhythm either electrically or drugs (if AF present >2 days electrical is preferred)

To restore sinus rhythm

Patients should be anticoagulated 3 weeks before and 4 weeks after cardioversion

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11
Q

What is the first line drug treatment strategy for maintenance AF

A

Rate control - except patients with new onset AF or if clinical judgement is used to say Rhythm control is more suitable (such as afib with secondary HF)

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12
Q

How can ventricular rate be controlled

A

Standard beta blocker
Or
Rate limiting calcium channel blocker (diltiazem or Verapamil as monotherapy)

Digoxin is good at controlling the ventricular rate at rest and is added when single treatment fails

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13
Q

In life threatening haemodynamic instability, when anticoagulation for 3 weeks in not possible
What can you do

A

Electrical cardioversion

Give parenteral anticoagulation and rule out left arterial thrombus immediately before procedure

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14
Q

What drug combo do you use if ventricular function is diminished

A

Beta blocker and digoxin

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15
Q

What drug do you use if AF is accompanied with congestive heart failure

A

Digoxin

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16
Q

If drug treatment to restore sinus rhythm is needed post cardioversion what should be used

A

Beta blocker

If that’s not appropriate oral anti-arrythmic drug (soltalol) or amiodarone

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17
Q

What drug should be given in patients with with AF and left ventricular impairment or heart failure

A

Amiodarone

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18
Q

What is paroxysmal AF and that’s the treatment

A

AF that occurs occasionally and usually stop spontaneously

IV adenosine or IV verapamil

Recurrent episodes: Treat with beta blocker (ventricular control) or oral anti-arrhythmic drugs (rhythm control)

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19
Q

What are the different area anti-arrythmic drugs work on

A 
Supraventricular arrhythmia (verapamil- rate limiting ca channel blocker) 
Ventricular arrhythmia (lidocaine)
And both (amiodarone)
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20
Q

What is arrhythmia

A

Abnormal heart rhythm

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21
Q

What is supraventricular arrhythmia

A

Abnormally fast heart rhythm due to improper electrical activity in the upper part of the heart (most common type)

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22
Q

What is ventricular arrhythmia

A

Abnormal heartbeats that originate in the lower chamber of the heart called ventricles

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23
Q

What is amiodarone used for and one main advantage

A

Most arrhythmia

Advantage is it doesn’t cause myocardial depression

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24
Q

What drug class is sotalol and what is one of its main uses

A

Beta blocker

And management of ventricular arrhythmia

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25
Q

What are the main drugs used in supraventricular arrhythmia

A

Adenosine(anti arrhythmic) first line

Cardiac glycosides (digoxin)

Verapamil (rate limiting calcium channel blocker)

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26
Q

Common drugs used for ventricular arrhythmia

A 
Iv Lidocaine (anti arrhythmic)
(No longer first choice- supraventricular and ventricular drugs used now)
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27
Q

What drugs are used for both supraventricular and ventricular arrhythmia

A

Amiodarone (anti arrhythmic)
Beta blocker
Disopyramide
Flecainide

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28
Q

Difference between atrial fibrillation and atrial flutter

A

atrial fibrillation is mate chaotic and more irregular that can affect heart health

Atrial flutter is fast but usually regular rhythm

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29
Q

What is the Vaughan Williams classification of drugs for arrhythmias

A

1 membrane stabilising block sodium channel

1a. Dispyramide
1b. lidocaine
1c. Flecainide

2 beta blockers ( EMAP)

3 block potassium channel eg: amiodarone and sotalol (also class 2)

4 rate limiting calcium channel blocker

(S B P C)

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30
Q

How is digoxin used and what for

A

It increases the force of contraction of the heart and reduces conductivity of the AV node
It is used in atrial fibrillation and heart failure

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31
Q

Why is digoxin once-daily dosing

A

It has a long half life

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32
Q

Common side effects of digoxin

A

Nausea vomiting and blurred vision

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33
Q

Possible adverse affects of amiodarone and when should they be monitored

A

Phototoxicity

Hyper or hypothyroidism (Shown by weight loss palpitation and insomnia)

Slight grey skin

Peripheral neuropathy

Taste disturbance

It increases the plasma concentration of warfarin, digoxin and phenytoin

Potassium levels, Thyroid function and liver function should be monitored every six months

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34
Q

Why should Sotelol be avoided in asthmatic patients

A

They are not cardioselective so act on the beta receptors in the heart and peripheral vasculature (liver bronchi and pancreas)

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35
Q

Which beta-blockers would you prescribe if a patient is asthmatic

A

Atenolol or bisoprolol

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36
Q

What are the indications to beta-blockers have excluding cardiac

A

Anxiety and in the prophylaxis of migraine

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37
Q

When should verapamil and diltiazem be avoided

A

In heart Failure

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38
Q

Common side effects of calcium channel blockers

A

Headache flushing oedema and swelling of the ankles

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39
Q

What is the interaction between calcium channel blockers and Simvastatin

A

Increases the risk of myopathy

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40
Q

What drug class is diltiazem

A

Calcium channel blocker

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41
Q

What drug class is verapamil, how does it work and what is it used for

A

Calcium channel blocker
Used in the treatment of angina hypertension and arrhythmias

It slows the heart reduces cardiac output and impairs a V conduction

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42
Q

What should verapamil not be used with that diltiazem can be used with and why

A

Beta-blocker

Can cause hypotension and asystole

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43
Q

Common side effect of verapamil

A

Constipation

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44
Q

Important safety information for sotalol

A

May prolong the QT interval and it occasionally causes life-threatening ventricular arrhythmias also particular care is required to avoid hypokalaemia

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45
Q

What is digoxin most useful for

A

Controlling ventricular response in persistent and permanent atrial fibrillation and atrial flutter it also has a role in heart failure

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46
Q

What should the heart rate remain above when given digoxin

A

60 bpm

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47
Q

What is the most important determinant factor of digoxin dose

A

RenalFunction

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48
Q

How is sinus rhythm maintains post-cardioversion

A

With a standard beta-blocker

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49
Q

Sum up amiodarone

A

Alters sinus rhythm to restore normal heart bear
Long half life
Loading dose may be required
Interactions or side effects can occur a year after due to long half life

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50
Q

Give an example of an anti fibrinolytic drug and what’s it used for?

A

Tranexamic acid

Used to
prevent bleeding
Treat bleeding associated with excessive fibrinolysis (eg surgery)
Management of menorrhagia (heavy mensuration)
Epistaxis (nose bleeds)
Thrombolytic overdose

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51
Q

What’s the risk of a patient having oral contraceptives and tranexemic acid?

A

Increased risk of thrombosis

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52
Q

Of the drug class antihaemorrhagics, give an example of a haemostatic and what is it used for?

A

Emicizumab

A biological medicine used as a monoclonal antibody that bridges factor 11 and 10 to restore function of missing activated factor 8- which is needed for haemostasis (stop bleeding)

Eg used in prophylaxis of haemorrage

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53
Q

For coagulation facto deficiencies, what are the possible 9 coagulation proteins that can be offered?

A 
Dried prothrombin complex 
Factor 7a (recombinant)
Factor 7 fraction- dried
Factor 11- dried
Factor 13 fraction- dried 
Fibrinogen- dried
Protein C concentrate 
Factor 8 inhibitor bypassing fraction 
Fresh frozen plasma
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54
Q

What’s a subarachnoid haemorrhage

A

Bleeding with ing the subarachnoid space, which is between the brain and the tissue covering the brain

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55
Q

Which calcium channel blocker is given after a subarachnoid haemorrhage and why?

A

Nimodipine

To prevent and/ or treat ischaemic neurological defects following a subarachnoid haemorrhage

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56
Q

What is Venus Thromboembolism?

A

It includes deep vein thrombosis and pulmonary embolism and occurs as a result of thrombus formation in a vein

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57
Q

The two methods of thromboprophylaxis are mechanical and pharmacological
Give an example of a mechanical prophylaxis

A

Anti-embolism stockings

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58
Q

Which beta-blockers are cardioselective and preferred in asthmatics ( clue: BAMAN)

A 
Bisoprolol
Atenolol 
Metoprolol
Nebivolol 
Aceburolol
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59
Q

Which beta-blockers are water-soluble (clue: SNAC) and what is the benefit of this

A

Sotalol
Nadolol
Atenolol
Celiprolol

Less likely to cause sleep disturbances and nightmares

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60
Q

Treatment for transient ischaemic stroke

A

Immediately: aspirin 300mg

Long term: Clopidogrel 75mg OD
Initiate statin 48hrs after

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61
Q

Treatment for ischaemic stroke

A

Initially: alteplase then aspirin 300mg for 14 days

Long term:
Clopidogrel 75mg (if not associated with AF)
Warfarin or oral anticoagulant IF associated with AF
Initiate statin 48 hours after

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62
Q

What’s a transient ischaemic attack

A

Mini stroke

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63
Q

Following an ischaemic stroke, what’s the BP target

A

<130/80mmHg

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64
Q

What drug class should not be started following a stroke to treat hypertension?

A

Beta blocker

Unless it’s indicated for a co-existing problem

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65
Q

When should a patient be given anticoagulation following intracerebral haemorrhage

A

If they’re at very high risk of a stroke or cardiac events

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66
Q

What are oral anticoagulation indicated for?

A

Thrombus formation or growth in the veins (due to the flow being slower moving and consisting of fibrin)

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67
Q

How does warfarin work and how long does it take?

A

Antagonises the effect of vitamin K and takes 48-72 hours

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68
Q

What do you do if you want to start a patient on warfarin but want immediate effect

A

Give the patient on unfractionated or LMWH concomitantly

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69
Q

What’s first line in artery thrombosis?

A

Aspirin

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70
Q

What is the preferred anticoagulation for vte prophylaxis of patients undergoing surgery

A

Unfractionated or LMWH

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71
Q

Why’s aspirin preferred over warfarin in arterial thrombi

A

Artery clots are mainly formed of platelets

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72
Q

What’s pulmonary embolism

A

Blocking the vein from the heart to the lungs

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73
Q

The main two types of VTE

A

Dvt and Pe

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74
Q

Three indications of warfarin

A

Treatment and prophylaxis of VTE
Atrial fibrillation
People with prosthetic heart valves

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75
Q

What conditions allow a target INR +/- 0.5 of 2.5

A

Treatment of DVT or PE
AF
Cardioversion
MI

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76
Q

What conditions allow a target INR +/- 0.5 of 3.5

A

Recurrent DVT or PE

Mechanical prosthetic heart valve

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77
Q

What do you do if patient has an embolism event while on warfarin and is being anticoagulated at the target INR

A

Consider increasing the INR target or adding an anti platelet drug

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78
Q

What’s the main adverse effect of all oral anticoagulants

A

Haemorrhage

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79
Q

What’s the antidote for major bleeding caused by warfarin

A

Phytomenadione (vitamin k) by slow IV
Give dried prothrombin complex if there are bleeding (if not available fresh frozen plasma)

Also stop the warfarin and restart when INR <5

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80
Q

How long before an elective surgery should a patient on warfarin stop taking it

A

Usually 5 days

(If the patient has had an event recently they can be bridged with a treatment dose of LMWH that they’ll stop a day before the surgery)

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81
Q

Difference between unfractionated heparin and LMWH

A

Unfractionated has a shorter duration of action but initiates anticoagulation rapidly

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82
Q

When are standard heparin preferred over LMWH

A

On those at high risk of bleeding because it’s effects can be terminated rapidly by stopping the infusion

And those with severe renal failure

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83
Q

When and Why are LMWH preferred over unfractionated heparins

A

In the prevention and treatment of VTE as they are as effective and have a lower risk of heparin induced thrombocytopenia and convient as OD dosing and don’t require monitoring
And less risk of osteoporosis

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84
Q

3 types of LMWH

A

Dalteparin (thrombin inhibitor)
Enoxaparin (inhibit factor x)
Tinzaparin (inhibit factor x)

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85
Q

Example of a heparinoid and whens it’s used?

A

Danaparoid

Used for prophylaxis of DVT in patients who develop heparin induced thrombocytopenia

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86
Q

Antidote for unfractionated and LMWH

A

Idarucizumab
Binds to dabigatran to reverse the anticoagulant effect

Or protamine sulphate

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87
Q

What are antiplatelet drugs used for

A

Decrease platelet aggregation and inhibit thrombus formation in arterial circulation

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88
Q

When is the use of aspirin 75mg beneficial

A

Secondary prevention of cardiovascular events ( people who already have cardiovascular disease)

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89
Q

When is clopidogrel and aspirin used

A

Following an ST- elevated MI or for AF when warfarin is not suitable

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90
Q

When should aspirin be contraindicated or cautioned?

A

Contra indicated:
Children under 16
Signs of active peptic ulcer

Cautioned
Asthmatics 
Uncontrolled hypertension 
History of peptic ulcer 
Elderly
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91
Q

What’s the interaction between all broad spectrum antibiotics and warfarin

A

They may all increase the risk of bleeding by killing off the bacteria in the gut responsible for making vitamin K

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92
Q

What’s the anticoagulant of choice following a hip/knee surgery or day surgery

A

Fondaparinux (inhibits factor Xa)

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93
Q

What’s the anticoagulation of choice for thromboprophylaxis after knee/ hip surgery

A

Dagibatran or Rivaroxaban

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94
Q

What’s the VTE prophylaxis of choice in pregnancy

A

LMWH
Lower risk of osteoporosis and heparin induced thrombocytopenia

Also doesn’t enter the placenta

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95
Q

What else can heparins cause excluding thrombocytopenia and osteoporosis

A

Hyperkalaemia- due to inhibition of of aldosterone secretion

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96
Q

List 4 NOACS

A

Rivaroxaban
Apixaban
Edoxaban
Dabigatran

All inhibit factor Xa

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97
Q

What abnormal side effects has come out for warfarin that will require the doctor to stop it

A

Skin rash- calciphylaxis

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98
Q

When are NOACs indicated

A

Prophylaxis of VTE in adults after knee or hip replacement
Prophylaxis of stroke and systemic embolism if patients with non-vulvar AF
Treatment of PE

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99
Q

Possible causes of hypertension

A

Renal disease
Endo crime causes
Contributory factors
Risk factors

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100
Q

What measurements is diagnosis for stage one hypertension

A

140/90 mmHg or higher

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101
Q

What measurements is the diagnosis of stage two hypertension

A

160/100 mmHg or higher

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102
Q

What value is diagnosed as severe hypertension

A

180/110 or higher

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103
Q

What antihypertensive would you give patients under 55 who are not African or Caribbean

A

Ace inhibitor if this is not tolerated or for an angiotensin II receptor antagonist if both are not tolerated to consider a beta-blocker

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104
Q

What antihypertensive do you offer a patient under 55 with single treatment was not sufficient and they are not African or Caribbean

A

Offer an ace inhibitor or angiotensin II receptor antagonist in combination with calcium channel blocker
If a calcium channel blocker is not tolerated give a thiazides like diuretic

If this fails add both a calcium channel blocker and thiazides like diuretic

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105
Q

What antihypertensive treatment do you offer patients over 55 and patience of any age that African or Caribbean

A

First night is a calcium channel blocker if this is not tolerated give a thiazides like diuretic

If this fails Give a calcium channel blocker or thiazide related diuretic in combination with an ace inhibitor or angiotensin II receptor antagonist

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106
Q

When treating hypertension what might you consider adding to reduce cardiovascular risk

A

Aspirin or a statin

Note these are not used to control blood pressure

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107
Q

What’s the target blood pressure range for patients over 80 years old

A

Below 150/90 mmHg

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108
Q

What’s the blood pressure range for patients with diabetes

A

Below 140/80 but below 130/80 if kidneys, eyes, or cerebrovascular disease are also present

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109
Q

Why is antihypertensive treatment particularly important in Diabetic patients

A

It prevents macrovascular and microvascular complications

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110
Q

How renal disease affects hypertensive treatment

A

Ace inhibitor should be used with caution
Thiazides Diuretics may be ineffective
High doses of loop diuretics may be required

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111
Q

Give examples of drugs are safe to use for hypertension in pregnancy

A

Labetalol, methyldopa and Nifedipine modified release

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112
Q

Name three centrally acting antihypertensive drugs

A

Methyldopa
Moxonidine
Clondine

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113
Q

What are the main indications of angiotensin converting enzyme inhibitors

A

Heart Failure
Hypertension
Diabetic nephropathy

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114
Q

What is clonidine used for and what is an important counselling point

A

hypertension
Migraine
Menopausal flushing

Avoid Abrupt withdrawal as can cause rebound habitation

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115
Q

What is methyldopa used for and what should you monitor

A

Hypertension in pregnancy and monitor blood count and a LFT

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116
Q

How do you beta-blockers work

A

They blocked the beta adrenoreceptor in the heart peripheral vascularture Bronchi pancreas and liver

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117
Q

When are beta-blockers contraindicated

A

In patients with second or 3rd° heart block and should be avoided in patients with a worsening unstable heart failure

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118
Q

Which beta-blockers have less affect on the beta-2 receptors

(Clue: MANBA

A 
Atenolol
Bisoprolol 
metoprolol 
Nebivolol 
Acebutolol
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119
Q

When are beta-blockers indicated

A 
Hypertension
Angina
Myocardial infarction
Arrhythmias
Heart Phalia
Thyrotoxicosis
Anxiety
Prophylaxis of migraine
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120
Q

Which beta-blockers block the alpha and beta receptor

A

Carvedilol

Labetalol

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121
Q

What are common side-effects of beta-blockers

A

Fatigue, coldness of extremities, and sleep Disturbances.

Bradycardia and headaches

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122
Q

Common side effects of an Ace inhibitor

A

Dry cough

Rash, diarrhoea, constipation, hepatic impairment, hyperkalaemia

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123
Q

Should calcium channel blocker is be avoided in heart failure

A

Yes with the exception of amlodipine as they can further depressed cardiac function

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124
Q

What drug class is verapamil and what is it used for and how does it work

A

Calcium channel blocker
Treatment of angina hypertension and arrhythmia

It slows the heart, reduces cardiac output and impairs AV node conduction

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125
Q

Common side effects of verapamil and

what should it not be used with

A

Constipation

Beta blocker

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126
Q

What’s the use of calcium channel blocker in unstable angina

A

They do not reduce the risk of myocardial infarction in unstable angina
The use of Diltiazem and verapamil should be reserved for patients resistant to treatment with beta blocker

127
Q

How do you calcium channel blocker is work

A

They reduce the inwards displacement of calcium irons therefore the heart contracting may be reduced the electrical impulses within the hall or depressed

128
Q

Give some examples of vasodilators used in hypertension and when they are used

A

Hydralazine used for resistant hypertension

Sildenafil is licensed for use in pulmonary arterial hypertension

129
Q

The 2 cardiovascular risk calculator

A

QRISK2

JBS3

130
Q

Tell me about primary prevention of CVD for anti platelets, antihypertensives and lipid lowering therapy

A

Anti platelet:
Not recommended for primary prevention

Antihypertensive:
Offered to patients with sustained elevated BP over 140/90mmHg

Lipid lowering therapy:
Statin offered after lifestyle factors and other conditions (diabetes, hypothyroidism) have been controlled

131
Q

Tell me about secondary prevention of CVD for anti platelets, antihypertensives and lipid lowering therapy

A

Antiplatelet:
Low dose aspirin or clopidogrel 75mg for stroke/TIA

Antihypertensive:
Offered to patients with sustained elevated BP over 140/90mmHg

Lipid lowering therapy:
A high intensity Statin offered, the dose at which a reduction in LDL- cholesterol of greater than 40% is achieved

132
Q

What is heart failure

A

Reduced cardiac output

Due to reduced (ventricle not contracting properly pushing out <40%) or preserved ejection fraction (ventricle to relaxing properly only mildly reduced)

133
Q

Signs and symptoms of HF

A

Signs:
Elevated jugular venous pressure
Pulmonary crackles
Pulmonary oedema

Symptoms:
SOB
Fatigue 
Wheezing
Persistent coughing 
Ankle swelling
134
Q

Things you monitor in HF and non-drug treatments

A

Lifestyle changes (smoking cessation, reduce alcohol consumption, increase exercise, weight control, diet)

Weight themselves daily and inform GP if gained 1.5-2kg over 2 days

Salt and fluid intake should be restricted

135
Q

Drug treatment for chronic heart failure with reduced ejection fraction

A
  1. Rate limiting CCB (verapamil + diltiazem)
  2. Diuretic to relieve breathlessness and oedema (usually looo diuretic like furosemide)
  3. BB that’s licensed for HF (eg bisoprolol)
  4. ACEi (eg ramipril) -> switch to ARB if ACEi not tolerated
  5. If HF symptoms persist despite all the above being added and optimised an aldosterone antagonist (eg: spironolactone) should be offered as add on
  6. If symptoms persist advise should be seeked for the use of amiodarone, digoxin (in patients with sinus rhythm digoxin is always recommended)
136
Q

Monitoring requirements for initiating ACE inhibitors and ARB

A

Serum potassium, sodium, renal function and BP should be monitored

137
Q

Monitoring requirements for initiating aldosterone antagonists

A

Serum potassium, sodium, renal function and BP should be monitored

138
Q

Monitoring requirements for beta blockers when initiating

A

Heart rate
BP
Symptoms control

139
Q

Drug treatment for chronic heart failure with preserved ejection fraction

A

Managed under heart failure specialist

For the relief of fluid retention symptoms a loop diuretic should be prescribed

140
Q

Possible adverse affect for the use of spironolactone and ACEi

A

Spironolactone = potassium sparing diuretic

Both increase potassium so can cause hyperkalaemia

141
Q

What effect does aldosterone inhibitors (potassium sparing diuretic) have on potassium (eg spironolactone)

A

Aldosterone increases the amount of potassium excreted in the urine, so the antagonist stops potassium being increased and increases potassium levels in the body

142
Q

What’s the treatment for hypercholesterolaemia and hypertriglyceridaemia

A

Statins are always first line

When it’s still not controlled with a maximal dose of statin may require an additional lipid regulating drug like Ezetimibe

143
Q

What may be added to statins to reduce triglyceride concentration

A

Fibrates

144
Q

How do you treat familial hypercholesterolaemia

A

Life long lipid modifying therapy and advice on lifestyle changes

145
Q

What do you give for lipid therapy if statin and ezetimibe are both inappropriate

A

Fibrate or a bile acid sequestrant (eg: colestyramine)

146
Q

Possible adverse effects of using a statin with fibrates

A

Muscle related side effects like rhabdomyolysis- breakdown of skeletal muscle

147
Q

How do bile acid sequestrants work

A

They bind to bile acids, preventing their reabsorption, this promotes hepatic conversion of cholesterol into bile acids

The increased LDL- receptor activity of liver cells increased the clearance of LDL- cholesterol from the plasma

148
Q

How does ezetimibe work

A

It inhibits the intestinal absorption of cholesterol (mainly lowers LDL cholesterol)

149
Q

What do fibrates do and give 2 examples

A

They decrease serum triglycerides (little effect on LDL cholesterol)

Eg: bezafibrate
Ciprofibrate
Fenofibrate

150
Q

How do statins work

A

They completely inhibit (3-hydroxy-3-methylglutatyl coenzyme A reductive) an eczema involved in cholesterol synthesis- especially in the liver

151
Q

What’s a common toxicity caused by statins

A

Muscle toxicity causing muscle pains

152
Q

Why’s nifedipine not used in hypertension and angina

A

Short acting so causes reflex tachycardia

153
Q

What’s the interaction with simvastatin and amlodipine and what’s the maximum recommended dose in conjugation with amlodipine, verapamil and diltiazem

A

Risk of myopathy- muscle weakness

Max for simvastatin= 20mg OD

154
Q

When should a patient be put on lipid regulating drugs for primary prevention

A 
Diabetic 
Over 85
>10% risk of CVD
eGFR< 60
Family history
Smokers
155
Q

What does bile acid sequesterants interfere with

A

Absorption of fat soluble vitamins (a, d, k and folic acid)

156
Q

Main adverse effects of statins

A

Myositis
Muscle effects
Liver toxicity
GI disturbances (Abdo pain, flatulence)

157
Q

How is Omega 3 fatty acids used to help lower cholesterol

A

Used to reduce triglycerides as alternative to fibrate and additional to statin

158
Q

Which beta blocker is not used for rate control

A

Sotolol

159
Q

What is stable angina

A

Predictable chest pain or pressure from an increase in in myocardial oxygen demand

160
Q

What is a drug treatment for acute attacks of stable angina

A

GTN spray

161
Q

What is the drug treatment for long term prevention of chest pain in patients with stable angina

A

Beta blocker as first line (rate limiting CCB if this is contraindicated)

If BB alone fails then BB and CCB should be started

If the combination fails then add a long acting nitrate (ivabradine, nicrandil) (consider this alone if both BB and CCB not tolerated)

162
Q

What’s the secondary prevention of cardiovascular events for patients with angina

A 
Low dose aspirin 
Statin 
Ace inhibitor (especially if they’re diabetic)
163
Q

How does nicorandil work

A

It’s a potassium channel activator with vasodilation properties
Used as an anti- angina

164
Q

What are the types of acute coronary syndrome

A

Unstable angina
NSTEMI
STEMI

165
Q

What’s the long term management of unstable angina and NSTEMI

A

Aspirin and clopidogrel
Beta blocker
Ace inhibitor / ARB
High dose statin

166
Q

What’s the initial management of patients presenting with an ACS (clue: M O A N)

A

Oxygen
Pain relief like morphine
Dual antiplatelet
Nitrates

Metoclopramide to prevent N+V
Heparin or LMWH

167
Q

Long term management for patients that have had a STEMI

A

First choice= PCI (stent)

Second choice= fibrinolytic therapy (alteplase)

Once resolved, the patient gets put on:

  • Dual antiplatelet
  • Beta blocker
  • Ace inhibitor
  • High dose statin
168
Q

Adverse effects of nitrates

A

Flushing
Headache
Postural hypotension

169
Q

How nitrates work and Examples of nitrates

A

Potent coronary vasodilators useful in treatment of angina

GTN
Isosorbide dinitrate
Isosorbide mononitrate

170
Q

What is given for cardiopulmonary resuscitation

A

Adrenaline 1 in 10000 (repeated every 3-5 minutes in necessary
Iv amiodarone should be considered
Lidocaine as an alternative to amiodarone if not available

171
Q

What are diuretics used for

A

Relieve oedema due to chronic heart failure and in lower doses to reduce blood pressure

172
Q

When are loop diuretics indicated

A

In pulmonary oedema due to left ventricular failure and in patients with chronic heart failure

173
Q

When is combination diuretic therapy effective

A

In patients with a team of resistant to treatment with one diuretic

174
Q

MOA of thiazides

And Why are the thiazide diuretics usually given in the morning

A

Inhibit sodium and chloride reabsorption at the distal convoluted tubule and increasing calcium reabsorption

They have a long duration of action of 12 to 24 hours so they are usually administered early in the day so that the diuresis does not interfere with sleep

175
Q

What can loop diuretics exacerbate

A

Diabetes

Gout

176
Q

What’s the drug action of Loop diuretics

A

Inhibit the sodium potassium chloride symporter
Reduce sodium and chloride reabsorption and in turn inhibit magnesium and calcium absorption resulting in increased urinary output

(They inhibit the re-absorption from the ascending limb of the loop of Henley in the renal tubules)

177
Q

Which Thiazide is preferred in hypertension and which thiazide is preferred in congestive cardiac failure

A

Indapamide in hypertension

Bendroflymethiazide in CCF

178
Q

How do tha use diuretics work and What adverse affects can thiazides have

A

Inhibit the na/cl co transporter in the distal convoluted tubule of the nephron. Preventing reabsorption of sodium and its osmotically associated water

Causes low potassium sodium and magnesium

Causes high calcium and glucose (exacerbate diabetes)

May cause gout

179
Q

What other drugs should you avoid giving thiazides with

A

Lithium- sodium depletion increases risk of toxicity

Beta blocker for hypertension for those with diabetes or at risk of developing diabetes

180
Q

What’s the risk of rapid IV administration of loop diuretics

A

Can cause tinnitus deafness

181
Q

What should loop diuretics not be given with as they can cause ototoxicity

A

Aminoglycosides (gentamicin or vancomycin)

182
Q

How are potassium sparing diuretics and aldosterone antagonist used

A

Given with thiazide or loop diuretics for the retention of potassium instead of potassium supplements

183
Q

Which Anti-depressant do you not give in MI (contra indicated)

A

TCA

Eg amytripiline

184
Q

What’s the best prescribed SSRI after an MI

A

Sertraline

185
Q

How are ADP receptor antagonist such as clopidogrel different in the mechanism of action to aspirin

A

They work by reversibly binding to the ADP receptors on the surface of platelets this process is independent of the Cox pathway which is how aspirin works

186
Q

What are common side effects of ADP receptor antagonist (clopidogrel, ticagrelor, prasugrel)

A

Bleeding
Gastrointestinal upset
Thrombocytopenia

187
Q

What is an important interaction for ADP receptor antagonist

A

Cytochrome p 450 inhibitors such as a OMeprazole, erythromycin, selective serotonin reuptake inhibitor is and some antifungals
This is due to clopidogrel being a prodrugthat requires metabolism by hepatic cytochrome p450 enzyme

188
Q

How long does it take for clopidogrel to reach its full antiplatelet effect

A

Seven days

189
Q

What are the most common adverse effects of aspirin

A 
Gastrointestinal irritation
Peptic ulceration
Haemorrhage
Bronchospasm
Tinnitus in regular high dose (ringing in the ear)
190
Q

When should aspirin not be given

A

If the patient is under 16 years old due to the risk of Reye’s syndrome

If the patient has a peptic ulceration

If the patient has gout as it may trigger an acute attack

191
Q

How long should the loading dose of 300mg aspirin be for acute coronary syndrome and for acute ischaemic stroke

A

Acs= once only

Stroke= 14 days

192
Q

How can you minimise gastric irritation from aspirin

A

Prescribe a proton pump inhibitor and it should be taken after food

193
Q

Name four direct oral anticoagulation and when they are indicated

A

Apixaban
Dabigatran
Edoxaban
Rivaroxaban

Used for:
VTE (DVT and PE)
AF

194
Q

How do you go four direct oral anticoagulation is work

A

Apixaban edoxaban and Rivaroxaban inhibit factor Xa preventing conversion of prothrombin to thrombin

Dabigatran directly inhibits thrombin

These all prevent the conversion of fibrinogen to fibrin preventing clot formation in veins

195
Q

Which DOAC must be taken with food as it affects its absorption

A

Rivaroxaban

196
Q

Give examples of fibrinolytic drugs and their indication

A

Alteplase and streptokinase

Indications include:
Stroke
ST elevated Myocardial infarction
Massive pulmonary embolism

197
Q

Alpha blockers examples, use and adverse effects

A

Doxazosin, tamsulosin

Used for benign prostatic enlargement or an add on for resistant hypertension (only doxazosin)

Adverse effects are postural hypotension, dizziness, syncope (fainting due to low BP)

198
Q

Important adverse effects of aldosterone antagonists

A

Hyperkalaemia

Gynaecomastia (breast)

199
Q

Example of an aldosterone antagonist and How do aldosterone antagonists work

A

Spironolactone

Inhibits the effect of aldosterone by Binding to the aldosterone receptor to increase sodium and water excretion and potassium retention (potassium sparing diuretic)

200
Q

When is atropine indicated

A

Severe or symptomatic bradycardia to increase heart rate

201
Q

What are intravenous nitrates for

A

Treatment of pulmonary oedema in combination with furosemide oxygen and a strong opioid (eg morphine)

202
Q

How can you differentiate supraventricular and ventricular arrhythmia from an ECG

A

Supraventricular has a narrow QRS complex where as ventricular has a wide QRS complex

203
Q

What’s the overall aim of diuretics for BP

A

Increase sodium excretion to increase water excretion in turn lowering blood pressure

204
Q

What transporters do the different diuretics inhibit and where are they located

A

Loop in the thick ascending limb inhibiting the Na/k/ cl transporter

Thiazide diuretic in the distal convulated tubule affecting the sodium /chloride transporter

Potassium sparing tubule in the collecting duct works on the potassium and sodium transporter

205
Q

What are the three types of atrial fibrillation

A

Paroxysmal AF- episodes stop within 48 hrs without treatment

Persistent AF- episodes last >7 days

Permanent AF - present all the time

206
Q

Torsade de pointes is prolonged QT interval, what causes this and what’s the treatment?

A

Cause
Sotalol, hypokalaemia, bradycardia

Treatment
Magnesium sulphate

207
Q

When is IV adenosine contra indicated for supraventricular arrhythmia

What’s an alternative

A

Asthma and copd

Verapamil

208
Q

Initial loading dose for amiodarone

A

200mg tds for 7 days
200mg bd for 7 days
200mg od as maintenance

209
Q

Side effects of amiodarone

A 
Nausea 
Vomiting 
Taste disturbance 
Pulmonary toxicity 
Reversible corneal micro deposits 
Phototoxicity 
Slate grey skin 
Tremor 
Sleep disorder 
Hyper/hypothyroidism
Jaundice
210
Q

What are the interactions with digoxin (clue: C R A S E D)

A 
Calcium channel brockers
Rifampicin 
Amiodarone (half digoxin dose)
St. John’s wort 
Erythromycin 
Diuretics
211
Q

What should you avoid giving in intracerebral haemorrhage

A

Aspirin
Statin
Anticoagulation

212
Q

What’s the only ACEi that’s taken twice daily

A

Captopril

213
Q

Which ACEi is taken before food

A

Perindopril

214
Q

What drug classes should be avoided in acute kidney injury (clue: D A M N)

A

Diuretics
Ace inhibitors /ARBs
Metformin
Nsaids

215
Q

Vasodilator antihyperrensives

A

Hydralazine

Minoxidil

216
Q

Which BB have intrinsic sympathomimetic activity

Advantages of this

Clue: PACO

A

Pindolol
Acebutol
Celiprolol
Oxprenolol

Less bradycardia and less coldness of extremities

217
Q

Drug causes for hyperlipideamia

A

Antipsychotics
Immunosuppressant
Corticosteroids
HIV drugs

218
Q

Why should statins be taken at night, what’s the exception?

A

Cholesterol synthesis greater at night so more effective

Atorvastatin

219
Q

What’s the MHRA warning for simvastatin 80mg

A

High risk of myopathy
Give only if high risk of CV complications or severe hypercholesterolaemia and treatment goals not achieved at lower dose

220
Q

What limits should be assessed for statin treatment and when should it be stopped

A 
Creatinine kinase (5x above upper limit)
Liver function (3x above upper limit)
Hb1ac
Lipid profile
Thyroid function 
Renal function
221
Q

What antibiotics drug class can you not take with statin

A

Macrolide

222
Q

What are a few statin dose adjustment due to drug interaction

A

Simvastatin
Max 10mg with fibrate
Max 20mg with amiodarone amlodipine diltiazem verapamil

Atorvastatin
Max 10mg with ciclosporin

Rosuvastatin
Max 20ng with clopidogrel

223
Q

Why are diuretics usually taken in the morning?

A

To avoid sleep disturbances

224
Q

What’s a use of spironolactone not related to the heart

A

Ascites in liver failure

225
Q

Two types of peripheral vascular diseases and what’s given for each

A

OCCLUSIVE (peripheral artery disease)
Low dose aspirin and a statin

VASOSPASTIC (Raynauds syndrome)
Stop smoking and avoid exposure to Cold
Nifedipine

226
Q

For you thrombocytopenia, platelet counts are recommended if the patient is receiving Heparin for how long

A

Longer than 5 days

227
Q

A statin is indicated when serum total cholesterol concentration is

A

> or = 5mmol/L

228
Q

What can you give if amiodarone causes hyperthyroidism

A

Give carbomazole and withdraw amiodarone

229
Q

Interactions with amiodarone

A 
Grape fruit 
Warfarin phenytoin digoxin 
Statins (myopathy)
BB, rate limiting CCB (myocardial depression)
Drugs with QT prolongation
230
Q

Signs of toxicity with digoxin (slow and sick)

A

(Worsened with HypO k+, mg2+,
HypER ca2+)

Bradycardia/ heart block
Blurred or yellow vision 
Nausea vomiting diarrhoea Abdo pain 
Confusion 
Rash
231
Q

What’s the only CCB licensed in arrhythmias

A

Verapamil

232
Q

When should primary prevention be offered when assessing 10year CVD risk score

A

> 10%

233
Q

What’s the hyperlipidaemia diagnosis

A

6mmol/L total cholesterol

234
Q

What’s the patient counselling point for taking a lipid regulating drug with a macrolide antibiotic

A

Stop taking statin until antibiotic course completed

The others avoid

235
Q

Counselling for taking a statin with fusidic acid

A

Restart 7 days after last oral dose

236
Q

Interaction of bile acid sequestrants

A

Impairs absorption of fat soluble vitamins and other drugs

Take other drugs 1 hour before or 4 hours after

237
Q

What do you switch spironolactone to if the patient gets gynaecomastia

A

Eplrenone

238
Q

Dose and strength when you initiate treatment with amiodarone

A

200mg TDS 1 week
200mg BD 1 week
200mg OD thereafter

239
Q

What blood parameter do you need when you prescribe warfarin

A

Prothrombin time (PTT)

240
Q

Rivaroxaban treatment dose for VTE

A

15mg BD for 21 days

Then 20mg OD

241
Q

A normal expected side effect for nitrates

A

Headache as it’s a vasodilator so increased blood flow to head

242
Q

How do you maintain effectiveness of nitrates by reducing tolerance

A

Twice a day dosing, take second dose after 8 hours not 12

This leaves a period of 4-12 hours with low levels

243
Q

What’s a suitable beta blocker in pregnancy

A

Labetalol

244
Q

What’s the MHRA alert for NSAID piroxicam

A

Do not exceed 20mg OD

245
Q

Can you give atorvastatin to an ACS patient taking a short course of clarithromycin

A

Yes but max 20mg

If not ACS withhold for the Clari period

246
Q

What’s the different duration for different indication of warfarin

A

6 weeks for proximal DVT (below the knee)

3 months for proximal DVT (above knee)

6 months for proximal DVT with unknown cause

Long term for recurrent DVT and AF

247
Q

Why does Rivaroxaban need to be taken after food?

A

Increased risk of GI Bleeds

248
Q

Which DOAC Is pH dependent

A

Dabigatran

249
Q

What is given for cardiopulmonary resuscitation

A

30 compressions for every 2 breaths

~100 compressions/min

250
Q

When should GTN SL tabs be discarded after opening

A

8 weeks

251
Q

When should GTN SL tabs be discarded after opening

A

8 weeks

252
Q

Side effects of calcium channel blockers

A

Palpitation
Peripheral oedema
Gingivial hyperplasia
Flushing

253
Q

What should a patients INR ideally be if they wanna switch from warfarin to apixaban straight away

A

<2

254
Q

Name a long acting beta blocker

A

Nadolol

255
Q

How long would you expect a patient to be on Rivaroxaban for vte prophylaxis following a hip replacement

A

35 days

256
Q

What drug class is triamterene and what’s a counselling point

A

Potassium sparing diuretic

Urine may look slightly blue

257
Q

Patient presents with pulse of 100bpm whats first line to obtain rate control

A

Beta blocker- bisoprolol

258
Q

What’s the risk associated with NOAC and epidural

A

Haematomata- clotted blood

259
Q

What should salt intake be restricted to a day

A

6g

260
Q

How long is it recommended to exercise weekly

A

30 minutes 5 days a week

261
Q

What’s the recommended alcohol consumption units per week

A

14 units

262
Q

Whens it appropriate to sample blood to monitor digoxin levels

A

6 hours after an oral dose has been administered

263
Q

Which calcium channel blocker must be prescribed by brand?

A

Diltiazem at a strength >60mg

Nifedipine

264
Q

When should you stop taking amiodarone

A 
Abdominal pain or tenderness 
Clay coloured stools 
Dark urine 
Decreased appetite 
Fever 
Headache 
Nausea and vomiting 
Skin rash 
Swelling of the feet or lower legs 
Tiredness or weakness 
Yellow eyes or skin
265
Q

What’s the maximum daily dose of ramipril if the eGFR is between 30-60ml/ minute

A

5mg

266
Q

Warfarin colour tablets

A

0.5mg white
1mg brown
3mg blue
5mg pink

267
Q

What’s the interaction between warfarin and some anti epileptics

A

Phenytoin carbamazepine

Enzyme inducers so warfarin in metabolised faster reducing the INR

268
Q

What’s first line for primary prevention of CVD for people who have a 10% or greater Qrisk

A

Atorvastatin 20mg

269
Q

Which drug have an interaction with cranberry juice

A

Warfarin

270
Q

How should dipyridamole be stored and for how long after being opened

A

In it’s original container

Discarded 6 weeks after opening

271
Q

MHRA ALERT Which drug used for stable angina can cause serious skin, mucosa and eye and GI ulceration

A

Nicrandil

272
Q

What electrolyte needs to be particularly monitored with digoxin

A

Potassium

273
Q

What other medications interact with warfarin

A 
NSAIDs 
Fluconazole 
Statins 
Ciprofloxacin 
St. John’s wort 
Anti epileptics 
Alcohol 
Cranberry juice 
Vitamin K
274
Q

Cytochrome p450 Enzyme inducers (CRAPGPSS)

A 
Carbamazepine 
Rifampicin 
Alcohol 
Phenytoin 
Griseofulvin
Phenobarbital 
Smoking 
St. John’s wort
275
Q

Cytochrome p450 Enzyme inhibitors (SIC FACES DOMG)

A 
Sodium valproate 
Isoniazid
Cimetidine
Fluoxetine/ fluconazole
Amiodarone 
Chloramphenicol 
Erythromycin 
Suphonamides 
Diltiazem 
Omeprazole 
Metronidazole 
Grape fruit juice
276
Q

How is dabigatran stored?

A

Special container with a 4 month expiry

277
Q

Advice on taking ACEi or ARB while pregnant

A

Avoid

278
Q

Which beta blockers are once daily dosing (clue: BACoN)

A

Bisoprolol
Atenolol
Celiprolol
Nadolol

279
Q

What eGFR are Thiazide diuretics no longer effective

A

< 30

280
Q

Vasodilators used in angina prophylaxis

A

Long acting nitrate
Ivabridine
Nicorandil
Ranolazine

281
Q

How often is digoxin plasma concentration measured

A

Only if digoxin toxicity is suspected

282
Q

When can simvastatin be sold OTC

A

Men aged 55-70 with or without risk factors

Men aged 45-54 with one or more risk factors

Post menopausal women aged 55-70 with one or more risk factors

Risk factors: 
Smoker 
Family history 
Overweight 
South Asian family origin
283
Q

When can orlistat be sold OTC

A

18 and over

BMI above 28

284
Q

What’s first line for hypertension in pregnant women

A

Enalapril

Nifedipine or amlodipine for Afro Caribbean

285
Q

How does the dose of rosuvastatin vary based on ethnicity

A

The initial and maximum dose is lower for patients with asian origin

286
Q

Why might you use fondaparinux over enoxaparin for acs

A

OD

Don’t need to weight the patient

287
Q

Which diuretic causes increased calcium

A

Thiazide type diuretic

288
Q

What organs do ACEi protect

A

Cardio

Renal

289
Q

Why does a patient need to be fully anticoagulanted before electrical cardioversion is attempted

A

Cardioversion does not break down the blood clot so puts them at risk of a stroke

290
Q

Monitoring requirements for amiodarone

A 
Annual eye test 
Chest x ray before treatment 
Liver function every 6 months 
LFT every 6 months 
Thyroid function every 6 months 
BP and ECG (causes hypotension and bradycardia)
Serum potassium (causes hypokalaemia)
291
Q

Why is a loading dose required for digoxin

A

Due to the long half life

292
Q

What are the maintenance dosing of digoxin for different conditions

A

AF- 125- 250mcg OD

HF- 62.5-125mcg OD

293
Q

What’s the clinical sign for heparin induced thrombocytopenia from heparin use

A

30% reduction in platelet
Skin allergy
Thrombosis

294
Q

What action should you take when INR is too high or bleeding on warfarin

A

Hold warfarin and restart when INR is below 5

Iv vitamin k is given if bleeding and PO vitamin k of no bleeding

295
Q

What’s normal, stage 1,2 and 3 BP and Who should you treat with stage 1, 2 and 3 hypertension

A

Normal= 120/80 mmHg

Stage 1 = 140/90mmhg
(Offer lifestyle advice) Treat if under 80 with target organ damage or CVD or diabetes

Stage 2= 160/100mmhg
Treat all

Stage 3= 180/110mmhg
Hypertensive crisis must be treated promptly but care must be taken to not reduce BP too quickly

296
Q

What’s blood pressure target for pregnant women and first like for gestational hypertension

A

150/100mmhg
140/90mmhg of target organ damage or given birth

Labetalol used in gestational hypertension (hepatotoxic)

Alternative:
Methyldopa (stopped 2 days after birth)
MR nifedipine

297
Q

When should the first dose of ACEi and ARBs be taken

A

Take first dose at bedtime

298
Q

What effects do ACEi have on the kidney

A

Renopeotective

But also nephrotoxic

299
Q

Side effect of vasoconstrictor sympathomimetics

A

Reduced perfusion to vital organs

300
Q

What ARBs are licensed in HF

A

Candersartan

Valsartan

301
Q

What beta blocker is used in HF for 70+

A

Nebivolol

302
Q

What diuretic should be used in HF if the patient has renal failure

A

Loop> thiazide (egfr<30) is the cut off

303
Q

Which fibrate should not be given with statins as it has the highest risk of myopathy

A

Gemfibrozil

304
Q

What medications started when a patient gets a PCI

A

Aspirin lifelong

+

Clopidogrel

  • one month elective
  • 12 months bare metal
  • 12 month+ drug eluting stent
305
Q

What’s the most potent loop diuretic

A

Bumetanide

306
Q

Which thiazide diuretic can you give in a patient eith eGFR less than 30ml/min

A

Metolazone

307
Q

What is an electrolyte disturbance that loop and thiazide diuretics do not share

(Only thiazides have)

A

Hypercalacaemia

308
Q

What’s the most suited thiazide diuretic used in acute retention or patient that dislikes frequent urination

A

Chlortalidone

309
Q

Which BB has the shortest duration of action so can be cleared by the body fastest

A

Metoprolol

310
Q

What rate should furosemide iv be given

A

4mg/ml

Reduce risk of ototoxicity

311
Q

When is Noac preferred over warfarin in AF

A

Non- valvular AF with >1 risk factors

312
Q

What’s preferred in african people

Ace or arb

A

Arb

313
Q

What group of meds is associated with a lichen planus (rash)

A

Thiazide diuretics

314
Q

Which anticoagulation med requires dose adjustment when being given with verapamil

A

Verapamil

Pre-reg (27 decks)

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