Chapter 2- CVS Flashcards
How do you manage spontaneous etopic beats
If the patient has a normal heart treatment is rarely required. If they are particularly troublesome beta blockers are sometimes effective and the safest
What are the aims of treating atrial fibrillation?
Reduce symptoms
Prevent complication especially stroke
What should all atrial fibrillation patients be assessed for?
Risk of stroke (CHADVASC)
Bleeding risk (HASBLED)
And thromboembolism
What are the two ways that atrial fibrillation can be controlled?
Controlling the ventricular rate (rate control)
Or
Attempting to restore and maintain Sinus rhythm (rhythm control)
If drug treatment fails to control symptoms of AF what’s another option
Ablation strategies
How is cardioversion done
Electrical- direct current
Pharmacological- anti arrhythmic drug (eg amiodarone)
With patients presenting acutely with AF and life-threatening Haemo dynamic instability, what is offered
Electrical cardioversion- rhythm control
With patients presenting acutely with AF and without life-threatening Haemo dynamic instability, what is offered?
<48= rate or rhythm control
> 48= rate control (verapamil, BB)
What is given if urgent rate control is required in an atrial fibrillation patient
Beta blocker (not sotalol) or verapamil (rate limiting ca channel blocker) intravenously
What is electrical cardioversion and when is it used in atrial fibrillation?
How long should the patient be anti coagulated for?
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
What is the first line drug treatment strategy for maintenance AF
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)
How can ventricular rate be controlled
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
In life threatening haemodynamic instability, when anticoagulation for 3 weeks in not possible
What can you do
Electrical cardioversion
Give parenteral anticoagulation and rule out left arterial thrombus immediately before procedure
What drug combo do you use if ventricular function is diminished
Beta blocker and digoxin
What drug do you use if AF is accompanied with congestive heart failure
Digoxin
If drug treatment to restore sinus rhythm is needed post cardioversion what should be used
Beta blocker
If that’s not appropriate oral anti-arrythmic drug (soltalol) or amiodarone
What drug should be given in patients with with AF and left ventricular impairment or heart failure
Amiodarone
What is paroxysmal AF and that’s the treatment
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)
What are the different area anti-arrythmic drugs work on
Supraventricular arrhythmia (verapamil- rate limiting ca channel blocker) Ventricular arrhythmia (lidocaine) And both (amiodarone)
What is arrhythmia
Abnormal heart rhythm
What is supraventricular arrhythmia
Abnormally fast heart rhythm due to improper electrical activity in the upper part of the heart (most common type)
What is ventricular arrhythmia
Abnormal heartbeats that originate in the lower chamber of the heart called ventricles
What is amiodarone used for and one main advantage
Most arrhythmia
Advantage is it doesn’t cause myocardial depression
What drug class is sotalol and what is one of its main uses
Beta blocker
And management of ventricular arrhythmia
What are the main drugs used in supraventricular arrhythmia
Adenosine(anti arrhythmic) first line
Cardiac glycosides (digoxin)
Verapamil (rate limiting calcium channel blocker)
Common drugs used for ventricular arrhythmia
Iv Lidocaine (anti arrhythmic) (No longer first choice- supraventricular and ventricular drugs used now)
What drugs are used for both supraventricular and ventricular arrhythmia
Amiodarone (anti arrhythmic)
Beta blocker
Disopyramide
Flecainide
Difference between atrial fibrillation and atrial flutter
atrial fibrillation is mate chaotic and more irregular that can affect heart health
Atrial flutter is fast but usually regular rhythm
What is the Vaughan Williams classification of drugs for arrhythmias
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)
How is digoxin used and what for
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
Why is digoxin once-daily dosing
It has a long half life
Common side effects of digoxin
Nausea vomiting and blurred vision
Possible adverse affects of amiodarone and when should they be monitored
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
Why should Sotelol be avoided in asthmatic patients
They are not cardioselective so act on the beta receptors in the heart and peripheral vasculature (liver bronchi and pancreas)
Which beta-blockers would you prescribe if a patient is asthmatic
Atenolol or bisoprolol
What are the indications to beta-blockers have excluding cardiac
Anxiety and in the prophylaxis of migraine
When should verapamil and diltiazem be avoided
In heart Failure
Common side effects of calcium channel blockers
Headache flushing oedema and swelling of the ankles
What is the interaction between calcium channel blockers and Simvastatin
Increases the risk of myopathy
What drug class is diltiazem
Calcium channel blocker
What drug class is verapamil, how does it work and what is it used for
Calcium channel blocker
Used in the treatment of angina hypertension and arrhythmias
It slows the heart reduces cardiac output and impairs a V conduction
What should verapamil not be used with that diltiazem can be used with and why
Beta-blocker
Can cause hypotension and asystole
Common side effect of verapamil
Constipation
Important safety information for sotalol
May prolong the QT interval and it occasionally causes life-threatening ventricular arrhythmias also particular care is required to avoid hypokalaemia
What is digoxin most useful for
Controlling ventricular response in persistent and permanent atrial fibrillation and atrial flutter it also has a role in heart failure
What should the heart rate remain above when given digoxin
60 bpm
What is the most important determinant factor of digoxin dose
RenalFunction
How is sinus rhythm maintains post-cardioversion
With a standard beta-blocker
Sum up amiodarone
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
Give an example of an anti fibrinolytic drug and what’s it used for?
Tranexamic acid
Used to
prevent bleeding
Treat bleeding associated with excessive fibrinolysis (eg surgery)
Management of menorrhagia (heavy mensuration)
Epistaxis (nose bleeds)
Thrombolytic overdose
What’s the risk of a patient having oral contraceptives and tranexemic acid?
Increased risk of thrombosis
Of the drug class antihaemorrhagics, give an example of a haemostatic and what is it used for?
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
For coagulation facto deficiencies, what are the possible 9 coagulation proteins that can be offered?
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
What’s a subarachnoid haemorrhage
Bleeding with ing the subarachnoid space, which is between the brain and the tissue covering the brain
Which calcium channel blocker is given after a subarachnoid haemorrhage and why?
Nimodipine
To prevent and/ or treat ischaemic neurological defects following a subarachnoid haemorrhage
What is Venus Thromboembolism?
It includes deep vein thrombosis and pulmonary embolism and occurs as a result of thrombus formation in a vein
The two methods of thromboprophylaxis are mechanical and pharmacological
Give an example of a mechanical prophylaxis
Anti-embolism stockings
Which beta-blockers are cardioselective and preferred in asthmatics ( clue: BAMAN)
Bisoprolol Atenolol Metoprolol Nebivolol Aceburolol
Which beta-blockers are water-soluble (clue: SNAC) and what is the benefit of this
Sotalol
Nadolol
Atenolol
Celiprolol
Less likely to cause sleep disturbances and nightmares
Treatment for transient ischaemic stroke
Immediately: aspirin 300mg
Long term: Clopidogrel 75mg OD
Initiate statin 48hrs after
Treatment for ischaemic stroke
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
What’s a transient ischaemic attack
Mini stroke
Following an ischaemic stroke, what’s the BP target
<130/80mmHg
What drug class should not be started following a stroke to treat hypertension?
Beta blocker
Unless it’s indicated for a co-existing problem
When should a patient be given anticoagulation following intracerebral haemorrhage
If they’re at very high risk of a stroke or cardiac events
What are oral anticoagulation indicated for?
Thrombus formation or growth in the veins (due to the flow being slower moving and consisting of fibrin)
How does warfarin work and how long does it take?
Antagonises the effect of vitamin K and takes 48-72 hours
What do you do if you want to start a patient on warfarin but want immediate effect
Give the patient on unfractionated or LMWH concomitantly
What’s first line in artery thrombosis?
Aspirin
What is the preferred anticoagulation for vte prophylaxis of patients undergoing surgery
Unfractionated or LMWH
Why’s aspirin preferred over warfarin in arterial thrombi
Artery clots are mainly formed of platelets
What’s pulmonary embolism
Blocking the vein from the heart to the lungs
The main two types of VTE
Dvt and Pe
Three indications of warfarin
Treatment and prophylaxis of VTE
Atrial fibrillation
People with prosthetic heart valves
What conditions allow a target INR +/- 0.5 of 2.5
Treatment of DVT or PE
AF
Cardioversion
MI
What conditions allow a target INR +/- 0.5 of 3.5
Recurrent DVT or PE
Mechanical prosthetic heart valve
What do you do if patient has an embolism event while on warfarin and is being anticoagulated at the target INR
Consider increasing the INR target or adding an anti platelet drug
What’s the main adverse effect of all oral anticoagulants
Haemorrhage
What’s the antidote for major bleeding caused by warfarin
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
How long before an elective surgery should a patient on warfarin stop taking it
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)
Difference between unfractionated heparin and LMWH
Unfractionated has a shorter duration of action but initiates anticoagulation rapidly
When are standard heparin preferred over LMWH
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
When and Why are LMWH preferred over unfractionated heparins
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
3 types of LMWH
Dalteparin (thrombin inhibitor)
Enoxaparin (inhibit factor x)
Tinzaparin (inhibit factor x)
Example of a heparinoid and whens it’s used?
Danaparoid
Used for prophylaxis of DVT in patients who develop heparin induced thrombocytopenia
Antidote for unfractionated and LMWH
Idarucizumab
Binds to dabigatran to reverse the anticoagulant effect
Or protamine sulphate
What are antiplatelet drugs used for
Decrease platelet aggregation and inhibit thrombus formation in arterial circulation
When is the use of aspirin 75mg beneficial
Secondary prevention of cardiovascular events ( people who already have cardiovascular disease)
When is clopidogrel and aspirin used
Following an ST- elevated MI or for AF when warfarin is not suitable
When should aspirin be contraindicated or cautioned?
Contra indicated:
Children under 16
Signs of active peptic ulcer
Cautioned Asthmatics Uncontrolled hypertension History of peptic ulcer Elderly
What’s the interaction between all broad spectrum antibiotics and warfarin
They may all increase the risk of bleeding by killing off the bacteria in the gut responsible for making vitamin K
What’s the anticoagulant of choice following a hip/knee surgery or day surgery
Fondaparinux (inhibits factor Xa)
What’s the anticoagulation of choice for thromboprophylaxis after knee/ hip surgery
Dagibatran or Rivaroxaban
What’s the VTE prophylaxis of choice in pregnancy
LMWH
Lower risk of osteoporosis and heparin induced thrombocytopenia
Also doesn’t enter the placenta
What else can heparins cause excluding thrombocytopenia and osteoporosis
Hyperkalaemia- due to inhibition of of aldosterone secretion
List 4 NOACS
Rivaroxaban
Apixaban
Edoxaban
Dabigatran
All inhibit factor Xa
What abnormal side effects has come out for warfarin that will require the doctor to stop it
Skin rash- calciphylaxis
When are NOACs indicated
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
Possible causes of hypertension
Renal disease
Endo crime causes
Contributory factors
Risk factors
What measurements is diagnosis for stage one hypertension
140/90 mmHg or higher
What measurements is the diagnosis of stage two hypertension
160/100 mmHg or higher
What value is diagnosed as severe hypertension
180/110 or higher
What antihypertensive would you give patients under 55 who are not African or Caribbean
Ace inhibitor if this is not tolerated or for an angiotensin II receptor antagonist if both are not tolerated to consider a beta-blocker
What antihypertensive do you offer a patient under 55 with single treatment was not sufficient and they are not African or Caribbean
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
What antihypertensive treatment do you offer patients over 55 and patience of any age that African or Caribbean
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
When treating hypertension what might you consider adding to reduce cardiovascular risk
Aspirin or a statin
Note these are not used to control blood pressure
What’s the target blood pressure range for patients over 80 years old
Below 150/90 mmHg
What’s the blood pressure range for patients with diabetes
Below 140/80 but below 130/80 if kidneys, eyes, or cerebrovascular disease are also present
Why is antihypertensive treatment particularly important in Diabetic patients
It prevents macrovascular and microvascular complications
How renal disease affects hypertensive treatment
Ace inhibitor should be used with caution
Thiazides Diuretics may be ineffective
High doses of loop diuretics may be required
Give examples of drugs are safe to use for hypertension in pregnancy
Labetalol, methyldopa and Nifedipine modified release
Name three centrally acting antihypertensive drugs
Methyldopa
Moxonidine
Clondine
What are the main indications of angiotensin converting enzyme inhibitors
Heart Failure
Hypertension
Diabetic nephropathy
What is clonidine used for and what is an important counselling point
hypertension
Migraine
Menopausal flushing
Avoid Abrupt withdrawal as can cause rebound habitation
What is methyldopa used for and what should you monitor
Hypertension in pregnancy and monitor blood count and a LFT
How do you beta-blockers work
They blocked the beta adrenoreceptor in the heart peripheral vascularture Bronchi pancreas and liver
When are beta-blockers contraindicated
In patients with second or 3rd° heart block and should be avoided in patients with a worsening unstable heart failure
Which beta-blockers have less affect on the beta-2 receptors
(Clue: MANBA
Atenolol Bisoprolol metoprolol Nebivolol Acebutolol
When are beta-blockers indicated
Hypertension Angina Myocardial infarction Arrhythmias Heart Phalia Thyrotoxicosis Anxiety Prophylaxis of migraine
Which beta-blockers block the alpha and beta receptor
Carvedilol
Labetalol
What are common side-effects of beta-blockers
Fatigue, coldness of extremities, and sleep Disturbances.
Bradycardia and headaches
Common side effects of an Ace inhibitor
Dry cough
Rash, diarrhoea, constipation, hepatic impairment, hyperkalaemia
Should calcium channel blocker is be avoided in heart failure
Yes with the exception of amlodipine as they can further depressed cardiac function
What drug class is verapamil and what is it used for and how does it work
Calcium channel blocker
Treatment of angina hypertension and arrhythmia
It slows the heart, reduces cardiac output and impairs AV node conduction
Common side effects of verapamil and
what should it not be used with
Constipation
Beta blocker
What’s the use of calcium channel blocker in unstable angina
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
How do you calcium channel blocker is work
They reduce the inwards displacement of calcium irons therefore the heart contracting may be reduced the electrical impulses within the hall or depressed
Give some examples of vasodilators used in hypertension and when they are used
Hydralazine used for resistant hypertension
Sildenafil is licensed for use in pulmonary arterial hypertension
The 2 cardiovascular risk calculator
QRISK2
JBS3
Tell me about primary prevention of CVD for anti platelets, antihypertensives and lipid lowering therapy
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
Tell me about secondary prevention of CVD for anti platelets, antihypertensives and lipid lowering therapy
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
What is heart failure
Reduced cardiac output
Due to reduced (ventricle not contracting properly pushing out <40%) or preserved ejection fraction (ventricle to relaxing properly only mildly reduced)
Signs and symptoms of HF
Signs:
Elevated jugular venous pressure
Pulmonary crackles
Pulmonary oedema
Symptoms: SOB Fatigue Wheezing Persistent coughing Ankle swelling
Things you monitor in HF and non-drug treatments
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
Drug treatment for chronic heart failure with reduced ejection fraction
- Rate limiting CCB (verapamil + diltiazem)
- Diuretic to relieve breathlessness and oedema (usually looo diuretic like furosemide)
- BB that’s licensed for HF (eg bisoprolol)
- ACEi (eg ramipril) -> switch to ARB if ACEi not tolerated
- If HF symptoms persist despite all the above being added and optimised an aldosterone antagonist (eg: spironolactone) should be offered as add on
- If symptoms persist advise should be seeked for the use of amiodarone, digoxin (in patients with sinus rhythm digoxin is always recommended)
Monitoring requirements for initiating ACE inhibitors and ARB
Serum potassium, sodium, renal function and BP should be monitored
Monitoring requirements for initiating aldosterone antagonists
Serum potassium, sodium, renal function and BP should be monitored
Monitoring requirements for beta blockers when initiating
Heart rate
BP
Symptoms control
Drug treatment for chronic heart failure with preserved ejection fraction
Managed under heart failure specialist
For the relief of fluid retention symptoms a loop diuretic should be prescribed
Possible adverse affect for the use of spironolactone and ACEi
Spironolactone = potassium sparing diuretic
Both increase potassium so can cause hyperkalaemia
What effect does aldosterone inhibitors (potassium sparing diuretic) have on potassium (eg spironolactone)
Aldosterone increases the amount of potassium excreted in the urine, so the antagonist stops potassium being increased and increases potassium levels in the body
What’s the treatment for hypercholesterolaemia and hypertriglyceridaemia
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
What may be added to statins to reduce triglyceride concentration
Fibrates
How do you treat familial hypercholesterolaemia
Life long lipid modifying therapy and advice on lifestyle changes
What do you give for lipid therapy if statin and ezetimibe are both inappropriate
Fibrate or a bile acid sequestrant (eg: colestyramine)
Possible adverse effects of using a statin with fibrates
Muscle related side effects like rhabdomyolysis- breakdown of skeletal muscle
How do bile acid sequestrants work
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
How does ezetimibe work
It inhibits the intestinal absorption of cholesterol (mainly lowers LDL cholesterol)
What do fibrates do and give 2 examples
They decrease serum triglycerides (little effect on LDL cholesterol)
Eg: bezafibrate
Ciprofibrate
Fenofibrate
How do statins work
They completely inhibit (3-hydroxy-3-methylglutatyl coenzyme A reductive) an eczema involved in cholesterol synthesis- especially in the liver
What’s a common toxicity caused by statins
Muscle toxicity causing muscle pains
Why’s nifedipine not used in hypertension and angina
Short acting so causes reflex tachycardia
What’s the interaction with simvastatin and amlodipine and what’s the maximum recommended dose in conjugation with amlodipine, verapamil and diltiazem
Risk of myopathy- muscle weakness
Max for simvastatin= 20mg OD
When should a patient be put on lipid regulating drugs for primary prevention
Diabetic Over 85 >10% risk of CVD eGFR< 60 Family history Smokers
What does bile acid sequesterants interfere with
Absorption of fat soluble vitamins (a, d, k and folic acid)
Main adverse effects of statins
Myositis
Muscle effects
Liver toxicity
GI disturbances (Abdo pain, flatulence)
How is Omega 3 fatty acids used to help lower cholesterol
Used to reduce triglycerides as alternative to fibrate and additional to statin
Which beta blocker is not used for rate control
Sotolol
What is stable angina
Predictable chest pain or pressure from an increase in in myocardial oxygen demand
What is a drug treatment for acute attacks of stable angina
GTN spray
What is the drug treatment for long term prevention of chest pain in patients with stable angina
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)
What’s the secondary prevention of cardiovascular events for patients with angina
Low dose aspirin Statin Ace inhibitor (especially if they’re diabetic)
How does nicorandil work
It’s a potassium channel activator with vasodilation properties
Used as an anti- angina
What are the types of acute coronary syndrome
Unstable angina
NSTEMI
STEMI
What’s the long term management of unstable angina and NSTEMI
Aspirin and clopidogrel
Beta blocker
Ace inhibitor / ARB
High dose statin
What’s the initial management of patients presenting with an ACS (clue: M O A N)
Oxygen
Pain relief like morphine
Dual antiplatelet
Nitrates
Metoclopramide to prevent N+V
Heparin or LMWH
Long term management for patients that have had a STEMI
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
Adverse effects of nitrates
Flushing
Headache
Postural hypotension
How nitrates work and Examples of nitrates
Potent coronary vasodilators useful in treatment of angina
GTN
Isosorbide dinitrate
Isosorbide mononitrate
What is given for cardiopulmonary resuscitation
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
What are diuretics used for
Relieve oedema due to chronic heart failure and in lower doses to reduce blood pressure
When are loop diuretics indicated
In pulmonary oedema due to left ventricular failure and in patients with chronic heart failure
When is combination diuretic therapy effective
In patients with a team of resistant to treatment with one diuretic
MOA of thiazides
And Why are the thiazide diuretics usually given in the morning
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
What can loop diuretics exacerbate
Diabetes
Gout
What’s the drug action of Loop diuretics
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)
Which Thiazide is preferred in hypertension and which thiazide is preferred in congestive cardiac failure
Indapamide in hypertension
Bendroflymethiazide in CCF
How do tha use diuretics work and What adverse affects can thiazides have
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
What other drugs should you avoid giving thiazides with
Lithium- sodium depletion increases risk of toxicity
Beta blocker for hypertension for those with diabetes or at risk of developing diabetes
What’s the risk of rapid IV administration of loop diuretics
Can cause tinnitus deafness
What should loop diuretics not be given with as they can cause ototoxicity
Aminoglycosides (gentamicin or vancomycin)
How are potassium sparing diuretics and aldosterone antagonist used
Given with thiazide or loop diuretics for the retention of potassium instead of potassium supplements
Which Anti-depressant do you not give in MI (contra indicated)
TCA
Eg amytripiline
What’s the best prescribed SSRI after an MI
Sertraline
How are ADP receptor antagonist such as clopidogrel different in the mechanism of action to aspirin
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
What are common side effects of ADP receptor antagonist (clopidogrel, ticagrelor, prasugrel)
Bleeding
Gastrointestinal upset
Thrombocytopenia
What is an important interaction for ADP receptor antagonist
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
How long does it take for clopidogrel to reach its full antiplatelet effect
Seven days
What are the most common adverse effects of aspirin
Gastrointestinal irritation Peptic ulceration Haemorrhage Bronchospasm Tinnitus in regular high dose (ringing in the ear)
When should aspirin not be given
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
How long should the loading dose of 300mg aspirin be for acute coronary syndrome and for acute ischaemic stroke
Acs= once only
Stroke= 14 days
How can you minimise gastric irritation from aspirin
Prescribe a proton pump inhibitor and it should be taken after food
Name four direct oral anticoagulation and when they are indicated
Apixaban
Dabigatran
Edoxaban
Rivaroxaban
Used for:
VTE (DVT and PE)
AF
How do you go four direct oral anticoagulation is work
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
Which DOAC must be taken with food as it affects its absorption
Rivaroxaban
Give examples of fibrinolytic drugs and their indication
Alteplase and streptokinase
Indications include:
Stroke
ST elevated Myocardial infarction
Massive pulmonary embolism
Alpha blockers examples, use and adverse effects
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)
Important adverse effects of aldosterone antagonists
Hyperkalaemia
Gynaecomastia (breast)
Example of an aldosterone antagonist and How do aldosterone antagonists work
Spironolactone
Inhibits the effect of aldosterone by Binding to the aldosterone receptor to increase sodium and water excretion and potassium retention (potassium sparing diuretic)
When is atropine indicated
Severe or symptomatic bradycardia to increase heart rate
What are intravenous nitrates for
Treatment of pulmonary oedema in combination with furosemide oxygen and a strong opioid (eg morphine)
How can you differentiate supraventricular and ventricular arrhythmia from an ECG
Supraventricular has a narrow QRS complex where as ventricular has a wide QRS complex
What’s the overall aim of diuretics for BP
Increase sodium excretion to increase water excretion in turn lowering blood pressure
What transporters do the different diuretics inhibit and where are they located
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
What are the three types of atrial fibrillation
Paroxysmal AF- episodes stop within 48 hrs without treatment
Persistent AF- episodes last >7 days
Permanent AF - present all the time
Torsade de pointes is prolonged QT interval, what causes this and what’s the treatment?
Cause
Sotalol, hypokalaemia, bradycardia
Treatment
Magnesium sulphate
When is IV adenosine contra indicated for supraventricular arrhythmia
What’s an alternative
Asthma and copd
Verapamil
Initial loading dose for amiodarone
200mg tds for 7 days
200mg bd for 7 days
200mg od as maintenance
Side effects of amiodarone
Nausea Vomiting Taste disturbance Pulmonary toxicity Reversible corneal micro deposits Phototoxicity Slate grey skin Tremor Sleep disorder Hyper/hypothyroidism Jaundice
What are the interactions with digoxin (clue: C R A S E D)
Calcium channel brockers Rifampicin Amiodarone (half digoxin dose) St. John’s wort Erythromycin Diuretics
What should you avoid giving in intracerebral haemorrhage
Aspirin
Statin
Anticoagulation
What’s the only ACEi that’s taken twice daily
Captopril
Which ACEi is taken before food
Perindopril
What drug classes should be avoided in acute kidney injury (clue: D A M N)
Diuretics
Ace inhibitors /ARBs
Metformin
Nsaids
Vasodilator antihyperrensives
Hydralazine
Minoxidil
Which BB have intrinsic sympathomimetic activity
Advantages of this
Clue: PACO
Pindolol
Acebutol
Celiprolol
Oxprenolol
Less bradycardia and less coldness of extremities
Drug causes for hyperlipideamia
Antipsychotics
Immunosuppressant
Corticosteroids
HIV drugs
Why should statins be taken at night, what’s the exception?
Cholesterol synthesis greater at night so more effective
Atorvastatin
What’s the MHRA warning for simvastatin 80mg
High risk of myopathy
Give only if high risk of CV complications or severe hypercholesterolaemia and treatment goals not achieved at lower dose
What limits should be assessed for statin treatment and when should it be stopped
Creatinine kinase (5x above upper limit) Liver function (3x above upper limit) Hb1ac Lipid profile Thyroid function Renal function
What antibiotics drug class can you not take with statin
Macrolide
What are a few statin dose adjustment due to drug interaction
Simvastatin
Max 10mg with fibrate
Max 20mg with amiodarone amlodipine diltiazem verapamil
Atorvastatin
Max 10mg with ciclosporin
Rosuvastatin
Max 20ng with clopidogrel
Why are diuretics usually taken in the morning?
To avoid sleep disturbances
What’s a use of spironolactone not related to the heart
Ascites in liver failure
Two types of peripheral vascular diseases and what’s given for each
OCCLUSIVE (peripheral artery disease)
Low dose aspirin and a statin
VASOSPASTIC (Raynauds syndrome)
Stop smoking and avoid exposure to Cold
Nifedipine
For you thrombocytopenia, platelet counts are recommended if the patient is receiving Heparin for how long
Longer than 5 days
A statin is indicated when serum total cholesterol concentration is
> or = 5mmol/L
What can you give if amiodarone causes hyperthyroidism
Give carbomazole and withdraw amiodarone
Interactions with amiodarone
Grape fruit Warfarin phenytoin digoxin Statins (myopathy) BB, rate limiting CCB (myocardial depression) Drugs with QT prolongation
Signs of toxicity with digoxin (slow and sick)
(Worsened with HypO k+, mg2+,
HypER ca2+)
Bradycardia/ heart block Blurred or yellow vision Nausea vomiting diarrhoea Abdo pain Confusion Rash
What’s the only CCB licensed in arrhythmias
Verapamil
When should primary prevention be offered when assessing 10year CVD risk score
> 10%
What’s the hyperlipidaemia diagnosis
6mmol/L total cholesterol
What’s the patient counselling point for taking a lipid regulating drug with a macrolide antibiotic
Stop taking statin until antibiotic course completed
The others avoid
Counselling for taking a statin with fusidic acid
Restart 7 days after last oral dose
Interaction of bile acid sequestrants
Impairs absorption of fat soluble vitamins and other drugs
Take other drugs 1 hour before or 4 hours after
What do you switch spironolactone to if the patient gets gynaecomastia
Eplrenone
Dose and strength when you initiate treatment with amiodarone
200mg TDS 1 week
200mg BD 1 week
200mg OD thereafter
What blood parameter do you need when you prescribe warfarin
Prothrombin time (PTT)
Rivaroxaban treatment dose for VTE
15mg BD for 21 days
Then 20mg OD
A normal expected side effect for nitrates
Headache as it’s a vasodilator so increased blood flow to head
How do you maintain effectiveness of nitrates by reducing tolerance
Twice a day dosing, take second dose after 8 hours not 12
This leaves a period of 4-12 hours with low levels
What’s a suitable beta blocker in pregnancy
Labetalol
What’s the MHRA alert for NSAID piroxicam
Do not exceed 20mg OD
Can you give atorvastatin to an ACS patient taking a short course of clarithromycin
Yes but max 20mg
If not ACS withhold for the Clari period
What’s the different duration for different indication of warfarin
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
Why does Rivaroxaban need to be taken after food?
Increased risk of GI Bleeds
Which DOAC Is pH dependent
Dabigatran
What is given for cardiopulmonary resuscitation
30 compressions for every 2 breaths
~100 compressions/min
When should GTN SL tabs be discarded after opening
8 weeks
When should GTN SL tabs be discarded after opening
8 weeks
Side effects of calcium channel blockers
Palpitation
Peripheral oedema
Gingivial hyperplasia
Flushing
What should a patients INR ideally be if they wanna switch from warfarin to apixaban straight away
<2
Name a long acting beta blocker
Nadolol
How long would you expect a patient to be on Rivaroxaban for vte prophylaxis following a hip replacement
35 days
What drug class is triamterene and what’s a counselling point
Potassium sparing diuretic
Urine may look slightly blue
Patient presents with pulse of 100bpm whats first line to obtain rate control
Beta blocker- bisoprolol
What’s the risk associated with NOAC and epidural
Haematomata- clotted blood
What should salt intake be restricted to a day
6g
How long is it recommended to exercise weekly
30 minutes 5 days a week
What’s the recommended alcohol consumption units per week
14 units
Whens it appropriate to sample blood to monitor digoxin levels
6 hours after an oral dose has been administered
Which calcium channel blocker must be prescribed by brand?
Diltiazem at a strength >60mg
Nifedipine
When should you stop taking amiodarone
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
What’s the maximum daily dose of ramipril if the eGFR is between 30-60ml/ minute
5mg
Warfarin colour tablets
0.5mg white
1mg brown
3mg blue
5mg pink
What’s the interaction between warfarin and some anti epileptics
Phenytoin carbamazepine
Enzyme inducers so warfarin in metabolised faster reducing the INR
What’s first line for primary prevention of CVD for people who have a 10% or greater Qrisk
Atorvastatin 20mg
Which drug have an interaction with cranberry juice
Warfarin
How should dipyridamole be stored and for how long after being opened
In it’s original container
Discarded 6 weeks after opening
MHRA ALERT Which drug used for stable angina can cause serious skin, mucosa and eye and GI ulceration
Nicrandil
What electrolyte needs to be particularly monitored with digoxin
Potassium
What other medications interact with warfarin
NSAIDs Fluconazole Statins Ciprofloxacin St. John’s wort Anti epileptics Alcohol Cranberry juice Vitamin K
Cytochrome p450 Enzyme inducers (CRAPGPSS)
Carbamazepine Rifampicin Alcohol Phenytoin Griseofulvin Phenobarbital Smoking St. John’s wort
Cytochrome p450 Enzyme inhibitors (SIC FACES DOMG)
Sodium valproate Isoniazid Cimetidine Fluoxetine/ fluconazole Amiodarone Chloramphenicol Erythromycin Suphonamides Diltiazem Omeprazole Metronidazole Grape fruit juice
How is dabigatran stored?
Special container with a 4 month expiry
Advice on taking ACEi or ARB while pregnant
Avoid
Which beta blockers are once daily dosing (clue: BACoN)
Bisoprolol
Atenolol
Celiprolol
Nadolol
What eGFR are Thiazide diuretics no longer effective
< 30
Vasodilators used in angina prophylaxis
Long acting nitrate
Ivabridine
Nicorandil
Ranolazine
How often is digoxin plasma concentration measured
Only if digoxin toxicity is suspected
When can simvastatin be sold OTC
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
When can orlistat be sold OTC
18 and over
BMI above 28
What’s first line for hypertension in pregnant women
Enalapril
Nifedipine or amlodipine for Afro Caribbean
How does the dose of rosuvastatin vary based on ethnicity
The initial and maximum dose is lower for patients with asian origin
Why might you use fondaparinux over enoxaparin for acs
OD
Don’t need to weight the patient
Which diuretic causes increased calcium
Thiazide type diuretic
What organs do ACEi protect
Cardio
Renal
Why does a patient need to be fully anticoagulanted before electrical cardioversion is attempted
Cardioversion does not break down the blood clot so puts them at risk of a stroke
Monitoring requirements for amiodarone
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)
Why is a loading dose required for digoxin
Due to the long half life
What are the maintenance dosing of digoxin for different conditions
AF- 125- 250mcg OD
HF- 62.5-125mcg OD
What’s the clinical sign for heparin induced thrombocytopenia from heparin use
30% reduction in platelet
Skin allergy
Thrombosis
What action should you take when INR is too high or bleeding on warfarin
Hold warfarin and restart when INR is below 5
Iv vitamin k is given if bleeding and PO vitamin k of no bleeding
What’s normal, stage 1,2 and 3 BP and Who should you treat with stage 1, 2 and 3 hypertension
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
What’s blood pressure target for pregnant women and first like for gestational hypertension
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
When should the first dose of ACEi and ARBs be taken
Take first dose at bedtime
What effects do ACEi have on the kidney
Renopeotective
But also nephrotoxic
Side effect of vasoconstrictor sympathomimetics
Reduced perfusion to vital organs
What ARBs are licensed in HF
Candersartan
Valsartan
What beta blocker is used in HF for 70+
Nebivolol
What diuretic should be used in HF if the patient has renal failure
Loop> thiazide (egfr<30) is the cut off
Which fibrate should not be given with statins as it has the highest risk of myopathy
Gemfibrozil
What medications started when a patient gets a PCI
Aspirin lifelong
+
Clopidogrel
- one month elective
- 12 months bare metal
- 12 month+ drug eluting stent
What’s the most potent loop diuretic
Bumetanide
Which thiazide diuretic can you give in a patient eith eGFR less than 30ml/min
Metolazone
What is an electrolyte disturbance that loop and thiazide diuretics do not share
(Only thiazides have)
Hypercalacaemia
What’s the most suited thiazide diuretic used in acute retention or patient that dislikes frequent urination
Chlortalidone
Which BB has the shortest duration of action so can be cleared by the body fastest
Metoprolol
What rate should furosemide iv be given
4mg/ml
Reduce risk of ototoxicity
When is Noac preferred over warfarin in AF
Non- valvular AF with >1 risk factors
What’s preferred in african people
Ace or arb
Arb
What group of meds is associated with a lichen planus (rash)
Thiazide diuretics
Which anticoagulation med requires dose adjustment when being given with verapamil
Verapamil
