CV Flashcards
1
Q
What’s the 2 methods for prophylaxis management?
A
Pharmacological Mechanical (IPU intermittent pneumotic compression stockings
2
Q
When is mechanical vte prophylaxis contraindicated?
A
Peripheral arterial disease
Peripheral neuropathy
Severe leg oedema
Local conditions e. G. Gangrene, dermatitis
3
Q
When would you use fondeparinux for vte prophylaxis?
A
When having abdominal and cardiac surgeries
4
Q
How long would you have vte prophylaxis after the surgery?
A
More than 7 days usually or until sufficient mobility
28 days for abdominal cancer
30 days for spine surgery
5
Q
What’s the vte prophylaxis plan for elective THR?
A
LMWH for 10 days followed by low dose aspirin for a further 28days
Or
LMWH for 28 days + mechanical stocking TED until discharge
Or
Rivaroxaban
6
Q
What’s the VTE prophylaxis plan for TKR?
A
Low dose aspirin for 14 day Or LMWH for 14 days + TED until discharge Or Rivaroxaban
7
Q
What’s the bridging process?
A
Give heparin and warfarin for at least 5 days or until the INR is over 2 for at least 24hrs,
8
Q
How would you give warfarin if
Need for rapid acting
For AF
For immediate effect
A
5 or 10mg od for 2dsys and the base on INR
Achieve anticoag in 3to4wks via 1 to 2mg od, then base on inr
Use heparin/LMWH for bridging, usually heparin
9
Q
How long would you take warfarin for Isolated calf DVT Provoked VTE Unprovoked DVT or PE Recurrent DVT/PE AF Heart valve?
A
6wks
3 months
3motnhs or 6 months to long term possibility
Long term for last 3
10
Q
What to do if a surgery is going to take place and pt is taking warfarin?
A
If elective, stop 5 days before surgery
Phytomenadione day before if inr is over 1.5
Bridging LMWH if high risk
If emergency, delay 6 to 12hrs + Phytomenadione
If emergency, no delay then prothrombin + Phytomenadione
11
Q
Why is LMWH preferred more than heparin?
A
Lower risk of osteoporosis and thrombocytopenia
12
Q
What’s the specific antidote for LMWH?
A
Protaminesulfate
13
Q
Other than ACS, what can cause an increase in troponium?
A
Sepsis
Inflammatory disease
14
Q
What’s the MHRA warning on nicorandil?
And another warning?
A
MHRA gives a second line risk of ulcer complications on mouth, skin, eye and GI
Do not drive until it is established that performance is not impaired
15
Q
In a hypertensive emergency, by how much do you have to reduce your BP? Within what hors?
A
20-25% within 24hrs
Hypertensive emergency is high BP with organ damage.
16
Q
What happens if you reduce BP too rapidly?
A
Hypotension crisis leading to cerebral infarction, blindness, deterioration in renal function, MI
17
Q
How to manage hypertensive emergency?
A
Sodium nitroprusside (unlicensed)
Nicardipine
Labetalol
Hydralazibe
18
Q
How to manage hypertensive urgency?
A
High BP over 180/110 without organ damage
Lavetalol
CCB
Amlodioibe, felodipine
19
Q
How do you treat hypotension shock?
A
Volume replacement if haemorrhage, sepsis but Not in cardiac shock
Use of sympathomimetics inotropes like adrenaline, dopamine but Not in haemodynamically stable pts as can cause cardiogenic shock
Vasoconstrictor e. G. Noradrenaline, norepinephrine
20
Q
What antihypertensive drugs are not advised to be used together?
A
BBs and diuretics
21
Q
For pts over 55 it African origin, who has high risk of Hf, what’s first line?
A
Thiazide like diuretics
22
Q
What’s the normal BP?
A
120/80
23
Q
What to do if BP is 140/90?
A
Offer lifestyle advice
Only treat if under 80 with target organ damage, 10yr CVD risk is over 20, renal disease, diabetic
24
Q
When do you start Hypertension treatment no exception?
A
When BP 160/100
25
What's the target BP for under 80 with atherosclerotic CVD?
130/80
26
What's the target BP in renal disease?
Below 140/90
Below 130/80 if CKD, diabetes, proteinuria of more than 1g in 24hrs (consider ACEi/ARB if proteinuria exist)
27
What's the target BP in diabetes?
140/90
130/80 if complications with eye, kidney, or cerebrovascular disease
28
Target BP for pregnant lady?
150/100
140/90 if target organ damage or given birth
29
Hypertension treatment for pregnant ladies?
```
Labetalol = hepatotoxic but first linr
Methyldopa = stop 2 days after birth
Mr nifedipine (unlicensed)
```
30
ACEi is taken OD except which drug
Captopril BD
31
Special way of taking perindopril?
Take 30-60mins before food
32
Higher risk of Hyperkalaemia when taking ACEi in what condition?
Renal impairment and diabetes
33
What kind of anaphylaxis shock does ACEi cause?
Angiodema
34
What drugs can cause acute kidney injury?
Diuretics
ACEi /ARBs
Metformin
NSAIDS
35
What hepatic effect does ACEi have?
Can cause jaundice, hepatic failure
| Stop ACEi if liver transaminases is 3x normal or jaundice occurs
36
What side effects does ACEi cause?
Oral ulcer, taste disturbance and hypoglycaemia
37
Which drugs are centrally acting antihypertensives?
Methyldopa
Clonidine
Monoxidine
38
Side effect of Methyldopa?
Drowsiness so careful driving
39
Side effect of Clonidine?
Flushing
40
What drugs are vasodilator antihypertensives?
Hydralazine
| Minoxidil
41
Side effect of hydralazine?
Fluid retention, tachycardia
| Don't use monotheraoy, always as adjunct e as on its own it can Cause the above side effect
42
Side effect of minoxidil?
Tachycardia, fluid retention and increase cardiac output
43
Side effects of BBs?
Bradycardia
Hypotention
Affected carbohydrate metabolism (hypo or hyperglycaemia)
Masks symptoms of Hypoglycaemia such as tremor, tachycardia
44
Who cannot use BBs?
Asthma as it can cause bronchospasm (eye drops can as well)
| Worsening unstable HF and heart block pts as BBs can depress the myocardium
45
Interaction between verapamil and BBs?
With verapamil injection, asystole and hypotention
| Also a risk of participating HF when used together in established ischaemia heart disease
46
Interaction between thiazide like diuretics and BBs?
Hyperglycaemia so avoid in diabetes
| COC and corticosteroids too
47
What's advice regarding nifedipine dispensing?
Maintain the same Mr brand
48
What's the overdose symptons of BBs?
Light-headedness, dizziness, syncope, bradycardia, hypotention
49
Side effects of CCBs?
Ankle swelling,
| Vasodilation side effects such as flushing, headaches (becomes less after a dew days)
50
When should you avoid rate limiting CCBs?
In HF bc they can further depress cardiac function and execerbate HF
51
Side effect of verapamil?
Constipation
| Only CCB licensed for arrhythmia
52
Dispensing caution on diltiazem
Maintain on same brand when doses over 60mg
53
Food interaction with CCB?
Grapefruit juice works as an enzyme inhibitor and increases CCB conc.
54
MHRA warning on hydrochlorothiazide?
Dose dependent increased risk of non melanoma skin cancer esp if long term
Limit exposure to sunlight and examine suspicious moles
55
Who cannot take propafenone?
Asthma, severe COPD
| Structural/ischaemia disease
56
Why can you not give rhythm control after 48hrs of onset?
Increased risk of stroke
57
What to do if ot us life threatening haemodynamically unstable?
Electrical cardioversion
58
What to give for paroxysmal and symptomatic afib?
Ventricular or rhythm control live BB or antiarrthmic drugs
Pill in poker like flecanide or propafenone is infrequent paroxysmal afib
59
How to treat atrila flutter?
Similar treatment as Afib but catheter ablation more suitable
60
What to give in pulse less or fibrillation?
Immediate defibrillation + CPR
IV amiodarone is given refractory to defibrillation
61
What to give in unstable sustained ventricular tachycardia?
Direct current cardioversion
| If this fails, give IV amiodarone and repeat direct current
62
What to give in stable sustained ventricular tachycardia?
IV antiarrthmic drug (amiodarone preferred)
63
What to give in non sustained ventricular trlachycardia?
Bb
64
Maintainance treatment for pts at high risk of cardiac arrest?
Most pts nerd cardiovascular defibrillator implant
| Some pts also require a drug; sotalol, BB alone or BB with amiodarone
65
What is torsade de pointes?
Prolonged QT interval
66
Treatment of torsade de pointes?
Magnesium sulphate
67
What causes torsade de pointes?
Sotalol and other drugs that prolong QT interval
Hypokalaemia
Bradycardia
68
How to manage paroxysmal superventriculat tachycardia?
Terminates spontaneously or with reflex vagal nerve stimulation e.g. Immersing face in ice, carotid sinus massage
2nd line is IV adenosine
3rd line is IV verapamil
If haemodynamically unstable = direct current cardioversion
If recurrent=catheter ablation or drugs e.g. Verapamil, diltiazem, BBs, flecanide or propafenone
69
IV adenosine is contra indicated against?
Cops asthma
70
Amiodarone has an extremely long half life, how long?
Up to 50 days
| So danger of interactions several months after stopping
71
Grapefruit act as an inducer or inhibitor to amiodarone?
Inhibitor
72
Is amiodarone an inhibitor or inducer?
Inhibitor
73
Interaction between digoxin and amiodarone?
Half dose of digoxin
74
Interaction between amiodarone and stations?
Increased risk of myopathy
75
Interaction between amiodarone and BBs?
Bradycardia, AV block and myocardial depression
76
Interaction between rate limiting CCBs and amiodarone?
Bradycardia, AV block and myocardial depression
77
What drugs contribute to QT prolongation?
```
Quinolones
Macrolides
TCAs
SSRIs
Lithium
Quinine
Hydroxychloroquinr
Antimalatials
Antiosychotics
```
78
Digoxin's therapeutic levels? When to take it?
1-2mcg/l
6hrs after dose
Regular monitoring is not required during maintenance unless toxicity suspected or in renal impairment
79
Digoxin dose for atrial flutter and non paroxysmal AF in sedentary pts?
125-250mcg
80
Digoxin dose for Worsening or severe heart failure?
62.5-125mcg
81
What electrolyte imbalance increase the risk of digoxin toxicity
```
Hypokalaemia
Hypomagnesium
Hypoxia
Hyoercalcaemia
Renal imapirment
```
82
What drug has the potential to increase plasma digoxin and predispose toxicity?
Amiodarone so half digoxin dose
Rate limiting CCBs
Enzyme inhibitors
83
Main digoxin drug interactions?
CRASED
```
CCBs rate limiting
Rifampicin
Amiodarone
St John's wort
Erythromycin
Diuretics
```
84
How to recognise stroke/TIA outside of hospital?
FAST
F=face = may droop on one side, not able to smile, mouth or eye dropped
A=arms=cannot be lifted or keep them lifted bc of weakness or numbness
S=speech=slurred speech
T=time to call 999
85
How to recognise stroke/TIA in hospitals?
Use of online tool ROSIER
Recognition of Stroke In the Emergency Room
Has there been LOC or syncope?
Any seizures activity?
FAS symptoms
Visual field defects
86
What's TIA?
Mini stroke which resolves within 24hrs
87
Initial management of TIA?
Aspirin 300mg stat
If C/I even if with PPI, clopidogrel 75mg OD but unlicensed
Investigation required within 24hrs
88
Long term treatment of TIA?
Clopidogrel 75mg OD
If C/I dipyridamole MR + aspirin + PPI
If aspirin also C/I = dipyridamole MR only
89
Dose of dipyridamole?
MR200mg BD preferably with food
90
Side effects of dipyridamole?
Diarrhoea, headache, hot flush, hypotention, nausea
91
Storing info on dipyridamole?
Should be dispensed in OP as desiccant and any remains should be discarded 6wks after opening
92
Initial management of ischaemia stroke?
Alteplase within 4.5hrs
Aspirin 300mg within 24hrs of thrombolysis or within 48hrs if not receiving thrombolysis
Clopidogrel if C/I unlicensed
Anticoagulation if at high risk of VTE
93
AF pt who had TIA, what to do with their Anticoagulants?
Stop Anticoagulant for 7days and substitute with aspirin
94
Why hypertention treatment only in emergency (if hypertensive crisis) with pts who just had a TIA?
Can cause decreased cerebral perfusion
95
Dose of alteplase?
900mg/kg over 60mins
96
Side effect of alteplase?
Risk of haemorrhage if serious bleeding stop use
| Anaphylaxis
97
What's HF?
Structural or functional abnormalities of the heart, resulting in reduced cardiac output
Normally the left ventricule loses its ability to contract normally leading to reduced EF but sometimes it loses the ability to relax and this leads to a normal EF
98
How to manage fatigue in HF?
IV iron if confirmed anaemia
| Oral Iron isn't absorbed well in HF
99
What is NT proBNP?
N terminal Pro B type natriunetic peptide is produced in the heart and released when the heart is working hard
Measured when HF is suspected
100
Refer pt if there NT proBNP value is over?
400ng
101
What kind of pts have reduced NT proBNP?
Obesitiy
African
Treatment with diuretics, ACEi ARB, BBs, mineralcorticoid receptor antagonist
102
What kind of pts have increased NT proBNP?
```
Over 70
Tachycardia
COPD
Diabetes
Liver cirrhosis
Exercise
Renal dysfunction
```
103
After how long is HF considered to be stable of chronic?
When symptoms remain unchanged for at least a month
104
What's the normal range of EF?
55% - 65%
105
How to calculate EF?
Amount of blood pumped out /amount of blood in chamber
106
Non drug treatment of Hf?
```
Cardiac rehabilitation like exercise and diet
Limit fluid intake to no more than 2L
Daily weight check
Reduced salt intake
Reduce alcohol consumption
```
107
Why dose rate limiting CCBs need to be avoided in HF?
They reduce cardiac contractility
108
How does loop diuretics work?
Act in the limb of the loop of Henle
| Inhibits the NaKCL Co transporter to increase excretion of Na, K and Cl
109
How does thiazide diuretics work?
Act on the proximal part of the distal tubule
| Inhibits the NACL Co transporter thus increases excretion of Na and urine volume
110
How does potassium sparing diuretics work?
Act on the distal convoluted tubule either by aldosterone antagonism (aldosterone antagonists like spironolactone and eplerenone) or direct inhibitor of epithelial sodium channell (amiloride)
111
Side effects of loop diuretics?
```
Fluid imbalance
Electrolyte imbalance (Hypokalaemia, Hyppnatraemic, hypochloride)
Hypotention
Rash
Hyperglycaemia
Raised serum creatinine
Headache
Dizziness
Tinnitus, deafness
Blood dyscrasia
```
112
Side effects of thiazide diuretics?
```
Electrolyte depletion like hypokalaemia, Hypomagnesium, this results in arrhythmia
Postural hypotention
Hyperuricaia
Hyperglycaemka
Impaired renal function
Impaired exercise tolerance
Erectile dysfunction (unknown mechanism)
Skin rash
Thrombocytopaenia
```
113
Specific side effect of bumetanide?
Gynecomastia
114
Side effects of k sparing diuretics?
```
Hyperkalaemia
Hyponatraemia
GI disturbances
Hypotention
Dry mouth
Confusion
Rash
```
115
1st line in HF treatment?
ACEi/ARB and beta blocker
| up titrate to minimum tolerated doses
116
Which ARB are licensed for HF?
Candesartan
| Valsartan
117
Which BBs are recommended for all grades if LVSD?
LSVD is an impairment of left ventricular performance
Bisoprolol
Cardevilol
118
What's recommended for mild to moderate HF over 70?
Nebivolol
119
2nd line HF treatment? And when to add it
If still symptomatic and LVEF is below 35%
Add MR antagonist, spironolactone
120
3rd line treamtnet of Hf is able to tolerate ACEi?
Enreresto (ARNI) to replace ACEi if still symptomatic and LVEF is below 35 %
121
3rd line treatment if sinus rhythm and HR is over 75bpm
Ivabradine
122
4th line treatment?
Digoxin
Or a heart transplantation
123
Rampirl dose for HF?
1.25-10mg
124
thiazide diuretics are ineffective if?
Renal failure below 30
125
For fluid overload, for symptomatic treatment of Hf, what should be added?
Loop diuretics or thiazide for mild HF
126
How to manage dose of ACEi for HF treatment?
Titrate every 2wks to highest tolerated dose
127
Monitoring ACEi in HF?
Urea and electrolytes, BP within 2wks of titration
| Max 50% rise in Cris acceptable. If more, reduce or stop
128
ACEi is contra indicated in?
Bilateral renal artery stenosis
Renal disease
Pregnancy
129
What does entresto contain?
Valsartan and sabcutiril
130
Side effects of entresto?
Symptomatic hypotention
Hyperkalaemia
Renal impairment
131
When can you start entresto?
Use 36hrs post ACEi or 1 day post ARB
132
Entresto is contra indicated in?
Pts with serum K level of over 5.4
Known history of angiodema related to previous ACEi or ARB therapy
Hereditary or idiopathic angiodema
Severe hepatic impairment, biliary cirrhosis and cholestasis
2nd and 3rd trimester of Preganancy
133
Side effects of BB?
```
Fatigue
Bradycardia
AV block
Postural hypotention
Bronchispasm
Vasoconstriction
Cold extremities
CNS effects (headache, dizziness)
Sleep disturbance = nightmare
Masks Hypoglycaemia
```
134
Dose advice on BBs for HF?
Gradually titrate up to maximum tolerated dose, titrate every 2wks
Do not stop suddenly
135
Monitoring for BB in HF?
Urea and electrolytes
HR
BP
Within 2wks of titration
136
Dose of spironolactone? Eplerenone?
25-50mg OD
| 25-50mg OD
137
Typical combination of drugs in HF treatment?
ACEi /ARB + BBs + MRAs + diuretics
138
General advice about HF treatment drugs?
Avoid NSAIDs as can lead to fluid retention
Low salt diet advised
Caution if taking aspirin unless indicated
139
Dose of Ivabradine for HF?
5-7.5mg BD
140
Side effects of Ivabradine?
```
Phosphenes (bright illuminations in the periphery of the visual field)
Blurred vision
Bradycardia
AV block
AF
BP change
Headache
Dizziness
```
141
Ivabradine is C/I in?
AF
Pregnancy as teratogenic
Enzyme inducer and inhibitors
142
Dose advice on Ivabradine?
Titrate every 2wks
If HR below 50 bpm 2.5mg BD
If HR 50-60 bpm 5mg BD
If HR over 60bpm 7.5mgBF
143
Dose of Ivabradine for over 75?
2.5mg BD
144
How to load digoxin in HF? Then it's maintenance dose?
Load with 500mcg BD Then OD
| Maintenance is 65mcg if creatine over 200, 125mcg if creatine below 200
145
Signs and symptoms of Hf congestion?
```
Increased breathlessness
Fatigur
Weight gain of over 1kg in 3 days
Tachycaedia
Pulmonary oedema
```
146
Dose of furosemide for HF? Bumetanide?
40mg up to 240mg is persistent
1mg up to 5mg if persistent
147
Equivalent dose of furosemide and bumetanide?
40mg=1mg
148
Who requires primary prevention of CV?
Type 1 diabetes
Type 2 diabetes only if CVD risk is over 10%
Anyone if 10yr QRISK score is over 10%
CKD or albuminuria
Hypercholestrrolaemia
85yr and above to reduce risk of non fatal MI
149
QRISK 2 calculation is unsuitable in which pts bc of them being already at high CV risk?
```
Type 1 diabetes
Established CV
Over 85
CKD eGFR below 60
Familial Hypercholestrrolaemia
```
150
What level of cholesterol will lead to diagnosis of hyperlipidaemia?
Over 6nmol/L of total cholesterol
151
Target total cholesterol levels?
Below 5mmol /L for healthy adults
| Below 4mmol/L for high risk adults
152
Target level of LDL?
Below 3mmol/L for healthy adultd
| Below 2mmol/L for high risk adults
153
Target level if HDL?
Over 1mmol/L = higher the better
154
Target level of triglycerides?
Below 1.7mmol/L
155
What drugs can cause hyperlipidaemia?
Antiosychotics
Immunosuporessants
Corticosterouds
Antiretrovirals (HIV drugs)
156
Conditions that cause hyperlipidaemia?
```
Hypothyroidism
Liver or kidney disease
DM
Family history of it
Lifestyle factors like smoking, excessive alcohol cobsumption
Obesity and a poor fatty diet
```
157
How does statins work?
Lowers LDL by the liver via inhibition if HMG Coa reductase
| Indirectly reduces triglycerides and increase HDL
158
Digoxin's serum conc. Level?
1.5-3mcg/L
159
What's a weak k sparing diuretic?
Amiloride
160
Secondary prevention dose of atirvastatin?
80mg
161
MHRA warning on simvastatin?
High risk of myopathy
=only give if high risk of CV complications or severe Hypercholestrrolaemia and treatment goals not achieved at lower dose
162
What's first line for treating Hypercholestrrolaemia and moderate hypertriglyceridaemia?
Statins
163
2nd line for severe Hypercholestrrolaemia or hyperglyceridaemis if not controlled by max dose of 1st line?
Add ezetimibe
164
What to add if triglycerides remain high even after LDL cholesterol conc. Has been reduced adequately?
Fibrate to statin
| Or Fibrate alone if statin c/I
165
Whats the criteria of being a high intensity statin?
Defined as a dose at which a reduction in LDL cholesterol of greater than 40% is achieved
166
General steps of hyperlipidaemia?
Statin
Ezetimibe
Fibrates
Bile acid sequestant like colestyramine
167
What increases the risk of myopathy when Co administered with statin?
Ezetimibe, Fibrates esp gemfibrozil
| Concomitant fusidic acid, restart statin 7days after last dose
168
Side effects of statins?
Rhabdomyolysis
Interstitial lung disease
= report short breath, cough, weight loss
Diabetes - statins can raise HBA1C or blood glucose levels
169
Monitoring requirements for statins?
```
Baseline lipid profile
Renal function
Thyroid function
HBA1C if high risk of developing diabetes
Liver
```
170
When to discontinue to statins?
Creatine kinase x5
| Liver transaminases x3
171
Max dose of statin when taken with fibrates?
10mg
172
Max dose of statin is 20mg when taken with?
Amiodarone
Amlodioine
Diltiazem
Verapamil
173
Max dose of atirvastatin when taken with ciclosporin?
10mg
174
Dose of rosuvastatin when taken with clopidogrel?
Initially 5mg then max 20mg
175
Statin and Preganancy, advice?
Statins are teratogenic
Need effective contraception during and 1month after stopping
Stop taking 3 months before conceiving and restart after BF finished
176
How does ezetimibe work?
Reduce blood cholesterol by inhibiting the absorption of cholesterol by the small intestine
177
How does fibrates work?
Lowers blood triglyceride levels by reducing the lover's production of VLDL (the triglyceride carrying particle that circulates in the body) and by speeding up the removal of triglycerides from the blood
178
All fibrates are used in combo with statins apart from?
Gemfibrozil which should not be used with statins as high risk of myopathy
179
How does specialist Bile acid sequentstrants work?
Binds to Bile acid preventing its reabsorption which promotes the conversion of cholesterol into Bile acids q
180
Important interactions of Bile acid sequestant?
Impairs absorption of fat soluble vitamins ADEK and other drugs so take other drugs 1hr before (4hrs for colevesrlam) or 4hrs after Bile acid sequentstrants
181
Important interactions of Bile acid sequestant?
Impairs absorption of fat soluble vitamins ADEK and other drugs so take other drugs 1hr before (4hrs for colevesrlam) or 4hrs after Bile acid sequentstrants
182
What's used to determine bleeding risk?
```
Has-bled (has been validated for warfarin but not for DOACs)
H=hypertention (over 160)
A=abnormal renal or liver (1 point each)
S=stroke
B=bleeding
L=labile INRs
E=elderly over 65
D=drugs or alcohol (1 point each)
```
0-2 low rusk
Over 3 is high risk of bleeding
183
Side effects of warfarin?
Bleeding
Painful skin rash
Blue/purple toe syndrome
184
What juice increases the effect of warfarin?
Cranberry and pomegranate
185
Which statins increase the effect of warfarin?
Fluvastatin and rosuvastatin
186
Warfarin tab colours
0.5 - white
1 - brown
3 - blue
5 - pink
187
What conditions does thiazide diuretics exacerbate?
Diabetes, gout and lupus
188
Reduce initial dose of Ivabradine if?
concurrent use of moderate CYP3A4 inhibitors (except diltiazem, erythromycin and verapamil where concurrent use is contraindicated).
