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Cardiovascular chapter > CV chapter > Flashcards

CV chapter Flashcards

1
Q

Name class 1 anti-arrhytmic drugs? + MOA

A

Class 1: disopyramide, lidocaine, flecainide/propafenone.

MOA: membrane stabilising drugs; Na+ blockers

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2
Q

Name class 2 anti-arrhytmic drugs ? + MOA

A

BB: propranalol, esmolol ect

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3
Q

Name class 3 anti-arrhytmic drugs ? + MOA

A
  • Potassium channel blockers
  • Amiodarone
  • Sotalol
  • Dronedarone
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4
Q

Name class 4 anti-arrhytmic drugs ? + MOA

A

CCB( rate limiting)

Verapamil, diltiazem (unlicensed)

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5
Q

What are the TWO s/e of DRONEDARONE?

A

hepatoxicity and HF

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6
Q

In which patient group is digoxin effective ?

A

Effective in sedentary patients with non-paroxysmal AF and in patients with associative CHF

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7
Q

What is AF?

A

abnormal. disorganised electrical signals fired cause the atria to quiver or fibrillate= rapid and irregular heartbeat

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8
Q

What are the symptoms of AF and complications?

A
  • Heart palpilations=pounding/fluttering

- Stroke and HF

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9
Q

What are the THREE types of AF ?

A

paroxysmal AF: episodes stop within 48 hours without treatment
persistent AF: episode last more than seven days
permanent AF: present all the time

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10
Q

Whats the difference between rate and rhythm control ?

A

rate control: controls ventricular rate

rhythm control: restores and maintains sinus rhythm

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11
Q

What are the two types of cardioversion ?

A
  • electrical= direct current

- pharmacological= anti-arrhythmic

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12
Q

If AF is present for more than 48 hours what cardioversion treatment is preferred ?

A

-electrical cardioversion is preferred. But should not be attempted until patient is fully anticoagulated, for 3 weeks and continue 4 weeks after = risk of stroke

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13
Q

What is the treatment for patients who are haemodynamically unstable ?

A

=electrical cardioversion; give parenteral anticoagulant and rule out left atrial thrombus immediately before procedure

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14
Q

What is preferred treatment for acute new-onset presentation of AF ?

A

rhythm control

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15
Q

Treatment for symptoms of AF present less than 48 hours? (haemodynamicly stable, not life threatening ) What if symptoms are present for more than 48 hours or uncertain when ?

A

< 48 hours: rate or rhythm control

> 48 hours: rate control ( verapamil or BB )

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16
Q

What is the first line for maintenance drug treatment for AF ?

A

1st line: rate control
BB, rate-limiting CCB, digoxin ( control ventricular rate at rest )
Monotherapy then dual therapy then can introduce rhythm control

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17
Q

What is the second line for maintenance drug treatment for AF ?

A

2nd line: rhythm control

BB, oral anti-arrhytmic drugs like amiodarone, sotalol

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18
Q

What is paroxysmal and symptomatic AF ?

A

symptoms come and go

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19
Q

What is the treatment for paroxysmal and symptomatic AF ?

A
  • PILL in pocket: if infrequent episodes: flecainide or propafenone: restores sinus rhythm if episode occurs.
  • ventricular or rhythm control= standard BB or anti-arrhytmic
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20
Q

What does CHADSVASC tool include?

A 
C- chornic HF or LVD
H- hypertension
A-age + 65-74
D-DM
S-stroke/TIA/ VTE history
V-vascular disease
S-sex category i.e female
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21
Q

What score of chadsvasc would indicate anticoagulant in all patient groups ?

A

2 or more: give

male= 0 and females =1; no anticoagulant needed, low risk

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22
Q

What is the choice of anticoagulant for new onset AF ?

A

parenteral anticoagulant like heparin

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23
Q

What is the choice of anticoagulant for diagnosed AF ?

A

Warfarin or NOAC ( non valvular AF with more than one risk factors; artificial heart valves )

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24
Q

What are the risk factors that must be considered when prescribing NOACs?

A

75+, HF, hypertension, DM, previous stroke or TIA

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25
Q

Whats is torsade de pointes and what are the causes ?

A

qt prolongation: lethal form of ventricular tachycardia

Hypokalaemia, severe bradycardia can cause it

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26
Q

How to treat torsade de pointes?

A

IV magnesium sulphate

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27
Q

Adenosine is contraindicated in what ?

A

COPD/asthma

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28
Q

What are the amiodarone side effects relating to the eyes? And what counselling would you give ?

A
  • corneal microdeposits
    -optic neuropathy/neuritis ( blindness )
    Counselling: night time glares when driving due to corneal microdeposits. Stop if vision impaired- may be sign of optic neuropathy/neuritis
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29
Q

What are the amiodarone side effects relating to the skin? and what counselling should you give ?

A

-phototoxicity ( burning, erythema )
-slate-grey skin on light exposed areas
Counselling: shield skin from light during treatment. use SPF for months after stopping

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30
Q

What are the amiodarone side effects relating to the nerves? and what counselling should you give ?

A

peripheral neuropathy

Counsel to report: numbness, tingling hands and feet, tremors

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31
Q

What are the amiodarone side effects relating to the lungs? and what counselling should you give ?

A

pneumonitis, pulmonary fibrosis.

Counsel to report SOB, dry cough

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32
Q

What are the amiodarone side effects relating to the liver? and what counselling should you give ?

A

hepatoxicity: report jaundice, nausea, vomiting, malaise, itching, abdominal pain, 3x raised liver transaminases

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33
Q

How can amiodarone effect thryoid function ?

A

amiodarone contains iodine, thus can cause hyperthyroidism or hypothyroidism

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34
Q

What are the signs of hyperthyroidism and what drugs can be used to treat?

A
  • weight loss, heat intolerance, tachycardia

- carbimazole if needed. withdraw amiodarone

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35
Q

What are the signs of hypothyroidism ?

A
  • weight gain, cold intolerance, bradycardia

- start levothyroxine without withdrawing amiodarone if essential

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36
Q

What are the monitoring requirements for amiodarone ?

A
  • annual eye test
  • chest x ray before treatment
  • liver function tests every six months
  • monitor TSH, T3, T4 before treatment and every six months
  • Blood pressure and ECG ( causes hypotension and bradycardia)
  • serum potassium ( causes hypokalaemia, enhances arrhytmogenic effect of amiodarone )
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37
Q

What is the half life for amiodarone and why is it important to keep it in mind ?

A

around 50 days, danger of interactions several months after stopping

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38
Q

Patient comes in and says he has been recently prescribed amiodarone and would like to know why he cant have grapefruit juice ?

A

increases plasma concentrations of amiodarone beacause grapferuit juice is an enzyme inhibitor

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39
Q

You are screening the following prescription that has the following drugs:
-Amiodarone
-Warfarin
What is the interaction ?

A

amiodarone is enzyme inhibitor, increases warfarin levels; risk of bleeding

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40
Q

You are screening the following prescription that has the following drugs:
-Amiodarone
-phenytoin
What is the interaction ?

A

amiodarone is enzyme inhibitor, increases levels of phenytoin

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41
Q

If amiodarone is prescribed together with digoxin what adjustments should be made for digoxin dose ?

A

half dose of digoxin should be prescribed

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42
Q

Patients who take amiodarone and statins are at risk of what ?

A

increased risk of myopathy

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43
Q

What interaction occurs between amiodarone and BB or CCB like verapamil and diltiazem ?

A

bradycardia, AV block, myocardial depression

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44
Q

What drug classes can cause QT prolongation ? Must be prescribed with caution in patients who are taking amiodarone

A
  • quinolones,
  • macrolides,
  • TCAs,
  • SSRIs,
  • Lithium,
  • quinine
  • hydroxychloroquinine
  • chloroquine
  • mefloquine
  • antipsychotics: especially sulpiride, pimozide, amisulpride
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45
Q

How does digoxin work?

A

increases force of myocardial contraction ( positive inotrope ) reduces conductivity in the AV node ( negative chronotrope )

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46
Q

What are the therapeutic levels of digoxin ?

A

1-2 mcg/L ( 6 hours after dose )

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47
Q

Are loading doses required for digoxin and why ?

A

yes due to long half life

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48
Q

What is the dose of digoxin in atrial flutter and non-paroxysmal AF in sedentary patients?

A

125-250 mcg

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49
Q

What is the dose of digoxin for worsening or severe HF ( in sinus rhythm )?

A

62.5 - 125 mcg

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50
Q

What is the bioavailability of digoxin elixir ?

A

75 %

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51
Q

What is the bioavailability of digoxin tablet ?

A

90%

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52
Q

What are the signs of digoxin toxicity ? usually toxicity is slow and sick

A
  • bradycardia/heart block
  • nausea, vomiting and diarrhoea, abdominal pain
  • blurred or yellow vision
  • confusion, delirium
  • rash
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53
Q

what predisposes to digoxin toxicity ?

A

hypokalaemia, hypomagnesaemia, hypercalcaemia, hypoxia and renal impairment

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54
Q

How digoxin toxicity is treated ?

A
  • withdraw digoxin; correct electrolyte imbalances.

- digoxin specific antibody for life threatening ventricular arrhythmias unresponsive to atropine

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55
Q

What drugs causes hypokalaemia ?

A

loop/thiazide: potassium loss in the urine
B2 agonist
steroids
theophylline

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56
Q

When would potassium supplements be indicated or potassium sparing diuretics?

A

if potassium is less than 4.5 mmol since its hypokalaemia

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57
Q

Which drugs increase digoxin plasma concentrations ?

A

amiodarone ( half digoxin), verapamil, diltiazem, macrolides, ciclosporin ( all enzyme inhibitors )

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58
Q

If a patient is on digoxin but says that they would like to buy ST JOHNS wort, what do you say ?

A

No, because it decreases digoxin concetration

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59
Q

GP calls you saying he want to prescribe rifampicin to a patient but you know that this patient is on digoxin, what should you say ?

A

rifampicin reduced digoxin concentrations

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60
Q

Which drug classes can reduce renal excretion and thus lead to digoxin toxicity ?

A

NAIDs, ACE inhibitors/ARBs

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61
Q

Digoxin interaction mnemonic ‘‘CRASED’’ explain each letter?

A 
C-CCB ( verapamil)
R-rifampicin
A-amiodarone
S-st johns wort
E- eryhtromycin
D-diuretics
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62
Q

What are the two types of venous thromboembolism ?

A

DVT: blood clot in a deep vein, usually calf of one leg
PE: detachment of blood clot which travels to the lungs and blocks the pulmonary artery

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63
Q

What are the 12 criteria of VTE risk assessment?

A
  • immobility
  • obesity BMI over 30
  • malignant disease
  • 60+
  • personal history of VTE
  • thrombophillic disorders
  • first degree relative with VTE
  • HRT/COC
  • varicose veins with phlebitis
  • pregnancy
  • critical car
  • significant co-morbidities
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64
Q

What factors would predispose to increased risk of bleeding that must be taken into consideration when conducting VTE risk assessment to patients who are admitted to hospital ?

A
  • thrombocytopenia ( low platelet )
  • acute stroke
  • bleeding disorders: acquired liver failure or inherited haeophillia, Von Willebrands disease
  • anticoagulants
  • systolic hypertension
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65
Q

Patients undergoing general surgery or orthopaedic surgery who are at high VTE risk, what type of VTE prophylaxis should be given ?

A

-Parenteral anticoagulants: low molecular weight heparin or unfractioned heparin in renal failure or fondaparinux
-NOACS; prophylaxis after knee/hip replacement surgery
Edoxaban for treatment and prevention of recurrent VTE

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66
Q

What is the duration of pharmacological VTE prophylaxis in general surgery ?

A

5-7 days or until sufficient mobility

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67
Q

What is the duration of pharmacological VTE prophylaxis in major cancer surgery in abdomen or pelvis ?

A

28 days

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68
Q

What is the duration of pharmacological VTE prophylaxis in knee/hip surgery ?

A

extended duration

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69
Q

What is usually initial treatment of VTE and how long is the treatment?

A
  • LMWH or unfractioned heparin in renal failure
  • at least 5 days and until INR at 2 or more for at least 24 hours
  • monitor APTT if unfractioned heparin given
  • start warfarin at the same time
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70
Q

What drug is used in VTE in pregnant women and why ?

A
  • LMWH, does not cross placenta
  • lower risk of osteoporosis and heparin induced thrombocytopenia
  • stop at labour onset
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71
Q

How does heparin work ?

A

unfractioned heparin activates antithrombin.

low molecular weight heparin inactivate factor Xa

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72
Q

Name LMWH ?

A

tinzeparin, enoxaparin, dalteparin

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73
Q

Which has longer duration of action LMWH or unfractioned heparin ?

A

LMHW

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74
Q

Which heparin is preferred if there is high risk of bleeding and renal impairment ?

A

unfractioned

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75
Q

Which heparin is generally preferred because it has lower risk of osteoporosis, heparin-induced thrombocytopenia?

A

LMWH

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76
Q

For which heparin it is essential to monitor activated partial thromboplastin time ( APTT )?

A

unfractioned

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77
Q

What are the side effects of heparins ?

A

Heamorrhage
Hyperkalaemia
Osteoporosis
Heparin induced thrombocytopenia

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78
Q

What to do if haemorrhage occurs while on heparin and rapid reversal is required ?

A

withdraw heparin. Give antidote protamine

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79
Q

Why heparins cause hyperkalaemia ?

A

heparins inhibit aldosterone secretion

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80
Q

Which patient groups are at higher risk of hyperkalaemia induced by heparins ?

A

DM
chronic kidney disease
monitor before treatment and if more than seven day use

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81
Q

How soon does heparin-induced thrombocytopenia occurs ?

A

occurs after 5-10 days.

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82
Q

What are the clinical signs of heparin-induced thrombocytopenia ?

A
  • 30 % reduction in platelets, skin allergy, thrombosis.

- Monitoring: before treatment and if more than four days use

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83
Q

How does warfarin work + how long it takes to work ?

A
  • antagonises actions of vitamin K in blood clotting

- 48 to 72 hours to work

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84
Q

What are the colours of the following strengths of warfarin

0.5 mg, 1 mg, 3 mg, 5 mg?

A

o.5 white
1 mg- brown
3 mg- blue
5mg -pink

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85
Q

What is initial dose of warfarin and how often should it be monitored ?

A

5 mg daily and monitor every 1-2 days

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86
Q

What is the maintenance dose of warfarin ?

A

3-9 mg at the same time each day

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87
Q

One patient is stable, how often their INR should be measured?

A

every three months

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88
Q

If the patient is prescribed warfarin for ISOLATED CALF DVT , how long should the treatment be for ?

A

6 weeks

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89
Q

If the patient is prescribed warfarin for PROVOKED VTE ( coc, pregnancy leg plaster cast), how long should the treatment be for ?

A

3 months

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90
Q

If the patient is prescribed warfarin for unrpovoked clots (AF) , how long should the treatment be for ?

A

at least 3 months/long term

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91
Q

What is the INR target for VTE, AF, MI, cardioversion, bioprosthetic mitral valve?

A

2.5

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92
Q

What is the INR target for recurrent VTE in patients receiving anticoagulant and INR above 2 ?

A

3.5

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93
Q

What patients should be given when warfarin is dispensed ?

A

yellow treatment booklet

anticoagulant alert card

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94
Q

What to do when warfarin bleeding occurs ?

A

stop warfarin, IV phytomenadione ( vitamin K)

dried prothrombin complex or fresh frozen plasma

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95
Q

What are the side effects of warfarin ?

A
  • bleeding ( nose bleeds loner than 10 min, bleeding gums, bruising )
  • calciphylaxis ( risk factor is end stage renal disease )
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96
Q

What action to take when INR is 5-8 + no bleeding?

A
  • withhold 1-2 dose
  • reduce maintenance dose
  • measure INR after 2-3 days
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97
Q

What action to take when INR is 5-8 and minor bleeding?

A
  • omit warfarin
  • IV phytomenadione
  • Repeat if INR still high after 24 hours
  • Restart warfarin when INR < 5.0
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98
Q

What action to take when INR is more than 8 but no bleeding ?

A
  • omit warfarin
  • oral phytomenadione
  • repeat if INR still high after 24 hours
  • restrat warfarin when INR less than 5
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99
Q

What action to take when INR more than 8 + minor bleeding ?

A
  • omit warfarin
  • IV phytomenadione
  • Repeat if INR still high after 24 hours
  • Restart warfarin when INR less than 5
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100
Q

If patient is planned to have elective surgery when should warfarin be stopped ?

A
  • 5 days before
  • give oral phytomenadione one day if INR higher than 1.5
  • restart warfarin on evening or next day
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101
Q

If patient is on warfarin but they need emergency surgery ?

A

delay 6-12 hours

no delay; give IV phytomenadione and dried prothrombin complex

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102
Q

If patient is on warfarin, but also high risk of VTE and they need surgery ?

A

switch from warfarin to LMWH and stop 24 hours before surgery

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103
Q

What if the patient still after surgery is at high risk of bleeding ?

A

start LMWH 48 hours after surgery

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104
Q

Which NOAC needs special container and has 4 month expiry ?

A

dabigatran

105
Q

Which NOACs are direct factor Xa inhibitors?

A

apixaban
edoxaban
rivaroxaban

106
Q

How does dabigatran work ?

A

direct thrombin inhibitor

107
Q

Explain ischaemic stroke/TIA ‘’ mini strokes’’ ?

A

-blood clot obstructs blood supply

108
Q

Explain haemorrhagic stroke ?

A

weak blood vessel in brain bursts

109
Q

What is long term management for TIA ( mini stroke )?

A
  • MR dipyridamole and aspirin
  • Statin irrespective of serum cholesterol
  • treat hypertension not with BB
110
Q

What is long term management for ischaemic stroke ?

A
  • clopidogrel
  • in AF related stroke, review for anticoagulant
  • Statin irrespective of serum cholesterol
  • treat hypertension not with BB
111
Q

What drugs should be avoided in intracerebral haemorrhage and what is the usual treatment ?

A
  • avoid aspirin, statin, anticoagulants; increases the risk of bleeding; only if essential
  • treat hypertension and take care to avoid hypoperfusion
112
Q

how does antiplatelet drugs work ?

cangrelor, prasugrel, ticagrelor

A

decrease platelet aggregation and inhibit thrombus formation in the arterial circulation

113
Q

why aspirin contraindicated in under 16 ?

A

reys syndrome

114
Q

How should Dipyridamole (secondary prevention of strokes ) be taken, and what expiry does persantin retard capsules have ?

A

30-60 min before food, has six week expiry, special container - has dessicant, retain in the container

115
Q

Name anticoagulants that are glycoprotein IIa/IIb inhibitors ?

A

adciximab
eptifibatide
tirofiban

116
Q

what is indication of clopidogrel ?

A

following acute coronary syndromes or PCI

117
Q

Learn hypertension guidelines

A

HEY

118
Q

What is normal BP ?

A

120/80

119
Q

what is stage 1 hypertension ?

A

140/90; offer lifestyle advice
only treat if under 80 with: target organ damage, retinopathy, CKD or CVD or 10 year CVD risk more than 20 % or if pt has renal disease or diabetes

120
Q

What is stage 2 hypertension ?

A

160/100= treat all

121
Q

what is stage 3 hypertension ?

A

> 180 systolic > 110 diastolic= hypertensive crisis

122
Q

What are the clinic blood pressure targets for under 80 years ?

A

<140/90

130/80 in atherosclerotic CVD or diabetes with kidney, eye or cerebrovascular disease

123
Q

What are the clinic blood pressure targets for over 80 years ?

A

<150/90

124
Q

What are the clinic blood pressure targets for renal disease ?

A

<140/90

<130/80 if CKD, diabetes, proteinuria > 1g in 24 hours. Consider ACE/ ARB if proteinuria present

125
Q

What are the clinic blood pressure targets for diabetics ?

A

<140/80

<130/80 if complications; eye, kidney

126
Q

What are the clinic blood pressure targets for pregnant women ?

A

<150/100 if chronic hypertension
<140/90 chronic hypertension and if target organ damage or given birth. Labetalol ( hepatoxic ) is widely used and first choice. Methyldopa needs to be stopped 2 days after birth. MR nifedipine is unlicensed.

127
Q

which is ace inhibitor is BD?

A

captopril

128
Q

which should perindopril be taken ?

A

30-60 min before food

129
Q

Name ARB? angiotensin 2 receptor blockers ?

A 
azilsartan
candersartan,losartan,valsartan
eprosartan
irbesartan
olmesartan
telmisartan
130
Q

What side effects ACE cause ?

A
  • persistent dry cough
  • hyperkalaemia ( higher risk in DM and renal impairment )
  • agioedema: anaphylactoid reactions
  • ORAL ULCER
  • taste disturbance
  • hypoglycaemia
131
Q

What renal effects ACE inhibitors have ?

A
  • renoprotective in renal disease :CKD
  • nephrotoxic= acute kidney injury; avoid DAMN: diuretics, ACE, ARBs, metformin, NSAIDs
  • reduces eGFR via efferent arteriole dilation. Avoid in renovascular disease, not to be given in severe bilateral stenosis.
132
Q

What hepatic effects ACE inhibitors have ?

A
  • cholestatic jaundice, hepatic failure

- STOP IF LIVER TRANSMINASES 3X NORMAL OR JAUNDICE OCCURS.

133
Q

If ACE inhibitors are given with potassium sparing diuretics or aldosterone antagonists or ARB or aliskeren, what electrolyte disturbance may occur ?

A

hyperkalaemia

134
Q

Why is better to avoid NSAIDs with ACE ?

A

nephrotoxicity and reduced eGFR

135
Q

Why you should avoid ACE a+ ARB in diabetic nephropathy?

A

can lead to renal impairment, hyperkalaemia and hypotension

136
Q

Read BNF on centrally acting antihypertensives ? name them

A

methyldopa: s/e driving; drowsiness
clonidine: s/e flushing
moxonidine

137
Q

Name vasodilator antihypertensives?

A

hydralazine: s/e fluid retention, tachycardia
minoxidil: tachycardia, fluid retention and increase cardiac output

138
Q

Name alpha blockers?

A

prazosin
terazosin
indoramin

139
Q

How does BB work ?

A

block beta receptors in the heart. peripheral vasculature, bronchi, pancreas and liver

140
Q

Which BB is used in hypertension in peri-operative period and has short half life ?

A

esmolol

141
Q

Which 4 BB have less bradycardia, less coldness of extremities and has intrinsic sympathomimetic activity?

A

Pindolol
acebutolol
celiprolol
oxprenolol

142
Q

Name 4 water soluble BB?

A 
celiprolol
atenolol
nadolol
sotalol
all are renally cleared: reduce dose in renal impairment
143
Q

Name 4 cardioselective BB?

A 
bisoprolol
atenolol
metoprolol
acebutolol
nebivolol
144
Q

Name 4 BB that have OD dosing ?

A 
bisoprolol
atenolol
celiprolol
nadolol
-intrisically long duration of action
145
Q

What are the side effects of BB ?

A
  • bradycardia, hypotension

- hyperglycaemia or hypoglycaemia+ masks symptoms of hypoglycaemia e.g. tachycardia

146
Q

In what disease conditions are BB contraindicated ?

A
  • Asthma: includes even BB eye drops like timolol
  • worsening unstable HF
  • second/third degree heart block
  • severe hypotension and bradycardia
147
Q

Two important interactions with BB ?

A
  • IV verapamil( asystole and hypotension ), hazardous oral verapamil
  • Thiazide diuretics: both cause hyperglycaemia thus avoid in diabetes and high risk of diabetes
148
Q

How does CCB work ?

A

blocks calcium channels to reduce force of contraction, conductivity and vascular tone

149
Q

Name dihydropyridine CCB?

A

cause vasodilation

  • amlodipine
  • felodipine
  • lacidipine
  • lercanidipine
  • nifedipine ( maintain the same MR brand )
150
Q

What are the common side effects of dihydropyridine CCB ?

A

ankle swelling
flushing
headaches

151
Q

Which CCB should be avoided in HF ?

A

rate-limitig; verapamil, diltiazem (maintain on same brand when doses over 60 mg )

152
Q

Which rate limiting CCB causes constipation and is licensed for arrhythmias ?

A

verapamil

153
Q

Which type of juice should be avoided when taking CCB ?

A

grapefruit juice

154
Q

How does vasoconstrictor sympathomimetics work ?

A

raise BP by acting on aplha-adrenergic receptors to constrict peripheral blood vessels

155
Q

vasoconstrictor sympathomimetics: examples ?

A

noradrenaline, phenylepherine ( longer acting: prolonged rise in BP )

156
Q

what are the side effects of vasoconstrictor sympathomimetics?

A

reduced perfusion to vital organs e.g. kidneys

157
Q

What are the symptoms of heart failure ?

A
  • dyspnoea during activity or at rest
  • exercise intolerance/fatigue
  • Oedema:
    1. pulmonary oedema=breathlessness, 2.peripheral oedema=swollen ankles, legs
158
Q

What is hyperlipidaemia ?

A

high blood levels of cholesterol, triglycerides or both

159
Q

What are the complications of hyperlipidaemia ?

A

Hyperlipidaemia causes artherosclerosis and in turn coronary heart disease (angina, MI), strokes and TIA, peripheral arterial disease

160
Q

Primary prevention of cardiovascular diseases if offered to which patient gourps?

A
  • type 1 DM
  • Type 2 DM only if CVD risk>10%
  • chronic kidney disease or albuminuria
  • familial hypercholesterolaemia
  • 85 years and above
161
Q

Secondary prevention is offered to which patient group ?

A

to those who have established CVD: coronary heart disease ( angina, MI ), cerebrovascular disease ( stroke, TIA ) and peripheral arterial disease

162
Q

What are the total cholesterol levels should be for healthy adults ?

A

no more than 5 mmol/L of total cholesterol

163
Q

What should total cholesterol be for high risk adults? ( target ? )

A

less than 4 mmol/L

164
Q

LDL ( bad cholesterol): what is the target for healthy adults ?

A

less than 3 mmol/L

165
Q

LDL ( bad cholesterol): what is the target for high risk adults?

A

less than 2 mmol/L

166
Q

HDL ( good cholesterol ) what is the target ?

A

more than 1 mmol/L, the higher the better

167
Q

What is the target for triglycerides ?

A

less than 1.7 mmol/L

168
Q

What mmol/L of total cholesterol would indicate diagnosis of hyperlipidaemia ?

A

6 mmol/L

169
Q

Which drugs cause hyperlipidaemia, drug classes ?

A
  • Antipsychotics ( epsecially second genereation )
  • immunosupressants
  • corticosteroids
  • antiretrovirals ( HIV drugs )
170
Q

What conditions would predispose a patient for hyperlipidaemia ?

A
  • hypothyroidism
  • liver or kidney disease
  • DM
  • family history of high cholesterol
  • lifestyle factors: smoking, excess alcohol consumption, obesity and a poor fatty diet
171
Q

Name all the classes of lipid regulating drugs ?

A 
STATINS
Fibrates
Ezetimibe
Bile acid sequestrants
Nicotinic acid group ( acipimox, nicotinic acid )
Lomitapide
Alirocumab
172
Q

Name all the fibrates ?

A

bezafibrate, ciprofibrate, fenofibrate, gemfibrozil

173
Q

Name all bile acid sequestrants ?

A

colesevelam, colestipol, colestyramine

174
Q

How do statins work ?

A

lowers LDL cholesterol synthesis by the liver via inhibition of HMG-VoA reductase ( indirectly reduces triglycerides and increases HDL cholesterol )

175
Q

At what time statins should be taken and why ?

A

all statins must be taken at night except ATORVASTATIN.

Cholesterol synthesis greater at night; more effective.

176
Q

what is the dose of atorvastatin in primary prevention ?

A

20mg OD

177
Q

what is the dose of atorvastatin in secondary prevention ?

A

80 mg OD

178
Q

Why should simvastatin at a dose of 80 mg must be only given to patients who are at high risk of CV complications and treatment goals are not achieved at lower dose ?

A

high risk of myopathy

179
Q

Name three high intensity statins?

A

atorvastatin, rosuvastatin ( 10 mg ), simvastatin

180
Q

Which drugs are used to treat primary and familial hypercholesterolaemia ?

A

high intensity statins: if statin not tolerated or contraindicated = EZETIMIBE

181
Q

Which drugs are used to treat moderate hypertriglyceridaemia ?

A

If statin not tolerated or contra-indicated= FIBRATE

182
Q

Before starting statins what underlying causes ( conditions ) must be corrected ?

A
  • hypothryoidism
  • uncontrolled DM
  • nephrotic syndrome ( albuminuria )
  • liver disease .e.g alcohol cirrhosis.
183
Q

What are the side effects of statins and what counselling you should provide?

A
  1. myopathy, myositis, rhabdomyolysis
    - Counsell: report tender, weak and painful muscles
  2. interstitial lung disease: counsel patients about SOB, cough and weight loss.
  3. Diabetes : statins can raise HbA1c or blood glucose levels, those who are diabetic or those at high risk of diabetes are at this risk
184
Q

Which patient groups would have high risk of muscle toxicity when on statins ?

A
  • personal or family history of muscle disorder
  • high alcohol intake
  • renal impairment
  • hypothyroidism/ treat before starting statin
185
Q

Which drugs taken together with statins may increase the risk of myopathy ?

A
  • concomitant ezetimibe or fibrates, especially GEMFIBROZIL

- Concomitant fusidic acid; restart statin seven days after last dose ( increased risk of rhabdomyolysis )

186
Q

Before starting statins what baseline test must be done ?

A

baseline lipid profile
renal function
thyroid function ( hypothryoidsim increase risk of muscle toxicity )
HbA1c if high risk of developing diabetes

187
Q

What are the two most important monitoring requirements for statins ?

A
  • liver function: discontinue if liver transaminases are 3X normal
  • Creatine kinase( released from the muscle when it is damaged=myopathy): discontinue if 5X normal
188
Q

Which drugs can increase statin levels ?

A 
amiodarone
grapefruit juice
diltiazem, verapamil
imidazole/triazole: itraconazole, ciclopsorin
amlodipine
189
Q

What is the max dose of SIMVASTATIN when it is given with fibrate ?

A

max 10 mg

190
Q

what is the max dose of simvastatin if it is given with amiodarone, amlodipine, diltiazem and verapamil ?

A

max 20 mg

191
Q

What is the max dose of atorvastatin when it is given with ciclosporin ?

A

max 10 mg

192
Q

What is the max dose of rosuvastatin and initially when given with clopidogrel ?

A

initially 5 mg, max 20 mg with clopidogrel

193
Q

What advice should be given to women of childbearing age who are on STATINS ?

A

have effective contraception during and one month after stopping

194
Q

If women comes in and says she would like to conceive but is on statins, what advice would you give ?

A

stop taking 3 months before conceiving and restart after breastfeeding is finished

195
Q

How does ezetimibe work ?

A

reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine.

196
Q

Why is better to avoid giving statins and ezetimibe together ?

A

myopathy ( rhabdomyolysis )

197
Q

How does fibrates work ?

A

lower blood triglyceride levels by reducing the liver’s production of VLDL ( the triglyceride-carrying particle that circulates in the blood) and by speeding up the removal of triglycerides from the blood

198
Q

What levels of total cholesterol would indicate severe hypertriglyceridemia ?

A

over 10 mmol/L

199
Q

Which fibrate has the highest risk of myopathy and should not be given with statins ?

A

gemfibrozil

200
Q

If patient is taking fibrates but they have renal impairment they are at risk of what ?

A

myopathy

201
Q

How does bile acid sequestrants work ?

A

binds and sequesters bile acids. The liver then produces more bile acids to replace those that have been lost.The body uses cholesterol to make bile acids, this reduces the amount of LDL cholesterol circulating in the blood

202
Q

Bile acid sequestrants impairs absorption of what type of vitamins ?

A

fat-soluble vitamins ADEK and other drugs

203
Q

How should other drugs be taking with bile acid sequestrants ?

A

take other drugs 1 hour before ( 4 hour before coleveselam) or 4 hours after bile sequestrants.

204
Q

MYocardial ischaemia ( stable angina ): what drugs are used to treat it ?

A
  • short-acting nitrates are used for acute angina attacks

- for long term prophylaxis of angina long acting nitrate sare used.

205
Q

Name short acting nitrates ?

A

glyceryl trinitrate

isosorbide dinitrate

206
Q

name long acting nitrates ?

A 
MR isosorbide dinitrate
isosorbide mononitrate
ivabradine
nicorandil
ranolazine
207
Q

How does glyceryl trinitrate work ?

A

converted to nitric oxide which is a short acting vasodilator; improves blood supply

208
Q

How long does glyceryl trinitrate sublingual tablets/spray effect last ?

A

20-30 minutes

209
Q

If a patient comes in and says to you I am suing my glyceryl trinitrate sublingual tablets or spray more than twice a week ? what should you advise ?

A

refer to GP since this indicated patient needs long term prophylaxis

210
Q

Glyceryl trinitrate sublingual tablets are in special container, foil-lined container with no cotton wadding and thus expires how long after opening ?

A

expires 8 weeks after opening

211
Q

How should glyceryl trinitrate should be taken ?

A
  • PRN or before angina-inducing activities e.g. exercise
  • Take sitting down as dizziness can occur: take first dose under tongue and wait 5 minutes, take second dose and wait 5 minutes, take third dose and wait 5 minutes.
  • 1 dose= 1 tablet or 1-2 sprays
  • If pain is still present CALL 99
  • 999rule: max 3 doses
212
Q

How should glyceryl trinitrate be taken ?

A
  • PRN or before angina-inducing activities e.g. exercise
  • Take sitting down as dizziness can occur: take first dose under tongue and wait 5 minutes, take second dose and wait 5 minutes, take third dose and wait 5 minutes.
  • 1 dose= 1 tablet or 1-2 sprays
  • If pain is still present CALL 99
  • 999rule: max 3 doses
213
Q

For long term angina prophylaxis which dugs can be given as monotherapy ?

A

BB or CCB ( diltiazem, contraindicated in LVSD)

214
Q

For long term angina prophylaxis which drugs can be given as dual therapy ?

A
  • BB + dihydropyridine CCB ( amlodipine, MR nifedipine, felodipine ) MAX 2 drugs
  • If one or both is contraindicated add/use vasodilator
215
Q

Name vasodilators used in long term prophylaxis of angina ?

A

ivabradine ( only in normal sinus rhythm )
ranolazine
nicorandil

216
Q

what is MHRA warning regarding nicorandil ?

A

Nicorandil is K-channel activator: use in adults only.
Now given second line risk of ulcer complications; mouth, skin, eye, gastro-intestinal. Do not drive until it is established performance is not impaired

217
Q

How does nitrates work ?

A

nitrates are potent coronary vasodilators and reduce venous return and cardiac output

218
Q

How is long acting nitrate ISOSORBIDE MONONITRATE MR and IR are taken ?

A

IR taken BD and MR is taken OD

219
Q

Which nitrate is also active sublingually and can be alternative to glyceryl trinitrate ?

A

MR isosorbide dinitrate taken BD

220
Q

Which nitrates cause tolerance?

A

with long acting preparations or transdermal patches

221
Q

How to overcome nitrates tolerance?

A
  • reduce blood nitrate concentrations to low levels for 4 to 12 hours a day.
  • Leave patches off for 8-12 hours ( overnight). in a day
  • Take second dose after 8 hours not 12 hours: for MR isosorbide dinitrate (BD) and Isosorbide mononitrate (BD)
  • MR isosorbide mononitrate is taken OD therefore does not produce tolerance
222
Q

What are the side effects of nitrates ?

A

Vasodilation, flushing, throbbing headache, dizziness, postural hypotension, tachycardia, dyspepsia, heartburn

223
Q

What are the side effects of injection of GTN and isosorbide dinitrate MI ?

A

severe hypotension, sweating, apprehension, restlessness, muscle twitching, retrosternal discomfort and palpitations.

224
Q

Why you should avoid abrupt withdrawal of nitrates and CCB in angina ?

A

worsens angina

225
Q

What is acute coronary syndrome ?

A

Myocardial infarction: NSTEMI/STEMI

Unstable angina

226
Q

How to treat medical emergency in the community of unstable angina/nstemi?

A

dispersible/chewable apspirin 300 mg STAT

GTN PRN sublingually ( 0.3-1mg) or spray (1-2)

227
Q

How to treat medical emergency in the community of STEMI?

A

same as unstable angina/nstemi can add on IV diamoprhine/ morphine + metoclopramide

228
Q

How to give CPR for cardiac arrest ?

A

30 compressions: 2 breaths

IV adrenaline 1 in 1000 every 3-5 min. If ventricular fibrillation present: IV amiodarone

229
Q

Which loop diuretic is most potent and which one cause gout and which one musculoskeletal pain ?

A

bumetanide most potent
furosemide : gout
Torasemide: musculoskeletal pain

230
Q

Name thiazide relate diuretics?

A

chlortalidone ( long half life)
indapamide ( less aggravation of diabetes)
metolazone ( still works in severe renal failure )
xipamide

231
Q

What are potassium sparing diuretics?

A

amiloride

triamterene ( blue urine in some lights )

232
Q

Name aldosterone antagonists ?

A

Spironolactone ( ascites liver failure )

eplerenone ( use in post acute MI )

233
Q

What type of diuretic is mannitol ?

A

osmotic diuretic

use in cerebral oedema

234
Q

Which diuretic is used in glaucoma and to which drug class it belongs ?

A

acetozolamide: carbonic anhydrase inhibitors

235
Q

How diuretics treat oedema ?

A

increase urine output by the kidneys i.e. promotes diuresis by inhibiting sodium reabsoprtion at different parts of the renal tubular system (nephron)

236
Q

How does loop diuretics work ?

A

inhbitis sodium, potasium, Cl- co-transpoerter is ascedning limb of the loop of henle
- 1 hour onset and six hour duration

237
Q

How fast loop diuretics work and how long is their duration of action ?

A

1 hour onset

They have 6 hour duration

238
Q

What side effects high doses of loop diuretics may cause ?

A

ototoxicity ( tinnitus, deafness)

acute urinary retention

239
Q

In which patients acute urinary retention are most likely to occur if they are using loop diuretics?

A

in benign prostatic hyperplasia

240
Q

Can furosemide exacerbate gout and cause hyperglycaemia and hyperuricaemia ?

A

yes

241
Q

what electrolyte deficiencies can loop diuretics cause ?

A

hypo K, NA, CL, Mg, Ca

242
Q

which loop diuretic may cause musculoskeletal pain ?

A

torasemide

243
Q

How does thiazide and related diuretics work ?

A

inhibits sodium and chlorine transporter in distal convoluted tubule

244
Q

What is the onset and duration of action of thiazide and related diuretics ?

A

1-2 hour onset

12-24 hour duration

245
Q

What are the side effects of thiazide and related thiazide diuretics ?

A

GI disturbances, impotence, high LDL/triglycerides

246
Q

Thiazides are not effective if eGFR is less than 30ml/min except ?

A

metolazone

247
Q

What electrolyte disturbances thiazide diuretics cause ?

A

hypo K, NA, CL, Mg and Hyper Ca

248
Q

What is the dose of bendroflumethiazide in heart failure and hypertension ?

A

HF: 5 mg

Hypertension 2.5 mg

249
Q

Which thiazide diuretic has long half life and can be given on alternate days if acute retention is a problem or dislikes frequent urination ?

A

chlortalidone

250
Q

How does potassium sparing diuretics work ?

A

promotes urination without the loss of potassium by inhibiting sodium channels in the distal convoluted tubule. They are weak diuretics used as an adjunct to LOOP and Thiazide diuretics.

251
Q

Name potassium sparing diuretics ?

A
  • triamterene ( urine looks blue in some lights )

- amiloride

252
Q

How does aldosterone antagonist work ?

A

inhibits aldosterone which causes sodium reabsorption via the NA/K/H cotransporter. Less potassium and hydrogen ions are exchanged for sodium and therefore less lost to the urine .

253
Q

What are the side effects of spironolactone ?

A
  • gynaecomastia, benign breast tumours, menstrual disturbances
  • hypertrichosis
  • change in libido
  • hyperkalaemia, hyperuraemia, hyponatraemia
254
Q

How does osmotic diuretics work ?

A

inhibits sodium and water reabsoprtion by increaseing the osmolarity of blood and renal filtrate.

255
Q

Name osmotic diuretics and their uses ?

A

cerebral odema
high intracranial pressure
-MANNITOL ( pharmacologically inert sugar )

256
Q

How simple gravitational oedema in the elderly is treated ?

A

low dose diuretic. Not for long term use, try alternative first like stockings, raising legs and movement

257
Q

What are the two types of peripheral vascular disease ?

A
  • occlusive: peripheral arterial disease caused by atherosclerosis.
  • vasospastic: raynaud’s syndrome
258
Q

How to treat occlusive peripheral arterial disease ?

A

aspirin 75 mg daily and statin as secondary prevention

259
Q

How to treat vasospastic PVD like raynauds syndrome ?

A

stop smoking and avoid exposure to cold, nifedipine

Cardiovascular chapter (4 decks)

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