CVS

Question 1

Management of ischaemic stroke

Answer 1

Initial management:
- Alteplase within 4.5h of onset, then…
- Aspirin 300mg for 14 days

Long term management:
1st: Clopidogrel 75mg OD
2nd: Dipyridamole MR 200mg BD AND Aspirin 75mg OD
3rd: Dipyrdamole MR 200mg BD OR Aspirin 75mg OD

Within 48h of stroke:
- High intensity statin - Atorvastatin 80mg
- Manage hypertension - no BBs

Question 2

Management of stable angina

Answer 2

Acute attacks:
- SL GTN - repeat every 5 mins if needed
- Call 999 if pain hasn’t passed after 15 mins

Long-term prevention:
- 1st: BB
- BB CI: Rate-limiting CCB
- 2nd: BB and CCD
- 3rd: LA Nitrate, Ivabradine, Nicorandil, Ranolazine

Secondary prevention:
- Aspirin 75mg + Low dose statin

Question 3

Management of ACS

Answer 3

Initial management:
- pain relief = GTN +/- morphine
- Aspirin 300mg
- O2 if indicated
- STEMI: PCI within 2h (Heparin if PCI is done through radial access)

Secondary management:
- Life-long aspiring 75mg
- Second anti-platelet for 12 months: Prasugrel, Ticagrelor, Clopidogrel (Prasugrel preferred in pts with PCI)
- ACEi
- BB
- High intensity statin

Question 4

Management of HF

AVOID RATE LIMITING CCB AND ALL OTHER CCBS EXCEPT AMLODIPINE

Answer 4

Long term management:

1st: ACEi and BB licensed for HF (Bisoprolol, Carvediol, Nebivolol)

2nd: If ACEi CI: ARB licensed for HF (Candesartan, Losartan, Valsartan)

3rd: If ACEi and ARB CI: Hydralazine

Symptoms persist - add spironolactone / eplerenone

Specialist if symptoms continue: Amiodarone, Digoxin, Sacubitril with valsartan, Ivabradine, Dapagliflozin

Relief of breathless and oedema: Loop diuretics (Furosemide, Buumetanide, or Torasemide)

Question 5

UFH

Answer 5

Activates antithrombin

Good in renal impairment

Shorter duration of action

Essential to measure APTT

Good for high risk of bleeding

Question 6

LMWH

Answer 6

Inactivates factor Xa

Used in pregnancy

Lower risk of osteoporosis and heparin induced thrombocytopenia

Longer duration of action

Question 7

Gestational HTN in pregnancy

Answer 7

1. Labetalol
2. Nifedipine
3. Methyldopa

Question 8

Occlusive Peripheral Vascular Disease - normally caused by atherosclerosis

Answer 8

Reduce risk with healthier lifestyle, aspirin 75mg OD and statin as secondary prevention of cardiovascular events

Naftidrofuryl oxalate has shown a greater increase in maximum walking distance and pain-free walking distance than cilostazol and pentoxifylline.

Question 9

Vasoplastic Peripheral Vascular Disease (Raynaud’s)

Answer 9

Avoid exposure to cold and smoking cessation

Nifedipine

Question 10

Max Simvastatin dosages:

Manufacturer advises max. 10 mg daily with concurrent use of bezafibrate or ciprofibrate.

Manufacturer advises max. 20 mg daily with concurrent use of amiodarone, amlodipine, or ranolazine.

Manufacturer advises reduce dose with concurrent use of some moderate inhibitors of CYP3A4 (max. 20 mg daily with verapamil and diltiazem).

Answer 10

Manufacturer advises max. 10 mg daily with concurrent use of bezafibrate or ciprofibrate.

Manufacturer advises max. 20 mg daily with concurrent use of amiodarone, amlodipine, or ranolazine.

Manufacturer advises reduce dose with concurrent use of some moderate inhibitors of CYP3A4 (max. 20 mg daily with verapamil and diltiazem).

Manufacturer advises max. 40 mg daily with concurrent use of lomitapide or ticagrelor.

Manufacturer advises max. 20 mg daily with concurrent use of elbasvir with grazoprevir.

Manufacturer advises usual max. 20 mg daily with concurrent use of bempedoic acid or bempedoic acid with ezetimibe; max. dose 40 mg daily in patients with severe hypercholesterolaemia and at high risk of cardiovascular complications.

Question 11

Max Atorvastatin dosages:

Manufacturer advises if concurrent use of ciclosporin is unavoidable, max. dose cannot exceed 10 mg daily.

Answer 11

Manufacturer advises if concurrent use of ciclosporin is unavoidable, max. dose cannot exceed 10 mg daily.

Manufacturer advises max. dose 40 mg daily when combined with anion-exchange resin for heterozygous familial hypercholesterolaemia.

Manufacturer advises max. dose 20 mg daily with concurrent use of elbasvir with grazoprevir.

Manufacturer advises max. dose 20 mg daily with concurrent use of letermovir without ciclosporin.

Manufacturer advises max. dose 20 mg daily with concurrent use of sofosbuvir with velpatasvir and voxilaprevir.

Question 12

Max Rosuvastatin dosages:

Initially 5 mg daily with concurrent use of clopidogrel—max. dose 20 mg daily.

Answer 12

Initially 5 mg daily with concurrent use of bezafibrate, ciprofibrate, and fenofibrate—40 mg dose is contraindicated.

Initially 5 mg daily with concurrent use of clopidogrel—max. dose 20 mg daily.

Initially 5 mg daily with concurrent use of elbasvir with grazoprevir—max. dose 10 mg daily.

Max. dose 10 mg daily with concurrent use of sofosbuvir with velpatasvir.

Reduce dose by half with concurrent use of teriflunomide.

Max. dose 5 mg daily with concurrent use of glecaprevir with pibrentasvir.

Max. dose 5 mg daily with concurrent use of regorafenib.

Initially 5 mg daily with concurrent use of atazanavir boosted with ritonavir—max. dose 10 mg daily.

Initially 5 mg daily with concurrent use of lopinavir boosted with ritonavir—max. dose 20 mg daily.