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Random Pre Reg Questions > CVS > Flashcards

CVS Flashcards

1
Q

What are the five licensed oral anticoagulants?

A

Warfarin

NOACs:
Apixaban
Rivaroxaban
Dabigatran
Edoxaban

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2
Q

What are the common symptoms of VTE

A

Pain and swelling in one (sometimes both) legs,
tenderness,
changes to skin colour and temperature,
Vein distension

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3
Q

Risk factors of VTE

A

Age (>65)
Temporary immobilisation
Major surgery or trauma
Pregnancy
Specific medical conditions eg. cancer
Oestrogen use
Overweight/ obese
Long periods of inactivity
Family history

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4
Q

Three factors that influence formation of thrombi

A

Abnormalities of;
- Blood flow (atrial fibrillation)
- Surfaces in contact with blood (mechanical heart valve)
- Clotting components (factor V, protein C and protein S deficiency)

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5
Q

What is used for prophylaxis of VTE?

A

For high risk patients (eg. Orthopaedic surgery)

LMWH
Fondaparinux
Unfractioned heparin (for renal impairment)
NOACS

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6
Q

What is the duration of prophylaxis tx of VTE

(Different types of surgery)

A
  • General surgery: 7 days (or until sufficient mobility
  • Major cancer surgery in abdomen or pelvis: 28 days
  • Spinal surgery: 30 days
  • Knee/hip surgery: extended duration
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7
Q

Treatment of VTE in pregnancy

A

LWMH preferred

  • lower risk of osteoporosis and heparin induced thrombocytopenia
  • stop at labour-onset or seek specialist advice if to continue
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8
Q

What are the two types of heparin?

A
  1. Unfractionated heparin (activates antithrombin)
  2. Low molecular weight heparin (inhibits factor Xa)
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9
Q

What VTE treatment is preferred in patients with high risk of bleeding and renal impairment (clearance: 15-50ml/min)? Why?

A

Unfractionated heparin

  • Shorter duration of action
  • Monitor APTT (activated partial thromboplastin time ie. How the body reacts to heparin)
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10
Q

Examples of LMWH

A

Tinzaparin
Enoxaparin
Dalteparin

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11
Q

What is the preferred treatment of VTE in pts with osteoporosis?

A

LMWH

  • Longer duration of action
  • Lower risk of osteoporosis and heparin induced thrombocytopenia (HIT)
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12
Q

Side effects of heparin

A
  • haemorrhage (STOP)
  • HypERkalaemia (higher risk in CKD and diabetes)
  • Osteoporosis
  • Heparin-induced thrombocytopenia (drop in platelet levels significantly - doesn’t occur till 5-10 day mark)
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13
Q

What is used to reverse the effect of heparin in emergency?

A

Protamine sulphate

  • partially reverses effect
  • binds to heparin to form stable iron pair which doesn’t have anticoagulating activity
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14
Q

What factors increase risk of bleeding?

A

‘CLITS’

  • Thrombocytopenia (low platelet)
  • Liver failure
  • Concurrent anticoagulants
  • Inherited disorders (haemophilia, Von Willebrand disease (VWD))
  • Systolic hypertension
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15
Q

What VTE prophylaxis treatment is preferred in pts undergoing abdominal, bariatric, thoracic or cardiac surgery?

A

Fondaparinux

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16
Q

What VTE prophylaxis is preferred in pts with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur

A

Fondaparinux

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17
Q

What is the choice of VTE prophylaxis in pts undergoing elective hip replacement

A

LMWH - 10 days
Then, low dose aspirin - 28 days

Or

LMWH - 28 days
With, anti-embolism stockings until discharge

Or

Rivaroxaban ( if CI, another NOAC)

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18
Q

What is the choice of VTE prophylaxis in pts undergoing elective knee replacement

A

Low dose aspirin / LMWH - 14 days
With, anti-embolism stocking until discharge

Or

Rivaroxaban (if CI, other NOAC)

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19
Q

Choice of VTE prophylaxis for acutely ill patients

A

7 aLiFe

LMWH - first line

Or

Fondaparinux

for minimum 7 days

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20
Q

VTE prophylaxis for acute stroke

A

Mechanical prophylaxis with intermittent pneumatic compression

Within 3 days of acute stroke and continued for at least 30 days

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21
Q

How long should VTE prophylaxis be continued in pregnant women?

A

LMWH continued until no longer at risk or discharge

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22
Q

VTE prophylaxis in women who gave birth or had a miscarriage during the past 6 weeks

A

LMWH
4-8 hours after event
Continue for a minimum of 7 days

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23
Q

Choice of treatment for pts with confirmed proximal DVT or PE

A

Apixaban or Rivaroxaban

If CI,

LMWH - >5 days
Then, dabigatran or edoxaban

OR

LMWH + warfarin - >5 days or until INR atleast 2.0 for 2 consecutive readings
Then, warfarin on it’s own

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24
Q

How long should pts with confirmed VTE take anticoagulant

A

Provoked VTE - 3 months
Unprovoked VTE - >3 months (>6 months in active cancer)

(3-6 months with active cancer)

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25
Q

What is the anticoagulant choice for pts who are not well tolerated in current long term treatment

A

Apixaban

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26
Q

What can be used with pts who decline continued anticoagulant tx

A

Aspirin (unlicensed)

Review annually

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27
Q

What should be checked in pregnant women before starting anticoagulants

A

FUL C
Baseline blood tests;
- Full blood count
- Coagulation screen
- Urea and electrolytes
- Liver function tests

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28
Q

What is the Rivaroxaban dose for VTE prophylaxis following knee replacement surgery?

A

10mg OD - 14 days

*to be started 6-10 hours after surgery *

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29
Q

What is the Rivaroxaban dose for VTE prophylaxis following hip replacement surgery?

A

10mg OD - 5 weeks

to be started 6-12 hours after surgery

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30
Q

What is the Apixaban dose for VTE prophylaxis following knee replacement surgery?

When to start?

A

2.5mg BD for 10-14 days

to be started 12-24 hours after surgery

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31
Q

What is the Apixaban dose for VTE prophylaxis following hip replacement surgery?

A

2.5mg BD for 32-38 days

to be started 12-24 hours after surgery

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32
Q

How long does warfarin take to work?

A

48-72 hours

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33
Q

What is the duration of tx with warfarin in isolated calf-vein VTE?

A

6 weeks

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34
Q

What are the vitamin k antagonists

A

’WAP’

-Warfarin
- Phenindione
- acenocoumarol

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35
Q

What is used as first line in cerebral artery thrombosis or peripheral artery occlusion?

A

Aspirin

More appropriate for transient ischaemic attacks

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36
Q

What is the acceptable range the INR can deviate from target?

A

0.5 units

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37
Q

How often should INR be monitored?

A
  • alternate days initially,
  • then every 1-2 weeks until stable,
  • then every 3 months
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38
Q

Target INR

A

2.5 - Most incidences
3.5 - Recurrent VTE in pts receiving anticoagulant and with an INR > 2

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39
Q

Colour of warfarin tablets

A

’BrB Pink’

White - 0.5mg
Brown - 1mg
Blue - 3mg
Pink - 5mg

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40
Q

Can warfarin be used in pregnancy?

A

No - teratogenic

Avoid especially in 1st and 3rd trimesters

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41
Q

Counselling points for warfarin

A
  • Take same time everyday
  • Notify anticoagulation clinic of changes to medication, lifestyle or diet
  • Stop 5 days before elective surgery
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42
Q

MHRA warnings with warfarin

A
  • Report calciphylaxis ; painful skin rash
  • Interaction with vitamin k antagonists and antivirals; changed in INR and efficacy of warfarin
  • Interaction with OTC oral miconazole gel (Daktarin); increases INR and risk of bleeding
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43
Q

What do you monitor with warfarin?

A
  • INR; alternate days initially, then every 1-2 weeks until stable, then every 3 months
  • Liver function; avoid in severe
  • Renal function; monitor INR more frequently in sever
  • Full blood count
  • Blood pressure
  • Thyroid function; warfarin metabolism can be affected
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44
Q

What to do if INR is 5.0 - 8.0 with no bleed

A
  • Withhold 1-2 doses
  • Reduce maintenance dose
  • Measure INR after 2-3 days
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45
Q

What to do when pt is experiencing major bleeding while on warfarin?

A
  • STOP warfarin
  • Give IV phytomenadione (vitamin K)
  • Dried prothrombin complex or fresh frozen plasma
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46
Q

What to do if INR is >8.0 with no bleed

A
  • Stop warfarin
  • Give oral phytomenadione (vitamin k)
  • Repeat dose if INR still too high after 24 hours

Restart warfarin when INR <5.0

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47
Q

What to do if INR is >5.0 with minor bleed

A
  • STOP warfarin
  • IV phytomenadione

Restart warfarin when INR < 5.0

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48
Q

What to do when pt is on warfarin and about to undergo elective surgery

A
  • Stop 5 days before
  • Oral Vitamin K for one day if INR >1.5
  • Restart next day
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49
Q

What to do when pt is on warfarin and about to undergo emergency surgery

A
  • IV phytomenadione; if surgery can be delayed by 6-12 hours
  • Add dried prothrombin
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50
Q

What to do when pt is on warfarin and about to undergo high risk of VTE

A
  • Temporarily switch to LMWH (using treatment dose) till 24 hours before surgery

If high risk of bleeding, LMWH should not be restarted till atleast 48 hours after surgery

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51
Q

NOACs mechanism of action

A
  • Dabigatran - direct thrombin inhibitor
  • Apixaban, Edoxaban & Rivaroxaban - direct factor Xa inhibitor
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52
Q

Patient counselling for NOACs

A
  • Give patient alert card
  • Alternative to warfarin
  • Lower bleeding risk
  • No need for regular monitoring
  • Fewer food and drug interactions
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53
Q

Which NOAC has highest bleeding risk?

A

Dabigatran

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54
Q

What drugs increase bleeding risk with NOACs?

A

’NAACS’

  • NSAIDS
  • Other anticoagulants
  • Antiplatelets
  • strong CYP3A4 inhibitors
  • SSRI or SNRI
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55
Q

Dose adjustments to Apixaban in renal impairment

A

Reduce dose - ABC (age, body weight, creatinine)

CrCl (15-29ml/min) or Cr > 133 micromol/L
OR
Age >80 years OR Weight < 61kg

Avoid if CrCl < 15ml/min

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56
Q

Dose adjustments to Rivaroxaban in renal impairment

A
  • Take with or after food for improved absorption
  • Reduce dose if CrCl 15-49ml/min
  • Avoid if CrCl <15ml/min
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57
Q

Dose adjustments to Dabigatran in renal impairment

A

Reduce dose if
- CrCl 30-50ml/min
- Age > 80
- High bleeding risk
- If also on verapamil or amiodarone

Avoid is CrCl < 30ml/min

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58
Q

How long do transient ischaemic attack last for?

A

< 24 hours

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59
Q

Warning signs of stroke

A

’FAST’

  • Face drooping
    -Arm weakness
    -Speech difficulty
    -Time to call 999
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60
Q

How to treat haemorrhagic stroke

A
  • Avoid ’ASA’ aspirin, statin and anticoagulants (increases risk of bleeding)
  • Treat hypertension
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61
Q

How is ischaemic stroke / TIA treated long term?

If first line CI?
If AF?
If hypertension

A
  • Clopidogrel 75mg OD

If CI;
- MR dipyridamole & Aspirin 75mg

If AF related, consider anticoagulant

If hypertension, treat with beta blocker

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62
Q

Counselling points for MR dipyridamole

A
  • Take 30-60 mins before food
  • Capsules have a 6 week expiry once opened
  • Keep in original container
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63
Q

When is antiplatelet used in stroke?

A

Only as secondary prevention when stroke has already occurred

Consider adding PPI for pts at high risk of GI bleed (impaired renal or hepatic function)

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64
Q

When is aspirin CI and why?

A

In children under 16
Reye’s syndrome

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65
Q

Risk factors of arrhythmias

A
  • Smoking
  • Excessive alcohol/ caffeine consumption
  • Obesity
  • Stress
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66
Q

Non cardiac risk factors of arrhythmias

A
  • Overactive or underactive thyroid, diabetes, electrolyte imbalance K, Mg, Na
  • Stimulants eg. Cocaine or amphetamine
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67
Q

What are the 4 different classes of anti-arrhythmic drugs

A
  • Membrane stabilising (Na blockers)
  • Beta blockers
  • K+ channel blockers
  • Calcium channel blockers (rate limiting)
  • Other (Adenosine, digoxin)
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68
Q

How is stroke risk assessed?

A

CHA2DS2-VASc

C - Chronic HF / left ventricular dysfunction
H - Hypertension
A2 - Age 75+
D - Diabetes
S2 - Stroke / VT history
V - Vascular disease
A - Age 65-74
Sc - Sex - female

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69
Q

What are the Na channel blocker drugs

A

Disopyramide
Lidocaine
Propafenone
Flecainide

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70
Q

What are the calcium channel blockers

A

Diltiazem
Verapamil

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71
Q

What are the potassium channel blockers

A

Amiodarone
Sotalol

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72
Q

What are examples of beta blockers

A

Propranolol
Bisoprolol

used to slow the heart rate

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73
Q

What is used in rhythm control for AF

A
  • Electrical cardio version
  • Amiodarone
  • Flecainide
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74
Q

What is used for acute new-onset of AF

life threatening/non life threatening

A

Life threatening - electrical cardioversion

Non-life threatening;
- <48 hours : Rate/Rhythm control
- > 48 hours : Rate control (verampil/beta blockers)

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75
Q

What is used is a pt with new onset AF requires urgent rate control?

A

IV beta-blockers

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76
Q

What is the preferred tx for AF if LVEF > 40%

A

Verapamil

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77
Q

What rate limiting drugs should be avoided in pts with AF and suspected concomitant acute decompensated heart failure

A

Calcium channel blockers

Seek specialist advice

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78
Q

What is used first line for maintenance tx of AF

A

Rate control

  • Beta blocker (not sotalol)
  • Rate limiting CCB (diltiazem or verapamil)
  • Digoxin (preferred in immobile pt)
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79
Q

What rhythm control is preferred in AF present for more than 48 hours

What safety measures?

A

Electrical cardio version

Delay for atleast 3 weeks until fully anti-coagulated
If not possible, heparin commenced immediately before and oral anticoag after cardioversion for atleast 4 weeks

Amiodarone started 4 weeks before and continued for up to 12 months after cardioversion

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80
Q

What is used second line for maintenance tx of AF

A

Standardised beta blockers
bisoprolol
metoprolol
carvedilol

consider combination therapy
- Avoid verapamil and beta-blockers - severe hypertension
- Beta-blockers + digoxin - preferred if ventricular function diminished

For rare infrequent episodes
Flecainide or propafenone
pill in pocket

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81
Q

What beta blockers are preferred in pts with diabetes?

A

Cardioselective beta-blockers

‘Be A MAN
Bisoprolol
Atenolol
Metoprolol
Acebutolol
Nebivilol

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82
Q

When should beta blockers be avoided

A
  • 2nd/3rd degree heart block
  • worsening unstable heart failure
  • pt with frequent hypoglycaemia
  • Asthma, bronchospasms
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83
Q

When is CCB (diltiazem and verapamil) contra indicated

A
  • Heart failure
  • Pregnant women

Diltiazem avoided throughout pregnancy
Verapamil avoid in 1st trimester

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84
Q

What is the target therapeutic level for digoxin?

When should it be measured?

A

0.7-2 mcg/L

To be measured 6 hours after a dose

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85
Q

Risk factors for digoxin toxicity

A
  • HypERCalcaemia
  • HypOkalaemia
  • HypOMagnesia
  • Low oxygen
  • Recent MI
  • Severe respiratory disease
  • Thyroid disease
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86
Q

Signs of digoxin toxicity

A

’Slow/Sick’

Slow: bradycardia, heart block
Sick: vomiting, nausea, diarrhoea and stomach pain

Blurred or yellow vision
Confusion, delirium and rash

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87
Q

Digoxin interactions

A

’CRASED’

CAlcuin channel blockers (verapamil)
Rifampicin
Amiodarone
St John’s Wart
Erythromycin
Diuretics

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88
Q

What CCBs need to be prescribed by brand?

A

MR Diltiazem
MR Nifedipine

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89
Q

Side effect of verapamil

A

Constipation
Improved by increased fibre and fluid intake

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90
Q

What to avoid with rate limiting CCB?

A

Grape fruit juice
increased CCB concentration

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91
Q

What is the loading dose for amiodarone?

A

200mg TDS for 7 days
200mg BD for 7 days
200mg OD as maintenance

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92
Q

Main interactions with amiodarone

A
  • Digoxin ; digoxin toxicity
    -warfarin, phenytoin - increase conc
  • Antivirals - Severe bradycardia and heart block
  • Beta blockers / Rate limiting CCBs
  • Statin
  • Grape fruit juice - toxicity
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93
Q

MHRA warning for amiodarone

A

Interaction with Sofosbuvir
Risk of bradycardia and heart block

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94
Q

Monitoring requirements for amiodarone

A
  • Annual eye test
  • Chest x-Ray before treatment
  • Liver function every 6 months
  • Thyroid glands before tx and every 6 months
  • Blood pressure and ECG
  • Serum potassium (hypokalemia)
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95
Q

Wha is the half life of amiodarone

A

About 50 days

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96
Q

Major side effect of amiodarone?
Interaction?

A

QT prolongation

Do not give with other QT prolongation drugs

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97
Q

What is used to assess bleeding risk?

A

HAS-BLED

Hypertension - 1
Abnormal liver function - 1
Abnormal renal function - 1
Alcohol (>8u/week) - 1
Stroke - 1
Bleeding - 1
Labile INRs (<60%) - 1
Elderly (>65)
Drugs (antiplatelets or NSAIDs)

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98
Q

Treatment for bleeding disorders

A

Tranexamic acid

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99
Q

Different stages of hypertension

A

Stage 1:
140/90 - 160/100mmHg
Daytime average: 135/85

Stage 2:
>160/100mmHg
Daytime average: >150/95

Severe:
>180/120

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100
Q

How is hypotensive urgency treated?
ie. Severe hypertension without acute damage to target organs

A

Labetolol or amlodipine

101
Q

What is used in hypertensive emergency

A

IV antihypertensive

102
Q

Hypertension risk factors

A

Age
Sex - Women up to 65 have lower bp
Ethnicity - black people more likely
Anxiety and emotional stress
Genetic factors
Social deprivation
Lifestyle

103
Q

Causes of hypertension

A
  • diabetes
  • drugs; NSIADs, steroids, SSNRI
  • herbal eg. Liquorice
  • recreational drugs
  • combined oral contraceptives
  • kidney disease
  • hormone problems - crushing syndrome
104
Q

Bp target in hypertension

A

<80 years: <140/90mmHg
>80 years: <150/90mmHg

established CVD or diabetes in the presence of kidney, eye or cerebrovascular disease: <130/80mmHg

diabetes: <140/80mmHg

105
Q

Target Bp In pregnancy

A

135/85

106
Q

When to treat stage 1 hypertension

A

>140/90mmHg

Pt <80 years
With target organ damage or 10 year CVD risk >20%

107
Q

Hypertension treatment in <55

A

Step 1: ACEi or ARB (if cough)

Step 2: Add CCB (if ACE/ARB step 1)
OR
Add Thiazide-like diuretics

Step 3: Combination of ARB/ACEi, CCB/TLD

108
Q

Hypertension treatment in >55 or black pts

A

Step 1: CCB
OR
thiazide-like diuretics

Step 2: Add ACEi/ARB

Step 3: Combination of ACEi/ARB, CCB/TLD

109
Q

When can’t CCB be given in hypertension

A

Oedema or high risk of heart failure

give TLD instead

110
Q

What’s used to treat resistant hypertension

A

Seek specialist advice

ACEi/ARB + CCB + TLD + diuretic (spironolactone)

111
Q

What is an alternate choice to spironolactone

A

Alpha blocker or beta blocker

112
Q

What is used in gestational hypertension

A

Labetalol
MR Nifedipine (unlicensed) - second line

Methyldopa- stop 2 days after birth

Give IV magnesium sulphate in critical care or severe pre-eclampsia or previous eclamptic fit

113
Q

Examples of ace inhibitors

A

Enalapril
Lisinopril
Perinopril
Ramipril

114
Q

ACEi drug interactions

A

’FANS’

  • ARB: hyperkalaemia, hypotension and renal impairment
  • NSAIDs: renal impairment
  • Spironolactone- hyperkalaemia
  • >80mg furosemide - hypotension (reduce or discontinue dose for 24 hours)
115
Q

When is ACE contraindicated

A
  • planning to be/ pregnant
  • breastfeeding women
116
Q

What antihypertensive cause dry cough?

A

ACE inhibitors

offer ARB

117
Q

Monitoring requirements for ACEi

A
  • Renal function
  • Serum electrolytes (K)
  • Blood pressure
118
Q

Side effects of ACEi

A

Dry cough
Hyperkalaemia
Renal impairment
Headaches
Dizziness

119
Q

Examples of dihydropyridine CCBs

A

Amlodipine
Felodipine
Nifedipine

120
Q

CCB food interactions

A

Avoid grapefruit juice
Statins

121
Q

Contraindication of CCB

A

Heart failure
Hepatic & Renal impairment

122
Q

Side effects of CCB

A

Headache
Dizziness
Swollen ankles
Constipation

123
Q

Examples of thiazide like diuretic

A
  • Indapamide
  • Chlortalidone
  • Metolazone - used in severe renal impairment
  • Xipamide
124
Q

What thiazides are used in hypertension?

A

Indapamide
Chlortalidone

125
Q

Side effect of long term TLD

A

HypOkalaemia
HypOnatraemia
Postural hypotension
Altered plasma-lipid concentration

126
Q

When are diuretics contraindicated

A

’PeARL’

  • Pregnant women
  • Addison’s disease
  • Renal impairment (eGFR <30mL/min)
  • Liver disease (severe)
127
Q

Monitoring requirements for diuretics

A

Renal function
Serum electrolyte (K and Na)
Liver function

128
Q

Examples of alpha blockers

A

Doxazosin
Terazosin

129
Q

What beta blocker is preferred in peri-operative period
Why?

A

Esmolol
Short half life

130
Q

Intrinsic sympathomimetic activity beta blockers

A

PACO

Pindolol
Acebutol
Celiprolol
Oxprenolol

less bradycardia and coldness of extremities

131
Q

Water soluble beta blockers

A

water CANS

Celiprolol
Atenolol
Nadolol
Sotalol

less nightmares and sleep disturbances
Reduce dose in renal impairment

132
Q

Cardioselective beta blockers

A

Be A MAN

Bisoprolol
Atenolol
Metoprolol
Acebutol
Nebivolol

less bronchospasm

133
Q

Once daily beta blocker

A

BACoN

Bisoprolol
Atenolol
Celiprolol
Nadolol

lond duration of action

134
Q

Side effects of beta blocker

A
  • Bradycardia
  • Hypotension
  • Hyper/Hypoglycaemia
  • Hypokalaemia
135
Q

How to treat heart failure

A

‘BANDAIDS’

Step 1: ACEi/ARB (candesartan, valsartan) + Betablocker
[titrate to highest dose of ACE/ARB first]
If Afro-Caribbean: Hydralazine & Nitrate

Step 2: Add Spironolactone

Step 3: Add Ivrabadine or digoxin or Amiodarone or Sacubitril valsartan

136
Q

Example of loop diuretic

A

Furosemide
Bumetanide
Torsemide

137
Q

What can be used as a prophylaxis for raynaud’s syndrome

A

Nifedipine

138
Q

What is used to assess risk of CVD

A

QRISK2 (<84 years)

if 10 year CVD risk score >10% = offer primary prevention

139
Q

What can cause hyperlipidaemia

A

Antipsychotic
Immunosuppressants
Corticosteroids
HIV drugs
HypOthyoidism - Low T4/T3
Liver or kidney disease
Diabetes

140
Q

Primary prevention of hyperlipidaemia

A

Atorvastatin 20mg

141
Q

Secondary prevention of hyperlipidaemia

A

Atorvastatin 80mg

established CVD

142
Q

When should statin be taken?
Exception

A

At night
Cholesterol synthesis greater at night; more effective

Exception: Atorvastatin

143
Q

What are the high-intensity statins and their dose

A

Atorvastatin: 20mg OD in primary prevention, 80mg OD in secondary prevention

Rosuvastatin 10mg

Simvastatin 80mg

144
Q

MHRA warning of simvastatin

A

High risk of myopathy

Give only if high risk of cardiovascular complications or severe hyper cholesterolaemia

145
Q

What is given as second line if hyperlipidaemia is not controlled by high intensity statin

A

Ezitimibe

146
Q

What is used if triglycerides still high after LDL reduced

A

Add Fibrate or Nicotinic acid

147
Q

Side effects of statin

A
  • Myopathy, Myositis, Rhabdomyolysis
  • Insterstitial lung disease (report short breath, cough, weight loss)
  • Diabetes

Report: tender, weak and painful muscles

risk increased by renal impairment, hypothyroidism
use with ezetimibe, Fibrates and fusidic acid

148
Q

Statin and fusidic acid

A

Stop statin while using fusidic acid and restart 7 days after last dose

149
Q

Warning signs of statin

A

Tender, weak and painful muscles - Myopathy

Shortness of breath, cough, weight loss - Interstital lung disease

150
Q

Monitoring requirements for statin

A

’THRoBe’

  • Baseline lipid pu - before
  • Renal function - before
  • Thyroid function; every 3 months
  • HbA1c - before
  • Liver function - before
151
Q

When to discontinue statin
with biological markers

A
  • sever muscle symptoms
  • 5x normal creatine kinase
  • transaminases 3x normal (liver function)
152
Q

Statin in pregnancy

A

Teratogenic

Effective contraception during and 1 month after stopping
discontinue 3 months before attempting to conceive

153
Q

Statin main interactions

A

Macrolides; Clarithromycin - Stop taking statin until antibiotic course completed

Fusidic acid - Restart 7 days after last dose of fusidic acid (oral) dose

Anti fungal - itraconazole, ketoconazole

154
Q

Simvastatin dose adjustments due to interactions

A

Max 10mg with Fibrate
Max 20mg with Amiodarone, amlodipine, Diltiazem, verapamil

155
Q

Atorvastatin dose adjustment due to interactions

A

Max 10mg with ciclosporin

156
Q

Rosuvastatin dose adjustments due to interactions

A

Initially 5mg
Max 20mg with Clopidogrel

157
Q

Bile acid sequestrants interaction

A

Colesevelem, colestipol, colestyramine

impairs absorption of fat-soluble vitamins ADEK and other drugs
Take other drugs 1 hour before (4 hours for coleveselam) or 4 hours after

158
Q

What ARB are licensed in heart failure

A

Candesartan
Valsartan
Losartan

159
Q

Preferred beta blocker in mid-moderate stable heart failure and 70+

A

Nebivolol

160
Q

What CCB can be used in heart failure

A

Amlodipine

used in patients with heart failure and angina

161
Q

What are the potassium sparing diuretics

A

Amiloride
Triamterene (blue urine in some lights)

162
Q

Side effect of loop diuretic

A

Ototoxicity
Acute urinary retention
Hyperglycaemia
Hyperuricaemia (gout - furosemide)
HypO K Na Cl Mg

163
Q

Side effects of thiazides and TLD

A

GI disturbance
Impotence
High LDL/Triglyceride
Diabetes
Gout
HypO K Na Cl Mg
HypER Ca

Ineffective if eGFR <30 except metolazone

164
Q

Loop diuretic dose in heart failure

A

BD (take last dose at 4pm)
20-40mg OM - Furosemide

165
Q

TLD dose in heart failure

A

OM 5mg

166
Q

What is used to treat occlusive PVD

A

Aspirin 75mg OD
Statin

167
Q

What is used in management of acute angina attack

Properties
If severe?

A

Glyceryl Trinitrate
IV opioid - severe MI (eg. Morphine)

  • effects last 20-30 minutes
168
Q

How to take short-acting nitrates

A
  • PRN
  • Take sitting down as dizziness can occur
  • Take 1st dose under tongue and wait 5 minutes
  • Take 2nd dose and wait 5 minutes
  • Take 3rd dose and wait 5 minutes
    (1 dose = 1 tablet or 1-2 sprays)
169
Q

What is used in long term prophylaxis of angina

A

‘C.B.Angina

  1. B-blocker or rate limiting CCB
  2. B-blocker + dihydropyridine CCB

If one or both CI add/use vasodilators
- Long acting nitrate
- Ivabradine
- Ranolazine
- Nicorandil (adult only, risk of ulcer complications, DO NOT DRIVE until it is established performance is not impaired)

170
Q

How to use nitrate patches

A
  • Leave patches off for 8-12 hours in a day (over night)
  • Take second dose after 8 hours
  • MR isosorbide mononitrate taken OD
171
Q

How to treat unstable angina (NSTEMI) if hypoxia

A

Oxygen

172
Q

NSTEMI tx in reperfusion

A

Antiplatelet effect
- Aspirin 300mg + Clopidogrel 300mg

Antithrombin
- Fondaparinux
- Heparin

173
Q

Duration of dual antiplatelet tx in angina with pt undergoing PCI

A

Aspirin (forever)
+
Clopidogrel

Elective = 4 weeks
Bare metal stent = 12 months
Drug - eluting stent = 12+ months

174
Q

Tx in cardiac arrest

A
  • 30 compressions: 2 breaths ~ 100 compressions/min
  • IV Adrenaline 1 in 1000 every 3-5 min
  • If ventricular fibrillation: IV AMIODARONE
175
Q

How should ACEi be taken with food

A

On an empty stomach 30-60 minutes before food

176
Q

Symptoms of Reye’s syndrome

A

Initially; persistent effortless vomiting, lack of enthusiasm and loss of energy, drowsiness, rapid breathing and seizures

Progress; extreme irritability, aggressive behaviour, delirium and coma

Raised LFTs and White cell count

177
Q

What PPIs reduce efficacy of clopidogrel

A

Esomeprazole
Omeprazole

178
Q

What is used to reverse effect of dabigatran

A

Idarucizumab

179
Q

Max daily dose of ramipril if eGFR 30-60

A

5mg daily

180
Q

Interaction between diuretics and digoxin

A

Diuretics (loop and TLD) cause HypOKalaemi which increase risk of toxicity

181
Q

Warfarin counselling

WARFARINISE

A

’WARFARINISE’

  • When to take: same time each day
  • Alcohol: may increase anticoagulant effect
  • Risk of bleeding: report unexpected bleeding
  • Follow up: monitor INR
  • Aspirin: AVOID
  • Reason for taking: slow down rate at which blood clots
  • Interactions: drastic changes in diet (esp. food with vit k)
  • Notify HCPs of warfarin: yellow book + alert card
  • INR: inform of their range
  • Skipped dose: if any missed, continue normal dose for the day
  • End of course: how long they need to take it for
182
Q

What to do if warfarin dose is missed

A

if any missed, continue normal dose for the day

183
Q

What juice does warfarin interact with

A

Cranberry
Pomegranate

184
Q

Warfarin interaction with vitamins

A

Vitamin E and K

Increase bleeding

185
Q

When can you give aspirin to under 16

A

Kawasaki

186
Q

Beta blockers in heart failure

A

‘NBC’

Carvidelol
Nebivolol
Bisoprolol

187
Q

What ACE is taking before food

A

Ferindopril

188
Q

MHRA warning with rivaroxaban

Reversal agent?

A

Erythromycin
increase risk of bleeding

take with food
Reversal agent: andexanet alpha

189
Q

ACE taken twice daily

A

Captopril

190
Q

When should the first dose of ACE be taking

A

At night

191
Q

When is digoxin dose halved with other drug

A
  • Amiodarone
  • Quinine
  • Donedarone
192
Q

What range is digoxin more likely to be toxic

A

1.5-3

193
Q

Pt having nausea with digoxin

A

Give BD

194
Q

What beta blocker is giving IV

A

Esmolol

195
Q

Bp target for pregnant

A

135/85

196
Q

Non valvular VTE tx

A

DOAC

197
Q

Valvular VTE tx

A

Warfarin

198
Q

Which DOAC doesn’t have a reversible agent

A

Edoxaban

199
Q

‘Dazzled by head light’ - what drug does this indicate

A

Amiodarone

200
Q

Indapamide side effects

A

Rash

201
Q

Warfarin dose

A

Initial: 5-10mg
Maintenance: 3-9mg

Same time each day

202
Q

Rivaroxaban dose
- treatment of VTE or PE
- prophylaxis of recurrent DVT or PE
- prophylaxis of stroke or AF with one risk factor
- prophylaxis of atherothrombotic events following ACS

A
  • Tx VTE/PE: initially 15mg BD x 21dy, maintenance 20mg OD
  • Prophylaxis recurrent DVT/PE: 10mg OD, 20mg in high risk
  • prophylaxis of stroke/AF: 20mg OD
  • Prophylaxis atherombic events: 2.5mg BD x 12 mths
203
Q

Dose of Apixaban
- tx of DVT/PE
- prophylaxis recurrent DVT/PE
- prophylaxis stroke/AF

A
  • tx of DVT/PE: 10mg BD x 7dy , maintenance 5mg BD
  • prophylaxis recurrent: 2.5mg BD
  • prophylaxis stroke/AF: 5mg BD, reduce to 2.5mg BD if >2 risk factors
204
Q

Dose of edoxaban

A

-Adult <61kg= 30mg OD
- Adult >61kg= 60mg OD

205
Q

Dabigatran dose in prophylaxis for knee replacement

A

110mg for 1-4 hours after surgery
Then, 220mg OD for 10 days

206
Q

Dabigatran prophylaxis dose for stroke

A

110mg - 150mg BD

207
Q

What is preferred first line in HF with diabetic pts

A

ACEi

208
Q

What is preferred first line in HF for pt with angina

A

Beta blocker

209
Q

What is used in HF if pt is Afro-Caribbean and not tolerating ACE/ARB

A

Hydralazine & Nitrate

210
Q

Drugs used is Heart failure

A

’BANDAIDS’

  • Beta blocker
  • ACEi / ARB
  • Nitrate / Hydralazine
  • Diuretic (MRA/loop/thiazide)
  • Amiodarone
  • Ivabradine
  • Digoxin
  • Sacubitril valsartan
211
Q

What vaccine should be offered in HF

A

Influenza vaccine
Pneumococcal Disease Vaccine

212
Q

What’s used in HF with reduced ejection fraction

A

<35%

  • Replace ACEi/ARB with Sacubitril valsartan
  • Add Ivabradine for sinus rhythm
213
Q

What drugs worsen heart failure

A
  • NSAIDs: Retains Sodium
  • CCB: Except Amlodipine
214
Q

What are the three types of ACS

A
  • Angina
  • NSTEMI
  • STEMI
215
Q

What cardiac marker is used to identify heart attack

A

Troponin

216
Q

Main Symptoms of angina

A
  • Chest pain (tight, sharp, stabbing, dull or heavy)
  • Spreads to left arm, neck, jaw or back
  • Triggered by physical exertion or stress
  • Stops within a few minutes of resting
  • Nausea, fatigue, SOB, sweating, dizziness
217
Q

Initial management of ACS (unstable angina, NSTEMI & STEMI)

A
  • Aspirin 300mg ASAP (Chew or disperse in water)
  • Nitrates
  • IV opioid eg. Morphine in severe pain
  • Oxygen if hypoxia
  • Insulin if glucose >11 mmol/L
218
Q

Secondary prevention of cardiovascular events following ACS

A

ACEi/ARB
+
Beta blockers (Alt. Diltiazem/ verapamil)
+
Dual antiplatelet (aspirin lifelong + clopidogrel - 12 mnths)
+
Dual/triple therapy with rivaroxaban (if troponin high)
+
Statin (if evidence of CVD)

219
Q

Rivaroxaban dose in ACS

A

2.5mg BD

used when elevated biomarkers

220
Q

If pt is using GTN spray more than twice a week what should be done?

A

Long term prophylaxis

221
Q

Dose of GTN tablet first used

A

300 mcg

222
Q

Difference between MR isosorbide mononitrate & dinitrate

A

MR Isosorbide Mononitrate: OD

MR Isosorbide Dinitrate: BD

223
Q

How to avoid tolerance effect with nitrate

A
  • Take MR Isosorbide OD (mononitrate)
  • For BD dose, take dose after 6-8hrs (give nitrate free period)
  • Leave patch off for 8-12hrs (usually overnight) in each 24 hours
224
Q

Prescribing and dispensing information for GTN S/L tablets

A
  • Available in 300, 500 & 600 mcg
  • Supply in glass containers of <100 tabs
  • Closed with foil line cap (not cotton wool wadding)
  • Discard after 8 weeks (rectal ointment as well)
225
Q

What drugs have risk of first dose hypotension and so first dose taken at night

A

Alpha blockers

doxazosin, prozasin, terazosin

226
Q

From what week in pregnancy do you commence daily dose oh aspirin for prophylaxis of pre-eclampsia

A

Week 12

227
Q

Side effect of nicorandil

A

Serious skin mucosal
Eye ulceration
GI ulcers

228
Q

What diuretic is associated with gynaecomastia

A

A condition that causes men’s breast to swell and become larger than normal

MRA diuretics

Eplerenone & spironolactone

229
Q

Target INR to switch from warfarin to DOAC

A

<2

230
Q

How long should be allowed to determine response from ACEi

A

4 weeks

231
Q

Is warfarin found in breast milk

A

No

232
Q

Drugs that cause hypertension

A
  • contraceptive pill
  • steroid
  • NSAIDs
233
Q

When should ticagrelor be discarded

A

12 weeks after opening

234
Q

Side effect of nitrate

A

Flushing
Headaches
Palpitations
Syncope - loss of consciousness

235
Q

Which CCB is licensed for tx of acute life-threatening hypertension

A

Nicardipine

236
Q

What is the most important test to do before starting statin

A

Liver function

repeat within 3 months and at 12 months

237
Q

A patient on simvastatin 40mg for secondary prevention of MI is not well controlled. What next?

A
  • changing to Fibrate if triglyceride is high
  • change to Atorvastatin (first line treatment)
  • add ezetimibe if statin has been titrated and still not controlled
238
Q

What beta-blocker is used in thyrotoxicosis

A

Propranolol

Reverses within 4 days

239
Q

Common side effect of ezetimibe

A

GI disturbance

240
Q

How should nicorandil be taken?

A

With breakfast and evening meal

241
Q

Can you put warfarin in a dosette box?

A

No

242
Q

Treatment of hypertension in diabetes

A

ACE - ‘ril’

OR

ARB - ‘sartan’

243
Q

Stroke pathway

A

1 - Aspirin 300 mg (immediately)
- Alteplase within 4.5 hours

2 - Long term
- Clopidogrel 75mg (lifelong)
- Aspirin + dipyridamole
- Aspirin or Dipyridamole

3 - for secondary prevention
- Atorvastatin 80mg

*Give antihypertensive NOT BB and lansoprazole for clopidogrel

244
Q

Pathway for stable angina

A

Acute : GTN
- every 5 mins, call 999 if 3rd dose is taken
- can be taken before exercise

Longterm tx
- Betablocker (or RL CCB)
- Betablocker + CCB (amlodipine)
- LA nitrate, Ivabradine, nicorandil, ranolazine
- aspirin 75mg
- Atorvastatin 20mg

245
Q

Heart failure pathway

A
  1. ACE + BB (low dose + titrate)
    • spironolactone/eplerenone
    • sacambutol + vasarltan or amiodarone or nicorandil or **
246
Q

What is used in thrombolysis in MI

A

Streptokinase
Alteplase

247
Q

Patient being treated for hypertension presents with painful rash but not itchy. What drug?

A

ACEi

248
Q

What CVS drug interacts with sildenafil

A

Isosorbide mononitrate
hypotension

Random Pre Reg Questions (12 decks)

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