CVS Flashcards
1
Q
What are the five licensed oral anticoagulants?
A
Warfarin
NOACs:
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
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
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
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)
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
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
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
8
Q
What are the two types of heparin?
A
- Unfractionated heparin (activates antithrombin)
- Low molecular weight heparin (inhibits factor Xa)
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)
10
Q
Examples of LMWH
A
Tinzaparin
Enoxaparin
Dalteparin
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)
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)
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
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
15
Q
What VTE prophylaxis treatment is preferred in pts undergoing abdominal, bariatric, thoracic or cardiac surgery?
A
Fondaparinux
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
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)
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)
19
Q
Choice of VTE prophylaxis for acutely ill patients
A
7 aLiFe
LMWH - first line
Or
Fondaparinux
for minimum 7 days
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
21
Q
How long should VTE prophylaxis be continued in pregnant women?
A
LMWH continued until no longer at risk or discharge
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
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
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)
25
What is the anticoagulant choice for pts who are not well tolerated in current long term treatment
Apixaban
26
What can be used with pts who decline continued anticoagulant tx
Aspirin (unlicensed)
Review annually
27
What should be checked in pregnant women before starting anticoagulants
**FUL C**
Baseline blood tests;
- Full blood count
- Coagulation screen
- Urea and electrolytes
- Liver function tests
28
What is the *Rivaroxaban* dose for VTE prophylaxis following **knee** replacement surgery?
10mg OD - 14 days
*to be started 6-10 hours after surgery *
29
What is the *Rivaroxaban* dose for VTE prophylaxis following **hip** replacement surgery?
10mg OD - 5 weeks
*to be started 6-12 hours after surgery*
30
What is the *Apixaban* dose for VTE prophylaxis following **knee** replacement surgery?
When to start?
2.5mg BD for 10-14 days
*to be started 12-24 hours after surgery*
31
What is the *Apixaban* dose for VTE prophylaxis following **hip** replacement surgery?
2.5mg BD for 32-38 days
*to be started 12-24 hours after surgery*
32
How long does warfarin take to work?
48-72 hours
33
What is the duration of tx with *warfarin* in isolated **calf-vein** VTE?
6 weeks
34
What are the vitamin k antagonists
**’WAP’**
-Warfarin
- Phenindione
- acenocoumarol
35
What is used as first line in cerebral artery thrombosis or peripheral artery occlusion?
**Aspirin**
More appropriate for transient ischaemic attacks
36
What is the acceptable range the INR can deviate from target?
0.5 units
37
How often should INR be monitored?
- *alternate days* initially,
- then *every 1-2 weeks* until stable,
- then *every 3 months*
38
Target INR
**2.5** - Most incidences
**3.5** - Recurrent VTE in pts receiving anticoagulant and *with an INR > 2*
39
Colour of warfarin tablets
**’BrB Pink’**
White - 0.5mg
**Br**own - 1mg
**B**lue - 3mg
**P**ink - 5mg
40
Can warfarin be used in pregnancy?
No - **teratogenic**
Avoid especially in 1st and 3rd trimesters
41
Counselling points for warfarin
- Take same time everyday
- Notify anticoagulation clinic of changes to medication, lifestyle or diet
- **Stop 5 days before elective surgery**
42
MHRA warning**s** with warfarin
- 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*
43
What do you monitor with warfarin?
- **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
44
What to do if INR is **5.0 - 8.0** with **no bleed**
- Withhold 1-2 doses
- Reduce maintenance dose
- Measure INR after 2-3 days
45
What to do when pt is experiencing major bleeding while on warfarin?
- **STOP warfarin**
- Give IV **phytomenadione (vitamin K)**
- **Dried prothrombin complex** or **fresh frozen plasma**
46
What to do if INR is **>8.0** with **no bleed**
- **Stop warfarin**
- Give *oral* **phytomenadione (vitamin k)**
- **Repeat dose** if INR still too high after *24 hours*
*Restart warfarin when INR <5.0*
47
What to do if INR is **>5.0** with **minor bleed**
- **STOP warfarin**
- IV **phytomenadione**
*Restart warfarin when INR < 5.0*
48
What to do when pt is on warfarin and about to undergo elective surgery
- Stop **5 days** before
- Oral **Vitamin K** for *one day if INR >1.5*
- Restart **next day**
49
What to do when pt is on warfarin and about to undergo **emergency surgery**
- **IV phytomenadione**; if surgery can be delayed by *6-12 hours*
- **Add dried prothrombin**
50
What to do when pt is on warfarin and about to undergo **high risk of VTE**
- 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*
51
NOACs mechanism of action
- **Dabigatran** - direct thrombin inhibitor
- **Apixaban, Edoxaban & Rivaroxaban** - direct factor Xa inhibitor
52
Patient counselling for NOACs
- **Give patient alert card**
- Alternative to warfarin
- **Lower bleeding risk**
- No need for regular monitoring
- Fewer food and drug interactions
53
Which NOAC has highest bleeding risk?
Dabigatran
54
What drugs increase bleeding risk with NOACs?
**’NAACS’**
- NSAIDS
- Other anticoagulants
- Antiplatelets
- *strong* CYP3A4 inhibitors
- SSRI or SNRI
55
Dose adjustments to Apixaban in renal impairment
**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**
56
Dose adjustments to Rivaroxaban in renal impairment
- Take with or after food for improved absorption
- **Reduce dose** if CrCl 15-49ml/min
- **Avoid** if CrCl <15ml/min
57
Dose adjustments to Dabigatran in renal impairment
**Reduce dose if**
- CrCl 30-50ml/min
- Age > 80
- High bleeding risk
- If also on **verapamil** or **amiodarone**
**Avoid is CrCl < 30ml/min**
58
How long do transient ischaemic attack last for?
< 24 hours
59
Warning signs of stroke
**’FAST’**
- **F**ace drooping
-**A**rm weakness
-**S**peech difficulty
-**T**ime to call 999
60
How to treat haemorrhagic stroke
- Avoid *’ASA’* **aspirin**, **statin** and **anticoagulants** (increases risk of bleeding)
- Treat hypertension
61
How is ischaemic stroke / TIA treated long term?
*If first line CI?*
*If AF?*
*If hypertension*
- **Clopidogrel 75mg OD**
If CI;
- MR dipyridamole & Aspirin 75mg
*If AF related, consider anticoagulant*
*If hypertension, treat with **beta blocker***
62
Counselling points for MR dipyridamole
- Take **30-60 mins before food**
- Capsules have a **6 week** expiry once opened
- **Keep in original container**
63
When is antiplatelet used in stroke?
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)
64
When is aspirin CI and why?
In children under 16
**Reye’s syndrome**
65
Risk factors of arrhythmias
- Smoking
- Excessive alcohol/ caffeine consumption
- Obesity
- Stress
66
Non cardiac risk factors of arrhythmias
- Overactive or underactive **thyroid**, **diabetes**, electrolyte imbalance **K, Mg, Na**
- Stimulants eg. Cocaine or amphetamine
67
What are the 4 different classes of anti-arrhythmic drugs
- Membrane stabilising (Na blockers)
- Beta blockers
- K+ channel blockers
- Calcium channel blockers (rate limiting)
- Other (Adenosine, digoxin)
68
How is stroke risk assessed?
**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
69
What are the Na channel blocker drugs
Disopyramide
Lidocaine
Propafenone
Flecainide
70
What are the calcium channel blockers
Diltiazem
Verapamil
71
What are the potassium channel blockers
Amiodarone
Sotalol
72
What are examples of beta blockers
Propranolol
Bisoprolol
**used to slow the heart rate**
73
What is used in rhythm control for AF
- Electrical cardio version
- **Amiodarone**
- Flecainide
74
What is used for acute new-onset of AF
*life threatening/non life threatening*
Life threatening - **electrical cardioversion**
Non-life threatening;
- <48 hours : Rate/Rhythm control
- > 48 hours : Rate control (**verampil/beta blockers**)
75
What is used is a pt with new onset AF requires urgent rate control?
IV beta-blockers
76
What is the preferred tx for AF if LVEF > 40%
Verapamil
77
What rate limiting drugs should be avoided in pts with AF and suspected concomitant acute decompensated heart failure
Calcium channel blockers
*Seek specialist advice*
78
What is used first line for maintenance tx of AF
*Rate control*
- Beta blocker (**not sotalol**)
- Rate limiting CCB (**diltiazem or verapamil**)
- **Digoxin** (preferred in immobile pt)
79
What rhythm control is preferred in AF present for more than 48 hours
*What safety measures?*
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**
80
What is used second line for maintenance tx of AF
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*
81
What beta blockers are preferred in pts with diabetes?
Cardioselective beta-blockers
‘**B**e **A MAN**
Bisoprolol
Atenolol
Metoprolol
Acebutolol
Nebivilol
82
When should beta blockers be avoided
- 2nd/3rd degree heart block
- worsening unstable heart failure
- pt with frequent hypoglycaemia
- Asthma, bronchospasms
83
When is CCB (diltiazem and verapamil) contra indicated
- Heart failure
- Pregnant women
*Diltiazem avoided throughout pregnancy*
*Verapamil avoid in 1st trimester*
84
What is the target therapeutic level for digoxin?
When should it be measured?
0.7-2 mcg/L
*To be measured 6 hours after a dose*
85
Risk factors for digoxin toxicity
- Hyp**ER**Calcaemia
- Hyp**O**kalaemia
- Hyp**O**Magnesia
- Low oxygen
- Recent MI
- Severe respiratory disease
- Thyroid disease
86
Signs of digoxin toxicity
**’Slow/Sick’**
Slow: bradycardia, heart block
Sick: vomiting, nausea, diarrhoea and stomach pain
**Blurred or yellow vision**
Confusion, delirium and rash
87
Digoxin interactions
**’CRASED’**
**C**Alcuin channel blockers (*verapamil*)
**R**ifampicin
**A**miodarone
**S**t John’s Wart
**E**rythromycin
**D**iuretics
88
What CCBs need to be prescribed by brand?
MR Diltiazem
MR Nifedipine
89
Side effect of verapamil
Constipation
*Improved by increased fibre and fluid intake*
90
What to avoid with rate limiting CCB?
Grape fruit juice
*increased CCB concentration*
91
What is the loading dose for amiodarone?
200mg **TDS** for *7 days*
200mg **BD** for *7 days*
200mg **OD** *as maintenance*
92
Main interactions with amiodarone
- **Digoxin** ; digoxin toxicity
-**warfarin, phenytoin** - increase conc
- **Antivirals** - Severe bradycardia and heart block
- **Beta blockers / Rate limiting CCBs**
- **Statin**
- **Grape fruit juice** - toxicity
93
MHRA warning for amiodarone
Interaction with **Sofosbuvir**
*Risk of bradycardia and heart block*
94
Monitoring requirements for amiodarone
- 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*)
95
Wha is the half life of amiodarone
About 50 days
96
Major side effect of amiodarone?
*Interaction?*
QT prolongation
**Do not give with other QT prolongation drugs**
97
What is used to assess bleeding risk?
**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)
98
Treatment for bleeding disorders
Tranexamic acid
99
Different stages of hypertension
Stage 1:
**140/90 - 160/100mmHg**
Daytime average: **135/85**
Stage 2:
**>160/100mmHg**
Daytime average: **>150/95**
Severe:
**>180/120**
100
How is hypotensive urgency treated?
*ie. Severe hypertension without acute damage to target organs*
**Labetolol** or **amlodipine**
101
What is used in hypertensive emergency
IV antihypertensive
102
Hypertension risk factors
**Age**
**Sex** - Women up to 65 have lower bp
**Ethnicity** - black people more likely
**Anxiety and emotional stress**
**Genetic factors**
**Social deprivation**
**Lifestyle**
103
Causes of hypertension
- diabetes
- drugs; NSIADs, steroids, SSNRI
- herbal eg. Liquorice
- recreational drugs
- combined oral contraceptives
- **kidney disease**
- **hormone problems** - *crushing syndrome*
104
Bp target in hypertension
**<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
Target Bp In pregnancy
135/85
106
When to treat stage 1 hypertension
**>140/90mmHg**
Pt <80 years
With target organ damage or 10 year CVD risk >20%
107
Hypertension treatment in <55
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
Hypertension treatment in >55 or black pts
Step 1: **CCB**
OR
**thiazide-like diuretics**
Step 2: Add **ACEi/ARB**
Step 3: Combination of **ACEi/ARB**, **CCB/TLD**
109
When can’t CCB be given in hypertension
Oedema or high risk of heart failure
*give TLD instead*
110
What’s used to treat resistant hypertension
**Seek specialist advice**
*ACEi/ARB + CCB + TLD + diuretic (**spironolactone**)*
111
What is an alternate choice to spironolactone
Alpha blocker or beta blocker
112
What is used in gestational hypertension
**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
Examples of ace inhibitors
Enalapril
Lisinopril
Perinopril
Ramipril
114
ACEi drug interactions
**’FANS’**
- **ARB**: *hyperkalaemia, hypotension and renal impairment*
- **NSAIDs**: *renal impairment*
- **Spironolactone**- *hyperkalaemia*
- **>80mg furosemide** - *hypotension (reduce or discontinue dose for 24 hours)*
115
When is ACE contraindicated
- planning to be/ pregnant
- breastfeeding women
116
What antihypertensive cause dry cough?
ACE inhibitors
*offer ARB*
117
Monitoring requirements for ACEi
- Renal function
- Serum electrolytes (K)
- Blood pressure
118
Side effects of ACEi
**Dry cough**
**Hyperkalaemia**
**Renal impairment**
Headaches
Dizziness
119
Examples of dihydropyridine CCBs
Amlodipine
Felodipine
Nifedipine
120
CCB food interactions
**Avoid grapefruit juice**
Statins
121
Contraindication of CCB
Heart failure
Hepatic & Renal impairment
122
Side effects of CCB
Headache
Dizziness
Swollen ankles
Constipation
123
Examples of thiazide like diuretic
- **Indapamide**
- **Chlortalidone**
- Metolazone - *used in severe renal impairment*
- Xipamide
124
What thiazides are used in hypertension?
Indapamide
Chlortalidone
125
Side effect of long term TLD
Hyp**O**kalaemia
Hyp**O**natraemia
Postural hypotension
Altered plasma-lipid concentration
126
When are diuretics contraindicated
’**P**e**ARL**’
- Pregnant women
- Addison’s disease
- Renal impairment (eGFR <30mL/min)
- Liver disease (severe)
127
Monitoring requirements for diuretics
Renal function
Serum electrolyte (K and Na)
Liver function
128
Examples of alpha blockers
Doxazosin
Terazosin
129
What beta blocker is preferred in peri-operative period
Why?
Esmolol
Short half life
130
Intrinsic sympathomimetic activity beta blockers
**PACO**
**P**indolol
**A**cebutol
**C**eliprolol
**O**xprenolol
*less bradycardia and coldness of extremities*
131
Water soluble beta blockers
water **CANS**
Celiprolol
Atenolol
Nadolol
Sotalol
*less nightmares and sleep disturbances*
*Reduce dose in renal impairment*
132
Cardioselective beta blockers
**B**e **A** **MAN**
Bisoprolol
Atenolol
Metoprolol
Acebutol
Nebivolol
*less bronchospasm*
133
Once daily beta blocker
**BAC**o**N**
Bisoprolol
Atenolol
Celiprolol
Nadolol
*lond duration of action*
134
Side effects of beta blocker
- Bradycardia
- Hypotension
- Hyper/Hypoglycaemia
- Hypokalaemia
135
How to treat heart failure
**‘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
Example of loop diuretic
Furosemide
Bumetanide
Torsemide
137
What can be used as a prophylaxis for raynaud’s syndrome
Nifedipine
138
What is used to assess risk of CVD
QRISK2 (<84 years)
*if 10 year CVD risk score >10% = offer primary prevention*
139
What can cause hyperlipidaemia
Antipsychotic
Immunosuppressants
**Corticosteroids**
HIV drugs
**HypOthyoidism** - Low T4/T3
Liver or kidney disease
**Diabetes**
140
Primary prevention of hyperlipidaemia
Atorvastatin 20mg
141
Secondary prevention of hyperlipidaemia
Atorvastatin 80mg
*established CVD*
142
When should statin be taken?
Exception
**At night**
*Cholesterol synthesis greater at night; more effective*
**Exception: Atorvastatin**
143
What are the high-intensity statins and their dose
**Atorvastatin**: *20mg OD in primary prevention, 80mg OD in secondary prevention*
**Rosuvastatin** *10mg*
**Simvastatin** *80mg*
144
MHRA warning of simvastatin
**High risk of myopathy**
Give only if high risk of cardiovascular complications or severe hyper cholesterolaemia
145
What is given as second line if hyperlipidaemia is not controlled by high intensity statin
Ezitimibe
146
What is used if triglycerides still high after LDL reduced
Add **Fibrate** or **Nicotinic acid**
147
Side effects of statin
- **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
Statin and fusidic acid
**Stop statin** while using fusidic acid and **restart 7 days after last dose**
149
Warning signs of statin
Tender, weak and painful muscles - **Myopathy**
Shortness of breath, cough, weight loss - **Interstital lung disease**
150
Monitoring requirements for statin
**’THR**o**B**e’
- Baseline lipid pu - *before*
- Renal function - *before*
- Thyroid function; every *3 months*
- HbA1c - *before*
- Liver function - *before*
151
When to discontinue statin
*with biological markers*
- sever **muscle symptoms**
- **5x** normal **creatine kinase**
- **transaminases** 3x normal *(liver function)*
152
Statin in pregnancy
**Teratogenic**
*Effective contraception during and 1 month after stopping*
***discontinue 3 months** before attempting to conceive*
153
Statin main interactions
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
Simvastatin dose adjustments due to interactions
Max **10mg** with **Fibrate**
Max **20mg** with **Amiodarone, amlodipine, Diltiazem, verapamil**
155
Atorvastatin dose adjustment due to interactions
Max **10mg** with **ciclosporin**
156
Rosuvastatin dose adjustments due to interactions
Initially **5mg**
Max **20mg** with **Clopidogrel**
157
Bile acid sequestrants interaction
*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
What ARB are licensed in heart failure
Candesartan
Valsartan
Losartan
159
Preferred beta blocker in mid-moderate stable heart failure and 70+
Nebivolol
160
What CCB can be used in heart failure
Amlodipine
*used in patients with heart failure and angina*
161
What are the potassium sparing diuretics
Amiloride
Triamterene *(blue urine in some lights)*
162
Side effect of loop diuretic
**Ototoxicity**
Acute **urinary retention**
**Hyperglycaemia**
Hyperuricaemia (**gout - furosemide**)
Hyp**O K Na Cl Mg**
163
Side effects of thiazides and TLD
**GI disturbance
Impotence
High LDL/Triglyceride
Diabetes
Gout
HypO K Na Cl Mg
HypER Ca**
*Ineffective if **eGFR <30 except metolazone***
164
Loop diuretic dose in heart failure
BD (take last dose at 4pm)
20-40mg OM - Furosemide
165
TLD dose in heart failure
OM 5mg
166
What is used to treat occlusive PVD
Aspirin 75mg OD
Statin
167
What is used in management of acute angina attack
Properties
If severe?
**Glyceryl Trinitrate**
IV opioid - severe MI (eg. Morphine)
- effects last 20-30 minutes
168
How to take short-acting nitrates
- 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
What is used in long term prophylaxis of angina
‘**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
How to use nitrate patches
- Leave patches off for **8-12 hours** in a day (over night)
- Take second dose after **8 hours**
- MR isosorbide mononitrate taken OD
171
How to treat unstable angina (NSTEMI) if hypoxia
Oxygen
172
NSTEMI tx in reperfusion
**Antiplatelet effect**
- Aspirin **300mg** + Clopidogrel **300mg**
**Antithrombin**
- Fondaparinux
- Heparin
173
Duration of dual antiplatelet tx in angina with pt undergoing PCI
**Aspirin** (forever)
+
Clopidogrel
Elective = 4 weeks
Bare metal stent = 12 months
Drug - eluting stent = 12+ months
174
Tx in cardiac arrest
- **30 compressions: 2 breaths ~ 100 compressions/min**
- **IV Adrenaline** *1 in 1000 every 3-5 min*
- If ventricular fibrillation: **IV AMIODARONE**
175
How should ACEi be taken with food
On an empty stomach 30-60 minutes before food
176
Symptoms of Reye’s syndrome
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
What PPIs reduce efficacy of clopidogrel
Esomeprazole
Omeprazole
178
What is used to reverse effect of dabigatran
Idarucizumab
179
Max daily dose of ramipril if eGFR 30-60
5mg daily
180
Interaction between diuretics and digoxin
Diuretics (loop and TLD) cause **HypOKalaemi** which **increase risk of toxicity**
181
Warfarin counselling
*WARFARINISE*
**’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
What to do if warfarin dose is missed
if any missed, continue normal dose for the day
183
What juice does warfarin interact with
Cranberry
Pomegranate
184
Warfarin interaction with vitamins
Vitamin E and K
*Increase bleeding*
185
When can you give aspirin to under 16
Kawasaki
186
Beta blockers in heart failure
‘**NBC**’
Carvidelol
Nebivolol
Bisoprolol
187
What ACE is taking before food
Ferindopril
188
MHRA warning with rivaroxaban
Reversal agent?
Erythromycin
*increase risk of bleeding*
**take with food**
Reversal agent: **andexanet alpha**
189
ACE taken twice daily
Captopril
190
When should the first dose of ACE be taking
At night
191
When is digoxin dose halved with other drug
- Amiodarone
- Quinine
- Donedarone
192
What range is digoxin more likely to be toxic
1.5-3
193
Pt having nausea with digoxin
Give BD
194
What beta blocker is giving IV
Esmolol
195
Bp target for pregnant
135/85
196
Non valvular VTE tx
DOAC
197
Valvular VTE tx
Warfarin
198
Which DOAC doesn’t have a reversible agent
Edoxaban
199
‘Dazzled by head light’ - what drug does this indicate
Amiodarone
200
Indapamide side effects
Rash
201
Warfarin dose
Initial: 5-10mg
Maintenance: 3-9mg
*Same time each day*
202
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
- **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
Dose of Apixaban
- tx of DVT/PE
- prophylaxis recurrent DVT/PE
- prophylaxis stroke/AF
- **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
Dose of edoxaban
-**Adult <61kg**= 30mg OD
- **Adult >61kg**= 60mg OD
205
Dabigatran dose in prophylaxis for knee replacement
110mg for 1-4 hours after surgery
Then, 220mg OD for 10 days
206
Dabigatran prophylaxis dose for stroke
110mg - 150mg BD
207
What is preferred first line in HF with diabetic pts
ACEi
208
What is preferred first line in HF for pt with angina
Beta blocker
209
What is used in HF if pt is Afro-Caribbean and not tolerating ACE/ARB
**Hydralazine** & **Nitrate**
210
Drugs used is Heart failure
**’BANDAIDS’**
- **B**eta blocker
- **A**CEi / ARB
- **N**itrate / Hydralazine
- **D**iuretic (MRA/loop/thiazide)
- **A**miodarone
- **I**vabradine
- **D**igoxin
- **S**acubitril valsartan
211
What vaccine should be offered in HF
**Influenza** vaccine
**Pneumococcal Disease** Vaccine
212
What’s used in HF with reduced ejection fraction
<35%
- Replace ACEi/ARB with **Sacubitril valsartan**
- Add **Ivabradine** for sinus rhythm
213
What drugs worsen heart failure
- **NSAIDs**: *Retains Sodium*
- **CCB**: *Except Amlodipine*
214
What are the three types of ACS
- Angina
- NSTEMI
- STEMI
215
What cardiac marker is used to identify heart attack
Troponin
216
Main Symptoms of angina
- 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
Initial management of ACS (unstable angina, NSTEMI & STEMI)
- **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
Secondary prevention of cardiovascular events following ACS
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
Rivaroxaban dose in ACS
2.5mg BD
*used when elevated biomarkers*
220
If pt is using GTN spray more than twice a week what should be done?
Long term prophylaxis
221
Dose of GTN tablet first used
300 mcg
222
Difference between MR isosorbide **mononitrate & dinitrate**
MR Isosorbide **Mononitrate**: **OD**
MR Isosorbide **Dinitrate**: **BD**
223
How to avoid tolerance effect with nitrate
- 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
Prescribing and dispensing information for GTN S/L tablets
- 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
What drugs have risk of first dose hypotension and so first dose taken at night
Alpha blockers
**doxazosin, prozasin, terazosin**
226
From what week in pregnancy do you commence daily dose oh aspirin for prophylaxis of pre-eclampsia
Week 12
227
Side effect of nicorandil
Serious skin mucosal
Eye ulceration
GI ulcers
228
What diuretic is associated with gynaecomastia
*A condition that causes men’s breast to swell and become larger than normal*
MRA diuretics
**Eplerenone** & **spironolactone**
229
Target INR to switch from warfarin to DOAC
<2
230
How long should be allowed to determine response from ACEi
4 weeks
231
Is warfarin found in breast milk
No
232
Drugs that cause hypertension
- contraceptive pill
- steroid
- NSAIDs
233
When should ticagrelor be discarded
12 weeks after opening
234
Side effect of nitrate
Flushing
Headaches
Palpitations
Syncope - loss of consciousness
235
Which CCB is licensed for tx of acute life-threatening hypertension
Nicardipine
236
What is the most important test to do before starting statin
Liver function
*repeat within 3 months and at 12 months*
237
A patient on simvastatin 40mg for secondary prevention of MI is not well controlled. What next?
- 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
What beta-blocker is used in thyrotoxicosis
Propranolol
*Reverses within 4 days*
239
Common side effect of ezetimibe
GI disturbance
240
How should nicorandil be taken?
With breakfast and evening meal
241
Can you put warfarin in a dosette box?
No
242
Treatment of hypertension in diabetes
**ACE** - ‘ril’
OR
**ARB** - ‘sartan’
243
Stroke pathway
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
Pathway for stable angina
**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
Heart failure pathway
1. **ACE** + **BB** (low dose + titrate)
2. + **spironolactone/eplerenone**
3. + **sacambutol + vasarltan** or **amiodarone** or **nicorandil** or **
246
What is used in thrombolysis in MI
Streptokinase
Alteplase
247
Patient being treated for hypertension presents with painful rash but not itchy. What drug?
ACEi
248
What CVS drug interacts with sildenafil
Isosorbide mononitrate
*hypotension*
