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mpharm year 3 sem 2 > week 5 > Flashcards

week 5 Flashcards

1
Q

define stroke

A

Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death.

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2
Q

define TIA

A

Transient ischaemic attack (TIA) — transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction

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3
Q

name 6 initial potential complications of a stroke

A
  • Haemorrhagic transformation of ischaemic stroke.
  • Cerebral oedema.
  • Seizures.
  • Venous thromboembolism — pulmonary embolism has been associated with 13-25% of deaths in the early period following stroke.
  • Cardiac complications — cardiac complications (myocardial ischemia, congestive heart failure, atrial fibrillation, and arrhythmias) are common due to shared aetiology.
  • Infection — people with stroke are at increased risk of infection including aspiration pneumonia, urinary tract infection, and cellulitis from infected pressure sores.
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4
Q

name 6 potential long term complications of a stroke

A
  • hemiparesis (weakness of one side of the body)
  • falls - due to ataxia (lack of co-ordination)
  • sensory problems (touch, temperature, pain)
  • dysphagia (raises issues in treatment- cannot swallow meds)
  • urinary and faecal incontinence
  • urinary incontinance can cause infections
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5
Q

what are the 4 steps for acute stroke care?

A
  • admit to stroke unit
  • imaging - CT scan- assess if haemorrhage or clot
  • swallow (dysphagia may occur)
  • assess meds- STOP all anticoagulants, thrombolytics, antiplatelets and NSAIDs pending CT result.
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6
Q

how long do we have to give thrombolysis?

A

4.5 hours from onset of symptoms

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7
Q

what are the dosing instructions for alteplase for a stroke?

A
  • Dose = 0.9mg /kg (max dose 90mg)
  • 10% of total dose as bolus over 2-3 mins
  • 90% of total dose infuse over 60 mins
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8
Q

how long do we need to wait after thrombolysis before giving aspirin? what dose do we give when we continue?

A
  • Leave 24h before giving aspirin- then give 300mg OD for 14 days
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9
Q

A-E secondary prevention of a stroke

A

antiplatelets
blood pressure
cholesterol
diabetes
exercise (and diet)

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10
Q

aspirin in stroke care

A

Aspirin given on the day of admission or the following day for all patients in whom a haemorrhagic stroke, or other contraindication has been excluded”
One off stat dose of aspirin 300mg
aspirin should be avoided for 24h post thrombolysis

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11
Q

anticoagulation after stroke
- for sinus rhythm patient
-for AF patient

A

*Patients in Sinus Rhythm
14 days aspirin 300 mg then clopidogrel 75 mg daily
Clopidogrel 75mg (unlicensed in TIAs)

*Patients in AF
Remember: x5 increased stroke risk
14 days aspirin 300 mg depending on impact of stroke
Anticoagulation is usually initiated 10-14 days after stroke
Remember also to alleviate symptoms of AF – rate control

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12
Q

blood pressure in stroke care

A

don’t want to decrease BP too much- this would reduce reperfussion (which we want)

only restart BP meds when patient is stable

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13
Q

cholesterol in stroke care- who should get statin, who should not??

A
  • Atorvastatin 40 mg – 80 mg is used 1ST line
  • Statins should NOT be used in patients with haemorrhagic stroke unless risk of vascular event outweighs risk of haemorrhagic event.
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14
Q

FAST

A

face drop - can they smile?
arms- can they lift both arms
speech- slurred? muddled?
time to call 999

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15
Q

define AF

A

supraventricular tachycardia characterised by disorganised atrial electrical activity

Resulting in absence of significant atrial depolarisation

No P waves on ECG

The ventricular rate is rapid and irregular

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16
Q

name 7 symptoms of AF

A
  • Breathlessness
  • Difficulty breathing
  • Dizziness, light-headedness
  • Palpitations
  • Difficulty exercising (even just walking)
  • Chest discomfort, pain (similar to angina pain)
  • Tiredness, weakness
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17
Q

how can we diagnose AF? (5)

A
  • ECG (used to diagnose as we can see irregular heart beat)
  • Holter monitor (only used for a few days)
  • Loop recorder (can be used for longer ie years)
  • Echo (AF can cause damage to myocardium- use echo to see this)
  • Blood test to check
    Diabetes
    Hyperthyroidism
    Anaemia
    Renal function
    Infections (can trigger AF- particularly severe chest infection)
    High cholesterol (doesn’t cause AF but part of CV risk)
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18
Q

what are the 2 options for alleviating symptoms of AF?

A

rate control
rhythm control

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19
Q

what is first line rate control in a patient with no other co morbidities?

A

beta blocker - atenolol

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20
Q

what are the 3 drug options for rate control in AF patients?

A

beta blocker (atenolol)
calcium channel blocker (verapamil)
digoxin

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21
Q

what would be first line in a AF patient who also has acute HF symptoms?

A

digoxin

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22
Q

what are the 2 drug options for rhythm control in AF?

A

amiodarone
flecainide

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23
Q

what would be first line for a young person with AF- for rhythm control?

A

flecainide (which is a sodium channel blocker)

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24
Q

what would be first line for an elderly person with AF- for rhythm control?

A

amiodarone

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25
Q

when can we not use flecainide for rhythm control in AF patients?

A

when they have any heart damage- so previous MI etc

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26
Q

describe the ‘pill in pocket’ approach

A

a younger person who is prone to getting AF symptoms but doesn’t want to be on long term medication (particularly young males- can cause ED)
give them a small supply to carry with them
use when they have symptoms
need to counsel on what to do if they have to use them- need to go to hospital to get checked out, need to be around people who can help if their BP drops too low

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27
Q

what is the normal apixaban dose?

A

5mg BD

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28
Q

what are the apixaban dose reduction criteria? (3)
what is the dose reduced to?

A

reduce to 2.5 BD
over 80 y/o
under 60kg
creatinine over 133 micro mol/L

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29
Q

what is the normal edoxaban dose?

A

60mg OD

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30
Q

what is the edoxaban dose reduction criteria ?

A

reduce to 30mg OD if CrCl 15-50ml/min

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31
Q

describe CHA2DS2-VASc score and how many points are associated

A

C – chronic heart failure – 1 point
H – hypertension – 1 point
A – age (>65 or >75) – 1 or 2 points
D – diabetes – 1 point
S – stroke/ TIA – 2 points
VA – vascular diseases (IHD (ischemic heart disease), PAD (peripheral artery disease) ) – 1 point
S – sex (female) – 1 point

32
Q

name 4 symptoms of digoxin toxicity

A

Nausea
Vomiting
Diarrhoea
Dizziness
Sign vs symptom- can we see it, it the patient complaining of it

33
Q

which part of the action potential does flecainide affect?

A

phase 0 upstroke

34
Q

how does flecainide reduce calcium current?

A

by reducing upstroke

35
Q

which part of the action potential does sotalol affect?

A

phase 2/3 repolarisation

36
Q

what affect does sotalol have on sodium and/or calcium currents?

A

not much

37
Q

what part of the action potential does amiodarone affect?

A

phase 2/3 repolarisation

38
Q

what is the advantage of prolonging the action potential?

A

increased refractory period

39
Q

what part of the action potential does verapamil affect?

A

phase 2- plateau

40
Q

how does verapamil reduce the potassium current?

A

because it is a calcium channel blocker and some potassium channels are activated by calcium

41
Q

what part of the action potential does verapamil affect in AV node cells?

A

reduces upstroke- phase 0

42
Q

how is AV node action potentials managed?

A

mediated by calcium

43
Q

name 2 treatment goal in atrial fibrillation

A

reduce heart rate
reduce stroke risk

44
Q

what is first line beta blocker in atrial fibrillation?

A

atenolol

45
Q

which commonly used beta blocker is not licensed in AF?

A

bisoprolol

46
Q

name 7 common side effects of atenolol (beta blockers in general)

A

bradycardia
headache
confusion
tiredness
dizziness
cold extremities
ercetile dysfunction

47
Q

why is amiodarone given as a loading dose and for how long?

A

14 days
takes 42 days to reach half life and 5 half lives to reach steady state

48
Q

name 5 counselling points for amiodarone

A
  • sunglasses/ sun block (extremely photosensitive)
  • regular liver and thyroid testing
  • yearly chest X-ray
  • advise - many interactions so should be cautious about OTC and herbals
49
Q

what statin does amiodarone interact with- what can we do?

A

simvastatin
can reduce dose to 20mg daily
or
change to atorvastatin

50
Q

what is first line in asthmatic patients who also have AF?

A

verapamil 40-120mg 3x daily
because beta blockers are contraindicated

51
Q

what 3 things are an apixaban dose dependent on?

A

age
weight
creatinine clearance

52
Q

what is the time frame for DCCV?

A

48 hours from onset of symptoms

53
Q

name 2 managements for proxysmal atrial fibrillation

A

check thyroid function
give holter monitor - need to monitor before giving medication

54
Q

what is the difference between a stroke and a TIA?

A

TIA only lasts 24 hours- stroke much longer- permanent damage

55
Q

what are the 2 different types of stroke?

A

ischemic and haemorrhagic

56
Q

what is the immediate treatment for a haemorrhagic stroke?

A

cool the patient down
surgery

57
Q

what are the different types of ischemic stroke?

A

embolic and thrombotic

58
Q

what kind of stroke is when something breaks off and travels to the brain (ie small piece of plaque)?

A

embolic

59
Q

what kind of stroke is when a clot forms in the brain?

A

thrombotic

60
Q

why do we need a CT scan in stroke pateints?

A

to determine what kind of stroke they are having- if any

looking for bleed (haemorrhagic stroke) or clot (ischemic)

61
Q

why is thombolysis treatment only offered for 4.5 hours after symptoms begin?

A

after this time the risk of bleeding and a possible haemorrhagic stroke very high- higher than benefit of this treatment

62
Q

why should we withhold hypertensive meds for a few days after stroke?

A

may reduce blood flow to the brain too much- need to be started by stroke specialist

63
Q

what is the after care (antiplatelt wise) for a stroke patent without AF?

A

give aspirin 300mg OD for 14 days
then clopidogrel long term

if they have ha thombolysis- wait 24 hours before starting aspirin

64
Q

what is the after care (antiplatelt wise) for a stroke patent with AF?

A

start aspirin 300mg OD for 14 days
then start anticoagulant (apixaban or edoxaban)

65
Q

name 3 things we need to think about when discharging a stroke patient

A
  • are they living alone- is there someone to help
  • can they take meds- both opening bottles/ poping out of foil AND swallowing tablets
  • lifestyle advice- smoking cessation, healthy diet, exercise
66
Q

which common anti seizure med can cause low sodium?

A

carbamazepine

67
Q

what factors need to be considered when comparing oral dosage with experimental in vitro IC50?

A

must have functional groups for engagement with target

need to make sure using physiological pH, ionic strength (salt content etc), temperature

68
Q

name 4 indications for anticoagulants

A

AF
DVT
pulmonary embolism
artificial heart valve replacement

69
Q

name 3 symptoms of DVT

A

swelling
warm to the touch
pain at the slightest touch

70
Q

name 4 factors affecting warfarin therapy

A
  • drug interactions
  • disease state
  • age
  • food and alcohol
71
Q

name 5 signs or side effects of too much warfarin

A

bruising
nose bleeds that won’t stop
bleeding gums
blood in urine, faeces etc
haemorrhagic stroke

72
Q

name 2 signs or side effects of too little warfarin

A
  • stroke
  • DVT

any kind of clotting really

73
Q

name 4 interactions with warfarin (drug, food, herbal etc)

A
  • miconazole- major interaction
  • cranberry juice
  • St John’s wart
  • glucosamine
74
Q

describe the MOA of warfarin

A

inhibits synthesis of vitamin K dependent clotting factors 2,7,9 and 10 - thus reducing clotting effects

75
Q

how often should stable warfarin patients get their INR checked?

A

every 12 weeks

76
Q

name 5 advantages of using a DOAC over warfarin

A
  • no INR monitoring needed
  • convenient
  • surgical procedures not really affected
  • fewer interactions
  • effective from first dose
77
Q

name 5 disadvantages of using a DOAC over warfarin

A
  • lack of monitoring- unaware of patient changes
  • increased GI side effects
  • compliance
  • monitoring of factors that= dose change
  • increased risk of MI with dabigatran

mpharm year 3 sem 2 (11 decks)

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