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Pharmacy > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

what are the symptoms of AF?

A

papitations
pounding/ fluttering
dizziness
SOB
tiredness

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2
Q

what are the three types of AF?

A

paroxysmal AF - episodes stop within 48 hours
persistent AF - episodes last > 7 days
permanent AF

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3
Q

what is the treatment for life threatening haemodynamic instability in AF?

A

electrical cardioversion

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4
Q

what treatment should be offered to patients who present with acute AF within the first 48 hours?

A

rate (beta blocker or rate limiting CCB)

AND

rhythm control (flecanide or amiodarone)

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5
Q

what treatment should be offered to patients who present with acute AF after 48 hours?

A

rate control

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6
Q

what are the treatment options for rate control?

A

beta-blocker (not sotalol)
rate limiting CCB (diltiazem or verapamil)
digoxin (non paroxysmal AF who are sedentary) (AF with congestive HF)

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7
Q

what are the treatment options for rhythm control?

A

beta blocker (not sotalol)
amiodarone, flecainide, propafenone, sotalol

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8
Q

what is the pill in the pocket approach and when can it be used?

A

used for patients with symptomatic paroxysmal AF
flecainide or propafenone

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9
Q

what is the treatment step process to managing AF?

A

rate control - monotherapy
rate control - dual therapy
rhythm control

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10
Q

what two tools are used to guide stroke prevention in AF?

A

CHA2DS2-VASc
ORBIT

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11
Q

what CHA2DS2-VASc score is required to offer stroke prevention?

A

All patients with a score of 2
Men with a score of 1

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12
Q

what drugs can be offered to patients who need stroke prevention in AF?

A

DOAC - non-valvular AF
Warfarin - valvular or DOAC not appropriate

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13
Q

what are the treatment options for paroxysmal supraventricular tachycardia?

A

1st spontaneous termination or reflex vagal nerve stimulation
2nd IV adenosine
3rd IV verapamil

Prevention: beta blockers or rate limiting CCBs

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14
Q

how do you treat torsade de pointes?

A

IV magnesium sulfate
beta blocker (not sotalol)

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15
Q

what are the causes of torsade de pointes?

A

sotalol and other drugs causing QT prolongation
hypokalaemia
bradycardia

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16
Q

what are the classes of anti-arrhythmics?

A

Class I: membrane stabilising (lidocaine, flecainide)
Class II: beta blockers (not sotalol)
Class III: Amiodarone, sotalol
Class IIII: CCBs (verapamil and diltiazem)

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17
Q

what is the loading dose for amiodarone?

A

200mg TDS for 7 days
200mg BD for 7 days
200mg OD thereafter

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18
Q

what are the side effects of amiodarone?

A

corneal microdeposits - night time glares when driving
optic neuropathy - STOP if vision impaired
phototoxicity - skin burns (use high SPF)
slate grey skin
peripheral neuropathy
pulmonary fibrosis
hepatotoxicity
thyroid (hyper and hypo)

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19
Q

what monitoring is required for amiodarone?

A

eye tests annually
chest x ray before treatment
LFTs 6 monthly
TFTs before and 6 monthly
BP and ECG
Serum potassium

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20
Q

which of the following does not interact with amiodarone?
grapefruit juice
warfarin
morphine
simvastatin
clarithromycin

A

morphine

grapefruit juice - enzyme inhibitor
warfarin - amiodarone is enzyme inhibitor
simvastatin - risk of myopathy
clarithromycin - QT prolongation

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21
Q

what is the therapeutic target level of digoxin?

A

1-2 mcg/L

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22
Q

what digoxin level is associated with an increased risk of toxicity?

A

1.5-3 mcg/L

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23
Q

what are the symptoms of digoxin toxicity?

A

hypokalaemia
hypercalcaemia
bradycardia/ heart block
nausea, vomiting, diarrhoea, abdo pain
blurred/ yellow vision
confusion
rash

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24
Q

what is the treatment for digoxin toxicity?

A

digoxin specific antibody

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25
Q

what effect do enzyme inhibitors have on digoxin?

A

increase plasma concentration, leading to toxicity

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26
Q

what effect do enzyme inducers have on digoxin?

A

reduce plasma concentrations, leading to subtherapeutic doses

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27
Q

what test can be used to diagnose a thromboembolism?

A

D-dimer

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28
Q

what are the DOACs?

A

edoxaban, rivaroxaban, apixaban, dabigatran

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29
Q

what are the reversal agents for the DOACs?

A

andexanet alfa - for apixaban and rivaroxaban
idarucizumab - for dabigatran
edoxaban has no reversal agent

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30
Q

which of the DOACs require an initial loading dose of a LMWH before treatment for confirmed PE/DVT?

A

dabigatran and edoxaban

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31
Q

which DOAC must be taken with food?

A

rivaroxaban (15mg and 20mg)

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32
Q

how long does warfarin take to act?

A

48-72 hours

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33
Q

what is the monitoring requirements for warfarin?

A

INR every 3 months once stable

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34
Q

what is the MHRA alert for warfarin?

A

calciphylaxis - painful skin rash

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35
Q

what are the warfarin targets?

A

2-3 - AF, VTE, MI
3-4 - recurrent VTE, valvular AF

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36
Q

what should be done if a patient presents with an INR of 5-8 and no bleeding?

A

withhold 1-2 doses
reduce maintenance dose
measure INR after 2-3 days

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37
Q

what should be done if a patient presents with an INR > 8 and no bleeding?

A

omit warfarin
oral phytomenadione
repeat if INR still high after 24 hours
restart warfarin when INR < 5

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38
Q

what should be done if a patient presents with an INR > 5 with bleeding?

A

omit warfarin
IV phytomenadione
repeat if INR still high after 24 hours
restart warfarin when INR < 5

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39
Q

what treatment options are available for stable angina?

A

Acute angina attacks:
Short acting nitrates - (1st GTN, 2nd isosorbide dinitrate)

Long term prophylaxis:
1st beta-blockers (atenolol, bisoprolol, metoprolol, propranolol)
2nd BB + CCBs (verapamil, diltiazem)
3rd Ivabradine, Ranolazine, Nicorandil, MR isosorbide dinitrate, isosorbide mononitrate

40
Q

what formulations does GTN come as?

A

sublingual spray and tablets

(tablets must be discarded after 8 weeks)

41
Q

how and when should you take GTN, and when should you escalate care?

A

when required OR before angina-inducing activities

take sitting down as dizziness can occur, under tongue, 1 dose is 1 tablet or 1-2 sprays

1st dose and wait 5 MINS,
2nd dose and wait 5 MINS,
3rd dose and wait 5 MINS,
if pain still present, CALL 999

42
Q

what is the risk with nicorandil?

A

ulcers (mouth, skin, eyes, GI)

43
Q

what is the risk with long acting nitrates which requires specific administration timings?

A

risk of tolerance

leave patches off for 8-12 hours
take second dose after 8 hours not 12 hours (MR isosorbide dinitrate and isosorbide mononitrate)
MR isosorbide mononitrate is take OD

44
Q

what is the side effects of nitrates?

A

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

45
Q

what three things come under ACS and how do you differentiate between them?

A

unstable angina - symptoms
NSTEMI - increased troponin but no ST elevation
STEMI - increased troponin and ST elevation

46
Q

how should ACS be initially managed?

A

aspirin 300mg
GTN with/ without morphine
oxygen if needed

47
Q

if a patient has a STEMI, what treatment should be offered?

A

PCI within 2 hours

*PCI can be considered in NSTEMI

48
Q

what secondary prevention medications would be appropriate following an NSTEMI/ STEMI?

A

DAPT - Aspirin lifelong with clopidogrel, prasugrel, ticagrelor for 12 months
ACE/ ARB
BB (12 months if reduced LVEF)
Statin
GTN

49
Q

how should you manage a stroke?

A

alteplase within 4.5 hours
aspirin 300mg daily for 14 days

50
Q

how should you manage a TIA?

A

aspirin 300mg daily

51
Q

what is the long term treatment of stroke?

A

1st clopidogrel
2nd MR dipyridamole + aspirin
3rd MR dipyridamole OR aspirin

52
Q

patients presenting to clinic with a BP over what need to perform ABPM?

A

> 140/90

53
Q

what is stage 1 hypertension?

A

140/90 - 160/100 (clinic)
135/85 - 150/95 (ABPM)

54
Q

what is stage 2 hypertension?

A

160/100 - 180/120 (clinic)
> 150/95 (ABPM)

55
Q

what is stage 3/ severe hypertension?

A

180/120

56
Q

when would you treat patients with stage 1 hypertension?

A

if <80 with CKD, diabetes, CVD or 10% CVD risk in 10 years

57
Q

what is the target BP for patients under 80?

A

140/90 (clinic)
135/85 (ABPM)

58
Q

what is the target BP for patients over 80?

A

150/90 (clinic)
145/ 85 (ABPM)

59
Q

what is the target BP if a patient is pregnant?

A

135/85

60
Q

what is the target BP if a patient has a high risk of CVD or target organ damage?

A

135/85

61
Q

what is the treatment step pathway for patients with hypertension who are < 55 years and/ or T2DM?

A

1st ACE/ARB
2nd + CCB/ TLD
3rd ACE/ARB + CCB + TLD
4th spironolactone (K<4.5) OR alpha/ beta blocker (K>4.5)

62
Q

what is the treatment step pathway for patients with hypertension who are < 55 years and/ or afro-carribean?

A

1st CCB
2nd + ACE/ ARB OR TLD
3rd ACE/ARB + CCB + TLD
4th spironolactone (K<4.5) OR alpha/ beta blocker (K>4.5)

63
Q

is an ACE or ARB preferred in afro-carribean patients?

A

ARB

64
Q

If a CCB is not tolerated due to oedema, what should be offered instead?

A

TLD

65
Q

If starting on a diuretic for hypertension, which is preferred?

A

thiazide like diuretic (indapamide) as opposed to a thiazide type diuretic

66
Q

which conditions increase a woman’s risk of pre-eclampsia during pregnancy?

A

diabetes
hypertension
CKD

67
Q

what treatment should be offered to women who are at increased risk of developing pre-eclampsia?

A

aspirin from week 12

68
Q

what treatment options are available for treating hypertension in pregnancy?

A

1st labetalol
2nd nifedipine

69
Q

what time should you take your first dose of an ACE?

A

bedtime

70
Q

which of the ACE is taken BD?

A

captopril

71
Q

which of the ACE needs to be taken 30-60 minutes before food?

A

perindopril

72
Q

what are the side effects of ACEs?

A

dry cough
hyperkalaemia
angioedema
hepatic effect (cholestatic jaundice, hepatic failure)
renal impairment

73
Q

which of the beta blockers have intrinsic sympathomimetic activity, and what benefit does this have?

A

Acebutolol
Pindolol
Celiprolol

these BBs cause less bradycardia and less coldness of extremities

Acebutolol Prevents Coldness

74
Q

which of the beta blockers are water soluble, and what benefit does this have?

A

Atenolol
Celiprolol
Sotalol
Nadolol

these BBs are less likely to cross the BBB and therefore less likely to cause nightmares and sleep disturbances

these BB are renally cleared, and may need dose reductions in renal impairment

Atenolol Can Stop Nightmares

75
Q

which of the beta blockers are cardioselective, and what benefit does this have?

A

Bisoprolol
Atenolol
Metoprolol
Acebutolol
Nebivolol

these BBs cause less bronchospasm and can be used in asthmatics if no other choice

B A MAN

76
Q

which of the beta blockers have intrinsically longer duration of action?

A

Bisoprolol
Atenolol
Celiprolol
Nadolol

these BBs have once daily dosing

BACoN

77
Q

which of the CCB requires the same brand prescribed?

A

nifedipine (modified release)
diltiazem (doses > 60mg)

78
Q

what are the side effects of CCBs?

A

gingival hyperplasia
ankle swelling
flushing
headache

79
Q

what treatments are available for hypotension and shock?

A

noradrenaline
phenylephrine (longer acting)

80
Q

which CCBs should be avoided in HF?

A

verapamil and ditiazem

81
Q

which BBs are licensed for HF?

A

bisoprolol, carvedilol, nebivolol

82
Q

which ARBS are licensed for HF?

A

candesartan, losartan, valsartan

83
Q

which diuretics are first line for patients with HF who have breathlessness and/or oedema?

A

loop diuretics

84
Q

what is the treatment pathway for HF?

A

ACE + BB (titrate low and slow) *
aldosterone antagonist (spironolactone/ eplerenone)
amiodarone, digoxin, entresto, ivabradine, dapagliflozin

*ARB if ACE not tolerated
*hydralazine + nitrate if ACE/ARB not tolerated

85
Q

what is the monitoring requirements for HF patients?

A

initiating ACE/ARB/MRNA:
potassium and sodium, renal function, and BP before, 1-2 weeks after starting and after each dose increase, monthly for 3 months, then 6 monthly thereafter

initiating BB:
HR and BP before and after dose increases

86
Q

define hyperlipidaemia?

A

> 6 mmol/L total cholesterol

87
Q

what are the lipid targets for hyperlipidaemia?

A

Total cholesterol < 5
Non - HDL < 4
LDL < 3
Triglycerides < 2
HLD > 1

88
Q

which statins do not need to be taken at night?

A

atorvastatin
rosuvastatin

89
Q

which of the statins are high intensity statins?

A

Atorvastatin: 20mg, 40mg, 80mg
Rosuvastatin: 10mg, 20mg, 40mg
Simvastatin: 80mg

90
Q

what is the MHRA alert for simvastatin?

A

high dose simvastatin (80mg) has increased risk of myopathy

91
Q

what are the side effects of the statins?

A

myopathy, myositis, rhabdomyolysis, interstitial lung disease, diabetes

92
Q

why should hypothyroidism be resolved prior to commencing a statin?

A

increased risk of muscle toxicity

93
Q

what are the monitoring requirements of statin treatment?

A

baseline lipids
renal function
TFTs
HbA1c

94
Q

what is first line for hyperlipidaemia?

A

statins

95
Q

what is second line for hyperlipidaemia?

A

ezetimibe

96
Q

what other options are available for hyperlipidaemia?

A

fibrates (fenofibrate)
bile acid sequestrants (colestyramine)

97
Q

what are the two types of vascular disease?

A

occlusive peripheral - statins + antiplatelets
vasospastic peripheral (raynauds) - nifedipine

Pharmacy (20 decks)

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