arrythmias + hypertension + heart failure

Question 1

what is the first line treatment to get rate control

Answer 1

a standard beta blocker (that is, a beta blocker other than sotalol) or a rate limiting calcium channel blocker (diltiazem or verapamil).

• note: If question has both beta blocker + CCB, chose beta-blocker as first line*

Question 2

which class of drugs should not be given to to patients with severe peripheral vascular disease

Answer 2

betablockers (e.g bisoprolol, atenolol)

note: this is because peripheral vascular disease is a common side effect of betablockers

Question 3

what is white/pink frothy sputum a common symptom of

Answer 3

heart failure

Question 4

what is , breathlessness particularly at night and swollen ankles/legs a common symptom of

Answer 4

heart failure

Question 5

why is the use of both ACE inhibitors and ARBs contraindicated

Answer 5

contraindicated because it increases the risk of hypotension, hyperkalemia and renal impairment

Question 6

which antihypertensive should be avoided in patients with severe bilateral renal artery stenosis

Answer 6

ramipril

Question 7

which class of antihypertensives interact with lithium

Answer 7

ACE inhibitors interact with lithium- they increase the concentration of lithium

note: ACE inhibitor e.g ramipril, enalapril, lisinopril

Question 8

which class of medications can cause peripheral coldness as a common side effect

Answer 8

beta blockers

note: it is common for beta blockers to cause cold extremities e.g cold hands + feet as a side effect

Question 9

what are the main side effects of Heparins

Heparin e.g: enoxaparin, dalteparin, heparin

Answer 9

• Haemorrhage
• Heparin-induced thrombocytopenia
• Hyperkalaemia

Question 10

which diagnostic technique can be used to assess what type of anticoagulation is required in patients suffering from atrial fibrillation

Answer 10

CHA2DS2VASc

Question 11

what is the first-line long term therapy for stable angina

Answer 11

• first line: beta-blockers
• rate-limiting CCB used if beta blockers not tolerated or patient has Prinzmetal’s angina

note: if a patient has prinzmetal angina they can also be treated with Dihydropyridine derivative calcium-channel blockers (such as amlodipine)

Question 12

which type of beta-blockers can be used in patients with asthma if there is no suitable alternative to beta-blockers

Answer 12

cardioselective beta-blockers e.g Atenolol, bisoprolol, metoprolol, nebivolol

note: beta-blockers are avoided in patients with asthma due to bronchospasm but if there are no other alternative, you can use cardioselective beta-blockers with caution

Question 13

which drugs should be avoided in patients with hyperlipidaemia + moderate liver disease

Answer 13

Statins & Ezetimibe should be avoided in liver disease

Question 14

what increases the risk of Rhabdomyolysis from statins

Answer 14

• HYPOthyroidism (should be managed before starting statin)
• Concomitant treatment with drugs that increase plasma-statin concentration
• concomitant treatment with a fibrate
• high doses of statin (e.g simvastatin 80mg, atorvastatin 20mg +, rosuvastatin 10mg +)
• personal or family history of muscular disorders/ muscular toxicity
• a high alcohol intake
• renal impairment

Question 15

which type of sulfonylureas have a higher risk of hypoglycemia

Answer 15

longer acting sulphonylureas (such as Glibenclamide, glyburide and glimepiride) have a higher risk of causing hypoglycemia than shorter acting sulphonylureas (such as gliclazide, glipizide, and tolbutamide)

Question 16

how does amlodipine interact with simvastatin

Answer 16

Amlodipine slightly increases the exposure to simvastatin.

Manufacturer advises adjust simvastatin dose to a max. 20 mg daily with concurrent use of amlodipine

Question 17

what is the first line treatments for hypertension WITH diabetes

Answer 17

ACEi or ARB

Question 18

why should patients taking hydrochlorothiazide report any new skin lesions or changes to skin lesions

Answer 18

MHRA warning: long-term use of hydrochlorothiazide increases the risk of non-melanoma skin cancer, especially in long-term use

Question 19

what is the preferred first-line diuretic for the management of hypertension

Answer 19

indapamide (a thiazide-like diuretic)

Question 20

what is the first line treatment for an afro-carribean patient WITH diabetes + hypertension

Answer 20

In Afro-Caribbean patients, a calcium channel blocker is usually the first choice of antihypertensive drug.

However, as this patient has diabetes, the first-line antihypertensive should be an ACE-inhibitor

Question 21

what monitoring is needed for patients taking proton pump inhibitors

Answer 21

serum-magnesium concentrations

PPIs cause hypomagnesemia

note: need to monitor especially when used with other drugs that cause hypomagnesaemia or with digoxin

Question 22

how often should patients taking amiodarone have their thyroid function monitored

Answer 22

Thyroid function tests need to be conducted before
treatment and then every 6 months

• amiodarone can cause HYPERthyroidism as common side effect

Question 23

what is the interaction between digoxin and itraconazole

Answer 23

Itraconazole increases the concentration of Digoxin

note: itraconazole normally used for different types of candidiasis infections, Athlete’s foot (tinea pedis), Ringworm (tinea corporis)

Question 24

what is the interaction between Sotalol + Citalopram/Escitalopram

Answer 24

Sotalol, Citalopram + Escitalopram all prolong the QT interval.

Most manufacturers advise avoiding the use of two or more drugs that are associated with QT prolongation

Question 25

what should a patient taking amiodarone do if they experience symptoms such as:

abdominal pain or tenderness; clay-coloured stools; dark urine; decreased appetite; skin rash, yellowing of skin or eyes

Answer 25

seek immediate medical attention - symptoms of hepatotoxicity

Question 26

what is the blood pressure for patients with hypertension who are UNDER 80 yrs old

• give clinic blood pressure and ambulatory/ home blood pressure

Answer 26

• clinic blood pressure: below 140/90 mmhg

- ambulatory/ home blood pressure: below 135/85 mmhg

Question 27

what is the target clinic blood pressure for patients with hypertension who are OVER 80 yrs old

• give clinic blood pressure and ambulatory/ home blood pressure

Answer 27

• clinic blood pressure: below 150/90 mmhg

- ambulatory/ home blood pressure: below 145/85 mmHg

Question 28

name the 3 antihypertensives that can be used in pregnancy

Answer 28

• labetalol (first line)
• methyldopa
• nifedipine (unlicensed)

Question 29

which statin is recommended for the primary prevention of CVD for people who have a 10% or greater 10-year risk of developing CVD

Answer 29

low dose statin- atorvastatin 20mg daily

note: also given as primary prevention in patients with: type 1 diabetes who are either aged over 40 years, have had diabetes for more than 10 years, have established nephropathy, or have other CVD risk factors

Question 30

which statin is recommended in secondary prevention of CVD

Answer 30

high dose statin - atorvastatin 80mg once daily

Question 31

which antihypertensives can cause “first dose hypotension”

Answer 31

Alpha-adrenoceptor blockers: e.g doxazosin, alfuzosin, prazosin

Question 32

which class of diuretics is associated with gynecomastia

Answer 32

aldosterone antagonists: e.g eplerenone, spironolactone

note: eplerenone is used in heart failure

Question 33

which 2 antihypertensive classes can cause oedema

Answer 33

• ACE inhibitors: they cause angioedema (more common in black patients)
• CCB: can cause peripheral oedema

Question 34

what advice should you give to a patient if they describe to you symptoms of digoxin toxicity

Answer 34

digoxin should be withdrawn - patient should stop taking it

note: A digoxin plasma concentration within the therapeutic range does not exclude digoxin toxicity. so patients can still have digoxin toxicity but plasma- concentration won’t show it

Question 35

which diagnostic test is used to measure cardiac function in heart failure

Answer 35

Pro B-type natriuretic peptide

• this will be raised in heart failure

Question 36

which classes of antihypertensives cause hyperkalemia

Answer 36

• ACE inhibitors

- ARBs

Question 37

which electrolytes are affected by thaizide-like diuretics and how

Answer 37

• HYPOkalaemia
• hyponatraemia
• hyperglycaemia
• hyperuricaemia

Question 38

how does amiodarone affect thyroid function

Answer 38

it can cause both HYPERthyroidism + HYPOthyroidism

Question 39

what can be given to a patient with unstable angina if glyceryl trinitrate spray is ineffective

Answer 39

Aspirin 300mg dispersible tablets + glyceryl trinitrate spray/ tablets

Question 40

which CHA2DS2-VASc Scores mean the patient doesn’t need to start anticoagulants (for both men + women)

Answer 40

low/ no risk of stroke is:

• score of 0 for men
• score of 1 for women

CHAD2DS2-VASC tells us a patients risk of stroke. Adults with non‑valvular atrial fibrillation and a CHA2DS2-VASC stroke risk score of 2 or above are offered anticoagulation

Question 41

what is a high HAS-BLED score

Answer 41

score of 3+ means high risk of bleeding

• need to review pt meds
• note: ORBIT is now also used to calculate risk of bleeding. An ORBIT score of 0-2 is low risk, 3+ is medium/high risk*

Question 42

what is the treat for STABLE angina

Answer 42

• GTN spray when required (can be used before exercise)
• For long-term prevention of chest pain: beta-blockers. verapamil + diltiazem can be used as alternatives e.g in For long-term prevention of chest pain in patients with stable angina,

secondary prevention:
- low dose aspirin (75mg) + statin (atorvastatin 80mg)