BNF - Chapter 2 - Cardiovascular System (Part 1) Flashcards
1
Q
What is an arrhythmia?
A
It is a condition which the heart beats with an irregular or abnormal rhythm
2
Q
Just give a quick summary of how the heart works?
A
- the sinoatrial node (SA) sends electrical impulses from the atrium causing it to contract and pump blood into the ventricles through a ‘junction box’ called the AV node.
- The impulses spreads into the ventricles, causing the muscle to contract and to pump out the blood.
3
Q
What are ectopic heart beats?
A
- They are changes in a heartbeat that is otherwise normal.
- These changes lead to extra or skipped heartbeats
4
Q
If ectopic beats are spontaneous and the patient has a normal heart is treatment required?
A
No treatment is rarely required and reassurance to the patient will often suffice.
5
Q
If ectopic beats are troublesome which drug class may be used?
A
- Beta-blockers are sometimes effective and may be safer than other suppressant drugs
6
Q
What is Atrial Fibrillation (AF)?
A
- In AF, electrical impulses do not originate in the SA node, but form a different part of the atrium or nearby pulmonary veins.
- These abnormal impulses become rapid and disorganised radiating through the atrial walls in an uncoordinated manner.
- This can cause the walls of the atria to fibrillate (quiver rapidly) rather than contracting normally.
7
Q
In AF why is there a risk of a blood clot(s) to form?
A
During AF, because the atria do not contract regularly, blood does not empty efficiently into the ventricles and begins to pool in the atria.. which can cause clots to form.
- If the blood clot become dislodged, they can travel to the brain causing a stroke.
8
Q
What is the treatment aims of AF?
A
To prevent stroke and VTE.
9
Q
How can AF be managed?
A
By controlling ventricular rate (‘rate control’) or attempting to restore and maintain sinus rhythm (‘rhythm control’).
10
Q
What should all patients with AF be assessed for?
A
Their risk of stroke and thromboembolism.
11
Q
What is the first line treatment for AF?
A
- Rate control is preferred first line option using a BETA BLOCKER (not sotalol) or
- Rate-limiting CALCIUM CHANNEL BLOCKER (e.g. DIltiazem or Verapamil)
12
Q
For treatment of AF if a single drug fails to control ventricular rate what may be used secondline?
A
- A combination of two drugs (beta blocker, Digoxin or Diltiazem) can be used
13
Q
For AF as third line option (rhythm control) which drugs can be used to achieve this?
A
- Beta-blocker
- but if beta-clocker is ineffective or not tolerated, an oral anti-arrhythmic drug such as SOTALOL, FLECAINIDE or AMIODARONE can be used.
14
Q
How long within should a referral be made if at any stage AF treatment fails to control symptoms?
A
Within 4 weeks
15
Q
How often should patients with AF be reviewed for anticoagulation, stroke and bleeding risk?
A
At least annually
16
Q
What should all patients with life-threatening haemodynamic instability caused by new-onset atrial fibrillation undergo?
A
- Electrical Cardioversion without delaying to achieve anticoagulation.
17
Q
In patients presenting acutely but without life-threatening haemodynamic instability what can be offered if the onset of arrhythmia is less than 48 hours?
A
- Rate or rhythm control can be offered
18
Q
If onset is more than 48 hours or uncertain then what is preferred?
A
- Rate control is preferred.
19
Q
If pharmacological cardioversion (not electrical cardioversion) has been agreed for AF which drug can be used?
A
- Intravenous Amiodarone hydrochloride
20
Q
What is an alternative to IV Amiodarone?
A
- Flecainide Acetate
21
Q
When is IV Amiodarone preferred over flacainide?
A
- if there is a structural heart disease
22
Q
For AF if urgent rate control is required which drug(s) IV can be used?
A
- A beta blocker or verapamil hydrochloride can be given intravenously.
23
Q
Which two ways can sinus rhythm be restored?
A
- Electrical cardioversion
- Pharmacological cardioversion (with an oral or intravenous antiarrhythmic drug e.g. flecainide acetate or amiodarone hydrochloride).
24
Q
If atrial fibrillation has been present for more than 48 hours is electrical or pharmacological cardioversion preferred?
A
- Electrical cardioversion is preferred and should not be attempted until the patient has been fully anticoagulated for at least 3 weeks.
- If this is not possible, parenteral anticoagulation should be commenced and a left atrial thrombus ruled out immediately before cardioversion
25
Oral anticoagulation should be given after cardioversion - how long should this be continued for?
For atleast 4 weeks.
26
Prior to cardioversion, what should be offered as appropriate?
- Offer rate control
27
When is digoxin only effective for controlling ventricular rate?
- Only good at controlling rate at rest, and should therefore only be used as monotherapy in predominantly sedentary patients with non-paroxysmal atrial fibrillation.
28
If ventricular function is diminished which combination of drugs is preferred?
- Beta-blocker (that is licensed for use in heart failure) and Digoxin is preferred.
29
Digoxin is also used when atrial fibrillation is accompanied by what?
When AF is accompanied by congestive heart failure.
30
To increase success of electrical cardioversion, and to maintain sinus rhythm when should amiodarone be initiated and for how long?
start it 4 weeks before and continue for up to 12 months after electrical cardioversion
31
When should Flecainide acetate or propafenone not be given when treating AF?
- These should not be given if there is known ischaemic or structural disease.
32
In patients with left ventricular impairment or heart failure which drug should be considered?
- Amiodarone
33
What is paroxysmal atrial fibrillation?
A type of atrial fibrillation where episodes come and go and usually stop within 48 hours without any treatment.
34
In symptomatic paroxysmal atrial fibrillation how is ventricular rhythm controlled?
1) with a standard beta-blocker
2) If symptoms persist or standard beta blocker is not appropriate then an oral anti-arrhythmic drug such as dronedarone, sotalol, flecainide, propafenone or amiodarone can be given.
35
In selected patients with infrequent episodes of symptomatic paroxysmal atrial fibrillation can they self-treat an episode of AF when it occurs?
Yes - to restore sinus rhythm the 'pill-in-the-pocket' approach can be used
- involves patient taking oral flecainide or propafenone
36
Which tool is used to assess the risk of stroke?
CHA2D-VASc assessment tool
37
Which tool is used to assess the risk of bleeding prior to and during anticoagulation?
HAS-BLED tool
38
What parameters are included in CHA2D-VASc score?
- Prior ischaemic stroke
- Transient ischaemic attacks
- Thromboembolic events
- Heart failure
- Left ventricular systolic dysfunction
- vascular disease
- Diabetes
- Hypertension
- Females
- Patients over 65 years
39
What is considered a low risk score of CHA2D-VASc tool?
- 0 for men
1 - for women
= low risk score and do not require an antithrombotic for stroke prevention
40
Which formulation of anticoagulation should be given to those with new onset atrial fibrillation who are receiving sub-therapeutic or no anticoagulation therapy?
Parenteral Anticoagulation
- Until assessment is made and appropriate anticoagulation is started
41
In AF, which anticoagulants are used?
May use:
- A vitamin K antagonist (Warfarin)
- or in non-valvular AF you can use apixaban, dabigatran, etexilate, edoxaban or rivaroxaban
42
Is Aspirin or Warfarin more effective at preventing emboli?
Aspirin is less effective at preventing emboli
43
Can aspirin be given as monotherapy solely for stroke prevention in AF?
No
44
If anticoagulant treatment is contraindicated or not tolerated what may be considered?
- Left atrial appendage occlusion can be considered.
45
What is recommended for paroxysmal supraventricular tachycardia?
- it will often terminate spotaneously
- OR with reflex vagal stimulation such as Valsalva manoeuvre, immersing the face in ice-cold water, or carotid sinus massage - such manoeuvres should be performed with ECCG monitoring
46
If effects of reflex vagal stimulation are transient or ineffective, then what may be given?
Intravenous adenosine
47
If adenosine is ineffective or contraindicated then what may be given?
Intravenous verapamil is an alternative - but this should be avoided in patients recently treated with beta-blockers
48
For Bradycardia (arrhythmia after MI) which drug should be given IV?
- Atropine sulfate - the dose may be repeated if necessary
- If there is a risk of asystole, or if the patient is unstable and has failed to respond to atropine sulfate, adrenaline/epinephrine should be given by intravenous infusion, and the dose adjusted according to response.
49
What do pulseless ventricular tachycardia or ventricular fibrillation require?
Requires resuscitation
50
For ventricular tachycardia which drug is the one of choice for restoring sinus rhythm?
- Amiodarone
| - If sinus rhythm is not restored, direct current cardioversion or pacing should be considered.
51
What is Tosade de pointes?
It is a form of ventricular tachycardia and it is associated with a long QT syndrome (usually drug-induced)
52
What are the other factors of torsade de pointes?
- hypokalaemia
- severe bradycardia
- genetic predisposition
53
Is torsade de pointes self-limiting?
Episodes are usually self-limiting, but are frequently recurrent and can cause impairment or loss of consciousness
- if not controlled the arrhythmia can progress to ventricular fibrillation and sometimes death.
54
Can anti-arrhythmic be used for torsade de pointes?
No as they can further prolong the QT interval
55
What drug treatment is used for torsade de pointes?
- Magnesium sulfate is usually effective
| - A beta-blocker (but not sotalol) and atrial (or ventricular) pacing can be considered
56
What can anti-arrhythmic drugs be classed according to?
They can be classified in those that they act on
- Supraventricular arrhythmias (occur in the area above the ventricles) (e.g. verapamil)
- Both Supraventricular and ventricular arrhythmias (Amiodarone)
- Ventricular arrhythmias (Lidocaine)
57
What can anti-arrhythmic drugs also be classed according to?
- Can be classed according to their effects on the electrical behaviour of myocardial cells during activity (the Vaughan William classification) although this classification is of less clinical significance
58
What are the four classes of the Vaughan Williams Classification?
Class I - membrane stabilising drugs e.g. lidocaine
Class II - Beta-blockers
Class III - Amiodarone; sotalol (also Class II)
Class IV - Calcium-channel blockers (includes verapamil but not dihydropyridines)
59
If two or more anti-arrhythmic drugs drugs are used why is special care needed?
The negative inotropic effects (weakening the heart's contractions and slow the heart rate) of anti-arrhythmic drugs tend to be additive
60
What effect does hypokalaemia have on drugs regarding arrhythmia?
- Hypokalaemia enhances the arrhythmogenic (pro-arrhythmic) effect of many drugs.
61
What is the usual treatment for paroxysmal supraventricular tachycardia?
- Adenosine
62
Why is adenosine usually the choice of drug?
It has a vert short duration of action (half life only about 8-10 seconds, but prolonged in those taking dipyridamole)
- most side effects are short-lived
63
Can adenosine be sued after a beta-blocker?
- Yes unlike verapamil
64
Can adenosine be used in patients with asthma?
Verapamil may be preferable to adenosine in asthma
65
Which cardiac glycoside can be used to slow the ventricular response in cases of atrial fibrillation and atrial flutter?
Digoxin
66
Is intravenous infusion of digoxin effective for rapid control of ventricular rate?
- No it is rarely effective
67
Which types of arrhythmias are cardiac glycosides (digoxin) contraindicated in?
Arrhythmias associated with accessory conducting pathways (e.g. Wolff-Parkinson-White Syndrome)
68
What is Wolff-Parkinson-White syndrome?
In Wolff-Parkinson-White (WPW) syndrome, an extra electrical pathway between your heart's upper and lower chambers causes a rapid heartbeat.
69
Which drug is effective for supraventricular tachycardias?
- Verapamil
| - IV dose followed by oral dose
70
With high doses of verapamil what may occur?
Hypotension
71
Which arryhthmias should Verapamil not be used for?
Tachyarrhythmias where the QRS complex is wide (i.e. broad complex) unless a supraventricular origin has been established beyond reasonable doubt.
72
Similar to digoxin which type of arrhythmias is verapamil CI in?
- in AF or Atrial flutter associated with accessory conducting pathways (e.g. Wolff-Parkinson-White syndrome).
73
Which IV beta blockers can be used to achieve rapid control of the ventricular rate?
- Esmolol
| - Propranolol
74
Which drugs work for both supraventricular and ventricular arrhythmias?
- Amiodarone
- Beta blockers
- Disopyramide
- Flecainide
- Procainamide (available from 'special-order')
- Propafenone
75
Which drug can be used for tachyarrhythmias associated with Wolff-Parkinson- White Syndrome?
- Amiodarone can be used
(but Digoxin and verapamil are Contraindicated)
Should only be initiated only under hospital or specialist supervision.
76
What is the advantage of using Amiodarone?
- It can be given IV as well as by mouth
| - Has the advantage of causing little or no myocardial depression
77
Does amiodarone have a long or short half life?
- a very long half life (extending to several weeks) and only needs to be given once (but high doses cause nausea unless divided)
78
How long may it take to reach steady state plasma amiodarone concentrations?
- Weeks or months (this is important when drug interactions are likely)
79
What does Disopyramide impair?
Impairs cardiac contractility
80
What additional effect does Disopyramide have which may limit the use in patients?
it has an antimuscarinic effect which limits its use in patients susceptible to angle-closure glaucoma or with prostatic hyperplasia.
81
Flecainide is in the same general class as which drug?
- Lidocaine
And can be sued for serious symptomatic ventricular arrhythmias
82
What is propafenone used for?
is used for the prophylaxis and treatment of ventricular arrhythmias and also for some supraventricular arrhythmias. It has complex mechanisms of action, including weak beta-blocking activity (therefore caution is needed in obstructive airways disease—contra-indicated if severe).
83
In summary which drugs are used for supraventricular arrhythmias?
- adenosine
- cardiac glycosides
- verapamil hydrochloride.
84
In summary which drug is used in ventricular arrhythmias?
- Lidocaine
| - Mexiletine is used in life threatening ventricular arrhythmias
85
In summary which drugs are used in both supraventricular and ventricular arrythmias?
- Amiodarone
- beta-blockers
- Disopyramide
- Flecainide
- Procainamide
- Propafenone
86
Can disopyramide be used for both ventricular and supraventricular arrhythmias?
Yes including after myocardial infarction, maintenance of sinus rhythm after cardioversion
87
Is Disopyramide an antiarrhythmic drug?
Yes
88
What Antiarrhythmic class is Disopyramide?
- Class IA
89
Give an example of Antiarrhythmic class IB?
- Lidocaine hydrochloride
90
What type of arrhythmias is lidocaine used for?
- Ventricular arrhythmias
91
Give an example of Antiarrhythmic class IC?
Flecainide Acetate
92
What type of arrhythmias is flecainide acetate licensed for?
- Supraventricular arrhythmias and ventricular arrhythmias
93
When flecainide is used concurrently with amiodarone what dose reduction does the manufacturer recommend?
Reduce the dose by half
94
What is the indication of propafenone hydrochloride?
- Ventricular arrhythmias
- Paroxysmal supraventricular tachy arrhythmias which include paroxysmal atrial flutter or fibrillation and paroxysmal re-entrant tachycardia involving the AD node or accessory pathway
95
Which class of antiarrhythmics does amiodarone belong to?
Class III
96
What is the usual dosing of amiodarone by mouth?
By mouth - 200mg three times a day for one week, then reduced to 200mg twice daily for a further week,, followed by maintenance dose, usually 200mg daily or the minimum dose required to control arrhythmia
97
What is the usual dose of amiodarone by IV?
Initially 5mg/kg, to be given over 20-120 minutes with ECG monitoring, subsequent infusions given if necessary according to response, maximum 1.2g per day
98
Is Dronedarone an antiarrhythmic drug?
Yes it is a multi-channel blocker anti-arrhythmic drug
99
What is the indication of dronedarone?
Maintenance of sinus rhythm after cardioversion in clinically stable patients with paroxysmal or persistent atrial fibrillation, when alternative treatments are unsuitable
100
What toxcity can dronedarone cause?
Pulmonary toxicity - Interstitial lung disease, pneumonitis and pulmonary fibrosis reported. Investigate if symptoms such as dyspnoea or dry cough develop and discontinue if confirmed.
101
Which eGFR range should dronedarone be avoided in?
- Avoid if eGFR less than 30ml/minute/1.73m2
102
Name two other drugs (antiarrhythmics) that can be used for rapid reversion to sinus rhythm?
- Adenosine
| - Vernakalant
103
How does Vernakalant work?
Vernakalant is an anti-arrhythmic drug that blocks potassium and sodium channels in the atria, thereby restoring normal heart rhythm
104
Which Beta-blocker is used for antiarrhythmic purposes?
Sotalol
105
Is sotalol lipid or water-soluble and selective or non-selective?
Sotalol is water-soluble and non-selective
106
What important safety information is provided in the BNF for sotalol?
- Sotalol may prolong QT interval, and it occasionally causes life-threatening ventricular arrhythmias
- Manufacturer advises particular care is required to avoid hypokalemia in patients taking sotalol - electrolyte disturbances, particularly hypokalemia and hypomagnesaemia should be corrected before sotalol started and during use
107
IF the range of QT interval exceeds a certain amount then the manufacturer advises to reduce the dose of sotalol or discontinue. What QT interval range is this?
If QT interval exceeds 550msec.
108
Is amiodarone considered a high-risk drug?
Yes
109
who or what setting can amiodarone be initiated in?
This drug should only be intiated under specialist supervision, usually in a hospital setting
110
Does amiodarone have a short or long half life?
Amiodarone has a very long half life (several weeks) and only needs to be given ONCE daily.
111
What can high doses of amiodarone cause which requires it to be given in divided doses?
Can cause nausea unless divided
112
How long can it take for amiodarone to reach steady state?
It can take weeks or months to reach steady state, but IV amiodarone acts relatively rapidly
113
How can amiodarone affect the eyes?
Most patients will develop corneal microdeposits (which is reversible on withdrawal of amiodarone),,, these rarely interfere with vision but drivers may be dazzled by headlights at night.
- If vision is impaired or if optic neuritis or optic neuropathy occur, amiodarone must be stopped to prevent blindness and expert advice sought.
114
Why do people taking amiodarone need to protect them self from sunlight?
Amiodarone can cause phototoxicity (toxic response after exposure of the skin to light)
- Patients are advised to shield skin from light using wide-spectrum sunscreen
115
For patients taking amiodarone why does thyroid function need to be checked?
- Amiodarone contains iodine which can cause both hyper and hypothyroidism hence thyroid function should be monitored every 6 months.
116
What are the signs and symptoms associated with hypothyroidism associated with amiodarone use?
- Weight loss
- palpitations
- insomnia
117
How can amiodarone-induced hypothyroidism be treated?
Can be treated with replacement therapy without withdrawing amiodarone if it is essential; careful supervision is required
118
What skin colour discoloration can amiodarone cause?
Slight grey skin discolouration as a side effect --> this is common
119
Which other test is required before treatment with amiodarone?
- Liver function tests are required before treatment + then every 6 months
120
What would need to be done if hepatoxicity is suspected for patient taking amiodarone?
The drug should be stopped
121
For patients taking amiodarone, what signs should lead you to suspect pneumonitis?
if a new/progressive shortness of breath or cough develops.
122
What do neurological symptoms in patients taking amiodarone suggest?
suggests patient is experiencing peripheral neuropathy (nerve dysfunction)
123
Amiodarone increases which three drugs if they are taken with amiodarone?
Amiodarone increases plasma concentration of warfarin, digoxin and phenytoin
124
When amiodarone is taking with digoxin what is recommended about the digoxin dose?
- dose of digoxin needs to be halved
125
Which drugs if taken with amiodarone increases the risk of arrhythmias?
- Amitriptyline, lithium, quinines, erythromycin and haloperidol.
126
Can amiodarone be given in pregnancy and during breastfeeding?
No - possible risk of neonatal goitre; use only if no alternative
Avoid in breastfeeding as it is present in milk in significant amounts - theoretical risk of neonatal hypothyroidism from release of iodine
127
What does co-administration of amiodarone and simvastatin increase the risk of?
Myopathy
128
What is the mode of action of beta blockers?
- They reduce the cardiac output by blocking beta 1 receptors in the heart. They also act on beta 2 receptors in the liver, bronchi and pancreas
129
Can beta blockers be used in uncontrolled heart failure?
No it is contraindicated in uncontrolled heart failure
130
Which beta blockers are water soluble?
Use Acronym CANS
Celiprolol
Atenolol
Nadolol
Sotalol
They are water soluble and can't cross the BBB, so they cause less sleep disturbances and less nightmares
131
Is it okay to stop beta-blockers abruptly?
No- advise patient to seek help from their GP
132
Why are beta blockers contraindicated in asthma?
due to their action on bronchi they can cause bronchospasm and should usually be avoided in patients with asthma.
133
Which beta blockers are cardio selective?
- Atenolol
- Bisoprolol
- Metoprolol
- Nebivolol
- Acebutolol
134
Why is there a risk of hypo/hyperglycaemia with betablockers in patients with or without diabetes?
- due to their action on the liver and pancreas they can affect carbohydrate metabolism causing either hyper or hypoglycaemia in patients with or without diabetes.
They can still be used in diabetes with caution - however they can MASK THE SYMPTOMS OF HYPOglycaemia
135
What are other uses of beta blockers?
- Angina (by reducing the work of the heart, and may prevent recurrence of MI
- They block sympathetic activity in HF
- Beta blockers can be used for anxiety (propranolol) and in the prophylaxis of migraine
136
Which two beta blockers can be used to reduce the mortality of heart failure?
- Bisoprolol
| - Carvedilol
137
Can beta blockers be used to reduce blood pressure?
Yes through various ways (but not fully understood) mechanisms
138
Which drug is a cardaic glycoside?
Digoxin
139
What is digoxin-specific antibody fragments indicated for?
For the treatment of known or strongly suspected life-threatening digoxin toxicity associated
140
What is digoxin maintenance dose determined by?
Ventricular rate at rest
141
When using digoxin, heart rate should not be allowed to fall below what?
Should not usually be allowed to fall persistently below 60 beats per minute
142
Why is digoxin rarely used for rapid control of heart rate?
Even with intravenous administration, response may take many hours; persistence of tachycardia is therefore not an indication for exceeding the recommended dose.
The intramuscular route is not recommended.
143
In patients with heart failure who are in sinus rhythm, is a loading dose record?
no it is not required and a satisfactory plasma-digoxin concentration can be achieved over a period of about a week
144
Does digoxin have a short or long half life?
Has a long half-life and maintenance doses need to be given only once daily (although higher doses may be divided to avoid nausea)
145
What parameter is the most important determinant of digoxin dosage?
- Renal function
146
Is the plasma concentration alone of digoxin a reliable indicator of toxicity?
No, but the likelihood of toxicity increases progressively through the range 1.5 to 3 micrograms/litre for digoxin
147
Which electrolyte imbalance predisposes patient to digoxin toxicity?
Hypokalaemia - as potassium and digoxin compete for the same enzyme
less potassium means less competition for digoxin (which is a pro drug)
148
How is hypokalaemia in patients taking digoxin managed?
- by giving a potassium-sparing diuretic or if necessary potassium supplementation
149
If toxicity of digoxin is suspected, what should be done?
- Digoxin should be withdrawn
150
What is the drug action of digoxin?
Digoxin is a cardiac glycoside that increases the force of myocardial contraction and reduces conductivity within the atrioventricular (AV) node.
151
With which drugs if digoxin is taken then the dose of digoxin should be halved?
- Amiodarone
- Dronedarone
- Quinine
152
Which electrolyte imbalances including hypokalaemia increases risk of digoxin toxicity?
- Hypokalaemia
- Hypomagnesemia
- hypercalcaemia
153
If blood monitoring of digoxin levels is required when should this be taken?
Sample should be taken at least 6 hours after a dose
154
Which electrolyte imbalance does digoxin increase the risk of?
- increases the risk of hypokalaemia and ways to overcome this are to take potassium-sparing diuretics, potassium supplements or eating food with high potassium e.g. bananas
155
What are the signs and symptoms of digoxin toxicity?
- Nausea/ vomiting
- Blurred/yellow vision
- Weight loss
- anorexia
- Palpitations
- hallucinations
abdominal pain
156
What are people with digoxin toxicity (overdose) treated with?
Treated with a digoxin specific antibody fragment a.k.a. Digifab
157
Does digoxin liquid and tablets have the same bioavalibility?
No, thus the patient's dose will change
158
What does tranexamic acid inhibit?
It inhibits fibrinolysis (impairs fibrin dissolution)
159
What can tranexamic acid be used to prevent?
to prevent bleeding ot to treat bleeding associated with excessive fibrinolysis (e.g. in surgery, dental extraction, obstetric disorders, and traumatic hyphaemia) and in the management of menorrhagia
160
Which other conditions or situations may tranexamic acid be also used for?
- hereditary angioedema
- Epistaxis
- Thrombolytic overdose
161
What is haemophilia?
It is a rare condition that affects the body's ability to clot. It is usually inherited. Most people who have it are male.
162
What is desmopressin used for?
is used in the management of mild to moderate haemophilia and von Willebrand’s disease.
It is also used for fibrinolytic response testing.
163
Is the drug Etamsylate used for heavy menstrual bleeding?
No, it is less effective than other treatments.
Etamsylate reduces capillary bleeding in the presence of a normal number of platelets; however, it does not act by fibrin stabilisation, but probably by correcting abnormal adhesion.
164
What is the dose and regimen for tranexamic acid in menorrhagia treatment?
Adult - by mouth -
| - 1g 3 times a day for up to 4 days, to be initiated when menstruation has started, maximum 4g per day
165
What is Von Willebrand (VWD)?
It is a blood disorder in which the blood does not clot properly. People with this disease have low levels of Von Willebrand factor, a protein that helps blood clot, or the protein doesn't perform as well as it should.
166
What is the indication of fresh frozen plasma?
- Major bleeding in patients on warfarin following phytomenadione (if dried prothrombin complex is unavailable)
- Replacement of coagulation factors or other plasma proteins where their concentration or functional activity is critically reduced
167
Which drug can be used for blood clots causing blocked catheters and lines?
Epoprostenol (prostacyclin) - used for inhibition of platelet aggregation during renal dialysis when heparins are unsuitable or CI.
168
What is the drug action of epoprostenol?
Epoprostenol is a prostaglandin and a potent vasodilator.
| It is also a powerful inhibitor of platelet aggregation.
169
What are the two types venous thromboembolism?
- Deep-vein Thrombosis (DVT)
| - Pulmonary Embolism (PE)
170
What does a venous thromboembolism refer to?
A blood clot that forms in a vein which partially or completely obstructs blood flow
171
Within how many days hospital admission is referred to as having an hospital-acquired venous thromboembolism?
VTE that occurs within 90 days of hospital admission
172
What are the risk factors for VTE?
- surgery
- Trauma
- Significant immobility
- Malignancy
- obesity
- Acquired or inherited hypercoagulable states
- pregnancy and the postpartum period
- hormonal therapy (Combined hormonal contraception or hormone replacement therapy)
173
Out of the two, which is the most common type of VTE?
DVT is the most common form of VTE.
174
What are the common sites in which a DVT usually occurs?
Usually occurs in the deep veins of the legs or pelvis but may affect other sites such as the upper limbs, and the intracranial and splanchnic veins.
175
What are the symptoms of DVT?
- Unilateral localised pain
- Swelling
- tenderness
- skin changes
- and/or vein distension
176
How does a pulmonary embolism (PE) usually occur?
- most commonly occurs when a thrombus, usually from a DVT, travels in the blood (embolus) and obstructs blood flow to the lungs causing respiratory dysfunction.
177
What are the symptoms of pulmonary embolism?
- Chest pain
- Shortness of breath
- and/ or haemoptysis
178
What is haemoptysis?
Haemoptysis is the coughing up of blood
179
For venous thromboembolism, what must all patients undergo?
A risk assessment to identify their risk of venous thromboembolism (VTE) and bleeding
180
What are the two methods of thromboprophylaxis?
- mechanical
| - pharmacological
181
What are the options of mechanical thromboprophylaxis?
- anti-embolism stockings that provide graduated compression and produce a calf pressure of 14-15mmHg
- intermittent pneumatic compression
182
How long should anti-embolism be worn for?
- They should be worn day and night until the patient is sufficiently mobile
183
Which patients should anti-embolism stockings not be offered to?
- patients admitted with acute stroke or those with conditions such as peripheral arterial disease
- peripheral neuropathy
- severe leg oedema
- local conditions (e.g. gangrene, dermatitis)
184
For thromboprophylaxis how soon should pharmacological prophylaxis start if this option is chosen?
- Should start as soon as possible or within 14 hours of admission
185
Can certain patients with bleeding risk be given pharmacological thromboprophylaxis?
Patients with risk factors for bleeding (e.g. acute stroke, thrombocytopenia, acquired or untreated inherited bleeding disorders) should only receive pharmacological prophylaxis when their risk of VTE outweighs their risk of bleeding.
186
Should patients receiving anticoagulant treatment who are at high risk of VTE be considered for prophylaxis of VTE?
These patients should be considered for prophylaxis if their anticoagulant treatment is interrupted, for example during the peri-operative period
187
To reduce the risk of VTE in surgical patients which form of anaesthesia should be used?
Regional anaesthesia should be used if possible over general anaesthesia
188
What is the difference between regional and general anaesthesia?
In general anesthesia, you are unconscious and have no awareness or other sensations. In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery.
189
In surgical patients how long should mechanical prophylaxis continue?
Until the patient is sufficiently mobile or discharged from hospital (or for 30 days in spinal injury, elective spinal surgery or cranial surgery).
190
In terms of pharmacological prophylaxis for surgery patients, what types of surgeries are low molecular weight heparin considered?
- general and orthopaedic surgery
191
What is orthopaedics?
Orthopedic surgery or orthopedics, is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders
192
In which surgery patients is Heparin (unfractionated) preferred in for thromboprophylaxis?
- In patients with renal impairment
193
Which surgery patients is fondaparinux an option for thromboprophylaxis?
or patients undergoing abdominal, bariatric, thoracic or cardiac surgery, or for patients with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur.
194
How long should pharmacological thromboprophylaxis continue in general surgery?
- should usually continue for at least 7 days post-surgery or until sufficient mobility has been re-established.
195
In cancer surgery or abdominal surgery - how long should pharmacological thromboembolism continue?
- extended to 28 days after major cancer surgery in the abdomen
- and to 30 days in spinal surgery
196
What thromboprophylaxis is recommended for patients undergoing an elective hip replacement?
should be given thromboprophylaxis with either a low molecular weight heparin administered for 10 days followed by low-dose aspirin for a further 28 days, or a low molecular weight heparin administered for 28 days in combination with anti-embolism stockings until discharge, or rivaroxaban. If these options are unsuitable, apixaban or dabigatran etexilate can be considered as alternatives. If pharmacological prophylaxis is contra-indicated, anti-embolism stockings can be used until discharge.
197
What thromboprophylaxis is recommended for patients undergoing an elective knee replacement?
- should be given thromboprophylaxis with either low-dose aspirin for 14 days, or a low molecular weight heparin administered for 14 days in combination with anti-embolism stockings until discharge, or rivaroxaban.
- If these options are unsuitable, apixaban or dabigatran etexilate can be considered as alternatives. If pharmacological prophylaxis is contra-indicated, intermittent pneumatic compression can be used until the patient is mobile.
198
For acutely ill medical patients who are at high risk of VTA what is the treatment steps?
1st line = low molecular weight heparin as first-line option
2nd line/ alternative to 1st line = Fondaparinux as an alternative for minimum of 7 days
Patients with renal impairment should be given either a low molecular weight heparin or heparin (unfractionated) and the dose should be adjusted as necessary.
199
In stroke patients which mechanical thromboprophylaxis can be used?
mechanical prophylaxis with intermittent pneumatic compression should be considered, as anti-embolism stockings are unsuitable in these patients
200
In acute stroke patients, how long should mechanical thromboprophylaxis be used?
Their use should be started within 3 days of the acute stroke and continued for 30 days, or until the patient is sufficiently mobile or discharged from hospital.
201
When should thromboprophylaxis be considered in pregnancy?
All pregnant women (who are not in active labour), or women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks, with a risk of VTE that outweighs the risk of bleeding should be considered for pharmacological prophylaxis.
202
Which pharmacological treatment is indicated for thromboprophylaxis in pregnancy?
- Use a low molecular weight heparin during hospital admission.
203
In pregnant women, how long should thromboprophylaxis be continued?
In pregnant women, prophylaxis should be continued until there is no longer a risk of VTE, or until discharge from hospital.
204
For women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks, within what time should thromboprohpylaxis start?
Within 4-8 hours after the event, unless contra-indicated, and continue for a minimum of 7 days.
205
What are the signs of haemodynamic instability which if seen in suspected PE patients should be referred immediately for hospital admission?
- pallor
- Tachycardia
- Hypotension
- Shock
- Collapse
206
What are the non-drug treatment of VTE?
- elastic graduated compression stockings may be used to manage leg symptoms after a DVT
- Mechanical interventions (such as inferior vena caval filters or percutaneous mechanical thrombectomy) can be considered in certain patients.
207
In terms of drug treatment for VTE, which drug should be offered if diagnostic investigations cannot be completed or results obtained with the required time frame?
- Offer interim therapeutic anticoagulation
208
Before starting treatment for VTE using anticoagulant - what tests should be carried out before treatment?
carry out baseline blood tests (including full blood count, renal and hepatic function, prothrombin time and activated partial thromboplastin time)
209
Which two anticoagulants can be used for treatment of VTE?
Offer either apixaban or rivaroxaban for patients with a confirmed proximal DVT or PE
210
For drug treatment of VTE what other drugs can be considered if apixaban or rivaroxaban are unsuitable?
- low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran etexilate or edoxaban; or
- LMWH given concurrently with a vitamin K antagonist for at least 5 days or until the INR is at least 2.0 for 2 consecutive readings, followed by a vitamin K antagonist on its own
211
Can you use heparin (unfractionated) with a vitamin K antagonist to treat a confirmed proximal DVT or PE?
- no unless the patient has renal impairment, established renal failure or an increased risk of bleeding
212
How long should anticoagulants be used for in patients with a confirmed provoked proximal DVT or provoked PE?
- Should be offered for at least 3 months (3 to 6 months for those with active cancer)
- if the factor that provoked VTE is no longer present
213
How long should anticoagulants be used for patients with an unprovoked DVT or PE?
- Should consider continuing anticoagulation beyond 3 months (beyond 6 months for those with active cancer)
214
Patients on long-term anti-coagulation treatment should be reviewed for what and how often?
At least once a year for general health, risk of VTE recurrence, bleeding risk and treatment preferences.
215
For pregnant patients (VTE treatment) - what routine measurement is recommended for women on LMWH who are at extremes of body weight?
Routine measurements of peak anti-Xa activity is recommended
For women who weigh (less than 50 kg or 90 kg or more).
or those with complicating factors (such as renal impairment or recurrent VTE)
216
What can be done if haemorrhage occurs as a result of treatment for VTE?
- it is usually sufficient to withdraw unfractionated or low molecular weight heparin
- But if rapid reversal of the effects of heparin is required, then protamine sulfate is a specific antidote (but only partially reverses the effects of low molecular weight heparins)
217
What is the antidote of heparin/ LMWH?
Protamine sulfate
218
What is the difference between transient ischaemic attack (TIA) and ischaemic stroke?
TIA (transient ischemic attack, also sometimes called a “mini-stroke”) begins just like an ischemic stroke; the difference is that in a TIA, the blockage is temporary and blood flow returns on its own. Since blood flow is interrupted only for a short time, the symptoms of a TIA don't last long – usually less than hour.
Most strokes are caused by a blood clot blocking an artery leading to the brain. These are called ischemic strokes.
219
What should patients who are suspected of having a transient ischaemic stroke receive immediately?
- Receive aspirin
- Those with aspirin hypersensitivity or those intolerant of aspirin despite the addition of PPI should receive a suitable alternative antiplatelet
220
Following a confirmed diagnosis of TIA, what should patients receive?
treatment for secondary prevention
221
What are the two types of stroke?
- Ischaemic stroke
| - Haemorrhagic stroke
222
What is the initial management of ischaemic stroke?
- If intracranial haemorrhage has been excluded by appropriate imaging techniques then altepase should be administered within 4.5 hours of symptom onset
223
For ischaemic stroke, after treatment with altepase within 4.5 hours what should be initiated next?
- Provided that intracranial haemorrhage has been excluded, treatment with aspirin 300mg (OD for 2 weeks) should be initiated as soon as possible within 24 hours of symptom onset
- A PPI should be considered for patients with a history of dyspepsia associated with aspirin
224
For ischaemic strokes can anticoagulants be used?
Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm
225
Can warfarin be used in ischaemic stroke?
Warfarin should not be given in the acute phase of an ischaemic stroke
226
What should patients with a disabling ischaemic stroke and AF receive?
should receive aspirin for 2 weeks before being considered for anticoagulant treatment.
227
What should Patients already receiving anticoagulation for a prosthetic heart valve who experience a disabling ischaemic stroke and are at significant risk of haemorrhagic transformation recieve?
Their anticoagulant treatment should be stopped for 7 days and substituted with aspirin
228
How should you treat hypertension in the acute phase of ischaemic stroke
Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore only be instituted in the event of a hypertensive emergency, or in those patients considered for thrombolysis.
229
What is the long term treatment following an TIA or ischaemic stroke?
- long term clopidogrel
- if clopidogrel CI then use MR dipyridamole in combination with aspirin
- A high intensity statin (such as atorvastatin should be initiated 48 hours after stroke symptom onset in patients not already taking statin, irrespective of patient's serum-cholesterol concentration.
Following the acute phase of ischaemic stroke, blood pressure should be measured and treatment initiated to achieve a target blood pressure of <130/80 mmHg. Beta-blockers should not be used in the management of hypertension following a stroke, unless they are indicated for a co-existing condition
230
In patients without AF, are anticoagulants recommended for prevention of stroke?
No, Anticoagulants are not routinely recommended in the long-term prevention of recurrent stroke, except when atrial fibrillation or other indications (such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection) are present.
231
What is the initial management of Haemorrhagic stroke?
- Surgical intervention may be required following intracerebral haemorrhage to remove the haematoma and relieve intracranial pressure.
- Patients presenting within 6 hours of symptom onset should be given rapid blood pressure lowering therapy if they have a systolic blood pressure between 150 and 220 mmHg and they do not fit any exclusion criteria.
232
For management of blood pressure during treatment for haemorrhagic stroke what systolic blood pressure should be aimed for and how long for?
A systolic blood pressure target of 130 to 140 mmHg should be aimed to be attained within 1 hour of starting treatment and maintained for at least 7 days.
Rapid blood pressure lowering should also be considered for patients presenting beyond 6 hours of symptom onset or who have a systolic blood pressure greater than 220 mmHg.
233
In the management of haemorrhagic stroke, in patient taking anticoagulants - what do you need to do?
Stop anticoagulant treatment and have this reversed.
234
What is the long-term management of haemorrhagic stroke?
- Aspirin and anticoagulant therapy is not recommended following a haemorrhagic stroke
- blood pressure should be measured and treatment should be initiated appropriately, taking care to avoid hypoperfusion.
- Statins should be avoided following intracerebral haemorrhage, however they can be used with caution when the risk of a vascular event outweighs the risk of further haemorrhage.
235
Are anticoagulants used for thrombus in slower-moving venous side of the circulation or in faster-flowing arteries?
anticoagulants is to prevent thrombus formation or extension of an existing thrombus in the slower-moving venous side of the circulation, where the thrombus consists of a fibrin web enmeshed with platelets and red cells.
Anticoagulants are of less use in preventing thrombus formation in arteries, for in faster-flowing vessels thrombi are composed mainly of platelets with little fibrin.
236
What are the three vitamin K antagonists?
- Warfarin
- Acenocoumarol
- Phenindione
237
How long do vitamin K antagnoist take to have full anticoagulant effect?
- at least 48 to 72 hours
238
Which of the three vitamin K antoginst is the drug of choice?
Warfarin
239
If immediate effect of warfarin is required, what other drug should it be given with concomitantly?
Unfractionated or LMWH
240
Oral anticoagulants should not be used in which thrombosis?
should not be used in cerebral artery thrombosis or peripheral artery occlusion as first-line therapy; aspirin is more appropriate for reduction of risk in transient ischaemic attacks.
241
For patients undergoing surgery, which drugs are preferred for thromoprphylaxis?
Unfractionated or a low molecular weight heparin
242
An INR within how many units of the target value is generally satisfactory?
Within 0.5 units of the target values - larger deviations require dosage adjustments
- Target values (rather than ranges) are now recommended
243
Which conditions have INR 2.5 as the target?
treatment of deep-vein thrombosis or pulmonary embolism (including those associated with antiphospholipid syndrome or for recurrence in patients no longer receiving warfarin sodium)
atrial fibrillation
cardioversion—target INR should be achieved at least 3 weeks before cardioversion and anticoagulation should continue for at least 4 weeks after the procedure (higher target values, such as an INR of 3, can be used for up to 4 weeks before the procedure to avoid cancellations due to low INR)
dilated cardiomyopathy
mitral stenosis or regurgitation in patients with either atrial fibrillation, a history of systemic embolism, a left atrial thrombus, or an enlarged left atrium
bioprosthetic heart valves in the mitral position (treat for 3 months), or in patients with a history of systemic embolism (treat for at least 3 months), or with a left atrial thrombus at surgery (treat until clot resolves), or with other risk factors (e.g. atrial fibrillation or a low ventricular ejection fraction)
acute arterial embolism requiring embolectomy (consider long-term treatment)
myocardial infarction
244
Which conditions have INR 3.5 as the target?
recurrent deep-vein thrombosis or pulmonary embolism in patients currently receiving anticoagulation and with an INR above 2
245
For isolated calf-vein deep vein thrombosis - how long is warfarin duration indicated?
For 6 weeks
246
What is the main adverse effect of oral anticoagulants?
Haemorrhage
247
Checking the INR and omitting doses when appropriate is essential. IF the anticoagulant is stopped but not reversed, how many days later should the INR be measured?
2-3 days later to ensure that it is falling
248
What should you do if there is a major bleeding when on wafarin?
stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; give dried prothrombin complex (factors II, VII, IX, and X); if dried prothrombin complex unavailable, fresh frozen plasma can be given but is less effective; recombinant factor VIIa is not recommended for emergency anticoagulation reversal
249
If INR>8.0, minor bleeding - what course of action is required?
stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin sodium when INR <5.0
250
If INR>8.0, no bleeding - what course of action is required?
stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]; repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0
251
If INR 5.0-8.0, minor bleeding, what course of action is required?
stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; restart warfarin sodium when INR <5.0
252
If INR 5.0-8.0, no bleeding, what course of action is required?
withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
253
Peri-operatice - how many days before should warfarin be stopped?
5 days before elective surgery
254
peri -operative what INR means phytomenadione should be given?
phytomenadione (vitamin K1) by mouth (using the intravenous preparation orally [unlicensed use]) should be given the day before surgery if the INR is ≥1.5.
255
After operative surgery - when can warfarin be resumed?
If haemostasis is adequate, warfarin sodium can be resumed at the normal maintenance dose on the evening of surgery or the next day.
256
What about patients stopping warfarin prior to surgery who are considered to be at high risk of thromboembolism?
may require interim therapy (‘bridging’) with a low molecular weight heparin (using treatment dose). The low molecular weight heparin should be stopped at least 24 hours before surgery; if the surgery carries a high risk of bleeding, the low molecular weight heparin should not be restarted until at least 48 hours after surgery.
257
What can be used in patients on warfarin who require emergency surgery?
- If the surgery can be delayed for 6-12 hours then IV phytomenadione (vitamin K1) can be used to reverse the anticoagulant effect
- If surgery cannot be delayed then dried prothrombin complex can be given in addition to intravenous phytomenadione (vitamin K1) and the INR checked before surgery.
258
Is there a greater risk with dual therapy of aspirin + warfarin or Clopidogrel + warfarin?
Bleeding risk with Aspirin + warfarin is lower
Bleeding risk with clopidogrel and warfarin is greater
259
List examples of direct acting anticoagulants (DOACs)?
- Apixaban
- Dabigantran
- Edoxaban
- Rivaroxaban
260
What is the MAO of dabigantran?
Dabigatran etexilate is a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation.
261
What is the MAO of apixaban, edoxaban and rivaroxaban?
are reversible inhibitors of activated factor X (factor Xa) which prevents thrombin generation and thrombus development.
262
Which anticoagulant can be used in atherothrombotic events in patients with cornary or peripheral artery disease?
Rivaroxaban
263
how long after the last dose is anticoagulant effects of DOACs diminished?
12 to 24 hours after the last dose is taken; therefore omitted or delayed doses could lead to reduction in anticoagulant effect
264
Reversal agents are available for dabigatran etexilate, apixaban, and rivaroxaban. What can be used for rapid reversal of dabigantran?
Idarucizumab is licensed for the rapid reversal of dabigatran etexilate in life-threatening or uncontrolled bleeding, or for emergency surgery or urgent procedures.
265
What can be used for the reversal of apixaban and rivaroxaban?
Andexanet alfa is licensed for the reversal of apixaban or rivaroxaban in life-threatening or uncontrolled bleeding.
266
Does heparin have a long or short duration of action?
Heparin initiates anticoagulation rapidly but has a short duration of action.
It is often referred to as ‘standard’ or heparin (unfractionated)
267
Do LMWH have shorter or longer duration of action compared to unfractionated heparin?
LMWH have longer duration of action
Although a low molecular weight heparin is generally preferred for routine use, heparin (unfractionated) can be used in those at high risk of bleeding because its effect can be terminated rapidly by stopping the infusion
268
Give three examples of LMWH?
- Dalteparin
- Enoxaparin
- Tinzaparin
269
Other than having longer duration of action what is another reason why LMWH is preferred over unfractionated heparin?
Because they are as effective and have a lower risk of heparin-induced thrombocytopenia
270
Give an example of a heparinoid?
Danaparoid
271
What is danaparoid used for?
Danaparoid sodium is a heparinoid used for prophylaxis of deep-vein thrombosis in patients undergoing general or orthopaedic surgery. Providing there is no evidence of cross-reactivity, it also has a role in patients who develop heparin-induced thrombocytopenia.
272
When can Epoprostenol (parenteral anticoagulant) be used?
Epoprostenol (prostacyclin) (Epoprostenol is a potent vasodilator) can be given to inhibit platelet aggregation during renal dialysis when heparins are unsuitable or contra-indicated
273
What else is Epoprostenol licensed for?
the treatment of primary pulmonary hypertension resistant to other treatment, usually with oral anticoagulation; it should be initiated by specialists in pulmonary hypertension.
274
Why must Epoprostenol be administered via continuous intravenous infusion?
It has a short half-life of approximately 3 minutes and therefore it must be administered by continuous intravenous infusion.
275
What is the MAO of fondaparinux?
Inhibitor of activated factor X
276
Which two oral anticoagulants may be affected by inhibitors/inducers?
rivaroxaban and apixaban
277
Is rivaroxaban and apixaban taken daily or twice daily?
```
Apixaban= twice daily
Rivaroxaban = once daily
```
278
What is the use of andexanet alfa?
Used for reversal of the anticoagulant effect of rivaroxaban and apixaban in life-threatening or uncontrolled bleeding
279
What is the MAO of adexanet alfa?
Adenxanet alfa is a recombinant form of human factor Xa protein which binds specifically to apixaban or rivaroxaban, thereby reversing their anticoagulant effects
280
Which monoclonal antibody is used to reverse the effects of dabigatran?
Idarucizumab
281
What is the MOA of dabigatran?
It is a humanised monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.
282
What do antiplatelets do?
They decrease platelet aggregation and inhibit thrombus formation in the arterial circulation, because in faster-flowing vessels, thrombi are composed mainly of platelets with little fibrin.
283
Is aspirin recommended for primary prevention in CVD?
No it is not recommended even in patients with or without diabetes or hypertension.
284
Can aspirin be used for secondary prevention of CVD?
Yes it can
285
For aspirin to be used as secondary prevention in CVD, what must be controlled before aspirin is given?
High blood pressure must be controlled
286
When is a combination of clopidogrel and low dose aspirin used?
for the prevention of atherothrombotic and thromboembolic events in patients with atrial fibrillation (and at least one risk factor for a vascular event), and for whom warfarin is unsuitable
- Also used following an ST-elevated MI
287
For prophylaxis of thromboembolism associated with prosthetic heart valves what drug is used as an adjunct to oral anticoagulation?
- Dipyridamole
| - MR versions are licensed for secondary prevention of ischaemic stroke and transient ischaemic attacks.
288
What drug is prasugrel usually given as a combination with and for what indication?
Prasugrel, in combination with aspirin, is licensed for the prevention of atherothrombotic events in patients with acute coronary syndrome undergoing percutaneous coronary intervention; the combination is usually given for up to 12 months.
289
Which drug is ticagrelor given in combination with and for what indication?
Ticagrelor, in combination with aspirin, is licensed for the prevention of atherothrombotic events in patients with acute coronary syndrome; the combination is usually given for up to 12 months.
290
Which drug is cangrelor given in combination with and for what indication?
Cangrelor, in combination with aspirin, is licensed for the reduction of thrombotic cardiovascular events in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) who have not received treatment with oral clopidogrel, prasugrel or ticagrelor prior to the procedure and in whom oral therapy with these drugs is not suitable. Cangrelor is to be used under expert supervision only
291
For patients selected for percutaneous coronary intervention (PCI), with placement of a coronary stent, which antiplatelets are used?
- These patients require dual antiplatelet therapy with aspirin and either cangrelor, clopidogrel, prasugrel, or ticagrelor.
- Aspirin therapy should continue indefinitely.
292
Following PCI in patients with stable angina which antiplatelets are recommended?
clopidogrel is recommended in addition to aspirin for at least 1 month after placement of a bare-metal stent, and for at least 6 months if a drug-eluting stent is used
293
What is the MAO of glycoprotein IIb/IIa inhibitors?
Glycoprotein IIb/IIIa inhibitors prevent platelet aggregation by blocking the binding of fibrinogen to receptors on platelets
294
Give an example of glycoprotein IIb/IIIa inhibitor?
Abciximab which is a monoclonal antibody
295
How many times can abciximab be used?
Abciximab should be used once only (to avoid additional risk of thrombocytopenia).
296
Which patients is aspirin contraindicated in?
- patients with active peptic ulceration
- haemophillia
- children under the age of 16 due to the risk of Reye's syndrome
297
Clopidogrel is an antiplatelet drug used to prevent thrombotic events in patients with a history of ....?
Ischaemic disease
298
Can aspirin be taken when breastfeeding?
Avoid - possible risk of Reye's syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infant if neonatal vitamin K stores low.
299
What is the dose of dipyridamole given for secondary prevention of ischaemic stroke with or without aspirin?
MR formulation - 200mg twice daily, to be taken preferably with food.
300
What is the doses of each when dipyridamole and aspirin is given for secondary prevention of ischaemic stroke and TIA?
25mg aspirin/ 200mg dipyridamole
| Twice daily
301
What important dispensing message is there regarding dispensing a formulation of dipyridamole with aspirin?
Dispense in original container (pack contains a desiccant) and discard any capsules remaining 6 weeks after opening.
302
In which patients is anticoagulants contraindicated and has been given an MHRA warning?
Patients with antiphospholipid syndrome.
| - Instead should be switched to a vitamin K antagonist - Warfarin
303
What dangerous side effects can occur with the use of heparins?
- Haemorrgahe (if this occurs it is usually suffcient to withraw heprain UF or LMWH. But if rapid reversal is required then protamine sulfate is a specific antidote (but only partially reverses effects of low molecular weight heparins).
- Heparin-induced thrombocytopenia (sign of this include a 30% reduction in platelet count, thrombosis, or skin allergy). If suspected then heparin should be stopped and alternative anticoagulant should be used.
- Hyperkalaemia (inhibition of aldosterone secretion by heparin can result in hyperkalaemia
304
what class of drug is argatroban?
It is a direct thrombin inhibitor (antithrombotic drug)
305
Give other examples of direct thrombin inhibitors?
- Argatroban
- Dabigatran
- Bivalirudin
306
What type of drug is urokinase?
Tissue plasminogen activator
307
List three examples if vitamin K antagonists?
Acenocoumarol
phenidione
Warfarin
308
What MHRA warning regarding warfarni was given in July 2016 and what should patients look out for?
On rare occasions warfarin use may lead to calciphylaxis - patients should be advised to consult their doctor if they develop a painful skin rash.
309
Who is hypertension more common in?
- in advancing age
- In women aged between 65-74years
- People of black African or African-Caribbean origin.
- Other risk factors include: social deprivation, lifestyle factors, anxiety, and emotional stress
310
In summary which non drug topics should be advised on for high blood pressure?
- - Healthy lifestyle changes
- exercise
- healthy diet
- low dietary sodium intake
- reduced alcohol intake (if excessive)
- Discourage excessive consumption of coffee and other caffeine-rich products
- smoking cessation
311
Which patients showing what blood pressure should be offered Ambulatory blood pressure monitoring or HBPM to help confirm diagnosis of hypertension?
Those presenting with 140/90mmHg or higher.
312
What is ABPM?
What is Ambulatory Blood Pressure Monitoring?
Ambulatory Blood Pressure Monitoring (ABPM) is when your blood pressure is measured as
you move around, living your normal daily life. It is measured for up to 24 hours. A small
digital blood pressure monitor is attached to a belt around your waist and connected to a cuff
around your upper arm. It is small enough not to affect your normal daily life and you can
even sleep with it on.
313
What is the advantage of ABPM?
- it avoids problems of 'white coat' syndrome (where your blood pressure rises because you are feeling anxious about being tested by doctor or nurse).
314
What is considered as stage 1 hypertension?
blood pressure between 140/90mmHg and 160/100mmHg and ambulatory daytime average of 135/85mmHg or higher
315
What is considered as stage 2 hypertension?
Clinical blood pressure of between 160/100mmHg and 180/120mmHg, and ambulatory daytime average of
150/95mmHg or higher
316
What is considered as having severe hypertension?
A clinical systolic blood pressure of 190mmHg or higher or clinical diastolic blood pressure of 120mmHg or higher
317
Which patients under 60 should you consider antihypertensive treatment + lifestyle advice?
those with stage 1 hypertension and an estimated cardiovascular risk below or equal to 10%
318
Which patients over 80 should you consider antihypertensive treatment + lifestyle advice?
With a clinic blood pressure of over 150/90 mmHg
319
Within how long should severe hypertension be treated?
If a patient has severe hypertension but no symptoms or signs indicating same-day referral (see below), carry out investigations for target organ damage as soon as possible. If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ambulatory or home blood pressure monitoring. If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days.
Refer patients for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension), or life-threatening symptoms for example new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
320
What risk should patients with confirmed hypertension be assessed for?
Assessment of cardiovascular risk
321
What investigations are included in the cardiovascular risk?
In these patients,glycated haemoglobin, electrolytes, creatinine, estimated glomular filtration rate, total and HDL cholesterol should be measured, tests for the presence of proteinuria, haematuria, and hypertensive retinopathy undertaken, and a 12-lead ECG performed.
322
What is the target blood pressure for patients below 80 years and those over 80 years old without other underlying conditions?
Under 80 years = below 140/90mmHg
(ABPM or average HBPM = 135/80mmHg)
Over 80 years = Below 150/90mmHg
(ABPM or average HBPM = 145/85mmHg)
323
Can ACE inhibitor and ARB be used together?
No the use together is not recommended
324
Which is preferred in black African or African-Caribbean family origin, ACE or ARB?
ARB is preferred instead of an ACE inhibitor
325
If starting or changing diuretic treatment for hypertension, which type and specific diuretic is preferred to be used?
offer a thiazide-like diuretic such as indapamide in preference to conventional thiazide diuretics, for example bendroflumethiazide or hydrochlorothiazide
326
Do patients with isolated systolic hypertension be treated the same way as those with both raised systolic and diastolic blood pressure?
Yes (systolic blood pressure 160mmHg or more)
327
What is the treatment steps for hypertension with type 2 diabetes in all patients (any age or origin), or hypertension without type 2 diabetes in those aged 55 years or below and not of black African or African-Caribbean origin?
Step 1: Offer an ACE inhibitor or ARB.
Step 2: In addition to an ACE inhibitor or ARB, add in a calcium channel blocker or thiazide-like diuretic. Offer a thiazide-like diuretic if there is evidence of heart failure. For full guidance on the management of chronic heart failure, see Chronic heart failure.
Step 3: Offer an ACE inhibitor or ARB, a calcium channel blocker and a thiazide-like diuretic.
Step 4: Before considering further treatment for a person with resistant hypertension, confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings, assess for postural hypotension and discuss adherence. If further treatment is required, consider seeking specialist advice, or the addition of low dose spironolactone [unlicensed indication] if potassium is 4.5 mmol/litre or less; or an alpha blocker or a beta blocker if potassium is greater than 4.5 mmol/litre.
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium and renal function within 1 month of starting treatment and repeat as needed thereafter.
Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs
328
What is the treatment steps for Hypertension without type 2 diabetes in patients aged 55 and over, or all ages of black African or African-Caribbean origin patients without type 2 diabetes?
Step 1: Offer a calcium channel blocker.
Step 2: In addition to a calcium channel blocker offer an ACE inhibitor, ARB or a thiazide-like diuretic.
Step 3: Offer an ACE inhibitor or ARB, a calcium channel blocker and a thiazide-like diuretic.
Step 4: Before considering further treatment for a person with resistant hypertension, confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings, assess for postural hypotension and discuss adherence. If further treatment is required, consider seeking specialist advice, or consider low dose spironolactone [unlicensed indication] if potassium is 4.5 mmol/litre or less; or an alpha blocker or a beta blocker if potassium is greater than 4.5 mmol/litre.
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium, and renal function within 1 month of starting treatment and repeat as needed thereafter.
Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs.
329
Lowering blood pressure in patients with diabetes reduces the risk of what complications?
Microvascular and macrovascular complications
330
In type 1 diabetes what is the target aim for clinical blood pressure?
Aim for a clinical blood pressure of 135/85mmHg or less unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80mmHg or less.
331
What is first line treatment of hypertension in debetic patients?
ACE inhibitor / ARB
332
Potential side effects should not prevent the use of particular class of drug in order to control blood pressure in diabetics. In particular what points should we note?
selective beta-blockers should not be avoided where indicated for adults on insulin;
low-dose thiazides may be used in combination with beta-blockers;
calcium channel blockers (use only long-acting preparations).
333
SIGN 2017 recommends which patient with certain renal disease should be offered blood-pressure lowering treatments?
- patients with:
- stage 3 or higher chronic kidney disease
- or micro or macroalbuminuria
- or who are on dialysis
334
What is albuminuria?
Albuminuria is a sign of kidney disease and means that you have too much albumin in your urine. Albumin is a protein found in the blood. A healthy kidney doesn't let albumin pass from the blood into the urine. A damaged kidney lets some albumin pass into the urine. The less albumin in your urine, the better.
335
What is the target blood pressure for hypertension in renal disease?
- a target clinical blood pressure below 140/90mmHg for patients with renal disease
- a blood pressure below 130/80mmHg is advised in patients with chronic kidney disease and diabetes or if urine albumin to creatinine ratio (ACR) exceeds 70 mg/mmol).
- SIGN (2017) recommend a blood pressure below 135/85 mmHg should be considered in patients with established cardiovascular disease and chronic kidney disease.
336
When treating hypertension in renal disease what frequency of administration of drugs is recommended?
- offer treatment with drugs taken only once a day
337
What percentage of women are affected by hypertensive disorders during pregnancy?
Approx. 8% to 10% of all pregnant women/
338
If pregnancy is diagnosed 20 weeks before what is this called or if it existed before pregnancy?
Chronic hypertension
339
If hypertension is diagnosed after 20 weeks gestation then what is this called?
Gestational hypertension
340
If hypertension occurs after 20 weeks gestation with features of multi-organ involvement then what is this called?
Pre-eclampsia
341
What are the symptoms of pre-eclampsia?
- severe headache
- problems with vision
- severe pain below ribs
- vomiting and sudden swelling of hands, feet or face accompanied with significant proteinuria and blood pressure greater than 140/90mmHg.
342
All pregnant women with hypertension should be referred to?
to a specialist
- Pregnant women with a first episode of hypertension (blood pressure of 140/90 mmHg or higher) after 20 weeks gestation should be referred to secondary care to be seen within 24 hours.
343
Urgent referral to secondary care for a same-day assessment is required for pregnant women with....?
severe hypertension (blood pressure of 160/110 mmHg or higher); referral urgency should be determined by an overall clinical assessment.
344
What conditions increase the risk or put pregnant women at high risk of developing pre-eclampsia?
f they have chronic kidney disease, diabetes mellitus, autoimmune disease, chronic hypertension, or if they have had hypertension during a previous pregnancy;
345
Which drug do pregnant women at high risk of pre-eclampsia be given?
Aspirin from week 12 of pregnancy until the baby is born
346
Which other risk factors indicates pregnant women to take aspirin for pre-eclampsia?
Women with more than one moderate risk factor for developing pre-eclampsia (first pregnancy, greater than 40 years of age, pregnancy interval of greater than 10 years, BMI above 35 kg/m² at first visit, multiple pregnancy, or family history of pre-eclampsia) are also advised to take aspirin [unlicensed indication] from week 12 of pregnancy until the baby is born.
347
For pregnant women with chronic hypertension who are already receiving antihypertensive treatment, which drugs should be stopped and why?
Stop ACE inhibitors, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities.
348
Which pregnant women should be offered antihypertensive treatment?
Women with pre-eclampsia, gestational or chronic hypertension who present with a sustained blood pressure of 140/90 mmHg or higher should be offered antihypertensive treatment.
349
What is first line treatment for hypertension in pregnant women?
- Labetalol
350
What is the target blood pressure for pregnant women?
Use labetalol to achieve a target blood pressure of less than 135/85mmHg.
351
If labetalol is unsuitable for hypertension in pregnancy then what drug should be considered (unlicensed use)?
Nifedipine (unlicensed) modified-release
352
What if labetalol and nifedipine are both unsuitable?
- Consider methyldopa
353
What should women with a blood pressure of greater than 160/110mmHg who require critical care during pregnancy or after birth receive?
should receive immediate treatment with either oral or intravenous labetalol hydrochloride, intravenous hydralazine hydrochloride, or oral nifedipine modified-release to achieve a target blood pressure of 135/85 mmHg or less
354
When is magnesium sulfate indicated for hypertension in pregnant women?
Give intravenous magnesium sulfate to women in a critical care setting with severe hypertension or severe pre-eclampsia or if they have or have previously had an eclamptic fit. Consider intravenous magnesium sulfate in severe pre-eclampsia if birth is planned within 24 hours
355
In women with pre-eclampsia where early birth is considered likely within 7 days, what course of drug should you consider?
A course of antenatal corticosteroids for fetal lung maturation
356
For women who have been managed with methyldopa during pregnancy, within how many days should this be stopped?
Women who have been managed with methyldopa during pregnancy should discontinue treatment within 2 days of the birth and switch to an alternative antihypertensive
357
If a women post birth needs to carry on taking anti hypertensives, can they breastfeed?
Yes - advise women with hypertension that the need to take anti hypertensives does not prevent them from breastfeeding should they wish to do so, although very low levels of antihypertensive medicines can pass into breast milk and most medicines are not tested in pregnant or breastfeeding women.
358
During post-natal period (post-birth) if anti hypertensive is still required then which drug should be offered first line?
- Offer enalapril
(monitor maternal renal function and serum potassium)
- First line for women of black African or African-Carribean family origin consider nifedipine or amlodipine first-line.
359
What if post-natal first line treatment is not enough to control blood pressure?
If blood pressure is not controlled with a single drug consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not tolerated or ineffective consider either adding labetalol hydrochloride or atenolol to the combination treatment or swapping one of the medicines being used for atenolol or labetalol.
360
Waht monitoring is required for the babies?
Blood pressure monitoring should be considered in babies born to mothers taking antihypertensives who are breastfeeding, and women should be advised to monitor their babies for any adverse reactions (for example: drowsiness, lethargy, pallor, cold peripheries or poor feeding).
361
What if a woman with hypertension in the post-natal period who do not plan to breastfeed, how should they be treated for hypertension?
Usual hypertension steps that would be used for non-pregnant women.
BNF - 'drugs for hypertension'
362
Vasodilators have a potent hypotensive effect, especially when used in combination with which drugs?
- with a beta-blocker and a thiazide
363
Why is hydralazine given as an adjunct to other anti-hypertensives for the treatment of resistant hypertension and not alone?
Hydralazine is rarely used; when used alone it causes tachycardia and fluid retention
364
Which drug can be given (unlicensed) to control severe hypertensive emergencies?
Sodium nitroprusside [unlicensed] is given by intravenous infusion to control severe hypertensive emergencies when parenteral treatment is necessary.
365
Can minoxidil be used for treatment of hypertension?
Yes but it should be reserved for the treatment of severe hypertension resistant to other drugs.
366
What is vasodilation accompanied by?
- increased cardiac output and tachycardia and the patients develop fluid retention
367
AS vasodilation can cause previous mentioned side effects, what drugs should be used along side?
addition of a beta-blocker and a diuretic (usually furosemide, in high dosage) are mandatory.
368
Why is minoxidil for hypertension unsuitable for females?
As it can cause hypertrichosis - excessive hair growth
| Hypertrichosis can develop all over the body or can be isolated to small patches.
369
Which alpha-receptor antagonists have vasodilator properties?
- Prazosin
- Doxazosin
- Terazosin
370
Which drugs as per BNF are licensed for the treatment of pulmonary hypertension?
Ambrisentan, bosentan, iloprost, macitentan, sildenafil, and tadalafil are licensed for the treatment of pulmonary arterial hypertension and should be used under specialist supervision.
Epoprostenol can be used in patients with primary pulmonary hypertension resistant to other treatments.
371
What class of anti-hypertensive is methyldopa an example of?
Central acting anti-hypertensive;
| it may be used for the management of hypertension
372
What are two other examples of centrally acting anti-hypertensives?
- Clonidine
| - Moxonidine
373
What is the disadvantage of sudden withdrawal of clonidine?
sudden withdrawal of treatment may cause severe rebound hypertension.
374
When is Moxonidine used for hypertension?
Moxonidine, a centrally acting drug, is licensed for mild to moderate essential hypertension. It may have a role when thiazides, calcium-channel blockers, ACE inhibitors, and beta-blockers are not appropriate or have failed to control blood pressure
375
What is a disadvantage od adrenergic neurone blocking drugs?
- These drugs do not control supine blood pressure and may cause postural hypotension. For this reason they have largely fallen from use, but may be necessary with other therapy in resistant hypertension
376
Give an example of adrenergic neurone blocking drugs?
- Guanethidine monosulfate
377
What drug class does indoramin belong to?
Alpha-adrenoreceptor blocker (antagonist)
378
What properties does prazosin have?
Prazosin has post-synaptic alpha-blocking and vasodilator properties and rarely causes tachycardia
379
What problem can can prazosin and other alpha-adrenoreceptor blockers cause?
It may, however, reduce blood pressure rapidly after the first dose and should be introduced with caution.
380
Give a list of the alpha-adrenoreceptor blockers that can be used for hypertension?
Doxazosin
Indoramin
Terazosin
Prazosin
381
What is benign prostatic hyperplasia?
- Also called prostatic gland enlargement - is a common condition as men get older.
- An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder. It can also cause bladder, urinary tract or kidney problems
382
Which alpha-adrenoreceptor blockers are indicated for benign prostatic hyperplasia?
- Alfuzosin
- doxazosin
- Indoramin
- Prazosin
- Tamsulosin
- Terazosin
383
What is the MAO of ACE inhibitors?
angiotensin-converting enzyme inhibitors (ACE inhibitors) inhibit the conversion of angiotensin I to angiotensin II.
384
What are the indications of ACE inhibitors?
- Heart failure (ACE inhibitors are used in all grades of heart failure, usually combined with a beta-blocker.
- Hypertension
- Diabetic nephropathy
- Prophylaxis of cardiovascular events
385
With use of ACE/ARBs what should be noted of the first dose?
Profound first-dose hypotension may occur when ACE inhibitors are introduced to patients with heart failure who are already taking a high dose of a loop diuretic (e.g. furosemide 80 mg daily or more).
386
ACE inhibitors should be initiated under specialist supervision and with careful clinical monitoring in those with severe heart failure or in those......?
receiving multiple or high-dose diuretic therapy (e.g. more than 80 mg of furosemide daily or its equivalent);
receiving concomitant angiotensin-II receptor antagonist or aliskiren;
with hypovolaemia;
with hyponatraemia (plasma-sodium concentration below 130 mmol/litre);
with hypotension (systolic blood pressure below 90 mmHg);
with unstable heart failure;
receiving high-dose vasodilator therapy;
known renovascular disease
387
When should renal function be monitored for ACE inhibitors?
- Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if features mentioned below present); hyperkalaemia and other side-effects of ACE inhibitors are more common in those with impaired renal function and the dose may need to be reduced.
388
What can concomitant use of Ramipril with NSAIDs increase the risk of?
Increase the risk of renal damage
| Increase risk of hyperkalaemia
389
Can ACE inhibitors be used in patients with severe bilateral renal artery stenosis?
Not recommended in patients known to have these forms of critical renovascular disease. ACE inhibitors reduce or abolish glomerular filtration and are likely to cause severe and progressive renal failure.
390
Do ACE inhibitors need to be avoided in silent renovascular disease?
ACE inhibitors should also be used with particular caution in patients who may have undiagnosed and clinically silent renovascular disease. This includes patients with peripheral vascular disease or those with severe generalised atherosclerosis.
391
Can combination products incorporating an ACE inhibitor with a thiazide or a calcium-channel blocker be used?
Use of these combination products should be reserved for patients whose blood pressure has not responded adequately to a single antihypertensive drug and who have been stabilised on the individual components of the combination in the same proportions.
392
Give examples of Angiotensin-II receptor antagonists?
Azilsartan medoxomil, candesartan cilexetil, eprosartan, irbesartan, losartan potassium, olmesartan medoxomil, telmisartan, and valsartan
393
Why are Angiotensin-II receptor antagonists preferred than ACE inhibitors which caused a dry cough for some patients?
unlike ACE inhibitors, they do not inhibit the breakdown of bradykinin and other kinins, and thus are less likely to cause the persistent dry cough
- They are therefore a useful alternative for patients who have to discontinue an ACE inhibitor because of persistent cough.
394
Give an example of a renin inhibitor?
Aliskiren which is a renin inhibitor that is licensed for the treatment of hypertension
395
Is concomitant use of two drugs affecting the renin-angiotensin system recommended?
Combination therapy with two drugs affecting the renin-angiotensin system (ACE inhibitors, angiotensin-II receptor antagonists, and aliskiren is not recommended due to an increased risk of hyperkalaemia, hypotension, and renal impairment, compared to use of a single drug. Patients with diabetic nephropathy are particularly susceptible to developing hyperkalaemia and should not be given an ACE inhibitor with an angiotensin-II receptor antagonist.
396
Which two angiotensin system drugs can be used but under specialist supervision if others have failed monotherapy or not tolerated?
Ace inhibitor with candesartan or valsartan
but this combination cannot be used together with an aldosterone antagonist or a potassium-sparing diuretic
397
Can clonidine be used for hypertension?
Yes
398
What dose of clonidine is used for hypertension?
Initially 50-100 micrograms 3 times a day, increase dose every second or third day, usual maximum dose 1.2mg daily
399
What can clonidine also be used for?
- Prevention of recurrent migraine
- prevention of vascular headaches
- Menopausal symptoms, particularly flushing and vasomotor conditions
400
Which beta-adrenoreceptors do beta-blockers act on?
block the beta-adrenoceptors in the heart, peripheral vasculature, bronchi, pancreas, and liver
401
What is meant by intrinsic sympathomimetic activity?
ISA, partial agonist activity
| - It represents the capacity of beta-blockers to stimulate as well as to block adrenergic receptors
402
Which beta-blockers have intrinsic sympathomimetic activity?
- Celiprolol
- Pindolol
- Acebutolol
- Oxprenolol
403
What is the advantage of using beta-blockers with intrinsic sympathomimetic activity?
- They tend to cause less bradycardia than other beta-blockers and may also cause less coldness of the extremities
404
Which beta-blockers are water soluble?
```
CANS acronym
Celiprolol
Atenolol
Nadolol
Sotalol
```
405
What are the advantages of water soluble beta blockers?
- Less likley to enter the brain, and may therefore cause less sleep disturbances and nightmares.
406
How are water soluble beta-blockers excreted?
Excreted via the kidneys and dosage reduction is often necessary in renal impairment.
407
For angina, what frequency of beta-blocker administration may be required?
Twice-daily even may be required with the modified release formulations
408
Which beta blockers have a longer duration of action and require only to be given usually once daily?
- Atenolol
- Bisoprolol
- Celiprolol
- Nadolol
409
What are the contraindications of beta-blockers?
- Patients with second or third degree heart block
- patients with worsening unstable heart failure; care is required when initiating a beta-blocker in those with stable heart failure
- Patients with asthma
410
Which beta-blockers have an addition action of arteriolar vasodilating action?
- Lobetalol
- Celiprolol
- Carvedilol
- Nebivolol
However, there is no evidence that these drugs have important advantages over other beta blockers in the treatment of hypertension
411
Which beta-blockers are cardio selective?
Atenolol
Bisoprolol
Metoprolol
Nebivolol
They are cardioselective and not cardiospecfiic.
They have a lesser effect on airways resistance but are not free of this side-effect
412
What are the side effects of beta-blockers?
associated with fatigue, coldness of the extremities (may be less common with those with ISA), and sleep disturbances with nightmares (may be less common with the water-soluble beta-blockers).
413
What can beta-blockers affect the metabolism of?
Can affect the carbohydrate metabolism, causing hypoglycaemia or hyperglycaemia in patients with or without diabetes; they can also interfere with metabolic and autonomic responses to hypoglycaemia, thereby masking symptoms such as tachycardia
414
Are beta-blockers contraindicated in diabetes?
No, although cardioselective beta-blockers may be preferred
| However, beta-blockers should be avoided altogether in those with frequent episodes of hypoglycaemia
415
Which beta-blocker combination with another drug should be avoided for treatment of uncomplicated hypertension in patients with diabetes or in those at high risk of developing diabetes?
Avoid beta-blocker in combination with a thiazide diuretic
416
What is the MAO of beta blockers in hypertension?
The mode of action of beta-blockers in hypertension is not understood, but they reduce cardiac output, alter baroceptor reflex sensitivity, and block peripheral adrenoceptors. Some beta-blockers depress plasma renin secretion. It is possible that a central effect may also partly explain their mode of action.
417
How do beta-blockers help with angina?
By reducing cardiac work beta-blockers improve exercise tolerance and relieve symptoms in patients with angina. As with hypertension there is no good evidence of the superiority of any one drug, although occasionally a patient will respond better to one beta-blocker than to another.
418
Can sudden withdrawal of beta-blocker worsen angina?
There is some evidence that sudden withdrawal may cause an exacerbation of angina and therefore gradual reduction of dose is preferable when beta-blockers are to be stopped.
419
Why can't beta-blockers be used with verapamil?
There is a risk of precipitating heart failure when beta-blockers and verapamil are used together in established ischaemic heart disease.
420
What is esmolol (beta-blocker) used for and when?
Esmolol hydrochloride is a relatively cardioselective beta-blocker with a very short duration of action, used intravenously for the short-term treatment of supraventricular arrhythmias, sinus tachycardia, or hypertension, particularly in the peri-operative period.
It may also be used in other situations, such as acute myocardial infarction, when sustained beta-blockade might be hazardous.
421
Is sotalol cardio-selective and what is it indicated for?
Sotalol hydrochloride, a non-cardioselective beta-blocker with additional class III anti-arrhythmic activity, is used for prophylaxis in paroxysmal supraventricular arrhythmias. It also suppresses ventricular ectopic beats and non-sustained ventricular tachycardia. It has been shown to be more effective than lidocaine in the termination of spontaneous sustained ventricular tachycardia due to coronary disease or cardiomyopathy. However, it may induce torsade de pointes in susceptible patients.
422
How do beta-blockers help in heart failure?
Beta-blockers may produce benefit in heart failure by blocking sympathetic activity
423
Which beta-blockers can be used for heart failure?
- Bisoprolol fumarate and carvedilol reduce mortality in any grade of stable heart failure
- nebivolol is licensed for stable mild to moderate heart failure in patients over 70 years
424
Which beta blocker has a use in thyrotoxicosis?
- Beta-blockers are used in pre-operative preparation for thyroidectomy.
- Administration of propranolol hydrochloride can reverse clinical symptoms of thyrotoxicosis within 4 days.
- Routine tests of increased thyroid function remain unaltered.
- The thyroid gland is rendered less vascular thus making surgery easier.
425
What are some other uses of beta-blockers?
- symptoms of anxiety
- prophylaxis of migraine
- Topically in glaucoma
426
Which beta-blockers are used topically for glaucoma?
- Betaxolol
- Levobunolol
- Timolol
427
Beta-blockers are contraindicated in asthma, but when there is no alternative, can a cardio-selective beta blocker be used?
Yes, under specialist supervision
428
What are the cautions for use of Beta-blockers?
- Diabetes
- Frist-degree AV block
- symptoms of hypoglycaemia
- Myasthenia gravis
429
What is the antidote to beta-blocker overdose?
- Intravenous atropine
430
Labetalol is safe during pregnancy, but what are the cautions or monitoring required?
- may be harmful in the first trimester
- If labetalol is used close to delivery, infants should be monitored for signs of alpha-blockade (as well as beta blockade)
431
Which laboratory test does labetalol interfere with?
- Catecholamines
432
What is the dose of bisoprolol used for hypertension?
80mg twice daily initially, dose should be increased at weekly intervals as required, maintenance 160-320mg daily
433
What is the usual dose of bisoprolol for treatment of hypertension/angina?
5-10mg once daily, maximum 20mg per day
434
WIth bisoprolol, someone with hepatic impairment what is the maximum dose that can be used for angina/hypertension?
10mg daily maximum
435
What is the maximum dose of bisoprolol daily in renal impairment when eGFR is less than 20ml/minute/1.73m2
10mg max daily
436
Which two drugs is co-tenidone a combination of?
Chlortalidone and atenolol
437
Can calcium channel blockers be used in heart failure?
Calcium channel blockers, with the exception of amlodipine, should be avoided in heart failure as they can further depress cardiac function and exacerbate symptoms.
With the exception of amlodipine, they can also increase mortality after myocardial infarction in patients with left ventricular dysfunction and pulmonary congestion
438
verapamil is used for which indications?
- treatment of angina, hypertension and arrhythmias
439
What effect does verapamil have?
It is a highly negatively inotropic calcium channel-blocker and it reduces cardiac output, slows the heart rate, and may impair atrioventricular conduction
440
What are the disadvantages of heart failure?
It may precipitate heart failure, exacerbate conduction disorders, and cause hypotension at high doses and should not be used with beta-blockers.
441
What is the most common side effect of verapamil?
Constipation
442
What is the difference in terms of their effects of nifedipine and verapamil?
Nifedipine relaxes vascular smooth muscle and dilates coronary and peripheral arteries. It has more influence on vessels and less on the myocardium than does verapamil hydrochloride, and unlike verapamil hydrochloride has no anti-arrhythmic activity. It rarely precipitates heart failure because any negative inotropic effect is offset by a reduction in left ventricular work.
443
Is amlodipine, felodipine, nifedipine and nicardipine have an affect in reducing myocardial contractility?
their effects and do not reduce myocardial contractility and they do not produce clinical deterioration in heart failure. They have a longer duration of action and can be given once daily.
444
What are the side effects of the calcium channel blockers, nifedipine, nicardipine, amlodipine and felodipine?
Side-effects associated with vasodilatation such as flushing and headache (which become less obtrusive after a few days), and ankle swelling (which may respond only partially to diuretics) are common.
445
Which calcium channel blocker can be used for the treatment of acute life-threatening hypertension?
Intravenous nicardipine hydrochloride is licensed for the treatment of acute life-threatening hypertension.
446
What are the only indications of lacidipine and lercanidpine?
They can only be used for hypertension.
447
For nimodipine - where does this usually act?
Preferentially acts on cerebral arteries
448
What is diltiazem used for?
Diltiazem hydrochloride is effective in most forms of angina; the longer-acting formulation is also used for hypertension.
449
Can diltiazem be used with beta-blockers?
because of the risk of bradycardia it should be used with caution in association with beta-blockers.
450
Which cells do calcium channel blockers influence?
They influence the myocardial cell, the cells within the specialised conducting system of the heart and the cells of vascular smooth muscle.
- Thus, myocardial contractility may be reduced, the formation and propagation of electrical impulses within the heart may be depressed, and coronary or systemic vascular tone may ne diminished.
451
What type of drug is amlodipine?
Amlodipine is a dihydropyridine calcium channel blocker
452
What is Exforge a brand name for (which ACE and ARB)?
Amlodipine + Valsartan
453
Which dihydropyridine calcium channel blocker needs to be taken 30-60 minutes before food?
Lercanidipine
454
Which dihydropyridine calcium channel blocker can be used in life threatening hypertension and also in life threatening hypertension in pregnancy?
Nicardipine
455
Which calcium channel blocker has an indication for raynaud's syndrome?
Nifedipine
456
Which calcium channel blocker has an indication for hiccups in palliative care?
Nifedipine
457
Which conditions are diuretics contraindicated in?
- Addison's disease
- Hypercalcaemia
- Hyponatraemia
- Refractory hypokalaemia
- Symptomatic hyperuricaemia
458
Which conditions can thiazides and related diuretics exacerbate?
- gout
- diabetes
- systemic lupus erythematosus
459
Hypokalaemia can occur with thiazides and related diuretics. Hypokalaemia is dangerous in severe cardiovascular disease and in patients being treated with which drug?
Cardiac glycosides - Digoxin
Increased susceptibility to toxicity of digoxin
460
In hepatic impairment, hypokalaemia can precipitate...?
encephalopathy
461
Can thiazides related diuretics be used in pregnanacy for hypertension?
NO - they may cuase neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte disturbances, and hypoglycaemia; placental perfusion may also be reduced.
- Stimulation of labour, uterine inertia, and meconium staining have also been reported.
462
Thiazides and related diuretics are ineffective if eGFR is less than what number?
If less than 30ml/min/1.73m2 and should be avoided
- Metolazone remains effective if eGFR is less than 30ml/min/m2 but is associated with a risk of excessive diuresis
463
What may large doses of bendroflumethiazide supress in breast feeding women?
Supress lactation
464
What is co-amilozide a combination of?
- Amiloride and hydrochlorothiazide
465
Are there any individual formulations of the diuretic - hydrochlorothiazide?
No - It is only available in the UK in combination with other drugs
466
What should patients be counselled on who are taking combination products that contain hydrochlorothiazide?
- cumulative dose dependent risk of non-melanoma skin cancer, particularly in long term use and advise patients to regularly check for and report any new or changed skin lesions or moles
- advise patients to limit exposure to sunlight and UV rays and use adequate sun protection
- examine all suspicious moles or skin lesions
467
What is the MAO of indapamide?
Indapamide is a thiazide-like diuretic with antihypertensive effects.
- At lower doses, vasodilation is more prominent than diuretics; the diuretic effect becomes more prominent with higher doses
468
In a patient renal disease, which diuretic should you use?
Thiazide diuretic work less well in renal disease, may need high dose loop diuretic
469
In which patients is the combination of an ACE inhibitor with aliskiren contraindicated in?
- In patients with an eGFR less than 60ml/min/m2
| - patients with diabetes
470
Can ACE inhibitors be used in pregnancy?
Not recommended unless essential. They may adversely affect fetal and neonatal blood pressure control and renal function; skull defects and oligohydramnios have also been reported
471
For a patient with renal impairment less than 15ml/min1.73/m2 what dose of candesartan can be used intitially?
4mg daily
472
What is the use of hydralazine?
- moderate to severe hypertension
- Heart failure
- hypertensive emergencies (including during pregnancy)
473
When is minoxidil used in hypertension?
In severe hypertension, in addtional to a diuretic and a beta blocker
474
What is Phaeochromocytoma?
A phaeochromocytoma is a rare tumour of the adrenal glands, which sit above the kidneys.
475
Which drug is used to treat hypertension in phaeochromocytoma?
Phenoxybenzamine hydrochloride
476
Which drugs are used for hypertensive crisis?
```
Sodium nitroprusside (used for hypertensive emergencies
- Hydralazine hydrochloride
```
477
What is pulmonary hypertension?
Pulmonary hypertension is high blood pressure in the blood vessels that supply the lungs (pulmonary arteries)
It's a serious condition that can damage the right side of the heart.
The walls of the pulmonary arteries become thick and stiff, and cannot expand as well to allow blood through.
The reduced blood flow makes it harder for the right side of the heart to pump blood through the arteries.
If the right side of your heart has to continually work harder, it can gradually become weaker. This can lead to heart failure.
478
Which drug is used in pulmonary hypertension?
Selexipag
479
What is the MAO of selexipag?
Selexipag is a selective prostacyclin (IP) receptor agonist
480
Which other drugs (endothelin receptor antagonists) can be used to treat pulmonary hypertension?
- Ambrisentan
- Bosentan
- Macitentan
-
481
Which drug is used for resistant pulmonary hypertension?
Riociguat (which is a guanylate cyclase stimulator)
482
Which other prostaglandin analogues can be used to treat pulmonary hypertension?
- Iloprost
| - Treprostinil
483
What is hypotension?
It is the medical term for low blood pressure (less than 90/60mmHg)
484
Why must the profound hypotension of shock be treated promptly?
- to prevent tissue hypoxia and organ failure
485
In hypotension shock why is volume replacement essential?
To correct the hypovolaemia associated with haemorrhage and sepsis but may be detrimental in cardiogenic shock
486
Depending on haemodynamic status what can be used to improve cardiac output for someone with hypotension shock?
- Sympathomimetic inotropes such as adrenaline/ epinephrine, dobutamine or dopamine
487
In cardiogenic shock why may it not be a good idea to use sympathomimetic inotropes?
In cardiogenic shock peripheral resistance is frequently high and to raise it further may worsen myocardial performance and exacerbate tissue ischaemia
488
How do vasoconstrictor sympathomimetics work?
Vasoconstrictor sympathomimetics raise blood pressure transiently by acting on alpha-adrenergic receptors to constrict peripheral vessels. They are sometimes used as an emergency method of elevating blood pressure where other measures have failed.
489
What is the danger of using vasoconstrictors?
The danger of vasoconstrictors is that although they raise blood pressure they also reduce perfusion of vital organs such as the kidney
490
What may spinal and epidural anaesthesia result in?
Sympathetic block with resultant hypotension
491
What type of sympathomimetic is dopamine?
- Intotropic
492
Give examples of sympathomimetics vasoconstrictors?
- Metaraminol
- Midodrine hydrochloride
- Noradrenaline/ norephinephrine
- Phenylephrine
