Cardio Flashcards
(207 cards)
1
Q
Which statin do you need to use in caution in Asian patients?
A
Rosuvastatin - higher risk of rhabdomyolysis
5-20mg max!
2
Q
What are the four electrolyte imbalances with digoxin?
A
Hypokalaemia
Hypomagnesemia
Hypoxia
Hypercalcaemia
3
Q
Which beta blocker has a long duration of action?
A
Nadalol
4
Q
What is the VTE prophylaxis dose for rivaroxaban following hip replacement surgery?
A
10 mg once daily for 5 weeks, to be started 6–10 hours after surgery.
5
Q
How long after opening GTN SL tablets do they need to be discarded?
A
8 weeks
6
Q
What electrolyte imbalances are thiazides and related diuetics contraindicated in?
A
Hypokalaemia
Hyponatraemia
Hypercalcaemia
Addisons disease too
7
Q
What are the contraindications of loop diuretics?
A
Hypokalaemia - can cause hepatic encephalopathy (use potassium-sparing diuretic to prevent this)
Hyponatraemia
Renal failure from nephrotoxic drugs
8
Q
Name two weak potassium-sparing diuretics
A
Amiloride and triamterene
9
Q
What drugs increase the risk of hyperkalaemia with potassium-sparing diuretics?
A
ACE/ ARB
10
Q
Name two Aldosterone antagonists
A
Spironolactone
Eplerenone
11
Q
Can you give potassium supplements with aldosterone antagonists?
A
No
12
Q
Which beta blockers have intrinsic activity?
A
Causes less coldness extremities and bradycardia
Pindalol
Acebutolol
Celiprolol
Oxprenolol
13
Q
Which beta blockers are more water-soluble?
A
Less of the drug moves to the brain = less sleep disturbance and nightmares
However, excreted by kidneys: caution in renal impairment
Celiprolol
Atenolol
Nadolol
Sotalol
14
Q
Which beta blockers are once daily preparations?
A
Bisoprolol
Atenolol
Celiprolol
Carvedilol
Nadolol
15
Q
Name a risk of the use of beta blockers in diabetic patients
A
Can mask the symptoms of hypoglycaemia as affects carbohydrate metabolism
16
Q
Can beta blockers be suddenly stopped?
A
No because it can exacerbate angina
17
Q
Can beta blockers be used with verapamil?
A
No because it can precipitate a risk of heart failure
18
Q
What are the common side effects of beta blockers?
A
Dizziness
Fatigue
Blurred vision
Cold hands and feet
Bradycardia
Bronchospasm
Diarrhoea
Nausea
19
Q
What are the contraindications for beta blockers?
A
Asthma
Block (heart block)
Cardiac failure
Diabetes mellitus (hypoglycaemic shock)
Extremities (occlusivearterial disease)
20
Q
What are the main contraindications with rate-limiting calcium channel blockers?
A
- Left ventricular dysfunction
- Heart failure - participate HF
- Diabetes - diltiazem may increase blood sugar
- Unstable angina or MI - avoid within 1 month of MI, may increase mortality in patient with left ventricular dysfunction
21
Q
What are some common calcium channel blocker side effects?
A
Ankle swelling
Flushing
Palpitations
Bradycardia (rate-limiting)
Hypotension
Dizziness
Gingival hyperplasia
Headache
22
Q
What is the prescribing pathway for stable angina (myocardial ischaemia)?
A
1st line: BB
- Bisoprolol, propranolol, metaprolol, atenolol
2nd line: Rate-limiting CCB
- Verapamil or diltazium
3rd line: BB & CCB
4th line: Nitrate with BB/ CCB OR as monotherapy
- Ivabradine, nicroandil, ranolazine
23
Q
How do you protect against cardiovascular events in patients with stable angina?
A
Low dose aspirin
Statin
Consider ACEi especially in diabetic patients
24
Q
What are the common side effects for Ranolzine?
A
Asthenia
Constipation
Vomiting
Head
25
Can you use ranolzine in renal impairment?
Avoid if CrCl <30ml/min
Caution in CrCl between 30-80ml/min
26
What are some important contraindications for Ivabradine?
Do not initiate for angina if HR <70
Do not initiate for heart failure if HR <75
2nd and 3rd degree heart block
Severe hypotension
27
What are the common side effects of ivrabradine?
Arrthymias
Atrioventricular block
Dizziness
Headache
Hypertension
Vision disorders
28
What are the common side effects of Nicorandil?
Can cause serious skin, mucosal and eye ulcerations including GI ulcers - discontinue treatment
Asthenia
Dizziness
Haemorrhage
Headache
Nausea
Vasodilation
Vomiting
29
If max. dose statin fails to control statin, what would be the recommendation?
Max dose statin + ezetimibe
30
Can a patient be prescribed a statin and a fibrate?
It increases the risk of muscle-related side effects and rhabdomyolysis therefore, it must be done under specialist supervision
31
Which fibrate must not be used with statins?
Gemfibrozil - increases risk of rhabdomyolysis considerably
32
What drug management should you consider for patients with primary heterozygous familial hypercholesterolemia whose LDL-cholesterol is not controlled on maximum tolerated lipid-lowering therapy?
Alirocumab
Evolocumab
33
What should you measure if a patient is experiencing muscle side effects with statins?
creatine kinase concentrations
34
What symptoms should you seek medical attention for if developed with a statin?
dyspnoea
cough
weight loss
All signs of interstitial lung disease (scarring of the lungs)
35
What is the contraception requirements for statins?
Adequate contraception is required during treatment and for one month after
Must be stopped 3 months before attempting to conceive as teratogenic
36
Which liver function test may prompt discontinuation of statins?
If serum transaminases are more than 3 times the upper limit of the reference range
37
What factor increases the risk of rhabdomyolysis with statins?
Hypothyroidism
38
What are the main symptoms of heart failure
SOB
Persistent cough or wheezing
Ankle swelling
Reduced exercise tolerance
Fatigue
39
What are the risk factors of heart failure?
Men
Diabetes
Smokers
Increased age
African-Caribbean patients with hypertension
Coronary heart disease
40
What are the complications of heart failure?
AF
CKD
Depression
Cachexia
Sexual dysfunction
Sudden cardiac death
41
What is reduced ejection fraction heart failure?
The left ventricle of the heart loses its ability to contract normally and presents with less than 40% ejection fraction
42
What is preserved ejection fraction heart failure?
The left ventricle uses its ability to relax normally = ejection fraction is normal or mildly reduced
43
What is the maximum salt intake in heart failure?
6g
Salt substitutes containing potassium should be avoided - risk of hyperkalaemia
44
What drugs should be avoided in reduced ejection heart failure?
Rate-limiting CCB and short-acting dihydropyridines (nifedipine or nicardipine)
These drugs reduce cardiac contractility
45
Which kind of diuretic is usually recommended in heart failure?
Loop diuretics
- relief of breathlessness and oedema
46
When should thiazide diuretics be avoided in renal impairment?
eGFR <30ml/min
47
Which beta blockers are licensed for heart failure?
Bisoprolol
Carvedilol
Nebivolol
48
Which ARBs are licensed for heart failure?
Losartan
Candesartan
Valsartan
49
What is the treatment pathway for heart failure?
Loop diuretic for symptomatic relief
1st: ACEi/ARB or BB
2nd: Spironolactone/ eplerenone (add-on) - unless contraindicated due to hyperkalemia or renal impairment
If ACE/ARB not tolerated: under specialist advice, hydralazine combined with a nitrate can be given considered if pt intolerant of ACEi/ARB
If symptoms persist, specialist should consider: SGLT2 OR replace ACE with sacubitril valsartan OR digoxin in sinus rhythm OR ivabradine
50
How do you treat a patient in sinus rhythm with worsening or severe HF despite optimal treatment?
Add-on therapy of digoxin
Also, consider an anticoagulant in patients with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus
51
Which beta blocker is least likely to cause bronchospams?
Atenolol
52
Which beta blockers are cardioselective?
B A MAN
Bisoprolol
Atenolol
Metoprolol
Acebutolol (to a lesser extent)
Nebivolol
These have a lesser effect on airway resistance but are not completely free from bronchospasm as a side effect
53
What is the prescribing pathway for a pregnant woman with HTN?
1st line: Labetalol
2nd line: nifedipine
3rd line: methyldopa
54
What are the BP targets with patients with diabetes?
T2DM - <140/90
T1DM - <135/85
If T1/2DM with complications- <130/80
55
What are the risks of digoxin toxicity?
HypOkalaemia
HypOmagnesaemia
HyERrcalcaemia
Hypoxia
Renal impairment
56
What are the signs of digoxin toxicity?
GI signs: N/V, abdominal pain, diarrhoea
Metabolic signs: hyperkalemia
CVS signs: bradycardia, hypotension
CNS signs: lethargy, confusion
Eyes: blurred, eye vision
57
Which drugs interact with digoxin?
CRASED
CCBs
Rifampicin
Amiodarone
St Johns Wort
Erythromycin
Diuretics
58
What antibiotics interact with warfarin?
Co-trimoxazole
Metronidazole
Macrolides
Fluroquinolones
Rifampicin
59
What are the requirements for ivabradine to be considered for HF?
In sinus rhythm
HR >75bpm
Ejection fraction <35%
60
What antifungals interact with warfarin?
Miconazole
Fluconazole
61
What antidepressants interact with warfarin?
SSRIs
62
What are the side effects of amiodarone?
Corneal deposits
Phototoxicity
Slate-grey skin
Peripheral neuropathy
Pulmonary fibrosis
Hepatoxicity
Thyroid dysfunction
63
What are the contraindications for aspirin?
Active peptic ulceration
Bleeding disorders
Children under 16 due to risk of Reye's syndrome - unless Kawasaki disease
Haemophilia
Previous peptic ulceration (analgesic dose)
Severe cardiac failure
64
What is the adrenaline dose for anyone >12?
500mcg IM (0.5ml)
OR
300mcg (0.3ml) if child is small or prepubertal
65
What is the adrenaline dose for children between 6-12?
300mcg IM (0.3ml)
66
What is the adrenaline dose for children <6?
150mcg (0.15ml)
67
What are the side effects of CCBs?
Dizziness
Flushing
Headache
Hypotension
Palpitations
Ankle swelling
Angioedema
ED
Gingival hyperplasia
Constipation - most likely with verapamil
Bradycardia, AV block and HF - with verapamil
68
What are the ADR of Ivabradine?
Visual effects (luminous phenomena)
69
Which heparin poses a higher risk of heparin-induced thrombocytopenia and osteoporosis?
Unfractioned heparin
70
Which heparin is preferred in renal impairment?
Unfractioned heparin
71
Which heparin is longer acting?
LMWH
72
Who should you not offer compression stockings to?
A patient admitted to the hospital with acute stroke or those that have:
- peripheral arterial disease
- peripheral neuropathy
- severe leg oedema
- local conditions
73
How quickly should you start thromboprophylaxis?
Within 14 hours of hospital admission
74
What type of surgical patients is fondaparinux preferred for?
Patients undergoing abdominal, bariatric, thoracic, and cardiac surgery or patients with lower limb immobilisation or fragility fractures to the pelvis, hip or proximal femur
75
What is the thromboprophylaxis treatment for a patient undergoing elective hip replacement?
Option 1: LMWH for 10 days followed by low dose aspirin for 28 days
Option 2: LMWH for 28 days with anti-embolism stockings until discharge
Option 3: rivaroxaban
If unsuitable, consider apixaban and dabigatran
76
What is the thromboprophylaxis treatment for a patient undergoing elective knee replacement?
Option 1: low-dose aspirin for 14 days
Option 2: LMWH for 14 days with anti-embolism stockings until discharge
Option 3: rivaroxaban
If unsuitable, consider apixaban and dabigatran
77
How do you treat proximal DVT or PE?
Apixaban or rivaroxaban
if unsuitable offer either:
- LMWH for at least 5 days followed by dabigatran or edoxaban
- LMWH with a vitamin K antagonist for at least 5 days or until INR at least 2 for 2 executive readings followed by a vitamin K antagonist on its own (this option is not routinely recommended fot proximal DVT/PE unless patient has renal impairment or at increased risk of bleeding)
78
What is the renal impairment limit for dabagatran?
Should not be used in eGFR <30ml/min
79
What do you use to reverse Heparin action?
Protamine sulfate
80
What is a transient ischaemia stroke (TIA)?
A stroke that only lasts a few minutes
Should receive aspirin immediately
81
What is the treatment for an acute ischaemia stroke?
- Alteplase if administered within 4.5 hours of symptom onset and intracranial haemorrhage excluded
- Aspirin should be started within 24 hours of symptom onset with a PPI if history of dyspepsia with aspirin
- ONLY if high risk of VTE = parenteral anticoagulant
82
What drugs should you avoid in ischemic stroke?
Warfarin
Anticoagulants
83
What is the aspirin treatment for patients with disabling ischaemic stroke and atrial fibrillation?
Aspirin for at least 2 weeks before anticoagulants
84
What is the long-term management of TIA or ischaemic stroke (not associated with AF?
Clopidogrel
If clopidogrel not tolerated or contraindicated: MR dipyridamole and aspirin
if aspirin and clopidogrel not tolerated or contraindicated: MR dipyridamole alone
If clopidogrel and dipyridamole contraindicated or not tolerated: aspirin alone
Also, add high-intensity statin within 48 hours after stroke symptoms if not already taking irrespective of serum-cholesterol concentration
85
What class of drugs should not be used in the management of hypertension following stroke?
Beta-blockers unless they are indicated for co-existing conditions
86
What is the onset of action of vitamin k antagonist?
48-72 hrs
87
Within how many units is INR considered generally satisfactory?
0.5 units
88
What is the course of action for a patient who has a major bleed while on warfarin?
1. stop warfarin
2. give IV phytomenadione
3. give dried thrombin complex (if unavailable - give fresh frozen plasma can be given but less effective)
89
What is the course of action for a patient with an INR of >8 and who has a minor bleed while on warfarin?
1. stop warfarin
2. give IV phytomenadione
3. after 24 hours: if INR still high repeat phytomenadione dose
4. when INR <5, restart warfarin
90
What is the course of action for a patient with an INR of >8 but has no bleeding while on warfarin?
1. stop warfarin
2. give phytomenadione orally (but using the intravenous preparation orally)
3. after 24 hours: if INR still high repeat phytomenadione dose
4. when INR <5, restart warfarin
91
What is the course of action for a patient with an INR of 5-8 with minor bleeding while on warfarin?
1. stop warfrain
2. give IV phytomenadione
3. when INR <5, restart warfarin
92
What is the course of action for a patient with an INR of 5-8 but has no bleeding while on warfarin?
Withhold 1 or 2 doses and reduce subsequent maintenance dose
93
When should warfarin be stopped before elective surgery?
5 days before
If INR more than or equal to 1.5 the day before surgery - give phytomenadione orally
If hemostasis adequate - resume normal warfarin dose evening of surgery or next day
94
What should you do if a warfarin patient requires surgery but is at high risk of VTE?
bridge with LMWH treatment dose but stopped 24 hours before the surgery
If surgery carries high risk of bleeding, LMWH should not be restarted until at least 48 hours after
95
What should you do if a warfarin patient requires emergency surgery?
If surgery can be delayed by 6-12 hours: give IV phytomenadione to reverse warfarin effects
If surgery cannot be delayed: give IV phytomenadione and dried thrombin complex and check INR before surgery
96
What is used for the reversal of dabigatran?
Adarucizumab
97
What is used for the reversal of apixaban or rivaroxaban?
Andexanet
98
What must be controlled before aspirin is given in primary prevention?
Hypertension
99
How long after opening MR dipyridamole must they be discarded?
6 weeks
100
Can you use apixaban in renal impairment?
Avoid in less than 15ml/min
Reduce dose to 2.5mg BD if serum creatinine 133micromol/L (CrCl 15-29ml/min) and over and is 80 or over or has a body weight of 60kg or less
101
What is the secondary prevention of cardiovascular disease - acute coronary syndrome (STEMI, NSTEMI, stable angina)?
Aspirin 75mg daily + 2nd antiplatelet for 12 months
Options:
- clopidogrel 75mg daily
- Prasugrel 5 mg once daily (10 mg if body weight is 60 kg or more and the patient is under the age of 75)
- Ticagrelor 90 mg twice daily for up to 12 months (reduced to 60 mg twice daily if treatment is extended beyond 12 months)
102
What must you discontinue in heart failure before introducing an ACEi?
Potassium supplements or potassium-sparing diuretics due to the risk of hyperkalemia
However, low-dose spironolactone can be used but monitor potassium closely
103
What is the secondary prevention of cardiovascular disease - peripheral arterial disease (PAD)?
Clopidogrel 70mg is preferred for the preventions of occlusive vascular events
If contraindicated, low-dose aspirin
For those at high risk of ischaemic events and low risk of bleeding - specialists recommended rivaroxaban 2.5mg BD + aspirin
104
What is the secondary prevention of cardiovascular disease - Percutaneous coronary intervention?
Those with stable coronary arterial disease undergoing PCI
- Aspirin and clopidogrel 75mg for 6 months
if high risk of bleeding = 1-3 month treatment
high ischaemia risk but no bleeding complications = up to 36 months
105
Patients with what condition are more susceptible to hyperkalemia with an ACEi?
Patients with diabetic nephropathy should not be given ACEi and ARB
106
What is the interaction between lithium and furosemide?
Furosemide increases concentration of lithium = lithium toxicity
Side effects: Vomiting, diarrhoea, muscle weakness, tremor, confusion
107
What are the electrolyte imbalances with furosemide?
Hyponatraemia
Hypomagnesaemia
Hypokalaemia
Hypocalcaemia
108
What are other ADRs of furosemide other than electrolyte imbalances?
Ototoxicity
Hypotension
Metabolic acidosis
Renal impairment from dehydration and direct toxic effect
Hyperglycaemia but less common than with thiazides
109
What are the main drugs that furosemide interacts with?
Lithium
Digoxin
Amiodarone
Citalopram
Quinine
Macrolide antibiotics
110
What conditions can loop diuretics exacerbate?
Diabetes
Gout
111
Which diuretic is used for cerebral oedema and raised intra-ocular pressure?
Mannitol
112
What is the treatment for secondary prevention of an MI?
1. anti-platelet therapy (aspirin longterm and ticagrelor for 12 months)
2. ACEi
3. BB
4. Statin
113
What is the management of AF maintenance?
1st RATE CONTROL:
- beta blocker (not sotalol)
- RL CCB
- Digoxin for non-paroxysmal AF (preferred for those with sedentary lifestyles)
2nd RHYTHM CONTROL
- pharmacological cardioversion: amiodarone, flecainide (if not structural heart disease), sotaolol
Reduce stroke:
- CHAD2DS2VASc if score more than 2 in women and more than 1 in men
- Warfarin or DOAC
114
What is CHAD2DS2VASc score?
A tool to assess a person's stroke risk
115
What drugs does clopidogrel interact with?
Reduced antiplatelet effects:
Carbamazepine
Cimetidine
Chloramphenicol
Ciprofloxacin
Erythromycin
Fluconazole
Omeprazole
The antiplatelet effect enhances the anticoagulant effect – increased risk of bleeding:
Warfarin - avoid
116
Which OTC painkiller should you avoid with ACEi/ARBs?
Ibuprofen - increased risk of hyperkalaemia especially when given with spironolactone or eplerenone
117
What is the interaction between SSRI and rivaroxaban?
Increased risk of bleeding - severe interaction
118
Do amiodarone and simvastatin interact?
yes - increased risk of muscle side effects because amiodarone increases exposure of simvastatin
119
What drink interacts with amlodipine?
Grapefruit juice
120
What is the maximum atorvastatin dose with ciclosporin?
Atorvastatin 10mg
121
What is the maximum simvastatin dose with ticagrelor 90mg tablets?
Simvastatin 40mg
122
What is the maximum simvastatin dose with amlodipine?
Simvastatin 20mg
123
What is the maximum simvastatin dose with ranolazine MR 375mg tablets?
Simvastatin 20mg
124
What are the administration instructions for perindopril?
Take 30-60 minutes before food
125
Which antihypertensive, if stopped abruptly, can cause rebound hypertension?
Clonidine hydrochloride
126
Which co-morbidity is least likely to co-exist with heart failure?
Asthma
127
What is the clinic reading for stage 3 hypertension?
180/120 mmHg
128
Which thiazide diuretic is least likely to cause hyperkalemia?
Indapamide - causes hypokalaemia
129
What are the side effects associated with indapamide?
Hyponatraemia
Hypokalaemia
Cardiac arrhythmias
May increase blood glucose
May increase LDL
Impotence in men
130
What is the dose for bendroflumethiazide for hypertension and oedema?
Hypertension: 2.5mg OD
Oedema: 5mg OD
131
What is the maximum dose of simvastatin with amiodarone?
Simvastatin 20mg
132
What is the maximum simvastatin dose with amlodipine and diltiazem?
Simvastatin 20mg
133
Which drug causes nightmares and sleep disturbances?
Propranolol
134
What is an important MHRS warning for Hydrochlorothiazide?
Can cause non-melanoma skin cancer, particularly in long-term use
- Seek medical attention
135
What is the general serum creatinine for a healthy male?
84-110 micromol/L
136
What is the risk of furosemide in pregnancy?
hypovolaemia
137
What is the interaction between statins and macrolides?
Risk of rhabdomyolysis
138
What is the interaction between gentamicin and loop diuretics?
Risk of renal failure
139
What is the interaction between ACEi and potassium-sparing diuretics?
Hyperkalaemia risk
140
What is the interaction between ACEi and metformin?
Enhance hypoglycaemic effect
141
What is the interaction between statins and amiodarone?
Risk of rhabdomyolysis
142
What is the interaction between thiazide diuretics and PPIs?
Hyponatraemia
143
What is the interaction between thiazide diuretics and lithium?
Increased lithium toxicity
144
What is the initial ACS treatment?
Sublingual/ buccal GTN for pain releief
IV morphine also for pain relief especially in MI
Aspirin loading dose
2nd antiplatelet (prasugrel, ticagrelor (180mg) & clopidogrel - prasugrel preferred if undergoing primary PCI
145
What is the secondary prevention of cardiovascular events?
- ACEi/ARB
- BB (continue indefinitely in reduced left ventricular ejection fraction otherwise discontinue after 12 months)
Consider diltiazem or verapamil as an alternative to BB in pt's who do not have pulmonary congestion or reduced LVEF
- Dual antiplatelet therapy (aspirin indefinitely, 2nd antiplatelet for 12 months)
if aspirin contraindicated = clopidogrel monotherapy
Another option: rivaroxaban with either aspirin alone or aspirin and clopidogrel (this option is recommended for elevated cardiac biomarkers)
- Statin
146
What thrombolytic drugs are used to treat MI?
Streptokinase and alteplase - found to reduce mortality
For acute MI: reteplase and tenecteplase
- Alteplase: given within 6-12 hours of symptom onset
- Reteplase and streptokinase: within 12 hours of symptom onset
- Tenecteplase: usually within 6 hours
Ideally all should be given within an hour
147
What is the digoxin dose for heart failure?
62.5mcg-125mcg
148
What is the digoxin dose for AF?
125mcg-250mcg
149
What drugs do you need to half the dose of digoxin dose with?
Amiodarone
Dronedarone
Quinine
If digoxin or another cardiac glycoside has been given in the preceding 2 weeks
In elderly
150
When would you increase digoxin dose?
When switching from IV to oral - increase dose by 20-33% to maintain the same plasma digoxin concentration
151
Which drugs increase plasma digoxin levels?
Amiodarone
Rate limiting CCB
Macrolides
Ciclosporin
152
Which drugs decrease plasma digoxin levels?
St John's Wort
Rifampicin
153
What drug class is angioedema more likely to happen in?
ACEi - common
Uncommon - CCB
154
Which drugs can cause hypokalaemia?
Diuretics
B2 agonists
Steroids
Theophylline
(These drugs predispose digoxin)
155
Which drugs decrease renal excretion?
NSAIDs
ACEi/ARB
(reduce digoxin dose when taking these as digoxin is also renally excreted)
156
What are the common side effects of Nicorandil?
- Skin, mucosal and eye ulcers (including GI) - stop treatment if ulcers occur (e.g. anal ulcers)
- Headache: common on initiation
- Flushing
- Asthenia
- Hyperkalaemia
- Abdominal pain
- N/V
- Diplopia (double vision)
157
What is the treatment of stable angina?
1st line: BB (atenolol, bisoprolol, metoprolol, propranolol)/ rate limiting CCB (if BB contraindicated)
2nd line: BB + rate limiting CCB
3rd line: long-acting nitrate
- Ivabradine
- Nicorandil
Ranolazine
(secondary prevention = Aspirin + statin)
158
What are the contraindications for BBs for stable angina?
Prinzmetals angina
Decompensated HF
159
What drugs would you consider in prinzmetals angina?
Dihydropyridine derivatives
- Amlodipine
160
What are the adverse effects of diuretics?
Hypotension
Ototoxicity
HYPO-Na/K/Mg/Ca
Hyperglycaemia (more common with thiazides)
Metabolic acidosis
Renal impairment from dehydration
Gout
161
Which drugs should be avoided in heart failure with reduced ejection fraction?
Rate limiting CCBs
Short-acting dihydropyridines - nifedipine or nicardipine
They reduce cardiac contractility
162
Which class of drugs turns your urine blue?
ENaC blockers e.g. Triamterene amiloride
Indication: used with thiazide or loop diuretics as an alternative to K supplementation
- Never give with aldosterone antagonists (spironolactone/ eplerenone)
163
How do you treat fluid overload in HF?
Used to relieve breathlessness and oedema
Typically with Loop diuretics e.g. furosemide, bumetanide, torasemide
Thiazides only of benefit in patients with mild fluid retention and an eGFR of >30ml/min
164
How is chronic heart failure with reduced ejection fraction treated?
1st line: ACEi/ARB +BB (bisoprolol, carvedilol, nebivolol)
2nd line: mineral corticosteroid receptor antagonist - spironolactone/ eplerenone (add-on therapy)
If intolerant of ACEi AND ARB: consider hydralazine + nitrate (esp in African Caribbean with moderate-severe HF)
3rd line: Amiodarone, digoxin, sacubitril with valsartan, ivabradine, empagliflozin, dapagliflozin
digoxin is recommended in sinus rhythm
165
Which ARBs are licensed for heart failure?
Candasartan, Losartan, Valsartan
166
What is the ADRs of spironolactone?
HYPERkaemia
HYPOnatraemia
HYPERchloraemic acidosis
HYPERtrichosis
Gynaecomastia
Change in libido
SCARS severe cutaneous adverse rxns
AKI
167
What are the main interactions of spironolactone?
ACEi/ARB
Lithium
Digoxin
NSAIDs
168
What is the interaction between isosorbide mononitrate and sildenafil?
Increased risk of hypotension - severe interaction avoid
169
How is MR isosorbide mononitrate taken?
OD
170
When should you stop the use of isosorbide mononitrate in the elderly?
If prescribed a long-acting nitrate with persistent postural hypotension - recurrent drop in systolic BP less than or equal to 20mmHg
171
What are some ADRs of isosorbide mononitrate?
FLushing
Dizziness
Hypotension
Headache
Tachycardia
Hypersensitivity
Circulation collapse
172
What are the statin doses for primary prevention?
ATorvastatin 20mg
Simvastatin 40mg
173
What are the modifiable risk factors for ACS?
Smoking
Obesity
HTN
Hyperlipidaemia
T2DM
174
What are the non-modifiable risk factors for ACS?
Increasing age
Male
Family history of ischaemia heart disease
175
What is the management of an NSTEMI?
Antiplatelet - aspirin 300mg and tricagrelor/pasugrel for 12 months
Anticoagulant - fondaparinux, UFH, LMWH
BB
Consider glycoprotein llb/llla antagonist (eptifibatide or trifiban) for those scheduled for angiography
Coronary angiography within 96 hours of admission
176
What condition is nifedipine used first line for?
Raynaud's syndrome - impact on blood circulation
Can cause painful vasospasm in response to cold or stress
Brand must be specified
177
Which drug works by inhibiting the intestinal absorption of cholesterol?
Ezetimibe
178
What is the target blood pressure for a pregnant woman?
135/85mmHg
179
What is the interaction between CCBs and Alpha-blockers?
Enhanced hypotensive effect and increases risk of first dose hypotension
180
What is the maximum infusion rate for furosemide?
4mg/minute
181
What is the initial loading dose for amiodarone?
200mg TDS for 7 days
200mg BD for 7 days
200mg OD maintenance dose
182
What is the contraindication for adenosine?
Asthma - bronchospams
183
What drug enhances the effects of adenosine?
Dipyridamole
- dipyridamole increases exposure of adenosine
184
What drug blocks the effects of adenosine?
Theophylline
185
What are the adverse effects associated with adenosine?
chest pain
bronchospasm
transient flushing
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
186
How do you treat paroxysmal supraventricular tachycardia?
1st line: reflux vagal stimulation - immersing face in ice-cold water, carotid sinus massage, Valsalva manoeuvre
2nd line: IV adenosine, if contraindicated = IV verapamil
Recurrent episodes: catheter ablation/ diltiazem/ verapamil/ sotalol/ flecainide/ propafenone
187
What are the adverse effects associated with ivabradine?
Visual effects, particular luminous phenomena, are common
headache
bradycardia
heart block
188
What type of treatment is preferred for AF when onset of symptoms is more than 48hrs?
Rate control
189
What class of drugs should be avoided in suspected concomitant acute decompensated HF with AF?
CCB
190
How do you treat AF with rate control?
1st line: BB (not stall)
2nd line: Rate limiting CCB
3rd line: Digoxin - only for initial rate control in patients with non-paroxysmal AF who are predominantly sedentary or when rate-limiting drugs are unsuitable
If monotherapy fails = consider 2 drugs from above
If this fails = rhythm control
If ventricular function diminished (LVEF <40%) = BB + digoxin preferred
191
How do you treat an acute presentation of AF for heamodynamically stable patients?
IV BB
OR
Verapamil if LVEF > or equal to 40%
192
How do you maintain sinus rhythm post-cardioversion?
1st line: standard BB
2nd line: anti-arrhythmic drugs - amiodarone, flecainide, propafenone
193
When should flecainide and propafenone be avoided?
Ischaemia or structural heart disease
For patients with left ventricular impairment or heart failure: consider amiodarone
- 2nd line would be considered dronedarone in patients with persistent or paroxysmal AF
194
How can you treat episodes of symptomatic paroxysmal AF using rhythm control?
'pill in pocket'
195
How do you treat bradycardia post-MI (arrhythmias after MI)
Particularly if complicated by hypotension
Atropine sulfate
Failed to respond: adrenaline
196
What is the VTE prophylaxis dose rivaroxaban following knee replacement?
10 mg once daily for 2 weeks, to be started 6–10 hours after surgery.
197
What is the eGFR limit for flecainide?
If eGFR <35ml/min - reduce dose to maximum of 100mg daily
198
What is a serious risk of SGLT2?
Fournier's gangrene - redness and swelling around genitals and fever
199
When are troponin I levels taken?
troponin I levels are taken immediately after chest pain is experienced and then after 12 hours to identify if the patients troponin levels have decreased
When heart muscle is damage, troponin leaks into blood stream and levels increase
200
Which thiazide or thiazide related diuretic can be used in eGFR less than 30ml/min?
Metolazone
201
Which type of CCB is vasocilatory adverse effects more associated with?
dihydropyridine calcium-channel blockers
Flushing, headaches, postural hypotension, ankle swelling
202
Which lipid are fenofibrates best at lowering?
Triglyceride
203
What monitoring is required when starts ACEi, ARB or mineralcorticoid receptor antagonist in HF?
1-2 weeks after starting treatment and at east dose increment then every 3 months then every 6 months:
Potassium
Sodium
Renal function
204
What is monitored when BBs are initiated?
HR
BP
205
What is the initial furosemide dose for patients with HF and preserved ejection fraction?
Furosemide 80mg
206
What is the management of an NSTEMI?
300mg ASAP
Fondapabruinx
Reperfusion (PCI or fibrinolysis) therapy OR medicines management
Medication management:
- ticagrelor + aspirin (if high risk bleeding - clopidogrel + aspirin)
207
Which beta blockers are licensed for AF?
Atenolol, acebutaolol, propranolol, metaprolol, nadolol, oxprenolol
