Cardiology - High Flashcards
(265 cards)
1
Q
What are the most commonly prescribed statins?
A
Atorvastatin
Simvastatin
Pravastatin
Rosuvastatin
2
Q
What are the clinical indications for the use of statins?
A
- Primary preventionof cardiovascular events (MI / stroke)
- Secondary prevention of cardiovascular events in patients with established cardiovascular disease
- Primary hyperlipidaemia
3
Q
What are the important adverse effects associated with the use of statins?
A
- Muscle pain and myopathy
- GI upset
- Rhabdomyolysis
- Drug-induced hepatitis
4
Q
Why is simvastatin taken at night?
A
Because simvastatin has a relatively short half-life and cholesterol is primarily synthesised in the early hours of the morning.
Other statins (atorvastatin) can be taken at any time during the day
5
Q
When should the use of statins be avoided?
A
In pregnancy and breastfeeding
6
Q
When should statins be used with caution?
A
Hepatic impairment
Dose should be reduced in renal impairment
7
Q
Which drugs interact with statins and to what effect?
A
- CYP enzyme inhibitors (metronidazole, amiodarone, irtaconazole, macrolides, etc)
- Amlodipine - reduces the metabolism of statins
- Grapefruit juice
8
Q
What action should be taken if a patient established on a statin is started on treatment with either amlodipine or a CYP inhibiting drug?
A
Dose of statin will likely need to be reduced.
If the course of the other drug is only short term then the statin can be held for the duration.
9
Q
What is a typical dose of simvastatin for primary prevention?
A
40mg OD
10
Q
What is a typical dose of atorvastatin for primary prevention?
A
20mg OD
11
Q
What % reduction in non-HDL cholesterol levels is the target 3 months after initiation of a statin?
A
40%
12
Q
What are the key points when counselling a patient on the use of statins?
A
- Seek medical attention if you experience muscle symptoms such as pain or weakness
- Blood tests are required 3 and 12 months after initiation
- Minimise alcohol intake
- Avoid grapefruit juice
13
Q
Which statins do not interact with grapefruit juice?
A
Pravastatin
Rosuvastatin
14
Q
Which condition can cause hyperlipidaemia and should be resolved before considering starting a patient on statins?
A
Hypothyroidism
15
Q
What monitoring requirements are there during the use of statins?
A
- Lipid profile at initiation and 3 months after
- LFTs at baseline, 3 months and 12 months after initiation
- Cholesterol levels for efficacy at any interval
(A rise in ALT to 3x the upper limit may be acceptable, but above this statins must be discontinued)
16
Q
What is the target blood pressure in individuals 80 years and older?
A
< 150/90
17
Q
What kind of calcium channel blocker is verapamil?
A
Non-dihydropyridine (Rate-limiting)
18
Q
What can be given when urgent rate control is required?
A
IV beta-blocker
Verapamil
19
Q
Which drugs can be used for pharmacological cardioversion?
A
Flecainide
Amiodarone
Flecaininde cannot be used if there is structural or ischaemic heart disease present
20
Q
Is rate- or rythm-control preferred when arrythmias have been present for more than 48 hours?
A
Rate-control
21
Q
If the onset was over 48 hours ago, is electric cardioversion or pharmacological cardioversion preferred in atrial fibrillation?
A
Electric cardioversion
But, the patient must have been anticoagulated for at least 3 weeks
22
Q
What is the preferred first line therapy for atrial fibrillation?
A
Rate-controlwith beta-blocker or rate-limiting calcium channel blocker (diltiazem or verapamil)
23
Q
Which beta-blocker cannot be used as rate-control?
A
Sotalol hydrochloride
24
Q
When is the use of digoxin monotherapy appropriate for rate control?
A
In patients with non-paroxysmal AF, who are sedentary, or in those where the use of other rate-limiting medications is unsuitable
25
What is the preferred therapy for a patient whose ventricular function is impaired (LVEF <40%)?
Bisoprolol + Digoxin
26
When monotherapy fails in initial rate-control for AF, which drugs are available for use in combination therapy?
Bisoprolol
Digoxin
Diltiazem
27
If drug treatment is required to maintain sinus rhythm post-cardioversion, what are the first- and second-line treatment options?
First-line - standard beta-blocker
Second-line - amiodarone or flecainide
## Footnote
Dronedarone can also be considered 2nd line in the treatment of paroxsymal AF
28
What is the "Pill-in-the-pocket" approach to treatment of AF?
For paroxysmal AF where the patient has infrequent episodes. They are able to take an anti-arrhythmic drug to treat an epsiode of AF when it occurs.
29
Which anticoagulants are recommended for non-valvular AF?
DOACs
30
What should be offered to patients with new-onset AF while a decision is made regarding their ongoing anticoagulation?
Parenteral anticoagulant (Heparin)
31
What is the difference between atrial fibrillation and atrial flutter?
Atrial fibrillation - atria beat irregularly
Atrial flutter - atria beat regularly, but faster than usual, and often faster than the ventricles
32
How long should anticoagulation be continued post-cardioversion?
At least 4 weeks
33
Which drugs are used for pharmacological cardioversion of atrial flutter?
Flecainide or Propafenone
(in conjunction with either beta-blocker, diltiazem, or verapamil)
34
When is catheter ablation preferred for cardioversion?
Recurrent atrial flutter
35
When does the dose of digoxin have to be halved?
When use concurrently with:
Amiodarone
Dronedarone
Quinine
36
What should be used to treat bradycaria post-myocardial infarction?
A dose of IV atropine
37
What is the preferred anti-arrhythmic drug for the treatment of ventricular tachycardia?
Amiodarone
38
What is Torsade de pointes and how can it be treated?
A usually self-limiting ventricular tachycrdia associated with QT prolongation.
It can be treated with a **beta-blocker**, but not anti-arrhythmics as these further prolong the QT interval.
39
Which electrolyte disorder enhances the pro-arrhythmic effects of anti-arrhythmic drugs?
Hypokalaemia
40
What class of anti-arrhythmic drug is flecainide?
Class I
41
What class of anti-arrhythmic drug are beta-blockers?
Class II
42
What class of anti-arrhytymic drug is amiodarone?
Class III
43
What class of anti-arrhythmic drug is verapamil?
Class IV
44
What class of anti-arrhythmic drug is dronedarone?
Class III
45
What class of anti-arrhythmic drug is licodcaine?
Class I
46
Which class of drugs does digoxin belong to?
Cardiac glycoside
47
What is the drug of choice for treating paroxsymal supraventricular tachycardia?
Adenosine
48
Is digoxin effective at rapid control in atrial flutter and atrial fibrillation?
No, may take several hours to take effect
49
Which drugs are effective at treating both ventricular and supraventricular arrhythmias?
Amiodarone
Beta-blockers
Flecainide
Propafenone
Disopyramide
50
Does amiodarone have a long or a short half-life?
Long (several weeks)
51
What are the downsides of using disopyramide intravenously and orally, respectively?
IV - decreases cardiac contractility
PO - has antimuscarinic effects
52
What is dispyarmide indicated for?
Prevention and treatment of ventricular and supraventricular arrhythmias, including after MI
53
What is the antidote for digoxin overdose?
Digifab
54
Which electrolyte disorders can increase the risk of digoxin toxicity?
Hypokalaemia
Hypomagnesaemia
Hypercalcaemia
55
Which drugs are used for the treatment of supraventricular arrhythmias?
Digoxin
Adenosine
Verapamil
56
What is Tranexamic acid used for?
Fibrinolysis and prevention and treatment of haemorrhage in trauma
57
Which drug is available for the treatment of subarachnoid haemorrhage?
Nimodipine
## Footnote
POM
58
List some risk factors for VTE
- Surgery
- Trauma
- Pregnancy and postpartum
- Hormonal therapy
59
What type of anticoagulant is preferred for general and orthopaedic surgery?
Low molecular weight heparin
60
When is the use of unfractionated heparin preferrable to other heparins for surgical VTE?
Renal impairment
61
How long should VTE prophylaxis be continued for post-surgery?
7 days, or until the patient recovers all of their mobility
62
How should patients undergoing elective hip relacement be anticoagulated?
LMW heparin for 10 days, followed by 28 days of low dose aspirin
## Footnote
DOACs are also a suitable option
63
How should patients undergoing elective knee replacement be anticoagulated?
Low dose aspirin for 14 days
64
What kind of anticoagulation is most appropriate for a pregnant inpatient?
LMW heparin
## Footnote
Until VTE is no longer a risk of they are discharged
65
Patients who have given birth, had a miscarriage, or termination of pregnancy within 6 weeks should be treated with what kind of VTE prophylaxis and for how long?
LMW heparin 4 - 8 hours after the event, and continued for at least 7 days
66
What are the first line treatment options for proximal VT or PE?
Apixaban
OR
Rivaroxaban
67
Which DOACs require 5 days of parenteral anticoagulation prior to their initiation?
Edoxaban
Dabigatran
68
How long should anticoagulation be continued for the treatment of DVT or PE?
3 months
69
How long should anticoagulation be continued for the treatment of AF?
Life-long
70
What kind of anticoagulation should a pregnant patient, or who has just given birth in the last 6 weeks receive for the treatment of VTE (DVT or PE)?
LMW heparin as soon as VTE suspected and then continued as maintenance unless diagnosis of DVT or PE excluded
71
Can the DOACs be used in pregnancy and breastfeeding?
No
72
When is alteplase no longer appropriate for the treatment of acute ischaemic stroke?
4.5 hours after onset of stroke
## Footnote
(It is also inappropriate in intracranial bleeding)
73
What is the first line treatment for ischaemic stroke, regardless of whether the patient has received alteplase?
300mg aspirin for 14 days
(Needs to be started 24 hours after thrombolysis / ASAP within 48 hours of symptom onset in those not receiving thrombolysis)
## Footnote
Consider PPI in addition
74
How should treatment be managed in patients receiving anticoagulation for a prosthetic heart valve who then suffer a disabling ischaemic stroke?
Anticoagulation should be stopped and replaced with aspirin 300mg OD for 7 days
75
What needs to be started within 48 hours of stroke onset, excluding anticoagulation or antiplatelet drugs?
High intensity statin such as **atorvastatin**
76
What drug should be used for long-term management following ischaemic stroke or TIA?
Clopidogrel
## Footnote
Dipyridamole with aspirin when clopidogrel is contraindicated or not tolerated
77
Can beta-blockers be used for hypertension following a stroke?
No
78
What is the target blood pressure range post-stroke?
< 130/80mmHg
79
What is the initial management of intracerebral haemorrhage within 6 hours of symptom onset?
Blood lowering medication if systolic BP is 150 - 220 down to target BP of 130 - 140 maintained for 7 days
80
Which drug class should ideally be avoided after intracerebral haemorrhage?
Statins
81
How long does it take for warfarin to produce its anticoagualnt effect after initiation?
48 - 72 hours
82
What is the typical target INR during warfarin therapy?
2.5
## Footnote
0.5 units within the target is acceptable
83
For which indications is the target INR 3.5 during warfarin therapy?
Recurrent DVT or PE in patients currently receiving anticoagulation
84
How many days before elective surgery should warfarin be stopped?
5 days
85
Which kind of anticoagulants are used to "bridge" warfarin therapy in those undergoing elective surgery who are at a highrisk of thromboembolism?
LMWH which should be stopped 24 hours before surgery
86
Reversal agents are not available for which of the DOACs?
Edoxaban
87
What reversal agents are available for DOAc overdose?
Andaxanet - Rivaroxaban and Apixaban
Idarucizumab - Dabigatran
88
Which has a shorter onset and duration of action, heparin (unfractionated) or low molecular weight heparins?
Heparin (unfractionated)
89
Which has a lower incidence of heparin-inducedthrombocytopenia, heparin (unfractionated) or low molecular weight heparins?
LMWH
90
Can aspirin be used in primary prevention of cardiovascular disease?
No, long-term use of low dose aspirin is only recommended for secondary prevention
| a.k.a in established cardiovascular disease
91
How long prior to surgery do DOACs need to stopped?
24 hours
92
What is the dose of edoxaban in an adult weighing < 61kg
30mg
93
What is the dose of edoxaban in an adult weighing > 61kg
60mg
94
When is a dose adjustment of edoxaban required and when should it be avoided?
CrCl 15ml/min - 50ml/min - reduce to 30mg OD
Avoid if CrCl <15ml/min
95
What is the typical dosing regimen of apixaban for the treatment of VDT or PE?
10mg BD for 7 days
Then
5mg BD
96
When is a dose reduction of apixaban necessary?
When used for prophylaxis of stroke and systemic embolism in non-valvular AF in patients in patients **>80yrs**, **< 60kg**, or with **CrCl 15 -29ml/min**
## Footnote
Dose reduced to 2.5mg BD
97
What are the MHRA warnings associated with the use of the DOACs?
- Increased risk of recurrent thrombotic eventsin patients with antiphospholipidsyndrome (June 2019)
- Reminder of bleeding risk, including availability of reversal agents (June 2020)
- Warfarin and other anticoagulants: Monitoring of patients during the Covid-19 pandemic (Octoer 2020)
98
What are the main contraindications for the use of the DOACs?
- Antiphospholipid syndrome
- Prosthetic heart valve
- Almost any condition with increased blled risk or recent surgery
- Concurrent use of any other anticoagulant
99
What is the MHRA warning specifically associated with the use of warfarin?
Reports of calciphylaxis (July 2016)
100
What are the common clinical indications for the use of calcium channel blockers?
1. Amlodipine and nifedipine can be used as first- and second-line treatment of hypertension
2. All calcium channel blockers are used to control symptoms of stable angina
3. Diltiazem and verapamil are used as cardiac rate control in supraventricular arrhythmias (AF, atrial flutter, etc)
101
What are the important adverse effects associated with the use of amlodipine and nifedipine?
- Ankle swelling
- Flushing
- Headaches
- Palpitations
102
What are the important adverse effects associated with the use of diltiazem and verapamil?
- Bradycardia
- Constipation
- Heart block
- Heart failure
## Footnote
Diltiazem has mixed vascualr and cardiac actions and causes any/all of the adverse effects associated with the use of CCBs
103
When is the use of amlodipine and nifedipine contraindicated?
- Unstable angina
- Severe aortic stenosis
- Cardiogenic shock
104
When is the use of verapamil and diltiazem contraindicated?
- Severe impairment of left venticular function
- Bradycardia
- Heart failure
- Hypotension
- Heart block
105
Which drugs cannot be given alongside non-dihydropyridine calcium channel blockers unless under specialist supervision and why?
Beta-blocker, because they are both negatively inotropic and chronotropic, and together may cause heart failure
106
Which calcium channel blocker has the longest half-life and duration of action?
Amlodipine
107
What is a typical dose of amlodipine for hypertension?
5 - 10mg OD
108
What is a typical dose of diltiazem for angina?
MR 90mg BD
109
What is a typical dose of verapamil for supraventricular arrhythmias?
40 - 120mg TD
110
What are the key pointswhen counselling a patient on the use of calcium channel blockers?
- Measures to reduce cardiac risk
- Side effects such as ankle oedema
111
Modified release preparations of which calcium channel blockers are not bioequivalent and as such should be ordered by brand?
Diltiazem
Nifedipine
112
What are the clinical indications for the use of amiodarone?
1. Supraventricular arrythmias (AF, atrial flutter, supraventricular tachycardia)
2. Ventricular tachycardia
## Footnote
Generally only used when other therapeutic options have been ineffective
113
When is the use of amiodarone contraindicated?
- Thyroid dysfunction
- Heart block
- Severe conduction disturbances
## Footnote
Amiodarone shouldalso be used with caution in those with severe hypotension
114
What are the most notable interactions with amiodarone?
- Grapefruit juice
- Digoxin
- Non-hydropyridine CCBs
- Drugs that prolong the QT
- Phenytoin
- Atorvastatin
- Warfarin
- Nitrofurantoin
115
What are the key points when counselling a patient on the use of amiodarone?
- Grey skin and photosensitivity (UV protection)
- Microdeposits in the eye
-
116
How do heparins affect potassium levels?
Increase
117
What are the common clinical indications for the use of ADP receptor antagonist antiplatelets?
1. Treatment of ACS, usually in combination with aspirin
2. Prevention of occlusion of coronary artery stents, usually with aspirin
3. Long-term secondary prevention of thrombotic events in patients with cardiovascular, cerebrovascualr and peripheral arterial disease
118
How long before elective surgery should clopidogrel be stopped?
7 days
119
What are the some adverse effects associated with the use of antiplatelets?
- Haemorrhage
- GI upset
- Thrombocytopenia (rare)
120
When is the use of antiplatelets contraindicated?
Active bleeding
121
Which drugs interact with clopidogrel and to what extent?
- Omeprazole - decreases efficacy of clopidogrel
- CYP inhibitors (erythromycin, SSRIs, metronidazole, etc)
122
What is the typical dosing regimen of clopidogrel for the treatment of ACS?
Loading of 300mg once only
Maintenance 75mg OD
123
What is the typical NSAID dose of aspirin for mild to moderate pain?
300 - 900mg QD (Max 4g)
124
What is the typical dose for the treatment of migraine?
900mg as a single dose at onset of symptoms
125
What are the indications for the use of aspirin?
1. Treatment of ACS and acute ischaemic stroke
2. Long-term secondary prevention of thrombotic events in patients with cardiovascular, cerebrovascualr and peripheral aterial disease
3. Mild to moderate pain and fever
126
What are the important adverse effects associated with the use of aspirin?
- GI irritation and ulceration
- Bronchospasm
- Haemorrhage
- Tinnitus
## Footnote
Overdose is characterised by hearing changes, hyperventilation, metabolic acidosis, confusion, followed by convulsions, cardiovascualr and respiratory arrest
127
What is the minimum age a patient can be to receive aspirin?
16 - risk of Reye's syndrome in children <16
128
When is the use of aspirin contraindicated?
- <16yrs
- Bleeding disorders
- Peptic ulceration
- Severe cardiac failure
129
Which drugs interact with aspirin and to what extent?
Antiplatelets - increased risk of bleeds
Anticoagulants - increased risk of bleeds
130
What is the typical dose and duration of aspirin for the treatment of ischaemic stroke?
300mg OD for 2 weeks
131
What are the beta-blockers indicated for?
1. Ischaemic heart disease toimprove symptoms and prognosis of ACS
2. Heart failure
3. Reduce ventricular rate and maintain sinus rythm in AF
4. Restore sinus rhythm is supraventricular tachycardia
5. Hypertension when ACEIs, ARBs, CCBs, and diuretics are insufficient
132
When is the use of beta-blockers contraindicated?
- Asthma
- Uncontrolled heart failure
- Heart block
- Concurrent use with non-dihydropyrine CCBs unless under specialist supervision
133
Which beta-blockers are cardioselective?
Atenolol
Bisoprolol
Metoprolol
134
What are some important adverse effects associated with the use of beta-blockers?
- Peripheral coldness
- Headache
- GI upset
- Sleep disturbances
- Impotence
135
Which beta-blockers are non-cardioselective?
Propranolol
Labetolol
Carvedilol
Sotalol
136
Can beta-blockers be use in asthma and COPD?
Asthma - No
COPD - Use is not contraindicatd but it is prudent to use amore cardioselective option such as bisoprolol to minimise risk of bronchospasm
137
When do beta-blockers require dose reduction?
In hepatic impairment
138
How should beta-blockers be dosed in heart failure?
They should be started at a **low dose and up-titrated slowly** as they can initially impair cardiac function
139
Which drugs interact with beta-blockers and to what effect?
- Non-dihydropyridine CCBs - increased risk of bradycardia, heart failure, and asystole
140
Which is usualy the beta-blocker of choice when starting acute treatment for ACS and other indications, and how is it dosed?
Metoprolol
25mg 8hrly
## Footnote
More responsive to dose adjustment in acute treatment - can be switched to OD preparations for long-term maintenance
141
What are the common indications for the use of digoxin?
1. In AF and atrial flutter to reduce ventricular rate (However beta-blockers or CCBs are usually more effective)
2. Severe heart failure in patients who are already taking an ACE, beta-blocker and either an aldosterone antagonist or ARB
142
When is the use of digoxin contraindicated?
- Constrictive pericarditis
- Myocarditis
- Ventricular tachycardia or fibrillation
143
Which drugs interact with digoxin and to what effect?
- Loop and thiazide diuretics - increase risk of hypokalaemia and thus digoxin toxicity
- Amiodarone - increase serum concentration of digoxin
- CCBs - increase serum concentration of digoxin
- Spironolactone - increase serum concentration of digoxin
- Dronedarone - increase serum concentration of digoxin
- Quinine - increase serum concentration of digoxin
144
What is a typical maintenance dose of digoxin for atrial fibrillation or atrial flutter?
125 - 250 micrograms OD
145
What needs to monitored during treatment with digoxin?
- Symptoms
- Heart rate
- Electrolytes
- Renal function
145
What is a typical maintenance dose of digoxin for heart failure?
62.5 - 125 micrograms OD
146
Treatment with which medication can cause ST segment elevation?
Digoxin
147
When should heparins be used with caution?
- Uncontrolled hypertension
- Clotting disorders
- Recent surgery or trauma
- Renal impairment (dose reduction)
148
What should be monitored in long term therapy with heparins?
- Potassium levels
- Platelet count
- Antifactor Xa activity
149
What are the threshold blood pressure readings indicative of Stage 1 hypertension?
Clinical BP between 140/90 and 160/90
(ambulatory home BP of >135/85)
150
What are the threshold blood pressure readings indicative of Stage 2 hypertension?
Clinical BP between 160/90 and 180/90
(ambulatory home BP of >150/95)
151
What are the threshold blood pressure readings indicative of severe hypertension?
Systolic >180
Diastolic >120
152
What is a target blood pressure during treatment of hypertension in a patient younger than 80yrs?
<140/90
(ambulatory home BP <135/85)
153
What is a target blood pressure during treatment of hypertension in a patient older than 80yrs?
<150/90
(ambulatory home BP <145/85)
154
What are the steps for the treatment of hypertension in patients over 55yrs or of black african or African-Caribbean origin (without type 2 diabetes)?
Step 1. CCB
Step 2. CCB + ACEI / ARB / thiazide-like diuretic
Step 3. CCB + ACEI/ARB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker
155
What are the steps for the treatment of hypertension in patients younger than 55yrs and not of black african or African-Caribbean origin?
Step 1. ACEi / ARB
Step 2. ACEi / ARB + CCB / thiazide-like diuretic
Step 3. ACEi / ARB + CCB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker
156
What are the steps for treatment of hypertension in patients with type 2 diabetes?
Step 1. ACE / ARB (always ARB in African/Caribbean origin)
Step 2. ACE / ARB + CCB / thiazide-like diuretic
Step 3. ACE / ARB + CCB + thiazide-like diuretic
Step 4. K+ less than 4.5 low dose spironolactone /// K+ more than 4.5 alpha-/beta-blocker
157
What is the target blood pressure for a patient with type 1 diabetes being treated for hypertension?
135/85
158
What is the antihypertensive drug of choice in pregnancy
Labetolol
159
Woemn if at moderate and high risk of hypertension during pregnancy are advised to take whatfrom week 12 until birth?
Aspirin
## Footnote
Unlicensed use
160
Which antihypertensives should be stopped on discovery of pregnancy?
- ACEis
- ARBs
- Thiazide and thiazide-like diuretics
## Footnote
Due to risk of congenital abnormalities
161
What are the second- and third-line choices for antihypertensives in pregnancy?
2nd - MR nifedipine
3rd - methyldopa
162
What action should be taken regarding methyldopa post pregnancy for the treatment for hypertension?
Methyldopa should be stopped within 2 days of birth and switched to an alternative antihypertensive
163
What are the first line choices of antihypertensives post-pregnancy in women who decide to breastfeed?
- Enalapril
- (African/Caribbean) nifedipine or amlodipine
164
Which drug class does methyldopa belong to?
Centrally acting antihypertensive
165
Which class of cardiac medications can mask the symptoms of hypoglycaemia?
Beta-blockers
## Footnote
Not contraindicated but cardioselective beta-blockers are preferred
166
167
Which calcium channel blocker can be used in heart failure?
Amlodipine
168
Which combination of drugs is sold under the brand name Entresto?
Sacubitril and valsartan
169
What is a typical dose of amlodipine for the treatment of angina or hypertension?
5 - 10mg OD
170
Which drug can be given in hypotensive crises?
Sodium itroprusside
171
How is heart failure characterised?
- Breathlessness
- Swelling of the ankles
- Reduced exercise tolerance
- Fatigue
- Elevated jugular venous pressure
- Pulmonary crackles
- Pulmonary oedema
172
What is the ejection fraction of the left ventricle in heart failure with reduced ejection fraction?
<40%
173
Which calcium chaneel blockers should be avoided in heart failure with a reduced ejection fration?
- Rate limiting CCBs (verapamil + diltiazem)
- Short acting hydropyridines (nifedipine + nicardipine)
## Footnote
These drugs reduce cardiac contractility
174
Which class of diuretics is the class of choice for the relief of breathlessness and oedema in patients with heart failure?
Loop diuretics
175
What is the first line therapy for heart failure irrespective of other comorbidities?
ACEi and beta-blocker
## Footnote
ARB if ACEi not tolerated or contraindicated
176
What is the second-line therapy option in worsening heart failure?
Consider adding aldosterone antagonist such as spironolactone to existing therapy
177
What is the third-line therapy option in worsening heart failure despite optimal treatment?
Specialist advice should be sought regarding the use of amiodarone, digoxin, Entresto, empaglaflizon, and dapagliflozin.
178
What are the 4 pillars of heart failure?
## Footnote
a.k.a most commonly prescribed combination for heart failure
ACEi
Beta-blocker
Aldosterone antagonist
SGLT2 inhibitor
## Footnote
Entresto replaces ACEi in this combination if prescribed
179
When is digoxin used in heart failure?
For those in sinus rhythm with worsening symptoms or severe heart failure
180
What are the monitoring requirements for treating heart failure?
- Serum potassium
- Serum sodium
- Renal function
- Blood pressure
- Heart rate
(all of these measured monthly for 3 months, then every 6 months)
181
When is the use of spironolactone contraindicated?
- Hyperkalaemia
- Anuria
- Addison's disease
182
How should Entresto be initiated in a patient already established on an ACEi?
Must wait at least 36 hours atfer last dose of ACEi before first dose of Entresto
## Footnote
Risk of angioedema
183
What can be used for the treatment of severe hypercholesterolaemia or hypertriglyceridaemia that is not adequately controlled by maximal dose of a statin?
Ezetimibe
184
Which statin is associated with the highest risk of myopathy?
Simvastatin
185
What is used to treat acute attacks of stable angina?
GTN
186
What are the first line options for the loing term prevention of chest pain in stable angina?
Beta-blocker (bisoprolol)
(rate-limiting CCB if BB not appropriate)
187
What si the second line option for the prevention of chest pain in stable angina when monotherapy is ineffective?
**Combined use of a beta-blocker and CCB**
(if this is not possible a **long-acting nitrate** can be used such as ivabradine, nicorandil, or ranolazine)
188
What should patients with stable angina be given for secondary prevention of cardiovascular events?
- Low dose aspirin
- Statin
- ACEi (particularly in diabetes)
189
What is the initial management for all acute coronary syndromes?
- Pain relief with GTN sublingual or buccal
- Loading dose of aspirin (300mg ONCE)
190
What is the initial management for STEMI?
- Loading dose of aspirin (300mg ONCE)
- Dual anti-platelet therapy (aspirin + clopidogrel/ticagrelor/prasugrel)
191
Which antiplatelet is preferred in patients receiving percutaneious coronary intervention following STEMI?
Prasugrel
192
What is the initial management of NSTEMI or unstable angina?
- Loading dose of aspirin (3oomg ONCE)
- Dual antiplatelet therapy
- Possibly antithrombin therapy with fondaparinux
193
For secondary prevention following STEMI and NSTEMI what should be offered to the patient?
- ACEi
- Beta-blocker
- Dual antiplatelet therapy
- Statin
194
How does secondary prevention differ following NSTEMi and STEMI in those with and without reduced left ventricular ejection fraction?
In those with reduced LVEF - beta-blocker continued indefinitely
In those without reduced LVEF - consider stopping beta-blocker after 12 months
195
When can calcium channel blockers such as verapamil and diltiazem be used as an alternative to beta-blockers for secondary prevention following NSTEMI and STEMI?
In patients without pulmonary congestion or without reduced LVEF
196
How long should dual antiplatelet therapy be continued following NSTEMI and STEMI?
Aspirin - indefinitely
Clopidogrel - consider stopping after 12 months
197
What are the first line diuretics for the treatment of hypertension?
Indapamide
Chlortalidone
198
What are the most commonly prescribed alpha-blockers?
Doxazosin
Tamsulosin
Alfuzosin
199
What are the common indications for the use of alpha-blockers?
1. Treatment of benign prostatic hyperplasia
2. Add-on treatment in resistant hypertension when other medicines are insufficient
200
What are the important adverse effects associated with the use of alpha-blockers?
- Hypotension
- Dizziness
- Syncope
## Footnote
Especially when used alongside other antihypertensives
201
When is the use of alpha-blockers contraindicated?
- Postural hypotension
202
What is a typical dose of tamsulosin?
400mcg OD
203
Which alpha-blocker is actually licensed for the treatment of hypertension?
Doxazosin
204
What is a typical dose of doxazosin?
4mg OD
(Max 8mg for BPH / Max 16mg for hypertension)
205
How should treatment with alpha-blockers be started?
Ideally, omit doses of other antihypertensives on the day the alpha blocker is started to avoid pronounced first-dose hypotension
206
What are the commonly prescribed aldosterone antagonists?
SPironolactone
Eplerenone
207
What are the common clinical indications for the use of aldosterone antagonists?
1. Ascites and oedema due to liver cirrhosis
2. Chronic heart failure
3. Primary hyperaldosteronism
208
What are the important adverse effects associated with the use ofaldosterone antagonists?
- Hyperkalaemia
- Gynaecomastia
209
Between spironolactone and eplerenone, which is less likely to cause endocrine side effects?
Eplerenone
210
Can aldosterone antagonists be used in pregnancy and breastfeeding?
No
211
When is the use of aldosterone antagonists contraindicated?
- Hyperkalaemia
- Severe renal impairment
- Addison's disease
212
Which drugs interact with aldosterone antagonists and to what effect?
Drugs that raise serum potassium (trimethoprim, ACEi/ARBs, heparin, NSAIDs, beta-blockers)
213
Which aldosterone antagonist is only licensed for the treatment of heart failure?
Eplerenone
214
What is a typical dose of spironolactone for the treatment of oedema/ascites in cirrhosis?
100mg OD
215
What is a typical dose of spironolactone in heart failure?
25mg OD
216
Describe the action of spironolactone as a diuretic
Spironolactone is relatively weak diuretic and is often given alongside a thiazide or loop diuretic, where it counteracts the potassium wasting effect and potentiates the diuretic effect.
## Footnote
Used together with furosemide at a ratio of 5:1 (Spiro 200mg / furosemide 40mg)
217
What are the most commonly prescribed ACE inhibitors?
Ramipril
Lisinopril
Perindopril
218
What are the common indications for the use of ACE inhibitors?
1. Hypertension
2. Chronic heart failure
3. Ischaemic heart disease
4. Chronic kidney disease and diabetic nephropathy
219
What are some important adverse effects associated with the use of ACE inhibitors?
- Hyperkalaemia
- Persistent dry cough
- Hypotension
- Renal failure
- Angioedema
- Anaphylactoid reactions
220
Can ACE inhibitors be used in pregnancy and breastfeeding?
No
221
When is the use of ACE inhibitors contraindicated?
- Renal impairment (eGFR <60)
- Angioedema
222
When must ACE inhibitors be used with caution?
- Renal artery stenosis
- AKI
- Low sodium diet
- African/Caribbean origin
- Dialysis
223
Which drugs interact with ACE inhibitors and to what effect?
- Drugs that elevate serum potassium (trimethoprim, heparin, NSAIDs, k-spring diuretics, beta-blockers, etc)
- Diuretics - Hypotension
- NSAIDs - ioncreased risk of nephrotoxicity
224
Is the starting dose of ramipril in heart failure typically higher or lower of that in other indications?
Lower
225
What is a typical starting dose of ramipril for heart failure or nephropathy?
1.25mg OD
## Footnote
(Can be uptitrated to 10mg OD)
226
What is atypical starting dose of ramipril for the treatment of hypertension?
2.5mg OD
## Footnote
(Can be uptitrated to 10mg OD)
227
What action should be taken when serum potassium rises above 5mmol/L in a patient taking ramipril?
Stop all other potassium elevating drugs
If despite this potassium rises above 6mmol/L then ramipil must be stopped
228
What are the most commonly prescribed angiotensin receptor blockers?
Losartan
Candesartan
Irbesartan
229
What are the common indications for the use of ARBs?
Generally used when ACEis are not tolerated or as alternative fisrt-line in certain demographics - indications are the same as ACEis:
1. Hypertension
2. Chronic heart failure
3. Ischaemic heart disease
4. Chronic kidney disease and diabetic nephropathy
230
What are some important adverse effects associated with the use of ARBs?
- Hypotension
- Renal impairment
- Hyperkalaemia
## Footnote
Less likely to cause dry cough or angioedema than ACEis
231
Can ARBs be used in pregnancy and breastfeeding?
No
232
When should ARBs be used with caution?
- Renal artery stenosis
- AKI
- CKD
233
Which drugs interact with ARBs and to what effect?
- Drugs that elevate serum potassium (trimethoprim, heparin, NSAIDs, k-sparing diuretics, beta-blockers etc)
- Diuretics - hypotension
- NSAIDs - nephrotoxicity
234
What is a typical starting dose of losartan for hypertension?
50mg OD (25mg >76yrs)
## Footnote
Increased up to 100mg if necessary
235
What is atypical starting dose of losartan for heart failure?
12.5mg OD
## Footnote
Increased up to 100mg if necessary
236
What are the most commonly prescribed loop diuretics?
Furosemide
Bumetanide
237
What are the common indications for loop diuretics?
1. Relief of breathlesness in acute pulmonary oedema
2. Symptomatic relief of fluid overload in chronic heart failure
3. Symptomatic relief of fluid overload in other oedematous states
238
What are some important adverse effects associated with the use of loop diuretics?
- Dehydration
- Hypotension
- Electrolyte depletion
- Hearing loss
- Tinnitus
239
When is the use of loop diuretics contraindicated?
- Hypovalaemia and dehydration
- Severe hyponatraemia
- Severe hypokalaemia
- Anuria
- Drug-induced renal failure
240
When should loop diuretics be used with caution?
- Gout - chronic use can worsen symptoms
- Hepatic encephalopathy
241
Which drugs interact with loop diuretics and to what effect?
- Other drugs that lower serum electrolyte levels
- Digoxin - risk of toxicity increased due to associated hypokalaemia
- Aminoglycosides - increasedrisk of nephrotoxicity and ototoxicity
242
1mg of bumetanide is equivalent to what dose of furosemide?
40mg
243
What are th most ommonly prescribed thiazide and thiazide-like diuretics?
Bendroflumethiazide
Indapamide
Chlortalidone
244
What are the common indications for the use of thiazide and thiazide-like diuretics?
1. As an alternative first-line treatment for hypertension where a CCB would normally be used
2. Add-on treatment for hypertension
245
What are some common adverse effects associated with the use of thiazide diuretics?
- Hyponatraemia
- Hypokalaemia
- Arrhythmias
- Preciptations of attacks of gout
246
When is the use of thiazide diuretics contraindicated?
- Electrolyte depletion
- Addison's disease
247
Which drugs interact with thiazide diuretics and to what effect?
- NSAIDs - reduce the effectiveness of thiazides
- Other diuretics - increase the risk of electrolyte and fluid depletion
248
What are the most commonly prescribed nitrates?
Isosorbide mononitrate
Glyceryl trinitrate
249
What are the common indications for the use of nitrates?
1. Short acting nitrates (GTN) are used for the management of chest pain in acute angina and acute ACS
2. Long acting nitrates (isosorbide) are used for angina prophylaxis where beta-blockers and/or CCBs have been insufficient
3. IV nitrates are used in the treatment of pulmonary oedema (usually in combination with furosemide and oxygen)
250
What are the main adverse effects associated with the use of nitrates?
- Flushing
- Headaches
- Light-headedness
- Tolerance in sustained use
251
When is the use of nitrates contraindicated?
- Aortic stenosis
- Hypotension
- Hypovolaemia
- Cardiac tamponade
- Marked anaemia
252
Which drugs interact with nitrates and to what effect?
- Phosphodiesterase inhibitors (sildenafil) - prolong the hypotensive effects of nitrates
- Antihypertensive medications
253
What is a typical dose of isosorbide mononitrate for angina prophylaxis?
30 - 120mg BD/TDS
254
What information should be given to a patient regarding the administration of GTN?
- Can be taken before tasks that normally bring on angina
- Nitrates are better at preventing than terminating angina
- Sit down for up to 5 minutes before and after administration to avoid postural hypotension
- Should have a nitrate free period of roughly 18 hours for long term use nitrates (BD dosing of morning and afternoon)
255
What are the common clinical indications for the use of warfarin?
1. VTE (concurrent heparin loading is required at initiation)
2. Embolism prophylaxis in patients with AF or prostheric heart valve
## Footnote
Lifelong treatment in those with mechanical heart valves
256
What is the main adverse effect associated with the use of warfarin?
Bleeding
257
When is the use of warfarin contraindicated?
- 48 hours postpartum
- Haemorrhagic stroke
- Acute bleeding risk
258
Can warfarin be used in pregnancy and breastfeeding?
It should ideally beavoided in pregnancy especially in the 1st and 3rd trimesters.
It is not present in breastmilk and appears safe.
259
Which drugs interact with warfarin and to what effect?
- Grapefruit juice
- CYP inducers - decrease serum warfarin levels and increase risk of clots
- CYP inhibitors - increase serum warfarin levels and increase the risk of bleeding
- Broad-spectrum antibiotics - kill gut flora that synthesise vitamin K, increasing bleeding risk
260
Which drugs interact with grapefruit juice?
- Warfarin
- Amiodarone
- Statins
- Antiplatelets
- Calcium channel blockers
- Immunosuppressants
261
Which statins are considered high-intensity?
Atorvastatin 20 - 40mg
Rosuvastatin 10 - 40mg
Simvastatin 80mg
## Footnote
Ordered highest to lowest intensity
262
When is the use of adenosine contraindicated?
- Asthma
- COPD
- Hypotension
- Decompensated heart failure
- Coronary ischaemia
263
263
Which cardiac medication requires the patient to receive a chest x-ray before its initiation?
Amiodarone
