Cardiology/ Stroke

Question 1

What are the different types of AF?

Answer 1

1. Paroxysmal- Episodes of AFib that last less than 7 days and typically resolve on their own.
2. Persistant- When AF lasts longer than 7 days and needs treatment.

Question 2

Management of AF

Answer 2

** For new/acute AF**
* If NEW AF (i.e., onset < 48 hours):
rate control OR rhthym control
* If onset > 48 hours: rate control

Maintentance
1. Rate control with monotherapy:
* Standard beta-blocker (not Sotalol)
* OR rate-limiting CCB (Diltiazem or Verapamil)
* Digoxin (only in sedentary patients with non-paroxysmal AF).

2. Rate control with dual therapy
3. Rhythm control
   * Pharmacological- Flecanide or Amiodarone
   * Electric cardioversion
   Drug treatment may be required post-procedure:
   - Standard beta-blocker
   - OR Sotalol, Propafenone, Amiodarone, Flecanide

Paroxysmal AF
1. Standard beta-blocker
2. If symptoms persist, Sotalol, Propafenone, Amiodarone, Flecanide
3. If patients have episodes of symptomatic paroxysmal AF, “pill-in-the-pocket” (Propafenone, Amiodarone, Flecanide)

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PLUS ANTICOAGULATION- with either Warfarin or DOAC

Question 3

DOAC- Treatment of VTE

Answer 3

1. Apixaban
   * 10mg BD 7days
   * 5mg BD
2. Rivaroxaban
   * 15mg BD 3 weeks
   * 20mg OD
3. Edoxaban
   * 60mg OD
   * 30mg OD if < 61kg
4. Dabigatran
   * 150mg BD (18-74)
   * 110mg - 150mg BD (75-79)
   * 110mg BD (80+)

Question 4

DOAC + warfarin reversal agents

Answer 4

• Apixaban- Andexanet alfa
• Rivaroxaban- Andexanet alfa
• Edoxaban- NONE
• Dabiatran- Idarucizumab
• Warfarin- Phytomenadione

Question 5

Stroke (Ischaemic) treatment

Answer 5

1. Initial management
   * Alteplase- within 4.5 hours
   * Aspirin 300mg - until 2 weeks after
2. Secondary prevention
   * Clopidogrel 75mg/ Aspirin 75mg
   * PPI
   * High intensity statin

Question 6

What beta-blockers are water soluble?

Answer 6

(Water CANS)

• Celiprolol
• Atenolol
• Nadolol
• Sotalol

Less likely to cross the BBB= less nightmares

Question 7

What beta-blockers are cardio-selective?

Answer 7

(BAtMAN)

• Bisoprolol
• Atenolol
• Metoprolol
• Acebutolol
• Nebivolol

Less likely to cause bronchospasms

Question 8

What beta-blockers are intrinsic sympathomimetic?

Answer 8

(Ice PAC)

• Pindolol
• Acebutolol
• Celiprolol

Less likely to cause cold extremeties

Question 9

Treatment of STABLE angina

Answer 9

1. Immediate relief of symptoms:
   GTN spray: 1 puff, wait 5 mins, another puff, wait 5 mins. If no improvement, call 999.
2. Prevention of symptoms:
   * Beta-blocker, OR CCB (e.g., Amlodipine)
   * If that doesnt work, Beta-blocker AND CCB
   * If that doesnt work, can add: Nicorandil, Ivabridine, or Ranolazine
3. Secondary prevention:
   * Aspirin
   * Atorvastatin
   * ACE
   * Atenolol (but will probably already be on a beta-blocker as above)

Question 10

ACS Protocol

Answer 10

1. Immediate relief of symptoms:
   * Apirin 300mg
   * GTN +/- Morphine
   * Oxygen (if required)
2. Secondary prevention:
   * DAPT: Aspirin 75mg (for life),
   * DAPT: Ticagrelor 90mg BD 1 year (can continue for a further 2 years with Ticagrelor 60mg BD if needed),
   Clopidogrel 75mg OD 1 year,
   OR Prasugrel for 1 year
   * Atorvastatin 80mg
   * ACE
   * Beta-blocker

Question 11

Treatment of Heart Failure

Answer 11

1. ACE and Beta blocker
2. If symptoms persist, add Spironolactone/ Eplerenone
3. If symptoms persist, can add:
   * Sacutabril/ Valsartan
   * Ivabradine
   * Dapagliflozin
   * Digoxin
   * Amiodarone

N.b., loop diuretics if fluid overloaded