Cardiovascular 2 Flashcards
(265 cards)
1
Q
What should be considered when using multiple anti-arrhythmic drugs simultaneously?
A
when using multiple anti-arrhythmic drugs together
their negative effects on the heart’s pumping ability add up (negative inotropic effects)
This is especially concerning if the heart’s function is already compromised (mycordial infarction)
as it can further decrease its ability to pump blood effectively
Therefore, caution is needed when prescribing these drugs together, particularly in patients with existing heart issues.
2
Q
How can hypokalaemia affect the pro- arrhythmic effect of many drugs?
A
Enhances it
when potassium levels are low, the heart is more prone to developing arrhythmias, and the effects of anti-arrhythmic drugs can be intensified, potentially leading to more severe or unpredictable outcomes
Potassium plays a crucial role in maintaining the electrical activity of the heart.
3
Q
Can a myocardial infarction compromise the function of the heart? (4)
A
During a heart attack, the blood flow to a part of the heart muscle is blocked, resulting in damage to that area of the heart- leading to cell death, formation of scar tissue
the heart cannot regenerate new muscle cells to replace those damaged during a heart attack- can only form scar tissue
Scar tissue does not contract or conduct electrical impulses like healthy heart muscle, so it can impair the heart’s overall ability to pump blood efficiently (can also increase the risk of abnormal heart rhythms (arrhythmias).
4
Q
What are potential long term complications of a myocardial infarction? (4)
A
Heart Failure: The loss of heart muscle function can reduce the heart’s ability to pump blood effectively, leading to heart failure
Arrhythmias: Scar tissue and changes in the heart’s electrical system can increase the risk of abnormal heart rhythms (arrhythmias)
Reduced Exercise Capacity: Some individuals may experience a decrease in exercise tolerance or shortness of breath due to the compromised function of the heart muscle.
Increased Risk of Future Events: Individuals who have had a heart attack are at higher risk of experiencing recurrent heart attacks or other cardiovascular events in the future.
5
Q
How can a patient significantly improve the heart’s overall health and function following a myocardial infarction? (4)
A
adopting a heart-healthy diet
regular exercise
quitting smoking
adhering to prescribed medications
6
Q
What is the recommended treatment for life-threatening new-onset atrial fibrillation?
A
Emergency electrical cardioversion
7
Q
What drugs can be used to control ventricular rate in atrial fibrillation if it’s not life-threatening?
A
a standard beta-blocker(excluding sotalol)
or
rate-limiting calcium channel blocker such as diltiazem or verapamil
If monotherapy fails, a combination of two drugs including a beta-blocker, digoxin, or diltiazem can be used.
8
Q
How can sinus rhythm (normal heart rhythm)be maintained after cardioversion?
A
so you’ve just done cardioversion for a patient and treated their abnormal heart rhythms. They now have a normal heart rate and we need to maintain it.
Maintain with:
a standard beta-blocker.
Alternatively,sotalol, flecainide, propafenone, or amiodarone may be considered.
9
Q
Why should verapamil be avoided in patients treated with beta-blockers?
A
due to the increased risk of severe hypotension and asystole.
When verapamil and beta-blockers are used together, they can have an additive effect on lowering blood pressure and slowing heart rate. This combination can lead to excessive lowering of blood pressure (severe hypotension) and dangerously slow heart rate (asystole), which can be life-threatening.
10
Q
What is cardioversion?
A
Cardioversion is a medical procedure used to convert an abnormally fast heart rate (tachycardia) or other cardiac arrhythmias to a normal rhythm
using either electricity or drugs
11
Q
When is electrical cardioversion preferred for atrial fibrillation?
A
Electrical cardioversion is preferred if atrial fibrillation has been present for more than 48 hours
procedure doesnt happen straight away
need to fully anticoagulate patient for at least 3 weeks before
and need to continue anticoagulate for 4 weeks after procedure
12
Q
What is atrial fibrillation characterized by?
A
irregular and often rapid heartbeats
13
Q
What are the symptoms of atrial fibrillation? (3)
A
palpitations
fatigue
shortness of breath
14
Q
What complications can atrial fibrillation lead to? (2)
A
Stroke
heart failure
15
Q
How does atrial fibrillation lead to an irregualr heartbeat in the ventricles?
A
In atrial fibrillation, the upper chambers of the heart (atria) beat irregularly and rapidly
they fibrillate (quiver)
This can result in **inefficient filling of the ventricles **
and irregular transmission of electrical impulses to the ventricles
leading to an irregular heart rate in the ventricles as well
16
Q
In atrial fibrillation, drugs are given to CONTROL the ventricular rate but not the atrial rate. Why is this?
A
controlling ventricular rate is often prioritized as it effectively improves symptoms and reduces risks
17
Q
What is electrical cardioversion? (3)
A
an electrical shock is delivered to the heart through paddles or patches placed on the ches
The shock interrupts the abnormal heart rhythm
and allows the heart’s natural pacemaker (the sinoatrial node) to reestablish a normal sinus rhythm.
18
Q
What is pharmacological cardioversion?
A
involves the use of medications
such as antiarrhythmic drugs
to help restore normal heart rhythm
19
Q
What assessments should be conducted for all patients with atrial fibrillation? (2)
A
risk of stroke
risk of bleeding
20
Q
How is risk of stroke identified? (8)
CHADSVAC
A
CHADSVAC
Congestive heart failure (1)
Hypertension (1)
Age 65-74 (1)
Diabetes mellitus (1)
Stroke/TIA/thrombo-embolism (2)
Vascular disease (1)
Age ≥ 75 (2)
Category of Sex Female (1)
21
Q
What CHA2DS2-VASc score indicates a very low risk of stroke for men and women ?
A
0 for men
1 for women
means they do not require antithrombotic therapy for stroke prevention
22
Q
How is the risk of bleeding assesed? (8)
A
HASBLED score
Hypertension (1)
Abnormal liver function (1)
Abnormal renal function (1)
Alcohol (≥ 8u / week) (1)
Stroke (1)
Bleeding (1)
Labile INRs (<60%) (1)
Elderly (Age >65) (1)
Drugs (antiplatelets or NSAIDs) (1)
23
Q
With what CHA2DS2-VASc score is oral anticoagulation recommended?
(men and women)
yes we look at stroke score for this
A
≥ 2 (men)
or ≥ 3 (women)
24
Q
What HAS- BLED score indicates a high risk of bleeding?
A
≥ 3
25
What is the primary function of amiodarone?
alters sinus rhythm to restore normal heart beat
26
Why may loading doses of amiodarone be required?
**Amiodarone has a long half-life**
it may take several days or even weeks to reach steady-state levels in the bloodstream when starting amiodarone therapy
so **loading doses** may be necessary **to achieve therapeutic levels quickly.**
27
What are the warning signs associated with amiodarone use? (7)
The cat hid in the new precious pool
Thyroid dysfunction
Corneal micro deposits
Hepatotoxicity
Impaired vision
Neurological effects
Pulmonary toxicity
Photo-toxic skin reactions
28
How long after stopping treatment with amiodarone can side effects occur?
Side effects can occur **up to a year after stopping** treatment
(due to the drug's long half-life)
29
What is the management strategy for corneal microdeposits caused by amiodarone?
Corneal microdeposits are **reversible on withdrawal of amiodarone**
(rarely interfere with vision)
30
How often should thyroid function tests be conducted in patients receiving amiodarone therapy?
before treatment initiation and then every 6 months during treatment
31
When is serum potassium (K+) measured in patients receiving amiodarone?
before initiating treatment with amiodarone.
32
Why is a chest x-ray performed before initiating treatment with amiodarone? (2)
**assess the patient's pulmonary status**
to **screen for potential pulmonary toxicity**, such as pneumonitis or pulmonary fibrosis
## Footnote
**Amiodarone has been associated with adverse pulmonary effects**, including pneumonitis and pulmonary fibrosis,
33
What is recommended for patients receiving intravenous (IV) amiodarone?
An ECG
| amiodarone can have profound effects on cardiac conduction and rhythm
34
What is the recommendation regarding the use of amiodarone during pregnancy?
Amiodarone should **only** be used during pregnancy **if** there is **no alternative**
(as there is a risk of neonatal goitre associated with its use)
| Neonatal goiter= enlargement of the thyroid gland in newborn infants.
35
Why is breastfeeding discouraged in mothers taking amiodarone? (2)
because the **drug** is **present in significant amounts in breast milk**
and there is a theoretical **risk of *neonatal* hypothyroidism** due to the release of iodine.
## Footnote
Excessive iodine exposure, such as that which can occur with medications like amiodarone, can disrupt the normal functioning of the thyroid gland.
36
Why can drug interactions with amiodarone occur even after treatment has stopped?
has a long half-life.
37
What severe cardiac complications can arise when sofosbuvir is taken with amiodarone?
can increase the risk of severe bradycardia and heart block.
| sofosbuvir= a medication used to treat hepatitis C
38
What medications may experience increased plasma concentrations when taken with amiodarone? (6)
Please put Fred’s dog down the court
Phenytoin
phenindione
Flecainide
Dabigatran
Digoxin
(The)
Coumarins
39
What are some medications that can increase the risk of ventricular arrhythmias when taken with amiodarone?
* amisulpride
* atomoxetine
* chloroquine
* citalopram
* disopyramide
* escitalopram
* haloperidol
* hydroxychloroquine
* levofloxacin
* lithium
* mizolastine
* mefloquine
* moxifloxacin
* phenothiazines
* pimozide
* quinine
* sulpiride
* telithromycin
* tolterodine
* tricyclic antidepressants
40
What **cardiac complications** are more likely to **occur** when **amiodarone** is taken **with** **beta-blockers, diltiazem, or verapamil?**(3)
can increase the risk of:
**bradycardia
atrioventricular (AV) block
myocardial depression**
## Footnote
AV heart block happens when the electrical impulses are delayed or blocked as they travel between your atria (the top chambers of your heart) and your ventricles (the bottom chambers of your heart).
Myocardial depression refers to a condition where the ability of the heart muscle (myocardium) to contract and pump blood is reduced
41
What drug interaction exists between amiodarone and simvastatin?
increased risk of **myopathy**
42
What is the primary function of sotalol?
**reduce heart rate in arrhythmias**
| its a beta- blocker
43
What safety **concern** is associated with sotalol use? (2)
Sotalol **can** **prolong the QT interval**
which can occasionally **lead to life-threatening ventricular arrhythmias.**
44
What monitoring is recommended for patients taking sotalol? (2)
undergo ECG and measurement of corrected QT interval
Additionally, monitor serum electrolytes (potassium, magnesium, calcium)
## Footnote
The corrected QT (QTc) interval is a measurement derived from the QT interval on an electrocardiogram (ECG)
The QT interval represents the time it takes for the heart's ventricles to depolarize and repolarize during each heartbeat.
45
What must be corrected before starting sotalol and during its use?
**electrolyte disturbances** (such as hypokalemia, hypomagnesemia, and hypercalcemia)
46
What is the primary function of digoxin? (2)
Digoxin **slows down** the **heart rate**
**while increasing the force of heart contraction**
47
What is the therapeutic range for digoxin?
1 to 2 mcg/L
48
What are the different bioavailabilities of digoxin in various dosage forms? (3)
| IV, tablet, elixir
IV (intravenous) - 100%, Tablet - 50-90%
Elixir - 75%.
49
What are some warning signs that patients taking digoxin should report to their doctor immediately? (6)
New cars get seen visually
**neurological symptoms** (weakness, lethargy, dizziness, headache, mental confusion, and psychosis)
any **cardiac symptoms** (arrhythmias and heart block)
**gastrointestinal symptoms** (anorexia, nausea, vomiting, diarrhea, abdominal pain)
**signs of overdose** (toxicity difficult to differentiate from clinical deterioration)
**visual symptoms** (blurred and/or yellow vision)
50
in which range is digoxin toxicity likely?
1.5 to 3 mcg/L
51
How should larger doses of digoxin be administered to avoid gastrointestinal symptoms?
should be divided
## Footnote
to avoid gastrointestinal symptoms such as anorexia, nausea, vomiting, diarrhea, and abdominal pain.
52
What should be done in the event of a digoxin overdose?
the medication should be stopped immediately
## Footnote
*(Toxicity is difficult to differentiate from clinical deterioration, and toxicity is likely through a range of 1.5 to 3 mcg)*
53
What electrolytes should be monitored in patients taking digoxin, and why? (2)
**Serum electrolytes**, including potassium (K+), magnesium (Mg2+), and calcium (Ca2+)
## Footnote
*because toxicity can be increased by electrolyte disturbances such as hypokalemia, hypomagnesemia, and hypercalcemia.*
54
Why is monitoring renal function important in patients receiving digoxin therapy?
because the **drug is primarily excreted by the kidneys**
## Footnote
Dose adjustments may be necessary in patients with renal impairment so that digoxin and its metabolites do not accumalate
55
How **often** should digoxin levels be measured in patients with **renal impairment?**
measure **at least every 6 hours**
## Footnote
(by taking blood samples and looking at the plasma concentration of digoxin)
56
What is the target heart rate that should be maintained in patients taking digoxin?
a heart rate **above 60 beats per minute**
57
What adjustments should be made in digoxin dosage for patients with renal impairment? (2)
* the digoxin dosage should be reduced
* plasma concentrations should be monitored
58
What are some drug interactions that can increase plasma concentration when combined with digoxin? (13)
* alprazolam
* amiodarone
* ciclosporin
* diltiazem
* itraconazole
* lercanidipine
* macrolides
* mirabegron
* nicardipin
* nifedipine
* quinine
* spironolactone
* verapamil
59
How can certain medications affect the risk of cardiac toxicity and digoxin toxicity when taken with digoxin?
Drugs that increase the risk of cardiac toxicity and digoxin toxicity (as cause hypokalaemia):
an army led troops and negotiated
* acetazolamide
* amphotericin
* loop diuretics
* or thiazides/related diuretics
Additionally, drugs that impair renal function, can affect plasma digoxin concentrations such as:
* nonsteroidal anti-inflammatory drugs (NSAIDs)
* angiotensin-converting enzyme (ACE) inhibitors
60
What are the treatment aims for conditions such as atrial fibrillation (AF)?
are to prevent complications such as stroke and venous thromboembolism (VTE)
61
What are the two main approaches for managing atrial fibrillation (AF)?
by **c****ontrolling ventricular rate** (rate control)
or attempting to **restore and maintain sinus rhythm** (rhythm control).
62
What is the preferred first-line option for rate control in atrial fibrillation (AF)?
Rate control in atrial fibrillation (AF) is preferably achieved using a beta-blocker (not sotalol)
or a rate-limiting calcium-channel blocker such as diltiazem or verapamil.
63
How is rhythm control achieved in atrial fibrillation (AF)?
Rhythm control in atrial fibrillation (AF) is achieved using a beta-blocker.
If a beta-blocker is ineffective or not tolerated, an oral anti-arrhythmic drug such as sotalol, flecainide, or amiodarone can be used.
64
Give an example of an anti-arrhythmic drug that acts on both supraventricular and ventricular arrhythmias.
Amiodarone
65
What class of drugs acts on only ventricular arrhythmias?
lidocaine
66
What is the mode of action of beta-blockers? (2)
reduce cardiac output
by blocking beta-receptors in the heart
(They also act on beta-receptors in the lungs, liver, bronchi, and pancreas)
67
Why are beta-blockers contraindicated in patients with uncontrolled heart failure?
because they **can further reduce cardiac output**
exacerbating heart failure symptoms.
68
Which beta-blockers are water-soluble and unable to cross the blood-brain barrier (BBB)?
* celiprolol
* atenolol
* nadolol
* sotalol
resulting in **fewer sleep disturbances and nightmares**.
| (CANS)
69
Why are cardioselective beta-blockers preferred in patients with asthma or COPD? (2)
because they have a weaker effect on beta-receptors in the bronchi
reducing the risk of bronchospasm.
70
How do beta-blockers affect carbohydrate metabolism?
Beta-blockers can affect carbohydrate metabolism
potentially causing either hyper- or hypoglycemia
(in patients with or without diabetes)
71
Besides reducing cardiac workload, in what other conditions are beta-blockers beneficial? (4)
Beta-blockers are beneficial in **angina** by reducing the workload of the heart and may prevent the recurrence of myocardial infarction (MI).
They also block sympathetic activity in **heart failure**, reducing mortality.
Additionally, beta-blockers such as propranolol can be used for symptoms of **anxiety**
and in the **prophylaxis of migraine**.
## Footnote
By reducing the force of contraction of the heart muscle, beta-blockers decrease the workload of the heart, thereby reducing oxygen demand.
Beta-blockers decrease the heart rate, which reduces myocardial oxygen demand. This can be particularly beneficial during exertion when the heart requires more oxygen.
72
What are the therapeutic uses of digoxin?
Digoxin is used to increase the force of myocardial (heart muscle) contraction
and reduce conductivity of the AV node.
It can be used for atrial fibrillation and heart failure.
73
What is the dosing frequency of digoxin?
Digoxin has a long half-life, allowing for **once-daily dosing.**
**However, if a patient is not responding** to the medication, the dose can be increased to one tablet **twice daily.**
74
When should blood monitoring be conducted for patients taking digoxin?
If blood monitoring is required, a sample should be taken at least 6 hours after a dose of digoxin.
75
How can the risk of hypokalemia be managed in patients taking digoxin? (3)
Patients can take
* potassium-sparing diuretics
* potassium supplements
* foods high in potassium, such as bananas.
76
What are the signs and symptoms of digoxin toxicity? (7)
"Nothing Beats Walking Among Peaceful, Harmonious Atmospheres."
* nausea/vomiting
* blurred/yellow vision
* weight loss
* anorexia
* palpitations
* hallucinations
* abdominal pain
77
What should be considered regarding the bioavailability of liquid and tablet formulations of digoxin?
**Liquid and tablet formulations** of digoxin
have **different bioavailabilities**,
meaning the patient's dose may need to be adjusted accordingly.
78
What is the primary mechanism of action of tranexamic acid, and for what medical conditions can it be used?
Tranexamic acid **inhibits fibrinolysis**
can be used to **prevent bleeding** associated with excessive fibrinolysis (e.g., surgery, dental extraction) and in the management of menorrhagia.
79
What conditions are included under venous thromboembolism (VTE)?
* deep-vein thrombosis (DVT)
* pulmonary embolism (PE)
80
Who should undergo risk assessment for VTE upon admission to the hospital?
All patients admitted to the hospital should undergo a risk assessment for VTE upon admission.
81
Which patients are considered to be at high risk for VTE? (6)
Patients considered to be at high risk for VTE include those
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* anticipated to have a substantial reduction in mobility
* obesity
* malignant disease
* history of venous thromboembolism
* thrombophilic disorder
* patients over 60 years old
82
What pharmacological prophylaxis options are available for high-risk patients to prevent VTE? (3)
Let's Unite Freely."
* low molecular weight heparin
* unfractionated heparin (if the patient is in renal failure)
* fondaparinux
83
What is the initial treatment for deep-vein thrombosis (DVT) and pulmonary embolism (PE)?
low molecular weight heparin **or** unfractionated heparin via intravenous (IV) infusion.
ALSO:
Warfarin is usually started concurrently
the heparin needs to be continued for at least 5 days **and** until INR is ≥2 for at least 24 hours.
84
Why is laboratory monitoring for unfractionated heparin essential during treatment?
Laboratory monitoring for unfractionated heparin is essential
preferably on a daily basis
**to ensure therapeutic levels and to prevent complications** (such as bleeding or inadequate anticoagulation)
85
Why are heparins preferred in pregnancy?
they do not cross the placenta
reducing the risk of harm to the fetus
86
Why are low molecular weight heparins (LMWHs) preferred over unfractionated heparin in pregnancy?
have a lower risk of osteoporosis and heparin-induced thrombocytopenia.
87
When should treatment with heparins be stopped during pregnancy?
Treatment with heparins should be stopped at the onset of labour
and advice should be sought from a specialist regarding management.
88
What should be done if hemorrhage occurs in a patient receiving heparin therapy?
If hemorrhage occurs, heparin should be withdrawn.
If rapid reversal of the effects is required, protamine sulfate can be administered as a specific antidote.
However, it only partially reverses the effects of low molecular weight heparins.
89
How does unfractionated heparin compare to low molecular weight heparins (LMWHs) in terms of onset of action and duration of action?
Unfractionated heparin initiates anticoagulation rapidly but has a short duration of action
while LMWHs have a longer duration of action.
90
Why are LMWHs generally preferred over unfractionated heparin? (3)
LMWHs are generally preferred because they are
* effective
* have a lower risk of heparin-induced thrombocytopenia
* require less frequent dosing due to their long duration of action.
91
Why can unfractionated heparin be used in patients at high risk of bleeding?
because its effect can be terminated rapidly by stopping the infusion.
92
What are the signs of heparin-induced thrombocytopenia, and when does it typically develop?
Signs of heparin-induced thrombocytopenia include:
* a 30% reduction in platelet count
* thrombosis
* skin allergy
It typically develops after 5–10 days of heparin therapy
93
What should be done if heparin-induced thrombocytopenia occurs?
heparin should be stopped
and an alternative anticoagulant such as argatroban or danaparoid should be given.
Platelet counts should return to the normal range in those who require warfarin.
94
How can heparins contribute to hyperkalemia, and which patients are more susceptible?
**Heparins inhibit aldosterone secretion**, which **can result in hyperkalemia**.
Patients that are more susceptible include:
* diabetes mellitus,
* chronic renal failure
* acidosis
* raised plasma potassium
* those taking potassium-sparing drugs
## Footnote
Plasma potassium concentration should be monitored before and during treatment, particularly if treatment is to be continued for longer than 7 days.
95
What is the recommended immediate treatment for transient ischemic attack (TIA), and what alternative is suggested if aspirin is contraindicated?
The recommended immediate treatment for TIA is aspirin 300 mg.
If aspirin is contraindicated, clopidogrel 75 mg should be taken immediately.
## Footnote
A transient ischaemic attack, also called a "mini stroke", is a serious condition where the blood supply to your brain is temporarily disrupted
96
What is the recommended initial management for ischemic stroke?
**Alteplase** is recommended **if** it can be administered within 4.5 hours of symptom onset.
**24 hours after thrombolysis:**
Treatment with aspirin 300 mg once daily for 14 days should be initiated
(If aspirin is contraindicated, clopidogrel 75 mg once daily is recommended)
## Footnote
Thrombolysis refers to a medical treatment aimed at dissolving or breaking down a blood clot (thrombus) that is blocking an artery in the brain, thereby restoring blood flow to the affected area.
97
What should be considered for long-term management after a transient ischemic attack (TIA)?
**modified-release dipyridamole** in combination **with aspirin** is recommended.
If aspirin is contraindicated, just use the modified-release dipyridamole alone
IF BOTH are contraindicated, clopidogrel alone is recommended.
98
What is the recommended long-term treatment for ischemic stroke?
**Clopidogrel** is recommended as long-term treatment for ischemic stroke.
If clopidogrel is contraindicated, modified-release dipyridamole in combination with aspirin is recommended.
99
How should stroke associated with atrial fibrillation be managed in the **long term?**
warfarin
100
When should a statin be initiated after the onset of stroke symptoms, and what lifestyle modifications should be advised to all stroke patients?
A statin should be initiated 48 hours after stroke symptom onset.
All patients should be advised to make lifestyle modifications, including beneficial changes to diet, exercise, weight, alcohol intake, and smoking.
101
What is a transient ischemic attack?
temporary episode of neurological dysfunction caused by a brief interruption in the blood supply to part of the brain.
It typically lasts for a few minutes to a few hours and resolves completely within 24 hours.
TIAs are often referred to as "mini-strokes" and serve as warning signs for a potential impending stroke.
Although TIAs do not usually cause permanent brain damage, they should be taken seriously as they indicate an increased risk of stroke in the near future.
102
How long does it typically take for the anticoagulant effect of warfarin to develop fully?
at least 48 to 72 hours.
103
What is the target INR (International Normalized Ratio) for most indications of warfarin therapy?
2.5
104
What is the recommended duration of warfarin therapy for isolated calf-vein deep vein thrombosis (DVT)?
6 weeks
105
When should warfarin therapy be continued for at least 3 months?
for unprovoked proximal DVT or PE
| may be required long term
106
What are the warning signs of haemorrhage associated with warfarin therapy, and how can it be reversed?
nosebleeds, bleeding from wounds, bruising, etc.
It can be reversed with phytomenadione.
107
What monitoring parameters are recommended for patients on warfarin therapy? (6)
* INR (on alternate days in the early days of treatment, then at longer intervals up to every 12 weeks)
* liver function
* renal function
* full blood count
* blood pressure
* thyroid function
108
Why should warfarin be avoided during pregnancy, especially in the first and third trimesters?
**Warfarin is teratogenic**
increasing the risk of congenital malformations
and placental, foetal, or neonatal haemorrhage.
109
Is warfarin considered safe during breastfeeding?
Significant amounts of warfarin are not present in breast milk
but there is an increased risk of haemorrhage, especially in vitamin K deficiency.
110
Which medications and substances can enhance the anticoagulant effect of warfarin? (5)
a nanny said stop children
* amiodarone
* NSAIDs
* SSRIs
* St. John’s wort
* corticosteroids
and many others...
111
How does hepatic impairment affect the use of warfarin? (2)
mild to moderate hepatic impairment: use with caution
severe hepatic impairment: avoid
112
How should warfarin be used in patients with renal impairment? (2)
mild to moderate renal imapirment: use with caution
severe renal impairment: INR should be monitored more frequently.
113
Why should anticoagulant treatment booklets and alert cards be issued to all patients?
help patients understand their treatment regimen
and serve as a reference for important information.
114
How should warfarin be taken in terms of timing and dosing if a dose is missed?
at the same time each day
once a day
with a full glass of water.
If a dose is missed, patients should not double the dose the next day
115
What should patients do if there are any changes to their medication, lifestyle, or diet while on anticoagulant therapy?
Patients should notify their anticoagulation clinic of any changes to their:
* medication
* lifestyle
* diet
to ensure appropriate management of their anticoagulant therapy.
116
What do brown, blue, and pink tablets of warfarin represent in terms of dosage? (3)
Brown tablets represent 1mg
blue tablets represent 3mg
pink tablets represent 5mg of warfarin.
117
How should the warfarin dose be expressed?
in milligrams
118
Which oral anticoagulants are indicated for prophylaxis in hip/ knee replacement surgery?
* apixaban
* dabigatran
* rivaroxaban
119
Name the enzyme inducers? (10)
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbital
Sulphonylurea’s
St John’s Wort
Barbiturates
Smoking
| Crap GP’s Shout BS
120
What are the enzyme inhibitors? (14)
Sodium Valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulphonamide’s
Ciprofloxacin
Omeprazole
Metronidazole
Grapefruit Juice
Fluoxetine
| Sickfaces.comGF
121
In which cases is aspirin proven to be beneficial?
Aspirin is proven to be beneficial in the **secondary prevention of cardiovascular disease**
but not in primary prevention.
122
What is the alternative to aspirin for secondary prevention of cardiovascular disease?
Clopidogrel
123
For what condition is dipyridamole licensed for secondary prevention?
Dipyridamole is licensed for secondary prevention of ischaemic stroke and transient ischaemic attacks.
124
Which medications are licensed for patients with acute coronary syndrome?
Prasugrel or ticagrelor, in combination with aspirin
## Footnote
Acute coronary syndrome is a term that describes a range of conditions related to sudden, reduced blood flow to the heart. These conditions include a heart attack and unstable angina
125
Why should aspirin-containing preparations not be given to children under 16 years?
due to the risk of Reye's syndrome, which can cause liver and brain damage.
126
What are the warning signs that should be reported immediately to a GP regarding oral antiplatelets? (6)
"Careful Hikers Hike High, Packing Backpacks."
* chronic gastrointestinal bleeding (severe abdominal pain, vomiting blood, tarry black or blood mixed with stools, feeling out of breath and dizzy)
* hemorrhage (unusual bruising or bleeding)
* hypersensitivity reactions to aspirin (severe itching or rash)
* heaviness in the center of the chest
* pregnancy (risk of hemorrhage and impaired platelet activity)
* breastfeeding (risk of Reye's syndrome).
127
What should be monitored in patients taking oral antiplatelets due to the increased risk of gastrointestinal bleeds?
Renal and hepatic function
128
When should modified-release dipyridamole capsules be discarded?
after 6 weeks of use
129
When should oral antiplatelets be taken in relation to food? (2)
All oral antiplatelets should be taken **with or just after food**
**except for dipyridam**
130
What interactions should be considered with clopidogrel regarding its antiplatelet activity? (13)
Clopidogrel's antiplatelet activity may be reduced by various drugs including:
* carbamazepine
* cimetidine
* ciprofloxacin
* erythromycin
* fluconazole
* fluoxetine
* itraconazole
* ketoconazole
* oxcarbazepine
* moclobemide
* lansoprazole
* pantoprazole
* rabeprazole
131
What is the usual protocol for stopping warfarin before elective surgery?
Warfarin is typically **stopped 5 days prior to any elective surgery**
and is **restarted almost immediately after the procedure.**
132
What is "bridging" therapy in the context of warfarin and surgery? (3)
Bridging therapy refers to **the use of a low molecular weight heparin** (LMWH) as interim therapy for **patients stopping warfarin prior to surgery**
especially those considered to have a high risk of venous thromboembolism (VTE).
It should be stopped 24 hours before surgery and resumed 48 hours afterwards
133
What treatment is required for patients needing emergency surgery while on warfarin?
**vitamin K1 with prothrombin complex** depending on the timescale.
134
What is the recommended approach regarding the overlap of anticoagulant therapy and antiplatelet therapy?
Ideally, anticoagulant therapy should not overlap with antiplatelet therapy.
The risk of bleeding is lower with Aspirin + Warfarin compared to Clopidogrel + Warfarin.
135
Can warfarin be used in patients with renal impairment?
Yes, warfarin can be used in patients with renal impairment
, but increased frequency of INR monitoring is needed, especially in cases of severe impairment.
136
What are the mechanisms of action for dabigatran, apixaban, and rivaroxaban?
Dabigatran is a thrombin inhibitor
while apixaban and rivaroxaban are inhibitors of activated factor X
137
How does the dosing frequency differ between rivaroxaban and the other oral anticoagulants?
Rivaroxaban has once daily dosing
whereas dabigatran and apixaban require twice daily dosing.
138
What should be considered regarding the cost of rivaroxaban compared to other oral anticoagulants?
Rivaroxaban is slightly cheaper compared to dabigatran and apixaban.
139
What is important to note about the potential interaction of apixaban and rivaroxaban with other medications?
Apixaban and rivaroxaban may be affected by enzyme inducers/inhibitors, necessitating caution when co-administered with other drugs.
140
What are the potential risks associated with high blood pressure? (4)
High blood pressure increases the risk of:
* stroke
* coronary events
* heart failure
* renal impairment
141
What lifestyle changes are recommended for managing hypertension? (6)
smoking cessation
weight reduction
reduction of alcohol and caffeine intake
reduction of dietary salt and saturated fat
increasing fruit and vegetable intake.
increasing exercise
142
What is considered normal blood pressure?
120/80 mmHg.
143
At what blood pressure readings does Stage 1 hypertension occur? (2)
Stage 1 hypertension occurs when clinic blood pressure is 140/90 mmHg
or when ambulatory daytime or home average is 135/85 mmHg.
144
When is it recommended to treat patients with Stage 2 hypertension? (2)
Treat all patients with Stage 2 hypertension, regardless of age, when:
* clinic blood pressure is 160/100 mmHg
* when ambulatory daytime or home average is 150/95 mmHg
145
What are the blood pressure targets for individuals over 80 years old? (2)
For individuals over 80 years old,
the blood pressure target is ≤ 150/90 mmHg
or ≤ 145/85 mmHg for ambulatory or home average readings.
146
What are the blood pressure targets for individuals under 80 years old? (2)
For individuals under 80 years old
the blood pressure target is ≤ 140/90 mmHg
or ≤ 135/85 mmHg for ambulatory or home average readings.
147
What are the blood pressure targets for individuals with cardiovascular disease or diabetes in the presence of kidney, eye, or cerebrovascular disease?
≤ 130/80 mmHg.
148
What is the first-line drug treatment recommended for individuals under 55 years old with hypertension
ACE inhibitor OR ARB
(Give beta- blocker if this contra- indicated)
149
What are the steps to managing blood pressure in indivdiuLA < 55 (4)
Step 1) ACEI/ ARB
- if contraindicated then Beta-blocker
Step 2) ACEI/ARB + Calcium channel blocker
- if not tolerated or risk of HF……. then Thiazide related diuretic (e.g. Chlortalidone or Indapamide)
NOTE: if given B-blocker in Step 1, then a Calcium channel blocker would be given in preference to a Thiazide related diuretic
Step 3) ACEI/ARB + Calcium channel blocker + Thiazide related diuretic
Step 4) Step 3 + low dose spironolactone or increase dose of thiazide diuretic if the plasma conc. is > 4.5mg/L
- if thiazide diuretic therapy is contraindicated then alpha or beta blocker can be given instead
150
What are the steps in managing blood pressure in African/ Carribean?
Step 1) Calcium channel blocker
- if not tolerated or ↑ risk of HF…. then Thiazide related diuretic (e.g. Indapamide)
Step 2) Calcium channel blocker or Thiazide related diuretic + ACEI/ARB
NOTE: ARB most preferred in afro-carribeans
Step 3 & 4) Same as <55
151
What is the recommendation regarding the use of aspirin in the primary prevention of cardiovascular events?
The use of aspirin in the primary prevention of cardiovascular events is of **unproven benefit.**
**instead use a statin**
152
What is the recommended treatment to minimize the risk of renal deterioration in individuals with diabetes and renal disease?
The use of an ACE inhibitor or ARB regardless of blood pressure
153
Which medications are considered safe for use in pregnancy for the treatment of hypertension? (2)
* Labetalol
* methyldopa
154
How is **hypertensive emergency defined**, and what is the recommended approach for treatment?
defined as **severe hypertension with acute damage to the target organs**
Prompt treatment with intravenous antihypertensive therapy is generally required, aiming to reduce blood pressure by 20–25% over the first few minutes to two hours.
155
What is hypertensive urgency, and how is it managed?
Hypertensive urgency is severe hypertension with acute target-organ damage.
Blood pressure should be reduced gradually over 24–48 hours with oral antihypertensive therapy, such as labetalol or other medications.
156
What to do if only systolic pressure of a patient is increased?
If just the systolic pressure is raised, then treat as regular hypertension; raised systolic pressure still poses an increased risk of cardiovascular disease.
157
What are the warning signs of potential adverse effects associated with antihypertensive medications? (13)
water retention
heaviness in the center of the chest triggered by effort or emotion
depression
extreme tiredness
thirst
excessive urination
irregular heartbeat
muscle weakness
nausea
pain or tightness in legs while exercising that disappears at rest
dizziness
light-headedness on standing
blurred vision (postural hypotension).
158
What parameters should be monitored while on antihypertensive medications? (4)
monitor blood pressure
heart rate
renal function
serum electrolytes.
159
What interactions should be considered with certain antihypertensive medications?
Interactions may occur with **medications** such as;
* diltiazem
* verapamil
* amlodipine
* ranolazine
* high-dose statins
ALSO **Grapefruit juice** can increase plasma concentration levels **of** ivabradine, aliskiren, and calcium channel blockers.
160
How can postural hypotension in the morning be prevented?
by sitting and standing up slowly.
161
What precaution should be taken regarding fluid intake while on antihypertensive medications?
It is recommended to drink an adequate volume of fluid daily while on antihypertensive medications.
162
Why should soluble over-the-counter preparations like analgesics be avoided while on antihypertensive medications?
due to their **high sodium content**, which may interfere with the efficacy of antihypertensive treatment.
163
What is advised regarding the maintenance of specific brands of diltiazem and nifedipine?
It is advised to **maintain the same brand** of diltiazem and nifedipine to ensure consistency in treatment.
164
Under what conditions should the initiation of drugs affecting the renin-angiotensin system be done under specialist supervision? (4)
* in individuals with severe heart failure, renovascular disease, hypovolemia, hyponatremia, hypotension
* those receiving multiple or high-dose diuretic therapy
* those recieving high-dose vasodilator therapy
* those taking ARB or aliskiren
165
What renal effects should be considered when prescribing ACE inhibitors?
ACE inhibitors should be best avoided in patients with known or suspected renovascular disease due to the risks of hyperkalemia. If used under specialist supervision, renal function should be monitored regularly. Concomitant treatment with NSAIDs increases the risk of renal damage, and potassium-sparing diuretics or potassium-containing salt substitutes increase the risk of hyperkalemia.
166
What does new onset cough in patients taking ACE inhibitors indicate?
bradykinin build-up.
167
How can anaphylactoid reactions be prevented in patients taking ACE inhibitors?
ACE inhibitors should be avoided *during:*
* dialysis with high-flux polyacrylonitrile membranes
* low-density lipoprotein apheresis with dextran sulfate
They should also be withheld *before* desensitization with wasp or bee venom
168
Why should ACE inhibitors be **used cautiously** in patients with known or suspected renovascular disease?
due to the risks of **hyperkalemia** associated with their use
**regular monitoring** of renal function is recommended in such patients
169
What precaution should be taken when initiating treatment with ACE inhibitors in patients also taking diuretics? (2)
should be initiated with **very low doses**
**especially if** the dose of diuretic is greater than 80 mg furosemide or equivalent
(close supervision is recommended in such cases)
170
What action should be taken if jaundice or marked elevations of hepatic enzymes occur during ACE inhibitor treatment?
the ACE inhibitor should be discontinued due to the risk of hepatic necrosis
171
Why is combination therapy with two drugs affecting the renin-angiotensin system (ACE and ARB) not recommended?
due to an increased risk of:
* hyperkalemia
* hypotension
* renal impairment
(This risk is particularly significant in patients with diabetic nephropathy)
172
What hepatic effects should be monitored during ACE inhibitor treatment?
* Jaundice
* marked hepatic enzymes levels
## Footnote
basically hepatic enzymes will rise but should go down on their own- if levels high monitor and see if they go down overtime. If dont, problem i guess
173
What is the advantage of beta blockers with intrinsic sympathomimetic activity?
* cause less bradycardia
* may also cause less coldness of the extremities
174
Which beta blockers are the most water-soluble and less likely to enter the brain? (2)
**Atenolol** and **sotalol**
potentially causing **less sleep disturbance and nightmares**.
175
Why can beta blockers lead to hypoglycaemia or hyperglycaemia?
because they can affect carbohydrate metabolism
leading to hypoglycemia or hyperglycemia
in patients with or without diabetes
## Footnote
Beta- blockers can also mask the symptoms of hypoglycemia in diabetic patients.
176
Should we avoid beta- blockers inpatients with a history of asthma or bronchospasm? What if theres no alternative available?
**YES, AVOID**
However, **if no alternative** exists, a **cardioselective beta blocker** can be given with caution and under specialist supervision.
177
What symptoms may indicate **excessive bradycardia with intravenous injection of beta blockers?** How can it be countered?
**Symptoms:**
* lightheadedness
* dizziness
* syncope
It can be **countered with intravenous atropine sulfate**.
| Syncope is also called fainting or "passing out."
178
What should be monitored in patients taking labetolol?
**Liver function**
due to the risk of severe hepatocellular damage, which is associated with both short-term and long-term treatment.
(If hepatotoxicity is confirmed, labetalol should be permanently discontinued)
179
What is the mechanism of action of verapamil and diltiazem?
Verapamil and diltiazem
non-dihydropyridine calcium channel blockers (RATE- LIMITING)
* block L-type calcium channels
* calcium used for muscle contraction so by blocking its entry, heart muscle relaxes
* this causes blood vessels to widen, which lowers blood pressure
* they also slow the rate of impulse conduction through the AV node, leading to a decrease in heart rate
## Footnote
These drugs are commonly used to treat conditions like high blood pressure, chest pain (angina), and certain heart rhythm problems.
non-dihydropyridines affect both the heart and blood vessels, leading to effects on heart rate and contractility in addition to vasodilation.
180
Why should verapamil and diltiazem be avoided in heart failure?
may **further depress cardiac function**
and cause clinically significant deterioration.
181
What effect do dihydropyridine calcium channel blockers have on peripheral blood vessels?
Dihydropyridine calcium channel blockers, such as amlodipine, felodipine, lacidipine, lercanidipine, and nifedipine, **cause relaxation of peripheral blood vessels.**
## Footnote
Dihydropyridines mainly target blood vessels, causing vasodilation and lowering blood pressure
while non-dihydropyridines affect both the heart and blood vessels, leading to effects on heart rate and contractility in addition to vasodilation
Dihydropyridines are often preferred for conditions like hypertension, where the main goal is to lower blood pressure
while non-dihydropyridines may be used for conditions like angina and certain heart rhythm problems, where their effects on heart rate and contractility are beneficial.
182
Why should prescribers **specify** the **brand** of **nifedipine MR** on prescriptions?
As different versions of nifedipine MR may not have the same clinical effect
183
In what conditions should the dose form of nifedipine not be used? (5)
* in hepatic impairment
* history of esophageal or gastrointestinal obstruction
* decreased lumen diameter of the gastrointestinal tract
* inflammatory bowel disease
* ileostomy after proctocolectomy
(Dose reduction may be required in severe liver disease)
184
What is shock, and why is it considered a medical emergency?
Shock is a medical emergency associated with a **high mortality rate**
It is characterized by **inadequate tissue perfusion and oxygen delivery to vital organs**.
185
What setting should the use of sympathomimetic inotropes and vasoconstrictors be confined to?
the intensive care setting
(it should be undertaken with invasive hemodynamic monitoring)
186
What are examples of vasoconstrictor sympathomimetics?
* noradrenaline (norepinephrine)
* phenylephrine
187
What is the danger associated with vasoconstrictors?
although they raise blood pressure, they also reduce perfusion of vital organs such as the kidney.
188
Why should adrenaline/epinephrine be used with extreme care when administered intravenously?
because it **can cause severe adverse effects**
It is typically used in CPR for cardiac arrest
should be administered by a specialist.
189
What forms the basis of treatment for all patients with heart failure due to left ventricular systolic dysfunction?
An ACE inhibitor together with a beta-blocker
190
In heart failure patients who continue to remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker, what medication can be added?
An aldosterone antagonist (such as spironolactone or eplerenone)
191
In which cases is digoxin reserved for patients with heart failure?
Digoxin is reserved for patients with worsening or severe heart failure **despite** treatment with an ACE inhibitor, beta-blocker, and aldosterone antagonist.
192
What medication should patients with fluid overload receive?
* loop diuretic
* thiazide diuretic
(with salt or fluid restriction where appropriate)
193
What should be avoided when using potassium-sparing diuretics (aldosterone antagonists) in conjunction with ACE inhibitors or ARBs?
**Potassium supplements**
(due to the risk of severe hyperkalemia)
194
What does the QRISK2 score calculate?
the 10-year risk of cardiovascular events
195
What does the JBS3 score calculate?
the lifetime risk of cardiovasclar events
196
What warrants treatment according to QRISK®2?
QRISK®2 score > 10%
197
Which medications are not recommended for primary or secondary prevention of cardiovascular disease? (4)
* Fibrates
* nicotinic acid
* bile acid sequestrants
* omega-3 fatty acid compounds
198
Who are considered individuals at high risk of developing cardiovascular disease for primary prevention? (6)
those with:
* diabetes mellitus
* hypertension
* smoking habit
* chronic kidney disease
* familial hypercholesterolaemia
* those aged 85 years or older
199
What is the **first- line drug** is offered to individuals at high risk **developing** cardiovascular **disease** if lifestyle modifications are inappropriate or ineffective?
A statin
200
What is the drug of first choice for treating severe hyperlipidaemia?
A statin
201
When should Total cholesterol, HDL-cholesterol, and non-HDL
cholesterol concentrations be checked?
before treatment
3 months after starting treatment
202
What additional lipid-regulating drug may be required if hyperlipidaemia is not controlled with a statin?
ezetimibe
203
What factors increase the risk of muscle toxicity associated with statin use? (6)
* personal or family history of muscular disorders
* previous history of muscular toxicity
* high alcohol intake
* renal impairment
* hypothyroidism
* being elderly
204
What drugs should be avoided when taking a statin due to the increased risk of myopathy? (3)
* fibrate
* nicotinic acid
* gemfibrozil
205
What drugs increase plasma- statin concentration? (4)
* macrolide antibiotics
* imidazole
* triazole antifungals
* ciclosporin
206
What should be done if patient develops muscular symptoms whilst taking statins?
**close monitoring of creatinine kinase**
## Footnote
(If severe muscular symptoms or raised creatine kinase occur during treatment; the treatment should be discontinued. The statin should be reintroduced at a
lower dose and the patient monitored closely; an alternative statin may be prescribed if not tolerated)
207
What **symptoms** should patients look out for as a **rare risk of statins** associated with **interstitial lung disease**? (3)
symptoms such as
* dyspnoea
* cough
* weight loss
## Footnote
patient should seek immediate medical attention
208
Why should hypothyroidism be corrected before starting lipid-regulating treatment?
As correcting hypothyroidism may resolve the lipid abnormality
But needs to be corrected ANYWAY as pt with untreated hypothyroidism who takes lipid-regulating drugs: has increased risk of myositis
209
What should be monitored before and during statin treatment?
**Liver function tests**
* should be measured **before** starting statin treatment
* and repeated **within 3 months**
* and **after 12 months starting** treatment
(due to potential liver function alterations)
210
Why should blood sugar levels be checked before starting statin treatment?
Statins can cause hyperglycaemia
so **patients at high risk of diabetes** should have blood sugar levels checked **before starting** statin treatment and t**hen repeated after 3 months**.
211
How should **acute** attacks of **stable **angina be managed?
with **sublingual glyceryl trinitrate**
(can be taken immediately before performing activities known to bring on an attack)
212
What should be done if acute attacks of stable angina occur more than twice a week?
regular drug therapy is required (not just sublingual GTN)
213
What medications should patients with stable angina be given?
beta-blocker or a calcium-channel blocker
The following may also be added: a long-acting nitrate, ivabradine, nicorandil, or ranolazine
214
What is the difference between unstable angina and NSTEMI?
Unstable angina and NSTEMI are both caused by partial blockage of a blood vessel.
However, patients with unstable angina have no evidence of myocardial necrosis
whereas in NSTEMI, myocardial necrosis (although less significant than with STEMI) will be evident.
## Footnote
NSTEMI and STEMI are both types of heart attacks, but they differ in their presentation and severity
NSTE-ACS (Non-ST Segment Elevation Acute Coronary Syndrome): This type of heart problem **includes unstable angina and NSTEM**I. It happens when there's not a complete blockage in a heart artery. Symptoms can be chest pain, shortness of breath, fatigue, and more. Changes in heart tests might not always show up.
STEMI (ST-Segment Elevation Myocardial Infarction): This is a severe type of heart attack caused by a complete blockage in a heart artery. Symptoms are often severe chest pain, trouble breathing, nausea, and sweating. Heart tests usually show specific changes. It needs urgent treatment to restore blood flow to the heart.
215
What medications are included in the initial management of unstable angina, NSTEMI, and STEMI? (6)
The initial management includes:
* aspirin (to limit clot size and allow blood flow)
* morphine (to relieve pain and anxiety)
* metoclopramide (to relieve nausea from morphine)
* oxygen (to ease labored breathing)
* nitrate (vasodilator to ease blood flow)
* LMWH (anticoagulant to prevent clot growth)
216
What are the **two** coronary interventions used in the additional acute management of STEMI?
**Percutaneous Intervention** (angioplasty plus stent): repairing blood vessel + stent
**Coronary artery bypass graft** (CABG): replacing the damaged vessel with one from another part of the body.
217
What is the alternative to PCI for acute management of STEMI?
**Fibrinolytics**
(stimulate plasmin production, which breaks down clots)
218
What is recommended for long-term management of ACS patients? (2)
| acute coronary syndrome (ACS)
**most** will **require standard angina treatment** to prevent recurrence of symptoms
**Additionally, MI patients should be discharged with the following** medications:
* dual-antiplatelet therapy for up to 12 months (aspirin plus clopidogrel, or prasugrel, or ticagrelor)
* thereafter, aspirin indefinitely
* beta-blocker, reviewed after 12 months
* ACE inhibitor, continued indefinitely
* and a statin for secondary prevention of cardiovascular events.
219
What is the main use of nitrates in the context of angina?
**potent coronary vasodilators**
useful in angina.
220
How does developing tolerance affect the therapeutic effects of nitrates?
Developing tolerance
**reduces the therapeutic effects of nitrates**
To **maintain effectiveness**, a **nitrate-free period** of 4 to 12 hours each day is usually recommended.
221
What should be done in case of serious bleeding associated with fibrinolytic therapy? (2)
calls for discontinuation of the thrombolytic
may need to administer of coagulation factors and antifibrinolytic drugs, such as tranexamic acid.
222
which statins can be taken at any time of day?
Atorvastatin + Rosuvastatin
223
what does atorvastatin interact with? (3)
clarithromycin
verapamil
fibrates (increasing plasma concentration).
224
when is simvastatin taken?
at NIGHT (Cholesterol levels are highest at night)
225
simvastatin interacts with bezafibrate. what would the max dose of simvastin be with this drug?
10mg
226
simvastatin interactions with amiodarone, verapamil, diltiazem and amlodipine. What would be its max dose with these drugs?
20mg
227
what are 3 interactions of simvastatin? (3)
clarithromycin
carbamazepine
grapefruit juice
228
what is the mechanism of action of ezetimbe?
inhibits intestinal absorption of cholesterol
229
What role do loop, thiazide, and potassium-sparing diuretics play in relieving oedema? (2)
relieve oedema due to chronic heart failure
pulmonary oedema caused by left ventricular failure
230
How should diuretics be initiated in elderly patients, and **why?**
initiated at a low dose **to minimize the risk of adverse effects**
then adjusted according to renal function
231
What is the risk associated with thiazide and loop diuretics regarding potassium loss?
Both thiazide and loop diuretics can cause hypokalaemia
**but the risk is greater with thiazides** than with loop diuretics.
232
In what condition can **hypokalaemia caused by diuretics** precipitate encephalopathy?
In hepatic failure
233
What condition can occur due to an enlarged prostate when initiating treatment with diuretics?
Urinary retention
so adequate urinary output should be established before initiating treatment
234
Can loop and thiazide-related diuretics exacerbate diabetes and gout?
Yes
235
What are some warning signs of potential adverse effects of diuretics that should be reported immediately to the GP? (11)
heaviness in the center of the chest
water retention
depression
extreme tiredness
thirst
excessive urination
irregular heartbeat
muscle weakness
nausea
gout
persistent light-headedness and dizziness.
236
What are drugs given with diuretics that will **enhance its hypotensive effect**?
when diuretics are given with:
* ACE inhibitors
* alpha-blockers
* ARBS
237
When potassium-sparing diuretics or aldosterone antagonists are given with certain medications, there is an increased risk of severe hyperkalaemia.
What are these medications? (5)
ACE inhibitors
ARBS
ciclosporin
potassium salts
tacrolimus.
238
What is the potential risk associated with hypokalemia caused by diuretics when combined with cardiac glycosides?
increases the risk of cardiac toxicity
239
How can the plasma concentration of eplerenone be affected by certain medications?
INCREASED plasma concentration of eplerenone: clarithromycin and itraconazole
DECREASED plasma concentration of eplerenone: Carbamazepine, phenobarbital, phenytoin, rifampicin, and St. John’s Wort
240
There is an increased risk of ototoxicity when loop diuretics are given with which antibiotics? (3)
aminoglycosides
polymyxins
vancomycin
241
What are the two main types of peripheral vascular disease?
* Occlusive
* vasospastic peripheral vascular disease
## Footnote
Occlusive Peripheral Vascular Disease: This happens when there's a blockage in the arteries of the arms or legs. often because of fatty deposits in the arteries, which make it hard for blood to flow properly.
Vasospastic Peripheral Vascular Disease: This is when the arteries in the arms or legs suddenly tighten up, making it harder for blood to flow. It can happen because of cold or stress.
242
What causes occlusive peripheral vascular disease?
Occlusion of the arteries
caused by atherosclerosis.
243
How can the risk of cardiovascular events associated with peripheral arterial occlusive disease be reduced? (6)
* smoking cessation
* controlling blood pressure
* regulating blood lipids
* optimizing glycaemic control in diabetes
* taking aspirin at a dose of 75mg
* reducing weight in obesity
244
What medications can alleviate symptoms of intermittent claudication and improve pain-free walking distance? (2)
Naftidrofuryl oxalate
Cilostazol
## Footnote
Intermittent Claudication: This is leg pain or discomfort that happens when you walk or exercise and goes away when you rest.
Cause: It's usually due to narrowed or blocked arteries in the legs, which reduces blood flow.
Symptoms: People with intermittent claudication might feel cramping, pain, or heaviness in their calf muscles when they walk or exercise. The pain typically goes away within a few minutes of resting.
Naftidrofuryl primarily acts as a vasodilator, works by relaxing and widening blood vessels, which helps to increase blood flow to the legs
while cilostazol has additional effects on platelets to help prevent blood clot formation.
245
When are medications used in the management of intermittent claudication?
Only when lifestyle interventions have failed to control symptoms
(it is a second-line treatment)
246
What lifestyle interventions are recommended for managing Raynaud’s syndrome?
* Avoidance of exposure to cold
* smoking cessation
## Footnote
raynauds syndrome is condition characterized by episodes of reduced blood flow to the fingers and toes
fingers or toes suddenly feel very cold and change color when it's chilly or you're stressed.
finegrs can turn white, then blue, and finally red when the blood comes back
may also experience numbness, tingling, or pain
247
What medication is used for reducing the frequency and severity of vasospastic attacks in Raynaud’s syndrome? What is an alternative?
Nifedipin
(alternatively Naftidrofuryl oxalate may produce symptomatic improvement)
## Footnote
Vasospastic attacks in Raynaud's syndrome are episodes where the blood vessels in the fingers or toes suddenly narrow or tighten up, leading to reduced blood flow to these areas.
248
What alternative medication may produce symptomatic improvement in Raynaud’s syndrome?
Naftidrofuryl oxalate.
249
Which of the following beta blockers has a long duration of action:
Sotalol
Metoprolol
Acebutol
Nadolol
Nadolol
250
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What are examples of a thiazide- like diuretic?
Metolazone
indapamide
251
After a successful hip replacement operation, a patient is given rivaroxaban 10mg 1 OD for prophylaxis of VTE. How long will they take it for?
35 days
252
After how many weeks should **GTN SL tablets** be discarded once they are in use?
8 weeks
253
What is an example of a loop diuretic?
Bumetanide
254
What are examples of a thiazide diuretic?
Bendroflumethiazide
Hydrochlorothiazide
Chlorthalidone
255
Give examples of potassium-sparing diuretics?
Amiloride
Triamterene
256
What drugs when given with diuretics increase the risk of ventricular arrhythmias ? (4)
amisulpride
atomoxetine
pimozide
sotalol
## Footnote
because diuretics cause hypokalaemia
so the risk of ventricular arrhythmias heightened when diuretics given with the following
257
What parameters should be monitored while taking diuretics? (3)
Blood pressure
serum electrolytes (such as sodium and potassium)
weight (as a measure of water loss)
258
When are potassium supplements or potassium-sparing diuretics seldom necessary in the routine treatment of hypertension?
necessary when thiazides are used in the routine treatment of hypertension
259
What should ideal cholestrol concentrations be?
**Total Cholesterol **should be ≤ 5 mmol/L
**Non-HDL Cholesterol **should be ≤ 4 mmol/L
**LDL-Cholesterol** should be ≤ 3 mmol/L
**HDL-Cholesterol** should be ≥ 1 mmol/L
260
What is the first-line drug treatment recommended for individuals over 55 years old, especially those of African or Caribbean origin?
a calcium channel blocker (CCB)
if this is not tolerated or high risk of heart failure then Thiazide related diuretic (e.g. Indapamide)
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What is severe hypertension? (2)
clinic systolic blood pressure ≥ 180 mmHg; or
clinic diastolic blood pressure ≥ 110 mmHg
262
How is digoxin toxicity treated?
treated with a digoxin-specific antibody fragment known as **Digifab**.
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Why should beta-blockers not be suddenly stopped? (3)
because abrupt cessation can lead to **rebound effects**
such as worsening angina, hypertension, or arrhythmias
Patients should be advised to seek advice from their GP before discontinuing beta-blocker therapy
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What combination of drugs can be used if a single drug fails to control ventricular rate in atrial fibrillation (AF)?
If a single drug fails to control ventricular rate in atrial fibrillation (AF)
a combination of two drugs can be used
including a beta-blocker, digoxin, or diltiazem
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When should liver function tests be monitored in patients taking amiodarone?
before starting amiodarone therapy and then every 6 months thereafter.
