Cardiovascular Drugs

Question 1

Antiplatelet drugs - Aspirin irreversibly acetylates … …-…, preventing production of thromboxane A2, thereby inhibiting platelet . Used in low dose for secondary prevention following MI, TIA/Stroke and for patients with angina or peripheral vascular disease. May have a role in primary prevention.

Answer 1

Aspirin irreversibly acetylates cycle-oxygenate, preventing production of thromboxane A2, thereby inhibiting platelet aggregation. Used in low dose for secondary prevention following MI, TIA/Stroke and for patients with angina or peripheral vascular disease. May have a role in primary prevention.
ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less gastric irritation. They have a role if truly intolerant of aspirin; with aspirin after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.

Question 2

ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less … irritation. They have a role if truly intolerant of …; with … after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.

Answer 2

ADP receptor antagonists (e.g. clopidogrel, prasugrel, ticagrelor) also block platelet aggregation, but may cause less gastric irritation. They have a role if truly intolerant of aspirin; with aspirin after coronary stent insertion; and in acute coronary syndrome. Glycoprotein IIb/IIIa antagonists (E.g. tirofiban) have a role in unstable angina/MI.

Question 3

What is acute coronary syndrome? (ACS)

Answer 3

A spectrum of conditions - unstable angina, NSTEMI, STEMI
Reduction of blood through coronary arteries
Usually after atherosclerotic plaque rupture

Question 4

Treatment aims of ACS:

Answer 4

Reduce cardiac ischaemia:
- Revascularisation
- Thrombolysis
- Medical management 
Reduce myocardial oxygen demand
Prevent recurrence (Secondary prevention)

Question 5

ACS - immediate management

Answer 5

Oxygen, nitrates, anti-emetics,
Anti platelet loading
Fondaparinux/LMWH

MONA - morphine, oxygen, nitrates, aspirin

Question 6

What long term management and secondary prevention would you expect an ACS patient to be discharged home with?

Answer 6

Long term management and secondary prevention
• DAPT - Aspirin + Clopidogrel/Prasugrel/Ticagrelor • ACE-inhibitors/ARB’s
• Beta-blockers
• Statins
• GTN spray
• Lifestyleadvice

Question 7

Aspirin - what is the loading dose?

Answer 7

300mg

Question 8

Aspirin - what is the maintenance dose?

Answer 8

75mg OD

Question 9

Aspirin should be taken with ….

Answer 9

Food

Question 10

What is clopidogrel loading dose?

Answer 10

300 or 600mg as per ESC

Question 11

What is the maintenance dose for clopidogrel?

Answer 11

75mg OD

Question 12

How long is clopidogrel usually given following MI?

Answer 12

About a year

Question 13

Ticagrelor loading dose?

Answer 13

180mg STAT

Question 14

Ticagrelor maintenance dose?

Answer 14

90mg BD

Question 15

Side effect of ticagrelor?

Answer 15

SOB

Question 16

Side effect of prasugrel?

Answer 16

GI bleeding

Question 17

Loading dose for prasugrel?

Answer 17

60mg STAT

Question 18

Prasugrel maintenance dose

>60kg =, <60kg or over 75yrs =

Answer 18

> 60 kg = 10mg OD

<60 kg or over 75yrs = 5mg OD

Question 19

Contraindications for ticagrelor:

Answer 19

Active bleeding, history of intracranial haemorrhage

Question 20

Contraindications for prasugrel:

Answer 20

History of stroke or TIA, active bleeding

Question 21

Beta-blockers - how do they work on the SA node? And how do they lower BP?

Answer 21

Slow the SA node - slow heart rate allows left ventricle to fill completely and lowers heart workload - also dilate arteries = lower blood pressure

Question 22

Contraindications and cautions for beta blockers

Answer 22

In history of asthma and obstructive airway disease
In 2nd and 3rd degree heart block
Unstable heart failure

Question 23

Side effects of beta blockers

Answer 23

Fatigue
Cold hands/feet
Nightmares/sleep disturbances
Breathing difficulties in asthmatics
Bradycardia
Masks symptoms of hypoglycaemia
Do not stop taking without doctor’s advice as you can get rebound tachycardia

Question 24

Why should you not stop taking beta blockers without doctor’s advice?

Answer 24

Chance of rebound tachycardia

Question 25

…. should be used within 24 hours following an MI in patients with ventricular enlargement due to a poorer prognosis

Answer 25

ACE inhibitors should be used within 24 hours following an MI in patients with ventricular enlargement due to a poorer prognosis

Question 26

With ACEi, it is important to monitor what?

Answer 26

Renal function and electrolytes

Question 27

Side effects of ACEi

Answer 27

Postural hypotension - advised take at night initially Loss of taste/appetite Persistent dry cough

Question 28

Statins - side effects

Answer 28

``` Muscle pain - must be reported to GP or cardiac rehab team Headache Nausea, vomiting and abdominal pain Alcohol - avoid high intake Avoid grapefruit ```

Question 29

What to avoid when taking statins?

Answer 29

High alcohol intake and grapefruit

Question 30

Target cholesterol levels: total cholesterol

Answer 30

≤ 5

Question 31

Target cholesterol levels: Non-HDL cholesterol

Answer 31

≤ 4

Question 32

Target cholesterol levels: Triglycerides

Answer 32

≤ 2.3

Question 33

Target cholesterol levels: LDL cholesterol

Answer 33

≤ 3

Question 34

Target cholesterol levels: HDL cholesterol

Answer 34

≥ 1

Question 35

What cholesterol is ‘bad’?

Answer 35

LDL

Question 36

Why is it advised to avoid grapefruit with statins?

Answer 36

Can cause the statin to stay in your body for longer, causing statin level to increase in blood and increases possibility of side effects

Question 37

How do nitrates help in angina?

Answer 37

Dilation of veins and collaterals - decreased oxygen demand of the heart and increasing coronary flow

Question 38

How do nitrates help in HF?

Answer 38

Dilation of conduit arteries, dilation of veins leads to reduced left ventricular end diastolic pressure, reduced wall stress and a reduction of mitral regurgitation

Question 39

ACS - nitrate effect

Answer 39

Dilation of conduit arteries, dilation of collaterals, antiaggregant effects leading to increased oxygen supply

Question 40

Reasons for using nitrates…

Answer 40

To relieve or prevent expected chest pain (GTN) | To prevent regular chest pain (nitrate tablets/patches)

Question 41

Side effects of nitrates:

Answer 41

Flushing, headache, dizziness, postural hypotension

Question 42

Does the headache with nitrates improve, stay the same, or get worse over time?

Answer 42

Usually reduces and becomes less severe over time

Question 43

What particular medications have an interaction with nitrates?

Answer 43

Medication for erectile dysfunction i.e. Sildenafil, verdenafil, tadalafil - causing significant drop in BP

Question 44

This patient is suffering from paroxysmal atrial fibrillation. In the absence of other cardiovascular co-morbidities, this patient can be managed with ….

Answer 44

This patient is suffering from paroxysmal atrial fibrillation. In the absence of other cardiovascular co-morbidities, this patient can be managed with flecainide.

Question 45

Which of the following best describes the pharmacological mechanism of aspirin? A Irreversible inhibition of cyclooxygenase B Direct inhibition of thrombin C Inhibition of the adenosine diphosphate (ADP) receptor D Potentiates the action of anti-thrombin III to inhibit factor Xa E Inhibition of the glycoprotein IIb/IIIa receptor

Answer 45

Aspirin is commonly used in patients with, or at risk, of ischaemic heart disease. It works through irreversible inhibition of cyclooxygenase.

Question 46

Direct inhibition of thrombin. …

Answer 46

Direct inhibition of thrombin. Dabigatran

Question 47

C: Inhibition of the adenosine diphosphate (ADP) receptor. …

Answer 47

C: Inhibition of the adenosine diphosphate (ADP) receptor. Clopidogrel

Question 48

D: Potentiates the action of anti-thrombin III to inhibit factor Xa.

Answer 48

Low molecular weight heparin.

Question 49

Which of the following is not a recognised adverse-effect of amiodarone? ``` A Hypothyroidism B Hyperthyroidism C Interstitial pneumonitis D Interstitial nephritis E Hepatotoxicity ```

Answer 49

All of the above are considered direct adverse-effects of amiodarone, except interstitial nephritis.

Question 50

Which of the following statements is false regarding aortic regurgitation? A It may be caused by connective tissue diseases (e.g. Marfan’s disease) B Acutely it may cause haemodynamic compromise C Quincke’s sign refers to pulsation of nail beds D It causes a pansystolic machinery murmur E Müller’s sign refers to pulsation of uvula

Answer 50

Aortic regurgitation causes an early diastolic murmur that is heard loudest at the left sternal edge. A pan systolic murmur may be heard in mitral regurgitation and with an interventricular septal defect. The latter may occur following a myocardial infarction with ischaemia to the interventricular septum or may be due to a congenital heart defect.

Question 51

Warfarin is one of the older indirect anticoagulants. Warfarin works on the vitamin K-dependent clotting factors (II, VII, IX, X) through the ..

Answer 51

Warfarin is one of the older indirect anticoagulants. Warfarin works on the vitamin K-dependent clotting factors (II, VII, IX, X) through the inhibition of vitamin K reductase.

Question 52

Which of the following is not a recognised adverse-effect of amiodarone? ``` Hypothyroidism Hyperthyroidism Interstitial pneumonitis Interstitial nephritis Hepatotoxicity ```

Answer 52

All of the above are considered direct adverse-effects of amiodarone, except interstitial nephritis.