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Pre-Reg November Exam '23 > Cardiovascular- HIGH > Flashcards

Cardiovascular- HIGH Flashcards

1
Q

When is amiodarone initiated for patients?

A

ONLY under specialist supervision, usually in secondary care (HIGH RISK DRUG)

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2
Q

What is amiodarone indicated for?

How does it act on the heart?

A

Arrhythmias- where past treatment has failed

Acts on both supraventricular and ventricular arrhythmias

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3
Q

What is the initial dosing schedule for amiodarone?

What is the maintenance dose?

A

Initial: 200mg TDS for 1 week, then 200mg BD for 1 week, then maintenance dose

Maintenance: 200mg OD

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4
Q

What potential adverse effects may be brought on by amiodarone therapy?

A
  1. Corneal microdeposits- rarely interfere with vision but drivers may be dazzled by headlights at night
  2. Phototoxicity- skin sensitive to sun light. Advise patients to use wide spectrum sunscreen
  3. Hyper/hypothyroidism- contains iodine (S&S- weight loss, palpitations and insomnia)
  4. Slight grey skin discolouration (very common)
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5
Q

What are the monitoring requirements for amiodarone?

A
  1. Thyroid function test- every 6 months
  2. LFTs- before treatment and every 6 months thereafter (any signs of hepatotoxicity- STOP TREATMENT)
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6
Q

What might a new/progressive SoB or cough indicate in amiodarone-taking patients?

A

Pneumonitis (inflammation of lungs)

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7
Q

With which other drugs does amiodarone INCREASE the risk of arrhythmias

A
  • Amitriptyline
  • Lithium
  • Quinines
  • Erythromycin
  • Haloperidol
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8
Q

Is amiodarone safe in pregnancy and BF?

A

Pregnancy- possible risk of neonatal goitre (doffuse of nodular enlargement of the thyroid gland). Only use if no alternative

BF- Avoid; present in milk in significant amounts; theoretical risk of neonatal hypothyroidism from release of iodine

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9
Q

What is the mode of action of beta blockers?

A

Reduce cardiac output by BLOCKING beta-receptors in the heart

Also act on beta-receptors in the liver, bronchi and pancreas

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10
Q

When are beta blockers contraindicated?

A

Uncontrolled heart failure

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11
Q

What kind of beta blocker should asthma and COPD patients recieve?

Examples?

A

Cardio-selective BBs

Atenolol, bisoprolol, Metoprolol, nebivolol and acebutolol

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12
Q

What are the side effects of beta blockers?

A
  • GI upset
  • Headache, dizziness, fatigue
  • coldness of extremities
  • Sleep disturbances (nightmares)
  • Affect carbohydrate metabolism- causing hypoglyacemia
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13
Q

When should beta blockers be avoided where possible?

A
  1. Asthma and COPD- action on bronchi can cause bronchospas
  2. Diabetes- action on pancreas and liver can reduce cardbohydrate metabolism and induce hypo/hyperglycaemia (use with caution)
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14
Q

Where should beta blockers be used in caution?

A

Diabetic patients- can mask hypoglyceamia

Cardioselective BB may be preferred

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15
Q

Wht are beta blockers indicated for?

A
  • Angina- reducing workload of heart and prevent recurrence of MI
  • Anxiety symptoms
  • Migraine prophylaxis
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16
Q

Examples of cardioselective beta blockers

A
  • Acebutol
  • Atenolol
  • Betaxolol
  • Bisoprolol
  • Celiprolol
  • Metoprolol
  • Nebivolol
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17
Q

Examples of non-selective beta blockers

A
  • Carvedilol
  • Labetalol
  • Nadolol
  • Oxprenolol
  • Pinolol
  • Propranolol
  • Stotalol
  • Timolol
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18
Q

What is the mode of action of digoxin?

A

Increase the force of myocardial (heart muscle) contraction and reduced contractivity of the AV node

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19
Q

What is digoxin indicated for?

A
  1. Atrial fibrillation
  2. Heart failure
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20
Q

What is the dosing schedule for digoxin?

What is their dose determined by ?

A

Long half life so OD dosing

However, if patient not feeling effects then can be BD

Dose determined by renal function

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21
Q

If required, when should bloods be taken for digoxin monitoring?

A

At least 6 hours after a dose

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22
Q

What are the S&S of digoxin toxicity?

A
  • N&V
  • Blurred/yellow vision
  • Weight loss
  • Anorexia
  • Palpitations
  • Hallucinations
  • Abdominal pain
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23
Q

How is digoxin toxicity treated?

Does the formulation affect the dose?

A

A digoxin specific antibody e.g. Digifab

YES- liquid and tablets have different bioavilabilities

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24
Q

What is tranexamic acid indicated for?

Dosing schedule?

A
  • Prevent bleeding associated with excessive fibronylosis e.g. surgery, dental extraction
  • Management of menorrhagia
  • 2-3 500mg tablets BD/TDS
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25
Q

What is the mode of action of tranexamic acid?

A

Inhibits excessive fibrinolysis (prevents blood clots from being broken down)

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26
Q

What is venous thromboembolism (VTE)?

Which two conditions come under this?

A

Thrombus (clot) formation in a vein

Deep-vein thrombosis (DVT) + Pulmonary Embolism (PE)

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27
Q

Which patient groups are at greater risk of venous thromoelmbolism?

A
  • > 60 years old
  • Limited mobility (secondary care- long stay!)
  • Obesity
  • Malignant disease
  • Thrombophilic disorder
  • History of VTE
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28
Q

What is pulmonary embolism?

A

Blocking of a vein from the heart to the lungs

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29
Q

How is VTE managed?

A

Prophylaxis with Low Molecular Weight Heparin (LMWH) e.g. apixaban

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30
Q

How is VTE managed in patients with renal failure?

A

Unfractionated heparin

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31
Q

What is given to patients if suffering with a haemorrhage while taking unfractionated heparin?

A

Protamine- given to reverse effects of unfractionated heparin

Only partially effective for LMWH

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32
Q

Can heparin be given in pregnancy?

What else may be preferred?

A

Yes- it doesn’t cross the placenta

However, LMWH preferred due to reduced risk of osteoporosis and heparin-induced thrombocytopenia (low platelet count)

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33
Q

What are the side effects of heparin?

A
  • Thrombocytopenia (reduced platelet count)
  • Hypokalaemia (low potassium)
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34
Q

What is the dosing schedule for a LMWH?

A

Duration of action is longer so is OD

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35
Q

What is warfarin indicated for?

A
  • Atrial fibrillation
  • Deep vein thrombosis (DVT)
  • Pulmonary embolism (PE)
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36
Q

What is the mode of action of warfarin?

How long before effects are felt?

A

Vitamin K antagonist (needed to produce clotting factors)

Usually takes at least 48-72 hours to feel full effect
If effect is needed sooner, use a heparin

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37
Q

How are doses calculated for warfarin?

What are the target ranges for AF, DVT, PE and mechanical aortic valves

A

Dose calculated based on patients INR

Targets:
* AF, DVT and PE = 2.5
* Mechanical aortic valve = 3.5

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38
Q

What are the counselling points for warfarin?

A

Ensure dose taken at same time each day

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39
Q

How often should INR be monitored?

Initially and then once stable?

A

Initially- daily or alternate days

Stable- longer durations up to 12 weeks apart

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40
Q

What patient changes may affect INR and require more frequent monitoring?

A
  • Decreased liver function
  • Medication changes
  • Diet
  • Smoking
  • Alcohol intake
  • Recent weight loss
  • Acute illness
  • Diarrhoea and vomiting
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41
Q

What is the main adverse effect of warfarin?

and how is it managed?

A

Haemorrhage (bleeding)

Warfarin stopped immediately and patient started on vitamin K

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42
Q

What is the management if no bleeding present but INR > 8

What if INR is 5-8

A

Give vitamin K orally, and withhold warfarin

Just withhold warfarin (no vitmain K)

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43
Q

How is warfarin therapy managed around elective surgery

and patients at particularly high risk of VTE

A

Stopped 5 days prior to surgery

Restarted almost immediately after the procedure

If high risk VTE, given ‘bridging’ therapy with LMWH- should be stopped 24h before surgery and restarted 48 hours after

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44
Q

How are warfarin patients managed during emergency surgery?

A

Given vitamin K with prothrombin complex depending on timescale

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45
Q

Which regimen has a greater bleeding risk?

Aspirin + Warfarin
or
Clopidogrel + Warfarin

A

Clopidogrel + Warfarin

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46
Q

Can warfarin be given in renal impairment?

A

Yes- increased frequency of INR monitoring needed in severe impairment

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47
Q

What is aspirin typically indicated for?

A

Secondary prevention of cardiovascualr disease (75mg OD)

can be given with prasugrel/ticagralor for prevention of thrombotic events in acute coronary syndrome (sudden reduced blood flow to heart)

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48
Q

What is the dosing regimen for rapid digitalisation in digoxin therapy?

A

0.75-1.5mg over 24h in divided doses

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49
Q

Common Se of digoxin

A
  • Dizziness
  • Blurred vision
  • Skin rash
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50
Q

What can cause increased levels of serum digoxin?

A
  • Renai imapirment (renally cleared)
  • Low body weight
  • P-glycoprotein transport inhibitors e.g. amiodarone, verapamil, macorlides (-mycin), azole antifungals (fluconazole), ciclosporin
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51
Q

Vigorous diuresis may result in…?

A

Increased risk of acute hypotension (low BP)

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52
Q

How is gravitational oedema managed?

A

Movement alone

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53
Q

How is cerebral oedema managed?

A

Osmotic diuretic i.e. IV mannitol

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54
Q

What can be used to manage altitude sickness prophylaxis

A

Carbonic anhydrous inhibitors e.g. acetazolamide

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55
Q

What complication can commonly arise from thiazide-like and loop diuretics?

A

Hypokalaemia- low potassium

Dangerous in severe CVD, esp in patients on cardiac glycosides e.g. digoxin

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56
Q

What can hypokalaemia in heart failure precipitate?

A

Encephalopathy- reduced blood flow/oxygen to the brain

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57
Q

How does hypokalaemia affect magnesium levels?

A

Increases risk of hypomagnesia (low magnesium)

This can lead to increased risk of arrhythmia in alcoholic cirrhosis

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58
Q

What is the mode of action of thiazide-like diuretics?

A

Inhibits the NaCl channel in proximal segment of the distal convoluted tubule

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59
Q

What are thiazide-like diuretics indicated for?

A

Treat oedema due to chronic heart failure

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60
Q

What condition can thiazide-like diuretics exacerbate

A

Diabetes

Do NOT use in gestational diabetes

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61
Q

What are the common side effects of thiazide-like diuretics?

A
  • GI disturbances
  • Postural hypotension
  • Hypokalaemia (avoid in refractory hypokalaemia)
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62
Q

What should be monitored while using thiazide-like diuretics?

A

U&Es

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63
Q

When should thiazide-like diuretics be taken?

A

Ideally in the morning

Can cause urinary urgency during the night

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64
Q

What are the bendroflumethiazide doses for oedema and HTN?

A
  1. Oedema- 5-10mg daily
  2. Hypertension- 2.5mg daily
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65
Q

What are the indapamide doses for regualr and SR forms?

A

Regular- 2.5mg OM
SR- 1.5mg OM

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66
Q

What is the mode of action for loop diuretics?

A

Inhibits reabsorption of NaCl in the loop of Henle

Results in increased excretion of water and loss of calcium and magnsium ions

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67
Q

What are loop diuretics indicated for?

A
  • Chronic heart failure
  • Pulmonary oedema due to left ventricular failure
  • often used with anti-hypertensives to increased BP control
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68
Q

What are the common side effects of loop diuretics?

A
  • GI upset
  • Pacreatitis
  • Hepatic encephalopathy
  • Postural hypotension
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69
Q

Common loop diuretics and thier dosing regimens

A
  1. Bumetanide- 1mg OM
  2. Furosemide- 20-40mg daily. MAX 120mg daily (resistant oedema dose)

Both act within 1 hr

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70
Q

Are potassium sparing diuretics given for hypertension?

Why?

A

No- when given with ACEi or ARBs, increased risk of hyperkalaemia

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71
Q

What must not be given with potassium sparing diuretics

A

Potassium supplementation

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72
Q

How should MR potassium supplements be taken?

A

Whole, with a full glass of water

Whilst sitting/standing

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73
Q

What is amiloride indicated for?

What else is typically given in this regimen?

A
  • Oedema
  • Hepatic cirrhosis with ascites

Given with furosemide (combination drug i.e. Frumil 40mg/5mg tabs)

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74
Q

What is the mode of action of aldosterone and subsequently aldosterone antagonists?

Example?

A
  • Aldosterone sysnthesised by adrenal glands and binds to mineralcorticoid receptors in kidney, colon and sweat glands
  • Increases reabsorption of sodium and water and excretion of potassium
  • Antagonists reduce this action and decreases sodium reabsoprtion and potassium excretion

e.g. spironalactone

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75
Q

What are the consequences of excess aldosterone in the body?

A

Pressure on CV system (increased intravascular fluid retention and volume overload)

76
Q

What is spironalactone indicated for?

A
  • Oedema
  • Ascites caused by liver cirrhosis
  • Hyperaldosteronism
77
Q

Common SE for spironalactone

A
  • GI upset
  • Malaise (general unwell)
  • Dizziness
  • Droswiness
78
Q

What is the maximum daily dose for spironalactone?

A

400mg daily

79
Q

What is the maximum daily dose for eplerenone?

A

50mg daily

80
Q

Which AF medication should be used in sedentary patients?

A

Digoxin- only effective for controlling ventricualr rate at rest

81
Q

What are the causes of Torsade de points (prolonged QT interval)

A
  • Drug induced

Can also be precipitated by:
* Hypokalaemia
* Bradycardia

82
Q

What is flecanide indicated for?
SE?
Dosing schedule and max daily?

A
  • Treat supraventricular and ventricular arrhythmia
  • Usually conserved for rapid control in heavy built patients
  • SE: Dizziness, pro-arrhythmic effects, fatigue
  • 50-100mg BD (MAX: 400mg daily)
83
Q

What is dronedarone indicated for?
SE?
Dosing schedule and max daily?

A
  • Controlling sinus rhythm after cardioversion (previous treatment failure
  • Initiated under specialist supervision
  • Increased risk of hepatic disorders and heart failure
  • 400mg BD
84
Q

Counselling points for dronedarone

A

Recognition of liver disorder e.g. jaundice, fever, malaise

Recognition of new-onset or worsening heart i.e. oedema, dyspnoea (SoB)

85
Q

Can beta blockers be used in pregnancy?

A

Avoid- may cause intr-uterine growth restriction, neonatal hypoglyacemia and bradycardi

Risk is greater in severe hypertension

86
Q

Caution for Labetalol use?

A

Liver damage reported with use - STOP at any sign of liver dysfunction and do not restart

87
Q

Propranolol max daily dose?

A

320mg daily

88
Q

Cautions for sotalol use?
Dosing schedule?

A
  • Prolongs QT interval (ECG monitoring required)
  • 80mg initially- may be adjusted every 2-3 days to allow monitoring of QT intervals
89
Q

Target clinic BP?

A

< 140/90 mmHg

90
Q

Complications of HTN in T2DM?

A

Increased risk of macro and microvascular complications

91
Q

Complications of HTN in T1DM?

A

Usually indicated diabetic nephropathy

92
Q

What effect can the rapid reduction of BP have on patients?

A

Can cause:
* Reduced organ perfusion
* Blindness
* Myocardial infarction

93
Q

What are the treatment steps for HTN in patients under 55 y/o

A

STEP 1: ACEi or ARB

STEP 2: (ACEi or ARB)+ (CCB or Thiazide)

STEP 3: (ACEi or ARB) + CCB + Thiazide

STEP 4: (ACEi or ARB) + CCB + Thiazide + (Low dose spiro../alpha blocker or BB)

94
Q

What are the treatment steps for HTN in patients over 55 y/o /Africa/Carribean

A

STEP 1: CCB

STEP 2: CCB + (ACEi or ARB or Thiazide)

Step 3: CCB + Thiazide + (ACEi or ARB)

Step 4: CCB + Thiazide + (ACEi or ARB) + (Low dose spiro../alpha blocker or BB)

95
Q

Treatment options for primary prevention of CVD when statins are contraindicated?

A
  • Ezetimibe
    OR
  • Bile acid sequestrants e.g. colestyramine or colestipol
96
Q

Typical regimen for secondary prevention of CVD?

A
  • Low dose aspirin (clopidogrel if aspirin contraindicated)
  • Antihypertensive therapy
  • High intensity statin e.g. 80mg atorvastatin
  • If LDL cholesterol remains high- consider ezetimibe or bile acid sequestrants e.g. colestyramine and colestipol
97
Q

What is clonidine indicated for?
Cautions?
Dosing?

A
  • Indicated for HTN, migraine, tourette syndrome
  • Sudden withdrawal can cause severe rebound hypertension
  • 50mcg BD
98
Q
A
99
Q

What is methyldopa indicated for ?
Cautions?
Dosing?

A
  • Indicated for HTN- has been used for HTn in pregnancy
  • Many patients will experience sedation in early treatment
  • 250mg TDS for 2 days. Adjusted no less than every two days to MAX daily dose of 3g
100
Q

What is doxazosin indicated for?
Cautions? SE?
Dosing (MAX?)

A
  • Indicated for HTN and BPH
  • May affect performance of skilled tasks
  • Usually given with a PDE5 inhibitor (e.g. sildenafil, tadalafil)
  • SE: coughing, fatigue, vertigo, sleep disturbances
  • MAX 16mg daily
101
Q

What is indoramin indicated for?
Contraindications?
Dosing (MAX?)

A
  • Indicated for HTN and treating utinary outflow obstruction due to BPH
  • Contraindicated in heart failure
  • MAX dose 200mg daily
102
Q

What is prazosin indicated for?
Contraindications?
Dosing (MAX?)

A
  • Indicated for HTN, congenital HF, Raynauds and BPH
  • Contraindicated in those with history of postural hypotension
  • MAX daily dose 20mg
103
Q

What is terazosin indicated for?
Contraindications?
Dosing (MAX?)

A
  • Indicated for HTN and BPH
  • Usual dose: 5-10mg daily (MAX 20mg)
104
Q

What is the RAAS system?

A

The Renin-Angiotensin-Aldosterone System (RAAS) is a hormone system, essential for regulating blood pressure and fluid balance

Primarily regulted by the rate of renal blood flow

105
Q

Which two classes of drugs are the basis for treatment of chronic heart failure?

In what circumstances mya this regimen be altered?

A

ACEi + BB

If ACEi not tolerated i.e. dry cough, ARB + BB is suitable

105
Q

What is the mode of action of ace inhibitors (ACEi)?

A

Inhibit the conversion of angiotensin I to angiotensin II Angiotensin II narrows blood vessels)

Blocks aldosterone and increases K+ accumulation

105
Q

What are the main indications that ACEi are used for?

A
  • Heart failure
  • HTN
  • Diabetic nephropathy
  • Prophylaxis of CVD events
106
Q

Points to consider before starting a patient on an ACEi

A

Risk of hyperkalaemia- stop K+ sparing diuretics and supplements

First dose can cause hypotension (diuretic dose may need to be reduced/stopeed 24 hours before

107
Q

Monitoring requirements for ACEi

A

Renal function

Discontinue if jaundice or elevted liver enzymes e.g. ALT, AST etc

108
Q

What are the two most common drug class interactions with ACEi

A

ACEi + NSAID = increased risk of renal damage

ACEi + K+ sparing diuretis = increased risk of hyperkalaemia

109
Q

What is captopril indicated for?
MAX dose?

A
  • Indicated for essential HTN and HF with diuretics
  • Max dose 150mg daily
110
Q

Maximum daily dose of enalapril?

A

40mg

111
Q

MAX daily dose of lisinopril?

A

40mg

112
Q

Typical dose for perindopril?
Instructions for administration?

A

5mg daily, increased to 10mg OD in the morning before meal

113
Q

Typical dose for quinapril?

A

Usually 20-40mg daily

114
Q

Typical ramipril dose?
MAX daily dose?

A

Initial: 2.5mg daily
MAX 10mg daily

115
Q

What is the mechanism of action of angiotensin receptor blockers (ARBs)?

A

Blocking AT1 receptors found in the heart, blood vessels and kidneys

Blocking the action of angiotensin II helps reduce BP and reduce damage to heart and kidneys

116
Q

Why are ARBs often a suitable alternative to ACEi?

A

Potentially tolerated better because they don’t inhibit breakdown of kinins (reduced risk of dry cough SE)

117
Q

Common SE of ARBs

A
  • Hyperkalaemia
  • Hypotension
  • Dizziness
118
Q

MAX daily dose of candesartan

A

32mg (highest strength tab remember!)

119
Q

Typical dosing for eprosartan

A

600mg OD

120
Q

Typical dosing and MAX daily for ibersartan

A

Initially 150mg daily increased to 300mg (MAX)

121
Q

Maximum daily dose for losartan

A

MAX 150mg daily

122
Q

Typical dosing and MAX daily for olmesartan

A

Usually 10-20mg (MAX 40mg daily)

123
Q

Typical dose and MAX daily for telmisartan

A

Usually effective at 40mg daily (MAX 80mg daily)

124
Q

Typical dose in HF for valsartan and MAX daily

A

160mg BD (MAX 320mg daily)

125
Q

Mechanims of action for nitrates

A

Coronary vasodilator

Direct relaxant effect on vascular smooth muscle, and dilation of coronary vessels to improve oxygen supply to the heart

126
Q

What are nitrates primarily indicated for?

A

Angina

127
Q

What is angina pain?

A

Tight pain in chest/neck/arm area

Comes from the heart muscle and is a sign that part of it is not getting enough oxygen to maintain its workload

128
Q

When are patients on nitrates more susceptible to developing tolerance?

A

When using long acting transdermal nitrate patches

If tolerance is suspected, leave patch off for 8-12 hours

Modified release forms of isosorbide mononitrate should be given OD

129
Q

Common SE of nitrates

A
  • Flushing
  • Headache
  • Dizziness
  • Postural hypotension
130
Q

What are the different forms of GTN indicated for? (sublingual, injection and transdermal)

A
  • Sublingual: prophylaxis and treatment of angina
  • Injection: control hypertension, myocardial infarction
  • Transdermal: angina prophylaxis
131
Q

Counselling points for GTN spray

A

At onset of attack:

  • 1-2 sprays under tongue
  • If symptoms not resolved, repeat at 5 min intervals for MAX 3 doses
  • If not resolved after 3 doses, seek medical attention
132
Q

Counselling points for GTN transdermal patch

A
  • Cange application site to prevent skin irritation
  • A patch-off period (8-12 hours) each 24 hours is recommended to avoid tolerance
  • If a patch loosens, replace with a new patch
  • MAX 2 transdermal patches daily
133
Q

Counselling points for isosorbide mononitrate (Elantan)

A
  • Have a “nitrate low” period (usually sleeping) when no tabs are taken to avoid tolerance
  • Do not use to treat angina attack
  • Avoid alcohol- can increase effect of Elantan and lower BP too much
134
Q

Mechanim of action of calcium channel blockers (CCBs)

A

Blocks movement of calcium into the heart, reducing contractility and electrical implses in the heart

135
Q

What may withdrawal from CCBs exacerbate?

A

Angina

136
Q

Common SE for CCBs

A
  • Ankle swelling
  • Flushing
  • Palpitations
  • Constipation (if taking verapamil)
137
Q

Typical dosing regimen for amlodipine
Points to consider?

A

5-10mg daily

Strongly affected by CYP3A4 inhibitors

138
Q

MAX daily dose of diltiazem
Points to consider?

A

MAX 360mg daily

Different MR forms available so prescriber must specify brand

139
Q

MAX daily dose for felodipine

A

MAX 10mg daily

140
Q

MAX daily dose of lercanidipine

A

MAX 20mg daily

141
Q

What is ivabradine indicated for?
Dosing schedule? MAX daily?

A

Indicated for angina in normal sinus rhythm, and mild-severe chronic HF

Taken twice a day with meals, morning and evening- usually 5mg BD (MAX 7.5mg BD)

142
Q

Dosing schedule for nicorandil

When is this offered to patients

A

Initially 10mg BD (MAX 40mg BD)

For patients who are intolerant to first line antianginal therapies

143
Q

Dosing schedule for ranolazine (Ranexa)
SE?

A

375-500mg BD

SE: dizziness, headache, constipation, vomiting and nausea

144
Q

What is claudication indicated for?
Cautions?
SE?
Dosing?
Points to consider?

A
  • Indicated for intermittnent claudication (muscle pain due to lack of oxygen triggered by activity)
  • SE: GI upset and dyspepsia
  • Dose: 100mg BD
  • Half the dose if patient on CYP3A4 inhibitor i.e. clarithromycin or CYP2C10 inhibitor i.e. erythromycin, omeprazole
  • Counsel patient on recognising blood disorders i.. bleeding, bruising, sore throat, fever
145
Q

What is the mechanism of action of adrenaline?

A

Acts on both alpha and beta receptors of the sympathetic nervous system, resulting in:

  • Increased HR and contractility (Beta1)
  • Peripheral vasodilation (Beta2)
  • Vasoconstriction (Alpha)
146
Q

Where do inotropic sympathetics act?

A

Act on Beta1 receptors, increasing contractility i.e. dobutamine

147
Q

What is the mechanims of action of dopamine

When is it used in clinical setting

A

A vasocontrictor sympathomimetic acting on Alpha receptors, increasing BP

May be used in an emergency to treat low BP, low HR and cardia arrest

148
Q

What is the mechanims of action of fibrinolytics

A

Activates plasminogen into plasmin which breaks down fibrin (clotting agent)

149
Q

What may be added to statins if lipids remain high?

A

Fenofibrate of nicotinic acid

150
Q

What does the combination of a statin and fenofibrate/nicotinic acid increase the risk of?

A

Increased risk of rhabdomyolysis

151
Q

What are the symptoms of rhabdomyolysis?

A
  • Severe muscle aching or swelling, especially in shoulders, thighs or lower back
  • Muscle weakness or stiffness
  • Dark urine (tea or cola coloured)
152
Q

What causes rhabdomyolysis?

A

Occurs when damagedmuscle tissue releases its proteins and electrolytes into the blood

These substances can damage the heart and kidneys and cause diability or permenant death

153
Q

What can be used in high lipid patients if intolerant to statins?

A

Ezetimibe

154
Q

What is the mechanism of action of statins

A

Act as competitive inhibitors of the enzyme HMG CoA reductase, preventing an early rate limiting step in biosythesis of cholesterol

155
Q

When are statins used in caution/avoided?

A

Caution: liver disease

Avoid in pregnancy- present in breats milk and can affect foetel development

156
Q

What is the management of muscle symptoms in statin use

A

Consider all potential causes:
* Rigorous exercise increases creatinine kinase (CK)- could cause muscle weakness/pain
* Hypothyroidism
* Infection
* Trauma before statin

If statin is cause of muscle SE, disontinue immediately. If symptoms resolve and CK levels return to normal, return to statin at low dose and monitor

157
Q

What are the SEs of statins?

A
  • Myalgia, myopathy, rhabdomyolsis
  • Hepatitis, jaundice
  • Headache
  • Dizziness
158
Q

Which factors increase risk of myopathy in statin use

A
  • Hypothyroidism
  • Family history
  • High dose
  • Drug combinations
159
Q

Which drug combinations result in greater risk of myopathy in statin therapy

A
  • Statin + fusidic acid (contraindicated- stop statin and restart 7 days after last fusidic acid dose)
  • Statin + fibrate
  • Statin + nicotinic acid
  • Statin + macrolides
160
Q

MAX dose of atorvastatin

A

80mg daily

161
Q

MAX dose of Fluvastatin

A

80mg daily

162
Q

MAX dose of pravastatin

A

40mg daily

163
Q

MAX dose of rosuvastatin

A

20mg daily

164
Q

MAX dose of simvastatin

A

80mg daily

165
Q

What is the mechanism of action of bile acid sequestrants?

A

Bile acid sequestrants are highly positively charge molecules that bind to the negatively charge bile acids in the intestine, inhibiting their lipid solubilizing activity and thus blocking cholesterol absorption

166
Q

What is a biproduct of bile acid sequestrant’s MoA?

How is this issue managed?

A

Interferes with absorption of fat soluble vitamins A, D, K and folic acid

Management: advise patients take these other drugs 1 hour before/ 4-6 hours after

167
Q

What is the maximum daily dose of the bile acid sequestrant cholestyramine (Questran 4g sachets)

How should they be taken?

A

MAX 36g daily (9 sachets)

Do not eat dry form. Mix with 150ml suitable liquid i.e. water, fruit juice

168
Q

What is the mechanism of action of ezetimibe?

A

Inhibits intestinal absorption of cholesterol

169
Q

Ezetimibe is often used adjunct to another medication, which?

What does this combination increase the risk of?

A

Used with statin, but can be monotherapy

Increased risk of rhabdomyalsis

170
Q

What is the dosing schedule for ezetimibe?

A

10mg daily

171
Q

What is the healthy amount of LDL cholesterol?

A

100mg/dl

172
Q

What are the SE of ezetimibe

A

Very favourable SE profile SEs:

  • Nausea
  • Diarrhoea
  • Fatigue
173
Q

What is the mechanism of action of fibrates?

A

Decrease serum triglycerides by activating peroxisome proliferator activated receptor alpha (PPARα), increasing lipolysis, activating lipoprotein lipase, and reducing apoprotein C-III.8,11,12 PPARα is a nuclear receptor and its activation alters lipid, glucose, and amino acid homeostasis

174
Q

When are fibrates considered for use in patients with high lipid counts

A

When statin therapy has failed to reduce triglycerides etc

175
Q

What adverse effect can statin + fibrate use have on patients

A

Increased risk of myositis (autoimmune response to attack muscles)

176
Q

What is fenofibrate indicated for?

A
  • Hyperlipidaemia
  • Hypertriglyceridaemia
177
Q

What is gemfibrozil indicated for?

A
  • Hypertriglyceridaemia
  • Hyperlipidaemia
  • Hypercholesterolaemia
178
Q

What must be ensured before starting gemfibrozil therapy?

A
  • Hypothyroidism and diabetes meelitus controlled as best as possible
  • Patient is on lipid-lowering diet
179
Q

Which adverse effects are associated with gemfibrozil

A
  • Myositis
  • Rhabdomyolysis
  • Myopathy
180
Q

What does gemfibrozil interact with?

A

Is an enzyme inhibitor of CYP2C8, CYP2C9, CYP2C19, CYP1A2

181
Q

When is gemfibrozil contraindicated?

A

Use with simvastatin

182
Q

What is nicotinic acid indicated for and when is it considered for patient use?

A

Indicated for dyslipidaemia

Adjunct with statin when statin monotherapy has failed to reduce LDL

183
Q

What are omega-3-fatty acids indicated for?

When are they considered for use?

A

Indicated for hyperlipidaemia

As an alternative for fibrate in addition to statin where monotherapy has failed

184
Q

What is the dosing schedule for omega-3-fatty acids?

A

Omacor: 2-4 caps daily with food

Pre-Reg November Exam '23 (10 decks)

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