Cardiovascular Masterclass Flashcards

Question

What are the main uses with digoxin?

Answer 1

Atrial fibrillation/ flutter – to reduce ventricular rate (beta-blocker, Non-dihydropyridine CCBs more effective) 3rd line in severe heart failure

Answer 2

benign prostatic hyperplasia Add -on for resistant hypertension

Answer 3

Report any symptoms of breathlessness, persistent cough, jaundice, restlessness, weight loss, tiredness or weight gain. Avoid drinking grapefruit juice as it can increase risk of side effects Avoid sun exposure to skin even on a cloudy day and use plenty of suncream. You will be started on a high dose, for one week only. Your dose will then be reduced over the following two weeks to a maintenance dose.

Answer 4

Liver function, cardiac function, thyroid function, renal function and chest x-ray. Liver and thyroid tests – every 6 months Potassium levels - can cause QT prolongation

Answer 5

Lithiumed Beta Ants Dig Diuretic Stats — they said Halo Grape, Pheny, QT!" 🔍 Breakdown: Lithiumed → Lithium: ↑ risk of arrhythmias, thyroid impact, CNS toxicity Beta → Beta-blockers: ↑ bradycardia, AV block Ants → Anticoagulants (e.g. warfarin): ↑ bleeding due to inhibited metabolism Dig → Digoxin: ↑ levels – reduce dose by 50% Diuretic → Loop & thiazide diuretics: cause hypokalaemia → ↑ amiodarone toxicity Stats → Statins (Simvastatin): ↑ risk of myopathy They said Halo → Haloperidol: ↑ QT, torsades de pointes Grape → Grapefruit juice: ↑ plasma concentration of amiodarone Pheny → Phenytoin: ↑ phenytoin levels (amiodarone inhibits metabolism) QT → Many of these ↑ QT interval (TCAs, Citalopram, Haloperidol, Amiodarone itself) Digoxin – increases concentrations of digoxin – reduce digoxin dose by half Diltiazem and verapamil – increases concentration of these - Can increase bradycardia, AV block, heart failure with these 2 TCA – increased risk of ventricular arrhythmias – avoid Beta blockers – increased risk of bradycardia, AV block and myocardial depression Citalopram – risk of ventricular arrhythmias – avoid Coumarins – amiodarone inhibits coumarin metabolism = enhanced anticoagulant effect Diuretics; loops and thiazides = risk of amiodarone toxicity if hypokalaemia occurs Grapefruit juice – plasma concentration of amiodarone increased Haloperidol – increased risk of ventricular arrhythmias Lithium – risk of ventricular arrhythmias, amiodarone can affect metabolism of lithium and both affect thyroid function – avoid Phenytoin – amiodarone inhibits phenytoin metabolism – increased conc. Simvastatin – increased risk of myopath

Answer 6

Hypotension – during IV infusion Lungs – pneumonitis Heart – bradycardia, AV block Liver – hepatitis – jaundice Skin – photosensitivity, grey discolouration Thyroid abnormalities – due to its iodine content Has a very long half life and can take months to clear rom the body

Answer 7

For primary prevention of CVD check lipid profile Liver enzymes at 3 and 12 months Signs of muscle symptoms

Answer 8

Newborns are routinely given a vitamin K injection shortly after birth to prevent vitamin K deficiency bleeding (VKDB), a condition that can cause severe bleeding due to low levels of vitamin K, which is essential for blood clotting. Oral vitamin K requires a second dose

Answer 9

Use 1 or 2 sprays under your tongue. If you're still in pain after 5 minutes you can have a second dose of 1 or 2 sprays under your tongue. Call 999 if you've taken 2 doses of GTN and you're still in pain 5 minutes after your 2nd dose aim the spray under the tongue and close your mouth immediately afterwards learn how to use the spray before an angina attack as you may need to use it in a hurry or in the dark sit down before using the spray and for a few minutes afterwards the most common side effects are headache and facial flushing

Answer 10

Target INR 2.5 DVT/PE Treatment: Includes antiphospholipid syndrome and recurrence after stopping warfarin. Atrial Fibrillation (AF). Cardioversion: Achieve target ≥3 weeks before; continue for ≥4 weeks after (can use INR 3 for up to 4 weeks pre-procedure). MANY OTHERS Target INR 3.5 Recurrent DVT/PE: While on anticoagulation with INR >2. Mechanical Prosthetic Heart Valves: Target depends on valve type, location, and patient risk factors. If embolic event occurs at target INR: Increase INR target or add antiplatelet therapy.

Answer 11

Its potent vasodilatory effects can lead to a reflex tachycardia, which may worsen myocardial ischemia. Amlodipine may be appropriate in stable angina or Prinzmetal’s angina (variant angina caused by coronary vasospasm), as its vasodilatory effects can relieve coronary artery spasm.

Answer 12

Stable angina is a chronic, manageable condition with predictable symptoms and lower short-term risk of heart attack. Unstable angina is an acute emergency with unpredictable, severe symptoms and a higher risk of heart attack or death, requiring urgent treatment.

Answer 13

1. QRISK Use: Primary prevention of cardiovascular disease (CVD) in non-AF patients. Purpose: 10-year risk of cardiovascular events (e.g., heart attack, stroke). Applicable to: General population aged 25–84 without prior CVD or AF. 2. HAS-BLED Use: Bleeding risk assessment, mainly in AF patients on anticoagulants. Note: May be used off-label for bleeding risk in non-AF anticoagulated patients. Not for: General cardiovascular risk in non-AF patients. 3. ORBIT Use: Bleeding risk in AF patients on oral anticoagulants. Not for: Non-AF patients unless on anticoagulants for other reasons. 4. CHA2DS2-VASc Use: Stroke risk in AF patients for anticoagulation guidance.

Answer 14

purine-rich foods, particularly red meat and seafood, increase the risk of gout as higher purine intake is associated with higher uric acid levels. For maintenance treatment, the aim is for serum uric acid levels below 300 micromol/L.

Answer 15

Need to fact check : Water soluble – atenolol, sotalol, nadolol – less likely to enter the brain, therefore less likely to cause sleep disturbance and nightmares Lipid soluble – labetalol, oxprenolol, propranolol, timolol - MORE LIKELY TO CAUSE NIGHTMARES Remember “PLOT” like the plot of a nightmare

Answer 16

(Hyponatraemia) - Both spironolactone and furosemide reduce sodium and this can be potentiated together

Answer 17

Mild (Na+ 130–135 mmol/L): Nausea Fatigue Headache Moderate (Na+ 125–129 mmol/L): Confusion Dizziness Vomiting Muscle weakness Severe (Na+ <125 mmol/L): Altered mental status Seizures Coma Respiratory distress Onset: Acute: Rapid symptoms (seizures, coma). Chronic: Milder symptoms (fatigue, cognitive impairment).

Answer 18

evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol below 1.8 mmol/L (equivalent to a non-HDL-cholesterol below 2.5 mmol/L in a non-fasting sample)

Answer 19

For long-term prevention of vascular events in people with ischaemic stroke or TIA without paroxysmal or permanent atrial fibrillation: clopidogrel 75 mg daily should be the standard antithrombotic treatment; aspirin 75 mg daily should be used for those who are unable to tolerate clopidogrel The combination of aspirin and clopidogrel is not recommended for long-term prevention of vascular events unless there is another indication e.g. acute coronary syndrome, recent coronary stent. [2023]

Answer 20

gynaecomastia breast neoplasm benign; breast pain

Answer 21

used for the treatment and prevention of angina pectoris headache (more common on initiation, usually transitory) Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative.

Answer 22

beta-blockers should not be given with verapamil or diltiazem (non-dihydropyridine calcium channel blockers) because of the risk of severe bradycardia, heart block, or profound hypotension.

Answer 23

INR above 8 or ANY INR with major/minor bleeding

Answer 24

Antibiotics Associated with Intracranial Hypertension Tetracyclines Examples: Tetracycline Doxycycline Minocycline (highest risk within this class) Fluoroquinolones (Less commonly reported) Examples: Ciprofloxacin Levofloxacin

Answer 25

Initially 15 mg twice daily for 21 days, to be taken with food, then maintenance 20 mg once daily, to be taken with food, for duration of treatment

Answer 26

“Offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding: Use LMWH as first-line treatment. If LMWH is contraindicated, use fondaparinux sodium”

Answer 27

Salt intake, max of 6g 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity a week men - no more than 30g of saturated fat daily. On average, women - no more than 20g of saturated fat a day.

Answer 28

Rationale: For people who are suspected to have DVT offer a D-dimer test (if ultrasound scan cannot be carried out within 4 hours). Additional information: Usual presentation of DVT - unilateral localised pain (this is usually throbbing in nature) that occurs when walking or bearing weight, and calf swelling (or more rarely, swelling of the entire leg). Tenderness. Skin changes, which include oedema, redness, and warmth. In suspected DVT, the two-level DVT Wells score can be used to assess the probability of DVT.

Answer 29

Positive inotrope → Increases the force of contraction by inhibiting the Na⁺/K⁺ ATPase pump, leading to increased intracellular calcium. Negative chronotrope → Slows heart rate by increasing vagal (parasympathetic) tone, making it useful for atrial fibrillation (AF) with rapid ventricular response. Used in: Atrial fibrillation (to control ventricular rate) Heart failure with reduced ejection fraction (HFrEF), particularly in symptomatic patients despite optimal therapy

Answer 30

Methyldopa taken during pregnancy should ideally be stopped within 2 days of birth as it may increase the risk of depression.

Answer 31

the bioavailability can be reduced by up to 40% otherwise

Answer 32

Alcohol can cause/worsen AF Alcohol can increase likelihood of doing silly things - falling over, bumping head Alcohol increases everyones bleed risk physiologically

Answer 33

It can cause BLUE-GRAY discolouration - look like smurf It can cause photosensitivity, which is more common - wear suncream for treatment and months following

Answer 34

3 to 10 months

Answer 35

Patients should go home in "SAABs" Statin, Aspirin, ACE inhibitor Beta blocker second/dual antiplatelet therapy

Answer 36

BMJ guidelines:For heart failure with reduced ejection fraction (HFrEF), the "four pillars" of treatment include: ACE inhibitors/ARBs/ARNIs: To manage neurohormonal dysfunction. Beta-blockers: To control heart rate and reduce strain on the heart. Mineralocorticoid receptor antagonists (MRAs): For reducing fluid retention and improving survival. SGLT2 inhibitors: A recent addition that significantly reduces heart failure-related hospitalizations. Diuretics are commonly used to manage symptoms but do not improve mortality. Monitoring and titration are key.

Answer 37

Reduces Intraglomerular Pressure In diabetes and CKD, the renin-angiotensin-aldosterone system (RAAS) is often overactive, leading to high glomerular pressure. ACE inhibitors dilate the efferent arteriole (the vessel exiting the glomerulus), reducing glomerular filtration pressure and slowing the progression of kidney damage. Reduces Proteinuria High glomerular pressure leads to protein leakage (albuminuria), which worsens kidney damage. ACE inhibitors reduce proteinuria, protecting the glomeruli from further injury. Lowers Blood Pressure Hypertension is a major cause of CKD progression. By lowering systemic blood pressure, ACE inhibitors reduce kidney stress and slow CKD progression.

Answer 38

can increase lithium concentration, increasing the risk of toxicity – this is the most concerning issue that should be acted upon first.

Answer 39

The trough level came back high, which means the interval between the doses should be increased. If the peak level was high, the dose should be decreased.

Answer 40

✅ If ACR < 70 mg/mmol → Below 140/90 mmHg (Ideal: 120–139/<90 mmHg) ✅ If ACR ≥ 70 mg/mmol → Below 130/80 mmHg (Ideal: 120–129/<80 mmHg) ✅ Aged ≥ 80 years (Type 1 Diabetes, any ACR) → Below 150/90 mmHg With ACR the higher the number the worse the kidney function and the more protein is being found in the urine

Answer 41

🔹 Dihydropyridines (More Likely to Cause Swelling) ✅ Common culprits: Amlodipine Nifedipine Felodipine Lercanidipine 🔹 Non-Dihydropyridines (Less Likely to Cause Swelling) Verapamil Diltiazem

Answer 42

CHA 2 DS 2 –VASc is a tool used to predict the risk of stroke in patients with atrial fibrillation. ORBIT and HAS-BLED are both tools used to predict the risk of major bleeding with anticoagulation in AF, however ORBIT is the preferred tool recommended by NICE guidelines.

Answer 43

📌 Low-Intensity Statins (Reduce LDL by <30%) Simvastatin 10 mg Pravastatin 10–20 mg Fluvastatin 20–40 mg 📌 Medium-Intensity Statins (Reduce LDL by 30–50%) Atorvastatin 10 mg Simvastatin 20–40 mg Pravastatin 40 mg Rosuvastatin 5 mg Fluvastatin 80 mg 📌 High-Intensity Statins (Reduce LDL by >50%) Atorvastatin 20–80 mg Rosuvastatin 10–40 mg Simvastatin 80 mg (Not routinely recommended due to risk of muscle toxicity)

Answer 44

Use 1-2 sprays under the tongue, repeat after five minute intervals if required. If chest pain persists five minutes after second dose, call 999

Answer 45

LMWH like enoxaparin or Dalteparin -it does not cross the placenta Sometimes unfractionated heparins

Answer 46

Bleeding Injection site reactions Heparin-induced thrombocytopenia – usually after 5-10 days Hyperkalaemia Skin necrosis

Answer 47

Use with caution in patients at increased risk of bleeding, including those with clotting disorders, severe uncontrolled hypertension, recent surgery or trauma Avoid during invasive procedures Renal impairment = use a lower dose or use unrationed heparin Avoid in severe hypertension Caution in elderly Caution in low body weight – increased risk of bleeding

Answer 48

Venous thromboembolism – LMWH 1st choice for VTE prophylaxis for inpatients and for initial treatment of Deep vein thrombosis and pulmonary embolism Acute coronary syndrome – LMWH part of 1st line therapy to improve revascularisation and prevent intracoronary thrombus progression

Answer 49

Dehydration Hypotension Dizziness Low electrolyte state: hyponatraemia, hypocalcaemia, hypokalaemia, metabolic alkalosis At high doses: hearing loss and tinnitus

Answer 50

Monitoring: Improvement in patients symptoms Increased urine output – indicates diuretic effect Monitor sodium, potassium and renal function Counselling: Take dose in the morning to avoid sleep disturbances Look out for signs of dehydration Diabetics – careful may affect your glucose levels

Answer 51

Lithium – levels of lithium increased due to reduced secretion Digoxin – toxicity may increase due to hypokalaemia Aminoglycosides – can increase risk of ototoxicity and nephrotoxicity Phenytoin – effects of furosemide antagonised by phenytoin Theophylline – increased risk of hypokalaemia Amiodarone – hypokalaemia increases toxicity of amiodarone Sotalol – hypokalaemia caused by loop diuretics increase risk of ventricular arrhythmias Beta 2 agonists – increased risk of hypokalaemia with high doses

Answer 52

Thiazides Bendroflumethiazide Thiazide- like Indapamide Chlortalidone

Answer 53

Side effects Hyponatraemia Hypokalaemia Cardiac arrhythmias May increase glucose concentrations – unmask type 2 diabetes May increase LDL- cholesterol and triglycerides Impotence in men - inability to get erection or orgasm

Answer 54

Avoid in hypokalaemia and hyponatraemia Reduce uric acid excretion – may precipate gout Diabetes – can increase glucose concentration Elderly – lower doses and adjust according to renal function Not effective in renal disease

Answer 55

Monitoring: Potassium levels Monitor electrolyte concentrations before therapy and 2-4 weeks into therapy Counselling: No effect of increasing dose from 2.5mg to 5mg and increases SE Take first dose in morning to avoid sleep disturbance May cause impotence in men Avoid ibuprofen – can interfere with the way it works.

Answer 56

NSAIDs – effectiveness of thiazides reduced by NSAIDs (aspirin 75mg is OK) Best avoid with loop diuretics – increased hypokalaemia (if combo given MONITOR K+ LEVELS) Digoxin – can increase toxicity due to hypokalaemia Lithium – reduce excretion of lithium – toxicity Sotalol – hypokalaemia increases risk of ventricular arrhythmias Corticosteroids – increase hypokalaemia

Answer 57

cyp inhibitors: amiodarone, diltiazem, verapamil, itraconazole, macrolides reduce metabolism of statin – increased risk of myopathy reduce dose of statin to max. 20mg or stop until interacting drug course is finished Fusidic acid – risk of myopathy – avoid – restart statin dose 7 days after last dose of fusidic acid Amlodipine – risk of myopathy – max. 20mg statin Bezafibrate – increased risk of myopathy – max. 10mg statin Carbamazepine – reduces concentration of simvastatin – increase statin dose Coumarins – warfarin – increases anticoagulant effect Grapefruit – increases plasma concentration of simvastatin

Answer 58

Flushing Throbbing headaches Light-headedness Hypotension Tolerance – sustained use To maintain drug effectiveness in such patients – reduce blood-nitrate concentrations to low levels for 4 – 8 hours each day Transdermal patches left off for 8-12 hours (overnight) in each 24 hours Isosorbide mononitrate immediate release: no more than twice daily Isosorbide dinitrate M/R tablets: no more than once daily Isosorbide dinitrate M/R tablets/immediate release isosorbide mononitrate tablets second dose given after about 8 hours rather than 12 hours (to allow for nitrate free period) Do not need nitrate therapy overnight – keep this as nitrate free period

Answer 59

Stable angina: GTN sublingual spray – spray and wait 5 mins spray again wait 5 mins spray again wait 5 mins then spray if no relief call 999. ISM – immediate release 2-3 times daily tablets for prevention ISM – modified release/ transdermal patches – once daily

Answer 60

1st line – hypertension (2nd line for Afro-Caribbean) 1st line – heart failure Ischaemic heart disease (angina) Diabetic nephropathy and CKD with proteinuria Block action of ACE to prevent conversion of ATI to ATII. ATII is a vasoconstrictor and stimulates aldosterone secretion = so blocking reduces peripheral vascular resistance (afterload), and lower BP. CKD: reduces intraglomerular pressure and slows progression of CKD. Heart failure: Reducing aldosterone secretion promotes sodium and water excretion which reduces venous return (preload).

Answer 61

🟢 Sublingual GTN – for attacks & pre-exertion use. 1st-Line: ✅ Beta-Blocker (Atenolol, Bisoprolol, Metoprolol, Propranolol) 🔹 Alternative if Contraindicated: ✔ Rate-Limiting CCB (Verapamil, Diltiazem) – Avoid in HF. ✔ Dihydropyridine CCB (Amlodipine) – For Prinzmetal’s angina. 2nd-Line (If Symptoms Persist on Monotherapy): ✅ Beta-Blocker + Dihydropyridine CCB (e.g., Amlodipine) ❌ Avoid Beta-Blocker + Verapamil/Diltiazem (Bradycardia risk). 🔹 If Combination Not Suitable – Add ONE of: ✔ Long-Acting Nitrate (Isosorbide Mononitrate) ✔ Ivabradine (HR >70 bpm, sinus rhythm) ✔ Nicorandil (K+ channel activator) ✔ Ranolazine (Safe in low BP) 3rd-Line (If Two-Drug Therapy Fails): 🔹 Refer for PCI or CABG.

Answer 62

NT-pro-BNP Testing & Referral: >2000 ng/L → Urgent specialist referral & echocardiography (within 2 weeks). 400–2000 ng/L → Routine referral & echocardiography (within 6 weeks). <400 ng/L → HF unlikely; consider specialist discussion if suspicion remains. Key Points: ESC threshold for normal: <125 pg/mL. NT-pro-BNP does not distinguish HF subtypes. Always arrange a 12-lead ECG. • Cardiac Troponins: Helps differentiate heart failure from acute coronary syndromes. 2. Electrocardiogram (ECG) • Identifies arrhythmias, previous myocardial infarction, or left ventricular hypertrophy. 3. Chest X-ray • Checks for pulmonary congestion, cardiomegaly, and pleural effusion. 4. Echocardiography (Echo) • The most important imaging test for heart failure. It assesses: • Ejection fraction (EF): Differentiates between heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). • Valve function, chamber size, and wall motion abnormalities. 5. Cardiac MRI • Used if more detailed imaging is needed, particularly for identifying underlying causes like cardiomyopathy or myocarditis. 6. Stress Testing (e.g., Exercise Tolerance Test, Dobutamine Stress Echo) • Evaluates the heart’s function under stress and helps assess ischemic heart disease. 7. Coronary Angiography • Used if coronary artery disease is suspected as the cause of heart failure.

Answer 63

* Cardiac e.g. arrhythmias, heart block * Neurological e.g. weakness, lethargy, dizziness, headache, mental confusion, psychosis * GI e.g. anorexia, nausea, vomiting, diarrhoea, abdominal pain * Visual e.g. blurred and/or yellow vision "**CA**n **N**ot **GI**ve **Visual**s" C – Cardiac: arrhythmias, heart block N – Neurological: confusion, dizziness, weakness, lethargy, psychosis G – GI: nausea, vomiting, anorexia, diarrhoea, abdominal pain V – Visual: blurred or yellow vision (xanthopsia) 💡 Think: when digoxin levels are high, you “Can Not Go Visual” properly.

Answer 64

Dipyridamole MR 200mg

Answer 65

🧠 Types of Stroke Flashcard 1️⃣ Transient Ischemic Attack (TIA) / Minor Ischemic Stroke ✅ Cause: Temporary blockage of a cerebral artery (clot/embolus) 📌 Symptoms: Stroke-like symptoms resolve within 24 hours 🩺 Diagnosis: Clinical + MRI/CT scan 💊 Management: Aspirin 300 mg (immediately), then Clopidogrel 75 mg daily Carotid Doppler (for stenosis) Secondary prevention (BP, statins, lifestyle) 2️⃣ Ischemic Stroke (85%) ✅ Cause: Permanent artery blockage (Thrombosis or Embolism) 📌 Symptoms: Sudden weakness, facial droop, speech difficulty 🩺 Diagnosis: CT/MRI (confirms infarct) 💊 Management: Thrombolysis (Alteplase) if within 4.5 hours Thrombectomy if large vessel occlusion Aspirin 300 mg for 2 weeks, then Clopidogrel 75 mg Long-term: BP control, statins, anticoagulation (if AF present) 3️⃣ Intracerebral Hemorrhage (15%) ✅ Cause: Ruptured brain vessel (💥 often due to hypertension) 📌 Symptoms: Sudden severe headache, vomiting, loss of consciousness Neurological symptoms worsen over time (vs ischemic stroke) 🩺 Diagnosis: CT scan (shows bleed) 💊 Management: Reverse anticoagulation (e.g., Vit K + prothrombin complex) Lower BP (IV labetalol/nicardipine, target SBP <140 mmHg) Surgery (for large hematomas)

Answer 66

🫀 Cardiovascular: ECG – Check heart rhythm and QT interval Blood pressure and heart rate 🫁 Respiratory: Chest X-ray – To detect pre-existing lung disease 🩺 Liver: Liver function tests (LFTs) – Baseline liver assessment 🦋 Thyroid: Thyroid function tests (TFTs): TSH, Free T4 – Amiodarone affects thyroid function 👁️ Ophthalmic: Eye examination – Baseline if visual symptoms present (due to risk of optic neuropathy) 💧 Renal: Electrolytes (K⁺, Mg²⁺) – Correct before starting to reduce arrhythmia risk

Answer 67

Factors which necessitate a dose reductions : Warfarin: * Weight loss * Smoking cessation * Acute illness Factors which necessitate a dose increase : * Weight gain * Diarrhoea * Vomiting Obviously changes to INR too

Answer 68

Water soluble Beta-blockers * Atenolol * Celiprolol * Nadolol * Sotalol Lipid soluble Beta-blockers * Labetalol * Metoprolol * Pindolol * Propranolol Water soluble: Less likely to enter the brain = less sleep disturbance and nightmares. Excreted by kidneys and dose reductions often needed in renal impairment

Answer 69

ACR < 70 mg/mmol: Systolic BP: <140 mmHg (target range 120–139 mmHg) Diastolic BP: <90 mmHg ACR ≥ 70 mg/mmol: Systolic BP: <130 mmHg (target range 120–129 mmHg) Diastolic BP: <80 mmHg Aged ≥ 80 years (regardless of ACR): Systolic BP: <150 mmHg Diastolic BP: <90 mmHg

Answer 70

Metolazone is particularly effective when combined with a loop diuretic (even in renal failure); profound diuresis can occur and the patient should therefore be monitored carefully. Indapamide (Thiazide-like) Effective down to eGFR ~30 mL/min/1.73m² Uniquely effective even in severe renal impairment (eGFR <30 mL/min/1.73m²).

Answer 71

When used for Treatment of deep-vein thrombosis or pulmonary embolism: Following the first 21 days of treatment for deep-vein thrombosis or pulmonary embolism, the usual dose of 20 mg once daily can be given, but consider reducing to 15 mg once daily if creatinine clearance 15–49 mL/minute and the risk of bleeding outweighs the risk of recurrent deep-vein thrombosis or pulmonary embolism. When used for Prophylaxis of recurrent deep-vein thrombosis or pulmonary embolism: When the recommended dose is 20 mg once daily, consider reducing to 15 mg once daily if creatinine clearance 15–49 mL/minute and the risk of bleeding outweighs the risk of recurrent deep-vein thrombosis or pulmonary embolism. When used for Prophylaxis of stroke and systemic embolism in patients with non-valvular atrial fibrillation: Reduce dose to 15 mg once daily if creatinine clearance 15–49 mL/minute.

Answer 72

All Calcium channel blockers! (common SE BNF)

Answer 73

within the DHP group, it is thought that those which are more lipophilic, thus stay at the site of action for longer (such as lercanidipine and lacidipine), may be associated with a lower incidence of ankle oedema ankle oedema incidence appears to be dose related Gather the current BP in order to assess the appropriate action Non-pharmacological interventions - these interventions include elevation of legs when in a prone position, or graduated compression stockings, may be an option in some patients with mild oedema little evidence to suggest these methods may be effective in reducing oedema Dosage adjustments - however note that the relationship with ankle oedema and CCB use may not occur in an exact dose-proportional relationship (1) as dose related side effect - reduction of dose may lead to resolution/improvement Switching to an alternative CCB switching between classes e.g DHP to non DHP CCB; or within the same class e.g. a third generation DHP, such a lercanidipine, with a lower reported incidence of ankle oedema may also be an option Adding an ACEi or ARB evidence that adding an ACEi to a CCB reduces the incidence of ankle oedema. The mechanism by which this occurs is not currently known (4) mechanisms by which ARBs reduce incidence of CCB induced ankle oedema remains unknown, but are likely to be similar to that involved when an ACEi is added to CCB therapy Adding a nitrate due to their venodilating action, may be offer some useful effects in treating CCB induced ankle oedema, but their use are limited by the practical considerations of having a stop-start regimen so tolerance does not develop (4) Discontinuation of CCB

Answer 74

IV potassium should never be given as a bolus due to cardiac arrest risk. I would recommend diluting in 1L of saline over ≥4 hours with cardiac monitoring.

Answer 75

✅ Very rare cases of new-onset or worsening myasthenia gravis or ocular myasthenia linked to statins. ✅ Most cases improved after stopping statins, but some symptoms persisted or recurred on rechallenge. ✅ Symptoms appeared within days to 3 months of starting statins. 🔍 Advice for Healthcare Professionals: 🔹 Refer suspected cases to a neurologist—discontinue statin if risks outweigh benefits. 📝 Patient & Carer Advice: 🔸 Inform doctor before starting statins if you have a history of myasthenia gravis. 🔸 Continue statin unless advised to stop. 🔸 Report symptoms: Muscle weakness (worse after activity) Double vision, drooping eyelids Difficulty swallowing, shortness of breath 🔸 Seek urgent medical help for severe breathing/swallowing problems.

Answer 76

Calcium channel blockers, with the exception of amlodipine, should be avoided in heart failure as they can fur‐ ther depress cardiac function and exacerbate symptoms. With the exception of amlodipine, they can also in‐ crease mortality after myocardial infarction in patients with left ventricular dysfunction and pulmonary congestion.

Answer 77

1mg – brown tablet. 3mg – blue tablet. 5mg – pink tablet.

Answer 78

🔬 Renal Function & Electrolytes: ✅ Check 1–2 weeks after starting treatment ✅ Check 1–2 weeks after each dose increase ✅ Annually thereafter, unless clinical concerns require more frequent monitoring 📉 Blood Pressure: ✅ Check 4 weeks after each dose titration ⚠️ Higher Risk Patients (e.g., PVD, diabetes, renal impairment, elderly) 🔍 Consider checking renal function & electrolytes within 1 week

Answer 79

Secondary Prevention Treatment after STEMI/NSTEMI Initiation: All patients should receive secondary prevention treatment post-STEMI and NSTEMI. Clinical judgment is needed for unstable angina. Core Medications: ACE Inhibitor (or ARB if intolerant) – Start once the patient is stable; continue indefinitely. Beta-Blocker – Start when stable. Continue indefinitely if reduced LVEF. Consider stopping after 12 months if LVEF is normal, based on patient discussion. Dual Antiplatelet Therapy (DAPT) – Aspirin (indefinite use) + a second antiplatelet (e.g., clopidogrel, ticagrelor, or prasugrel) for up to 12 months unless contraindicated. Alternative: Clopidogrel monotherapy for aspirin hypersensitivity. Anticoagulation (e.g., Rivaroxaban) can be used alongside aspirin or DAPT for high-risk patients with elevated cardiac biomarkers. Statin – High-intensity statin therapy recommended for all with clinical cardiovascular disease. Special Considerations: Patients requiring long-term anticoagulation (e.g., for atrial fibrillation) need an individualized approach to balancing thrombotic vs. bleeding risks. Alternatives for Beta-Blockers: Diltiazem or verapamil in patients without pulmonary congestion or reduced LVEF.

Answer 80

🚫 STOPP Criteria: Helps identify potentially inappropriate prescriptions in older adults. ⚠️ Antiarrhythmic Therapy Warning: Not recommended as first-line for supraventricular tachyarrhythmias. Why? ❌ Higher risk of side effects than beta-blockers, digoxin, verapamil, or diltiazem. 🔍 Always consider safer alternatives! ✅

Answer 81

Dabigatran → Praxbind (idarucizumab) Apixaban & Rivaroxaban → Ondexxya (andexanet alfa)

Answer 82

Unfractionated heparin is the preferred choice as it is primarily cleared by the liver, meaning no dose adjustments are required in renal impairment.

Answer 83

✅ Answer: Peripheral arterial disease (PAD) / Intermittent claudication listed in BNF as: Peripheral vascular disease & Cerebral vascular disease 💡 Learning Point: 🔹 Naftidrofuryl oxalate is a vasodilator used to improve walking distance in patients with intermittent claudication due to peripheral arterial disease (PAD). 🔹 It works by improving oxygen supply to tissues and reducing lactic acid build-up in muscles. 🔹 Lifestyle changes such as smoking cessation, exercise, and diet are also key in managing PAD.

Answer 84

✅ Answer: Chronic stable angina (as an add-on therapy when other anti-anginal drugs are insufficient) 💡 Learning Points: 🔹 Ranolazine is an anti-anginal medication that works by inhibiting late sodium currents in myocardial cells, reducing myocardial oxygen demand. 🔹 It does not significantly affect heart rate or blood pressure, making it useful for patients who cannot tolerate beta-blockers or calcium channel blockers. 🔹 Common side effects: Dizziness, constipation, nausea, and QT prolongation (monitor ECG in high-risk patients). 🔹 Avoid in: Severe renal or hepatic impairment and use with caution in QT-prolonging drugs.

Answer 85

✅ Answer: Beta-blockers or calcium channel blockers (CCBs) 💡 Learning Points: 🔹 First-line options: Beta-blockers (e.g., bisoprolol, atenolol) – preferred if no contraindications. Calcium channel blockers (CCBs) (e.g., amlodipine, diltiazem) – alternative if beta-blockers are unsuitable or in combination therapy if symptoms persist. 🔹 If monotherapy is ineffective, a combination of a beta-blocker and a non-rate-limiting CCB (e.g., amlodipine) can be used. 🔹 Second-line options: Long-acting nitrates (e.g., isosorbide mononitrate) Nicorandil Ivabradine Ranolazine 🔹 All patients should also receive: Aspirin (or clopidogrel if contraindicated) A statin Sublingual GTN for acute angina attacks

Answer 86

✅ Answer: Eplerenone 💡 Learning Points: 🔹 Eplerenone is specifically indicated for heart failure with reduced ejection fraction (HFrEF) post-MI to improve survival and reduce hospitalisation. 🔹 Why not spironolactone? Spironolactone is preferred in chronic HFrEF, but eplerenone is first-line post-MI due to a lower risk of gynecomastia and endocrine side effects.

Answer 87

🚨 Major Risk: Increased Bradykinin → Severe Angioedema 🔹 Neprilysin inhibitors (e.g., sacubitril in sacubitril/valsartan) block neprilysin, an enzyme that degrades bradykinin. 🔹 ACE inhibitors (e.g., ramipril, lisinopril) also increase bradykinin by inhibiting its breakdown. 🔹 Combined use leads to excessive bradykinin accumulation, increasing the risk of life-threatening angioedema (swelling of face, lips, throat). ❌ Clinical Implication: 🔺 Neprilysin inhibitors and ACE inhibitors should NEVER be used together. 🔺 A washout period of at least 36 hours is required when switching from an ACE inhibitor to sacubitril/valsartan to reduce angioedema risk.

Answer 88

WARFARIN INHIBITS FACTORS II, VII, IX AND X.

Answer 89

Diuretics, thiazide and loop diuretics Indapamide meant to have less affect on diabetes Beta blockers can mask the symptoms of diabetes

Answer 90

Alanine Aminotransferase (ALT) Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy

Answer 91

Advise the patient to stop taking digoxin and refer for medical review urgently. The BNF monograph recommends that if toxicity occurs, digoxin should be withdrawn as serious manifestations can occur requiring urgent specialist management. A digoxin plasma concentration within the therapeutic range does not exclude digoxin toxicity.

Answer 92

Colchicine

Answer 93

Atenolol, bisoprolol fumarate, celiprolol hydrochloride, and nadolol. (NICE)

Answer 94

Antibiotics 🦠 Macrolides: Clarithromycin, Erythromycin, Azithromycin Fluoroquinolones: Ciprofloxacin, Levofloxacin Antifungals: Fluconazole, Voriconazole Antipsychotics 🧠 Haloperidol Chlorpromazine Quetiapine Risperidone Antidepressants 💊 Citalopram Escitalopram Amitriptyline Antiarrhythmics ❤️ Amiodarone Sotalol Other Drugs Ondansetron (antiemetic) Methadone (opioid) Domperidone (prokinetic)

Answer 95

flushing, headache, and postural hypotension

Answer 96

CHD risk assessment tools should not be used to guide management of people with FH because they are already at a high risk of premature CHD. (NICE)

Answer 97

Itraconazole has negative inotropic effects, which means it reduces the strength of heart muscle contractions. This can exacerbate congestive heart failure (CHF), particularly at higher doses (e.g. 200 mg twice daily). MHRA warning: Avoid itraconazole in patients with ventricular dysfunction or history of heart failure, unless the benefit outweighs the risk.

Answer 98

Allopurinol is indicated in the prophylaxis of gout and is a first-line choice. For long-term control of gout, the formation of uric acid from purines may be reduced with the xanthine-oxidase inhibitors, allopurinol or febuxostat. Either option may be offered as first-line treatment, taking into account the patient's preference and co-morbidities. However, NICE recommends alloprurinol in patients who have major cardiovascular disease.

Answer 99

✅ Answer: 🍖 High intake of meat and seafood 🍷 Alcohol consumption (≥10g/day) 💊 Diuretics use ⚖️ Obesity 💓 Hypertension, coronary heart disease, heart failure 🍬 Diabetes mellitus 🩺 Chronic kidney disease 📈 High triglycerides 🚹 Male gender

Answer 100

Atorvastatin: Grapefruit juice increases exposure – caution advised. Simvastatin: Grapefruit juice increases exposure – avoid. Rosuvastatin: No interaction listed in the BNF. pravastatin does not interact with grapefruit juice ✅ Not all statins have a significant interaction with grapefruit juice.

Answer 101

injection at birth to prevent serious bleeding, including intracranial bleeding.

Answer 102

💊 Drug Class: Beta-blocker (topical ophthalmic) 📌 Systemic Absorption: Systemically absorbed despite topical use Can cause systemic beta-blocker effects (e.g. ↓ HR, ↓ BP, bronchospasm) 🫀 Cardiovascular Risks: Use caution in: Coronary heart disease Prinzmetal’s angina Cardiac failure First-degree heart block May cause bradycardia, hypotension, heart failure exacerbation Monitor pulse rate and watch for signs of heart failure 🧊 Vascular Concerns: Use with caution in severe peripheral circulatory disorders (e.g. Raynaud's) 🫁 Respiratory Risks: Contraindicated in asthma ❌ (risk of bronchospasm, including fatal cases) Use with caution in mild/moderate COPD only if benefits outweigh risks 🍬 Endocrine Considerations: May mask signs of hypoglycaemia (Caution in diabetes, especially labile or insulin-dependent) May also mask signs of hyperthyroidism 👁️ Ocular Side Effects: Can cause dry eyes Caution in patients with corneal disease 💡 Tip to Reduce Systemic Absorption: Nasolacrimal occlusion or closing eyelids for 1–2 minutes post-instillation (Reduces systemic uptake)

Answer 103

Direct Factor "Xa" Inhibitors Drugs: Apixaban Rivaroxaban Edoxaban Betrixaban (not commonly used in the UK) Direct Thrombin (Factor IIa) Inhibitor Drug: Dabigatran

Answer 104

CAN NOT BEAT Carvedilol, Nebivolol, Bisoprolol

Answer 105

CNS: “Confused, sleepy king” → Confusion, Drowsiness, Headache, Ataxia Hormonal/Endocrine: “Man-boob, sex blues” → Gynecomastia, Impotence, Menstrual Irregularities GI/Metabolic: “Sick belly, sour blood” → Nausea, Vomiting, Abdominal pain, Metabolic acidosis Other: “Rocky kidneys & rashy skin” → Kidney stones, Hypersensitivity

Answer 106

water CANS Celiprolol: Atenolol: . Nadolol: . Sotalol: .

Answer 107

Ice PACO pindolol, acebutolol, Celiprolol hydrochloride and oxprenolol hydrochloride

Answer 108

Cardioselective Beta Blockers Are MEAN Celiprolol Bisoprolol Betaxolol Acebutolol Metoprolol Esmolol Atenolol Nebivolol

Answer 109

The BANCers bisoprolol fumarate, atenolol, nadolol, celiprolol hydrochloride

Answer 110

"CaNeBis 🍁 helps HF" Carvedilol, Nebivolol, Bisoprolol Bisoprolol fumarate and carvedilol: Reduce mortality in any grade of stable heart failure. Nebivolol: Licensed for stable mild to moderate heart failure in patients over 70 years

Answer 111

When choosing antihypertensive drug treatment for adults of black African or African–Caribbean family origin, consider an ARB, in preference to an ACE inhibitor.

Answer 112

Some antiepileptics- phenytoin, carbamazepine, phenobarbitone or rifampicin are likely to reduce DOAC levels so should be discussed with an anticoagulation specialist

Answer 113

AAA C ⚡ INITIAL MANAGEMENT Thrombolysis: ➔ Give Alteplase or Tenecteplase within 4.5 hours if no intracranial haemorrhage (confirmed by imaging). ➔ Must be administered by experienced staff in a specialist stroke centre. After Thrombolysis: ➔ Start antiplatelet (e.g., aspirin) after 24 hours (if no bleeding). No Thrombolysis but disabling stroke: ➔ Start aspirin ASAP within 24 hours ➔ Continue for 2 weeks, then switch to long-term antithrombotic. Other Important Points: ➔ Use a PPI if GI bleed risk. ➔ If aspirin allergy ➔ Use clopidogrel. ➔ No routine anticoagulants unless DVT/PE present or mechanical heart valve (special cases only). ➔ Warfarin not given in acute phase. ➔ Treat hypertension only if hypertensive emergency. 🛡️ LONG-TERM MANAGEMENT Antiplatelet: ➔ Clopidogrel monotherapy preferred. ➔ If clopidogrel not suitable ➔ use aspirin. Anticoagulation: ➔ Only if atrial fibrillation or other embolic risks. ➔ Timing based on stroke severity. Statins: ➔ Start high-intensity statin (e.g., atorvastatin) ASAP, even if cholesterol normal. Blood Pressure Management: ➔ Avoid beta-blockers unless another clear indication. Lifestyle Modifications: ➔ Healthy diet, exercise, smoking cessation, alcohol moderation.

Answer 114

⚡ INITIAL MANAGEMENT Pain Relief: ➔ GTN (sublingual/buccal) 💊 early. ➔ IV opioids (e.g., morphine) 💉 if needed. Antiplatelet: ➔ Aspirin loading dose ASAP 🚑. ➔ Document if given before hospital 📝. Oxygen: ➔ Only if O2 sat low (<94%) 🌬️❗. Blood Sugar: ➔ Monitor glucose 🩸. ➔ If >11 mmol/L ➔ start insulin infusion 💉. ❤️ STEMI MANAGEMENT Goal: Restore blood flow fast! 🏃‍♂️🫀 Primary PCI preferred if: ➔ Within 12 hrs of symptoms ⏳. ➔ PCI within 120 mins 🕑 vs fibrinolysis. Medications: ➔ Aspirin + second antiplatelet (prasugrel, ticagrelor, clopidogrel) 💊💥 Prasugrel is the preferred agent for most patients undergoing a primary PCI. ➔ Heparin if radial access 💉. ➔ Bivalirudin if femoral access (unlicensed) 🚨. ➔ Antithrombin agent during fibrinolysis 🛡️. 💔 NSTEMI / UNSTABLE ANGINA MANAGEMENT Strategy: Risk-based ➔ Revascularisation 🏥 or conservative 🛌. Medications: ➔ Aspirin + second antiplatelet combo 💊💊. ➔ Fondaparinux unless immediate angiography 🔬. ➔ Heparin if renal impairment 🩺 or for PCI 🛠️. 🛡️ SECONDARY PREVENTION AFTER ACS Lifestyle Changes: ➔ Cardiac rehab 🏋️‍♀️, diet 🥗, exercise 🏃‍♂️, stop smoking 🚭, reduce alcohol 🍷. Medications: ➔ ACE inhibitor 🌡️ (or ARB if intolerant). ➔ Beta-blocker ❤️ (continue long-term if reduced LVEF). ➔ Dual antiplatelet therapy (DAPT) for 12 months ⏲️. ➔ High-intensity statin 🛢️. Special cases: ➔ If aspirin allergy ➔ use clopidogrel 🧪. ➔ Can use rivaroxaban + aspirin ± clopidogrel if biomarkers ↑ 🔥. ➔ Tailor antithrombotic therapy if ongoing anticoagulation ⚖️.

Answer 115

Goal: Restore blood flow ASAP to save heart muscle 🫀⏳ 🚑 Initial Management Pain relief ➔ Give glyceryl trinitrate (GTN) 💨 (sublingual or buccal). Morphine if pain severe 💉. Aspirin loading dose immediately 🥄. Monitor oxygen saturations — only give oxygen if hypoxic (SpO2 < 94%) 🌬️. Monitor blood glucose → If >11.0 mmol/L, start insulin infusion 💉. 🛠️ Reperfusion Therapy Primary PCI (Percutaneous Coronary Intervention) preferred 🛠️: ✅ If within 12 hours of symptoms AND ✅ If can be performed within 120 minutes compared to fibrinolysis. Fibrinolysis (thrombolysis - alteplase) offered if PCI not available soon 🧪. 💊 Antiplatelet and Anticoagulant Treatment Aspirin + second antiplatelet (one of): ➔ Prasugrel (preferred if PCI unless high bleeding risk) ➔ Ticagrelor ➔ Clopidogrel (if others unsuitable) Heparin (unfractionated) if PCI via radial access ✋. Bivalirudin [unlicensed] if PCI via femoral access 🦵. Glycoprotein IIb/IIIa inhibitors if indicated during PCI 🧬. If fibrinolysis, give antithrombin agent at same time ⚡. 🧠 Secondary Prevention (Post-STEMI) Dual antiplatelet therapy (Aspirin + second agent) for up to 12 months. ACE inhibitor started once haemodynamically stable 🏥. Beta-blocker started and continued long-term (especially if low LVEF) ❤️‍🩹. Statin (high-intensity like Atorvastatin) immediately 🧈. Lifestyle changes: healthy diet, exercise, smoking/alcohol advice 🏃‍♂️🍎🚭. Hi

Answer 116

Goal: Prevent further cardiac events and progression 🚧. 🚑 Initial Management Pain relief ➔ GTN + morphine if needed 💨💉. Aspirin loading dose immediately 🥄. Monitor oxygen saturations — only give oxygen if needed 🌬️. Monitor blood glucose — Insulin if >11.0 mmol/L 💉. 🔎 Risk Stratification Assess risk of future cardiac events to decide management: High risk ➔ Early coronary angiography + PCI if needed 🏥. Lower risk ➔ Conservative medical management 🛡️. 💊 Antiplatelet and Anticoagulant Treatment Aspirin + second antiplatelet (one of): ➔ Ticagrelor (often preferred) ➔ Clopidogrel ➔ Prasugrel (if angiography + PCI planned) Antithrombin therapy: ➔ Fondaparinux (unless immediate angiography planned) 💉. ➔ Unfractionated heparin in significant renal impairment. If PCI needed ➔ Give heparin in the catheter lab. 🧠 Secondary Prevention (Post-NSTEMI) Dual antiplatelet therapy (Aspirin + second agent) for up to 12 months. ACE inhibitor started when stable 🏥. Beta-blocker started and continued long-term (especially if low LVEF) ❤️‍🩹. Statin (high-intensity like Atorvastatin) immediately 🧈. Lifestyle changes: healthy diet, exercise, smoking/alcohol advice 🏃‍♂️🍏🚭.

Answer 117

A loop Diuretic

Answer 118

✅ Key Advantages of DOACs: 🧪 No routine INR monitoring needed – unlike warfarin, which requires regular blood tests. 🍽️ Fewer food interactions – no need to avoid vitamin K-rich foods (like leafy greens). 💊 Predictable dosing – fixed daily doses, no frequent adjustments. ⏱️ Faster onset of action – typically within hours vs. days for warfarin. ⚖️ Lower risk of intracranial bleeding – especially in patients with atrial fibrillation. 📉 Shorter half-life – quicker offset if the drug needs to be stopped (useful pre-surgery). ✅ Lower Risk: 🧠 Intracranial bleeding (less than with warfarin) ➖ Similar Risk: 🔴 Overall major bleeding (similar or slightly lower than warfarin) ⚠️ Higher Risk: 🩸 GI bleeding – esp. with rivaroxaban & dabigatran, particularly in older adults

Answer 119

Labetalol is used because: ⚡ It provides rapid BP reduction 💉 Administered IV for immediate effect 🔄 It's a combined alpha- & beta-blocker, allowing controlled titration ✅ Recommended by NICE for hypertensive emergencies due to its efficacy & safety

Answer 120

Alkalosis hypochloraemic; constipation; diarrhoea; dizziness; electrolyte imbalance; **erectile dysfunction**; fatigue; headache; **hyperglycaemia**; **hyperuricaemia**; nausea; postural hypotension; skin reactions; vomiting

Answer 121

ENTRESTO cant be used due to ARB If neither ACE inhibitors nor ARBs are tolerated, seek specialist advice and consider hydralazine in combination with nitrate for people who have heart failure with reduced ejection fraction. [2010] NICE

Answer 122

Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative. (BNF)

Answer 123

Metolazone is particularly effective when combined with a loop diuretic (even in renal failure); profound diuresis can occur and the patient should therefore be monitored carefully. BNF Manufacturer advises metolazone remains effective if eGFR is less than 30 mL/minute/1.73 m2 but is associated with a risk of excessive diuresis. BNF Indapamide - avoid in severe impairment (ineffective if creatinine clearance less than 30 mL/minute).

Answer 124

500 micrograms 2–4 times a day until symptoms relieved, total dose per course should not exceed 6 mg, do not repeat course within 3 days. as per BNF