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GPhC BNF > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

Which NOAC has twice daily dosing?

Which has once daily dosing?

A

Twice daily: Apixaban (5mg BD), Dabigatran (150mg BD)

once daily: Rivaroxiban (20mg OD)

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2
Q

Which NOAC requires loading?

A

Apixaban

10mg twice daily for 7 days followed by 5mg BD maintenance

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3
Q

Which NOAC interacts with verapamil and subsequently requires a dose reduction? What other medication has the same interaction?

A

Dabigatran

Verapamil increases dabigatran levels, so patients also on verapamil need to take a reduced dose of dabigatran (110mg BD as opposed to 150mg BD)
Same with amiodarone- use max dose of 110mg dabigatran with amiodarone

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4
Q

Which one of the three NOACs is a DIRECT THROMBIN inhibitor?

What are the other two?

A

Dabigatran is a direct thrombin inhibitor

Apixaban and rivaroxaban are Direct factor Xa inhibitors (remember ban Xa)

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5
Q

An INR within ____ units of the target range is generally satisfactory

A

0.5 units

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6
Q

A target INR of ____ is used for most things! Eg treatment of DVT/PE, AF patients, electrical cardioversion, myocardial infarction…

A

2.5 used for most things

Apart from recurrent DVT/PE if patient was already on anticoagulation with a INR over 2 and they still got a clot… Aim for 3.5 here (thinner blood)
Or if they have a mechanical heart valve! Ask manufacturer for the target INR, also if a clot occurs whilst at the target INR then increase the target INR

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7
Q

Do the NOACS have any food interactions?

A

No

But remember to take Rivaroxiban with food to increase absorption

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8
Q

Which NOAC may be crushed an mixed with apple purée/ put through an NG tube before administration?

A

Rivaroxiban

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9
Q

Which CCBs need to be avoided in Heart failure?

A

Verapamil and diltiazem

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10
Q

When should a target INR of 3.5 be used? What is the target for most other conditions?

A

Only when the patient has had a DVT or PE when receiving anticoagulation with warfarin / NOACs and had an INR of 2 or more, they must be susceptible to clots so need a higher target of 3.5.

For most other conditions we set a target of 2.5

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11
Q

Warfarin’s time to peak effect ranges from 3-5 days, so it is not good if immediate effects are needed. NOACs have a much faster onset to action, what is this? Which is the fastest?

A

1 - 4 hours

Dabigatran fastest: peak action 0.5-2 hours after oral admin

(Apixaban and rivaroxaban take around 2-4 hours to peak)

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12
Q

What is the difference between Phytomenadione and Phenindinone?

A

Phytomenadione is the reversal agent for warfarin overdose

Phenindinone is another oral anticoagulant (coumarin) like warfarin!

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13
Q

What baseline tests do patients need before commencing on a NOAC?
Which NOAC is least likely to be chosen with renal impairment ?

A

Baseline renal function - dose reduction required in renal impairment

Dabigatran has most caution with renal function: it is CI if CrCl is under 30 ml/min
Apixaban and Rivaroxiban are less dependent on renal function

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14
Q

Which NOACs require hepatic metabolism therefore should not be used in severe liver disease?

A

Apixaban

Rivaroxiban

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15
Q

We know that warfarin interacts with a lot of the CYP enzyme inhibitors and inducers, Which NOACs also have a similar problem? Can you think of any interactions?

A

Apixaban and Rivaroxiban

CYP3A4 inhibitors effect these: ketoconazole, itraconazole,

Inducers effect these: carbamazepine, rifampicin, phenytoin, St. John’s wort

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16
Q

Which NOAC cannot be put in a compliance aid?

A

Dabigatran

It is moisture sensitive
Shouldn’t put warfarin in too

Can put Apixaban and rivaroxaban in

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17
Q

Which NOAC needs the warning label “swallow whole, do not chew or crush”

A

Dabigatran

Opening capsules increase risk of bleeding

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18
Q

Which is more problematic if a dose is missed, warfarin or the NOACs?

A

NOACs - shorter half life so if dose is missed there is more time without coagulation

If miss a dose of a NOAC- usually take it ASAP (if within 6 hours with dabigatran) but with warfarin usually just skip it and move on to next

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19
Q

What is the reversal agent for LMWHs?

A

Protamine sulfate

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20
Q

Name me three LMWHs

A

Dalteparin

Enoxaparin

Tinzaparin

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21
Q

When in pregnancy should warfarin be avoided?

A

First trimester for sure
Crosses the placenta especially in first and third trimester

Safe in breast feeding

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22
Q

Which NOAC is commonly used following Total hip replacement/ knee replacement ?

A

Rivaroxiban

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23
Q

Which NOAC caused the most GI side effects?

What other random SEs does this cause?

A

Rivaroxaban: constipation, diarrhoea, abdo pain, nausea, vomiting

Also causes:
pain in extremities
Pruritis (itchy)
Rash

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24
Q

What is heparin induced thrombocytopenia and which heparins is it more common with?

A

Development of very low platelet count
It is an immune mediated reaction that can develop after 5-10 days

More common with UFH than LMWHs

Management: stop the heparin, use something else like the Heparinoid Danaparoid

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25
Q

What anticoagulant is indicated in patients with a history of heparin-induced thrombocytopenia?

A

Danaparoid

This is a Heparinoid so won’t cause the Same reaction

26
Q

What heparin should we choose in patients with renal impairment?

A

UFH (un fractionated heparins). Still may require dose reduction

This is because the LMWHs Dalteparin, enoxaparin and tinzaparin have their risk of causing bleeds increased in renal impairment

27
Q

Dalteparin vs dabigatran?

A

Dalteparin is LMWH

Dabigatran is a NOAC

28
Q

What is the treatment for a VTE (DVT or PE)?

A

LMWH or UFH
Continue the heparin for at least 5 days or until the INR has been over 2 for 24 hours
LMWH usually preferred as they have a longer duration of action, however if the patient has a high risk of bleeding or has renal impairment choose UFH (as effects can be more rapidly reversed)

Warfarin usually started at same time (but takes around 3 days to start working)
Heparins are used because they give most rapid effects

29
Q

What can be used for VTE treatment in pregnant women?

A

Heparins are Safe in pregnancy as they do not cross the placenta.

LMWHs usually preferred as they carry a lower risk of osteoporosis and heparin induced thrombocytopenia

Dose alteration will be needed as LMWHs eliminated more rapidly in pregnancy

NB: BNF states not licensed for treatment of VTE in pregnancy for Dalteparin, enoxaparin, tinzaparin

30
Q

What do we need to monitor with heparins?

A 
Weight- dose based on weight
Renal function- espesh with LMWH
Platelet count (must be over 50)
K+ (can cause hyperkalemia) 
LFTs
31
Q

What is Bivalirudin and when is it used?

A

Remember this is the “rude boi drug”

It’s a thrombin inhibitor, and it used as an anticoagulant for those undergoing PCI and in NSTE-ACS

32
Q

What is the anticoagulant used in NSTEMI/ unstable angina episode is angiography is NOT planned within the next 24 hours? What kind of drug is this?

A

Fondaparinux
Synthetic pentasaccharide

If angiography is planned: used LMWH as can easily reverse their effects due to shorter half life

33
Q

Which beta blocker has been associated with severe liver damage?

A

Labetalol

34
Q

Sotalol is a beta blocker commonly used in ventricular arrhythmias, different tachycardias and as Rhythm control following cardioversion in AF. There is an important safety warning that comes with Sotalol, do you know what it is?

A

QT prolongation! May cause life threatening ventricular arrhythmias!!

Electrolyte disturbance- especially Hypokaleamia and hypomagnesaemia- need to be sure these are corrected before starting Sotalol or there will be even more risk of arrhythmias

35
Q

What are the nitrates (GTN, isosorbide dinitrate, isosorbide mononitrate) used in?

A

Principle role in ANGINA- they reduce venous return so reduce left ventricular work of the heart

36
Q

What are some of the undesirable effects of the nitrates? (3)

A

Flushing
Throbbing Headache
Postural hypotension / dizziness

37
Q

GTN is one of the most effective drugs at providing rapid symptom relief from angina, it’s effects only last for ______

A

20-30 minutes

38
Q

You know GTN has a short duration of action, what about isosorbide mononitrate/ dinitrate?

A

Much longer- MR has duration of 12 hours, but not as rapid onset so not as effective for rapid symptomatic relief of angina

NB: isosorbide mononitrate is just the active metabolite of dinitrate

39
Q

NITRATES can lead to TOLERANCE and reduced therapeutic effects if long-acting preparations used/ transdermal preps used. What can be done to overcome this?

A

Need to reduce blood nitrate concentration for 4-12 hours each day to avoid tolerance.

Eg. If transdermal: leave the patch off overnight
If MR isosorbide dinitrate: give the second of the two daily doses after 8 hours rather than 12 hours

40
Q

What if patients on Statin therapy develop symptoms of Dysponea, cough and weight loss, what should be done?

A

Seek medical attention ASAP as this could indicate interstitial lung disease

41
Q

Why is brand specific prescribing required with Nifedipine preparations?

A

Different versions of the the MR preparations may not have the same clinical effects

NB: ADALAT - LA and VALNI- XL are both not appropriate in hepatic impairment

42
Q

Why should adequate urinary output be established before initiating therapy with a Loop diuretic?

A

Because loops can result in urinary retention if there if an enlarged prostate/ other disruption of urinary flow…

Loops usually stimulate more urine production!

43
Q

If a loop diuretic (eg. Bumetanide, furosemide, co-amilofruse) is needed twice daily, when should the doses be taken?

A

One in the morning and one before 4pm- no later than this otherwise person will be weeing through the night

44
Q

Which ACE inhibitor can cause Stomatitis (mouth ulcers, sores)?

A

Ramipril!

All ACEi’s may cause ulcers- ‘Apthous stomatitis/ canker sores’ is the medical term

45
Q

What is sodium nitroprusside prescribed for?

A

Hypertensive emergencies

Rapidly reduces blood pressure

46
Q

What anti-platelet drug can cause a throbbing headache as a side effect?

A

Dipyridamole

47
Q

What does a positive D-dimer test indicate?

A

High level of cross-linked fibrin by-products, i.e. a clot has formed - DVT/ PE

48
Q

Max dose of furosemide daily?

A

120mg in divided doses.

Remember furosemide is a loop and if given twice daily the second dose should be before 4pm so around 2pm

49
Q

Following admission to hospital when should a VTE risk assessment be carried out?

A

Within 24 hours

50
Q

What does mechanical prophylaxis involve with VTE prevention?

A

Stockings, hoisery, blow up thing etc

51
Q

Can you think of any risk factors for VTE?

NB: Classed as HIGH risk if one or more of these are present! VTE risk assessment within 24 hours of admission

A 
Active cancer/ cancer treatment
Aged > 60
Dehydration
History of DVT/VTE
Obesity: BMI over 30
Comorbidites- Heart disease, endocrine, inflammatory condition
COC's/ Tamoxifen/ HRT
Varicose veins
Pregnancy
52
Q

Can you think of any risk factors for bleeding?

A 
Recent surgery
recent stroke
Spinal intervention
anticoagulants
Uncontrolled HTN
Acute liver failure
53
Q

For patients treated for DVT, PE and prevention of their re-occurence, who want to switch from warfarin to the NOAC rivaroxiban, at what INR can they do so?

A

Once INR is less than or equal to 2.5

54
Q

As HIT develops the platelet count typically begins to fall _____ days after starting Heparin.

A

5-10 days

Patients who receive any type of heparin (LMWH and UFH, remember its more common with UFH) should have a baseline platelet count, but after this platelet monitoring is not usually needed.

55
Q

Colestyramine is a Bile acid sequesterant used in hypercholesteremia when a statin and ezetimibe have failed. When should patients be advised to take other medicines with this?

A

Take other medicines at least 1 hour before or 4 hours after Colestyramine as it can effect their absorption considering it tampers with bile acid

56
Q

What medication should be added if a patient has a particularly high level of TRIGLYCERIDES?

A

Fenofibrate

57
Q 
A patient has suffered muscle pain with three different statins now, and the consultant asks you where to go next. Their Triglycerides are within range. Your options are:
Fenofibrate
Ezetimibe
Nicotinic acid
Colestyramine
A

Usual guidance: Statin&raquo_space; Ezetimibe&raquo_space; Fibrate if TGL is high/ bile aid sequesterant/ nicotinic acid.

Ezetimibe may also cause Myalgia so rule this out.
Patients TGL’s are normal so rule out Fibrates.

Best option: probably Colestyramine (bile acid sequesterant)

58
Q

What is the reversal agent for Dabigatran?

A

Idarucizumab- a monoclonal Antibody

59
Q

Which is more potent Loop: Bumetanide or Furosemide?

A

Bumetanide

Bumetanide dosing: 1mg BD usually, resistant oedema= 5mg

Furosemide: max dose 120mg

60
Q

Why don’t Afro-carribean patients respond as well to ACE inhibitors/ ARBs?

A

Because these work on the renin-angiotensin system and it has been established that black people have low circulating renin

61
Q

What kind of drug is Amiloride?

A

Potassium sparing diuretic - hyperkaleamia risk !!

GPhC BNF (48 decks)

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