Chapter 2- Cardiovascular

Question 1

Which anticoagulant is preferred in renal impairment?

Answer 1

Heparin (unfractionated)

Low molecular weight heparin is suitable in all types of general and orthopaedic surgery

Question 2

Which anticoagulant is used for venous thromboembolism in pregnancy?

Answer 2

Heparins (do not cross placenta)

Low molecular weight heparins are preferred(low risk osteoporosis and HIT). They are eliminated more rapidly in pregnancy

Question 3

What drug is used for rapid reversal of effects of heparin?

Answer 3

Protamine (but only partially reverses the effects of lmw heparins)

Question 4

Which anticoagulant should not be commenced in acute phase of ischaemic stroke?

Answer 4

Warfarin
(anticoagulants nor recommened as alternative to antiplatelets in Acute ischaemic stroke in pateints who are in sinus rhythm

Question 5

What drugs are used in long term management of TIA or ischaemic stroke?

Answer 5

1st Clopidogrel
2nd MR dipyridamole and aspirin (either alone or in combi)
Stroke with af: warfarin
Statin within 48 hrs
Blood pressure meds(not b blocker) with target bp <130/80

Question 6

Name vitamin K antagonists

Answer 6

Warfarin, phenindione, acenocoumarol

Question 7

How long till onset of vit k antagonists

Answer 7

48 to 72 hrs.

Unfractionated or lmw heparin is given if immediate effect is required

Question 8

Should initial dose of anticoagulants be given after base line PT time is determined?

Answer 8

No. Initial dose should not be delayed

Question 9

INR 5-8 no bleeding

Answer 9

Omit 1 or 2 doses of warfarin and reduce maintenance dose

Question 10

Inr 5-8 minor bleeding

Answer 10

Stop warfarin. Phytomenadione by slow iv infusion. Restart warfarin if INR <5

Question 11

Inr >8 no bleeding

Answer 11

Stop warfarin. Phytomenadione p.o.

Repeat phytomenadione dose if INR still high after 24 hrs. Restart warfarin when Inr <5

Question 12

Inr >8 minor bleeding

Answer 12

Stop warfarin, phytomenadione by slow IV.

Repeat phytomenadione if INR is high after 24 hrs. Restart warfarin inr <5

Question 13

Heparin vs lmw heparin

Answer 13

Unfractionated heparin has short duration of action compared to lmw heparin.

The former is also preferred in high risk of bleeding since its effect can be terminated rapidly by stopping the infusion

Question 14

Which heparin is preferred in prevention of venous thromboembolism and treatment of dvt and pe?

Answer 14

Lmw heparins e.g enoxaparin, dalteparin, tinzaparin

They are as effective and have lower risk of heparin induced thrombocytopaenia.
Duration of action is longer(once daily subcutaneous admin is possible)

Question 15

When is aspirin used for prevention of cardiovascular disease?

Answer 15

Secondary prevention

It is not recommended in primary prevention of cvd in patients with or eithout diabetes or hypertension

Question 16

What is the dose of aspirin for secondary prevention of cvd

Answer 16

75 mg

Question 17

Why is aspirin c/i in children under 16 years?

Answer 17

It hass an association with Reye’s syndrome

Question 18

When no strength is stated in a prescription for aspirin, what strength should be dispensed?

Answer 18

300 mg.

Question 19

Aspirin exception to legal category

Answer 19

32 pack up to 100 pack

Question 20

What should you keep in mind when dispensing MR dipyridamole

Answer 20

It should be dispensed in its original container and any capsules remaining should be discarded 6 weeks after opening

Question 21

Give examples of factor Xa inhibitors

Answer 21

Apixaban. Edoxaban. Fondaparinux. Rivaroxaban

Question 22

How can rivaroxiban be administered?

Answer 22

With food

May be crushed and mixed with water or apple puree

Question 23

What concomitant drugs require edoxaban dose to be adjusted?

Answer 23

Max 30.od with ciclosporin, ketoconazole, erythromycin, dronedarone

Question 24

What are signs of heparin induced thrombocytopaenia?

Answer 24

30% reduction of platelet count
Skin allergy
Thrombosis

Question 25

What monitoring requirements are needed for heparins

Answer 25

HIT: plasma counts Hyperkalaemia: plasma K conc. Aldosterone secretion is inhibited thus causing hyperkalaemia. More susceptible in diabetes mellitus, chronic renal failure, acidosis, k sparing drugs

Question 26

Which heparin is a biological medicine and should be prescribed and dispensed by brand name?

Answer 26

Enoxaparin sodium | Arovi, Inhixa, Clexane

Question 27

What is the direction for administration when taking dabigatran with amiodarone or verapamil?

Answer 27

They should be taken at the same time.

Question 28

Why are vit k antagonists avoided in pregnancy?

Answer 28

Can cross placenta with risk of congenital malformations and placental, feral or neonatal haemorrhage esp during lask weeks of pregnancy and at delivery. Stopping before 6th wk of gestation may laregly avoid the risk of fetal abnormality.

Question 29

What is an important safety information by MHRA/CHM regarding warfarin?

Answer 29

Can cause calciphylaxis. Advice patients to consult doctor if they develop painful skin rash.

Question 30

What is stage 1 hypertension and when does it need oharmacological treatment?

Answer 30

Clinic bp 140/90, ABPM 135/85 | Treat in <80 with target organ damage, cvd, diabetes, 10 yr cv risk >20%

Question 31

What is stage 2 hypertension?

Answer 31

Clinic bp 160/100, ABPM 150/95

Question 32

What is 1st line treatment for hypertension in diabetes? Target bp?

Answer 32

Ace inhibitors. | <140/80. If with kidney, eye or cerebrovascular disease: 130/80

Question 33

What medications can be given for hypertension in pregnancy?

Answer 33

LABETALOL METHYLDOPA NIFEDIPINE MR(unlicensed)

Question 34

What medication is needed to prevent pre eclampsia in at risk pregnant patients?

Answer 34

Aspirin once daily from wk 12 of pregnancy until baby is born

Question 35

What side effect of minoxidil requires use of b blocker and a diuretic?

Answer 35

Tachycardia and fluid retention due to vasodilatation

Question 36

What are indications for acei

Answer 36

Heart failure usually with B blocker. Hypertension in <55(caucasian) HT in type 1 with diabetic nephropathy. 2ndary prevention of MI/cardiovascular events

Question 37

NSAID +ACEi

Answer 37

Increased risk of renal impairment

Question 38

K sparing diuretic + acei

Answer 38

Hyperkalaemia

Question 39

Which beta blockers are water soluble?

Answer 39

``` remember: Water CANS Celiprolol Atenolol Nadolol Sotalol ```

Question 40

How are water soluble b blockers excreted?

Answer 40

Renally- reduction in impairment

Question 41

Long acting b blockers that allows it to be taken once daily

Answer 41

Atenolol Bisoprolol Celiprolol Nadolol

Question 42

Cardioselective beta blockers

Answer 42

``` Be A MaN Bisoprolol Atenolol Metoprolol Nebivolol ```

Question 43

Common side effects of beta blockers

Answer 43

Cold extremities Fatigue Sleep disturbance with nightmares

Question 44

Why is beta blocker not advised for diabetes?

Answer 44

It interferes with carbohydrate metabolism causing hypo or hyperglycaemia. Not contraindicated in diabetes although cardiospecific are preferred. Should be avoided in frequent hypoglycaemia and uncomplicated HT in patients with diabetes or at high risk

Question 45

What does combination of b blocker and verapamil do in established ischaemic heart disease?

Answer 45

Precipitating of heart failure

Question 46

Can beta blockers be used in unstable heart failure?

Answer 46

No. Only in stable HF. Bisoprolol and carvedilol. Nebivolol in >70 with stable mild.or.moderate HF

Question 47

Which beta blocker can be used for thyrotoxicosis?

Answer 47

Propranolol which can reverse clinical symptoms within 4 days

Question 48

Which type of CCB has less effect on myocardium and therefore rarely precipitates heart failure?

Answer 48

Dihydropyridines | E.g nifedipine, amlodipine, felodipine, nicardipine

Question 49

Ddo prescribers need to specify the specific brand when prescribing diltiazem?

Answer 49

Only for MR formulations containing >60 mg.

Question 50

Which CCBs should be prescribed by brand?

Answer 50

Diltiazem and nifedipine

Question 51

At what eGFR are thiazide and related diuretics ineffective?

Question 52

Can thiazide and related diuretics be used for gestational hypertension?

Answer 52

No. Can cause a lot of s/e

Question 53

Important safety info with hydrochlorothiazide

Answer 53

Increased risk of non melanoma skin cancer particularly in long term use Limit exposure to sunlight and uv rays Examine suspicious moles or skin lesions

Question 54

Acei and aliskiren is contraindicated in these conditions

Answer 54

Diabetes mellitus and eGFR <60 ml/min/1.73m2

Question 55

When should acei be discontinued?

Answer 55

Marked elevation of hepatic enzymes or jaundice occur- reports of cholestatic jaundice, hepatitis, fulminant hepatic necrosis, hepatic failure

Question 56

Patients with heart failure and angina may be safely treated with this

Answer 56

Amlodipine Rate limiting ccbs and short acting dihydropyridines should be avoided in reduced ejectipn fraction since it reduces cardiac contractility

Question 57

Name a bile acid sequestrant and what may the patient require when treatment is prolonged?

Answer 57

Colesevelam/colestyramine/colestipol. | Interference with absorption of fat soluble vitamins may require supplements of A, D, K and folic acid

Question 58

Waht should be managed adequately before statin treatment?

Answer 58

Hypothyroidism

Question 59

Statin + fusidic acid interaction

Answer 59

Temporarily discontinue statin and restart after 7 days after last fusidic acid dose