Conditions Flashcards
(286 cards)
1
Q
what is ARRHYTMia and how are they detected
A
abnormal rate and rhytm of heart caused by an obstruction in the electrical conduction in the heart
Detected via ECG
2
Q
symptoms of arrthymias
A
breathlessness, chest discomfort, stroke, palpitations, syncope
3
Q
how is the risk of stroke assessed in those who have atrial fibrillation
A
CHAD2DS2Vasc score
MEN= 1 WOMEN=2
4
Q
How is the risk of stroke managed in af
A
anticoagulants- doacs
2nd line warfarin
5
Q
How is the risk of bleeding assessed in AF
A
ORBIT score
6
Q
what is acute AF and how is the life threatening and non-threatening sytoms treated
A
acute means it is new onset of AF
life-threateniing- emergency electrical conversion (electrical shock)
non-life threatening= pharmacological cardioversion e.g amiodarone , flecanide and beta blockers
if under 48hrs can give rate or rhytm control
if over 48 hrs onset or it is uncertain then give rate control
7
Q
What is paroxysmal AF?
A
episodes of AF Athat stops within 7 days usually within 48 hrs without any treatment
pt only takes medications when symptoms occur
8
Q
What are the causes arrthymias
A
aging, hypertrension, heart conditions, cardiomyopathy
9
Q
what is cardioversion
A
restores sinus rhythm of the heart
10
Q
which parenteral anticoagulant is given to patients with acute (new onset) AF who are recieving no anticoagulation and are waiting for the appropriate anticoagulant to be started
A
heparin
11
Q
first line and second line anticoagulation for af
A
DOACS E.G apixaban and edoxaban are first line
if ci e.g due to renal impairment use warfarin
12
Q
supraventricular arrthymia drugs
A
verapamil, adenoside, cardiac glycosides
13
Q
ventricular arrthymia drugs
A
Lidocaine sotalol
14
Q
what class are amiodarone and sotalol in the vaughan william classification for arrthytmic drugs
A
class 3, sotalol is also class 2
15
Q
which is first line for arrthymias= rate or rhythm control
What are the exceptions
A
Rate control except when
atrial flutter suitable for ablation strategy- use heat or cold energy to block electrical activity
AF with reversible cause e.g MI, Hyperthyroidism, PE, caffine/ alcohol
heart failure caused by AF
or if rthym control is more appropriate
16
Q
drugs that are used for rate control in af
DIVED BETA
A
beta blockers (not sotolol)
rate limiting calcium channel blocker e.g verapamil and diltiazem
digoxin *monnotherfapy only considered for initial rate control in patients with non paroxysmal af and other drugs unsuitable.
digoxin also used if patient has congestive heart failure
17
Q
Which drug combinations can be used if monotheray doensnt work for rate control for AF
BB and DD
A
Beta blocker
digoxin
Diltiazem
18
Q
what drugs are used for rhythm control
FABrhythmS;PD
A
beta blockers (not sotalol) as first line flecanide (avoid in heart disease) amiodarone propafenone (avoid in heart disease) dronedarone sotalol (beta blocker but not first line
19
Q
What are the two types of cardioversion
A
pharmacological: flecanide and amiodarone-if they have structural or ischaemic heart disease
electrical: electric shocl
20
Q
why is antoicoagulant given before cardioversion if stroke is over 48 hrs and how many weeks before and how long is it conrinued for after
If it is not possibke to be given before- what should be done/used instead
A
The prcodeure of electrical cardioversion can spread around the blood clot whihc can go to the brain and cause a dtroke. anticoag should be given 3 weeks before cardioversion to avoid this and continued for 4 weeks after
if not possible give heparin immediatly then cardioversion
21
Q
what does CHA2DS2-VASC score
A
congedstive heart failure=1 hypertension=1 age equal and over 75 years=2 age 65-74=1 diabetes mellitus=1 Stroke/TIA. thrombo-embolism= Vascular disease=1 Sex Female=1 vascular disease includes previous MI, PAD or aortic plaque
22
Q
what score of CHA2D2SVAS2C SCORE reqiures anticoagulation
A
2 and above
AN2COAGULANTS
23
Q
what does ORBIT stand for
A
Older than 74yrs=1 Reduced haemoglobin (history of anemia)=2 Bleeding history e.g gi bleed, intracranial bleed or haemorrhage stroke=2 Inadequate renal function (GFR<60)=1 Treatment with antiplatelet=1
24
Q
What do the different ORBIT scores mean in terms of risk of bleeding
A
0-2 low risk
3 medium risk
4-7 high risk
25
what does HASBLED stand for
```
hypertension (160/90) 1
abnormal liver or kidney function 1
stroke 2
bleeding history 1
lacible inr 1
elderly (over 65) 1
drug treatment- antiplatelet or nsaid / alcohol 1-2
```
26
what is torsades de pointes
type of arrthymia where the heart beats in an irregualr way usually too fast so not enough oxygen is being pumped around the body resulting in blackouts, faininting and deaths
27
Which rhythm control drugs should be avoided in heart disease
Propagenone and flecanide
28
What are the triggers for torades de pointes
stress, strenous exercise, sudden noise, hypokaleamia, bradycardia and drugs such as sotalol
29
what is the treatment for torsades de pointes
IV magnesium sulphate
30
which drugs can cause QTC Prolongation
| ABCDDE
```
Anti-arrthymics e.g amiodarone, sotalol, flecanide
antiBiotics
antispsyChotics
antiDepressants
Diuretics
antiEmetics- ondansetron
```
31
what is the dose for amiodarone
200mg tds 1 week then 200mg bd for a week then 200mg od
32
amiodarone s/e
| ami is a photosensitive BITCH
```
Photosensitivity = grey slate skin so use at least spf 30
bradycardia
Interstitial lung disease
thyroid dysfunction= contains iodine
corneal- occular
hepatic
```
33
c/i of amiodarone
iodine sensitivity
| thyroid function
34
monitoring of amiodarone
```
TFT 6 MONTHS
LFT
Potassium
chest x ray
annual eye tests
ECG with IV use
Blood pressure
```
35
what pt counselling associated with amiodarone
shield from sunlight- wear sunscreen
seek medical attention if have follwoing s/e= SOB, lightheadness, palipitations, fainting, unusual tiredeness, chest pain
36
amiodarone drug interactions
QT prolongation
statin- increased risk of myopathy
lityhium- increased risk of arrthymia
increased plasma conc with warfarin, digoxin, ciclosporin and phenyoin
37
what is the therapeutic range for amiodarone
1-2.
| above 1.5 is increased toxicity
38
MOA of digoxin
increases force of myocardial contraction and decreases HR by reducing conductivity in atrio-ventricular node.
39
digoxin dose for atrial fibrillation maintenance
125-250mg od- loading dose required
| 62.5-125mcg od- no loading dose required used for heart failure sinus rhthym
40
is digoxin excreted renally or hepatically
reanlly
| reduce dose in elderly
41
if a patient is on digoxin and has nausea what can you do to the dose
half dose of digoxin because it has long half life
42
why can you switch between formualtions of digoxin
different formulations have different bioavailablities and has a narrow therapeutic range
43
what is the therapeutic range for digoxin
1-2mcg/L
44
What is the toxic range for digoxin
1.5mcg/L-3MCG/L
| increases progressively through this range
45
whys hould the digoxin range in elderly be reduced
more suseptible to toxicity
46
Digoxin predisposes to which electrolyte disturbances
hypokalaemia
hypomagnesia
hypercalcaemia
hypoxia
47
what d given to prevent hypokalaemia in digoxin
k spaing diuretics or k supplements
48
what steps hsould be taken if digoxin toxicity occurs
withdraw digoxin
| if life threatening use digifab- digoxin specific antibody fragments
49
what the signs of digoxin toxicity
yellow vision
arrthymias
cardiac construction disorder
dizziness, nausea etc
50
monitoring requirements for digoxin
Plama-digoxin conc= taken 6 hrs after a dose
serum electrolytes
renal function- reduce in renal impairement
51
drug interactions with digoxin
| CRASED
```
renal excreted= NDSAIDS, ARBS/ACEI
enzyme inducers- reduced digoxin conc
enzyme inhibitors- increase digocin conc
Decreased potassium e.g diuretics, theophylline, steroids
CCCB
RIFAMPICIN
AMIODARONE
ST JOHNS WORT
ERYTHROMYCIN
DIURETICS
```
52
antifibrolytiic drugs
tranexamic acid- inihibits fibrolysis
53
uses of antifibrolytics and doses
prevents bleeding e.g surgery or dental extraction
management of menorrhagia 1g tds for up to 4 days max 4g a day and start when menstration starts
herediatry angioedema, epistaxis (nose bleeds) , general fibrolysis and thromboltic overdose,
epistaxis- 1g tds for 7 days
fibrinolysis 1-1.5g 2-3 times a day
54
which patients are at high risk of VTE
```
BMI over 28
contraceptives- HRT COC
Low mobility
malignnat disease e.g cancer
pregnancy
dehydration
over 60 years
family history of vte
thrombophilic disorder
```
55
what is used for pharmacological prophylaxis (unconfirmed) in DVT and PE
LMWH
Unfractionated heparin
Fondaparinux
DOACS
56
what pharmacological treatment is used for DVT and PE
1st line Rivaroxaban, apixaban
pregnant : LMWH / Heparin
Alternative LMWH for 5 days follwed by dabigatran/ edoxaban
renally impaired 15-50 offer either apixaban rivaroxaban or lmwh for 5 days follwed by rivaroxban or apixaban
57
when should you not use mechanical prophylaxis of DVT/PE for a pt in hospital
acute stroke, peripherfal arterial disease, peripheral neuropathy, severe leg oedema or local conditions e.g gangrenen or dermatitis
58
What anticoagulants and when are they given to patients undergoing orthopeadic surgery
Offer pharmacological prophylaxis for patiets undergoing surgery within 14 hrs of admission or before
use LMWH
unfractioned heparin preferred in patinets with renal impairment or increased risk of bleeding
59
which surgeries should fondaparinux be given for VTE and how long post surgey
hip/knee replacement, hip fracture, G.I Bariatric or day surgery procedures
7 days or until patient is mobile
60
when are DOACS used as pharmacological thromboprophylaxis
elective hip/knee replacement after LMWH or low dose aspirin
61
when shounld unfractionated heparins be used as pharmacological thromboprophylaxis
renal cleareance 15-50ml/min or increased bleeding risk
62
which anticoagulants can be used in pregnancy and why
heparins are safe as they dont cross the placenta
lmwh preferred due to lower risk of osteoporosis abd heparin induced thrombocytopenia (low platelets)
lmwh are eliminated more rapidly in pregnancy so may need to adjust the dose
63
for a confirmed dvt or pe how long should anticoagulant be given for
at least 3 -6 months for active cancer
| 3 months otherwise
64
for provoked e.g due to pregnancy or contraception dvt and PE how long is anticoagulant treatment
3 months
| 3-6 months active cancer
65
unprovoked DVT or PE how long is the duration of anticoagulation treatment
Over 3 months
| active cancer for over 6 months
66
in patients who has dvt or pe decline anticoagulant treatment which medication should be used
aspirin or another antiplatelet
67
what is the most common side effect of heparins and lmwh and what do we do to reverse it
Haemorrhage if it occurs then withdraw
| protamine sulphate is the antidote but only partially revserses effects of lmwh
68
what are the three different types strokes
| HIT
Haemorrhagic stroke
ischaemic stroke
transient ischaemic stroke
69
What are the symptoms of stroke
```
FAST
face drop
arm weakness
slurred speech
time to act- call 999
```
70
how is haemorrhagic stroke treated
surgey (avoid all meds)
| and treat the hypetension
71
how is TIA treated initially
give aspirin 300mg immediately with ppi if dsypepsia and arrange urgent care within 24 hrs
clopidogrel -unlicensed 75mg if intolerant of aspirin
72
what is the initial management for ischaemic stroke
alteplase if within 4-5 hrs of stroke symptoms and intracranial haemorrhage has been excluded OR
aspirin 300mg or clopidrogrel 75mg within 24hrs of symproms onset
73
when is anticoagulant given in stroke
long term managememt if the patient has AF, DVT or thrombosis
74
Long term management of stroke- tia/ ischaemic stroke
| CLAAS
Clopidogrel 75mg OD OR
MR dipyramidole 200mg BD + aspirin 75mg OD OR
MR dipyramidole 200mg BD if the above contraindicated
Lifestyle
Anticoagulant/Warfarin if af dvt or thrombosis instead of antiplatelets
Antihypertensives - keep bp below 130/80 but avoid BB because increases the risk of stroke
Statins 48hrs after stroke- high intensity atorv 20-80mg
75
a patient has a TIA in a pharmacy do you give 300mg or call 999
If the patient has a haemorrhagic stroke, aspirin will make them bleed even more
need to determine what type of stroke it is and need to do this by a scan in a hospital
76
name the caourmarins and phenindiones and how long it takes for them to be fully efefctive
warfarin, acenocoumarol and phenindione
takes 48-72hrs to get full effect
warfarin is drug of choice
different streghths
77
name the different strengths of warfarin and their colours
0.5 white
1mg brown
3mg blue
5mg pink
78
what are the mhra warnings associated with warfarin
pts with renal disease are more likely to get calciphylaxis whihc is a painful rash that needs to be referred to the GP
miconazole- daktarin oral gel causes bleeding e.g unexplained bruising, nose bleeds, blood in urine- stop and seek medical advice
79
Whar is the antidote for warfarin
phytomendione
| vitamin k1
80
which foods and drinks should be avoided when taking warfarin
cranberry juice
Pomegranate juice increases INR
avoid diet change- liver sprouts, brocoli, green tea, salalds and leafy green vegetables
alcohol- heavy drinking decreases effects of warfarin
81
why cant warfarin be given in pregnancy
Teratogenic especially in 1st and 3rd trimester
crosses placenta leading to fetal abnormalities
risk of haemorrhage due to vitamin k deficiency
82
which conditions require an INR value of 2.5
| MORE IMPORTSNAT TO LEARN THIS CARD THAN 2.5 CARD
```
treatment DVT or PE
AF
Cardioversion
dilated cardiomyopathy
mitral stenosis regurgitation
myocardial infarction
acute arterial embolism
```
83
whihch conditions requires an INR of 3.5
| MORE IMPORTSNAT TO LEARN THIS CARD THAN 2.5 CARD
reccurent dvt/pe
mechanical prosthetic heart valves
if within 0.5 it is satifactory
84
if pt has major bleed on warfarin
STOP WARFARIN
| phytomendione by slow iv injection and/or dried prothrombin complex/ fresh frozen plama (less effective)
85
if patient has inr over 8 and minor bleeding what should you do
stop warfarin
phytomendione slow iv injection. repeat dose of vit k if inr still high sfter 24hrs
restart inr when under 5
86
if patient has inr over 8 but no bleeding
stop warfarin
iv phytomindione by mouth whihc is unliscend. repeat vit k if inr still high after 24 hrs
restart when inr under 5
87
if pt has inr between 5-8 and minor bleed
stop warfarin
phytomiodione by slow iv injection
restart inr when below 5
88
if patient has inr between 5-8 and no bleed what should be done
withold warfarin for 1 to 2 doses
| reduce subsequent maintenance doses
89
when is phytomendione given by slow iv
major bleed
| minor bleeds inr 5 upwards
90
when is phytomindione iv given by mouth
no bleeding but inr over 8
91
what are the drug intercations assocaited with warfarin
enzyme inducers decrease the effects
enzyme inhibitors , benzafibrates and amiodarone increase the effect
aspirin increases the risk of bleeding
92
whihc has a higher risk of bleeding
Clopidogrel and warfarin OR
Aspirin and warfarin
clopidogrel and warfarin
| can use together but should reduce the amount of time together or withold antiplatelet whilst taking warfarin
93
what is the difference between heparin and lmwh
heparin
intiates anticoagulation rapidly but for a short amount of time- used for pts with increased risk of bleeding becaus eyou can stop it very quickly by stopping infusion
LMWH
Doesn’t cross placenta so can be used in pregnancy
preferred over heparin because it is very effective and less risk of heparin induced thrombocytopenia and osetoporisis
longer cation and given once daily
doesnt require monitoring
20,000 unit/ml syringe licensed for extended treatmnet and prophylaxis of VT in patinets with solid tumors
94
moa of antiplatelets
decrease platelet aggregation and inhibit thrombus formation in the arterial circulation
95
is aspirin used in primary or secondary prevention of cvd
secondary
| give ppi if high risk of bleeding
96
indication of dipyridamole
prophylaxis of thromboembolism assocaietd with prosthetic heart valves
mr for secondary prevntion of ischaemic stroke and tia- 200mg bd with food
97
what is the important prescriiing and dispensing information associated with dipyridamole
should be dispensed in its original container- pack contains desicant and any remaining caps should be discarded 6 weeks after opening the pack
98
when are doacs preffered to warfarin in AF
Non valvular AF e.g due to thyroid dsyfunction etc. DOACS preferred
stenosis and problem with valves are valvular AF where warfarin is more suitable
99
when do you give anticoagulant for prevention of stroke
diabetes, hypertension , previous MI, stroke/TIA, age equal to or above 75years
use chadvasc score
100
which parameters require dose reduction in DOACS?
| ABCD
age= equal to or above 80
body weight under 61/60kg
Crcl=15-50
drugs e.g verapamil, amiodarone, erthyromycin, ciclosporin
101
What drug is contra-indicated in antiphospholipid syndrome?
doacs because this condition creates an immune response whihc creates antibodies which makes blood clot increases the risk of recurrent thrombotic events
102
Which doac is given in heart attacks- ACS and dose
Rivaroxaban at 2.5mg BD
103
what dose is rivaroxaban given at for stroke prophylaxis
20mg OD
104
What dose is rivaroxaban given at for VTE prophylaxis
10mg OD
105
What dose is apixaban given at for VTE prophylaxis
2.5mg BD
106
What dose is apixaban given at for stroke prophylaxis
5mg BD
107
How many times daily are each of the DOACS given
Once a day
Rivaroxaban
Edoxaban
Twice a day
Apixaban
Dabigatran
108
what needs to be monitored when giving doacs
kidneys
109
do all doacs have patient alert cards
yes
110
moa of dabigaTran
direct thrombin inhibitor with a rapid onset of action
111
apiXAban EdoXAban and rivaroXAban moa
direct and reversible inhibitors of factor Xa
112
which doac does not have an antidote
edoxaban
| edoxaban has no ban
113
what is the antidote for dabigatran
idarucizumab
114
what is the antidote for apixaban
anadexanet alfa
115
what is the antidote for rivaroxaban
Andexanet Alfa
116
what are the indications doacs
prophylaxis of stroke and systemic embolism in non valvular AF
secondary prevention of DVT and PE
Prevention of VTE in hip or knee replacement
rivaroxaban for atherosclerotic events in ACS
117
what is the mOA of warfarin
inhibits vitamin K by dreasing clotting factors II, VII, IX and X
118
what is the mhra advice surrounding rivaroxaban dosing
15mg and 20mg has to be given with food
119
when should dose of 5mg BD of apixaban for stroke prophylaxis be reduced to 2.5mg BD
ABCC
```
2 of the following (creatinine count as the same point)
age over or equal to 80
body weight equal to or over 60kg
creatinine equal to or over 133
creatinine clearance of 15-50
```
120
what is the normal dosing for warfarin
initially 4-10mg then maintain at 3-9mg taken at the same time daily
121
what is the dose of dabigatran given for prophylaxis of VTE after knee replacement
110mg for 1-4 hours after surgery then 220mg OD for 10 days
122
What dose of dabigatran is given for prophylaxis of stroke and when should it be reduced
150mg BD
if pt over or equal to 80 years old reduce to 110mg BD
on verapamil
or crcl=30-50ml/min
75-79 years old reduce dose to 110-150mg BD
123
when is dose of edoxaban dose reduced
erythromycin, ciclosporin, ketoconazole and dronedarone
or weight less than 61kg
or crcl=15-50
124
what is the cautionary label given with edoxaban and apixaban
Label 10
read the additional information given with this medicine
125
what is the cautionary label given with dabigatran
| label 10 and 25
read the additional information given with this medicine
| swallow this medicine whole- do not chew or crush
126
what strenth tabelts do dabigatran come in
75mg, 110mg, 150mg caps
127
what strength does apixaban come in
2.5mg and 5mg
128
what strength tabelts does rivaroxaban come in
2.5mg, 10mg, 15mg, 25mg
129
what strength tabelts does edoxaban come in
15mg, 30mg, 60mg
130
Contraindications of anticoagulants
dont give to anticoagulants together
confitions with risk factors of bleeding
antiphospholipid syndrome
switching between rivaroxaban and warfarin
131
when tranxexamic acid is given p med what is indication, age and duration
4 days
merrhagia
18 and over
132
what are the red flags for tranxeminc acid and where would you refer them to
increased risk of dvt with contraceptive
colour vision chnage or viusual impairment - discontinue
leg, arms swollen or red are signs of dvt so refer to hospital
coughing up blood or anaphylactic reaction
133
when is tranexamic acid contra-indicated
epilepsy, DVT, PE, irregular periods, renal problems, pregnancy
134
non-modifiable risks of CVD
```
over 50 starts to increase
ove 85 particular risk
south asian
men
family history
```
135
what is the difference between QRISK 2 and QRISK 3 and what does it do
Incrased risk of CKD, lupus, migraine, steroid use, atypical antipsychotics, mental illness, erectile dysfunction
estimates 10 year risk
136
what does JBS3 measure
estimates lifetime risk of cvd risk
137
what is ASSIGN
assign estimates 10 year risk
138
What QRISK score elicits starting a statin
equal to or above 10%
139
what are the exemptions to the cardiovascular risk assessments
```
pts with
diabetets type 1
established cvd
CKD
Familial hypercholesterimia
equal to or over 85 years old esp if they spoke
```
140
what are the drugs given in primary prevention of CVD
Antihypertensives if over 140/90
| low dose statin 20mg atorv
141
causes of hyperlipidemia
hypothyroidism
antipychotics, immunosuppressant , corticosteroids
diabetes
142
what is a high intensity statin and examples
a statin that reduces ldl by 40%
| atorv and rosuvastatin and 80mg simvastatin are high intensity
143
what statin and dose should be used for primary prevntion of cvd
atorvastatin 20mg
144
what is second line to statins for hypercholesterolemia
either start ezetimibe or use both ezetimibe and statin
| can then use fibrats, bile acid sequestrant or nicotinic acid after talking to specialist
145
when are fenofibrates used
fenofibrate are better at reducing triglycerides than statins
146
why should statins and fibrates not be used together
increased of rhabdomylisis- breakdown of mucsle
147
what should be monitored when starting statins
```
lipid profile
liver enzymes and 3 and 12 months in
cK
Hba1c/ fasting blood glucose and 3 months in
hypothyroidism
renal function
```
148
why should statins and gemfibrozil not be used together
considerable risk of rhabdomylysis
149
what is the moa of statin
inhibits the HMG CoA reductase which is found in the liver and produces cholesterol
150
why is statin drug of choice over fenofibrate
statins reduce risk of heart attack and total mortality
151
which statins are safe to give in breastfeeding and pregnancy
None as its teratogenic - discontine three months before starting to concieve
contraception needed during treatment and 1 month afterwards
152
patient and carer advice given to patients for statin
unexplained muscle pain tenderness and weakness
153
whichh statins can be given at any time of day
atorvastatin
| rosuvavstatin
154
what is the max dose of simvastatin can be given with amlodipine, amiodarone or ranolazine and what is the risk
20mg- when given with amlodipine its like doubling the dose so increases the risk of rhabdomylysis
155
When to stop statins when measuring lft and CK levels
3 times the upper limit of LFT
| 5 times the upper limit of CK
156
important interacctions with statins
enzyme inducers and inhibitors
157
what is the max dose of simvassttain taht cna be given with fibrates
10mg
158
what is the max dose that can be given of atorvastatin with ciclosporin
10mg
159
what is the max dose of rosouvastatin that can be given with clopidogrel
20mg
160
what is the highest dose of fluvastatin
80mg
161
what is the highest dose of prvastatin that cna be given
40mg
162
what is the highest dose of Rosuvastatin that can be given
40mg
163
is prvaastatin low, medium or high statin
all strengths are low
164
which statins and doses are medium intensity
20, 40mg Simvastatin
10mg atorvastatin
80mg fluvastatin
5mg rosouvastatin
165
what are the two types of heart failure and what the differences
acute heart failure- sudden symptoms so emergency
| chronic heart failure- symptoms ongoing
166
what are the symptoms of heart failure
```
SOB
Persistent coughing/wheezing
ankle swelling
reduced exercise tolerance
chest pain
palpitations
risk greater in smokers, men and increases with age
```
167
what causes heart failure
```
CHD especially MI
Hypertension
heart valve
Cardiomyopathy
arrythmias
excess drugs, alcohol
thyroid dysfunvction, severe anaemia leading to reduced cardiac output
```
168
how is heart failure diagnosed
physical examination- pulse enlarged herat, fluid retention
| blood tets- measure BNP or NT-proBNP. They both increase in heart failure
169
when should pt report weight changes with heart failure
1.5-2kg in 2 days report to GP
170
what does heart failure mean
not enough blood is going into and out of the heart so it doenst function properly
171
which medications are used in heart failure with reduced ejection ( which is most common type of HR and what I will be examined on)
ACBD
optimise dose of ACEI/ARB then add beta blocker if needed or vice versa
better to start with acei if diabeteic or fluid overload or BB if angina
if symptoms persist then add MRA e.g spironolactone
If patient is afro-Caribbean or therer is another reason pt can't take ACEI or ARB then use hydralazine and Nitrate
specialist advice if none of this worksqho can add sacubitril, ivabradine, digoxin or hydralazine and nitrate
ACEI/ARB
BB
CCB- only amlodipine
Diuretics e.g loop, MRA e.g spironolactone
172
Which beta blockers are used in herat failure
nebivolol, bisporolol, carvedilol
173
when are loop diuretics used in heart failure
| when are thiazide like diuretics used in heart failure
thiazides ae used for mild fluid retention and eGFR is over 30
loop diuretics is used to relieve breathlessness and oedema
174
whihc MRA are liscensed for heart failure
eplerenone, spironolactone
175
which vaccines should be offered to patients who have heart failure and how often
Influenza and pneumococcal vaccines annually
176
which drugs should be stopped/avoided in heart failure because they worsen it
NSAIDS-increase sodium retention , CCB unless amlodipine
177
which acei are licensed for HF
Perindopril, ramipril, captopril, enalapril, lisinopril, quinapril, fosinopril
178
if a patient has COPD/diabetes/erectile dysfunction/ PVD or was old and they had HF
do you give a beta blocker
yes because the benefits outweigh the risk
179
whihc ARBs can be used in heart failure
candasartan, losartan, valsartan
180
what are the second line add on treatments for HF
Aldosterone antagonists e.g spironolatone, epelerone
| dapaglifozin/empaglifozin 10mg od
181
what are the three types of acs
NSTEMI
STEMI
Unstable angina
182
What is ACS physiology
plaque ruptures in a coronary artery that causes a partical or complete blocakage of the artery. the obstruction restricts the blood supply to the heart-lack of oxygen leads to ischaemia (chest pain). Angina is often the first sign
If obstruction is extensive heart muscle starts to die causing myocardial infarction
183
What are the symptoms of angina
tight sharp stabbing dull and heavy chest pain
radiates to left arm neck, back, jaw
triggered by exertion and stress
stops within few minutes of lying down
184
difference between unstable and stable angina
stable= predictable due to exercise/stress and stops on resting
unstable angina= unpredicable so occurs whilst resting, longer and recurring, chest pain more severe
185
what is the initial management of ACS in hospital
```
GTN Sublinfual/buccal tablets
IV Opioids e.g morphine ASAP
aspirin 300mg alt clopidogrel ASAP
oxygen If needed
insulin if hyperglycaemia glucose over 11mmol/L
```
186
what is secondary management of patients STEMI or NSTEMI
Cardiac rehab- lifestyle
ACEI/ARB
BB or verapamil/diltiazem
Dual antiplatelet therapy- aspirin and clopidogrel for 12 months OR
Triple therapy - aspirin, clopidogrel and rivaroxaban if the the patine has really high cardiac biomarkers
Statin
187
what are the common side effcts of nitrates
ypertensio, fkushing, headaches
188
gtn spray length of action
quick acting- 20-30 minutes
189
when should a patient be switched from gtn spray to gtn tablets
if using spray moe than twice a week, need the tablet
| 300mcg tablet most appropriate when first used. alternatively can use the aerosol spray
190
wich form of gtn can be used if longer duration of action is required
transdermal patches
| however tolerance can grow
191
prophylaxis of angina using gtn- what is the dose
1 tablet before activity
| 1-2 sprays under the tongue
192
treatment of angina using gtn- dose
Sublingual tablets 1 tablet repeated at 5 min interval if required. if not resolved after three doses call 999
spray 1-2 doses under tongue for either prophylaxis or treatment
one patch changed every 24hrs
193
moa and role of nitrates
potent coronary vasodilators but main benefit is reduction in venous return which reduces left ventricular work.
193
moa and role of nitrates
potent coronary vasodilators but main benefit is reduction in venous return which reduces left ventricular work.
194
isosorbide dinitrate
active sublingually effective in patients requiring infrequently
effective by mouth even though slow onset
effect persist for a few hours
195
difference in dosage between dinitrate MR preps and mononitrate MR preparations
mononitrate is given once a day
| dinitrate is given twice a day- has a duration of 12 hours
196
isosorbide mononitrate IV glyceryl trinitrate/iv isosorbide dinitrate
when is one used over the other
isosorbide mononitrate- angina prophylaxis
| IV glyceryl trinitrate/iv isosorbide dinitrate-vfor severe symptoms or sublingual can't be used
197
what is the main caution associated with nitrates and how can it be prevented?
tolerance
take isosorbide mononitrate MR tabs because it is once daily
for twice daily tablets- take the second dose after 6-8 hrs not 12 hrs to allow for a nitrate period
leave patch off for 8-12 hrs- overnight in each 24 hrs
198
what strengths do GTN sublingual tablets come in and what are the dispensing and storage requirements
```
300mcg
500mcg
600mcg
tablets supplied in glass container not over 100 tabs
closed with foil line cap
no cotton wool wadding
discard after 8 weeks
rectal ointment discarded 8 weeks after opening
```
199
how do you take gtn tablets or spray- when what dose etc
take before exertion e.g before exercising
take when required
dose: 1 tablet or 1-2 sprays. no more than 3 at any one time
take sitting down due to postural hypotension
1st dose wait 5 mins
2nd dose wait 5 mins
3rd dose wait 5 mins
chest pain persists call 990
200
three types of blood pressure
home done at home using automatic machine
clinic in drs or hospital
ambulatory- 24 hr monitoring
201
what is established cvd
```
CVD is a general term for conditions affecting the heart or blood vessels
-stroke/tia
mi
angina
pad
```
202
what are the target organs
heart
brain
kidney (CKD)
eye (retinopathy)
organs investigated if blood pressure is high
e.g ventricular hypertrophy, CKD, hypertensive retinopathy, increased urine albumin: creatinine ratio
203
What is the definition of the different stages of hypertension
both stage 1 and 2 have to have both clinic and ambulatory readings
```
stage 1 hypertension
clinic BP= >140/90-160/100
home/ambulatory=>135/85
stage 2 hypertension
clinic BP 160-100mm/hg- 180/120
home/ambulatory 150/95mmHg
stage 3 hypertension
clinic systolic BP= >180 or
diastolic >120
high blood pressure at repeated clinic encounters- persistent hypertension
```
204
what is accelerated hypertension aka
| malignant hypertension
severe increase in bp to over 180/120 and most often over 220/120
signs include
-retinal haemorrhage
papilloedema- swelling optic nerve
usually associated with target organ damage
205
Overview of hypertension diagnosis
no hypertension and nor organ damage= measure clinic bp every 5 years and more frequently if close to 140/90
no hypertension but target organ damage= investigate causes further
high bp offer ambulatory or home to confirm diagnosis
investigate and assess cvd risk
206
when is medication given or not given for stage one persisitent hypertension
```
If she is under 80 and has one of the follwing:
target organ dammage e.g ckd
established cvd
renal disease
Diabetes
qrisk 10 and above
lifestyle advice
If over 80:
drug treatment and advice
if under 40 yrs:
investigate secondary causes of hypertension
if under 60
estimated cvd qrisk
offer lifestyle advice and drug Treatment
```
207
do you always treat stage 2 hypertension with medciation
medication no matter age
208
if stage 3 or severe hypertension how do you treat
IV antihypertensives
209
same day specialist refferal for pts with hypertension 180/120 and above with any of the follwing signs:?
retinal haemorrhage
papilloedema- accelerated hypertension
life threatening symptoms- new confusion , chest pain, signs of heart failure pr acute kidney injury
suspected phaeochromocytoma e.g postural hypotension, headache, palpitations, abdo pain, pallor, diaphoresis
210
if pt has 180/120 or over and dont have any of the warning signs what investigatiomns/monitoring/drug treatment should be used
carry out investigations for target organ dmage asap
if therer is damamge then start antihypertensive treatment immediately without results of further bp tetst
if no damage then repeat clininc bp 7 days later
211
is BB contra-indicated indecompensated - severe-, HF or unstable angina- yeds or no
yes
212
what are the drug classes for antihypertensives used in order
```
acei/arb
ccb
Thiazide like diuretic
low dose spironolactone
beta blocker/alpha blocker
```
213
if an african man aged 80 has diabetes, which antihypertensive is used firdst line
acei or arb
214
If ccb is not tolerfated due to oedema or heart failure
offer thiazide like diuretic
| use indapamide or chlotriazdone over bendroflumethazide -unless pt is already on bendro
215
Cautions for ACE I
Afro-car
severe renal carribbean
Pregnancy/breast feeding
aliskiren egfr under 60 or diabetic angioedema
216
side effects assocaited withe ace inhibitors
angioedema
cough
hyperkalaemia
217
Cautions for ARB
Afro-car
severe renal carribbean
Pregnancy/breast feeding
aliskiren egfr under 60 or diabetic angioedema
218
Side effects associated with arb
hyperkaleamia
| angiooedema
219
cautions associated with with CCB
Oedema
HF except amlodipine
unstable angina/ decompensated hf
220
side effect of ccb
oedema
221
cautions for thiazide diuretics and thiazide like diuretics
diabetes
gout
egfr under 30
addisons
222
sid eeffects assocaited with thiazide /like diuretics
hypokalaemia
hyperuricaemia
hypercalcaemia
hyponatraemia
223
what are the cautions associated spironolactone
addisons
| hyperkalaemia
224
what are the side effects associated with spironolactone
gynaecomastia
| hyperkalaemia
225
what are the cautions associated with beta blockers
asthmatics
copd
unstable hf
226
what aew the side effects asocaited with beta blockers
bradycardia
227
what are the cautions associated with alpha blockers
history of syncope in benign prostatic hyoerplasia or posturaL hypotension
228
what are the side effects associated with alpha blockers
orthostatic hypotension- laying flat standing always hypo
229
what age diffrentiates between giving an acei/arb or a ccb as first line treatment in hypertension
55 years ol
230
what is step 4 of antihypertensive treatment
low dose spironolactone if potassium is equal to or under 4.5
alpha blocker or beta blocker if blood potassium level is over 4.5
231
what is the first line and other treatments for antihypertensive treatment in type 1 diabetics
```
acei/arb first line
BB
CCB- long acting prep e.g MR nifedipine or amlodipine (standard)
Diuretics in combo with bb
not stepwise just use as monotherapy
```
232
what is first second and third line treatment for hypertension in pregnant women
1st line oral labetalol
2nd Line MR Nifedipine
3rd line IV Methyldopa= stopped 2 days after giving birth
233
What is the initial, maintenance and max dose of labetalol given in pregnancy
Adult dose; initially BD, dose to be increased in intervals of 14 days
usual dose 200mg BD Increased if necessary to 800mg daily in 2 divided doses
maximum of 2.4g per day
234
Is labetalol taken with food or without food
with food
235
how should higher doses e.g 800mg of labetalol be divided
3-4 divided doses
236
```
What are the targets thresholds for starting antihypertensive for: (clinic)
Pregnancy
Renal disease (CKD)
renal disease and diabetes
type 1 diabetes with albuminuria or clinical features that increase the risk of ckd
type 1 diabetes
under 80
80 or over
```
```
Pregnancy = over 140/90
Renal disease (CKD)= over 140/90
renal disease and diabetes = over 130/80
type 1 diabetes with albuminuria or clinical features that increase the risk of ckd= equal to or over 130/80
type 1 diabetes= equal to and over 135/85
under 80= equal to or above 140/90
80 or over = equal to or above 150/90
```
237
what is the moa of beta blockers
bloc adrenoreceptors in the heart bronchi, pancreas liver and peripheral vasculature- blood vessels outside the heart
slow the heart and can depress the myocardium
beta blockers are all equally effective
238
where are the b1 and b2 receptors in the body
```
b1=heart (one heart)
b2 lungs (2 lungs)
```
239
Which BB cause less bradycardia and less coldness on extremities
ICE PACO
```
Intrinsic sympathomimetic activity= ability of bb to stimulate and also block adrenergic receptors
Pindolol
acebutolol
Celiprolol
Oxprenolol
```
240
what is the benefit of water soluble bb and examples
| CANS (water cans) NA A
Water soluble bb are less likely to enter the brain therefore cause less sleep disturbance and nightmares
excreted by the kidneys- dosage reduction necessary in renal impairment
Celiprolol
Atenolol
Nadolol
Sotalol
241
what is the difference between cardio selective BB and other BB and examples
BE A MAN NE AE
```
less effect on bronchi receptors
lesser effect on airway resistance
selective but not specific
used in well controlled asthma if no alternative
Bisoprolol
Atenolol
Metoprolol
Acebutolol
Nebivolol
```
242
How often are short acting vs long acting BB administered and which BB are long acting
BACN A AN
```
Short duration of action
given two- three times a day
MR given once for hypertension
Long action give
Bisoprolol
Atenolol
Celiprolol
Nadolol
```
243
What are the side effect of beta blockers
```
fatigue
coldness of extremities
sleep disturbances
bradycardia
hypotension
hypo/hyperglycaemia-
masks hypoglycaemia
BB can interfere with the metabolism of carbohydrates causing hypoglycaemia or hyperglycaemia in patients with or without diabetes, they can also interfere with metabolic and autonomic responses to hypoglycaemia, thereby masking symptoms such as tachycardia
```
244
can BB be given to patients with asthma
precipitates bronchospasm- avoid in pts with history of asthma
given to pts with well controlled asthma/copd if no alt
for co-existing conditions e.g HF or MI
Give cardio selective BB with caution
Atenolol, bisoprolol, metoprolol, nebivolol and acebutolol- have less effects on B2 receptors therefore cardioselective but not cardiospecific
245
are beta blockers contra-indicated in diabetics
no
use with caution- cardioselectivity preferred
affects carbs metabolism in pts with and without diabetes
avoid in pts with frequent episodes of hypoglycaemia
246
which type of BB is preffered in both diabetics and asthmatics
cardioselective BB
247
What are some of the uses of beta blockers
```
hypertension
angiina
mi
arrthymia
hf
anxieety- ptopranolol
migraine -propranolol
glaicoma
thyrotoxicosis- propranolol
```
248
what are the contra-indications of BB
```
asthma/copd
marked bradycardia
prinzmetal's angina
2nd/3rd degree av block
uncontrolled heart failure
```
249
What are the cautions associated with BB
1st degree av block
symptoms of thyrotoxicosis and hypoglycaemia may be masked
verapamil and diltiazem
may reduce response to adrenaline
250
What are the cautions associated with BB
1st degree av block
symptoms of thyrotoxicosis and hypoglycaemia may be masked
verapamil and diltiazem
may reduce response to adrenaline
251
what severe adr does IV verapamil have with BB
hypotension and bradycardia
252
what are the three classes of CCB
Dihydropyridines
Phenylaklyamines
Benzothiazepines
253
example of dipyramidines and moa
amlodipine, nifedipine, lacidinpine, felodipine
relax sm- vasodilatory effect
no anti-arrthymic affect
254
example and moa of phenylalkylamines CCB
```
verapamil
treat hypertension, angina and arrhinias
very inotropic CCB (Can slow HR down very low)
minimal vasodilatory effect compare to dihydropyridines
causes constipation
cardiac depressant
may precipitate heart failure
do not use with beta blocker
```
255
moa and example of benzothiazepine CCB
diltiazem
cardiac depressant and vasodilatory effects
intermediate between classes
effective in angina
longer acting formulations used in hypertension
less -ve inotropic effect than verapamil
caution with bb due to bradycardia
256
CCB in unstable angina
ccb DO NOT REDUCE THE RISK OF mi IN UNSTABLE ANGINA
Verapamil and diltiazem should be reserved for pts resistant to treatment with BB
Sudden withdrawal of CCB can exacerbate angina
257
what is the prescribing and dispensing information associated with diltiazem
prescribed by brand
| different MR preps containing ove r60mg may not have the sam effect
258
nicorandil indications and where it exerts its action
long and short term treatment of angina
arterial and venous vasodilatory effects
L channel activator with nitrate component
other drugs ivabradine and ranolazine
259
side effects to CCB
```
Dizziness
flushing
Headaches
Postural hypotension
GI disorders
ankle swelling
skin reactions
sudden withdrawal of CCB may exacerbate myocardial ischaemia
```
260
moa, indications and examples of thiazide and related diuretics
inhibit sodium reabsorption in the beginning distal convulated tubule
acts within 1-2 hrs of oral admin and effects last for 12-24 hrs
give in mooring to avoid diuresis overnight which can affect sleep
indication- lower doses reduce bp
higher doses used for oedema due to CHF- More biochemical effects than lower doses - K, Na, uric acid, glucose, lipids with little advantage on bp
examples
Bendroflumethiazide- mild to moderate HF or hypertension
Chlortalidone- long duration of action and may be given on alt days
indapamide- lowers bp with less effects on electrolytes and less aggrabation of diabetes
261
contra-indications of thiazide and related diuretics
hypokalaemia, hyponatraemia, hypercalcaemia and Addison's disease- low levels of sodium and high levels of potassium
262
cautions associated with thiazides and relate diuretics
hypokalaemia- loop and thiazides but higher with thiazides
hypokalaemia dangerous in CVD or cardiac glycosides
K sparing diuretics of potassium supplements can be used
in hepatic failure, hypokalaemia can lead to encephalopathy, particularly in alcoholic cirrhosis
elderly more susceptible to s/e- give lower dose
not use on long term basis sue to gravitational oedema- responds to increased movement, raising legs and support stockings
can exacerbate diabetes and gout due to the hyperuricaemia and hyperglycaemia
263
s/e of thiazide and related diuretics
constipation. electrolyre imbalance, headache, postural hypotension, skin reactions
264
should thiazide and related diuretics be used in pregnancy
thiazides and related diuretics should not be used to treat gestational hypertension
may cause neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte imbalances
265
can thiazide and thiazide like diuretics be used in renal and hepatic impairement
caution in severe hepatic disease
| ineffective if egfr under 30 so should be avoided
266
moa and examples of loop diuretics
inhibits reabsorption from the acsending loop of henel- powerfule diuretics
used in pulmonary oedema duw to left ventricular heart failure and in CHF
Stronger diuretics than thiazides and can be used for resistant oedema
can exacerbate diabetes (but hyperglycaemia less likely than with thiazides) and gout
examples- furosemide and bumetanide
both act within 1hr or oral admin and in similar activity
diuresis is complete within 6 hrs so can be given twice a day without interfering with sleep
267
contra-indications associated with loop diuretics
renal failure, hypokalaemia, severe hyponatraemia, liver cirrhosisi
higher dose or rapid I.V admin loop diuretics may cause tinitus and deafness
renal impairemment
268
what colour can furosemide and triamterene color urine
blue
269
which are the strong k sparring/ aldosterone antagonists
eplerone
spironolactone
k supplements must not be given with aldosterone antagonists
270
examples of weak k sparing diuretics and aldosterone antagonists
amiloride
tiamterene
potassium supplements must not be given with potassium sparing diuretics
k sparing diuretics and acei can cause severe hyperkaelaemia
271
what is the main side effcet associated with spironolactone
gynaecomastica
272
other diuretics and thier indications
combo diuretic therapy
mannitol- osmotic diuretic used to treat cerbral oedema and raised ocular pressure
mercurial diuretics- effective but hardly used due to nephrotoxicity
acetazolamide (carbonic anhydrase inhibitor\0- weak diuretic used for mountain sickness prophylaxis
eye drops of dorzolamide and brinzolamide inhibit formation of aqueous humour and used in glauccoma
273
moa and indications of ACEI
inhibit conversion of angiotensin 1 to angiotensin 2
| Indications - heart failure, hypertension, diabetic neuropathy , prophylaxis of CV events
274
Contra-indications associated with ACEI
In combo with aliskiren contraindicated in pts with diabetes and pts with egfr under 60
275
cautions associated with ACEI
Afro-caribbean
Concomitant diuretics
frugs that cause hypotension e.g diuretics
276
Use of ACEI in heart failure
used in heart failure with beta blockers
can be used in stable and unstable heart filure
discontinue k sparing diuretics and k supplements bedfore starting ACEI due to risk of hyperkalaemia- low dose spironolactone can be used but closely monitored
profound first dose hypotension with pts with heart failure already taking a high dose loop diuretic e.g furosemide 80mg or more so take at night sitting down
277
when should ACEI be administered under specialist supervision
```
sevre hf
pts recieving high dose diuretic
unstable heart failure
hyponatraemia
hypotension
CKD
Hypovolaemia
reciving aliskiren
renovascular disease
```
278
whar are the main side effects associated with ACEI
```
angiooedema- may be delayed and more common in afro-caribbean
angina pectoris
constipation
G.I
Electrolyte imbalance
persistent dry cough
alopecia
skin reactions
```
279
REnal impairement assocaited with ACEI
renal functions and electrolytes before starting acei
hyperkalaemia
acei cause renalimpairement in elderly
concommitant use with NSAIDS or k sparing diuretics due to hyperkalemia
avoid in renovascular disease
280
Contra-indications of ACEI
acei and aliskiren contraindicated if egfr under 60 or diabetes
discontinue if marked heaptic enzyme or jaundice occur
281
Cautions, monitoting, preganncy, directions for admin assocaited with ACEI
Monitor: renal function electrolytes
directions for admin: first dose at bedtime
renal impairement- caution start low and adjust
prenancy: avoid- affects fetal and neonatal bp and renal function also skull defects reported
avoid during dialysis to prevent anaphylactic reactions
282
ARB examples, indications, use in pregnancy / rnal impairment and eldelry
Less likely to give dru cough- does not inhibit break down of bradykinin and other kinins
used when ACEI contrindicatied or not tolerated
avoid in preganancy and use with caustion in rnal impairememnt or elderly
283
what are the side effects associated with ARB
Hypotension dizziness and hyperkalaemia
284
name the renin inhibitor, indication and caution
inhibits renin directly- renin converts angiotensisn to angiotensin 1
aliskiren is licensed for treatment of hypertension alone or in combo with other antihypertensives
ACEI and Aliskiren should not be given together due to increased risk of hyperkalaemia, hypotension or renal impairement compared to a single drug
example; aliskiren
285
How long after taking digoxin should a blood assay be taken
6 hrs
