CV chapter Flashcards
(259 cards)
1
Q
Name class 1 anti-arrhytmic drugs? + MOA
A
Class 1: disopyramide, lidocaine, flecainide/propafenone.
MOA: membrane stabilising drugs; Na+ blockers
2
Q
Name class 2 anti-arrhytmic drugs ? + MOA
A
BB: propranalol, esmolol ect
3
Q
Name class 3 anti-arrhytmic drugs ? + MOA
A
- Potassium channel blockers
- Amiodarone
- Sotalol
- Dronedarone
4
Q
Name class 4 anti-arrhytmic drugs ? + MOA
A
CCB( rate limiting)
Verapamil, diltiazem (unlicensed)
5
Q
What are the TWO s/e of DRONEDARONE?
A
hepatoxicity and HF
6
Q
In which patient group is digoxin effective ?
A
Effective in sedentary patients with non-paroxysmal AF and in patients with associative CHF
7
Q
What is AF?
A
abnormal. disorganised electrical signals fired cause the atria to quiver or fibrillate= rapid and irregular heartbeat
8
Q
What are the symptoms of AF and complications?
A
- Heart palpilations=pounding/fluttering
- Stroke and HF
9
Q
What are the THREE types of AF ?
A
paroxysmal AF: episodes stop within 48 hours without treatment
persistent AF: episode last more than seven days
permanent AF: present all the time
10
Q
Whats the difference between rate and rhythm control ?
A
rate control: controls ventricular rate
rhythm control: restores and maintains sinus rhythm
11
Q
What are the two types of cardioversion ?
A
- electrical= direct current
- pharmacological= anti-arrhythmic
12
Q
If AF is present for more than 48 hours what cardioversion treatment is preferred ?
A
-electrical cardioversion is preferred. But should not be attempted until patient is fully anticoagulated, for 3 weeks and continue 4 weeks after = risk of stroke
13
Q
What is the treatment for patients who are haemodynamically unstable ?
A
=electrical cardioversion; give parenteral anticoagulant and rule out left atrial thrombus immediately before procedure
14
Q
What is preferred treatment for acute new-onset presentation of AF ?
A
rhythm control
15
Q
Treatment for symptoms of AF present less than 48 hours? (haemodynamicly stable, not life threatening ) What if symptoms are present for more than 48 hours or uncertain when ?
A
< 48 hours: rate or rhythm control
> 48 hours: rate control ( verapamil or BB )
16
Q
What is the first line for maintenance drug treatment for AF ?
A
1st line: rate control
BB, rate-limiting CCB, digoxin ( control ventricular rate at rest )
Monotherapy then dual therapy then can introduce rhythm control
17
Q
What is the second line for maintenance drug treatment for AF ?
A
2nd line: rhythm control
BB, oral anti-arrhytmic drugs like amiodarone, sotalol
18
Q
What is paroxysmal and symptomatic AF ?
A
symptoms come and go
19
Q
What is the treatment for paroxysmal and symptomatic AF ?
A
- PILL in pocket: if infrequent episodes: flecainide or propafenone: restores sinus rhythm if episode occurs.
- ventricular or rhythm control= standard BB or anti-arrhytmic
20
Q
What does CHADSVASC tool include?
A
C- chornic HF or LVD H- hypertension A-age + 65-74 D-DM S-stroke/TIA/ VTE history V-vascular disease S-sex category i.e female
21
Q
What score of chadsvasc would indicate anticoagulant in all patient groups ?
A
2 or more: give
male= 0 and females =1; no anticoagulant needed, low risk
22
Q
What is the choice of anticoagulant for new onset AF ?
A
parenteral anticoagulant like heparin
23
Q
What is the choice of anticoagulant for diagnosed AF ?
A
Warfarin or NOAC ( non valvular AF with more than one risk factors; artificial heart valves )
24
Q
What are the risk factors that must be considered when prescribing NOACs?
A
75+, HF, hypertension, DM, previous stroke or TIA
25
Whats is torsade de pointes and what are the causes ?
qt prolongation: lethal form of ventricular tachycardia
| Hypokalaemia, severe bradycardia can cause it
26
How to treat torsade de pointes?
IV magnesium sulphate
27
Adenosine is contraindicated in what ?
COPD/asthma
28
What are the amiodarone side effects relating to the eyes? And what counselling would you give ?
- corneal microdeposits
-optic neuropathy/neuritis ( blindness )
Counselling: night time glares when driving due to corneal microdeposits. Stop if vision impaired- may be sign of optic neuropathy/neuritis
29
What are the amiodarone side effects relating to the skin? and what counselling should you give ?
-phototoxicity ( burning, erythema )
-slate-grey skin on light exposed areas
Counselling: shield skin from light during treatment. use SPF for months after stopping
30
What are the amiodarone side effects relating to the nerves? and what counselling should you give ?
peripheral neuropathy
| Counsel to report: numbness, tingling hands and feet, tremors
31
What are the amiodarone side effects relating to the lungs? and what counselling should you give ?
pneumonitis, pulmonary fibrosis.
| Counsel to report SOB, dry cough
32
What are the amiodarone side effects relating to the liver? and what counselling should you give ?
hepatoxicity: report jaundice, nausea, vomiting, malaise, itching, abdominal pain, 3x raised liver transaminases
33
How can amiodarone effect thryoid function ?
amiodarone contains iodine, thus can cause hyperthyroidism or hypothyroidism
34
What are the signs of hyperthyroidism and what drugs can be used to treat?
- weight loss, heat intolerance, tachycardia
| - carbimazole if needed. withdraw amiodarone
35
What are the signs of hypothyroidism ?
- weight gain, cold intolerance, bradycardia
| - start levothyroxine without withdrawing amiodarone if essential
36
What are the monitoring requirements for amiodarone ?
- annual eye test
- chest x ray before treatment
- liver function tests every six months
- monitor TSH, T3, T4 before treatment and every six months
- Blood pressure and ECG ( causes hypotension and bradycardia)
- serum potassium ( causes hypokalaemia, enhances arrhytmogenic effect of amiodarone )
37
What is the half life for amiodarone and why is it important to keep it in mind ?
around 50 days, danger of interactions several months after stopping
38
Patient comes in and says he has been recently prescribed amiodarone and would like to know why he cant have grapefruit juice ?
increases plasma concentrations of amiodarone beacause grapferuit juice is an enzyme inhibitor
39
You are screening the following prescription that has the following drugs:
-Amiodarone
-Warfarin
What is the interaction ?
amiodarone is enzyme inhibitor, increases warfarin levels; risk of bleeding
40
You are screening the following prescription that has the following drugs:
-Amiodarone
-phenytoin
What is the interaction ?
amiodarone is enzyme inhibitor, increases levels of phenytoin
41
If amiodarone is prescribed together with digoxin what adjustments should be made for digoxin dose ?
half dose of digoxin should be prescribed
42
Patients who take amiodarone and statins are at risk of what ?
increased risk of myopathy
43
What interaction occurs between amiodarone and BB or CCB like verapamil and diltiazem ?
bradycardia, AV block, myocardial depression
44
What drug classes can cause QT prolongation ? Must be prescribed with caution in patients who are taking amiodarone
- quinolones,
- macrolides,
- TCAs,
- SSRIs,
- Lithium,
- quinine
- hydroxychloroquinine
- chloroquine
- mefloquine
- antipsychotics: especially sulpiride, pimozide, amisulpride
45
How does digoxin work?
increases force of myocardial contraction ( positive inotrope ) reduces conductivity in the AV node ( negative chronotrope )
46
What are the therapeutic levels of digoxin ?
1-2 mcg/L ( 6 hours after dose )
47
Are loading doses required for digoxin and why ?
yes due to long half life
48
What is the dose of digoxin in atrial flutter and non-paroxysmal AF in sedentary patients?
125-250 mcg
49
What is the dose of digoxin for worsening or severe HF ( in sinus rhythm )?
62.5 - 125 mcg
50
What is the bioavailability of digoxin elixir ?
75 %
51
What is the bioavailability of digoxin tablet ?
90%
52
What are the signs of digoxin toxicity ? usually toxicity is slow and sick
- bradycardia/heart block
- nausea, vomiting and diarrhoea, abdominal pain
- blurred or yellow vision
- confusion, delirium
- rash
53
what predisposes to digoxin toxicity ?
hypokalaemia, hypomagnesaemia, hypercalcaemia, hypoxia and renal impairment
54
How digoxin toxicity is treated ?
- withdraw digoxin; correct electrolyte imbalances.
| - digoxin specific antibody for life threatening ventricular arrhythmias unresponsive to atropine
55
What drugs causes hypokalaemia ?
loop/thiazide: potassium loss in the urine
B2 agonist
steroids
theophylline
56
When would potassium supplements be indicated or potassium sparing diuretics?
if potassium is less than 4.5 mmol since its hypokalaemia
57
Which drugs increase digoxin plasma concentrations ?
amiodarone ( half digoxin), verapamil, diltiazem, macrolides, ciclosporin ( all enzyme inhibitors )
58
If a patient is on digoxin but says that they would like to buy ST JOHNS wort, what do you say ?
No, because it decreases digoxin concetration
59
GP calls you saying he want to prescribe rifampicin to a patient but you know that this patient is on digoxin, what should you say ?
rifampicin reduced digoxin concentrations
60
Which drug classes can reduce renal excretion and thus lead to digoxin toxicity ?
NAIDs, ACE inhibitors/ARBs
61
Digoxin interaction mnemonic ''CRASED'' explain each letter?
```
C-CCB ( verapamil)
R-rifampicin
A-amiodarone
S-st johns wort
E- eryhtromycin
D-diuretics
```
62
What are the two types of venous thromboembolism ?
DVT: blood clot in a deep vein, usually calf of one leg
PE: detachment of blood clot which travels to the lungs and blocks the pulmonary artery
63
What are the 12 criteria of VTE risk assessment?
- immobility
- obesity BMI over 30
- malignant disease
- 60+
- personal history of VTE
- thrombophillic disorders
- first degree relative with VTE
- HRT/COC
- varicose veins with phlebitis
- pregnancy
- critical car
- significant co-morbidities
64
What factors would predispose to increased risk of bleeding that must be taken into consideration when conducting VTE risk assessment to patients who are admitted to hospital ?
- thrombocytopenia ( low platelet )
- acute stroke
- bleeding disorders: acquired liver failure or inherited haeophillia, Von Willebrands disease
- anticoagulants
- systolic hypertension
65
Patients undergoing general surgery or orthopaedic surgery who are at high VTE risk, what type of VTE prophylaxis should be given ?
-Parenteral anticoagulants: low molecular weight heparin or unfractioned heparin in renal failure or fondaparinux
-NOACS; prophylaxis after knee/hip replacement surgery
Edoxaban for treatment and prevention of recurrent VTE
66
What is the duration of pharmacological VTE prophylaxis in general surgery ?
5-7 days or until sufficient mobility
67
What is the duration of pharmacological VTE prophylaxis in major cancer surgery in abdomen or pelvis ?
28 days
68
What is the duration of pharmacological VTE prophylaxis in knee/hip surgery ?
extended duration
69
What is usually initial treatment of VTE and how long is the treatment?
- LMWH or unfractioned heparin in renal failure
- at least 5 days and until INR at 2 or more for at least 24 hours
- monitor APTT if unfractioned heparin given
- start warfarin at the same time
70
What drug is used in VTE in pregnant women and why ?
- LMWH, does not cross placenta
- lower risk of osteoporosis and heparin induced thrombocytopenia
- stop at labour onset
71
How does heparin work ?
unfractioned heparin activates antithrombin.
| low molecular weight heparin inactivate factor Xa
72
Name LMWH ?
tinzeparin, enoxaparin, dalteparin
73
Which has longer duration of action LMWH or unfractioned heparin ?
LMHW
74
Which heparin is preferred if there is high risk of bleeding and renal impairment ?
unfractioned
75
Which heparin is generally preferred because it has lower risk of osteoporosis, heparin-induced thrombocytopenia?
LMWH
76
For which heparin it is essential to monitor activated partial thromboplastin time ( APTT )?
unfractioned
77
What are the side effects of heparins ?
Heamorrhage
Hyperkalaemia
Osteoporosis
Heparin induced thrombocytopenia
78
What to do if haemorrhage occurs while on heparin and rapid reversal is required ?
withdraw heparin. Give antidote protamine
79
Why heparins cause hyperkalaemia ?
heparins inhibit aldosterone secretion
80
Which patient groups are at higher risk of hyperkalaemia induced by heparins ?
DM
chronic kidney disease
monitor before treatment and if more than seven day use
81
How soon does heparin-induced thrombocytopenia occurs ?
occurs after 5-10 days.
82
What are the clinical signs of heparin-induced thrombocytopenia ?
- 30 % reduction in platelets, skin allergy, thrombosis.
| - Monitoring: before treatment and if more than four days use
83
How does warfarin work + how long it takes to work ?
- antagonises actions of vitamin K in blood clotting
| - 48 to 72 hours to work
84
What are the colours of the following strengths of warfarin
| 0.5 mg, 1 mg, 3 mg, 5 mg?
o.5 white
1 mg- brown
3 mg- blue
5mg -pink
85
What is initial dose of warfarin and how often should it be monitored ?
5 mg daily and monitor every 1-2 days
86
What is the maintenance dose of warfarin ?
3-9 mg at the same time each day
87
One patient is stable, how often their INR should be measured?
every three months
88
If the patient is prescribed warfarin for ISOLATED CALF DVT , how long should the treatment be for ?
6 weeks
89
If the patient is prescribed warfarin for PROVOKED VTE ( coc, pregnancy leg plaster cast), how long should the treatment be for ?
3 months
90
If the patient is prescribed warfarin for unrpovoked clots (AF) , how long should the treatment be for ?
at least 3 months/long term
91
What is the INR target for VTE, AF, MI, cardioversion, bioprosthetic mitral valve?
2.5
92
What is the INR target for recurrent VTE in patients receiving anticoagulant and INR above 2 ?
3.5
93
What patients should be given when warfarin is dispensed ?
yellow treatment booklet
| anticoagulant alert card
94
What to do when warfarin bleeding occurs ?
stop warfarin, IV phytomenadione ( vitamin K)
| dried prothrombin complex or fresh frozen plasma
95
What are the side effects of warfarin ?
- bleeding ( nose bleeds loner than 10 min, bleeding gums, bruising )
- calciphylaxis ( risk factor is end stage renal disease )
96
What action to take when INR is 5-8 + no bleeding?
- withhold 1-2 dose
- reduce maintenance dose
- measure INR after 2-3 days
97
What action to take when INR is 5-8 and minor bleeding?
- omit warfarin
- IV phytomenadione
- Repeat if INR still high after 24 hours
- Restart warfarin when INR < 5.0
98
What action to take when INR is more than 8 but no bleeding ?
- omit warfarin
- oral phytomenadione
- repeat if INR still high after 24 hours
- restrat warfarin when INR less than 5
99
What action to take when INR more than 8 + minor bleeding ?
- omit warfarin
- IV phytomenadione
- Repeat if INR still high after 24 hours
- Restart warfarin when INR less than 5
100
If patient is planned to have elective surgery when should warfarin be stopped ?
- 5 days before
- give oral phytomenadione one day if INR higher than 1.5
- restart warfarin on evening or next day
101
If patient is on warfarin but they need emergency surgery ?
delay 6-12 hours
| no delay; give IV phytomenadione and dried prothrombin complex
102
If patient is on warfarin, but also high risk of VTE and they need surgery ?
switch from warfarin to LMWH and stop 24 hours before surgery
103
What if the patient still after surgery is at high risk of bleeding ?
start LMWH 48 hours after surgery
104
Which NOAC needs special container and has 4 month expiry ?
dabigatran
105
Which NOACs are direct factor Xa inhibitors?
apixaban
edoxaban
rivaroxaban
106
How does dabigatran work ?
direct thrombin inhibitor
107
Explain ischaemic stroke/TIA '' mini strokes'' ?
-blood clot obstructs blood supply
108
Explain haemorrhagic stroke ?
weak blood vessel in brain bursts
109
What is long term management for TIA ( mini stroke )?
- MR dipyridamole and aspirin
- Statin irrespective of serum cholesterol
- treat hypertension not with BB
110
What is long term management for ischaemic stroke ?
- clopidogrel
- in AF related stroke, review for anticoagulant
- Statin irrespective of serum cholesterol
- treat hypertension not with BB
111
What drugs should be avoided in intracerebral haemorrhage and what is the usual treatment ?
- avoid aspirin, statin, anticoagulants; increases the risk of bleeding; only if essential
- treat hypertension and take care to avoid hypoperfusion
112
how does antiplatelet drugs work ?
| cangrelor, prasugrel, ticagrelor
decrease platelet aggregation and inhibit thrombus formation in the arterial circulation
113
why aspirin contraindicated in under 16 ?
reys syndrome
114
How should Dipyridamole (secondary prevention of strokes ) be taken, and what expiry does persantin retard capsules have ?
30-60 min before food, has six week expiry, special container - has dessicant, retain in the container
115
Name anticoagulants that are glycoprotein IIa/IIb inhibitors ?
adciximab
eptifibatide
tirofiban
116
what is indication of clopidogrel ?
following acute coronary syndromes or PCI
117
Learn hypertension guidelines
HEY
118
What is normal BP ?
120/80
119
what is stage 1 hypertension ?
140/90; offer lifestyle advice
only treat if under 80 with: target organ damage, retinopathy, CKD or CVD or 10 year CVD risk more than 20 % or if pt has renal disease or diabetes
120
What is stage 2 hypertension ?
160/100= treat all
121
what is stage 3 hypertension ?
> 180 systolic > 110 diastolic= hypertensive crisis
122
What are the clinic blood pressure targets for under 80 years ?
<140/90
| 130/80 in atherosclerotic CVD or diabetes with kidney, eye or cerebrovascular disease
123
What are the clinic blood pressure targets for over 80 years ?
<150/90
124
What are the clinic blood pressure targets for renal disease ?
<140/90
| <130/80 if CKD, diabetes, proteinuria > 1g in 24 hours. Consider ACE/ ARB if proteinuria present
125
What are the clinic blood pressure targets for diabetics ?
<140/80
| <130/80 if complications; eye, kidney
126
What are the clinic blood pressure targets for pregnant women ?
<150/100 if chronic hypertension
<140/90 chronic hypertension and if target organ damage or given birth. Labetalol ( hepatoxic ) is widely used and first choice. Methyldopa needs to be stopped 2 days after birth. MR nifedipine is unlicensed.
127
which is ace inhibitor is BD?
captopril
128
which should perindopril be taken ?
30-60 min before food
129
Name ARB? angiotensin 2 receptor blockers ?
```
azilsartan
candersartan,losartan,valsartan
eprosartan
irbesartan
olmesartan
telmisartan
```
130
What side effects ACE cause ?
- persistent dry cough
- hyperkalaemia ( higher risk in DM and renal impairment )
- agioedema: anaphylactoid reactions
- ORAL ULCER
- taste disturbance
- hypoglycaemia
131
What renal effects ACE inhibitors have ?
- renoprotective in renal disease :CKD
- nephrotoxic= acute kidney injury; avoid DAMN: diuretics, ACE, ARBs, metformin, NSAIDs
- reduces eGFR via efferent arteriole dilation. Avoid in renovascular disease, not to be given in severe bilateral stenosis.
132
What hepatic effects ACE inhibitors have ?
- cholestatic jaundice, hepatic failure
| - STOP IF LIVER TRANSMINASES 3X NORMAL OR JAUNDICE OCCURS.
133
If ACE inhibitors are given with potassium sparing diuretics or aldosterone antagonists or ARB or aliskeren, what electrolyte disturbance may occur ?
hyperkalaemia
134
Why is better to avoid NSAIDs with ACE ?
nephrotoxicity and reduced eGFR
135
Why you should avoid ACE a+ ARB in diabetic nephropathy?
can lead to renal impairment, hyperkalaemia and hypotension
136
Read BNF on centrally acting antihypertensives ? name them
methyldopa: s/e driving; drowsiness
clonidine: s/e flushing
moxonidine
137
Name vasodilator antihypertensives?
hydralazine: s/e fluid retention, tachycardia
minoxidil: tachycardia, fluid retention and increase cardiac output
138
Name alpha blockers?
prazosin
terazosin
indoramin
139
How does BB work ?
block beta receptors in the heart. peripheral vasculature, bronchi, pancreas and liver
140
Which BB is used in hypertension in peri-operative period and has short half life ?
esmolol
141
Which 4 BB have less bradycardia, less coldness of extremities and has intrinsic sympathomimetic activity?
Pindolol
acebutolol
celiprolol
oxprenolol
142
Name 4 water soluble BB?
```
celiprolol
atenolol
nadolol
sotalol
all are renally cleared: reduce dose in renal impairment
```
143
Name 4 cardioselective BB?
```
bisoprolol
atenolol
metoprolol
acebutolol
nebivolol
```
144
Name 4 BB that have OD dosing ?
```
bisoprolol
atenolol
celiprolol
nadolol
-intrisically long duration of action
```
145
What are the side effects of BB ?
- bradycardia, hypotension
| - hyperglycaemia or hypoglycaemia+ masks symptoms of hypoglycaemia e.g. tachycardia
146
In what disease conditions are BB contraindicated ?
- Asthma: includes even BB eye drops like timolol
- worsening unstable HF
- second/third degree heart block
- severe hypotension and bradycardia
147
Two important interactions with BB ?
- IV verapamil( asystole and hypotension ), hazardous oral verapamil
- Thiazide diuretics: both cause hyperglycaemia thus avoid in diabetes and high risk of diabetes
148
How does CCB work ?
blocks calcium channels to reduce force of contraction, conductivity and vascular tone
149
Name dihydropyridine CCB?
cause vasodilation
- amlodipine
- felodipine
- lacidipine
- lercanidipine
- nifedipine ( maintain the same MR brand )
150
What are the common side effects of dihydropyridine CCB ?
ankle swelling
flushing
headaches
151
Which CCB should be avoided in HF ?
rate-limitig; verapamil, diltiazem (maintain on same brand when doses over 60 mg )
152
Which rate limiting CCB causes constipation and is licensed for arrhythmias ?
verapamil
153
Which type of juice should be avoided when taking CCB ?
grapefruit juice
154
How does vasoconstrictor sympathomimetics work ?
raise BP by acting on aplha-adrenergic receptors to constrict peripheral blood vessels
155
vasoconstrictor sympathomimetics: examples ?
noradrenaline, phenylepherine ( longer acting: prolonged rise in BP )
156
what are the side effects of vasoconstrictor sympathomimetics?
reduced perfusion to vital organs e.g. kidneys
157
What are the symptoms of heart failure ?
- dyspnoea during activity or at rest
- exercise intolerance/fatigue
- Oedema:
1. pulmonary oedema=breathlessness, 2.peripheral oedema=swollen ankles, legs
158
What is hyperlipidaemia ?
high blood levels of cholesterol, triglycerides or both
159
What are the complications of hyperlipidaemia ?
Hyperlipidaemia causes artherosclerosis and in turn coronary heart disease (angina, MI), strokes and TIA, peripheral arterial disease
160
Primary prevention of cardiovascular diseases if offered to which patient gourps?
- type 1 DM
- Type 2 DM only if CVD risk>10%
- chronic kidney disease or albuminuria
- familial hypercholesterolaemia
- 85 years and above
161
Secondary prevention is offered to which patient group ?
to those who have established CVD: coronary heart disease ( angina, MI ), cerebrovascular disease ( stroke, TIA ) and peripheral arterial disease
162
What are the total cholesterol levels should be for healthy adults ?
no more than 5 mmol/L of total cholesterol
163
What should total cholesterol be for high risk adults? ( target ? )
less than 4 mmol/L
164
LDL ( bad cholesterol): what is the target for healthy adults ?
less than 3 mmol/L
165
LDL ( bad cholesterol): what is the target for high risk adults?
less than 2 mmol/L
166
HDL ( good cholesterol ) what is the target ?
more than 1 mmol/L, the higher the better
167
What is the target for triglycerides ?
less than 1.7 mmol/L
168
What mmol/L of total cholesterol would indicate diagnosis of hyperlipidaemia ?
6 mmol/L
169
Which drugs cause hyperlipidaemia, drug classes ?
- Antipsychotics ( epsecially second genereation )
- immunosupressants
- corticosteroids
- antiretrovirals ( HIV drugs )
170
What conditions would predispose a patient for hyperlipidaemia ?
- hypothyroidism
- liver or kidney disease
- DM
- family history of high cholesterol
- lifestyle factors: smoking, excess alcohol consumption, obesity and a poor fatty diet
171
Name all the classes of lipid regulating drugs ?
```
STATINS
Fibrates
Ezetimibe
Bile acid sequestrants
Nicotinic acid group ( acipimox, nicotinic acid )
Lomitapide
Alirocumab
```
172
Name all the fibrates ?
bezafibrate, ciprofibrate, fenofibrate, gemfibrozil
173
Name all bile acid sequestrants ?
colesevelam, colestipol, colestyramine
174
How do statins work ?
lowers LDL cholesterol synthesis by the liver via inhibition of HMG-VoA reductase ( indirectly reduces triglycerides and increases HDL cholesterol )
175
At what time statins should be taken and why ?
all statins must be taken at night except ATORVASTATIN.
| Cholesterol synthesis greater at night; more effective.
176
what is the dose of atorvastatin in primary prevention ?
20mg OD
177
what is the dose of atorvastatin in secondary prevention ?
80 mg OD
178
Why should simvastatin at a dose of 80 mg must be only given to patients who are at high risk of CV complications and treatment goals are not achieved at lower dose ?
high risk of myopathy
179
Name three high intensity statins?
atorvastatin, rosuvastatin ( 10 mg ), simvastatin
180
Which drugs are used to treat primary and familial hypercholesterolaemia ?
high intensity statins: if statin not tolerated or contraindicated = EZETIMIBE
181
Which drugs are used to treat moderate hypertriglyceridaemia ?
If statin not tolerated or contra-indicated= FIBRATE
182
Before starting statins what underlying causes ( conditions ) must be corrected ?
- hypothryoidism
- uncontrolled DM
- nephrotic syndrome ( albuminuria )
- liver disease .e.g alcohol cirrhosis.
183
What are the side effects of statins and what counselling you should provide?
1. myopathy, myositis, rhabdomyolysis
- Counsell: report tender, weak and painful muscles
2. interstitial lung disease: counsel patients about SOB, cough and weight loss.
3. Diabetes : statins can raise HbA1c or blood glucose levels, those who are diabetic or those at high risk of diabetes are at this risk
184
Which patient groups would have high risk of muscle toxicity when on statins ?
- personal or family history of muscle disorder
- high alcohol intake
- renal impairment
- hypothyroidism/ treat before starting statin
185
Which drugs taken together with statins may increase the risk of myopathy ?
- concomitant ezetimibe or fibrates, especially GEMFIBROZIL
| - Concomitant fusidic acid; restart statin seven days after last dose ( increased risk of rhabdomyolysis )
186
Before starting statins what baseline test must be done ?
baseline lipid profile
renal function
thyroid function ( hypothryoidsim increase risk of muscle toxicity )
HbA1c if high risk of developing diabetes
187
What are the two most important monitoring requirements for statins ?
- liver function: discontinue if liver transaminases are 3X normal
- Creatine kinase( released from the muscle when it is damaged=myopathy): discontinue if 5X normal
188
Which drugs can increase statin levels ?
```
amiodarone
grapefruit juice
diltiazem, verapamil
imidazole/triazole: itraconazole, ciclopsorin
amlodipine
```
189
What is the max dose of SIMVASTATIN when it is given with fibrate ?
max 10 mg
190
what is the max dose of simvastatin if it is given with amiodarone, amlodipine, diltiazem and verapamil ?
max 20 mg
191
What is the max dose of atorvastatin when it is given with ciclosporin ?
max 10 mg
192
What is the max dose of rosuvastatin and initially when given with clopidogrel ?
initially 5 mg, max 20 mg with clopidogrel
193
What advice should be given to women of childbearing age who are on STATINS ?
have effective contraception during and one month after stopping
194
If women comes in and says she would like to conceive but is on statins, what advice would you give ?
stop taking 3 months before conceiving and restart after breastfeeding is finished
195
How does ezetimibe work ?
reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine.
196
Why is better to avoid giving statins and ezetimibe together ?
myopathy ( rhabdomyolysis )
197
How does fibrates work ?
lower blood triglyceride levels by reducing the liver's production of VLDL ( the triglyceride-carrying particle that circulates in the blood) and by speeding up the removal of triglycerides from the blood
198
What levels of total cholesterol would indicate severe hypertriglyceridemia ?
over 10 mmol/L
199
Which fibrate has the highest risk of myopathy and should not be given with statins ?
gemfibrozil
200
If patient is taking fibrates but they have renal impairment they are at risk of what ?
myopathy
201
How does bile acid sequestrants work ?
binds and sequesters bile acids. The liver then produces more bile acids to replace those that have been lost.The body uses cholesterol to make bile acids, this reduces the amount of LDL cholesterol circulating in the blood
202
Bile acid sequestrants impairs absorption of what type of vitamins ?
fat-soluble vitamins ADEK and other drugs
203
How should other drugs be taking with bile acid sequestrants ?
take other drugs 1 hour before ( 4 hour before coleveselam) or 4 hours after bile sequestrants.
204
MYocardial ischaemia ( stable angina ): what drugs are used to treat it ?
- short-acting nitrates are used for acute angina attacks
| - for long term prophylaxis of angina long acting nitrate sare used.
205
Name short acting nitrates ?
glyceryl trinitrate
| isosorbide dinitrate
206
name long acting nitrates ?
```
MR isosorbide dinitrate
isosorbide mononitrate
ivabradine
nicorandil
ranolazine
```
207
How does glyceryl trinitrate work ?
converted to nitric oxide which is a short acting vasodilator; improves blood supply
208
How long does glyceryl trinitrate sublingual tablets/spray effect last ?
20-30 minutes
209
If a patient comes in and says to you I am suing my glyceryl trinitrate sublingual tablets or spray more than twice a week ? what should you advise ?
refer to GP since this indicated patient needs long term prophylaxis
210
Glyceryl trinitrate sublingual tablets are in special container, foil-lined container with no cotton wadding and thus expires how long after opening ?
expires 8 weeks after opening
211
How should glyceryl trinitrate should be taken ?
- PRN or before angina-inducing activities e.g. exercise
- Take sitting down as dizziness can occur: take first dose under tongue and wait 5 minutes, take second dose and wait 5 minutes, take third dose and wait 5 minutes.
- 1 dose= 1 tablet or 1-2 sprays
- If pain is still present CALL 99
- 999rule: max 3 doses
212
How should glyceryl trinitrate be taken ?
- PRN or before angina-inducing activities e.g. exercise
- Take sitting down as dizziness can occur: take first dose under tongue and wait 5 minutes, take second dose and wait 5 minutes, take third dose and wait 5 minutes.
- 1 dose= 1 tablet or 1-2 sprays
- If pain is still present CALL 99
- 999rule: max 3 doses
213
For long term angina prophylaxis which dugs can be given as monotherapy ?
BB or CCB ( diltiazem, contraindicated in LVSD)
214
For long term angina prophylaxis which drugs can be given as dual therapy ?
- BB + dihydropyridine CCB ( amlodipine, MR nifedipine, felodipine ) MAX 2 drugs
- If one or both is contraindicated add/use vasodilator
215
Name vasodilators used in long term prophylaxis of angina ?
ivabradine ( only in normal sinus rhythm )
ranolazine
nicorandil
216
what is MHRA warning regarding nicorandil ?
Nicorandil is K-channel activator: use in adults only.
Now given second line risk of ulcer complications; mouth, skin, eye, gastro-intestinal. Do not drive until it is established performance is not impaired
217
How does nitrates work ?
nitrates are potent coronary vasodilators and reduce venous return and cardiac output
218
How is long acting nitrate ISOSORBIDE MONONITRATE MR and IR are taken ?
IR taken BD and MR is taken OD
219
Which nitrate is also active sublingually and can be alternative to glyceryl trinitrate ?
MR isosorbide dinitrate taken BD
220
Which nitrates cause tolerance?
with long acting preparations or transdermal patches
221
How to overcome nitrates tolerance?
- reduce blood nitrate concentrations to low levels for 4 to 12 hours a day.
- Leave patches off for 8-12 hours ( overnight). in a day
- Take second dose after 8 hours not 12 hours: for MR isosorbide dinitrate (BD) and Isosorbide mononitrate (BD)
- MR isosorbide mononitrate is taken OD therefore does not produce tolerance
222
What are the side effects of nitrates ?
Vasodilation, flushing, throbbing headache, dizziness, postural hypotension, tachycardia, dyspepsia, heartburn
223
What are the side effects of injection of GTN and isosorbide dinitrate MI ?
severe hypotension, sweating, apprehension, restlessness, muscle twitching, retrosternal discomfort and palpitations.
224
Why you should avoid abrupt withdrawal of nitrates and CCB in angina ?
worsens angina
225
What is acute coronary syndrome ?
Myocardial infarction: NSTEMI/STEMI
| Unstable angina
226
How to treat medical emergency in the community of unstable angina/nstemi?
dispersible/chewable apspirin 300 mg STAT
| GTN PRN sublingually ( 0.3-1mg) or spray (1-2)
227
How to treat medical emergency in the community of STEMI?
same as unstable angina/nstemi can add on IV diamoprhine/ morphine + metoclopramide
228
How to give CPR for cardiac arrest ?
30 compressions: 2 breaths
| IV adrenaline 1 in 1000 every 3-5 min. If ventricular fibrillation present: IV amiodarone
229
Which loop diuretic is most potent and which one cause gout and which one musculoskeletal pain ?
bumetanide most potent
furosemide : gout
Torasemide: musculoskeletal pain
230
Name thiazide relate diuretics?
chlortalidone ( long half life)
indapamide ( less aggravation of diabetes)
metolazone ( still works in severe renal failure )
xipamide
231
What are potassium sparing diuretics?
amiloride
| triamterene ( blue urine in some lights )
232
Name aldosterone antagonists ?
Spironolactone ( ascites liver failure )
| eplerenone ( use in post acute MI )
233
What type of diuretic is mannitol ?
osmotic diuretic
| use in cerebral oedema
234
Which diuretic is used in glaucoma and to which drug class it belongs ?
acetozolamide: carbonic anhydrase inhibitors
235
How diuretics treat oedema ?
increase urine output by the kidneys i.e. promotes diuresis by inhibiting sodium reabsoprtion at different parts of the renal tubular system (nephron)
236
How does loop diuretics work ?
inhbitis sodium, potasium, Cl- co-transpoerter is ascedning limb of the loop of henle
- 1 hour onset and six hour duration
237
How fast loop diuretics work and how long is their duration of action ?
1 hour onset
| They have 6 hour duration
238
What side effects high doses of loop diuretics may cause ?
ototoxicity ( tinnitus, deafness)
| acute urinary retention
239
In which patients acute urinary retention are most likely to occur if they are using loop diuretics?
in benign prostatic hyperplasia
240
Can furosemide exacerbate gout and cause hyperglycaemia and hyperuricaemia ?
yes
241
what electrolyte deficiencies can loop diuretics cause ?
hypo K, NA, CL, Mg, Ca
242
which loop diuretic may cause musculoskeletal pain ?
torasemide
243
How does thiazide and related diuretics work ?
inhibits sodium and chlorine transporter in distal convoluted tubule
244
What is the onset and duration of action of thiazide and related diuretics ?
1-2 hour onset
| 12-24 hour duration
245
What are the side effects of thiazide and related thiazide diuretics ?
GI disturbances, impotence, high LDL/triglycerides
246
Thiazides are not effective if eGFR is less than 30ml/min except ?
metolazone
247
What electrolyte disturbances thiazide diuretics cause ?
hypo K, NA, CL, Mg and Hyper Ca
248
What is the dose of bendroflumethiazide in heart failure and hypertension ?
HF: 5 mg
| Hypertension 2.5 mg
249
Which thiazide diuretic has long half life and can be given on alternate days if acute retention is a problem or dislikes frequent urination ?
chlortalidone
250
How does potassium sparing diuretics work ?
promotes urination without the loss of potassium by inhibiting sodium channels in the distal convoluted tubule. They are weak diuretics used as an adjunct to LOOP and Thiazide diuretics.
251
Name potassium sparing diuretics ?
- triamterene ( urine looks blue in some lights )
| - amiloride
252
How does aldosterone antagonist work ?
inhibits aldosterone which causes sodium reabsorption via the NA/K/H cotransporter. Less potassium and hydrogen ions are exchanged for sodium and therefore less lost to the urine .
253
What are the side effects of spironolactone ?
- gynaecomastia, benign breast tumours, menstrual disturbances
- hypertrichosis
- change in libido
- hyperkalaemia, hyperuraemia, hyponatraemia
254
How does osmotic diuretics work ?
inhibits sodium and water reabsoprtion by increaseing the osmolarity of blood and renal filtrate.
255
Name osmotic diuretics and their uses ?
cerebral odema
high intracranial pressure
-MANNITOL ( pharmacologically inert sugar )
256
How simple gravitational oedema in the elderly is treated ?
low dose diuretic. Not for long term use, try alternative first like stockings, raising legs and movement
257
What are the two types of peripheral vascular disease ?
- occlusive: peripheral arterial disease caused by atherosclerosis.
- vasospastic: raynaud's syndrome
258
How to treat occlusive peripheral arterial disease ?
aspirin 75 mg daily and statin as secondary prevention
259
How to treat vasospastic PVD like raynauds syndrome ?
stop smoking and avoid exposure to cold, nifedipine
