CVS Flashcards
(216 cards)
1
Q
Symptoms of AF?
A
Palpitations, dyspnoea, dizziness and tiredness
2
Q
What is paroxysmal AF?
A
Symptoms for less than 7 days
3
Q
What is persistent AF?
A
Symptoms for more than 7 days
4
Q
What is permanent AF?
A
Symptoms all the time
5
Q
What are the two different types of AF control?
A
Rate and rhythm
6
Q
What is first line treatment for AF?
A
Rate control with monotherapy
7
Q
What medications are used in rate control of AF?
A
Beta blockers (not sotalol)
Rate limiting CCB (diltiazem and verapamil)
Digoxin
8
Q
Which rate limiting CCB can cause constipation?
A
Verapamil
9
Q
When can digoxin be used as monotherapy in AF?
A
For sedentary patients or patients with HF
10
Q
What can be given if monotherapy rate control is not effective?
A
Dualtherapy with beta blocker + digoxin
11
Q
What can be given if dual therapy rate control is not effective?
A
Rhythm control
12
Q
What medications are used in rhythm control?
A
Beta blocker or anti arrhythmic drug
13
Q
Exceptions to 1st line treatment of AF?
A
New onset within 48 hours = Rate/rhythm control
Patients with HF and reduced ejection fraction = dual therapy
Reversible cause
14
Q
Which rate limiting CCB can never be given with a beta blocker?
A
Verapamil = severe bradycardia and hypotension
15
Q
What medications are used for “pill in a pocket”
A
Flecainide or propafenone
16
Q
When should “pill in a pocket” be used?
A
Infrequent episodes
17
Q
When should “pill in a pocket” never be used?
A
In ischaemic heart disease
18
Q
What is Torsade de pointes?
A
A life threatening form of arrhythmia caused by prolonged QT interval
19
Q
Symptoms of torsade de pointes?
A
Fainting or seizures
20
Q
Treatment of torsade de pointes?
A
IV magnesium sulphate
21
Q
What does the CHASVASc score measure?
A
Risk of stroke
22
Q
What does the orbit score measure?
A
Risk of bleeding for patients on anticoagulants in AF
23
Q
What does CHADSVASc stand for?
A
C = chronic HF or LV dysfunction
H = hypertension
A2 = age 75+
D = diabetes
S2 = stroke / ischaemic attack / VTE history
V = vascular disease
A = aged between 65 - 75
Sc = sex category (females = 1)
24
Q
What CHADSVASc score prompts anticoagulation?
A
2+ = anticoagulation with warfarin or DOAC
25
What does ORBIT stand for?
O = over 75
R2 = reduced Hb / anaemia
B2 = bleeding history
I = insufficient kidney function (<60)
T = treatment with anti platelets
26
What ORBIT score prompts avoiding anticoagulation?
Men = 2+
Women = 3+
27
What anti arrhythmic class is amiodarone?
3
28
Loading dose of amiodarone?
200mg TDS for 7 days, then 200mg BD for 7 days, then 200mg OD as maintenance
29
Side effects of amiodarone?
“PHONES”
P = pulmonary toxicity / QT prolongation
H = hyper/hypothyroidism / hepatic impairment
O = optic neuropathy
N = neuropathy of the limbs
E = eyes - corneal micro deposits
S = slate grey skin / photosensitivity
30
Amiodarone interactions?
“BCDDGW”
Beta blocker
CCB
Digoxin
Diuretics
Grapefruit juice
Warfarin
31
What is the therapeutic drug range for digoxin?
0.8 - 2micrograms/L
32
How long after doses should digoxin blood samples be taken?
6 hours post dose
33
Does digoxin require a loading dose?
Yes due to its long half life
34
When is digoxin contraindicated?
When heart rate is less than 60bpm
35
Digoxin dose in atrial flutter or non-paroxysmal AF?
125 - 250mg
36
Digoxin dose in worsening or severe HF?
62.5 - 125mg
37
Signs of digoxin toxicity?
“GRACE”
G = GI disorders
R = rash
A = arrhythmias caused by hypokalaemia
C = CNS effects E.g. confusion
E = eyes E.g. blurred or yellowing vision
38
What electrolyte disturbances can digoxin cause?
Hypokalaemia
Hypomagnesaemia
Hypercalcaemia
39
How should electrolyte disturbances caused by digoxin be treated?
Withdraw digoxin while electrolyte imbalances are corrected
40
Digoxin interactions?
“CRASED”
C = CCB
R = Rifampicin
A = amiodarone, quinine and donedarone - half dose of digoxin
S = SJW
E = erythromycin
D = diuretics
41
What is tranexamic acid?
Antifibrinolytic which helps reduce bleeding
42
Typical tranexamic acid dose?
1g TDS for 4 days
(7 days for nose bleeds)
43
What are the two types of VTE?
PE and DVT
44
VTE risk factors?
Immobility
Obesity
Cancer
60+
VTE history
HRT/COC
Pregnancy
45
Bleeding risk factors?
Thrombocytopenia (low platelet count)
Acute stroke
Bleeding disorder: acquired (E.g. liver disease) or inherited (e.g. haemophilia)
Anticoagulant use
Systolic hypertension
46
When should stockings be avoided?
In stroke patients
47
How long should stockings be used for?
Until sufficiently mobile / 30 days for spinal injuries
48
When is unfractionated heparin preferred over LMWH?
Renal impairment or increased risk of bleeding
49
Heparin alternative?
Fondaparinux
50
How long are heparins normally given for surgical VTE prophylaxis?
General surgery = 7 days
Abdominal surgery or cancer patients = 28 days
Spinal surgery = 30 days
51
Surgical VTE prophylaxis in hip surgery?
LMWH for 10 days then 28 days of low dose aspirin
OR
LMWH for 28 days + stockings/rivaroxaban
52
Surgical VTE prophylaxis in knee surgery?
Low dose aspirin for 14 days
OR
LMWH for 14 days + stockings/rivaroxaban
53
Which heparin is used if the patient has an increased risk of bleeding?
Unfractionated
54
Which heparin has lower risk of osteoporosis and thrombocytopenia?
LMWH
55
Reversal agent for LMWH?
Protamine (partial reversal)
56
Which electrolyte disturbance is caused by LMWH?
Hyperkalaemia
57
Which heparin causes osteoporosis when used long term?
Both but risk higher with unfractionated
58
How long does it take for warfarin to work?
2-3 days
59
Typical warfarin dose?
10mg OD for 2 days
Then 3-9mg OD
60
What should be done if a dose of warfarin is missed?
Take as soon as you remember if on the same day. If next dose is due omit previous dose (I.E. never take more than one in a day)
61
How long is warfarin given for an isolated calf DVT?
6 weeks
62
How long is warfarin given for a provoked VTE?
3 months
63
How long is warfarin given for an unprovoked VTE?
At least 3 months
64
What colour is the 0.5mg warfarin tablet?
White
65
What colour is the 1mg warfarin tablet?
Brown
66
What colour is the 3mg warfarin tablet?
Blue
67
What colour is the 5mg warfarin tablet?
Pink
68
Normal INR range for warfarin?
2.5
69
INR range in recurrent VTE while the patient was on anticoagulants?
3.5
70
How often is INR checked?
Every 12 months
71
MHRA alert for warfarin? (2)
1. Calciphylaxis - report painful rash
2. Miconazole (Daktarin) - severe interaction
72
What should be done if a patient taking warfarin has no bleeding but INR is between 5-8?
Hold 1 - 2 doses. Restart when INR below 5
73
What should be done if a patient taking warfarin has no bleeding but INR is >8?
Stop warfarin and give oral phytomenadione.
Repeat after 24 hours if still high.
Restart warfarin when INR is below 5.
74
What should be done if a patient taking warfarin has minor bleeding and INR is between 5-8?
Stop warfarin and give IV phytomenadione.
Restart warfarin when INR is below 5.
75
What should be done if a patient taking warfarin has minor bleeding and INR is >8?
Stop warfarin and give IV phytomenadione.
Repeat after 24 hours if still high.
Restart warfarin when INR is below 5.
76
What should be done if a patient taking warfarin has major bleeding and INR is between 5-8?
Stop warfarin and give IV phytomenadione + dried prothrombin.
Restart warfarin when INR is below 5.
77
What should be done if a patient taking warfarin has major bleeding and INR is >8?
Stop warfarin and give IV phytomenadione + prothrombin.
Repeat after 24 hours if still high.
Restart warfarin when INR is below 5.
78
When should patients taking warfarin report nose bleeds?
If they last greater than 10mins
79
When should patients taking warfarin report headaches?
Always due to risk of SAH
80
Main OTC interactions with warfarin?
Cranberry juice, pomegranate juice, leafy veg (high in vit K), Miconazole and NSAIDs
81
How long before surgery should warfarin be stopped?
5 days
82
What can be done if a patient needs to stop taking warfarin for a surgery but is at high risk of VTE?
Bridge with LMWH
83
Rivaroxaban MHRA interaction?
Erythromycin increases risk of bleeding
84
Rivaroxaban dose for VTE prophylaxis?
10mg OD
35 days = hip
14 days = knee
85
Rivaroxaban dose in recurrent VTE?
10mg OD for 6months
20mg if at high risk
86
Rivaroxaban dose in VTE treatment?
15mg BD for 21 days, then 20mg OD
87
Rivaroxaban dose in stroke prevention in AF?
20mg OD
(Always double VTE prophylaxis)
88
Rivaroxaban dose in acute coronary syndrome?
2.5mg BD 12 months
89
Apixaban dose for VTE prophylaxis?
2.5mg OD
Hip = 32-38 days
Knee = 10-14 days
90
Apixaban dose for recurrent VTE?
2.5mg BD
91
Apixaban dose for VTE treatment?
10mg BD for 7 days, then 5mg BD
92
Apixaban dose in stroke prevention in AF?
5mg BD (2.5mg if 80+, <61kg or Creatinine >133)
93
When is the Apixaban dose in stroke prevention in AF halved?
2.5mg if 80+, <61kg or Creatinine >133
94
Apixaban and rivaroxaban reversal agent?
Andexanet alpha
95
Dabigatran dose for VTE prophylaxis?
220mg OD
Hip = 35 days
Knee = 14 days
150mg OD if 75+ and taking amiodarone or verapamil
96
When should dabigatran dose be reduced when given for VTE prophylaxis?
150mg OD if 75+ and taking amiodarone or verapamil
97
Dabigatran dose for VTE treatment or stroke prevention in AF?
150mg BD
If 75+, moderate RI, or increased risk of bleeds = 110-150mg BD
If 80+ and taking verapamil = 110mg BD
98
Edoxaban dose for VTE prevention, treatment or stroke prophylaxis for stroke in AF?
60mg OD
If <60kg = 30mg OD
99
Which medications require edoxaban dose to be halved from 60mg to 30mg?
“DECK”
Donederone
Erythromycin
Ciclosporin
Ketoconazole
100
Which DOACs are given OD?
“RE”
Rivaroxaban
Edoxaban
101
Which DOACs are given BD?
“AD”
Apixaban
Dabigatran
102
Which DOACs can be given in dyspepsia?
“EA”
Edoxaban
Apixaban
103
Which DOACs should be avoided in liver impairment?
“ED”
Edoxaban
Dabigatran
STOP if ALT/ALP = 2x normal
104
What is a transient ischaemic attack (TIA)?
Temporary disruption in blood supply causing stroke-like symptoms
105
Initial management of ischaemic stroke?
Alteplase if given within 4.5hours of symptom onset.
Aspirin ASAP within 24 hours of onset
106
Long term treatment of ischaemic stroke or TIA?
Clopidogrel + high intensity statin + anti hypertensive (not a beta blocker unless indicated for another condition)
107
Long term treatment of ischaemic stroke or TIA when Clopidogrel is not suitable?
Aspirin +/- Dipyridamole MR
+ high intensity statin + anti hypertensive (not a beta blocker unless indicated for another condition)
108
Haemorrhagic stroke long term treatment?
Anti-hypertensive.
Aspirin, statins and anticoagulants are contraindicated.
109
Counselling for dipyridamole?
Take 30-60mins before food
Discard after 30 days
110
Counselling for dipyridamole MR tablets?
Take after food
Discard after 6 weeks
111
What is a normal blood pressure?
120/80
112
What is stage 1 hypertension and how is it treated?
>140/90
Give lifestyle advice
113
When should stage 1 hypertension be treated pharmacologically?
When the patient is:
Over 80 and >150/90
Under 80
Target organ damage
Diabetes
Kidney disease
114
What is stage 2 hypertension and when should it be treated?
160/100
Treat all
115
What is hypertensive crisis?
>180/110
Treat promptly
116
Treatment of hypertension if the patient is <55 or has T2DM?
ACE/ARB
(ARB preferred if they’re black)
117
Treatment of hypertension if the patient is >55 or afro Caribbean?
CCB
118
Step up treatment of hypertension if the patient is <55 or has T2DM?
+ CCB or TLD (in HF)
119
Step up treatment of hypertension if the patient is >55 or afro Caribbean?
+ ACE/ARB or TLD (in HF)
120
Third step up in treatment of hypertension?
ACE/ARB + CCB + TLD
121
Fourth step up in treatment of hypertension?
If K+ < 4.5 = + spironolactone
If K+ > 4.5 = + alpha blocker or beta blocker
122
1st line treatment of hypertension in pregnancy?
Labetalol (hepatotoxic)
Alternatives = nifedipine MR or methyldopa
123
When should gestational hypertension treatment be stopped?
2 days after birth
124
BP target for someone under 80?
<140/90
125
BP target for someone over 80
<150/90
126
BP target for someone with diabetes?
<130/80
127
BP target for a pregnant woman?
<135/85
128
Which ACE can be given BD?
Captopril
129
Which ACE must be given 30-60mg a before food?
Perindopril
130
Side effects of ACE/ARB?
Hyperkalaemia
Hypoglycaemia
Angioedema
Teratogenic
Nephrotoxicity
Hepatotoxicity
Taste disturbance
Oral ulcers
Indigestion
131
Which CCBs are brand specific?
Nifedipine MR
Diltiazem MR
132
Which CCBs are more cardio selective?
Rate limiting CCBs - avoid in HF
133
Which CCB can cause constipation?
Verapamil
134
Side effects of CCBs?
“DEATH FOG”
Dizziness
Erectile dysfunction
Ankle swelling
Tachycardia
Headaches
Flushing
Oedema
Gingival hyperplasia
Can also cause interstitial lung disease
135
Which juice should be avoided with CCBs?
Grapefruit juice
136
Symptoms of heart failure?
Dyspnoea
Oedema
Pink sputum
137
Treatment of fluid overload in heart failure?
Loop or thiazide diuretic
138
Which thiazide diuretic is effective in eGFR < 35?
Metolazone
139
1st line treatment of heart failure?
ACE + beta blocker
140
Alternatives to ACE in heart failure treatment?
ARB
Or hydralazine + nitrate
141
Which beta blockers can be used in heart failure?
“CBN”
Carvedilol
Bisoprolol
Nebivolol (if 70+ with mild-moderate stable HF)
142
When can Nebivolol be used in HF?
if 70+ with mild-moderate stable HF
143
What can be added to 1st line treatment of HF if symptoms persist?
Aldosterone antagonist E.g. spironolactone
144
Which loop diuretic is most likely to cause gout?
Furosemide
145
Which loop diuretic is is most likely to cause musculoskeletal pain?
Torasemide
146
Which thiazide diuretic can be used on alternate days due to long half life?
Chlortalidone
147
Which thiazide diuretic is least likely to aggregate diabetes?
Indapamide
148
Which thiazide diuretic is brand specific?
Metolazone
149
Which aldosterone antagonist can be used in liver ascites?
Spironolactone
150
Which potassium sparing diuretic can turn your urine blue?
Triamterene
151
Onset of action of loop diuretics?
1 hour
152
Duration of action of loop diuretics?
6 hours
153
Which electrolytes can be reduced by furosemide?
All
154
Key side effect of loop diuretics?
Ototoxicity
155
Why must loop diuretics and aminoglycosides be separated by long periods?
Ototoxicity
156
Thiazide diuretics onset?
1-2 hours
157
Thiazide diuretic duration of action?
12-24 hours
158
Which diuretics can exacerbate gout?
Both thiazides and loop diuretics. Loops exacerbate more.
159
Which diuretics can cause GI disturbance?
Thiazide diuretics
160
Which diuretics can cause impotence?
Thiazides
161
Which electrolytes are decreased by thiazide diuretics?
All except calcium which increases
162
Which thiazide diuretic can cause skin cancer?
Hydrochlorothiazide
163
Side effects of aldosterone antagonist diuretics?
Gynaecomastia and hypertrichosis (excessive hair growth all over the body)
164
Do aldosterone antagonists increase or decrease potassium levels?
Increase
165
Which beta blocker should be given by IV?
Esmolol
166
Which beta blocker can be used for migraine prophylaxis and anxiety?
Propranolol
167
Which beta blocker can cause QT prolongation leading to torsade de pointes?
Sotalol
168
Warning label for beta blockers?
Do not stop unless GP tells you to
169
Which beta blockers are least likely to cause bradycardia or coldness to extremities?
“ice PACO”
Pindolol
Acebutol
Celiprolol
Oxprenolol
170
Which beta blockers are most water soluble meaning they least effect sleep disturbance?
“watering CANS”
Celiprolol
Atenolol
Nadolol
Sotalol
171
Which beta blockers are most cardio selective and therefore least likely to cause bronchospasms?
“B A MAN”
Bisoprolol
Acebutol (least cardio selective)
Metoprolol
Atenolol
Nebivolol
172
Which beta blockers are the longest acting meaning they can be given OD?
“BACoN / CAN B”
Bisoprolol
Atenolol
Celiprolol
Nadolol
173
Beta blocker side effects?
“BAD FISH”
Bronchospasm / bradycardia
Atrioventricular block
Disturbs glucose metabolism (hypo/hyper)
Fainting / dizziness
Impotence
Sleep disturbances
Hypotension / HF / cold hands and feet
174
What is the main cause or peripheral (AKA occlusive) arterial disease?
Atherosclerosis restricting the blood supply but resolves shortly
175
Treatment of peripheral (AKA occlusive) arterial disease?
Secondary prevention = high intensity statin + aspirin
176
Treatment of vasospastic arterial disease?
Avoid triggers E.g. smoking/stress.
If serious give nifedipine.
177
What is given for primary prevention of CVD?
Low dose of high intensity statin E.g. 20mg atorvastatin
178
What is given for secondary prevention of CVD?
High dose of high intensity statin E.g. 80mg atorvastatin
179
What is added to secondary prevention of CVD with atherosclerosis?
Low dose aspirin
180
What is added to secondary prevention of CVD with stoke/TIA?
Clopidogrel
Or dipyridamole + aspirin
181
Cholesterol targets?
“5 4 3 2.3 1”
Total cholesterol < 5
Non-LDL < 4
LDL < 3
Triglycerides < 2.3
HDL > 1
182
Which drugs can cause hyperlipidaemia?
“AITCH”
Antipsychotics
Immunosuppressants
Thiazide diuretics
Corticosteroids
HIV meds
183
1st line treatment of hyperlipidaemia?
Statins (low intensity) treat high LDL and moderately high triglyceride levels
184
Additional treatment to statins in severe hyperlipidaemia?
Ezetimibe
185
Additional treatment to statins if triglycerides are still high?
Fibrates E.g. benzofibrate, fenofibrate
186
What is the treatment of familial hypercholesterolaemia?
High intensity statin
Or ezetimibe
187
Which statins are short acting so should be taken at night?
Fluvastatin and simvastatin
188
What is the LDL reduction required to be considered a high intensity statin?
>40%
189
Which statins and what doses are considered high intensity statins?
Atorvastatin - 20mg for primary prevention, 80mg for secondary prevention
Rosuvastatin - 20mg
Simvastatin - 80mg
190
Main side effect of Simvastatin?
Myopathy / rhabdomylosis
191
When are statins cautioned?
Hypothyroidism - monitor TSH
Kidney damage
Pregnancy - teratogenic - use contraception for up to 1 month after stopping
192
Side effects to look out for in statins?
Interstitial lung disease - report SOB
Diabetes - monitor HbA1c
Hepatotoxicity - stop if LFTs 3 x normal
193
Can a macrolide be given with a statin?
No due to risk of rhabdomylosis
194
Which fibrate should never be given with a statin?
Gemfibrozic due to risk of rhabdomylosis
195
What is the maximum dose of simvastatin that can be given concomitantly with benzofibrate or ciprofibrate?
10mg
196
What is the maximum dose of simvastatin that can be given concomitantly with amiodarone, amlodipine, diltiazem or verapamil?
20mg
197
What is the maximum dose of atorvastatin that can be given concomitantly with Ciclosporin?
10mg
198
What is the maximum dose of Rosuvastatin that can be given concomitantly with benzofibrate, ciprofibrate or fenofibrate?
5mg
199
Expiry for GTN sublingual tablets?
8 weeks
200
Examples of long acting nitrates?
GTN patches
Isosorbide dinitrate - BD (lasts 12H)
Isosorbide mononitrate MR (given OM)
201
Examples of vasodilators used in angina?
Nicorandil
Ivabradine
Ranolazine
202
MHRA alert for nicorandil?
Skin, eye and mucosa ulceration
203
Treatment of acute attacks in stable angina?
GTN spray/SL
204
GTN spray/SL counselling?
GTN SL every 5mins if needed
If no response after 2 call 999
Max 3 doses
205
1st line prophylaxis of stable angina?
Beta blocker
Or rate limiting CCB
206
2nd line prophylaxis of stable angina?
Beta blocker + rate limiting CCB (not verapamil)
207
Treatment of unstable angina/NSTEMI?
Low dose aspirin + high intensity statin + clopidogrel (for 12 months) + anti-angina drug
208
Treatment of STEMI?
Low dose aspirin + high intensity statin + clopidogrel (4 weeks) + ACE + beta blocker
209
Treatment of unstable angina/NSTEMI in a medical emergency?
Aspirin 300mg (chew or disperse in water) + GTN
210
Treatment of STEMI in a medical emergency?
Aspirin 300mg (chew or disperse in water) + GTN + IV diamorphine/morphine + metoclopramide
211
What are the 2 different types of stent?
Bare metal and drug-eluting
212
What medications should a patient be offered if they have a bare metal stent?
Aspirin indefinitely + clopidogrel (in stable angina) for 1 month
213
What medications should a patient be offered if they have a drug-eluting stent?
Aspirin indefinitely + clopidogrel (in stable angina) for 6 months
214
What can be done to digoxin dose if the patient experiences nausea?
Give as BD instead
215
Which side effect of amiodarone doesn’t require the patient to stop taking it?
Corneal micro deposits
216
Which is preferred in HF with reduced EF, Spironolactone or eplerenone?
Eplerenone
