PPT

Question 1

What is a risk of giving heparin

Answer 1

Heparin induced thrombocytopaenia

Question 2

What blood tests would you do before giving LMWH and why?

Answer 2

COAG screen and FBC

To ascertain baseline coagulation status and to ensure platelet count is normal before starting a heparin (risk of heparin induced thrombocytopenia)

Question 3

What blood tests would you do before CTPA

Answer 3

UnEs

Assess baseline renal function

Question 4

What drugs are used to anticoagulate someone with PE

Answer 4

LMWH along with vitamin K antagonist (warfarin) for 5 days (monitor INR)

Question 5

Why is LMWH used first line for PE

Answer 5

Not many side effects (some risk of bleeding) and predictable half life

Question 6

Difference between using anticoagulants or thrombolytics in PE

Answer 6

Thrombolyse if patient has massive PE and haemodynamically unstable

Question 7

If a patient is on warfarin and experiences a major bleed what should you give them?

Answer 7

Stop warfarin
Give IV vitamin K 5mg (phytomenadione)
Prothrombin complex concentrate - if not available then FFP*

Question 8

Co-trimoxazole tends to be used in elderly because..

Answer 8

Less association with pseudomembranous colitis (C.diff)

Question 9

Verapamil should not be taken with B-blocker due to risk of..

Answer 9

Bradycardia, heart block or even congestive cardiac failure

Question 10

Clarithromycin should not be given with..

Answer 10

Statin

Risk of rhabdo

Question 11

When is amiodarone given over fleicanide for rhythm control in AF?

Answer 11

In patients with structural heart disease (such as ill-functioning valves)

Question 12

How to check for end-organ damage in hypertension

Answer 12

Kidney function - Albumin-creatinine ration (ACR) from urine

Bloods - glucose, UnEs, creatinine, EGFR, serum cholesterol

Fundoscopy - retinopathhy

12 lead ECG

Question 13

If ACE inhibitor is not tolerated (ie cough) give..

Answer 13

ARB (losartan/Candesartan)

Question 14

Main SE of ACE inhibitors

Answer 14

Hypotension
Persistent dry cough
Hyperkalaemia
Angioedema

Question 15

Avoid ACE inhibitors in patients with..

Answer 15

Renal artery stenosis
AKI
Pregnant or breastfeeding women

Question 16

ACE inhibitors might be helpful in

Answer 16

CKD

Question 17

ACEi drug interactions

Answer 17

K sparing diuretics, potassium supplements - risk of hyperkalemia

NSAIDs - risk of AKI due to hypotension

Question 18

What should be done before starting an ACE inhibitor

Answer 18

Check electrolytes and renal function and repeat 1-2 weeks into treatment

Question 19

Primary prevention in those who have a 10% risk of developing CVD

Answer 19

Statin 20mg

Question 20

Statin MOA

Answer 20

HMG-CoA reductase inhibitor

Inhibits the rate-limiting enzyme in hepatic cholesterol synthesis

Question 21

Statins SE

Answer 21

Headache
GI disturbances
Myopathy - rhabdo
Rise in liver enzymes (ALT)

Question 22

Statins should be used in caution in patients with

Answer 22

Hepatic impairment

Pregnancy and breastfeeding (can affect fetal development)

Question 23

Statins drug interactions

Answer 23

Drugs that reduce metabolism of drug (higher conc for longer) - amiodarone, macrolides (clarithromycin), conazole, protease inhibitors

Avoid grapefruit juice - affects CYP3A4 and reduces statin metabolism -> increased risk of myopathy

Question 24

Which bloods need checking with statins

Answer 24

Checking LFTs at baseline, 3 months and 12 months

Risk of hepatic impairment

Question 25

Stable angina - what medications would you start patient on?

Answer 25

``` Aspirin Statin Betablocker/Ca channel blocker Nitrate (GTN) Nicorandil ```

Question 26

Beta blockers SE

Answer 26

``` Dizziness, fatigue Hypotension Erectile dysfunction Broncoconstriction (asthma) Raynaud's (Cold hands) Bradycardia/heart block Masking hypoglycaemia ```

Question 27

Beta blocker contraindications

Answer 27

Uncontrolled HF Asthma Sick sinus syndrome Verapamil (may precipitate severe bradycardia)

Question 28

Ca channel blockers (Verapamil and Diltiazem) SEs

Answer 28

Headache and flushing Tachycardia Peripheral oedema Constipation

Question 29

GTN SEs

Answer 29

Hypotension Tachycardia Headaches Flushing

Question 30

Aspirin MOA

Answer 30

COX1 and COX2 inhibitor

Question 31

Aspirin SE

Answer 31

GI irritation Ulceration Haemorrhage Bronchospasm

Question 32

NSTEMI management

Answer 32

``` Morphine - relieve chest pain Oxygen - if hypoxic Nitrates Aspirin 300mg Antithrombin therapy (Heparin immediately, Ticagrelor for 12mo, IV glycoprotein inhibitor for high risk patients ```

Question 33

STEMI management

Answer 33

Aspirin Clopidogrel LMWH heparin Oxygen PCI Thrombolysis

Question 34

When is rhythm control favoured in AF

Answer 34

``` Younger than 65 years Symptomatic Reversible cause First presentation Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol) HF secondary to AF ```

Question 35

When is rate control favoured in AF

Answer 35

Older than 65 | Hx of IHD

Question 36

Rate control drugs for AF

Answer 36

Beta blocker Ca channel blocker Digoxin (only really used if pt has HF)

Question 37

Rhythm control drugs for AF

Answer 37

Sotalol Amiodarone Flecainide

Question 38

Amiodarone SE

Answer 38

``` Thyroid dysfunction (hypo and hyper) corneal deposits Pulmonary fibrosis/pneumonitis Liver fibrosis/hepatitis Peripheral neuropathy Myopathy Photosensitivity 'slate-grey' appearance Thrombophlebitis Bradycardia QT interval prolongation ```

Question 39

Investigation for PE

Answer 39

Well's score ``` Signs and symptoms of DVT PE is most likely HR >100 Immobilisation of at least 3/7 or 6/52 Previous PE or DVT Haemoptysis Malignancy ```

Question 40

What treatments to initiate for PE

Answer 40

LMWH or Direct factor Xa inhibitor (apixaban)

Question 41

For a massive PE should you use fractioned or unfractioned heparin

Answer 41

unfractioned heparin However difficult to control INR

Question 42

Blood tests needed prior to starting LMWH for PE

Answer 42

COAG screen and FBC To ascertain baseline coagulation status and to ensure platelet count is normal before starting a heparin (risk of heparin induced thrombocytopenia)

Question 43

Risk with heparin

Answer 43

Heparin induced thrombocytopenia (low platelets)

Question 44

When is thrombolysis used in PE

Answer 44

If it's a severe PE and patient haemodynamically unstable Needed to break down clot immediately

Question 45

What factors need to be considered when starting LMWH

Answer 45

Body weight to calculate dose Pregnancy Severe renal impairment

Question 46

When starting warfarin you need to continue LMWH for 5 days - why?

Answer 46

Warfarin takes around 5 days to reach an appropriate level of anticoagulation

Question 47

How to treat a high INR

Answer 47

Oral vitamin K

Question 48

Major bleed on warfarin give

Answer 48

IV phytomenadione (Vitamin K)

Question 49

Advantages of DOACs

Answer 49

No monitoring needed (predictable) Disadvantages - no reversal agent yet

Question 50

How long on warfarin if first episode of PE

Answer 50

3 months

Question 51

Why does hyponatraemia occur in pneumonia?

Answer 51

SIADH | or other medications (thiazides, loop diuretics, spironolactone)

Question 52

To correct hyponatraemia give..

Answer 52

IV fluids (NaCl or Hartmanns) and stop drugs contributing to hyponatraemia ALWAYS check UnE's

Question 53

What type of healthcare acquired infections does broad spectrum antibiotics predispose you to?

Answer 53

C diff MRSA ESBL (Extended-spectrum beta-lactamases are enzymes that confer resistance to beta lactam ABX)

Question 54

Which ABX predispose you to C Difficile

Answer 54

Clindamycin Broad spectrum penicillins Cephalosporins

Question 55

Compliance

Answer 55

patient expected to stick to regimen prescribed by doctor, without question!

Question 56

Concordance

Answer 56

A mutually agreed contract between doctor and patient, to take medicines in a way which suits both parties

Question 57

Adherence

Answer 57

why a patient may not take medicines in the way agreed between doctor and patient (lack of understanding or doesn't agree with what was decided)

Question 58

Complete control of asthma is defined as..

Answer 58

No daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, normal lung function

Question 59

Asthma management

Answer 59

SABA SABA + ICS SABA + ICS + LTRA SABA + ICS + long-acting beta agonist (LABA)

Question 60

A low dose ICS should be used if

Answer 60

Inhaled SABA used more than 3x a week Symptomatic 3x a week or more Waking at night due to asthma at least once a week

Question 61

Given an example of a LABA

Answer 61

Salmeterol or formeterol Formoterol has a more rapid onset of action

Question 62

Severe asthma

Answer 62

PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm

Question 63

Life threatening asthma

Answer 63

``` PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma ```

Question 64

SE of beta agonist (salbutamol)

Answer 64

Fine tremor | Tachycardia

Question 65

Acute asthma treatment

Answer 65

``` Oxygen driven salbutamol nebuliser Ipratropium bromide Hydrocortisone IV Magnesium sulfate IV Aminophylline IV fluids ```

Question 66

HF treatments

Answer 66

First-line treatment = an ACE-inhibitor and a beta-blocker*. Generally, one drug should be started at a time second-line treatment= either an aldosterone antagonist, ARB or a hydralazine in combination with a nitrate if symptoms persist cardiac resynchronisation therapy or digoxin** should be considered. An alternative is ivabradine. Diuretics should be given for fluid overload

Question 67

Normal INR

Answer 67

Patients on anticoagulants usually have a target INR between 2 and 3 VTE target INR = 2.5, if recurrent 3.5 AF target INR = 2.5 Mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.