1
Q
how is hypertension diagnosed
A
clinic reading >140/90 and ABPM or HBPM avg. >135/85
2
Q
stage 1 clinic reading
A
140/90 to 159/99
3
Q
stage 2 clinic reading
A
160/100 to 180/120
4
Q
stage 3 clinic reading
A
> 180/120
5
Q
BP target for under 80 with/out T2 DM
A
140/90
6
Q
BP target for under 80 w/ T1DM/CKD & ACR <70
A
140/90
7
Q
BP target for under 80 w/ T1DM/CKD & ACR >70
A
130/80
8
Q
BP target for over 80 w/ or w/out DM
A
150/90
9
Q
BP target for over 80 w/ T1DM/CKD & ACR <70
A
140/90
10
Q
BP target for over 80 w/ T1DM/CKD & ACR >70
A
130/80
11
Q
pregnancy BP target
A
135/85
12
Q
first line hypertension treatment
A
under 55 OR T2DM - ACEi/ARB
over 55 OR African/Caribbean - CCB
13
Q
second line hypertension treatment
A
under 55 OR T2DM - add CCB
over 55 OR African/Caribbean - add ACEi/ARB or TLD
14
Q
third line hypertension treatment
A
ACEi/ARB and CCB and TLD
15
Q
forth line hypertension treatment
A
if potassium <4.5 - low dose spironolactone
if potassium >4.5 - alpha/beta blocker
16
Q
which medication is preferred in patients of African or Caribbean heritage
A
ARB over ACEi
17
Q
ACEi examples and S/E
A
lisinopril, ramipril, perindopril
Cough - switch to ARB
Hyperkalaemia
Hepatic failure
Angioedema
Renal impairment
Renal impairment
Dizziness/headaches
18
Q
ARB examples and S/E
A
candesartan, irbesartan, losartan
Hyperkalaemia
Hepatic failure
Angioedema
Renal impairment
Dizziness/headaches
19
Q
ACEi/ARB interactions
A
renally toxic - K+ sparing diuretics, NSAIDs
hyperkalaemia - heparins, NSAIDs, BB
volume depletion - diuretics
increases lithium plasma levels
20
Q
ACEi/ARB monitoring requirements
A
RF & U&Es before, 1-2wks post dose change
BP 4 wks post titration
21
Q
alpha blocker examples
A
alfuzosin, doxazosin, tamsulosin
22
Q
alpha blockers C/I
A
postural hypotension
micturition syncope (fainting while urinating)
23
Q
alpha blockers S/E
A
hypotension - first dose ON
AVOID IN PREGNANCY
24
Q
beta blocker cardioselective
A
bisoprolol
atenolol
metoprolol
acebutolol
nebivolol
- less likely to cause bronchospasm
25
beta blockers water soluble
celiprolol
atenolol
nadalol
sotalol
- less likely to cross BBB - no nightmares
26
beta blockers S/E
bronchospasm (C/I in asthma)
bradycardia and HF
causes hyperglycaemia
masks hypoglycaemia
27
beta blocker interactions
digoxin and rate limiting CCB - heart block
28
dihydropyridine calcium channel blockers
amlodipine, felodipine, lercanidipine
29
rate limiting calcium channel blockers
diltiazem, verapamil
30
calcium channel blockers
dizziness
flushing
gingival hyperplasia
headache
peripheral oedema
AV block - rate limiting
31
hypertension treatment in pregnancy
1. labetolol
2. nifedipine
3. methyldopa
32
symptoms of preeclampsia
severe headache
vision problems
severe pain below ribs
vomiting
sudden hand/face/feet swelling
33
preeclampsia treatment
75mg-150mg aspirin a day from 12 weeks
34
antihypertensives to avoid in pregnancy
ACEi/ARBs & TLD - increased defect risk
35
4 types of AF
paroxysmal - episodes stop within 7 days
persistent- >7 days
longstanding persistent- >12m
permanent
36
risk factors for AF
hypertension
ischaemic heart disease
heart failure
thyrotoxicosis
valvular heart disease
intercurrent illness
electrolyte imbalance
alcohol
37
symptoms of AF
irregular pulse with or without
breathlessness/reduced exercise tolerance
palpitations
chest tightness/pain
dizziness
fatigue
sleep disturbance
38
blood thinning treatment in AF
assess bleed/stroke risk - start DOAC (if C/I or unsuitable - warfarin)
UNLESS <65 y/o and no risk factors other than sex
39
when do you not offer rate control treatment in AF
reversible AF
HF as a result of AF
<48hrs onset
rhythm control is more suitable
40
1st line AF treatment
BB (Not sotalol) or rate limiting CCB
digoxin if pt sedentary or other options C/I
- review in 1 week - refer to specialist
41
2nd line specialist treatment AF
dual therapy BB/rate limiting CCB/digoxin - usually C/I
42
3rd line specialist treatment for AF
rhythm control - amiodarone or dronedarone
43
what to do if AF persists for >48hrs
electrical cardioversion
- amiodarone 4 wks prior and 12 months post
- min. 3 week anti-coag prior and 4 weeks post
- consider BB/sotalol/propafenone/amiodarone/flecainide
44
how to treat paroxysmal AF
BB - if symptoms persist offer sotalol/propafenone/amiodarone/flecainide
if symptomatic - flecainide
45
how to treat atrial flutter
rhythm/rate control but cardioversion is best
46
how is paroxysmal supraventricular tachycardia treated
usually terminates spontaneously alone
- Valsalva manoeuvre
- carotid sinus massage
WITH ECG ON
or IV adenosine/verapamil
- BB/rate limiting CCB/flecainide to prevent
47
how to treat Torsades des pointes (QT prolongation)
IV mag sulphate
NO anti-arrhythmic makes it worse
48
monitoring required for amiodarone
TFTs (hypo/hyper)
LFTs (hepatically cleared)
U&Es
ECG
annual eye exam
49
side effects of amiodarone
pulmonary toxicity
thyroid dysfunction
hepatoxicity
cardio toxicity (brady)
corneal microdeposits
blue/grey skin (photosensitivity)
50
interactions with amiodarone
hypokalaemia
QT prolongation
bradycardia (BB/CCB)
CYP450 inhibitor
51
therapeutic range digoxin
0.7-2ng/ml
52
levels and signs of digoxin toxicity
1.5-3ng/ml
SA/AV block - bradycardia
diarrhoea and vomiting
blurred/yellow vision
dizzy, confused, depressed
(sick and slow)
53
when are digoxin blood levels taken
6-12hrs post dose
54
digoxin antidote
digoxin antibody
55
digoxin interactions
TCAs - arrythmias
BB- AV block, incr plasma conc
hypokalaemia
CYP450 inducers - reduce conc
CYP450 inhibitors - increase conc
56
apixaban C/I
CrCl <15ml/min
liver disease
prosthetic heart valve
pregnancy/breastfeeding
antiphospholipid syndrome
57
apixaban cautions
>80y/o + BW <60kg
CrCl 15-29ml/min
58
switching from warfarin to apixaban
if INR <2 start apixaban, if 2-2.5 start next day
59
switching from apixaban to warfarin
2 days concomitant use until INR in range
60
how are DOACs switched
direct switch between DOACs
61
DOAC monitoring
FBC, clotting screen, LFTs, RF - yearly unless >75 (4m) or CrCl<60 (monitor 10/CrCl - 6m if 60)
62
C/I dabigatran
2x upper limit of liver enzymes
liver disease
CrCl <30
prosthetic heart valve
pregnancy/breastfeeding
63
Target INR for warfarin
2.5 - VTEs, AF, post-MI,
3.5 - recurrent VTE, mechanical heart valve
64
what to do if a patient has a major bleed on warfarin
stop - IV phytomenadione, dried prothrombin
65
what to do with a patient with a minor bleed on warfarin
INR >8 - stop - IV phytomenadione
INR 5-8 - stop - IV phytomenadione
66
what to do with a patients who's INR is out of range but are not bleeding
INR >8 - stop, oral phytomenadione
INR 5-8 - miss 1-2 dose
restart when INR <5
67
warfarin side effects
MHRA - necrosis and vascular calcification
bleeding
teratogenic
68
interactions with warfarin
tramadol - increase INR
miconazole - increase INR
cranberry juice - increase INR
CYP450 inducers/ inhibitors
Vit K rich foods
69
what to do with warfarin and surgery
minor/low bleed risk - continue if INR <2.5
severe bleed risk - stop 3-5 days prior, bridge with LMWH if needed stop 24hrs prior (INR >1.5 day before surgery give vit K)
70
guidance around emergency surgery and warfarin
if surgery can be delayed 6-12hr - IV vit K
if cant be delayed - IV vit K and dried prothrombin
71
MOA of apix/edox/rivarox
direct, reversible Xa inhibitor
72
dabigatran MOA
reversible inhibitor of free thrombin
73
apixaban antidote
andexanet alpha
74
when is apixaban dose reduction required
stroke/embolism - >80y/o, Cr - 133, BW <60 give 2.5mg BD
75
when is edoxaban dose reduction required
weight <60kg
CrCl 15-50
76
when is rivaroxaban dose reduction required
15mg instead of 20mg if CrCl 15-49
77
when is dabigatran dose reduction required
75-79y/o or CrCl 30-50 150mg instead of 220 for post surgery prophylaxis and 110-150 for other indications max 110 if >80y/o
78
how long is VTE prophylaxis required post surgery
hip replacement - 28-35 days
knee replacement - 10 days
79
advantages to LMWH
lower risk of thrombocytopenia, longer duration of action, preferred in pregnancy
80
how is haemorrhage treated in LMWH treatment
protamine sulphate
81
aspirin interaction
increases MTX toxicity
82
clopidogrel interactions
omeprazole/esomeprazole
83
C/I of tranexamic acid
convulsions
renal impairment
Hx thrombotic events
84
S/E of tranexamic acid
nausea
vomiting
diarrhoea
85
treatment of HF with reduced ejection fraction
1. ACEi + BB + MRA + SGLT2i (if symptoms resist stop ACEi and start entresto - 36hr washout)
2. specialist
86
specialist treatment options for HF with reduced ejection fraction
ivabradine - if sinus rhythm, HR >75 and EF <35%
digoxin
cardiac resynchronisation if QRS 120 and EF <35
Hydralazine in combination with nitrate if ACE inhibitors ARNIs and ARBs are not tolerated
87
Management of HF with preserved ejection fraction
MRA and SGLT2i
measure Pro BNP
88
which BB are licensed for use in FH
bisoprolol, carvedilol, nebivolol
89
which ACEi are licensed for use in HF
captopril, enalapril, lisinopril, ramipril, perindopril
90
which MRA are licensed for use in HF
spironolactone, eplerenone
91
which SGLT2i are licensed for use in HF
dapagliflozin, empagliflozin
92
how is oedema treated in HF
loop diuretics preferred - furosemide
93
MOA loop diuretics
block Na, K, Cl co-transporters at ascending loop of henle
94
MOA thiazide diuretics
inhibits Na/Cl co-transporter in renal distal convoluted tubule
95
MOA of potassium sparing diuretics
reduce sodium transport by blocking channel in late distal tubule
96
MOA aldosterone antagonist
inhibits aldosterone, reduces Na reabsorption in distal tubule
97
considerations when choosing diuretics
thiazide - last 24hrs give AM to avoid sleep disruption
loop - last 6 hours can be BD without disrupting sleep
98
loop and thiazide diuretic side effects
hypokalaemia
hyperglycaemia
hypotension
exacerbates gout
hyponatraemia and hypomagnesaemia
99
potassium sparing diuretic side effects
hyperkalaemia
benign breast tumor
gynaecomastia
change in libido
hyponatraemia and hypomagnesaemia
100
diuretic interactions
loop&aminoglycosides - nephro/ototoxicity
Loop - QT prolongation
loop&thiazide- hypokalaemia
potassium sparing- hyperkalaemia
all reduce lithium excretion
101
early management of acute coronary syndrome - STEMI
aspirin 300mg
if within 12hr - PPCI/fibrinolysis
if over 12hr - ticagrelor and aspirin (or clopid if high bleed risk)
102
early management of acute coronary syndrome - NSTEMI/unstable angina
aspirin 300mg
fondaparinux/PCI within 2hr
prasugrel and aspirin post PCI (clopid if already on anticoag)
GRACE - assess risk
103
low GRACE risk post NSTEMI/unstable angina
ticagrelor and aspirin consider angiography/PCI if indicated
104
high GRACE risk post NSTEMI/unstable angina
immediate angiography and PCI within 72hr
prasugrel if PCI otherwise ticagrelor and aspirin
105
post STEMI
ACEi/ARB
DAPT - clopidogrel for 12m
BB
statin
106
management of stable angina
1. GTN (999 post 2 doses)
PLUS BB or CCB (if not tolerated consider monotherapy of long acting nitrate, nicorandil, ivabradine, ranolazine)
DVLA
107
Phosphodiesterase type-5 inhibitors and GTN
12hrs between nitrate and avanafil
24 sildenafil
48 for tadalafil
108
angina and air travel
no recent changes - fine
chest pain on minimal exertion - consider O2 on flight
pain at rest - O2 on flight and medical escort
109
if uncontrolled angina symptoms on BB
add/switch long acting dihydropyridine CCB (amlodipine, nifedipine, felodipine) OR nitrate, nicorandil, ivabradine, ranolazine
110
if uncontrolled angina symptoms on CCB
add/switch BB - no rate limiting CCB with BB!
OR add nitrate, nicorandil, ranolazine, ivabradine
111
management of acute haemorrhagic stroke
1. rapid BP control (130-139) - IV - labetalol, GTN, nicardipine
2. reverse any anticoag
3. do not start statin, review meds
112
antidote for dabigatran
idarucizumab
113
management of ischaemic stroke
BP <185/110
1. tenecteplase within 4.5hr - trace gentamicin
2. alteplase 4.5-9hr
114
secondary management of ischaemic stroke no AF
if minor/TIA - DAPT for 30/21 days - monotherapy for life
if mod/severe - 300mg aspirin x 14 days and lifelong clopidogrel
115
secondary management of ischaemic stroke with AF
- Chadvasc2 and orbit
DOAC
- TIA/minor within 5 days
- mod/severe 5-14 days aspirin 300mg before
BP, lipid modification and lifestyle
116
holistic care post stroke
- mirtazapine for mood/appetite
- pain post - neuropathic
- prog only contraception
- cant drive until 1m post, >3m if multiple TIA
- no sildenafil until >3m
117
VTE treatment
apix/rivarox or 5 days LMWH then edox/dabigat or 5 days LMWH then warfarin until INR 2
118
length of DVT treatment
provokes - 3m
unprovoked >3m
active cancer 3-6m
recurrent - long term
119
VTE prophylaxis in pregnancy
LMWH in hospital and 4-8hrs post birth/miscarriage/termination for minimum 7 days
120
cholesterol targets
total <5
HDL >1
non-HDL <2.6
LDL <2
non-fasting triglycerides <2.3
121
who is offered primary CVD prevention
>85/yo QRISK >10
T2DM QRISK >10
T1DM >40y/o or >10yr/nephropathy
CKD
QRISK >10
122
high intensity statins
atorvastatin 20-80mg
rosuvastatin 10-40mg
simvastatin 80mg
123
medium intensity statin
atorvastatin 10mg
Fluvastatin 80mg
rosuvastatin 5mg
simvastatin 20-40mg
124
low intensity statin
fluvastatin 20-40mg
pravastatin 10-40mg
simvastatin 10mg
125
monitoring for statins
lipids, TFTs, RF, LFTs, CK
- stop if LFTs >3x upper limit
- If CK >5x upper limit, hold x 7 and retest, if still 5x stop
126
statins side effects
muscle pain - myopathy and rhabdomyolysis
interstitial lung disease
teratogenic
127
statin interactions
CYP450 inducers decrease statins
CYP450 inhibitors increase statins
oral fusidic acid - stop and restart 7 days later
128
max simvastatin dose when prescribed with...
20mg - amlodipine, amiodarone, diltiazem/verapamil
10mg - fibrates
129
max atorvastatin dose when prescribed with...
10mg - ciclosporin, tipranavir
130
GPhC exam
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