1
Q
Which is NOT included in the CHADSVAS score?
- Hypertension
- Renal Impairment
- Aged 65-74
- Diabetes
A
Renal Impairment
2
Q
Which would score 2 POINTS when calculating the CHADSVAS score?
- Female gender
- Age 65-74
- Previous stroke/TIA/thromboembolism
- Existing vascular disease including MI/atherosclerosis/peripheral disease
A
Previous stroke/TIA/thromboembolism
The other risks would score one point each
3
Q
What does the CHADSVASC score measure?
A
Stroke + thromboembolism risk in AF
4
Q
When would you use the CHADSVASC score?
A
To assess risk of stroke and thromboembolism in AF
5
Q
What is ‘rate control’ in AF?
A
Where the heart remains in AF but the ventricular heart rate is reduced
6
Q
What is ‘rhythm control’ in AF?
A
Where the heart is converted back to sinus rhythm either through electrical or pharmacological cardioversion
7
Q
What should be used for 1st line rate control in AF?
A
Beta-blockers or rate limiting CCBs
8
Q
Which drug should not be used in rate control of AF?
- Digoxin
- Verapamil
- Amiodarone
- Propranolol
A
Amiodarone
9
Q
When is ‘pill in the pocket’ used?
A
Paroxsymal AF
10
Q
Which drug is the ‘pill in the pocket’ for paroxsymal AF?
A
Flecainide 300mg or Propafenone 600mg
11
Q
Which antiarrythmic class is flecainide?
A
Class Ic
12
Q
What score in CHADSVAS means that stroke prevention is indicated?
A
1 or more for men
2 or more for women
13
Q
Which is NOT included in the HAS-BLED score?
- abnormal liver function
- age >65
- harmful alcohol consumption
- hypotension
A
Hypotension
uncontrolled hypertension is
14
Q
‘Anticoagulation should not be withheld solely because of risk of falls’
True or False
A
True
15
Q
Which is included in the HAS-BLED score?
- labile INR
- use of anti-epileptic drugs
- risk of falls
- abnormal thyroid function
A
Labile INR
Poorly controlled INR, less than 60% time in range
16
Q
‘Hypokalaemia can induce long QT syndrome’
True or false?
A
True
17
Q
‘Verapamil is a positive inotrope’
True or false?
A
False - it is a negative inotrope
18
Q
‘Anti-arrythmics can never cause arrythmias’
True or false?
A
False - in some circumstances anti-arrythmics can provoke arrythmias
19
Q
Which calcium channel blocker is licensed for atrial fibrillation?
- Verapamil
- Amlodipine
- Diltiazem
A
Verapamil
Diltiazem can be used but this is an unlicensed treatment
20
Q
Why should digoxin only be started in sedentary patients?
A
It is only effective at controlling the ventricular rate at rest
21
Q
What is the aim of rate control in AF?
A
Reduce the ventricular rate to <100
22
Q
Which is a common side effect of verapamil?
- constipation
- vomiting
- hallucinations
- anorexia
A
Constipation
23
Q
When should diltiazem be prescribed by brand?
- All MR preparations
- In elderly patients
- MR preparations containing over 60mg
- Always
A
MR preparations containing over 60mg.
Different versions of MR preps containing over 60mg may not have the same clinical effect
24
Q
Which statement is FALSE?
- Sotalol can prolong the QT interval
- Sotalol is a selective beta blocker
- Sotalol is contra-indicated in asthma
- Sotalol can cause life threatening ventricular arrythmias, particularly in hypokalaemia
A
Sotalol is a selective beta blocker
It is non-selective
25
Name a class II anti-arrythmic
Class II = Beta blockade
| propranolol, esmolol, sotalol
26
Name a class III anti-arrythmic
```
Class III = K+ channel blockade
amiodarone, sotalol (also class II)
```
27
Name a class IV anti-arrythmic
Class IV = calcium channel blockade
| diltiazem, verapamil
28
Name a class Ic (strong) anti-arrythmic
flecainide, propafenone
29
Name a class Ia (moderate) anti-arrythmic
quinidine
30
Name a class Ib (weak) anti-arrythmic
lidocaine
31
How do class I anti-arrythmics work?
Membrane stabilising drugs
| Work via sodium channel blockade
32
What is the major interaction between verapamil and beta-blockers?
Cardiac depressant effects
| Risk of asystole, bradycardia and sinus arrest
33
Which CCB can never be given with beta-blockers
Verapamil - risk of cardiac depression
34
How does digoxin work?
Cardiac glycoside
| Increases force of myocardial contraction and reduces conductivity in the AV node
35
What is xanthopsia?
Colour vision deficiency - a 'yellowing' of vison
| Caused by digoxin toxicity
36
Which drug can cause a yellowing of vision?
Digoxin - causes xanthopsia
| Sign of digoxin toxicity
37
Which of these is not a sign of digoxin toxicity?
- blurred vision / visual disturbances
- vomiting
- syncope
- abdominal pain
Syncope - although fatigue and delirium are common signs
38
'Digoxin is mainly hepatically cleared'
| True or False?
False - it is largely eliminated renally
39
Which of these can contribute to digoxin toxicity?
- Hypernatraemia
- Dehydration
- Hypokalamia
- Liver disease
Hypokalaemia can contribute to digoxin toxicity
40
Which of these would not be involved in causing digoxin toxicity?
- AKI
- Hypokalaemia
- Use of vitamin D supplements
- Hypertension
Hypertension
41
Name the four DOACs
Rivaroxaban
Apixaban
Edoxaban
Dabigatran
42
Which is not an indication for an anticoagulant?
- PE
- DVT
- AF
- HTN
HTN
43
What is the most common side effect of anticoagulants
Bleeding/ haemorrhage
44
What colour is a 1mg warfarin tablet?
Brown
45
What colour is a 3mg warfarin tablet?
Blue
46
What colour is a 5mg warfarin tablet?
Pink
47
What colour is a 500mcg warfarin tablet and why is this not usually stocked?
White
| Easily confused with other tablets
48
What is the maximum amount of time that a patient on warfarin can go without having their INR checked?
12 weeks
49
How long does it take for the anticoagulant effect of warfarin to develop?
48 to 72 hours
50
What can be given to reverse the effects of warfarin?
Vitamin K (phytomenadione)
51
In which circumstance would you advise to stop warfarin and give vitamin K by a slow IV injection?
- INR >8, no bleeding
- INR 6, minor bleeding
- INR 5, no bleeding
- INR 2, minor bleeding
INR 6 and minor bleeding
For unexpected bleeding at therapeutic levels you should always investigate the possibilty of underlying causes
52
In which circumstance would you advise to stop warfarin and give vitamin K injection orally?
- INR >8, no bleeding
- INR 6, minor bleeding
- INR 5, no bleeding
- INR 2, minor bleeding
INR >8 no bleeding
| unlicensed use of vitamin K injection
restart warfarin when INR <5
53
Which drugs interact with digoxin?
- alfacalcidol
- ramipril
- amoxicillin
- prednisolone
- salbutamol
Alfacalcidol - increased risk of digoxin toxicity. Manufacturer advises monitor.
Prednisolone - increased risk of digoxin toxicity. Manufacturer advises caution.
Salbutamol - increased risk of digoxin toxicity. Manufacturer advises caution.
54
'There is an interaction between macrolides and digoxin'
| True or false?
True - macrolides can cause a 2x to 4x increase in digoxin concentration, advised to monitor digoxin levels
55
'Hypokalaemia contributes to digoxin toxicity'
| True or False
TRUE - monitor for K+ depleting diuretics as this can increase the risk of digoxin toxicity
56
Which anti-arrythmic class is amiodarone in?
Class III
| K+ channel blockade
57
Which system is NOT affected by amiodarone?
- Skin
- Renal
- Thyroid
- Respiratory
Renal
58
'Amiodarone has a short half life'
| True or false?
False
Amiodarone has a long half life and takes several weeks to reach steady state. Because of this, drug interactions can still occur several weeks after treatment cessation
59
What colour can amiodarone potentially cause skin to become?
Slate-grey
60
Which drug can cause patients to become dazzled by headlights at night?
Amiodarone
61
What effect can amiodarone have on the eyes?
Causes corneal microdeposits which can cause patient to be dazzled
Reversible on withdrawal of treatment
62
How does amiodarone affect the thyroid and what is the reason for this?
Can cause disorders in thyroid function - both hyper and hypo.
Because amiodarone contains iodine.
Hyperthyroidism can be permanent and fatal
63
What monitoring should a patient prescribed amiodarone have?
Thyroid function tests at beginning of treatment and every 6 months
Chest x-ray prior to treatment + should be told to report any new/progressive SOB
Liver function tests at beginning of treatment and every 6 months
64
Which drug does NOT interact with amiodarone
- warfarin
- simvastatin
- lithium
- ramipril
- bisoprolol
RAMIPRIL
warfarin - inhibited metabolism, increase in anticoagulant effect
simvastatin - increased risk of myopathy
lithium - increased risk of arrythmias
bisoprolol- increased risk of cardiovascular side effects
65
Why should amiodarone NEVER be given with sofosbuvir/ hep C treatments
Risk of severe bradycardia and heart block
| MHRA warning
66
'Warfarin is teratogenic'
| True or false?
True - risk of congenital malformations in first trimester
67
Which vitamin K antagonist can rarely cause calciphylaxis?
Warfarin
- more common in patients with renal disease
- patients should report any painful skin rash
68
What is the interaction between St John's Wort and warfarin?
St John's wort decreases the INR/anticoagulant effect
69
What is the interaction between fluconazole and warfarin?
Fluconazole raises the INR/ increases anticoagulant effect
70
What is the target concentration/therapeutic range for serum digoxin?
1 - 2 mcg/L
| Toxicity can occur >2.0 mcg/L
71
What is the approx time for dioxin to reach steady state?
7 days
72
When should a digoxin level be taken?
Pre-dose or 6 - 8 hours post dose
73
Name two non-dihydropyridine calcium channel blockers
Verapamil + diltiazem
74
What are the advantages of beta blockers with intrinsic sympathomimetic activity?
Less coldness to the extremities and bradycardia
| can stimulate as well as block adrenergic receptors
75
Which beta blockers have intrinsic sympathomimetic activity?
Celiprolol
Oxprenolol
Pindolol
76
How do beta blockers work?
Block beta-adrenoreceptors in the heart, peripheral vasculature, bronchi, pancreas and liver
They slow the heart rate and depress the myocardium
77
What are the four most water soluble beta blockers?
```
Sotalol
Nadolol
Atenolol
Celiprolol
(SNACK without the K)
```
78
What are the advantages of water soluble beta blockers?
They are less likely to enter the brain and therefore are less likely to cause side effects such as sleep disturbance and nightmares
79
How are water soluble beta blockers excreted?
Via the kidneys
| May need dose reductions in renal impairment
80
'Most beta blockers have a short duration of action'
| True or False?
True - they may need to be taken 2 - 3 times per day
81
Name 4 beta blockers that can be given once daily due to an intrinsically longer duration of action
```
Atenolol
Bisoprolol
Celiprolol
Nadolol
(ABCN)
```
82
Why should beta-blockers be avoided in asthma?
Beta blockers can precipitate bronchospasm
83
Name the cardioselective beta blockers
```
Atenolol
Bisoprolol
Metoprolol
Nebivolol
Acebutolol
```
84
What does the term 'cardioselective beta blocker' mean?
These beta blockers have less of an effect on the B2 (bronchial) receptors.
They can have a lesser effect on airways resistance and should be used in patients with a history of asthma or COPD.
85
Which is NOT a side effect of beta blockers?
- Dry Eyes
- Hyperkalaemia
- Cold extremities
- Syncope
- Fatigue
Syncope
86
In which condition would a beta-blocker be CONTRAINDICATED?
- Diabetes
- Psoriasis
- Second degree heart block
- COPD
- Myasthenia gravis
Second degree heart block
Beta-blockers are cautioned in the other listed conditions
87
Why are beta-blockers cautioned in diabetes?
- They can affect carbohydrate metabolism, causing hyper or hypoglycaemia
- They can also mask symptoms of hypos such as tachycardia by interfering with metabolic and autonomic responses
88
'Abrupt withdrawal of beta-blockers should be avoided'
| True or False?
True
| Esp in ischaemic disease as can cause worsening of myocardial ischaemia
89
'Propranolol can be used for anxiety and prophylaxis od migraine'
True or False?
True
90
What serious side effect can occur when beta-blockers are given IV?
Excessive bradycardia
Symptoms = dizziness, light headedness and syncope
Can be treated with IV atropine
91
'Labetalol is a selective beta blocker'
| True or False?
False - it is a non-selective alpha and beta blocking drug
92
Can labetalol be used in hepatic impairment?
NO - avoid.
| Risk of liver damage
93
What monitoring is required for patients taking labetalol?
Patients should be monitored for signs of liver damage.
There is a risk of severe hepatocellular damage
LFTs required after first sign of liver dysfunction and stop treatment if there is evidence of any liver damage or jaundice
94
'Liver damage only occurs in patinets who take labetalol long term'
True or False?
False - there is risk of liver damage in short term and long term treatment
95
Can sotalol affect the QT interval?
Yes.
| Sotalol can prolong the QT interval and cause life-threatening ventricular arrythmias
96
What monitoring is required for a patient taking sotalol?
ECG and monitor QT interval
| Monitor electrolytes and AVOID/CORRECT hypokalaemia and hypomagnesaemia or any other disturbances
97
Name the 2 non-dihydropyridine CCBs
Verapamil and diltiazem
98
What is the most common side effect of verapamil?
Constipation
99
Name some dihydropyridine CCBs
Amlodipine, felodipine, nifedipine, lercanidipine, nicardipine
100
How do dihydropyridine CCBs work?
Relax vascular smooth muscle and dilate coronary and peripheral arteries
101
'Dihydropyridine CCBs have anti-arrythmic activity'
| True or False?
False
102
Which dihydropyridine CCBs have a long duration of action and can be given once daily?
Amlodipine + felodipine
103
'Side effects of dihydropyridine CCBs are mainly to do with vasodilation'
True or False?
True
| Flushing, headache and ankle swelling are common
104
Can calcium channel blockers cause ankle swelling?
Yes
105
What would IV Nicardipine be used to treat?
Acute life-threatening hypertension
106
How do dihydropyridine CCBs work?
- Interfere with inward displacement of calcium ions through slow channels of active cell membranes
- Influence myocardial cells, cells in the conducting system of the heart and vascular smooth muscle cells
- Can reduce myocardial contractility, depress electrical impulses and diminish vascular tone
107
Dihydropyridine CCBs rarely precipitate heart failure, why is this?
Because the negative inotropic effect (depression of electrical impulses) is offset but reduction in left ventricular work
108
Which is NOT a sign of calcium channel blocker overdose?
- Hyperglycaemia
- Coma
- Confusion
- Angioedema
- Agitation
Angioedema
109
'All preparations of nifedipine must be prescribed by brand'
True or False?
False - only MR preps should be prescribed by brand
110
Which brands of Nifedipine must be avoided in oesophageal/GI obstruction, hepatic impairment + IBD?
Adalat LA and Valni XL
111
What is normal blood pressure?
120/80
112
What is classed as 'stage 1' hypertension
BP >140/90 clinic or >135/85 home/ambulatory
113
'Verapamil and diltiazem must be avoided in heart failure'
| True or False?
True - can cause depression of cardiac function and clinical deterioration
114
Which patient would NOT be treated for stage 1 hypertension?
- 52 y/o with angina and BP 150/91
- 48 y/o with CKD stage 3 and BP 141/96
- 79 y/o with no co-morbidities and BP 145/87
- 66 y/o with T2DM and BP 140/90
- 79 y/o with no co-morbidities and BP 145/87
Patient has hypertension but is <80 with no risk factors
115
What is classed as stage 2 hypertension?
BP >160/100 clinic or 150/95 at home
116
Which patients with stage 2 hypertension would receive treatment with anti-hypertensives?
Every patient with stage 2 hypertension would recieve treatment
117
What would be the target blood pressure for a 91 year old patient receiving anti-hypertensives?
<150/90 clinic or <145/85 home
| For all patients over 80
118
What would be target blood pressure for a 49 year old patient receiving anti-hypertensives?
<140/90 clinic or <135/85 home
| For patients under 80 with no co-morbidities
119
What is the target blood pressure for patients receiving anti-hypertensives with cardiovascular disease or diabetes with eye, kidney or CVD?
<130/80
120
When using a stepwise approach to hypertension, how long should be left between steps to determine response?
4 weeks
121
What is the stepwise approach for hypertension for patients under 55?
1. ACEi/ARB (if not tolerated give beta-blocker)
2. Add CCB
3. Add thiazide-like diuretic
4. Add low dose spironolactone or alpha/beta blocker if diuretics not tolerated
122
What is the stepwise approach for hypertension for patients over 55 or with African or Carribean family origin?
1. CCB (if not tolerated/HF give thiazide-like diuretic)
2. Add ACEi/ARB
3. Add thiazide-like diuretic
4. Add low dose spironolactone or alpha/beta blocker if diuretics not tolerated
123
ACEi or ARB?
| Which is preferred in patients of African/Carribean heritage?
ARB
124
Should aspirin be prescribed for patients with uncontrolled hypertension?
No, only for secondary prevention in cardiovascular disease
125
What causes a dry cough with ACEi?
Build up of braydkinin
126
Which is not a side effect of ACEi?
- Taste disturbances
- Angioedema
- Profound hypotension
- Agitation
- Pancreatitis
Agitation
127
What monitoring is required for patients receiving ACEi?
Renal function and electrolytes should be monitored before treatment, before dose adjustments and during treatment
128
'ACEi can have hepatic effects'
| True or False?
True - there is a risk of choleostatic jaundice, hepatitis and hepatic failure.
Treatment should be discontinued if there is a marked elevation of hepatic enzymes or evidence of jaundice
129
Why should an ACEi and ARB not be used together?
There is an increased risk of hypotension, hyperkalaemia and renal impairment
130
Which is not a side effect of ARBs?
- Angioedema (w delayed onset)
- Hyperkalaemia
- Dry cough
- Symptomatic hypotension
Dry cough
131
Name some ARBs
Candesartan, Losartan, Irbesartan, Valsartan, Telmisartan
132
What is diuresis?
Increased or excessive urine
133
How do thiazide + related diuretics work?
Inhibit sodium re-absorption at the beginning of the distal convoluted tubule
134
How quickly do thiazide + related diuretics work?
Act within 1-2 hours of administration
135
How long is the duration of action thiazide + related diuretics?
12 - 24 hours
136
What time of day should thiazide + related diuretics be administered?
Early so diuresis does not interrupt sleep
137
'Thiazide + related diuretics are generally ineffective if eGFR <30'
True or False?
True - except metolazone
138
Why are low-dose thiazide + related diuretics recommended for the treatment of hypertension?
Lower doses produce maximal BP-lowering effects with less biochemical disturbance
Lower doses - vasodilation more prominent than diuresis
139
Which types of diuretics can cause hypokalaemia?
Thiazide + related diuretics and loop
140
Which thiazide + related diuretic has a long duration of action?
Chlortalidone
| Useful if rapid diuresis causes acute retention or if patients dislike altered urination
141
What are some problems with diuretics that cause hypokalaemia?
In hepatic failure hypokalaemia can precipitate encephalopathy/coma
Hypokalaemia is also dangerous in patients with severe cardiovascular disease
142
'Thiazide + related diuretics are cautioned in diabetes as they can excerbate this condition and cause hyperglyceaemia'
True or False?
True.
Loop diuretics also have this effect but hyperglycaemia is more likely with thiazide + related diuretics.
Indapamide is associated with less metabolic disturbance including less aggrivation of diabetes.
143
Which thiazide + related diuretic can be combined with a loop diuretic to give profound diuresis?
Metolazone.
| Even effective when eGFR <30 but risk of excessive diuresis, patient requires careful monitoring
144
Why can loop diuretics not be used in patients with enlarged prostates?
Risk of urinary retention
145
How quickly do loop diuretics act?
Within 1 hour of oral administration.
| IV furosemide has a peak of 30 mins
146
What is the duration of action for loop diuretics?
Diuresis complete within 6 hours. Suitable for BD dosing without interrupting sleep
147
'The diuresis associated with loop diuretics is dose-related'
True or False?
True
148
How is diuretic-resistant oedema treated?
Loop diuretic combined with bendroflumethiazide or metolazone
149
How is furosemide administered IV?
Max rate of 4mg/min
150
What are the risks of giving furosemide IV?
Can cause ototoxicity (tinnitus and deafness) if administered too quickly
151
When are weak diuretics amiloride+ triamterene used?
Given with thiazidelike or loop diuretics as a more effective alternative to potassium supplements.
Act as weak diuretics that cause potassium retention
152
Potassium-sparing diuretics should never be given with ... ?
Potassium supplements
| ACEi / ARBs - risk of severe hyperkalaemia
153
'Aldosterone antagonists are potassium sparing'
| True or False?
True - contraindicated in hyperkalaemia
154
Why should diuretics be used with caution in the elderly?
They are particularly susceptible to side effects. Low doses should be used initially then adjusted according to renal function
155
'Brinzolamide and dorzolamide are diuretics'
| True or false?
True - they inhibit the formation of aqueous humour
156
Why are heparins less useful in preventing thromboembolism in arteries?
They are faster flowing vessels, thrombi are formed of less fibrin
157
Why is heparin preferred to LMWH where there is a high bleeding risk?
Heparin has a short duration of action therefore the effect can be terminated rapidly when the infusion is stopped
158
What is the reversal agent for heparin?
Protamine sulfate
159
Name the LMWHs
Dalteparin
Enoxaparin
Tinzaparin
160
Why are LWMH preferred to heparin in the prevention and treatment of VTE?
- Lower risk of heparin-induced thrombocytopenia
| - Longer duration of action - once daily dosing is possible
161
Which LMWHs are licensed for extended treatment and prophylaxis of VTE in patients with solid tumours?
Dalteparin and Tinzaparin
162
What are the 3 main side effects of heparin?
Haemorrhage
Heparin-induced thrombocytopenia
Hyperkalaemia
163
What are the signs of heparin-induced thrombocytopenia?
- 30% reduction in platelet count
- Thrombosis
- Skin allergy
164
Why does heparin cause hyperkalaemia?
Inhibits aldosterone secretion
165
Which patient would NOT be at higher risk for hyperkalaemia caused by LMWH?
- CKD stage 4
- Diabetic
- Receiving IV antibiotics
- Taking regular spironolactone
Patient receiving IV antibiotics
166
When might factor Xa levels be monitored in a patient receiving LMWH?
If they are renally impaired or over or under weight
167
Which of these does NOT increase risk of VTE?
- Hepatic impairment
- Age >60
- Obesity
- Malignant disease
- Reduced mobility
Hepatic impairment
168
'Pharmacological prophylaxis should start within 14 hours of admission'
True or False?
True
169
Which DOAC can be used for oral treatment and prophylaxis of VTE?
Edoxaban
170
In the diagnosis of heart failure what is the range/significance of the N-terminal proBNP level?
Suspect a diagnosis of heart failure if the N-terminal pro BNP level is 400-2000ng/L
If the level is <400 then HF is unlikely
A high level can also indicate AF
171
What are some non-pharmacological treatments for heart failure?
- Exercise based rehab
- Smoking cessation
- Reduced alcohol intake
172
Name the New York Heart association classification of HF symptoms
Class I - no limitations on exercise
Class II - slight limitation of physical activity
Class III - marked limitation of physical activity
Class IV - symptoms of heart failure present at rest
173
'Verapamil and diltiazem should never be used in heart failure'
True or False?
True - the negative inotropic action can further depress cardiac function and cause clinically significant deterioration
174
What are the aims of treatment in heart failure?
- Relieve symptoms
- Improve exercise tolerance
- Reduce acute exacerbations
- Reduce mortality
175
Which two treatments should always be initiated in HF with LVSD?
- ACEi
| - Beta blocker
176
Which ARBs are licensed in heart failure?
Candesartan, losartan and valsartan
177
Which beta blockers are licensed in heart failure?
Bisoprolol, carvedilol, nebivolol (in over 70s with mild HF)
178
'In heart failure beta blockers should follow the start low and go slow rule'
True or false
True
They should be titrated slowly and heart rate, blood pressure and clinical status should be monitored following each dose increase
179
'Beta blockers may initially cause a deterioration in symptoms when initiated in heart failure'
True or false?
True
180
Which MRA is usually started in heart failure?
MRA = mineralcorticoid receptor antagonist
| Spironolactone 25-50mg OD
181
'Spironolactone does not affect mortality when used in heart failure'
True or false?
False - it can reduce mortality
182
Which criteria must be met for specialist treatment with ivabradine for heart failure?
HF with LVSD,
NYHA class II-IV symptoms,
Treatment with ACEi, B blocker and MRA,
Heart rate over 75 BPM
183
What is the minimum resting heart rate that a patient taking ivabradine should be maintained at?
Resting heart rate should be above 50bpm
184
Patients taking ivabradine should be monitored for ....
Bradycardia and AF
185
What is sacubitral?
Neprilysin inhibitor, used with valsartan in specialist treatment of heart failure
186
Does digoxin reduce mortality in heart failure?
No but can improve symptoms and reduce hospitalisation
187
When should digoxin be used in heart failure?
Specialist use only
| In worsening/severe HF with LVSD that remains symptomatic with all other treatments
188
How regularly should patients with heart failure be monitored?
Minimum of every 6 months.
| Monitor at shorter intervals (days to 2 weeks) if clinical condition or drug treatment changes
189
Which is not included in the QRISK2 score calculator?
- Diabetes status
- Systolic BP
- BMI
- Diet
- Severe mental illness
Diet
190
Which drugs can cause dyslipidaemia as a side effect and so are included in the QRISK2 calculator?
- Antipsychotics
- Corticosteroids
- Immunosuppressants
191
Can a diagnosis of erectile dysfunction increase your risk of heart disease/stroke?
Yes
192
'Cardiovascular risk is underestimated in patients taking antihypertensive drugs'
True or false?
True
193
How are statins categorised?
In terms of % reduction in LDL-cholesterol levels
- low intensity is 20-30% reduction
- medium intensity is 30-40% reduction
- high intensity is >40% reduction
194
Which is an example of high-intensity statin therapy?
- Atorvastatin 20mg
- Simvastatin 10mg
- Fluvastatin 80mg
Atorvastatin 20mg
195
Which is an example of medium-intensity statin therapy?
- Atorvastatin 40mg
- Rosuvastatin 5mg
- Pravastatin 40mg
Rosuvastatin 5mg
| Pravastatin is always low-intensity therapy
196
How should a QRISK2 score of over 10% be treated?
High-intensity statin eg, atorvastatin 80mg
197
Why is simvastatin 80mg not recommended?
MHRA found increased risk of myopathy with high dose simvastatin.
198
How is statin therapy monitored?
Total cholesterol, HDL and non-HDL cholesterol should be monitored before treatment and 3 months into treatment.
Aiming for >40% reduction in non-HDL cholesterol
199
Why is it important to correct hypothyroidism before initiating a statin?
Correcting hypothyroidism may resolve the lipid abnormality and untreated hypothyroidism has an increased risk of myositis with lipid regulating drugs
200
'Statins reduce cardiovascular disease and total mortality irrespective of initial cholesterol concentration'
True or False?
True
| They are also more effective than other lipid-regulating drugs at reducing LDL-cholesterol concentration
201
'Statins are more effective than fibrates are reducing triglyceride concentration'
True or false?
False
202
How do bile acid sequestrants such as cholestyramine work?
Bind to bile acids and prevent reabsorption, promoting hepatic conversion of cholesterol into bile acid
203
What counselling should be given with bile acid sequestrants?
- They can interfere with the absorption of fat soluble vitamins
- They can affect absorption of other drugs so should be taken 1 hour prior or 4-6 hours after other drugs
204
Which drug that inhibits intestinal absorption of cholesterol can be given if a statin is not tolerated?
Ezetimibe 10mg OD
205
How do statins work?
Competitively inhibit HMG CoA reductase, an enzyme involved in cholesterol synthesis especially in the liver
206
Which patients are at increased risk of muscle toxicity caused by statins?
- Personal/family history of muscle disorders
- High alcohol intake
- Renal impairment
- Hypothyroidism
207
How is baseline creatinine kinase used when monitoring statin treatment?
Statins should be avoided if creatinine kinase is persistently five times the upper limit of normal
208
In patients with diabetes taking a statin how should HbA1c be measured?
Before treatment and 3 months after initiation as risk of hyperglycaemia
Do not discontinue statin if HbA1c is increased as benefits outweigh risks
209
Can statins be taken in pregnancy?
No.
Risk of congential abnormalities and decreased cholesterol synthesis can affect foetal development.
Use adequate contraception during treatment and discontinue 3 months before trying to get pregnant.
210
How should patients taking statins be counselled?
Report any muscle pains, tenderness or weakness
211
How should liver function be monitored in patients taking statins?
Monitor before treatment and at 3 and 12 months.
More frequently if signs of hepatotoxicity.
Avoid in active liver disease and use with caution if history of liver disease.
212
Why should most lipid-regulating medicines be taken at night?
Cholsterol levels are highest at night and this allows the drugs to work best
213
Which statins do NOT need to be taken at night?
Atorvastatin and Rosuvastatin
| Have a longer duration of action and can also be taken in the morning
214
What is first line treatment for stable angina?
1. Sublingual GTN - take before activities known to trigger an attack
2. B-blocker or (rate-limting) CCB titrated to max. tolerated dose
215
What therapy can be added in patients with stable angina who cannot tolerate a CCB or B-blocker?
Monotherapy with:
- long acting nitrate
- Ivabradine
- Nicorandil
- Ranolazine
216
Why should patients taking ivabradine be monitored for bradycardia and AF?
It lowers heart rate through action on the sinus node.
| Discontinue if HR is persistently below 50bpm
217
'Ivabradine is a black triangle drug'
| True or false?
True
218
'Nicorandil can cause serous ulceration'
| True or false?
True - including GI ulcers which may perforate. Stop treatment if ulceration occurs
219
Name some cautions for ranolazine?
Weight <60kg, eGFR <80ml/min (avoid if <30), elderly, QT interval prolongation
220
How do nitrates work?
They are potent coronary vasodilators
| Also reduce venous return meaning reduction in left ventricular work
221
Some common side effects of nitrates?
- Flushing
- Headache
- Postural hypotension
222
NItrates are cautioned in patients with 'tolerance'. How can tolerance be reduced with different nitrate preparations?
Transdermal patches - leave off for 8-12 hours/day
MR isosorbide dinitrate + isosorbide mononitrate - Give the 2nd of 2 daily doses after 8 hours not 12
MR isosorbide mononitrate - give OD
223
How long do the effects of sublingual GTN last?
20-30 mins
224
When does the 'POM' restriction not apply to adrenaline?
When 1mg of 1 in 1000 adrenaline is used for emergency treatment of anaphylaxis
225
Which drugs are used in the long term management of ACS?
```
- Dual antiplatelet
Aspirin + clopidogrel/ticagrelor/prasugrel for 12 months
- B-blocker
- ACEi
- Statin
- Nitrate (if angina/MI)
- Eplenerone (if MI in HF)
```
Pre-reg revision
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