Chapter 2: Cardiovascular Flashcards

Question

How should non-sustained VT be treated?

Answer 1

beta blocker

Answer 2

For patients at high risk of cardiac arrest - most patients: cardioverter defibrillator implant (ICD) - some patients also require a drug: sotalol, bb alone or bb with amiodarone *ICD sends electrical pulses to regulate abnormal heart rhythms, especially those that could be dangerous and cause a cardiac arrest.

Answer 3

A form of VT associated with a prolonged QT interval

Answer 4

Causes: sotalol and other drugs that prolong QT, hyPOkalaemia, and bradycardia Treatment: Magnesium sulphate

Answer 5

Paroxysmal supraventricular tachycardia (PSVT) is a type of abnormal heart rhythm, or arrhythmia. It occurs when a short circuit rhythm develops in the upper chamber of the heart. This results in a regular but rapid heartbeat that starts and stops abruptly. This will often terminate spontaneosuly or with reflex vagal stimulation such as a valsalva mmanoeuvre, immersing the face in ice-cold water or carotid sinus massage - performed with ECG monitoring

Answer 6

IV adenosine (c/i in COPD/asthma) if ineffective or c/i Alternative: IV verapamil (avoid in patients recently treated with beta blockers) * if haemodynamicaly ly unstable = direct current cardioversion * recurrent episodes = cather ablation OR drugs (rate limiting CCBs, sotalol, flecainide ir propafenone)

Answer 7

CLASS 3 - used in arrhythmias e.g. supraventricular and ventricular arrhythmia INITIAL LOADING DOSE: - 200mg TDS for 7 days, - 200mg BD for 7 days and then, - 200mg OD as maintenance

Answer 8

EYES: - corneal micro-deposits pt counselling = night time glares when driving - optic neuropathy/ neuritis (blindness). counselling = STOP if impaired vision SKIN: - phototoxicity (burning, erythema) - slate-grey skin on light exposed areas counselling = shiled skin from light, wide spec SPF for months after stopping NERVES: - peripheral neuropathy, counselling = numbness, tingling hands and feet, tremors LUNGS: - pneumonitis, pulmonary fibrosis, Counselling = SOB, dry cough LIVER: - hepatoxicity. counselling = report jaundice, N+V, malaise, itching, bruising, abdominal pain. 3X raised liver transaminases) THYROID DYSFUNCTION (contains iodine) - hyperthyroidism (weight loss, heat intolerance, tachycardia) --> give carbimazole if nec. stop amiodarone - hypothyroidism (weight gain, cold intolerance, bradycardia). start levothyroxine without stopping amiodarone if essential

Answer 9

- annual eye test - chest xray before treatment - LFTs every 6 months - monitor TSH, T3, T4 before treatment and every 6 months - blood pressure and ECG (causes hypotension and bradycardia) - serum K (causes hypokalaemia; enhances arrhythmogenic effect of amiodarone)

Answer 10

AMIODARONE HAS EXTREMELY LONG HALF LIFE = 50 days (danger of interactions several months after stopping) - increased plasma amiodarone concs = grapefruit juice (enzyme inhibitor) - amiodarone is an enzyme inhibitor = warfarin, phenytoin, digoxin (half dose) - increased risk of myopathy = statins - bradycardia, AV block and myocardial depression = bbs, rate limiting CCBs - QT prolongation = increased risk of ventricular arrhythmia = quinolones, macrolides, TCAs, SSRIs, lithium, quinine, hydroxychloroquine, anti-malarials (chloroquine and mefloquine), antipsychotics (especially sulpiride, pimozide, amisulpride)

Answer 11

Cardiac glycoside: increases force of myocardial contraction (positive ionotrope) reduces conductivity in the AV node (negative chronotrope) (INCREASE OUTPUT FORCE + DECREASE RATE OF CONTRACTIONS) *high risk drug*

Answer 12

1-2 microgram/L (Cp 6 hours after dose) Monitoring is not required during maintenance treatment unless toxicity suspected OR in renal impairment (renally cleared

Answer 13

- loading dose required due to long half life - maintenance once daily: - atrial flutter and non-paroxysmal AF in sedentary patients = 125-250 mcg - worsening or severe HF (in sinus rhythm) = 62.5 - 125mcg - different dosage forms have different bioavailabiility e.g. elixir = 75% tablet = 90% IV = 100%

Answer 14

"Slow and sick". Risk of toxcitiy in hypO K+, hypO Mg2+, hypER Ca2+, hpoxia and renal impairment - bradycardia/heart block - nausea, vomiting and diarrhoea, abdominal pain - blurred or yellow vision - confusion, delirium - rash

Answer 15

WITHDRAW. Correct electrolyte imbalances | Digoxin-specific antibody for life threatning ventricular arrthymias unresponsive to atropine

Answer 16

- HyPOkalaemia predisposes to digosin toxicity; diuretics (loop/thiazide), b2 agonist, steroids, theophylline (if K+<4.5mmol/L: give K+ supplements OR K+ sparing diuretic preferred) - increase plasma digoxin conc = toxicity: amiodarone (half digoxin dose), rate limiting CCBs, macrolides, ciclosporin (enzyme inhibitors) - decreased plasma digoxin conc = subtherapeutic dose: st johns wort, rifampicin (enxyme inducers) - reduced renal excretion = toxicity (digoxin renally excreted): NSAIDs, ACEis/ARBs

Answer 17

CRASED ``` Calcium channel blockers (verapamin/diltiiazem) Rifampicin Amiodarone St Johns wort Erythromycin Diuretics ```

Answer 18

1. Deep vein thrombosis (DVT): a blood clot occurs in a deep vein, usually in calf of one leg 2. Pulmonary embolism (PE): detachment of blood clot which travels to the lungs and blocks the pulmonary artery

Answer 19

- immobility - obesity BMI >30 - malignant disease - 60+ years - personal history of VTE - thrombophilic disorders - 1st degree of relative with VTE - HRT/combined oral contraceptive - varicose veins with phlebitis (inflammation of vein) - pregnancy - crticial care - significant co-morbidities

Answer 20

- thrombocytopenia (low platelet) - acute stroke - bleeding disorders * acquired: liver failure * inherited: haemophilia, Von Willebrands disease - anticoagulants - systolic hypertension

Answer 21

- compressin stockings - for patients scheduled for surgery continued until sufficiently mobile

Answer 22

- for high VTE risk patients undergoing general/orthopaedic surgery OR admitted to hospital as general medical patients. (if c/i offer mechanical prophylaxis) PARENTERAL ANTICOAGULANTS: - low molecular weight herapin OR - unfractionated heparin in renal failure OR - fondaparinux NOACs: - prophylaxis AFTER knee/hip replacement surgery - edoxaban: treatment and prevention of recurrent VTE

Answer 23

- general surgery: 5-7 days or until sufficient mobility - major cancer surgery in abdomen or pelvis: 28 days - knee/hip replacement sugery: extended duration

Answer 24

- LMWH OR unfractionated heparin in renal failure . For at least 5 days and until INR at 2 or more for at least 24 hours. Monitor APTT if unfractionated heparin given. - Start oral anticoagulant at same time; usually warfarin

Answer 25

- heparins - LMWH is the preferred choice - lower risk of osteoporosis and heparin-induced thrombocytopenia - stop at labour onset. seek specialist advice on continuing after birth

Answer 26

- Activated partial thromboplastin time - Blood test that characterizes coagulation of the blood, with a substance added to make it clot faster - A typical aPTT value is 30 to 40 seconds - Important to monitor with unfractionated heparin

Answer 27

(parenteral anticoagulant) - unfractionated heparin activates antithrombin - low molecular weight heparin inactivate factor Xa

Answer 28

- standard heparin - shorter duration of action - preferred choice if: = high risk of bleeding = renal impairment - essential to measure APTT (activated partial thromboplastin time)

Answer 29

- tinzeparin - enoxaparin - dalteparin - longer duration of action - generally preferred choice; lower risk of: = osteoporosis = heparin-induced thrombocytopeonia - used in pregnancy

Answer 30

- haemorrhage: withdraw heparin, if rapid reversal required = antidote protamine - hyperkalaemia: heparins inhibit aldosterone secretion. Higher risk in diabetes and CKD. Monitor before treatment and if >7 days use - osteoporosis - heparin-induced thrombocytopoenia: occurs 5-10 days after. Clnical signs: 30% reduction in platelets, skin allergy, thrombosis. Monitoring: before treatment and if >4 days use

Answer 31

- heparinoid - argatroban - hirudin - flushes - epoprostenol - fondaparinux

Answer 32

- oral anticoagulant (high risk drug) - antagonise actions of vitamin K in blood clotting - takes 48-72 hours to work

Answer 33

- 5mg initially and monitor every 1-2 days | - maintenance dose: 3-9mg at same time every day

Answer 34

- INR every 3 months once stable

Answer 35

- isolated calf DVT = 6 weeks - provoked VTE (COCs, pregnancy, leg plaster cast) = 3 months - unprovoked (e.g. AF) = at least 3 months/ long term

Answer 36

- 2.5 = VTE, AF, MI, cardioversion, bioprosthetic mitral valve. - 3.5 = recurrent VTE in patients recieving antocoagulant and INR > 2

Answer 37

- yellow treatment booklet | - anticoagulant alert card

Answer 38

Changes in INRL - MHRA/CHM advice: direct acting anti-virals to treat chronic hepatitis C: risk of infection with vitamin K antagonsts and changes in INR; affects efficacy of warfarin. Closely monitor INR Increased INR = increased risk of bleeding - MHRA/CH< advice: OTC oral miconazole gel (daktarin) c/i in patients taking warfarin, Closely monitor if miconazole prescribed. Miconazole permanent enzyme inhibitor; increases anticoagulant effect of warfarin counselling: stop and seek immediate medical attention if any sign of bleeding e.g. nose bleeds or blood in urine

Answer 39

- Bleeding e.g. nose bleeds <10 mins, bleeding gums, bruising. antidote = vitamin K; phytomenadione - Calciphylaxis (a serious, uncommon disease in which calcium accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death) * MHRA/CHM advice: warfarin reports of calciphylaxis. counselling: report painful skin rash. Consider stopping if calc diagnosed. risk factor: end stage renal disease

Answer 40

- MAJOR BLEEDING - stop warfarin - IV phytomenadione (vit k) - dried prothrombin complex or fresh frozen plasma

Answer 41

- withhold 1-2 dose - reduce maintenance dose - measure INR after 2-3 days

Answer 42

- omit warfarin - IV phytomenadione - repeat if INR still high after 24 hours - restart warfarin when INR < 5 -

Answer 43

- omit warfarin - oral phytomenadione - repeat if INR still high after 24 hours - restart warfarin when INR < 5

Answer 44

- omit warfarin - IV phytomenadione - repeat if INR still high after 24 hours - restart warfarin when INR <5

Answer 45

ELECTIVE - stop warfarin 5 days before elective surgery - give oral phytomenadione one day if INR > 1.5 - restart warfain on evening or next day EMERGENCY - delay 6-12 hours - no delay; give IV phytomenadione and dried prothrombin complex IF HIGH RISK OF VTE - VTE in last 3 months, AF with previous stroke/TIA, mechanical valve = bridge with LMWH (treatment dose) and stop 24 hours before surgery HIGH RISK OF BLEEDING - start LMWH 48 hours after surgery

Answer 46

Novel Oral Anticoagulants: inhibits specific clotting factors i.e. thrombin or factor Xa

Answer 47

- dabigatran - direct thrombin inhibitor, special container - 4 month expiry - apixaban* - edoxaban* - rivaroxaban* * direct factor Xa inhibitors USE: increasingly used as an alternative to warfarin. Advantages: rarely causes bleeding and no monitoring required NOACs come with patiet alert card

Answer 48

1. ISCHAEMIC = BLOOD CLOT OBSTRUCTS BLOOD SUPPLY - ischaemic strokes - transient iscaemic attack (mini strokes) 2. HAEMORRHAGIC = WEAK BLOOD VESSEL IN BRAIN BURSTS - intracerebral haemorrhage

Answer 49

TIA : MR dipyridamole and aspirin ISCHAEMIC STROKE: clopidogrel, in AF-related stroke - review for anticoagulant BOTH TIA/ISCHAEMIC STROKES: statin irrespective of serum cholesterol, treat hypertension; not with beta blockers unless indicated for another condition

Answer 50

- avoid aspirin, statin and anticoagulants (increases risk of bleeding; only give if essential) - treat hypertension and take care to avoid hypoperfusion

Answer 51

Decrease platelet aggregation and inhibit thrombus formation in the arterial circulation

Answer 52

- aspirin - clopidogrel - dipyridamole - cangrelor - prasugrel - ticagrelor - abciximab (monoclonal antibody)* - eptifibatide * - tirofiban* * glycoprotein IIa/IIb inhibitors

Answer 53

75mg daily

Answer 54

following ACS or PCI

Answer 55

2nd preventionn of strokes. Take tabs 30-60 mins before food. Persantin retard capsules special container - 6 week expiry

Answer 56

ACEi or ARB *if not c/i or not tolerated: beta blocker

Answer 57

CCB *if high risk of heart failure or CCB not tolerated: thiazide like diuretic

Answer 58

ADD CCB *if high risk heart failure or CCB not tolerated: thiazide like diuretic

Answer 59

ADD ACEi or ARB *ARB preferred in african/carribbean patients

Answer 60

ACEi/ARB + CCB +TLD

Answer 61

low dose sprionolactone OR high dose TLD if K+ > 4.5 If other diuretics c/i or ineffective, add alpha or beta blocker

Answer 62

1: 140/90mmHg = offer lifestyle advice, only treat if under 80 with: target organ damage (LV hypertrophy, CKS, retinopathy), CVD or QRISK >20%, renal disease, diabetes 2. 160/100mmHg = treat all 3. > 180 systolic >110 diastolic = hypertensive crisis. Hypertensive emergency = acute target organ damage, IV reduce BP slowly; otherwise reduced organ perfusion = blindness, MI, cerebral infarction and severe renal impairment. Hypertensive urgency = without target organ damage - oral reduce Bp slowly over 24-48 hrs

Answer 63

<140/90 130/80 in atherosclerotic CVD OR diabetes with kidney, eye or cerebrovascular disease

Answer 64

<140/90 <130/80 if CKD, diabetes, proteinuria >1g in 24 hours . Consider ACEi/ARB if proteinuria present

Answer 65

<140/80 <130/80 if compliacations; eye, kidney or cerebrovascular disease

Answer 66

< 150/100 chronic hypertension <140/90 chronic hypertension and if target organ damage or given birth LABETALOL (hepatotoxic) is widely used and first choice in gestational hypertension. METHYLDOPA (stop 2 days after birth)/ MR NIFEDIPINE (unlincensed

Answer 67

Inhibits the conversion of angiotensin 1 to angiotensin 2

Answer 68

``` Captopril (BD) Enalapril Fosinipril Imidapril Lisinopril Moexipril Perindopril (30-60 mins before food) Quinapril Ramipril Trandolapril ``` Taken OD except captopril. Take first dose at bed time

Answer 69

``` Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan ```

Answer 70

- persistent dry cough (give ARB as alternative) - hyperkalaemia *higher risk in renal impairment and diabetes mellitus - anaphylactoid reactions e.g. angioedema - nephrotoxic - oral ulcer - taste disturbance - hypoglycaemia - avoid in pregnancy

Answer 71

- renoprotective in renal disease e.g. CKD - nephrotoxic = acute kidney injury; avoid DAMN Diuretics, ACE/ARB, Metformin, Nsaids - reduces egfr via efferent arteriole dilation - avoid in renovascular disease (may give in unilateral renal artery stenosis NOT severe bilateral stenosis)

Answer 72

- cholestatic jaundice, hepatic failure | - stop if liver transaminases 3x normal or jaundice occurs

Answer 73

- hyperkalaemia: aliskeren, ARB, K+ sparing diuretics/aldosterone antagonists - nephrotoxicity and reduced eGFR: NSAIDs (afferent arteriole constriction) - hypotension: diuretics (volume depletion = low BP) - renal impairment, hyperkalaemia and hypotension: renin-angiotensin system drugs ACE/ARB, renin inhibitor. Avoid concomitant ACE + ARB in diabetic nephropathy

Answer 74

blocks angiotensin 2 receptor, does not inhibit the breakdown of bradykinin; alterntaive to ACE if persistent dry cough present

Answer 75

- methyldopa (side effects = driving; drowsiness) - clonidine (side effects = flushing) - moxonidine

Answer 76

- hydralazine (side effects = fluid retention, tachycardia) | - minoxidil (side effects = tachycardia, fluid retention and increase cardiac output)

Answer 77

- prazosin - terazosin - indoramin

Answer 78

Beta-blockers block beta-adrenoreceptors in the heart, peripheral vasculature, bronchi, pancreas and liver

Answer 79

ice PACO water CANS Be A MAN BACoN

Answer 80

Pindolol Acebutol Celiprolol Oxprenolol - intrinsic sympathomimetic activity - less bradycardia - less coldness of extremeties

Answer 81

Celiprolol Atenolol Nadolol Sotalol - water soluble; less likely to cross BBB - less nightmares and sleep disturbances * reduce dose in renal impairment as renally cleared

Answer 82

``` Bisoprolol Atenolol Metoprolol Acebutol Nebivolol ``` - cardio-selective = less bronchospasm - well-controlled asthma under a specialist if no other choice

Answer 83

Bisoprolol Atenolol Celiprolol Nadolol - once daily dosing - intrinsically long duration of action

Answer 84

- bradycardia, hypotension | - hyperglycaemia OR hypoglycaemia (masks symptoms of hyPO e.g. tachycardia)

Answer 85

- asthma: causes bronchospasm (includes b-blocker eye drops e.g. timolol) - worsening unstable heart failure - second/third degree heart block - severe hypotension and bradycardia

Answer 86

- Asystole and hypotension (verapamil injection) | - hypERglycaemia; avoid in diabetes/high risk (thiazide-like diuretcis)

Answer 87

- blocks calcium channels to reduce force of contraction, conductivity and vascular tone

Answer 88

- dihydropyridine: vasodilation | - rate limiting

Answer 89

- amlodipine - felodipine - lacidipine - lercanidipine - nifedipine (maintain the same MR brand) side effects: ankle swelling, flushing, headaches (common)

Answer 90

- verapamil (causes constipation, only CCB licensed for arrhythmias) - diltiazem (maintain on same brand when doses >60mg) *AVOID IN HEART FAILURE

Answer 91

- increased CCB concentrations with grapefruit juice(enzyme inhibitor) (avoid)

Answer 92

Pheochromocytoma is a type of neuroendocrine tumor that grows from cells called chromaffin cells. The tumor releases hormones that may cause high blood pressure, headache, sweating and symptoms of a panic attack Beta-blocker + alpha blocker (phenoxybenzamine) treats symptoms: headache, excess sweating and a hard, fast heartbeat (palpitations).

Answer 93

Vasoconstrictor sympathomimetics: raise blood pressure transiently by acting on alpha-adrenergic receptors to constrict peripheral blood vessels

Answer 94

- noradrenaline - phenylephrine (longer acting: prolonged rise in BP) side effects: reduced perfusion to vital organs e.g. kidneys

Answer 95

- dysponea (sudden severe SOB) during an activity or at rest - exercise intolerance/ fatigue - oedema: * pulmonary oedema = breathlessmess * peripheral oedema = swollen ankles/legs

Answer 96

- N-terminal pro-B-type natriuretic hormone (NT-proBNP) - refer people with suspected HF with NT-proBNP above 2000ng/L (236pmol/L) urgently to specialist for echocardiography within 2 weeks - refer between 400 and 2000 for echo within 6 weeks

Answer 97

obesity, African or African–Caribbean family background, or treatment with diuretics, ACE inhibitors, BBs, ARBs or mineralocorticoid receptor antagonists (MRAs) can reduce levels of serum natriuretic peptides

Answer 98

high levels of serum natriuretic peptides can have causes other than heart failure (e.g., age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [eGFR less than 60 ml/minute/1.73], sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver). REFER TO NICE FOR MORE ON HF

Answer 99

ACE/ARB + B-BLOCKER - perindopril, ramipril, captopril, enalapril, lisinopril, quinapril or fosinopril - and beta blocker licensed for HF (bisoprolol, carvedilol in all grades or nebivolol in mild-mod) - first line treatment to reduce morbidity and mortality - ARB licensed for heart failure (candesartan, losartan, valsartan) considered if ACE not tolerated

Answer 100

hydralazine + isosorbide dinitrate (specialist use)

Answer 101

- Add spironolactone OR eplerenone after acute MI with LVSD or mild HF (unless c/i due to hyperkalaemia or renal impairment) ALT: - hydralazine +isosorbide dinitrate considered under specialist advoce in patients intolerant of ACE/ARB (in particular african/caribbean origin with mod-sev HF) - sacubutril valsartan (LVEF <35% and taking ACE/ARB)

Answer 102

Add ivabradine (added to standard therapy if patient in sinus rhytmm and heart rate >75) OR Add digoxin (worsening or severe heart failure - does not reduce mortality but may reduce symptoms and hospitalisation) OR amiodarone

Answer 103

anticoagulation

Answer 104

- serum potassium and sodium, renal function and BP should be checked prior to starting, 1-2 weeks after and at each dose increment . Once taret dose is reached, monitor monthly for 3 months and then at least every 6 months

Answer 105

- heart rate, BP and symptom control should be assessed at the start of treatment and after each dose change

Answer 106

- loop diuretics | - thiazide diuretucs in mild HF (ineffective in renal failure eGFR <30)

Answer 107

high blood levels of cholesterol, triglycerides or both

Answer 108

CVD - hyperlipidaemia causes atherosclerosis and in turn: - coronary heart disease (angina, MI) - strokes and TIA - peripheral arterial disease

Answer 109

- type 1 diabetes mellitus - type 2 diabetes mellitus only if CVD risk >10% - QRISK >10% - CKD or albuminuria - familial hypercholesterolaemia - 85 years + (reduce risk of non-fatal MI)

Answer 110

- In patients with established CVD (coronary heart disease (angina/MI), cerebrovascular disease (stroke/TIA) and peripheral arterial disease)

Answer 111

- type 1 diabetes mellitus - established CVD - over 85 yrs - CKD (eGFR <60) - familial hypercholesterolemia (score will be underestimated)

Answer 112

6mmol/L total cholesterol

Answer 113

=/< 5mmol/L total for healthy adults | =/< 4mmol/L for high risk adults

Answer 114

=/<3mmol/L LDL for healthy adults | =/<2mmol/L for high risk adults

Answer 115

>1mmol/L HDL ("good cholesterol - higher the better)

Answer 116

<1.7mmol/L

Answer 117

- antipsychotics - immunosuppressants - corticosteroids - antiretrovirals (HIV drugs)

Answer 118

- hypothyroidism - liver or kidney disease - diabetes mellitus - family history of high cholesterol - lifestyle factors : smoking, excess alcohol, obesity and poor fatty diet

Answer 119

- statins - fibrates (bezafibrate, ciprofibrate, fenofibrate, gemfibrozil) - ezetimibe - bile acid sequestrants (colesevelam, colestipol. colestyramine) - nicotinic acid group (acipimox, nicotinic acid, omega-3 fatty acid) - lomitapide - alirocumab

Answer 120

- lowers LDL cholesterol synthesis by the liver via inhibition of HMG-CoA reductase (indirectly reduces triglycerides and increase HDL cholesterol)

Answer 121

``` Atorvastatin* Rosuvastain * Pravastatin Simvastatin Fluvastatin ``` *dont need to be taken at night ONCE DAILY (for other statins cholesterol synthesis is greater at night; more effective)

Answer 122

atorvastatin 20mg OD (primary) | atorvastatin 80mg OD (secondary)

Answer 123

Defined as the dose at which a reduction in LDL greater than 40% - rosuvastatin 10, 20,40mg - atorvastatin 20,40,80mg - simvastatin 80mg (MHRA WARNING high risk of myopathy: give only if high risk of CVD complications or severe hypercholesterolaemia and treatment goals not achieved at lower dose)

Answer 124

High intesnsity statin or ezetimibe if statin c/i or not tolerated

Answer 125

If statin not tolerated or c/o = fibrate

Answer 126

Fibrate OR nicotinic acid (also lowers LDL)

Answer 127

- hypothyroidism - uncontrolled diabetes mellitus - nephrotoxic synfrome (albuminuria) - liver disease e.g. alcohol cirrhosis

Answer 128

- hypothyroidism - uncontrolled diabetes mellitus - nephrotoxic synfrome (albuminuria) - liver disease e.g. alcohol cirrhosis

Answer 129

- myopathy, myositis, rhabdomyolysis (report tender, weak and painful muscles) - higher risk of muscle toxicity in: - -> personal or family history of muscle disorder - -> high alcohol intake - -> renal impairment - -> hypothyroidism; treat before starting statin - increased risk of myopathy with: - -> concomitant ezetimibe or fibrates, especially gemfibrozil - -> concomitant fusidic acid: restart statin 7 days after last dose (increased risk of rhabdomyolysis) - interstitial lung disease (report SOB, cough, weight loss) - raised HcA1c or BG levels (caution in diabetes)

Answer 130

- baseline lipid profile - renal function - thyroid function - HbA1c if high risk of developing diabetes - if severe muscle symptoms: DISCONTINUE - creatine kinase: discontinue if 5x normal (if level returns to normal and muscle symptoms resolve a statin can be reintroduced at a lower dose and monitor) - liver function: discontinue if liver transaminases 3x normal

Answer 131

- increased statin levels = increased myopathy risk: amiodarone, grapefruit juice, CCBs e.g. diltiazem, amlodipine, imidazole/triazole antifungals e.g. itraconazole, ciclosporin - macrolide antibiotic e.g. clarithromycin: stop taking statin until antibiotic course completed - fibrates (esp gemfibrozil): Avoid - fusidic acid: restart statin 7 days after last fusidic acid (oral) dose

Answer 132

Simvastatin: max 10mg with fibrate max 20mg with amiodarone, amlodipine, diltiazem, verapamil Atorvastatin: max 10mg with ciclosporin Rosuvastatin initially 5mg, max 20mg with clopidogrel

Answer 133

TERATOGENIC - effective contraception during and 1 month after stopping - stop taking 3 months before conceiving and restart after breastfeeding finished

Answer 134

- reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine - alternative to statin in familial and primary hypercholesterolaemia

Answer 135

Can increase risk of myopathy when used together with statins

Answer 136

lowers blood triglyceride levels by reducing the livers production of VLDL (the triglyceride-carrying particle that circulates in the blood) and by speeding up the removal of triglycerides from the blood Interactions: myopathy with statins

Answer 137

- bezafibrate - fenofibrate - ciprofibrate - gemfibrozil: do not use with stain as high risk of myopathy (rhabdomyolysis)

Answer 138

Binds and sequesters bile acids. The liver then produces more bile acids to replace those that have been lost. The body used cholesterol to make bile acids, this reduces the amount of LDL cholesterol circulating in the blood (SPECIALIST USE)

Answer 139

- colesevelam - colestipol - colestyramine Interactions: impaired absorption of fat-soluble vitamins ADEK and other drugs. Take other drugs 1 hour before (4hrs for coleveselam) or 4 hours after bile acid sequestrant

Answer 140

``` GTN Isosorbide dinitrate (s/l) ```

Answer 141

- MR isosorbide dinitrate - isosorbide mononitrates Also used in prophylaxis - BBs - CCBs - Ivabradine - Ranolazine - Nicorandil

Answer 142

- converted to nitric oxide which is a short acting vasodilator; improves blood supply

Answer 143

- sublingual tablet/spray - effects last 20-30 mins - if using more than twice a week --> need long term prophylaxis - *special container for tablets, expires 8 weeks ater opening, foil-lined container with no cotton wadding

Answer 144

- when required OR - before angina inducing activities e.g. exercise - take sitting down as dizziness can occur - take 1st dose under tongue and wait 5 mins - take 2nd dose and wait 5 mins - take 3rd dose and wait 5 mins - if pain is still present call 999

Answer 145

- Beta blocker (atenolol, bisoprolol, metoprolol or propranolol) OR - rate limiting CCB (diltiazem/verapamil) if bb are c/i *BB + dihydropyridine CCB (amlodipine, nifedipine MR, felodipine) may be effective in patients with prinzmetal's angina

Answer 146

VASODILATORS: - long acting nitrate - ivabradine (only in normal sinus rhythm) - ranolazine - nicorandil in adults only (K-channel activator) MHRA/CHM warning: now given 2nd line risk of ulcer complications: mouth, skin, eye, GI. Do not drive until it is established performance is not impaired

Answer 147

- nitrates are potent coronary vasodilators and reduce venous return and cardiac output

Answer 148

- with long acting preparations or transdermal patches - maintain effectiveness by reducing blood nitrate concentrations to low levels for 4-12 hours a day 1. leave patches off for 8-12 hrs (overnight) per day 2. take second dose after 8 hours not 12 hours for MR isosorbide dinitrate BD and isosorbide mononitriate BD 3. MR isosorbide mononitrate is taken OD therefore does not produce tolerance

Answer 149

- vasodilation, flushing, throbbing headache, dizziness, postural hypotension, tachycardia, dyspepsia, heartburn - injection (GTN and isosorbide dinitrate in MI) = severe hypotension, sweating, apprehension, restlessness, muscle twitching, retrosternal discomfort - avoid abrupt withdrawal of nitrates (and CCB) --> worsens angina

Answer 150

1. O2 if hypoxia 2. ISCHAEMIC PAIN: - GTN/IV isosorbide dinitrate - IV diamorphine/morphine with metoclopramide 3. REPERFUSION: - aspirin 300mg + clopidogrel 300mg. - PCI or thrombolytic (altepase within 4.5 hrs; steptokinase within 12hrs - avoid 4 days) 4. PREVENT RE-OCCLUSION SYSTEMIC AND EMBOLISATION: parenteral anticoagulant 5. LONG TERM MANAGEMENT = SAAB: Statin, ACE inhibitor, Aspirin indefinitely, Beta blocker. Clopidogrel (4 weeks = STEMI, 12 months = NSTEMI/Unstable angina)

Answer 151

Percutaneous coronary intervention (PCI), can be gievn with glycoprotein IIb/IIa inhibitor ``` - Dual antiplatelet therapy: Aspirin (forever) + Clopidogrel OR ticagrelor/prasugrel elective = one month bare metal stent = 12 months drug-eluting stent = 12 months ```

Answer 152

UNSTABLE ANGINA AND NSTEMI - disp/chew aspirin 300mg STAT + note - GTN as required sublingually or spray STEMI; - as above but add on IV diamorphine/morphine + metoclopramide

Answer 153

CARDIOPULMONARY RESUSCITATION - 30 compressions: 2 breaths - approx 100 compressions/min IV adrenaline 1 in 1000 every 3-5 mins (sympathetomimetic ionotrope used in cardiogenic shock) If ventricular fibrillation present: IV amiodarone

Answer 154

in the morning to avoid sleep disruption

Answer 155

- bumetanide (most potent) - furosemide (gout) - torasemide (musculoskeletal pain) Used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure

Answer 156

- bendroflumethiazide - cyclopenthiazide Used to relieve oedema due to chronic heart failure and in lower doses, reduce BP

Answer 157

- chlortalidone (long half life) - indapamide (less aggrevation of diabetes) - metolazone (still works in severe renal failure) - xipamide

Answer 158

- amiloride - triamterene (blue urine in some lights) +spironolactone + eplerenone

Answer 159

- sprionolactone (ascites liver failure) - eplerernone (used in post-acute MI) *(also known as K-sparing)

Answer 160

Mannitol (used in cerebral oedema)

Answer 161

- acetozolamide (used in glaucoma)

Answer 162

Increased urine output by the kidneys e.g. promotes diuresis by inhibiting sodium reabsorption at different parts of the renal tubular system (nephron)

Answer 163

- inhibit Na+/K+/Cl- co transporter in ascending limb of loop of henle - 1 hour onset - 6 hour duration - side effects: - -> ototoxicity (tinnitus, deafness), - -> acute urinary retention (too rapid diuresis, *caution in benign prostatic hyperplasia although less likely in low doses) - -> hyperglycaemia (diabetes - can exacerbate) although less likely than with thiazides - -> hyperuricaemia (gout) - can exacerbate - -> HYPO K+, Na+, Cl-, Mg2+ (alcoholic cirrhosis) - -> HYPER Ca2+

Answer 164

``` HEART FAILURE (BD take last dose at 4pm) 20-40mg OM - furosemide doses ``` RESISTANT HYPERTENSION Bumetanide (most potent) Torasemide (musculoskeletal pain) Furosemide

Answer 165

- Inhibits Na+/Cl- transporter in distal convoluted tubule - 1-2 hour onset - 12-24hr duration - side effects: - -> GI disturbances - -> impotence - -> high LDL/triglycerides - -> hyperglycaemia (diabetes) - -> hyperuricaemia (gout) - -> HYPO K+, Na+, Cl-, Mg2+ (alcohol cirrhosis) - -> HYPER Ca2+ - ineffective if eGFR <30ml/min except metolazone

Answer 166

- Inhibits Na+/Cl- transporter in distal convoluted tubule - 1-2 hour onset - 12-24hr duration - side effects: - -> GI disturbances - -> impotence - -> high LDL/triglycerides - -> hyperglycaemia (diabetes) - -> hyperuricaemia (gout) - -> HYPO K+, Na+, Cl-, Mg2+ (alcohol cirrhosis) - -> HYPER Ca2+ - ineffective if eGFR <30ml/min except metolazone

Answer 167

HEART FAILURE OM 5mg HYPERTENSION OM 2.5mg - bendroflumethiazide doses - indapamide (less diabetes exacerbation) - metolazone (use in severe RF) - chlortalidone (long half life given on alternate days if acute retention is a problem or dislikes frequent urination)

Answer 168

Promotes urination (diuresis) 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

Answer 169

- triamterene (urine can look blue) - amiloride USE: - preferred over K+ supplements in counteracting HYPOkalaemia SIDE EFFECTS: - hyperkalaemia INTERACTIONS: - hyperkalaemia: avoid concomitant ACE/ARB, K+ supplements, aldosterone antagonist

Answer 170

Inhibits aldosterone which causes sodium reabsorption via the Na+/K+/H+ co transporter. Less potassium and hydrogen ions are exchanged for sodium and therefore less lost to the urine

Answer 171

- spironolactone (use in ascites in liver failure) - eplerenone SIDE EFFECTS: - gynaecomastia, benign breast tumours, menstrual disturbances - hypertrichosis - change in libido - HYPERkalaemia, hyperuraemia, HYPOnatraemia INTERACTIONS: - severe hyPERkalaemia: K+sparing diuretics, K+ supplements, ACE/ARBs MHRA: aldosterone antagonists and ACEi/ARB in heart failure: risk of potentially fatal/severe hyperkalaemia. Monitoring of blood electrolytes is essential

Answer 172

Inhibits sodium and water reabsorption by increasing the osmolarity (solute concentration) of blood and renal filtrate. Osmotic diuretics act on the parts of nephron that are water permeable; proximal convoluted tubule and descending limb of the loop of henle

Answer 173

MANNITOL (pharmacologically inert sugar) USES: - cerebral oedema - high intracranial pressure

Answer 174

- low dose diuretic | - not for long term use, try alternatives first e.g. stockings, raising legs and movement

Answer 175

- either occlusive (intermittent claudication) in which occlusion of the peripheral arteries is caused by atherosclerosis (peripheral arterial disease) OR - vasospastic (e.g raynauds syndrome)

Answer 176

- aspirin 75mg daily and statin as secondary prevention of CVD

Answer 177

- stop smoking and avoid exposure to cold | - nifedipine used to reduce the frequency and severity of vasospastic attacks

Answer 178

- anti-fibrinolytic drug - inhibits fibrinolysis, can be used to prevent bleeding or to treat bleeding associated with excessive fibrinolysis (e.g. in surgery, dental extraction, obstetric disorders, and traumatic hyphaema) and in the management of menorrhagia

Answer 179

- used in the management of mild-moderate haemophilia and von willebrands dosease. also used for fibrinolytic response testing

Answer 180

- streptokinase (given within 12 hours) - altepase (given within 6-12 hours) Been shown to reduce mortality in MI. Reteplase (within 12 hours) and tenecteplase (early as poss) also licensed in MI. Thrombolytic drugs are indicated for patients with acute MI for whom benefit outweigh risk - Altepase, streptokinase and urokinase can be used for other thromboembolic disorders such as DVT and pulmonary embolism

Answer 181

Dissolve blood clots by activating plasminogen, which forms a cleaved product called plasmin. Plasmin is a proteolytic enzyme that is capable of breaking cross-links between fibrin molecules, which provide the structural integrity of blood clots

Answer 182

- oxprenolol - pindolol - acebutolol - celiprolol - cause less bradycardia - causes less coldness of the extremeties

Answer 183

- atenolol - celiprolol - nadolol - sotalol - less likely to cross the blood - brain barrier - less likely to cause nightmares and disrput sleep - excreted renally

Answer 184

- atenolol - bisoprolol - celiprolol - nadolol - once daily dosing

Answer 185

- labetolol - celiprolol - carvedilol - nebivolol - lower peripheral resistance (*the resistance of the arteries to blood flow. As the arteries constrict, the resistance increases and as they dilate, resistance decreases. Peripheral resistance is determined by three factors: Autonomic activity: sympathetic activity constricts peripheral arteries.) - no evidence that these have any important advantages over others

Answer 186

- atenolol - bisoprolol - metoprolol - nebivolol - acebutolol (to a lesser extent( - good for patients with well-controlled asthma/copd where there's no alternative available - good for patients who have suffered heart failure or MI - lesser effect om airway resistance - less effect on beta-2 receptors - preferred in diabetic patients

Chapter 2: Cardiovascular Flashcards

(214 cards)