Active Recall Notes Cardiovascular System PDF

SELF ASSESSMENT – BNF CHAPTER 2 (CARDIOVASCULAR SYSTEM) CARDIOVASCULAR QUIZ This quiz is designed to test your knowledge Learn the answers word for word. Get a friend to test you. Also do the MCQ questions at the end. POSSIBLE QUESTIONS ON THIS TOPIC 1. What is an arrythmia?...

SELF ASSESSMENT – BNF CHAPTER 2 (CARDIOVASCULAR SYSTEM) CARDIOVASCULAR QUIZ This quiz is designed to test your knowledge Learn the answers word for word. Get a friend to test you. Also do the MCQ questions at the end. POSSIBLE QUESTIONS ON THIS TOPIC 1. What is an arrythmia? (Raheem) 2. What are the symptoms of an arrythmia? (Miranda) 3. How is heart rate classified (normal, high and low)? (Shali) 4. What is paroxysmal atrial fibrillation and what is given to treat it? (Gloria) 5. What is new onset atrial fibrillation and what’s used to treat it? (Raheem) 6. What is pill in pocket? (Miranda) 7. What are the main causes of an arrythmia? (Shali) 8. What are the different types of arrythmias? (Gloria) 9. What are the 4 main treatment options for arrythmias? (Raheem) 10. What are the 2 main treatment aims of managing AF? (Miranda) POSSIBLE QUESTIONS ON THIS TOPIC 11. What is assessed in all patients with AF? (Shali) 12. What is given in life threatening new onset atrial fibrillation? (Gloria) 13. What is given in non life threatening new onset atrial fibrillation? (Raheem) 14. What parenteral anticoagulants are given to patients with new onset AF while they are staying in hospital? (Miranda) 15. What oral anticoagulants are given to patients with new onset AF? (Shali) 16. What is given to patients if DOACS are contraindicated? (Gloria) 17. What drugs are given to treat supraventricular arrythmiasa? (Raheem) 18. What drugs are given to treat ventricular arrythmias? (Miranda) 19. What drugs are given to treat supraventricular and ventricular arrythmias? (Shali) 20. What is the Vaugh Williams classification system and what is in each class? (Gloria) POSSIBLE QUESTIONS ON THIS TOPIC 21. What type of control is preferred 1st line to manage AF? (Raheem) 22. Which patients are rate control not preferred in managing AF? (Miranda) 23. What drugs are used for rate control? (Shali) 24. What if monotherapy for rate control fails, what’s the next step? (Gloria) 25. What drugs are used for rhythm control? (Raheem) 26. When is electric cardioversion preferred and what precautions need to be made to prevent a stroke from happening? (Miranda) 27. How do assess stroke risk and the risk of bleeding? (Shali) 28. What does each part of the CHAD2SVAS2C for and what score requires anticoagulant therapy? (Gloria) 29. What anticoagulants are preferred 1st line patients with a CHAD2SVAS2C of > 2? (Raheem) 30. What is given as an alternative if the 1st line option is C/I or not tolerated? (Miranda) POSSIBLE QUESTIONS ON THIS TOPIC 31. What constitutes “vascular disease” in CHAD2SVAS2C? (Shali) 32. What is the ORBIT score, what does each part stand for and how is the score interpreted? (Gloria) 33. What is the HASBLED tool, what does each part stand for and how is the score interpreted? (Raheem) 34. What is torsade de pointes? (Miranda) 35. What are the main causes of torsade de pointes and what is used to treat it? (Shali) 36. What drugs prolong the QT interval? (Gloria) 37. What is amiodarone indicated for and what is the usual dose? (Raheem) 38. How does amiodarone work? (Miranda) 39. What are the main C/I for amiodarone? (Shali) 40. What are the monitoring requirements of amiodarone? (Gloria) POSSIBLE QUESTIONS ON THIS TOPIC 41. Is amiodarone safe in P+BF? (Raheem) 42. What are the warning signs/ side effects of amiodarone? (Miranda) 43. What patient advice would you give to someone taking amiodarone? (Shali) 44. What are the main drug interactions of amiodarone? (Gloria) 45. What is digoxin used for and what is the usual dose? (Raheem) 46. Is digoxin safe in P+BF? (Miranda) 47. How does digoxin work and what's the therapeutic range? (Shali) 48. What needs to be monitored when taking digoxin? (Gloria) 49. What are the warning sings/ side effects of taking digoxin? (Raheem) 50. What patient advice would you give someone taking digoxin? (Miranda) POSSIBLE QUESTIONS ON THIS TOPIC 51. What are the main drug interactions when taking digoxin? (Gloria) 52. What should be given to prevent digoxin toxicity? (Raheem) 53. What are the 2 main types of VTE? (Miranda) 54. Rank these 3 classes of drugs in terms of their bleeding risk, lowest to highest (anti platelets, anticoagulants and thrombolytics)? (Shali) 55. Which hospital patients need to have a VTE and bleeding risk assessment when admitted? (Gloria) 56. Which patients are at high risk of VTE? (Raheem) 57. What mechanical and pharmacological measures do we use for DVT and PE prevention? (Miranda) 58. When should pharmacological prevention be initiated when people are admitted? (Shali) 59. What drugs are given 1st line in VTE prophylaxis for all forms of general surgery? (Gloria) 60. What’s given if the 1st line option isn’t safe or unsuitable for VTE prophylaxis? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 61. Give examples of heparins? (Miranda) 62. What electrolyte imbalances can occur when taking heparins? (Shali) 63. What is fondaparinux sodium used for? (Gloria) 64. How long should VTE prophylaxis be continued for after surgical before you can stop it? (Raheem) 65. What type of surgery can LMWH be used for VTE prophylaxis in? (Miranda) 66. What 2 conditions are unfractionated heparins preferred over LMWH for VTE prophylaxis? (Shali) 67. What is used for confirmed cases of DVT or PE? (Gloria) 68. What anticoagulants are given in pregnancy and why? (Raheem) 69. What dose adjustments are needed if a pregnant patient needs heparins and why? (Miranda) 70. How long should confirmed cases of DVT or PE be treated for in patients who are healthy and those with active cancers? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 71. How long should unprovoked cases of DVT or PE be treated for in patients who are healthy and those with active cancers? (Gloira) 72. How long should provoked cases of DVT or PE be treated for in patients who are healthy and those with active cancers? (Raheem) 73. What DOAC can patients switch to if they’re currently using anticoagulants to treat DVT’s or PE’s and what can patients be given as a alternative if they decline using a DOAC? (Miranda) 74. What’s the most common side effect of heparins and what’s given to treat reverse it? (Shali) 75. What are the 3 main types of stroke and what's the difference between each one? (Gloria) 76. What are the main symptoms of having a stroke? (Raheem) 77. As a general rule of thumb, if someone's having a stroke, what’s the 1st thing you do? (Miranda) 78. Why don’t you given aspirin asap when someone is having a stroke? (Shali) 79. What is used in the initial management of a TIA and an ischemic stroke and what’s the time frame? (Gloria) POSSIBLE QUESTIONS ON THIS TOPIC 81.When are anticoagulants indicated in stroke patients? (Shali) 82.When are anticoagulants used in the long term management of strokes? (Miranda) 83.What is used in the initial and long term management of a haemorrhagic stroke? (Gloria) 84.When is warfarin given as an alternative oral anticoagulant to DOAC’s? (Raheem) 85.What are the 4 strengths that warfarin comes in and what color are the boxes they come in? (Miranda) 86.What are the 2 main MHRA/CMH warnings with warfarin? (Shali) 87.What is given as an antidote to warfarin? (Gloria) 88.What foods need to be watched out for when taking warfarin? (Raheem) 89.Is warfarin safe in pregnancy and breast feeding? (Miranda) POSSIBLE QUESTIONS ON THIS TOPIC 91. What are the initial and maintenance doses of warfarin and when should doses be given? (Gloria) 92. What do you do with the warfarin if the INR is high or the patient is bleeding? (look at the table) (Raheem) 93. What are the main DDI’s to watch out for when taking warfarin? (Miranda) 94. Which has a higher risk of bleeding, Warfarin & aspirin or warfarin and clopidogrel? (Shali) 95. What are the differences between LMWH and unfractionated heparins? (Gloria) 96. Is aspirin used for primary prevention or secondary prevention of CV events or can it be used for both? (Raheem) 97. Give examples of antiplatelet drugs and how they work? (Miranda) 98. What is given in combination with aspirin if there is a risk of bleeding? (Shali) 99. What is the dispensing and prescribing information regarding MR dipyramidole? (Gloria) POSSIBLE QUESTIONS ON THIS TOPIC 101.Which DOAC is the only used for ACS? (Miranda) 102.What are the 4 most important parameters when dealing with DOACs? (Shali) 103.Which DOACS are given once daily and which are given twice daily? (Gloria) 104.What are the doses of rivaroxaban and apixaban for the VTE prevention and stroke? (Raheem) 105.What needs to be monitored when taking DOAC’s and why? (Miranda) 106.What are the main contraindications of DOAC’s? (Shali) 107.Which has more bleeding, DOAC’s or warfarin? (Gloria) 108.Which DOAC’s work by inhibiting factor XA and thrombin? (Raheem) 109.Which DOAC’s have an antidote, which don’t and what is the antidote for each DOAC? (Miranda) 110.What are the main indications of DOAC’s? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 111.What is monitored when taking DOAC’s? (Gloria) 112.What is MHRA/ CMH/ dispensing label for rivaroxaban doses of 15mg and above? (Raheem) 113.When do you reduce the dose of apixaban to 5mg twice daily to 2.5mg twice daily? (Miranda) 114.When should the dose of DOAC’s be reduced generally speaking? (Shali) 115.What are the main labels found on each of the DOAC’s? (Gloria) 116.What is tranexamic acid used for and how does tranexamic acid work? (Raheem) 117.What needs to be monitored when taking tranexamic acid? (Miranda) 118.What are the main side effects of tranexamic acid? (Shali) 119.How should tranexamic acid be taken? (Gloria) 120.What increases the risk of a DVT when taking tranexamic acid? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 121.What are the main contraindications of tranexamic acid? What is tranexamic acid used for? (Miranda) 122.What’s the max dose of tranexamic acid? (Shali) 123.Is tranexamic acid safe in P+BF? (Gloria) 124.When must a patient be referred if they’re on tranexamic acid? (Raheem) 125.In simple terms, what is cardiovascular risk assessment and prevention all about? (Miranda) 126.What are the non modifiable risk factors of getting CVD? (Shali) 127.What are the modifiable risk factors of getting CVD? (Gloria) 128.What are the aims of treatment for CVD? (Raheem) 129.What are the main risk assessment tools used to assess the risk of cardiovascular events in the UK and how long do they assess the risk for? (Miranda) 130.Which risk assessment tool is the only one that assess life time risk as well as 10 year risk? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 131.What score should patients be started on drugs for primary prevention? (Gloria) 132.What is the difference between QRISK2 and QRISK3? (Raheem) 133.Which patients are risk calculators not used in? (Miranda) 134.Which drugs are used in primary prevention and secondary prevention? (Shali) 135.Which statin is preferred in primary prevention of CVD and why? (Gloria) 136.What causes hyperlipidemia? (Raheem) 137.What patients are at risk of developing hyperlipidaemia? (Miranda) 138.Which patients should be started on statins regardless of their cholesterol levels? (Shali) 139.What counts are established cardiovascular disease? (Gloria) 140.Which statins are high intensity statins and what dose do they start being high intensity? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 141.What are the lipid ranges for normal patients and high risk patients? (table) (Miranda) 142.Which type of lipids do statins lower? (Shali) 143.Which drugs are not routinely recommended for primary and secondary prevention of cardiovascular events? (Gloria) 144.What drugs are given for hypercholesterolemia and what is the treatment steps? (Raheem) 145.What is given as an add on to statin/given as an alternative to statin if it’s not tolerated? (Miranda) 146.When is fenofibrate and nicotinic acid used for lowering lipid levels? (Shali) 147.How do statins work? (Gloria) 148.Which lipid lowering drugs are more effective at lowering triglycerides and which are more effective at loweing LDL? (Raheem) 149.When are statins considered in younger patients? (Miranda) 150.Are statins safe for pregnancy and breast feeding? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 151.How long should adequate be used for when taking a statin? (Gloria) 152.How long should a statin be stopped for before trying to conceive? (Raheem) 153.What is the patient and career advice for all statins? (Miranda) 154.When are statins indicated in patients? (Shali) 155.When are dose adjustments considered when taking a statin? (Gloria) 156.What are the main side effects of statins? (Raheem) 157.Which statins can be taken any time of the day? (Miranda) 158.What doses of atorvastatin are used in primary prevention and secondary prevention? (Shali) 159.Which statin (name and strength) has an MHRA warning and what is the MHRA warning? (Gloria) 160.What is the main MHRA warning/dose adjustment that needs to be made when taking simvastatin with amlodipine? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 161.What are the main dose adjustments that need to be made when taking the high intensity statins with other common drugs? (Miranda) 162.What do we monitor before and after starting a statin and how often do we monitor them? (Shali) 163.What are the main interactions to watch out for when taking statins? (Gloria) 164.What is heart failure? (Raheem) 165.How is heart failure classified? (Miranda) 166.What are the main symptoms of heart failure? (Shali) 167.What are the 2 main types of heart failure and what is the difference between the 2? (Gloria) 168.Which patients are more at risk of heart failure? (Raheem) 169.What are the main causes of heart failure? (Miranda) 170.How is heart failure diagnosed? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 171.What are the main aims of treatment for heart failure? (Gloria) 172.What drugs are used to treat heart failure? (Raheem) 173.What's the treatment pathways for heart failure? (Miranda) 174.Which vaccines need to be given annually in patients with heart failure? (Shali) 175.Which drugs are given for which complications in patients with heart failure? (slide 235) (Gloria) 176.Which antidiabetic drugs are used in the management of heart failure and what is the rationale behind it? (Raheem) 177.Which aldosterone antagonists are used for heart failure and what’s the main contraindications? (Miranda) 178.What are the 3 main types of ACS and what's the difference between each? (Shali) 179.Whats the difference between angina and a heart attack (MI)? (Gloria) 180.What causes ACS? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 181.Rank the 3 types of ACS from most severe to least severe? (Miranda) 182.What are the symptoms of angina? (Shali) 183.What's the difference between stable and unstable angina? (Gloria) 184.What’s used in the initial management and secondary prevention of MI and unstable angina? (Raheem) 185.What’s used in the management of stable angina, both short and long term management? (Miranda) 186.What are nitrates and how do they work? (Shali) 187.What are the 3 most common types of sublingual GTN? (Gloria) 188.What's the most common side effect of nitrates? (Raheem) 189.When should long term prophylaxis considered if someone is already taking GTN? (Miranda) 190.What is the rule 3 when dealing with treatment of angina?(Shali) POSSIBLE QUESTIONS ON THIS TOPIC 191.What is the difference between the dinitrate MR preparations and the mononitrate MR preparations? (Gloria) 192.What's the main caution with nitrates and how do you prevent it? (Raheem) 193.What strengths do the GTN sublingual sprays come in and what's the dispensing and storage requirements? (Miranda) 194.How do you take GTN when you have an angina attack? (Shali) 195.What are the 3 common ways of measuring hypertension? (Gloria) 196.What are the main risk factors of hypertension? (Raheem) 197.What does establish cardiovascular disease mean? (Miranda) 198.What are your target organs? (Shali) 199.What are the different stages of hypertension? (Gloria) 200.What is accelerated hypertension? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 200. How is hypertension diagnosed? (Miranda) 201. If there’s no target organ damage and no hypertension at all, how often should patients have their blood pressure monitored? (Shali) 202. Which hypertensive stages do we start blood pressure meds regardless of whether they have target organ damage? (Gloria) 203. Under what conditions do we start patients on blood pressure meds if they have stage 1 hypertension? (Raheem) 204. What are the main signs that someone is having accelerated hypertension? (Miranda) 205. What needs to be investigated asap if someone has severe hypertension but no obvious symptoms? (Shali) 206. What drug classes are used in treating hypertension? (Gloria) 207. Draw a simplified diagram explaining the treatment steps for hypertension? (Raheem) 208. Which drug classes are given to diabetics regardless of age and race? (Miranda) 209. Give a treatment overview of treatment of hypertension in patients with type 1 diabetes? (Shali) POSSIBLE QUESTIONS ON THIS TOPIC 211.Give examples of ACE inhibitors and ARB’s? (Gloria) 212.How do ACE and ARB’s work? (Raheem) 213.Are ACE & ARB’s safe in pregnancy? (Miranda) 214.What are the main side effects/ warning signs ACE inhibitors and ARB’s? (Shali) 215.What are the main contraindications of ACE inhibitors and ARB’s (Gloria) 216.What are the main drug interactions to watch out for with ACE and ARBs? (Raheem) 217.What are the main monitoring requirements of ACE and ARB;s? (Miranda) 218.Give examples of calcium channel blockers? (Shali) 219.Are calcium channel blockers safe in pregnancy? (Gloria) 220.What are the 3 main types of calcium channel blockers? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 221.How do calcium channel blockers work? (Miranda) 222.What are the main contraindications of calcium channel blockers? (Shali) 223.What are the main side effects of calcium channel blockers? (Raheem) 224.What are the main drug interactions for calcium channel blockers? (Miranda) 225.Give examples of thiazide diuretics? (Shali) 226.How do thiazide diuretics work? (Gloria) 227.Are thiazide diuretics safe in pregnancy and breast feeding? (Raheem) 228.What are the main side effects of thiazide diuretics? (Miranda) 229.What are the main contraindications of thiazide diuretics? (Shali) 230.What are the main monitoring requirements for thiazide diuretics? POSSIBLE QUESTIONS ON THIS TOPIC 231.What are the main drug interactions for thiazide diuretics? (Raheem) 232.How does spironolactone work? (Shali) 233.Is spironolactone safe in pregnancy and breast feeding? (Miranda) 234.What are the main side effects of spironolactone? (Gloria) 235.What are the main contraindications for spironolactone? (Raheem) 236.When is it given to treat hypertension and what potassium level needs to be observed before starting it? (Miranda) 237.What are the main drug interactions for spironolactone? (Shali) 238.Give examples of alpha blockers? (Gloria) 239.How do alpha blockers work? (Raheem) 240.Are they safe in pregnancy and breast feeding? (Miranda) POSSIBLE QUESTIONS ON THIS TOPIC 241.What are the main side effects of alpha blockers? (Shali) 242.What are the main contraindications of alpha blockers? (Gloria) 243.What potassium levels must a person have for them to be suitable to start on an alpha blockers for hypertension? (Raheem) 244.Give examples of beta blockers? (Miranda) 245.How do beta blockers work? (Shali) 246.What are the main side effects of beta blockers? (Gloria) 247.What are the main contraindications of beta blockers? (Raheem) 248.What potassium levels must a person have for them to be suitable to start on a beta blocker for hypertension? (Miranda) 249.Are beta blockers safe in pregnancy and breast feeding? (Shali) 250.What are the main drug interactions for beta blockers? (Gloria) POSSIBLE QUESTIONS ON THIS TOPIC 251.What are the other uses of beta blockers? (Raheem) 252.Can beta blockers be used in asthma and COPD? (Miranda) 253.Which type of beta receptors are found in the lungs and which are found in the heart tissue? (Shali) 254.Which beta blockers cause less cold extremities and bradycardia? (Gloria) 255.Which beta blockers are water soluble? (Raheem) 256.Which beta blockers are cardio selective? (Miranda) 257.Which beta blockers have a long duration of action? (Shali) 258.Which drugs are used to treat hypertension in pregnancy? (Gloria) 259.Give examples of loop diuretics and what are their main uses? (Raheem) POSSIBLE QUESTIONS ON THIS TOPIC 261.What are the main contraindications of loop diuretics? (Miranda) 262.What are the main side effects of loop diuretics? (Gloria) 263.What 2 conditions can loop diuretics exacerbate? (Raheem) 264.What are the main drug interactions with loop diuretics? (Miranda) 265.When do dose adjustments need to be made when taking loop diuretics? (Shali) 266.Give examples of potassium sparing diuretics? (Gloria) 267.What are the hypertension targets? (Raheem) ANSWERS Q1: What is an arrhythmia? A1: What is an arrhythmia? Abnormal rate or/& rhythm of the heart Memory trick: ARRythmia Abnormal Rate Rhythm Q2: What are the symptoms of an arrhythmia? A2: What are the symptoms of an arrhythmia? SOB Abnormally fast, slow or irregular pulse Dizziness/ feeling faint Palpitations REMEMBER: SAD palpitations Q3: How is heart rate classified (normal, high and low)? A3: How is heart rate classified (normal, high and low)? BRADycardia 100bpm Q4: What is paroxysmal atrial fibrillation and what is given to treat it? A4: What is paroxysmal atrial fibrillation and what is given to treat it? Paroxysmal AF — episodes lasting longer than 30 seconds but less than 7 days (often less than 48 hours) that are self-terminating and recurrent Treatment (rhythm control) u Adenosine u Or IV verapamil (avoid if on BB) u Beta blockers (including sotalol) u Flecanide u Cardioversion Q5: What is new onset atrial fibrillation and what’s used to treat it? A5: What is new onset atrial fibrillation and what’s used to treat it? Definition: first time having persistent or paroxysmal AF. Treatment: Cardioversion to control rhythm 1st line using either electric therapy or drugs Electricity u flecainide (avoid in ischaemic or structural heart disease) Give Amiodarone (if patient has heart problems) Q6: What is pill in pocket? A6: What is pill in pocket? Pt takes a single oral dose of an antiarrhythmic drug at the time of the onset of palpitations Q7: What are the main causes of an arrythmia?  Heart conditions: CHD- angina, MI A7: What are Heart valve disease the main HYPERtension causes of an Ageing arrythmia? Cardiomyopathy (disorder of heart muscle) Congenital (from birth) abnormalities in the electrical pathway Q8:.What are the different types of arrhythmias? A8:.What are the different types of arrhythmias? (Gloria) Ectopic beats AF Paroxysmal AF Atrial flutter Paroxysmal supraventricular tachycardia. Ventricular Supraventricular In the exam, focus on AF. Q9: What are the 4 main treatment options for arrhythmias?  Surgery: remove any congenital abnormalities in the conductive tissue such as in the case of wolff parkinson white syndrome A9: What are the 4 main Drugs treatment options for Pacemakers/implantable arrhythmias? defibrillators Cardioversion Q10: What are the 2 main treatment aims of managing AF? A10: What are the 2 main treatment aims of managing AF? reduce symptoms prevent complications e.g. stroke and PE/ DVT Q11: What is assessed in all patients with AF? A11: What is assessed in all patients with AF? Risk of conditions forming from blood clots: 1) Stroke 2) Thromboembolism: PE/DVT Balance both with the risk of bleeding Q12: What is given in life threatening new onset atrial fibrillation? A12: What is given in life threatening new onset atrial fibrillation? Rhythm control (electrical cardioversion) Q13: What is given in non life threatening new onset atrial fibrillation?  A13: What is given in non life threatening new onset atrial fibrillation? offer either rate or rhythm control if the onset of the arrhythmia is less than 48 hours offer rate control if onset is more than 48 hours or is uncertain Q14: What parenteral anticoagulants are given to patients with new onset AF while they are staying in hospital? A14: What parenteral anticoagulants are given to patients with new onset AF while they are staying in hospital? Heparin Q15: What oral anticoagulants are given to patients with new onset AF? A15: What oral anticoagulants are given to patients with new onset AF DOACS (READ) Rivaroxaban Edoxaban Apixaban Dabigatran Q16: What is given to patients if DOACS are contraindicated? A16: What is given to patients if DOACS are contraindicated? Warfarin Q17: What drugs are given to treat supraventricula r arrhythmias? A17: What drugs are given to treat supraventricular arrhythmias? Verapamil Adenosine antiarrhythmic agent Digoxin ** Memory trick: Supraventricular arrhythmias = VadD Q18: What drugs are given to treat ventricular arrhythmias? A18: What drugs are given to treat ventricular arrhythmias? Cardioversion (direct current) if haem unstable Amiodarone Lidocaine CAP LB Propafenone Beta blockers including Sotalol Q19: What drugs are given to treat supraventricular and ventricular arrythmias? A19: What drugs are given to treat supraventricular and ventricular arrythmias? Amiodarone (oral or IV) Beta blockers Flecainide Propafenone ABFP Q20: What is the Vaugh Williams classification system and what is in each class? A20: What is the Vaughan Williams classification system and what is in each class? Arrhythmic drugs that are classified according to its effect on electrical behaviour of myocardial cells during activity. Class 1: lidocaine and flecainide (Na channel blockers) Class 11: Beta blcokers Class 111: amiodarone and sotalol (11) (potassium channel blockers) Class 1V: CCB (verapamil and diltiazem) but not dihydropyridines Q21: What type of control is preferred 1st line to manage AF? ( A21: What type of control is preferred 1st line to manage AF? Rate control drugs are always prefered 1st line ideally. There are some cases where rhythm control is preferred 1st line It all depends on the type of arrhythmia and what other conditions patients have. Q22: Which patients are rate control NOT preferred in managing AF?  A22: Which patients are rate control NOT preferred in managing AF? (Miranda) Rhythm control prefered first line in: New onset AF Atrial flutter AF with reversible cause e.g. MI, HYPERthyroidism, excess caffeine and alcohol HF primarily caused by AF Rhythm control more suitable Q23: What drugs are used for rate control? A23: What drugs are used for rate control? Monotherapy: Beta blockers [not sotalol] OR Rate limiting CCB (Diltiazem [unlicensed] or Verapamil) OR Digoxin (in pts with non-paroxysmal AF, sedentary lifestyle, other treatment unsuitable) Digoxin also used when AF is accompanied by congestive heart failure CHF MT: DIVED BETA (DIltiazem, VErapamil, Digoxin, BETA blockers) Dual therapy if above fail; Digoxin or diltazem with a beta blocker MT: DD BB Q24: What if monotherapy for rate control fails, what’s the next step? A24: What if monotherapy for rate control fails, what’s the next step? Combination therapy with any of the 2; Beta blocker Digoxin Diltiazem If above fails use cardioversion. Q25: What drugs are used for rhythm control? A25: What drugs are used for rhythm control? Beta blockers (always given 1st line) Flecainide (always avoid in heart disease) Amiodarone Propafenone Dronedarone Sotalol (although it's a beta blocker, use last line) Memory trick: Rhythm = FABPDS Q26: When is electric cardioversion preferred and what precautions need to be made to prevent a stroke from happening? A26: When is If AF >48 hrs = electrical electric cardioversion is preferred over cardioversion pharmacological cardioversion preferred and But need to delay until pt is fully what anticoagulated for at least 3 weeks bc there is a risk of stroke with electrical precautions cardioversion need to be If delay not possible = give heparin made to immediately BEFORE cardioversion prevent a Oral anticoagulation given AFTER stroke from cardioversion and continued for happening? AT LEAST 4 weeks Q27: How do assess stroke risk and the risk of bleeding? A27: How do assess stroke risk and the risk of bleeding? STROKE RISK BLEEDING RISK CHA2DS2 VASC tool ORBIT Others: Atria, qstroke (higher accuracy than hasbled & atria) Q28: What does each part of the CHAD2SVAS2C for and what score requires anticoagulant therapy? A28: What does each part of the CHA2-DS2-VASC for and what score requires anticoagulant therapy? Offer anticoagulants in pt with score of 2 or more. Q29: What anticoagulants are preferred 1st line in patients with a CHAD2SVAS2C of > 2? A29: What anticoagulants are preferred 1st line patients with a CHAD2SVAS2C of > 2? Women with a CHAD2SVAS2C score of 2 or more, and men with a score of 1 or more, need anticoagulants DOACS are preferred 1st line This includes: Rivaroxaban Edoxaban Apixaban Dabigatran Memory trick: Female ≥ 2 or Male ≥ 1 = READ Q30: What is given as an alternative if the 1st line option is contraindicated or not tolerated? A30: What is given as an alternative if the 1st line option is contraindicated or not tolerated? Warfarin Q31: What constitutes “vascular disease” in CHAD2SVAS2C?  Previous MI A31: What constitutes “vascular disease” in Peripheral arterial CHAD2SVAS2C? disease Aortic plaque Q32: What is the ORBIT score, what does each part stand for and how is the score interpreted? A32: What is the ORBIT score, what does each part stand for and how is the score interpreted? Low risk 0-2 medium risk 3 High risk 4-7MT; 3 makes u bleed Older than 74 yrs 1 Reduced hemoglobin (history of anemia) 2 Bleeding history(GI and intracranial bleeding 2 or heamorogic stroke Inadequate renal function (eGFR 3 then you should avoid anticoagulants. Q34: What is torsade de pointes? A34: What is torsade de pointes? Dangerous type of arrhythmia associated with QT prolongation can lead to deaths Q35: What are the main causes of torsade de pointes and what is used to treat it? A35: What are the main causes of torsade de pointes and what is used to treat it? CAUSES: Stress, strenuous exercise, sudden noise e.g alarm, drug e.g sotalol, HYPOkalaemia, BRADYcardia TREATMENT: IV infusion Magnesium Sulfate (1st line) Better blockers (not Sotalol) Q36: What drugs prolong the QT interval? A36: What drugs prolong the QT interval? A-AntiArrhythmics [Amiodarone, Sotalol, Flecainide] B-AntiBiotics [quinolones, macrolides, aminoglycosides] C-AntipsyChotics [Haloperidol, quetiapine, risperidone] D-AntiDepressants [ SSRIs, TCAs] D-Diuretics (increase risk) E- AntiEmetics [Ondansetron] Q37: What is amiodarone indicated for and what is the usual dose? A37: What is amiodarone indicated for and what is the usual dose? (Raheem) Uses: AF Ventricular arrhythmias Dose: 200mg TDS for 1 week, 200mg BD for 1 week, 200mg once daily forever Memory trick: dose = 200mg 3,2,1 (1 week) Q38: How does amiodarone work? A38: How does amiodarone work? CLASS 3 BLOCKS POTASSIUM ANTIARRHYTHMIC CHANNELS DRUG Q39: What are the main C/I for amiodarone?  Thyroid A39: What are the main C/I dysfunction for amiodarone? Iodine sensitivity Q40: What are the monitoring requirements of amiodarone?  Thyroid function test (before rx & every 6 months A40: What are Liver function test b/4 rx & every 6 months ) the monitoring Serum potassium( hypokalemia) requirements of Chest x-ray amiodarone? Annual eye tests ECG (IV use) B/P Q41: Is amiodarone safe in P+BF?  Generally no because A41: Is there’s a risk of damaging the child's thyroid gland amiodarone (neonatal goitre) safe in P+BF? (Raheem) BUT can be used if there’s no alternative. Q42: What are the warning signs/ side effects of amiodarone? A42: What are the warning signs/ side effects of amiodarone? Photosensitivity Bradycardia Interstitial lung disease Thyroid → hypo/ hyper Corneal microdeposits - dazzling headlights. Hepatic Clay coloured stools REMEMBER → Ami is a Photogenic BITCH Q43: What patient advice would you give to someone taking amiodarone?  Stop amiodarone immediately if any warning signs. A43: What patient Shield skin from sunlight during and advice would several months after treatment you give to someone Use a wide spectrum sunscreen- min taking spf 30 amiodarone? Shortness of breath Light headnesses Seek medical Palpitation attention if following Fainting symptoms develop: Unusual tiredness Chest pain Q44: what are the main drug interactions with amiodarone? A44: what are the main drug interactions with amiodarone? Due to long half life, DDI’s can occur months after stopping it. Arrhythmias when taken with anything that can prolong QT such as antipsychotics, antidepressants (SSRI and TCA), antibiotics (Macrolides and quinolones), lithium, methadone, hydroxyzine, fluconazole, voriconazole, (see which drugs affect QT) Myopathy with simvastatin AV block, heart depression and bradycardia when taken with CCB’s and BB’s Amiodarone increases plasma conc when taken with warfarin, digoxin, dabigatran, flecainide, phenytoin. When taking digoxin and amiodarone together, take half the usual dose of digoxin. Q45: What is digoxin used for and what is the usual dose? A45: What is Uses AF Heart failure digoxin used for and what is AF: 125mcg- 250mcg Doses Heart failure: the usual 62.5mcg- 125mcg dose? (Raheem) Memory trick: dose for HF is ½ of AF Q46: Is digoxin safe in pregnacy and breastfeeding? A46: Is digoxin Pregnancy → dose needs to be safe in adjusted pregnancy and Breast feeding → amount too small to be harmful breastfeeding? Q47: How does digoxin work and what's the therapeutic range?  Increases force of myocardial contraction and decreases heart A47: How rate by reducing conductivity in atrioventricular node does digoxin work and Therapeutic range: 1-2mcg/L what's the therapeutic range? Toxicity range: 1.5-3mcg/L Q48: What needs to be monitored when taking digoxin?  Plasma-digoxin conc taken at least 6hrs after dose. A48:What needs to be monitored Monitor serum electrolyte (toxicity increased with imbalance of when taking potassium and magnesium) digoxin? Renal function (dose reduction). Q49: What are the warning signs/ side effects of taking digoxin? A49: What are the warning N&V BLURRED/YELLOW VISION DIARRHEA signs/ side effects of taking digoxin? HEART BLOCKS DIZZINESS HALLUCINATIONS AND ARRHYTHMIAS Q50: what patient advice would you give someone taking digoxin? A50: what patient advice would you give someone taking digoxin? Look out for digitalis toxicity signs Patient counselling is advised for digoxin elixir (use pipette).. Q51: What are the main drug interactions when taking digoxin? A51: What are the main drug interactions when taking digoxin? Take half the max dose of digoxin if you’re also taking: amiodarone, dronedarone and quinine. NSAIDS, ACE & ARB: reduces renal excretion Enzyme inducers: St john’s wort and rifampicin (reduces digoxin conc) Macrolides amiodarone ( ½ digoxin dose) rate limiting CCB e.g verapamil (reduces digoxin conc) Drug which reduces potassium conc( thiazide and loop diuretic, theophylline steroid) MT: CRASED; CCB(verapamil), rifampicin, amiodarone, st john’s wort, erythromycin, diuretics, Q52: What should be given to prevent digoxin toxicity? A52: What should be given to prevent digoxin toxicity? Potassium sparing diuretics such as amiloride, spironolactone and triamterene. This prevents the hypokalemia that predisposes someone to digoxin toxicity. If digoxin toxicity occurs, give digoxin specific antibodies Q53: What are the 2 main types of VTE? A53: What are the 2 main types of VTE? DVT → clot in body (legs) PE → blockage of artery in lungs Q54: Rank these 3 classes of drugs in terms of their bleeding risk, lowest to highest (anti platelets, anticoagulants and thrombolytics)?  A54: Rank these 3 classes of drugs in terms of their bleeding risk, lowest to highest (anti platelets, anticoagulants and thrombolytics)? Antiplatelets (guns) -> anticoagulants (Bazooka) -> thrombolytics (Bombs) Aspirin/clopidogrel -> warfarin/rivaroxaban -> alteplase Q55: Which hospital patients need to have a VTE and bleeding risk assessment when admitted? A55: Which hospital patients need to have a VTE and bleeding risk assessment when admitted? All patient admitted to the hospital for Medical Surgery or Pregnancy Q56: Which patients are at high risk of VTE? A56: Which patients are at high risk of VTE? (Raheem) Pregnant women Elderly (60+) People who are immobile for long Cancerous patients Overweight patients Patients on HRT, contraceptives and tranexamic acid Dehydration History of DVT Q57: What mechanical and pharmacological measures do we use for DVT and PE prevention? A57: What mechanical and pharmacological measures do we use for DVT and PE prevention? Mechanical Anti-embolism stockings - wear stockings day and night until pt is mobile Do NOT offer stockings to pts with acute stroke, peripheral arterial disease, peripheral neuropathy, severe leg oedema, local conditions e.g. gangrene or dermatitis Pharmacological LMWH 1st line → for ALL types of general & orthopaedic surgery Unfractionated heparin preferred for pts with renal impairment or increased risk of bleeding Fondaparinux DOACs preferred to warfarin Q58: When should pharmacological prevention be initiated when people are admitted?  When: A58: When should pharmacological prevention be initiated when Risk of VTE > risk of people are bleeding admitted? Start as soon as possible or within 14 hours of admission Q59: What drugs are given 1st line in VTE prophylaxis for all forms of general surgery? A59: What drugs are given 1st line in VTE prophylaxis for all forms of general surgery? LMWH Unfractionated preferred in renal impairment or increased risk of bleeding. Q60: What’s given if the 1st line option isn’t safe or unsuitable for VTE prophylaxis? A60: What’s given if the 1st line Unfractionated option isn’t heparins safe or unsuitable for VTE Warfarin prophylaxis? Q61: Give examples of heparins?  Unfractionated heparin A61: Give LMWH → enoxaparin, dalteparin, examples of nadroparin, tinzaparin, heparins? certoparin MT: all end in parin Q62: What electrolyte imbalances can occur when taking heparins? A62: What electrolyte imbalances can occur when taking heparins? HYPERkalaemia (rare) Q63: What is fondaparinux sodium used for? A63: What is fondaparinux sodium used for? Hip and knee replacement surgery. Hip fracture surgery. GI bariatric or Day surgery procedures. Q64: How long should VTE prophylaxis be continued for after general surgery before you can stop it? A64: How long should VTE At least 7 days after prophylaxis be the operation continued for after general surgery before Or at least until they you can stop can move it? Q65: What type of surgery can LMWH be used for VTE propyhlaxis in? A65: What type of surgery can LMWH be used for VTE propyhlaxis in? All types of general and orthopaedic surgery Q66: What 2 conditions are unfractionated heparins preferred over LMWH for VTE prophylaxis? A66: What 2 conditions are unfractionat Renal impairment ed heparins preferred over LMWH for VTE Increased bleeding prophylaxis in risk surgery? Q67: What is used for confirmed cases of DVT or PE? (Gloria) A67: What is used for confirmed cases of DVT or PE? Rivaroxaban Apixaban MT: R.AP.E Alternatively LMWH at least 5 days followed by dabigatran or edoxaban MT: LED Q68: What anticoagulants are given in pregnancy and why? A68: What anticoagulants are given in pregnancy and why? Heparins can be given in pregnancy. LMWH 1st line They’re safe because they don’t cross the placenta and thus they won’t harm the baby. Q69: What dose adjustments are needed if a pregnant patient needs heparins and why? A69: What dose LMWH preferred to heparins bc adjustments lower risk of osteoporosis and heparin-induced are needed thrombocytopenia if a pregnant patient LMWH are eliminated more rapidly in pregnancy = dose needs alteration needed (need to be heparins and a higher dose) why? Q70: How long should confirmed cases of DVT or PE be treated for in patients who are healthy and those with active cancers?  A70: How long should confirmed cases of DVT or PE be treated for in patients who are healthy and those with active cancers? 3 months at least for healthy patients 3-6 months for active cancer patients Q71: How long should unprovoked cases of DVT or PE be treated for in patients who are healthy and those with active cancers? A71: How long should unprovoked cases of DVT or PE be treated for in patients who are healthy and those with active cancers? Unprovoked >3 months Active cancer >6 months Q72: How long should provoked cases of DVT or PE be treated for in patients who are healthy and those with active cancers?  Provoked means the DVT A72: How long and PE were caused by should something. provoked cases of DVT or PE be treated for in patients who In normal patients, treat are healthy for 3 months. and those with active cancers? For active cancers at least 3-6 months. Q73: What DOAC can patients switch to if they’re currently using anticoagulants to treat DVTs or PEs and what can patients be given as an alternative if they decline using DOAC? A73: What DOAC can patients switch Switch to apixaban if current to if they’re treatment is a DOAC currently using anticoagulants to treat DVTs or PEs and what can patients be given Consider aspirin (unlicensed) as a alternative if for pts who decline continued they decline using anticoagulation treatment DOAC? Q74: What’s the most common side effect of heparins and what’s given to treat reverse it?  A74: What’s the most common side effect of heparins and what’s given to treat reverse it? Haemorrhage Protamine sulfate is the antidote (only partially reverse effects of LMWH) Q75:What are the 3 main types of stroke and what's the difference between each one? A75: What are the 3 main types of stroke and what's the difference between each one? Hemorrhagic stroke ( about 15% of strokes) Ischaemic stroke Transient ischaemic stroke MT: HIT Q76: What are the main symptoms of having a stroke? A76: What Facial falls are the main Arms floppy symptoms of having a Speech slurred stroke? Time to call 999 asap Q77: As a general rule of thumb, if someone is having a stroke, what is the 1st thing you do? A77: As a general rule of thumb, if someone is having a stroke, what is the 1st thing you do? Ring 999 - need to go to hospital ASAP Q78: Why don’t you give aspirin asap when someone is having a stroke? A78: Why don’t you given aspirin asap when someone is having a stroke? Haemorrhagic stroke has to be ruled out first Q79: What is used in the initial management of a TIA and an ischemic stroke and what’s the time frame?  A79:What is used for Transient Ischaemic Attack (T.I.A) and Minor Ischaemic Stroke? (Update to dosing ) Transient Ischaemic Stroke (T.I.A) Aspirin 300mg (1st line) / Clopidogrel (alternative) If presenting within 24hrs & low risk of bleeding (Give Dual therapy) u Clopidogrel + Aspirin (followed by clopidogrel monotherapy)Aspirin 300mg 1dose followed by Aspirin 75mg for 21 days or u Ticagrelor + Aspirin (followed by clopidogrel (unlicensed or Ticagrelor (unlic) monotherapy. Aspirin 300mg for 1 dose followed by aspirin 75mg for 30 days u Patients who can’t have dual therapy give clopidogrel monotherapy (unlicensed) u Proton pump (for patients with dyspepsia on aspirin or patients on dual therapy) Aspirin & clopidogrel T.I.A stroke doses Aspirin/clopidogrel 300mg 1dose followed by Aspirin/clopidogrel 75mg Management of Disabling Acute Ischaemic Stroke u Alteplase or Tenecteplase (unlicensed) within 4.5 hours u Aspirin 300 mg once daily for 14 days, to be started 24 hours after thrombolysis or u As soon as possible within 24 hours of symptom onset in patients not receiving thrombolysis. u After 14 days (2 weeks) transition treatment to long term management Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm. However, anticoagulants may be indicated in patients with ischaemic stroke and symptomatic deep vein thrombosis or pulmonary embolism. Q80: What’s used in the long term management of a TIA and an ischemic stroke? A80: What’s used in the long term management of a TIA and an ischemic stroke? (Raheem) Q81: When are anticoagulants indicated in stroke patients?  Anticoagulants are not recommended as alternative to antiplatelets A81: When are anticoagulants indicated in Parenteral anticoagulant may be used if high risk of stroke patients? DVT or PE Oral anticoagulants are only given in patients who have AF Q82: When are anticoagulants used in the long term management of strokes? A82: When are anticoagulants used in the long term management of strokes Avoid anticoagulants unless pt as AF, thrombosis or DVT Q83: What is used in the initial and long term management of a hemorrhagic stroke? A83: What is used in the initial and long term management of a hemorrhagic stroke? Initial management: surgery Long term management: Treat hypertension Avoid all other drugs Q84: When is warfarin given as an alternative oral anticoagulant to DOAC’s? A84: When is Contraindicated due warfarin given to renal function as an alternative oral anticoagulant Warfarin more to DOAC’s? suitable. Q85: What are the 4 strengths that warfarin comes in and what colour are the boxes they come in? A85: What are the 4 strengths that warfarin comes in and what colour are the boxes they come in? 0.5mg → white 1mg → brown 3mg → blue 5mg → pink Q86: What are the 2 main MHRA/CMH warnings with warfarin? A86: What are the 2 main MHRA/CMH warnings with warfarin? 1) CALCIPHYLAXIS a) Common in renal disease b) Painful rash c) Refer to GP 1) MICONAZOLE (DAKTARIN) ORAL GEL a) Causes bleeding b) Stop and seek medical advice: i) Unexplained bruising ii) Nose bleed iii) Blood in urine Q87: What is given as an antidote to warfarin? A87:What is given as an antidote to warfarin? Vitamin K: phytomenadione Q88: What foods need to be watched out for when taking warfarin? A88: What foods need to be watched out for when taking warfarin? Pomegranate and cranberry juice Alcohol Leafy greens and things rich in vitamin K. Avoid abrupt diet changes. Affects the INR and thus might need to change the warfarin dose. Q89: Is warfarin safe in pregnancy and breastfeeding?  NO - teratogenic → crosses placenta leading to foetal abnormalities A89: Is warfarin safe in Avoid in pregnancy esp in 1st and 3rd trimesters and esp during last few pregnancy and weeks of pregnancy and delivery breastfeeding? Risk of haemorrhage → increased by vitamin K deficiency Q90: What conditions require an INR of 3.5 and 2.5? (Shali) A90: What conditions require an INR of 3.5 and 2.5? 2.5 3.5 DVT/ PE Recurrent DVT/ PE AF Mechanical prosthetic heart valves Cardioversion Dilated cardiomyopathy Mitral stenosis or regurgitation MT: 3.5 for recurrent DVT/PE and artificial heart valves, everything else is 2.5 Myocardial infarction Acute arterial embolism Q91: What are the initial and maintenance doses of warfarin and when should doses be given? A91:What are the initial and maintenance doses of warfarin and when should doses be given? Initially 5-10 mg on day 1, subsequent doses dependent on the prothrombin time, Lower induction can be given over 3-4 weeks in eldrly pt and those who do not require rapid anticoagulation. Maintenance dose 3-9 mg daily to be taken at the same time. Q92: What do you do with the warfarin if the INR is high or the patient is bleeding? (look at the table) A92: What do you do with the warfarin if the INR is high or the patient is bleeding? (look at the table) Q93: What are the main DDIs to watch out for when taking warfarin? A93: What are the main DDIs to watch out for when taking warfarin? Miconazole - increase effect of warfarin St jons wart - decrease effect of warfarin Alcohol - decrease effect of warfarin Amiodarone - increase effect of warfarin Aspirin - increase risk of bleeding Bezafibrate - increase effect of warfarin Carbamazepine - decrease effect of warfarin Doxycycline - increase INR so enhances effects of warfarin REMEMBER - SABACAM St johns, amiodarone, bezafibrate, alcohol, carbamazepine, antiplatelets & anticoagulants and miconazole Q94: Which has a higher risk of bleeding, Warfarin & aspirin or warfarin and clopidogrel? A94: Which has a higher risk of bleeding, Warfarin & aspirin or warfarin and clopidogrel? warfarin and clopidogrel >>> warfarin & aspirin Q95: What are the differences between LMWH and unfractionated heparins? A95: What are the differences between LMWH and unfractionated heparins? LMWH Unfractionated heparin Lower risk of heparin induced Shorter duration of action. thrombocytopenia. Preferred in renally imparied Longer duration of action can be patient. given once daily and Used in pt with bleeding risk, subcutaneously making it more because its effect can be convenient to give. terminated rapidly. Not preferred in renally imapired Not for routine use. patient. Used for routine use Q96: Is aspirin used for primary prevention or secondary prevention of CV events or can it be used for both? A96: Is aspirin used for primary prevention or secondary prevention of CV events or can it be used for both? Secondary prevention only No evidence of benefit in primary prevention. Q97: Give examples of antiplatelet drugs and how they work?  Aspirin, clopidogrel, dipyridamole A97: Give examples of Others - prasugrel, ticagrelor, cangrelor antiplatelet drugs and Glycoprotein IIb/IIIa inhibitors —> how they abciximab (monoclonal antibody), tirofiban, eptifibatide work? MOA → decrease platelet aggregation and inhibit thrombus formation in the arterial circulation Q98: What is given in combination with aspirin if there is a risk of bleeding? A98: What is given in combination with aspirin if there is a risk of bleeding? PPI Aspirin + clopidogrel increases risk of bleeding Q99: What is the dispensing and prescribing information regarding MR dipyridamole? A99: What is the dispensing MR caps should be dispensed in the original container (pack and contains a dessicant) prescribing information regarding MR Discard any remaining caps 6 dipyramidole? weeks after opening. Q100: What type of AF is warfarin and DOAC’s preferred for?  Warfarin - Valvular A100: What AF type of AF is warfarin and DOACS - Non - DOAC’s Valvular AF preferred for? MT: VW - Valvular Warfarin Q101: Which DOAC is only used for ACS? A101: Which DOAC is only used for ACS? Rivaroxaban Q102: What are the 4 most important parameters when dealing with DOACs? A102: What are the 4 most important parameters when dealing with DOACs? Age (>80) Body weight ( 133 and EGFR 15- 20) Q105: What needs to be monitored when taking DOCAs and why?  Routine monitoring is NOT required A105: What needs to be monitored Effects last 12-24 hours (OD- when taking BD) DOCAs and why? Monitor for signs of bleeding or anaemia - STOP if severe bleeding occurs Q106: What are the main contraindications of DOAC’s?  Active bleeding A106: What are the main contraindications Antiphospholipid syndrome of DOAC’s? Immune response releases antibodies- increases risk of blood clots and thus thromboembolism Q107: Which has more bleeding, DOAC’s or warfarin? A107: Which has more bleeding, DOAC’s or warfarin? Warfarin Q108: Which DOAC’s work by inhibiting factor XA and thrombin? A108: Which DOAC’s work by inhibiting factor XA and thrombin? Factor Xa Inhibitors Thrombin inhibitors Apixaban Dabigatran Edoxaban Rivaroxaban Memory trick: Remember Dabigatran is the only DOAC that’s a thrombin inhibitor and everything else is a factor Xa inhibitor Xaban = Xa inhibitor Dabigatran = T from thrombin Q109: Which DOACs have an antidote, which don’t and what is the antidote for EACH DOAC?  Rivaroxaban & apixaban A109: Which antidote → andexanet DOACs alfa (ondexxya) have an antidote, Dabigatran (pradaxa) which don’t antidote → idarucizumab and what is (Praxbind) the antidote for EACH DOAC? Edoxaban → NO antidote Q110: What are the main indications of DOAC’s?  Prophylaxis of stroke and systemic embolism in pts with non-valvular AF A110: What are the Secondary prevention and treatment of DVT and/or PE main indications Prevention of VTE after elective hip or of DOAC’s? knee replacement surgery Rivaroxaban is used for prevention of atherothrombotic events including ACS Q111: What is monitored when taking DOAC’s? A111: What is monitored when taking DOAC’s? Signs of bleeding , if severe stop rx Anaemia Q112: What is MHRA/ CMH/ dispensing label for rivaroxaban doses of 15mg and above? A112: What is MHRA/ CMH/ dispensing label for rivaroxaban doses of 15mg and above? Take with food Q113: When do you reduce dose of apixaban from 5mg twice daily to 2.5mg twice daily? A113: When do you reduce dose of apixaban from 5mg twice daily to 2.5mg twice daily? Switch in pt with at least 2 risk factors: 80 years + Body weight ≤60kg Serum Creatinine >133mcmol/L Clearance 15-20 ml/min Q114: When should the dose of DOAC’s be reduced generally speaking? A114: When should the dose of DOAC’s be reduced generally speaking? Rivaroxaban Crcl Edoxaban Weight, Crcl, drugs Apixaban 2 out of 3: Age, bodyweight, Crcl, Creatine, Dabigatran Age, Crcl, Drug Q115: What are the main labels found on each of the DOAC’s? A115: What are the main labels found on each of the DOAC’s? Rivaroxaban (xarelto) label 21 15 & 20 mg tabs (take with or just after food Edoxaban (lixiana) and apixaban (eliquis) 2.5 & 5 mg Label 10: Read the additional info given with this medicine. Dabigatran (Pradaxa ) 75, 110, 150 mg label 10 & 25 swallow this med whole do not chew or crush the caps. Q116: What is tranexamic acid used for and how does tranexamic acid work? A116: What is tranexamic acid used for and how does tranexamic acid work? Fibrinolysis (both general and local) Epistaxis Menorrhagia Stop bleeding trauma Hereditary angioedema Memory trick: FEMSH MOA: stops fibrin from getting broken down which then prevents bleeding. Q117: What needs to be monitored when taking tranexamic acid? A117: What needs to be monitored when taking tranexamic acid? Regular liver function tests in long term management of hereditary angioedema Q118: What are the main side effects of tranexamic acid? A118: What are the main side effects of tranexamic acid? Diarrhoea Reduce dose Nausea Vomiting Q119:.How should tranexamic acid be taken? A119: How should tranexamic acid be taken? (Gloria) 1 g 3 times a day for up to 4 days. Max 4g/day Q120: What increases the risk of a DVT when taking tranexamic acid? A120: What increases the risk of a DVT when taking tranexamic acid? If the patient is on combined contraceptive and HRT Q121: What are the main contraindications of tranexamic acid? What is tranexamic acid used for?  A121: What are the main contraindications of tranexamic acid? contraindications : Epilepsy, DVT, PE, irregular periods, renal problems, pregnancy Q122: What’s the max dose of tranexamic acid? A122: What’s the max dose of tranexamic acid? maximum 4 g per day when used for menorrhagia Q123: Is tranexamic acid safe in P+BF? A123: Is tranexamic acid safe in P+BF? Use only if potential benefit outweigh the risk- crosses the placenta. B/F small amount present in milk , antifibrinolytic effect in infant unlikely. Q124: When must a patient be referred if they’re on tranexamic acid? A124: When must a patient be referred if they’re on tranexamic acid? P+BF < 18 years or > 45 years No improvement after 3 menstrual cycles PCOS or endometrial cancer Women taking contraceptives, estrogens, tamoxifen and warfarin Obese and diabetics. Renal impairment History of convulsions Signs of DVT or PE (chest pain, leg cramps) Q125: In simple terms, what is cardiovascular risk assessment and prevention all about? A125: In simple terms, what is cardiovascular risk assessment and prevention all about? CVD = group of disorders of the heart and blood vessel caused by atherosclerosis and thrombosis Examples: CHD (angina & MI), stroke, peripheral arterial disease and aortic disease and hypertension Cardiovascular risk assesses the likelihood of a person developing the above Cardiovascular risk prevention can be lifestyle or pharmacological interventions that prevent the above from happening e.g. giving statin to lower cholesterol or giving antihypertensives to reduce BP Q126: What are the non modifiable risk factors of getting CVD?  1. Age 50+ - The older a person is, the greater the risk of developing CVD. 2. Gender at all ages men have a higher risk of A126: What are CVD than women, and on average develop CVD about 10 years earlier. the non 3. Family Hx modifiable risk reflects a shared environment, genetic factors, or both. A positive factors of family history of premature CVD death is = increased risk of early and getting CVD? lifetime CVD. 4. Ethnicity South Asian /sub-Saharan African origin increased risk of CVD, while people of South American or Chinese origin have a lower risk compared with people of European origin. Q127: What are the modifiable risk factors of getting CVD?  Hypertension Abnormal lipids Obesity A127: What are Diabetes melitus the modifiable Psychosocial factor risk factors of Low physical activity getting CVD? Poor diet Smoking Excess alcohol Q128: What are the aims of treatment for CVD?  Reduce modifiable A128: What risk factors are the aims of treatment for CVD? Using lifestyle and drugs Q129: What are the main risk assessment tools used to assess the risk of cardiovascular events in the UK and how long do they assess the risk for?  QRISK 2 (england and wales) - A129:What are estimates 10 year risk the main risk assessment QRISK 3 (england and wales) - estimates 10 year risk tools used to assess the risk of Updated QRISK 2 version → including CKD, lupus, migraine, steroid use, atypical cardiovascular antipsychotics, mental illness, ED events in the UK and how long JBS3 (england and wales)→ estimates do they assess LIFETIME risk of CVD event the risk for? ASSIGN (scotland) → estimates 10 year risk Q130: Which risk assessment tool is the only one that assess lifetime risk? A130: Which risk assessment tool is the only one that assess life time risk? JBS3 Q131: What score should patients be started on drugs for primary prevention? A131: What score should patients be started on drugs for primary prevention? CVD Risk Greater than or equal to 10% Start Atorvastatin 20 mg Q132: What is the difference between QRISK2 and QRISK3?  QRISK 3 is an updated more advanced version of QRISK 2 A132: What is the Main differences include: difference CKD from stage 3 between Migraines Severe mental illness QRISK2 and Corticosteroid use QRISK3? SLE Antipsychotic use ED Systolic BP variability Q133: Which patients are risk calculators not used in? A133: Which patients are risk calculators not used in? High risk patients: (using risk calculator UNDERESTIMATES the score) Type 1 diabetes Established CVD CKD Familial hypercholesterolaemia Risk increases with age → ≥85 yrs at high risk esp if they smoke or have hypertension 10 year risk of CVD ≥10% Q134: Which drugs are used in primary prevention and secondary prevention? A134: Which drugs are used in primary prevention and secondary prevention? Lipid lowering drugs Statins Antihypertensives Antiplatelets Clopidogrel, low dose aspirin, dipyridamole Q135: Which statin is preferred in primary prevention of CVD and why? A135: Which statin is preferred in primary prevention of CVD and why? (Gloria) ATORVASTATIN 20 MG HIGH INTENSITY STATIN MT: A = ANY TIME AND CAN BE TAKEN AT ANY TIME OF THE DAY. Q136: What causes hyperlipidemia? A136: What causes hyperlipidemia? Hypothyroidism Liver or kidney disease Diabetes Drugs: Antipsychotics, Familial Lifestyle: Smoking and Corticosteroids and hypercholesterolemia obesity Calcineurin Inhibitors Q137: What patients are at risk of developing hyperlipidaemia? A137: What patients are at risk of developing hyperlipidaemia? The high risk patients → should be given statin regardless of serum cholesterol levels: Diabetes type 1 → ALL pts Diabetes type 2 → only if CVD risk >10% CKD Familial hypercholesterolaemia Age ≥85 yrs Drugs: Antipsychotics, Corticosteroids and Calcineurin Inhibitors 10 year risk of CVD ≥10% Q138: Which patients should be started on statins regardless of their cholesterol levels? A138: Which patients should be started on statins regardless of their cholesterol levels? 1. Diabetes [type 1]- all patients 2. Diabetes [type 2]- only if cvd risk > 10% 3. CKD 4. Family hx of high cholesterol 5. Ageing 85+ esp if smoker/Hypertension 6. 10 year risk of CVD >10% Q139: What counts as established cardiovascular disease? A139: What counts as established cardiovascular disease? Patient who have suffered the following condition: CHD (MI & angina) Cerebrovascular disease (TIA/ stroke) Peripheral artery disease (hypertension) Q140: Which statins are high intensity statins and what dose do they start being high intensity? A140: Which statins are high intensity statins and what dose do they start being high intensity? High intensity statin is a statin that reduces LDL by at least R A S 40% or more Memory trick: Write the table 10 20 80 Q141: What are the lipid ranges for NORMAL people and HIGH RISK patients? A141: What are the lipid ranges for NORMAL people and HIGH RISK patients? Q142: Which type of lipids do statins lower? A142: Which type of lipids do statins lower? non-HDL-cholesterol: LDL  Q143: Which drugs are not routinely recommended for primary and secondary prevention of cardiovascular events? A143: Which drugs are not routinely recommended for primary and secondary prevention of cardiovascular events? Do not use fibrates Nicotinic acid Bile sequent Omega 3 acid compound for primary and secondary prevention of CVD. Q144: What drugs are given for hypercholesterole mia and what is the treatment steps? A144: What drugs are given for hypercholesterolemia and what is the treatment steps? Start of with a statin. You can use it with ezetimibe if statin not good enough or you can use the ezetimibe all by itself. If these 2 options don’t work, then refer to specialist. They’ll give you fibrates, nicotinic acid or bile sequestrants. Q145: What is given as an add on to statin/ given as an alternative to statin if it’s not tolerated? A145: What is given as an add on to statin/ given as an alternative to statin if it’s not tolerated? Ezetimibe Q146: When is fenofibrate and nicotinic acid used for lowering lipid levels? A146: When is fenofibrate and nicotinic acid used for lowering lipid levels? Fenofibrate + statin If triglyceride is high Nicotinic acid To lower triglyceride and LDL cholesterol concentration Q147: How do statins work? A147: How do statins work? Statin competitively inhibit 3-methylglutaryl coenzyme A ( HMG CoA) reductase an enzymes involved in the synthesis of cholesterol in d liver. Q148: Which lipid lowering drugs are more effective at lowering triglycerides and which are more effective at loweing LDL? A148: Which lipid lowering drugs are more effective at lowering triglycerides and which are more effective at lowering LDL? Statins more effective at lowering LDL Fibrates reduce triglycerides Nicotinic Acid lowers triglycerides and LDL Q149: When are statins considered in younger patients? A149: When are statins considered in younger patients? Familial hypercholesterolaemia - genetic Q150: Are statins safe for pregnancy and breastfeeding? A150: Are statins safe for pregnancy and breastfeeding? PREGNANCY avoided (discontinue 3 months before attempting to conceive) congenital anomalies have been reported and the decreased synthesis of cholesterol possibly affects fetal development. Adequate contraception is required during treatment and for 1 month afterwards. BREAST FEEDING Avoid Manufacturer advises Q151: How long should adequate contraception be used for when taking a statin? A151: How long should adequate contraception be used for when taking a statin? Adequate contraception is used during and 1 month after treatment. Q152: How long should a statin be stopped for before trying to conceive? A152: How long should a statin be stopped for before trying to conceive? At least 3 months before you try conceiving Additional contraception needed for at least 1 month Q153: What is patient and carer advice for ALL statins? A153: What is patient and carer advice for ALL statins? Report unexplained muscle pain, tenderness or weakness rhabdomyoliss Q154: When are statins indicated in patients? A154: When are statins indicated in patients? primary prevention of CVD Secondary prevention of CVD Pts with family hx of hypercholesterolaemia Primary hypercholesterolaemia Q155: When are dose adjustments considered when taking a statin? A155: When are dose adjustments considered when taking a statin? Dose adjustment is required if there is a risk of myopathy when give with other drugs such as: Amlodipine + ciclosporin = 10 mg Rosuvastatin + clopidogrel = 20 mg Simvastatin + fibrate = 10 Simvastatin + amlodipine, rate limiting CCB = 20 mg MT: Sim 20: Ran Am Ros 20mg: CloRo At 10mg: CIAT RO 10mg: CIRO Q156: What are the main side effects of statins? A156: What are the main side effects of statins? Sleep disorders Nausea Diarrhea Constipation Headache Q157: which statins can be taken any time of day? A157: which statins can be taken any time of day? Atorvastatin Rosuvastatin Q158: What doses of atorvastatin are used in primary prevention and secondary prevention? A158: What doses of atorvastatin are used in primary prevention and secondary prevention? Primary prevention of cardiovascular Secondary prevention of events in pts at high risk of a first cardiovascular events cardiovascular event 20 mg OD; increased if necessary up to 80 mg 80 mg OD OD, dose to be increased at intervals of at least 4 weeks. Q159: Which statin (name and strength) has an MHRA warning and what is the MHRA warning? A159: Which statin (name and strength) has an MHRA warning and what is the MHRA warning? Simvastatin 80 mg risk of rhabdomyolysis Q160: What is the main MHRA warning/dose adjustment that needs to be made when taking simvastatin with amlodipine? A160: What is Risk of myopathy/ the main rhabdomyolysis with MHRA simvastatin at doses of >20mg warning/dose adjustment that needs to Maximum simvastatin dose with amlodipine is 20 mg once be made daily. when taking simvastatin with Amlodipine can be as high as amlodipine? you like but simvastatin must 20mg or lower. Q161: what are the main dose adjustments that need to be made when taking the high intensity statins with other common drugs? A161: what are the main dose adjustments that need to be made when taking the high intensity statins with other common drugs? Max dose simvastatin 20mg with amlodipine, amiodarone and rate limiting CCBs (diltiazem + verapamil) Max dose simvastatin 10mg with fibrate Max dose atorvastatin 10mg with ciclosporin Max dose rosuvastatin 20mg with clopidogrel MT: Sim 20: Ran Am Ros 20mg: CloRo At 10mg: CIAT RO 10mg: CIRO Q162: What do we monitor before and after starting a statin and how often do we monitor them? A162: What do we monitor before and after starting a statin and how often do we monitor them? BEFORE AFTER starting Full lipid profile nonfasting TSH Renal function Creatinine kinase -avoid if >5 time upper limit LFT, repeat within 3 months + 12 months - discontinue if >3 times upper limit Diabetes (HBA1c/fasting blood glucose) repeat within 3 months Q163: What are the main interactions to watch out for when taking statins? A163: What are the main interactions to watch out for when taking statins? Amiodarone colchicine nicotinic acid, fibrates: increase risk of rhabdomyolysis. Carbamazepine: increase risk hepatotoxicity Clarithromycin, erythromycin & grapefruit juice ketoconazole/is miconazole : increase exposure to simvastatin Amlodipine ; risk of rhabdomyolysis. Q164: What is heart failure?  A164: What is heart failure? Heart not working as it should be. Failing to preferom Definition: clinical syndrome showing structural/ functional abnormalities leading to reduced cardiac output Memory trick: Failure = failure to pass minimum requirements Q165: How is heart failure classified?  1) how sudden symptoms come on → chronic/ acute A165: How is heart failure classified? 2) how much blood the heart manages to pump out with each heartbeat (reduced or preserved ejection volume) Q166: What are the main symptoms of heart failure? A166: What are the main SOB - DURING EXERCISE/REST- DUE PERSISTENT COUGHING/ ANKLE SWELLING TO PULMONARY WHEEZING symptoms OEDEMA (PULMONARY of heart CRACKLES) failure? REDUCED EXERCISE FATIGUE TOLERANCE Q167: What are the 2 main types of heart failure and what is the difference between the 2? A167: What are the 2 main types Acute H/F: symptoms come on suddenly, requires treatment in of heart d hospital by admission failure and what is the difference Chronic H/F : symptom has been on for a while , treated as between an out pt. Can dev to AHF the 2? Q168: Which patients are more at risk of heart failure?  CHD Hypertension A168: Which Heart valve disease patients are Arrhythmias more at risk Cardiomyopathy of heart Thyroid disorders failure? Anemia Alcohol and drugs that are cardiotoxicity Q169: What are the main causes of heart failure? A169: What are the main causes of heart failure? Coronary heart disease (CHD) - most common cause esp after MI Hypertension - more common cause in african/ afro-carribean population Cardiomyopathy Disease of heart valves Arrhythmias Meds that damage the heart muscle → e.g. excess alcohol, cocaiine, some chemotherapy agents Non heart conditions e.g. hypo/hyperthyroidism, severe anaemia can leads to reduced cardiac output Q170: How is heart failure diagnosed?  Higher Pulse rate, enlarged heart, fluid Physical examination retention (crackle in lungs, swollen ankles, enlarged liver) B-type netriuteic peptide Blood parameters (BNP) A170: How is which are high in heart failure: N-terminal pro-B-type natriuretic peptide heart failure (NTproBNP) diagnosed? Urine test ECG Chest x-ray Q171: What are the main aims of treatment for heart failure?  Reduce mortality A171: What are the main aims Relieve symptoms of treatment Improve exercise tolerance for heart failure? Reduce acute exacerbation. Q172: What drugs are used to treat heart failure? A172: What drugs are used to treat heart failure? Beta Blockers ACE/ARB Nitrates & Hydralazine Diuretics (Loop and MRA’s) SGLT2 (Dapagliflozin & Empagliflozin) Amiodarone Ivabradine Digoxin Sacrabutril and Valsartan Memory Trick: HF = BAND SAIDS Q173: what’s the treatment pathways for heart failure? A173: what’s the treatment pathways for heart failure? 1st line ACE/ ARB for patients with fluid retention/ diabetes and/or BB for pts with angina ADD eplerenone or spironolactone if ACE/ ARB + BB not working ADD hydralazine + nitrate If pt cant tolerate ACE/ ARB from start, start with hydralazine + nitrate instead (total - 4 drugs - eplerenone/ spironolactone + BB + hydralazine + nitrate) ONLY CCB safee in HF is amlodipine Refer to specialist if no improvement to give: Sacrabutril - replaces ACE/ ARB Digoxin (HF with AF) Ivabradine and hydralazine + nitrate (for afro-carribean decent) Dapagliiflozin + empagliflozin → used for HF and diabetes (never given on iits own) Q174: Which vaccines need to be given annually in patients with heart failure? A174: Which vaccines need to be given Flu vaccine annually in patients with heart Pneumococcal failure? vaccine Q175: Which drugs are given for which complications in patients with heart failure? (slide 235) A175: Which drugs are given for which complications in patients with heart failure? (slide 235) Stop all drugs which can worsen H/F e.g Nsaids retains water,CCB except Amlodipine. Give loop diuretic to relieve oedema & breathlessness Prescribe ACE or ARB but only one at a time to the max effective dose b/4 switching. Ace/ arb if pt is diabetic BB if pt has angina Arb if unable to take Ace Hydralazine or Nitrate if unable to take ACE/ arb otr african/ caribbean. Q176: Which antidiabetic drugs are used in the management of heart failure and what is the rationale behind it? A176: Which antidiabetic drugs are used in the management of heart failure and what is the rationale behind it? SGLT2 Inhibitors - Mainly Rational: Dapagliflozin and Empagliflozin Reduces mortality from heart failure Reduces hospital admission Reduces the fluid retention thats often associated with heart failure. Q177: Which aldosterone antagonists are used for heart failure and what’s the main contraindications? A177: Which aldosterone antagonists are used for heart failure and what’s the main contraindications? Eplerenone + spironolactone HYPERkalaemia - for both Contraindications: Addison's disease + anuria (kidneys are not producing urine) - for spironolactone Q178: What are the 3 main types of ACS and what's the difference between each? A178: What are the 3 main types of ACS and what's the difference between each? MT: SUN STEMI - ST elevation full heart attack , complete obstruction, death of cardiac muscle UNstable Angina - UNpredictable, occurs on resting, longer, recurring, severe NSTEMI -non-ST elevation partial heart attack, some muscle cells die Q179: What the difference between angina and a heart attack (MI)? A179: What the Angina is a partial difference blockage of the arteries between angina and MI is a complete blockage a heart thereby restricting blood attack (MI)? supply to the heart. Q180: What causes ACS? A180: What causes ACS? Plaquing in Block Death of the arteries blood flow heart tissue Q181: Rank the 3 types of ACS from most severe to least severe  STEMI - most severe A181: Rank the 3 types of ACS from NSTEMI - not serious most severe to least severe Unstable angina - least severe Q182: What are the symptoms of angina? A182: What are the symptoms of angina? (Shali) Chest pain (tight, sharp, stabbing, dull/heavy) Spread to left arm, neck, jaw or back Triggered by physical exertion or stress Stops within a few minutes of resting Nausea Fatigue Shortness of breath Sweating Dizziness Q183: What's the difference between stable and unstable angina? A183: Pain that comes on exertion i.e What's the during exercise and stops on difference resting (stable ) predictable between stable and Pain that comes while unstable resting(unstable) unpredictable angina? Q184: What’s used in the initial management and secondary prevention of MI and unstable angina? Q185: What is used in the management of stable angina, both short and long term management?  Acute atacks → GTN for relief A185: What is Long term prevention used in the 1st line → BB management If BB CI due to severe HF, asthma, COPD or of stable prinzmetals angina → CCB Can give CCB + BB (but never verapamil + BB) angina, both Refer to specialist short and long Long acting nitrate → ivabradine, nicorandiil, term ranolaziine → give either of these as monotherapy if CCB/ BB is contraindicated management? OF if 2 drugs fail to control angina Offer low dose aspirin, statin + ACEI (for diabetics) Q186: What are nitrates and how do they work? A186: What are nitrates Potent vasodilators and how do they work? Reduction in venous return= reduces left ventricular work Q187: What are the 3 most common formulations of GTN? A187: What are the 3 most common formulations of GTN? For angina: Tablet Sprays Patches Rectal creams and foams for hemorrhoids Q188: What's the most common side effect of nitrates?  Flushing A188: What's the most Hypotension common side effect of nitrates? Headaches Q189: When should long term prophylaxis be considered if someone is already taking GTN? A189: When should long term prophylaxis be considered if someone is already taking GTN? If using GTN spray MORE than TWICE a week, then long-term prophylaxis is required Q190: What is the rule of 2 when dealing with treatment of angina? A190: What is the rule of 2 when dealing with treatment of angina?(Shali) *NEW* Take before exertion e.g before exercising Taken prn DOSE: usually 1 tablet or 1-2 sprays (not more than three doses recommended at any one time) Take sitting down due to postural HYPOtension Sublingual doses: 1) Take 1st dose and wait 5 mins 2) Take 2nd dose and wait 5 mins 3) Call 999 if pain still persists after 2nd dose = medical emergency Q191: What is the difference between the dinitrate MR preparations and the mononitrate MR preparations? A191: What is the difference between the dinitrate MR preparations and the mononitrate MR preparations? MR dinitrate has a duration of action of up to 12 hrs (given twice daily) MR Mononitrate =Mono (once daily) Q192: What's the main caution with nitrates and how do you prevent it? A192: What's the main caution with nitrates and how do you prevent it? Patients can develop tolerance. Mono nitrates are better because they don’t have the same tolerance problems. So continue taking it once daily. To prevent tolerance: MR oral preparation to be taken once daily For the dinitrates take twice a day, but make sure the second dose is at least 6-8 hours and not every 12 hours. For patches, take it off for at least 8-12 hours. Q193: What strengths do the GTN sublingual sprays come in and what’s the dispensing and storage requirements?  A193: What strengths do the GTN sublingual tablets come in and what’s the dispensing and storage requirements? Available in: 300, 500 & 600mcg Tabs supplied in glass contains of NOT MORE THAN 100 tabs Closed with foil line cap NO cotton wool wadding Discard after 8 weeks Rectal ointment should be discarded after 8 weeks of opening Q194: How do you take GTN when you have an angina attack? A194: How do you take GTN when you have an angina attack? Take 1st dose and wait 5 mins Take 2nd dose and wait 5 mins Call 999 if pain still persists after 2nd dose = medical emergency SUBLINGUAL SPRAY (400–800 mcg), under the tongue and then close mouth SUBLINGUAL TABLET 1 tablet, dissolve the tablet under your tongue—do not swallow. Q195: What are the 3 common ways of measuring hypertension?  Clinic B/p A195: What are the 3 common ways of Ambulatory b/p measuring hypertension? Home B/p monitoring. Q196: What are the main risk factors of hypertension? A196: What are the main risk factors of hypertension? There is no known cause Main risk factors include: Age Family history. Smoking Alcohol Lack of exercise High salt diet Overweight Secondary (Renal and endocrine disorders like cushings) Q197: What does establish cardiovascular disease mean?  TIA CVD = general Heart attack term for conditions Angina affecting the heart A197: What or blood vessels Narrow arteries Stroke does establish cardiovascular disease mean? MT: THANS Q198: What are your target organs?  Heart A198: What Brain are your target organs? Kidney Eye Q199: What are the different stages of hypertension?  Stage Stage 1 Clinic: (140/90 mmHg to 159/99 mmHg), 1 Ambulatory/home (135/85 mmHg to 149/94 mmHg). A199: What are the different Stage Stage 2 Clinic: 160/100 mmHg or higher but less than 180/120 mmHg, stages of 2 Ambulatory/home 150/95 mmHg or higher. hypertension? Stage Stage 3 Clinic:180 mmHg or higher, or a clinic diastolic blood 3 pressure of 120 mmHg or higher. Q200: What is accelerated hypertension?  Accelerated (or malignant) hypertension is a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). A200: What is Medical emergency that requires same day hospital accelerated visit to specialists. hypertension? Treated IV Q201: How is hypertension diagnosed? A201: How is hypertension diagnosed? Clinical BP 140/90-180/120 → offer ABPM/ HBPM to confirm diagnosis If readings are high = confirmation of diagnosis Q202: If there’s no target organ damage and no hypertension at all, how often should patients have their blood pressure monitored? A202: If there’s no target organ EVERY 5 YEARLY damage and no hypertension at all, how often should patients have their blood pressure IF NEAR 140/90- monitored? MORE FREQUENTLY Q203: Which hypertensive stages do we start blood pressure meds regardless of whether they have target organ damage? A203: Which hypertensive stages do we start blood pressure meds regardless of whether they have target organ damage? Stage 2 Bp of 160/100 mmHg. Q204: Under what conditions do we start patients on blood pressure meds if they have stage 1 hypertension? Q205: what are the main signs that someone is having accelerated hypertension? A205: what Signs of retinal haemorrhhage are the main and/ or papilloedema (swelling of optic nerve) signs that someone is having accelerated Pt might describe it as eye pain hypertension? Q206: What needs to be investigated asap if someone has severe hypertension but no obvious symptoms? A206: What needs to be investigated asap if someone has severe hypertension but no obvious symptoms? TARGET ORGANS CVD RISK (HEART, BRAIN KIDNEY, EYES) Q207: What drug classes are used in treating hypertension?  Ace/arb A207: What drug classes BB are used in treating CCB hypertension? diuretics. Q208: Draw a simplified diagram explaining the treatment steps for hypertension? A208: Draw a simplified Learn the diagram on the next page diagram explaining the treatment All diabetic regardless of age, give ACE/ARB. For black diabetics, give steps for ARB instead of ACE because they’re more likely to get dry cough. hypertension? Q209: Which drug classes are given to diabetics regardless of age and race? A209: Which drug classes are given to diabetics regardless of age and race? ACE for all diabetics ARB for afro-caribbean origin with diabetes Q210: Give a treatment overview of treatment of hypertension in patients with type 1 diabetes? A210: Give a treatment overview of treatment of hypertension in patients with type 1 diabetes? MT: ABCD ACEi/ARB[1st line]- start low and titrate up In no particular order: BB -okay even with insulin CCB - long acting only e.g MR nifedipine, amlodipine Diuretics (low dose thiazide) + BB Q211: Give examples of ACE inhibitors and ARB’s?  ACE; ARB’s: Ramipril Lisinopril. Losartan, Candesartan, A211: Give Captopril Olmesartan, examples of ACE inhibitors and Enalapril Telmisartan, Fosinopril valsartan, Perindopril Imidapril , Irbesartan, eprosartan, ARB’s? quinapril, azilsartan trandolapril ends in ‘‘ sartan’’ All ends in ‘’pril’’ Q212: How do ACE and ARB’s work?  ACE: ARB: A212: How Blocks the angiotensin Blocks the receptor that angiotensin do ACE and converting enzyme usually binds to This stops the Effect is lower blood ARB’s work? cascade that pressure. causes people to normally raise their blood pressure Effect is lower blood pressure. Q213: Are ACE and ARB safe in pregnancy and breast feeding? A213: Are ACE and ARB safe in pregnancy? No Q214: What are the main side effects/ warning signs ACE inhibitors and ARB’s? A214: What are the main side effects/ warning signs ACE inhibitors and ARB’s? Alopecia Angioedema - delayed, afro caribbean Persistent dry cough Electrolyte imbalance (hyperkalemia) Skin reactions Constipation GI  Q215:.What are the main contraindications of ACE inhibitors and ARB’s  Ace + aliskiren ( C/I in pt with eGFR < 60 ml/min/1.73m, diabetes ) A215:.What are the main Discontinued if marked contraindications elevation of hepatic enzyme of ACE inhibitors of jaundice occurs. and ARB’s History of angioedema. Q216: What are the main drug interactions to watch out for with ACE and ARBs?  A216: What are the main drug interactions to watch out for with ACE and ARBs? Interaction Drugs Hypotension with Alcohol, CCB’s, SGLT2, BB, alpha blockers and antipsychotics etc Hyperkalemia with Potassium salts, Potassium sparing diuretics, heparins, epoetins, calcineurin inhibitors, NSAID’s, Eplerenone, drospirenone Q217: What are the main monitoring requirements for ACE and ARBs? A217: What Renal function and electrolytes before starting ACE (and are the main increasing the dose) monitoring requirements for ACE and Plasma potassium conc (particularly in elderly + those ARBs? with renal impairment) for ARB Q218: Give examples of calcium channel blockers? A218: Give examples of calcium channel blockers? 1. Dihydropyridine a. amlodipine, felodipine, lacidipine, lercanidipine hydrochloride, nicardipine hydrochloride, nifedipine, and nimodipine b. All end in “dipine” 2. Phenylalkylamine a. Verapamil 3. Benzothiazepines a. Diltiazem  Q219: Are calcium channel blockers safe in pregnancy? A219: Are calcium channel blockers safe in pregnancy? Avoid , but risk to fetus should be balanced against uncontrolled maternal hypertension. Q220: What are the 3 main types of calcium channel blockers? A220: What are the 3 main types of calcium channel blockers? (Raheem) Dihydropyridines: All end in “dipine” Used mainly for hypertension because they work on vascular smooth muscles No benefit for treating arrhythmias Phenylalkylamines: (Verapamil) Used for treating hypertension, angina and arrhythmias Don’t use to treat heart failure, especially with BB as has cardiodepressive effect. Benzothiazepines (Diltiazem) Used for hypertension and angina only Both cardiodepressant and vasodilator. Q221: how do CCBs work? A221: how do CCBs work? Interfere with inward displacement of calcium ions through slow channels of active cell membranes Q222: What are the main contraindications of calcium channel blockers? A222: What are the main contraindications of calcium channel blockers? Cardiogenic shock; significant aortic stenosis; unstable angina Acute porphyrias within 1 month of myocardial infarction Q223: What are the main side effects of calcium channel blockers? A223: What are the main side effects of calcium channel blockers? N&V Odema Constipation Flushing Headache Dizziness Q224: What are the main drug interactions for CCBs?  Grapefruit juice (enzyme inhibitor) can increase CCB Concs A224: What Increases risk of hypotension → alpha are the blockers, beta blockers, ACE/ ARB, diuretics main drug interactions Increases risk of bradycardia → verapamil + acebutolol for CCBs? Amiodarone + verapamil → increases risk of cardiodepression Q225: Give examples of thiazide diuretics? A225: Give examples of thiazide diuretics? Bendroflumethiazide Chlorthalidone Indapamide Q226: How do thiazide diuretics work? A226: How do thiazide diuretics work? They inhibit Na+ reabsorption at the beginning of the distal convoluted tubule. Q227: Are thiazide diuretics safe in pregnancy and breastfeeding? A