03 Cardiovascular Review Helen Flashcards by Chris Clark

What BP is considered HTN crisis?

> 180/120

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What are the initial drug choices for Stage 1 HTN w/o compelling indications?

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination

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What are the initial drug choices for Stage 2 HTN w/o compelling indications?

2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

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What is the formula to calculate LDL?

LDL = TC - TG/5 - HDL. Invalid if TG > 400

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What is the primary lipid goal?

Almost always LDL, however if TG > 500 –> risk of pancreatitis and TG becomes primary lipid goal at that point

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What did the THRIVE study show?

Compared niacin/laropiprant (anti-flushing agent) to statin. No risk reduction with niacin combo but had increased risk of nonfatal but serious SE

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What are the primary coagulation factors targeted for Unfractionated Heparin (UFH)?

Primarily inhibits Xa and IIa (1:1 ratio)

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What are the primary coagulation factors targeted for Low Molecular Weight Heparin (LMWH)?

Xa&raquo_space; IIa (3:1 ratio). Enoxaparin, Dalteparin

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What are the primary coagulation factors targeted for Specific Indirect Xa Inhibitors?

Xa. Fondaparinux

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What are the primary coagulation factors targeted for Specific Direct Xa Inhibitors?

Xa. Rivaroxaban, Apixaban

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What are the primary coagulation factors targeted for DTIs?

Specific IIa Inhibition. Argatroban, Lepirudin, Divalirudin, Dabigatran

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What are the primary coagulation factors targeted for VKA?

II, VII, IX, X. Warfarin

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What is Dabigatran (Pradaxa) approved for?

Non-Valvular AF!!! Inactivates both free and fibrin-bound thrombin. Does not require routine lab monitoring

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What is Rivaroxaban (Xarelto) approved for?

Approved for Non-Valvular AF and VTE (pvt + tx). No direct effect on platelet function. Does not require routine monitoring

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What are the contraindications for Rivaroxaban (Xarelto) use?

Patients with CrCl < 30 and severe liver disease, bleeding risk, pregnancy and lactation

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What is Apixaban (Eliquis) approved for?

Non-Valvular AF

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When should Apixaban (Eliquis) be avoided?

CrCl < 25. Severe hepatic impairment (Child-Pugh C)

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What is the dosing of Apixaban (Eliquis) like?

5mg PO BID. 2.5mg PO BID if two of the following: > 80 yo, < 60kg, SCr > 1.5

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What did the ARISTOTLE trial show?

Apixaban vs. Warfarin. Apixaban was more favorable

What needs to be remembered about Dabigatran, Rivaroxaban, and Apixaban?

New oral anticoagulants are currently NOT approved for patients with valvular disease

What is the general ACS approach?

Initial evaluation + initial therapy (MONA) PRN –> GO after the clot (antiplatelet + Antithrombin) + Antianginal to decrease HR, contractility, preload, afterload (BB, CCB, nitrate) –> Disease modification (ACEI, Statin +/- Aldosterone blocker)

What is usually used when going after the clot?

Two antiplatelets +/1 P2Y, GP IIb/IIIa. Anticoagulation. +/- thrombolytics (STEMI) or PCI/CABG

What is antiplatelet therapy like for DES (Drug Eluting Stents)?

ASA (high dose) for AT LEAST 3-6 months (3 after sirolimus/everolimus eluting stent, 6 after paclitaxel eluting stent) then low dose indefinitely. PLUS. P2Y at least 12 months

What is antiplatelet therapy like for BMS (Bare Metal Stents)?

ASA high dose for AT LEAST 1 month, then low dose indefinitely. PLUS. P2Y UP TO 12 months

What is antiplatelet therapy like for Non Invasive?

Low dose ASA indefinitely. P2Y UP TO 12 months

What are the P2Y Receptor Inhibitors used?

Clopidogrel. Ticagrelor. Prasugrel. Ticlopidine

Which P2Y Receptor Inhibitors need to be held 5 days before surgery?

Clopidogrel and Ticagrelor

Which P2Y Receptor Inhibitors need to be held 7 days before surgery?

Prasugrel

Which P2Y Receptor Inhibitors need to be held 10-14 days before surgery?

Ticlopidine

Which P2Y Receptor Inhibitor is contraindicated in a patient with a history of TIA or Stroke?

Prasugrel

What needs to be monitored for ALL P2Y Receptor Inhibitors?

Bleeding, H/H, Platelets

What is Cangrelor?

Potent IV reversible and fast acting ADP receptor antagonist. Antiplatelet effects are immediate post bolus and maintained with continuous infusion. VERY short half-life, platelet function restored within 1 hour after stopping infusion

What are some High Risk freatures?

Cardiac enzyme "leak". Prolonged ongoing rest pain (> 20 minutes). Pulmonary edema. Dynamic ST changes > 1mm. New or worsening mitral regurgitation murmur. New S3 or rales. Hypotension (SBP < 90). DIABETES

**What are the ABSOLUTE contraindications for Thrombolytics?

Prior ICH. Known structural cerebral vascular lesion (AVM). Known malignant intracranial neoplasm. Ischemic stroke w/in 3 months EXCEPT acute stroke w/in 3 hours. Suspected aortic dissection. Active bleeding or bleeding diathesis. Significant closed head or facial trauma w/in 3 months

What are the Anti-Ischemics used?

NTG. BB. CCB. Ranolazine

What is often used as a Statin for the disease modifying therapy?

Lipitor 80mg PO QD x16 weeks then to LDL goal

What are the Aldosterone Receptor Antagonists used?

Spironolactone. Eplerenone

What is the Pathophysiology of Chronic Stable Angina (CSA)?

Plaque build-up. Gradual obstruction of coronary artery lumen

What is the Treatment Approach of Chronic Stable Angina (CSA)?

Reduce myocardial oxygen demand. Increase myocardial oxygen supply

What is the Treatment of Chronic Stable Angina (CSA)?

Antiplatelet. Anti-anginal. Disease modifying

What is the Pathophysiology of Acute Coronary Syndrome (ACS)?

Acute obstruction of coronary artery lumen. Acute plaque rupture (+/- vasospasm)

What is the Treatment Approach of Acute Coronary Syndrome (ACS)?

Target active thrombosis. Reduce myocardial oxygen demand. Increase myocardial oxygen supply

What is the Treatment of Acute Coronary Syndrome (ACS)?

MONA. Antiplatelet. Anticoagulant. Anti-anginal. Disease modifying

What is the treatment approach for Chronic Systolic HF?

ALL patients w/o contraindications should be on: ACEI (or ARB) + BB --> All patients will require for fluid volume management: Loop +/- Thiazide diuretic --> To optimize symptoms and as CHF progresses: Digoxin, Spironolactone, Combo ACEI/ARB, ISDN/Hydralizine (esp in AA population) --> For refractory ischemia or HTN: Amlodipine, Long-acting nitrates

What do you look at for Acute Decompensated HF (ADHF)?

If patient is warm and wet (use diuretics, Nesiritide, Vasolidators) or Cool and wet (congestion: use reduce fluids, inotropes)

What are the only Antiarrhythmics to be used in patients with Structural Heart Disease (HF or LVH)?

Amiodarone! Dofetilide/Ibutilie. Ia

What are the only Antiarrhythmics to be used in patients with Structural Heart Disease (CAD)?

Sotalol! III. Ia