cardiac medication

Question 1

Dyslipidemia screening

Answer 1

Men and women ≥ 40 yrs. of age (or post menopausal women)

Ethnicity: South Asian and First Nations people are at increased risk (consider earlier screening)

Patients with the following conditions (regardless of age):
DM
Obesity (BMI ≧ 30)
Chronic kidney disease (eGFR ≦ 60 mL/min)
FHx of premature CAD (Men < 55 yrs., Women < 65 yrs. in a 1st degree relative) & those that have a family hx. of dyslipidemia
Known atherosclerosis: CAD, MI, PCI/CABG, PVD, CVA/TIA, carotid arterial disease, AAA
Stigmata of dyslipidemia (arcus cornea, xanthelasma)
Inflammatory disease (RA, SLE, IBD)
HIV (Rx: HARRT)
Current tobacco use
HTN (includes hypertensive diseases in pregnancy i.e. preeclampsia)
Erectile dysfunction, COPD

Question 2

screening of dyslipidemia

Answer 2

Lipid profile (non-fasting state)
TC (total cholesterol)
LDL-C (low density lipoprotein)
HDL-C (high density lipoprotein)
non-HDL-C (non-HDL-cholesterol)
TG
FBG, HbA1C level
Electrolytes (eGFR)
Lipoprotein (a) – once in a person’s lifetime at initial screening

Question 3

non-HDL-C =

Answer 3

TC minus HDL-C

Question 4

Apolipoprotein B (ApoB)

Answer 4

main component of LDL and VLDL (very low density lipoprotein)

Question 5

Framingham Risk Score

Answer 5

High Risk: FRS of ≥ 20%
Intermediate Risk: 10%-19.9%
Low Risk: < 10%

Question 6

Statin Indications

Answer 6

Atherosclerotic Cardiovascular Disease (ASCVD)
Most people with DM
- Age ≥ 40 yr.; Age ≥ 30 yr. + DM x 15 yrs.
- Microvascular disease
CKD: Age ≥ 50 yr. and eGFR < 60 mL/min
LDL ≥ 5.0 mmol/L

Question 7

MOA of statin

Answer 7

Competitively block HMG-CoA reductase, a key rate limiting enzyme in cholesterol synthesis
Block the conversion of HMG-CoA to mevalonic acid
Reduce hepatic cholesterol synthesis
Upregulation of LDL receptors, increases hepatic uptake of LDL-C from circulation

Question 8

Pleiotropic effects of statins

Answer 8

Improve endothelial function
Increase NO bioavailability
Inhibit inflammatory response
Stabilize atherosclerotic plaques

Question 9

Contraindications to Prescribing Statins

Answer 9

Active or Chronic Liver Disease
Pregnancy and during breastfeeding

Question 10

side effects of statins

Answer 10

Myalgia
Myositis (inflammation of skeletal muscles)
Rhabdomyolysis

Question 11

Baseline Testing before initiating statins

Answer 11

TSH (hypothyroidism is a risk factor for statin intolerance)
Liver function
Renal function/creatinine: (CKD are at higher risk of statin)

Monitor labs at minimum every 6 months, with any changes in therapy, or if suspected adverse effects

Repeat a lipid profile in 4-6 weeks to reassess if at target

Question 12

Primary prevention treatment threshold

Answer 12

IF non-HDL-C > 2.6 mmol/L or LDL-C ≥ 2.0 mmol/L or ApoB ≥ 0.8 g/L and on maximally tolerated statin dose, the next step is to discuss add-on therapy
First line add on therapy in primary prevention is Ezetimibe
Note that PCSK9 inhibitors are not recommended in primary prevention

Question 13

Secondary prevention treatment threshold

Answer 13

IF the non-HDL-C ≥ 2.4 mmol/L or LDL-C ≥ 1.8 mmol/L or ApoB ≥ 0.7g/L, the next step is to intensity therapy with addition of ezetimibe and/or PCSK9 inhibitor

Question 14

Ezetimibe

Answer 14

Inhibits absorption of dietary cholesterol in the small intestine
Metabolized in both the small intestine and liver but not by CYP450 enzyme system

Question 15

PCSK9 Inhibitors

Answer 15

Monoclonal antibody that inhibits PCSK9, a protein that targets LDL receptors, and clears LDL from the blood

Question 16

PCSK9 Inhibitors side effects

Answer 16

urticaria, rash, angioedema

Question 17

Hypertriglyceridemia medication

Answer 17

Fibric Acids (fenofibrate)

contraindication: Severe Renal or Hepatic Disease

*Can increase serum Cr

Question 18

ASA MOA

Answer 18

COX inhibitor - Irreversibly inhibits platelet aggregation

Question 19

ASA side effects

Answer 19

GI bleeding, dyspepsia, thrombocytopenia, allergic RXN (aspirin induced asthma)

Question 20

ASA is indicated for

Answer 20

ASA is indicated for the secondary prevention of CV disease

Question 21

Antiplatelet Therapy (APT)

Answer 21

Selectively inhibit ADP (adenosine diphosphate) induced platelet aggregation

Platelet P2Y12 receptor antagonists: Clopidogrel, Ticagrelor, Prasugrel

Question 22

ACE Inhibitors MOA

Answer 22

Prevent the conversion of angiotensin I to II; Angiotensin II is a potent vasoconstrictor
ACEi cause arterial and venous vasodilation
Block the breakdown of bradykinin

e.g. ramipril, perindopril

Question 23

Adverse effects of ACEi

Answer 23

Angioedema (life threatening)
ACE induced cough (ARBs can be used in patients with ACE induced cough)
Renal dysfunction, hyperkalemia
Hypotension

Cautious use in patients with RAS, single kidney, CKD (contraindicated in bilateral RAS)

Contraindicated in pregnancy (fetal malformations/death)

Question 24

Beta-Blockers MOA

Answer 24

↓myocardial oxygen demand, ↓ HR, ↓contractility

Question 25

adverse effects of beta-blockers

Answer 25

Bradycardia (contraindicated in heart 2nd/3rd degree heart block)
Hypotension
Fatigue, Sleep disturbance, Nausea
Sexual dysfunction
Bronchospasm
Worsen claudication symptoms

Question 26

nitrates MOA

Answer 26

↑ myocardial oxygen via vasodilation of coronary arteries (release of NO)

Question 27

MOA of calcium channel blockers

Answer 27

CCBs ↑ myocardial oxygen by vasodilation of coronary arteries

Question 28

Amlodipine is used to treat

Answer 28

angina & HTN (no arrhythmic action)

Question 29

side effects of amlodipine

Answer 29

HA, ↓BP, peripheral edema

Question 30

Non-dihydropyridines: Diltiazem, Verapamil

Answer 30

control HR by prolonging the refractory period of AV node; Arrhythmic use – i.e. managing SVT/tachyarrhythmia’s

Question 31

side effects of Non-dihydropyridines (Diltiazem, Verapamil)

Answer 31

↓ HR, ↓ BP, AV block
↓ HR and contractility - worsen HF