Cardiac Pt 2 Arrhythmia, Dyslipidemia Flashcards
Atrial Fibrillation
- ___ventricular d_________ which occurs when the atria _____ instead of beating effectively
- Results in loss of “atrial ___”
- Also results in ____ of blood which could potentially ____
- Supraventricular dysrhythmia , quiver
- X “kick”
- stasis, clot
AF Anticoagulation Statistics
- AF accounts for 25% of all ____ in the elderly
- AF is estimated to be responsible for 70,000 strokes/year
- _____ ~62% RRR (regular rate and rhythm)
- _____ ~ 22% RRR
- Asbolute RR still depends on _____ risk
- strokes
- Warfarin
- Aspirin
- baseline
+Vitamin K Antagonists
(1)
Warfarin (Coumadin)
- Warfain is a hideous drug - antiquity*
- Factors II, VII, IX, and X all dependent on Vitamin K*
- Fun fact: where was warfarin discovered? -* ts used in rat poison - rats eat it, bleed out, and die- Pts will say “im not gonna eat that rat poison!” you will an you’ll like it!
- Aspirin more recently shown that it doesn’t really work bc more for arterial clots*
- Warfarin name - Wisconsin Alumni Research Foundation = WARF*
+Warfarin
MOA
- Inhibits synthesis of _____ _ dependent clotting _____ (4) and regulatory _____ (2)
- Prevents ______ and _______ of new thrombi
- No effect on? (2)
- Vitamin K, clotting factors (II, VII, IX, X), proteins C and S
- formation, propagation
- circulating clotting factors, formed thrombi
+Warfarin
Therapeutic Uses
(3)
- DVT/PE
- Afib
- heart valve replacement
+Warfarin PK
- Bioavailability > __%
- Onset __-__hrs (full effect takes __-__ days)
- Duration ~ __-__ days
- Metabolism through what?
- _____ variations in these isoenzymes
- interpatient _____ in ___ requirements
- Highly _____ bound (~90%)
- 90%
- 24-72 hrs (5-7 days) bc you have to deplete all clotting factors
- 2-5 days
- Enzymes CYP450, 2C9, 3A4
- genetic
- variability, dose
- protein
+Warfarin Dosing
- __ mg oral ____ daily
- Lower doses of __ mg once daily for (4)
- ex) one pt may require a very small dose (1 mg) wherease another may need higher doses (15mg) to achieve same level of anticoagulation
- Lower doses of __ mg once daily for (4)
- Dose adjustments based on what lab value?
- 5mg once daily
- 2 mg - elderly, frail, malnourished, liver failure
- INR
Hideous drug bc HUGGEE interpatient variability - theres a website that helps us dose - but it even says 50% accuracy
+Warfarin
AE (4)
- Bruising
- Bleeding
- Skin necrosis
- Teratogenic
CANNOT TAKE IN PREGNANCY
+Warfarin
Drug and Food Interactions
Many drug-drug interactions
Drug-food interactions with foods high in Vitamin K - reduces effect of Warfarin (green leafy vegetables, chickpeas, tea)
+Reversal of Warfarin
What medication?
- Promotes the ____ formation of _____ required for normal _____
- Onset of action
- PO: __-__ hrs
- IV: __-__ hrs
- AE (1)
- Caution with?
Vitamin K
- hepatic, factors, clotting
- Onset
- 6-12 h
- 1-2 h
- Hypersensitivity with rapid IV admin**
- Reinstitution of warfarin therapy
Reversal of Warfarin
- _____
- Factors (4)
- Protein (2)
- FDA approved for urgent reversal of warfarin therapy in adult pts with acute major _____ or requring reversal for an invasive _____
- Dose is determined by patient ____ and pretreatment ___
- Black box warning =
-
Kcentra a better reversal agent compared to vitamin K - can work better acutely
- II, VII, IX, X
- C, S
- bleeding, procedure
- weight, INR
- increased risk fo arterial/venous thromboembolic events
+Afib Algorithm
- Mechanical heart _____ or moderate or severe mitral ______
- If yes -> What meds?
- If no -> Estimate ____ risk based on (2) risk factors
- valves, mitral stenosis
- VKA (IA)cd
- Stroke, CHA2DS1 - VASc risk factors
for heart valves and mitral stenosis -> straight to warfarin
+Afib Algorithm
- If 0 risk factors =
- If 1 risk factor =
- No antiplatelet or anticoagulant tx (IIIB)
- Rare- only for pts with only AFIB and nothing else
- OAC should be considered (IIaB)
+Afib Algorithm
- If > 2 risk factors
- ____ is indicated (assess for _____, correct reversible ___ risk factors)
- _____ o_____ devices may be considered in pts with clear contraindications for OAC (IIbC)
- Group of Drugs
- Group of Drugs
- ____ is indicated (assess for _____, correct reversible ___ risk factors)
-
> 2
- OAC, contraindications, bleeding
- LAA occluding
- NOAC
- VKA
- OAC, contraindications, bleeding
+Afib Algorithm
NOAC (4)
Non Vitamin K Antagonist Oral Anticoagulants
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
Cardiac Electrophysiology
- Na+ currents contribute to ________ while K+ and Ca2+ channels control ___________
- Na+ channesl are ____ channels while Ca2+ channels consist of 2 types: __ (Long lasting) and __ (Transient)
- Channels are mainly in 3 states: R____, O____, In_____ or C_____
- Depolarization, Repolarization
- fast, 2 types: L, T
- Resting, Open, Inactivated or Closed
Antiarrhythmic Medications
- Class I = ______ channel blockers
- Class II = BB (Propranolol, Metop, Esmolol)
- Class III = ______ channel blockers
- Class IV = CCB (Verapamil, Diltiazem)
- Misc = Digoxin, Adenosine
- Class I = Sodium Channel Blockers
- Class III = Potassium Channel Blockers
Class I Sodium Channel Blockers
- Class Ia
- Quinidine (Quinidex)
- Procainamide (Procanbid)
- Disopyramide (Norpace)
- Class Ib
- ________
- Mexiletine (Mexitil)
- Class Ic
- ________
- ________
- Class Ia
- Class 2a
- Lidocaine (Xylocaine)
- Class Ic
- Flecainide (Tambocor)
- Propafenone (Rythmol)
Class III Potassium Channel Blockers
(3)
Sotalol (Betapace)
Amiodarone (Cordarone)
Dofetilide (Tikosyn)
Class Ic Antiarrhythmics
Propafenone
- M____ taste, di_____, acute decompensated heart ____
- Br_____, ____cardia, heart b____ (negative ___tropic and __-blocking properties)
- Contraindicated in pts with ____ (Class III, IV), l___ disease, and v____ disease
- DI: d____, w____, as well as drugs that inhibit ____ 2D6, 1A2, 3A4
- Metallic, dizziness, HF
- Bronchospasm, Bradycardia, block, ino, B
- HF, liver, valvular
- digoxin, warfarin, CYP
Generally - many antiarrhythmics not safe for HF - only one that is safe is AMIO
Clas Ic Antiarrhythmics
Flecainamide
- D_____, tr____, acute decompensated heart ____ (negative inotropic effects)
- Contraindicated in pts with __ __, C _ _, _____ disease
- Drug interaction with _______
- Dizziness, tremor, HF
- HF, CAD, Valvular disease
- Digoxin
+Amiodarone (Cordarone)
- Possess pharmacologic effects from ___ ____ Vaughn Williams Classes
- Blocks _____, ______, _____ channels
- Anti____ properties
- Drug of _____* in patients with ____ ____*
- Used in (2)
- all three
- sodium, potassium, calcium
- adrenergic
- choice*, heart failure
- atrial and ventricular arrhythmia
Amiodarone (Cordarone) PK
- Pharmacokinetics
- Formulations (2)
- Erratic absorption when admistered ____
- _____ half life ~ __-__ days
- Highly _____
- Metabolized through the _____
- Potent ______ of CYP 3A4 and PgP
- Many drug-___ interactions (2)
- PK
- PO, IV
- PO
- prolonged, 40-60 days
- lipophilic
- liver
- Inhibitor
- drug: Digoxin, Warfarin
- ITS TAKES MONTHSS FOR amio to wash out - highly lipophilic*
- Reeks havoc on Drug interactions -> since many of the pts that need amio are probably on dig and warfarin - creates a problem - when pt needs amio has to reduce empiric dose of dig or warf or else will get amio toxicity*
+Amiodarone
AE
Although is not very cardiotoxic in HF - effects literally every other organ in our body
+Class III Antiarrhythmics
Sotalol
- Acute decompensated __, ____cardia, AV ____, wh____, ___ within _ days of initiation, b________
- Contraindicated in pts with baseline (2)
- ______ mandatory for initiation, obtain ___ every _-_ hrs after first __ doses, _____-dose every __ days
- HF, Bradcardia, AV block, wheezing, TdP 3, bronchospasm
- QTC > 440msec, CrCL <40ml/min (renally eliminated)
- Hospitalization, QTC 2-3 hrs after 5 doses, double every 3 days
+Class III Antiarrhythmics
Dofetilide
- _ _ _, D_____
- Drug interactions with? (1)
- Contraindicated in pts with (2)
- ______ mandatory for initiation, obtain QTC _-_ hrs after ____* of the first __ doses
- Does ___ increase ______ in pts with HF
- TdP, Diarrhea
- CYP 3A4 inhibitors
- QTC > 440msec, CrCL < 20ml/min (renally eliminated)
- Hospitalization, 2-3, EACH*, 5
- NOT, increase MORTALITY
Adenosine
- Indications (2)
- Do not give fo runstable or irregular ____morphic ____ complex tachycardia bc may cause degeneration to what heart rhythm?
- Half life:
- Rapidly removed from plasma through cellular elements of the ____ and by the uptake of the vascular _____ wall
- AE
- Cardiac (2)
- Non-Cardiac (3)
- SVT, sinus tachycardia
- polymorphic, wide -> Vfib
- 0.6-10 secs
- blood, endothelial
- AE
- bradycardia, cardiac arrest
- flushing, bronchospasm, HA
Dyslipidemia
Cholesterol (______)
- Essential component of cell _____
- Precursor to ____ compounds
- Derived from ____ and ____ absorption
- Fuel used to generate energy for ____ contraction and _____ reactions
Lipoproteins
- membranes
- steroid
- liver, diet
- muscle, metabolic
Adult Treatment Panel III: Lipid Classification (no on exam)
-
LDL
- Optimal:
- Near optimal/above optimal:
- Borderline high:
- High:
- Very High:
-
HDL
- Low:
- High:
-
Total Cholesterol
- Desirable:
- Borderline high:
- High:
-
Triglycerides
- Normal:
- Borderline High:
- High:
- Very High:
+Drug Therapies for Dyslipidemia
(6)
- HMG-CoA reductase inhibitors
- Niacin
- Fibrates
- Cholesterol absorption inhibitors
- Omega-3 fatty acids
- PCSK9 Inhibitors
HMG CoA Reductase Inhibitors
MOA
Otherwise known as “_____”
Inhibits enzyme responsible for coverting HMG-CoA to mevalonate (rate-limiting step in production of cholesterol)
“Statins”
HMG CoA Reductase Inhibitors
Indications
Drug of Choice for LDL reduction
- Also significantly reduces death and recurrent MI in pts with CAD
+HMG CoA Reductase Inhibitors
(4)
Atorvastatin (Lipitor)
Pravastatin (Pravachol)
Simvastatin (Zocor)
Rosuvastatin (Crestor)
+HMG CoA Reductase Inhibitors
- Lowers ___ concentrations (24-60%)
- Lowers ___ concentrations (7-40%)
- ____ HDL concentrations (5-15%)
- LDL
- TG
- Raises
HMG CoA Reductase Inhibitors
AE
- ___pathy - ____ aches, pains -> r______
- Increased ____ enzmes -> fulminant hepatic ____
- New onset _____ (w high intensity therapies)
- Myopathy -> Muscle aches, pains -> rhabdomyolysis
- liver -> failure
- diabetes
HMG CoA Reductase Inhibitors
Contraindications (2)
Severe active liver disease
Pregnancy
HMG CoA Reducatse Inhibitors PK
+HMG CoA Reductase Inhibitors
Drug Interactions
- CYP3A4 substrates (3)
- Avoid strong CYP3A4 _____
- Preferable to use (2)
- _______: Increased risk of myopathy/rhabdo when coadministered with statins (risk is greater with g_____ than with f_____)
- ______: doses > __g/day increases risk of myopathy/rhabdo
- simvastatin, atorvastatin, lovastatin
- inhibitors (GRAPEFRUIT JUICE)
- pravastatin, rosuvastatin
- Fibrates, gemfibrozil, finofibrate
- Niacin, >1g/day
Niacin
MOA
Inhibits mobilization of free fatty acids from peripheral adipose tissue to the liver
Niacin
Effects on lipids:
- Lowerls LDL concentrations (__-__%)
- Lowers TG concentrations (__-__%)
- Raises HDL concentrations (__-__%)
- 15-25%
- 20-50%
- 15-25%
Niacin
(3)
Niacin (immediate release niacin)
Slo-Niacin (sustained release niacin)
Niaspan (extended release niacin)
Niacin
AE
- ____glycemia/glucose ______
- Hyper______
- ___ distress (so take with ___ to lessen effects)
- Increased hepatic ______ (______ release appears to be more hepatotoxic than other preparations)
- F______
- extended and sustained release are ____ likely to cause flushing
- Minimized with ___ or ____ 30 min prior to niacin, taking at ___ time, and avoiding ___ beverages, ____ foods, and __ showers at time of admin
- Hyperglycemia, glucose intolerance
- Hyperuricemia
- GI, food
- Transaminases (sustained)
- Flushing *its terrible! i call BS on asa/ibup helping
- less
- ASA, Ibuprofen, bed, hot, spicy, hot
+Fibrates
MOA
Reduces rate of lipogenesis in the liver
+Fibrates
Effects on lipids
- Lowers LDL concentrations with normal TG (__-__%)
- Raises LDL concentrations with very high TG (__%)
- Lowers TG concentrations (__-__%)
- Raises HDL concentrations (__-__%)
- 2-20%
- 45%
- 30-55%
- 18-22%
- Excessively high triglycerides for a long period of time -> pancreatitis*
- So a lot of times used to prevent pancreatitis more than cholesterol*
+Fibrates
Agents (2)
Gemfibrozil (Lopid)
Fenofibrate (TriCor)
Fibrates
AE (4)
Contraindications (1)
- Dyspepsia
- Gallstones
- Myopathy
- Increased hepatic transaminases
- Severe renal or hepatic disease
+Cholesterol Absorption Inhibitors
MOA
Inhibits cholesterol absorption by the small intestine
+Cholesterol Absorption Inhibitors
(1)
Ezetimibe (Zetia)
+Cholesterol Absorption Inhibitors
Effects on Lipids
- Lowerls LDL concentrations (__-__%)
- Raises HDL concentrations (_-_%)
- Lowers TG concentrations (__-__%)
- 18-20%
- 1-5%
- 7-17%
+Cholesterol Absorption Inhibitors
Contraindications
- Active liver disease
- Possibly increased cancer risk, evidence conflicting
Omega-3 Fatty Acids
MOA
Uknown (reduction in TG synthesis)
+Omega-3 Fatty Acids
(2)
Lovaza
Vascepa
Prescribed not OTC
Omega-3 Fatty Acids
- Lowers TG concentrations (__-__%)
- May raise LDL concentrations when TG concentrations are very high - only _____ (__%)
- Raises HDL concentrations - only _____ (__-__%)
- 26-45%
- Lovaza, 45%
- Lovaza 11-14%
+Vascepa
FDA approved for?
(What type of med is it)
CV risk reduction
Omega 3 Fatty Acid
Omega-3 Fatty Acids
AE
Lovaza (3)
GI (burping, taste perversion, dyspepsia)
Inhibition of platelet aggregation
Bleeding
+PCSK9 Inhibitors
MOA
- mAb binds clirculating PCSK9 and prevents d_____ of _____
- _____ LDLR -> so they can _____ blood ____-C
- __-__% LDL as a _____*
- prevents degradation of LDLR
- increases LDLR -> clear LDL
- 50-70% , monotherapy
- Newest drugs*
- Inreasing recycling of LDL receptors that clears LDL*
Statins vs PCSK9 Inhibitors
Who may need PCSK9 Inhibitors?
(3)
- Statin intolerant
- Genetic disorder (FH)
- Uncontrolled on statins
Average Annual Cost of Therapy
+PCSK9 Inhibitors
(2)
Evolocumab (Repatha)
Alirocumab (Praluent)
+Evolocumab (Repatha)
- Route
- _____ mg every 2 weeks
- _____ mg once monthly
- Is it FDA labeled for prevention of CV?
- Guideline recommended with ______
- SQ
- 140
- 420
- YES FDA labeled for prevention of CV events in pts with established ASCVD
- statins
+Alirocumab (Praluent)
- Route
- ___ mg every 2 weeks
- ____mg monthly
- Is it FDA labeled for prevention/reduction in CV events?
- Guideline recommended with _____
- SQ
- 75mg
- 300mg
- No but still effective
- statins
+Major Recommendations for Statin Therapy for Atherosclerotic Cardiovascular Disease Prevention
