Cardiac Pt 2 Arrhythmia, Dyslipidemia Flashcards
1
Q
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 ____
A
- Supraventricular dysrhythmia , quiver
- X “kick”
- stasis, clot
2
Q
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
A
- strokes
- Warfarin
- Aspirin
- baseline
3
Q
+Vitamin K Antagonists
(1)
A
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*
4
Q
+Warfarin
MOA
- Inhibits synthesis of _____ _ dependent clotting _____ (4) and regulatory _____ (2)
- Prevents ______ and _______ of new thrombi
- No effect on? (2)
A
- Vitamin K, clotting factors (II, VII, IX, X), proteins C and S
- formation, propagation
- circulating clotting factors, formed thrombi
5
Q
+Warfarin
Therapeutic Uses
(3)
A
- DVT/PE
- Afib
- heart valve replacement
6
Q
+Warfarin PK
- Bioavailability > __%
- Onset __-__hrs (full effect takes __-__ days)
- Duration ~ __-__ days
- Metabolism through what?
- _____ variations in these isoenzymes
- interpatient _____ in ___ requirements
- Highly _____ bound (~90%)
A
- 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
7
Q
+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?
A
- 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
8
Q
+Warfarin
AE (4)
A
- Bruising
- Bleeding
- Skin necrosis
- Teratogenic
CANNOT TAKE IN PREGNANCY
9
Q
+Warfarin
Drug and Food Interactions
A
Many drug-drug interactions
Drug-food interactions with foods high in Vitamin K - reduces effect of Warfarin (green leafy vegetables, chickpeas, tea)
10
Q
+Reversal of Warfarin
What medication?
- Promotes the ____ formation of _____ required for normal _____
- Onset of action
- PO: __-__ hrs
- IV: __-__ hrs
- AE (1)
- Caution with?
A
Vitamin K
- hepatic, factors, clotting
- Onset
- 6-12 h
- 1-2 h
- Hypersensitivity with rapid IV admin**
- Reinstitution of warfarin therapy
11
Q
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 =
A
-
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
12
Q
+Afib Algorithm
- Mechanical heart _____ or moderate or severe mitral ______
- If yes -> What meds?
- If no -> Estimate ____ risk based on (2) risk factors
A
- valves, mitral stenosis
- VKA (IA)cd
- Stroke, CHA2DS1 - VASc risk factors
for heart valves and mitral stenosis -> straight to warfarin
13
Q
+Afib Algorithm
- If 0 risk factors =
- If 1 risk factor =
A
- No antiplatelet or anticoagulant tx (IIIB)
- Rare- only for pts with only AFIB and nothing else
- OAC should be considered (IIaB)
14
Q
+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)
A
-
> 2
- OAC, contraindications, bleeding
- LAA occluding
- NOAC
- VKA
- OAC, contraindications, bleeding
15
Q
+Afib Algorithm
NOAC (4)
A
Non Vitamin K Antagonist Oral Anticoagulants
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
16
Q
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_____
A
- Depolarization, Repolarization
- fast, 2 types: L, T
- Resting, Open, Inactivated or Closed
17
Q
Antiarrhythmic Medications
- Class I = ______ channel blockers
- Class II = BB (Propranolol, Metop, Esmolol)
- Class III = ______ channel blockers
- Class IV = CCB (Verapamil, Diltiazem)
- Misc = Digoxin, Adenosine
A
- Class I = Sodium Channel Blockers
- Class III = Potassium Channel Blockers
18
Q
Class I Sodium Channel Blockers
- Class Ia
- Quinidine (Quinidex)
- Procainamide (Procanbid)
- Disopyramide (Norpace)
- Class Ib
- ________
- Mexiletine (Mexitil)
- Class Ic
- ________
- ________
A
- Class Ia
- Class 2a
- Lidocaine (Xylocaine)
- Class Ic
- Flecainide (Tambocor)
- Propafenone (Rythmol)
19
Q
Class III Potassium Channel Blockers
(3)
A
Sotalol (Betapace)
Amiodarone (Cordarone)
Dofetilide (Tikosyn)
20
Q
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
A
- 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
21
Q
Clas Ic Antiarrhythmics
Flecainamide
- D_____, tr____, acute decompensated heart ____ (negative inotropic effects)
- Contraindicated in pts with __ __, C _ _, _____ disease
- Drug interaction with _______
A
- Dizziness, tremor, HF
- HF, CAD, Valvular disease
- Digoxin
22
Q
+Amiodarone (Cordarone)
- Possess pharmacologic effects from ___ ____ Vaughn Williams Classes
- Blocks _____, ______, _____ channels
- Anti____ properties
- Drug of _____* in patients with ____ ____*
- Used in (2)
A
- all three
- sodium, potassium, calcium
- adrenergic
- choice*, heart failure
- atrial and ventricular arrhythmia
23
Q
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)
A
- 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*
24
Q
+Amiodarone
AE
A
Although is not very cardiotoxic in HF - effects literally every other organ in our body
25
Q
+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
A
- 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
29
Q
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:
A
37
Q
HMG CoA Reducatse Inhibitors PK
A
56
Q
+PCSK9 Inhibitors
MOA
- mAb binds clirculating PCSK9 and prevents d_____ of _____
- _____ LDLR -> so they can _____ blood ____-C
- __-__% LDL as a _____*
A
- prevents degradation of LDLR
- increases LDLR -> clear LDL
- 50-70% , monotherapy
- Newest drugs*
- Inreasing recycling of LDL receptors that clears LDL*
57
Q
Statins vs PCSK9 Inhibitors
A
58
Q
Who may need PCSK9 Inhibitors?
(3)
A
- Statin intolerant
- Genetic disorder (FH)
- Uncontrolled on statins
59
Q
Average Annual Cost of Therapy
A
63
Q
+Major Recommendations for Statin Therapy for Atherosclerotic Cardiovascular Disease Prevention
A
