Cardio Flashcards
Chronic stable angina sees ____ changes in ECG and ___ changes in troponin
no changes in ECG or troponin
unstable angina ECG and troponin
ST depression, no changes in troponin
what is the differentiating factor between ACS and nagina pectoris
ACE lasts >5 min + not relieved by NTG
what is the acute sx tx for stable angina
NTG up to 3x
what is the chronic symptom tx for stable angina
BB (often 1st line, esp in HF), DHP-CCBs (FANN - 1st line for uncomplicated ptx)
BB + ____ CCBs = avoid due to risk bradycardia, AV node block, fatigue
NDHP
to decrease mortality for stable angina, what should be started? what should be stopped?
ACEi/ARB, ASA (clopi if ASA intol), HD statin to target LDL <1.8
Stop HRT and NSAIDs
what should be started for treatment of NTEMI or unstable angina?
BMONAH
if a NSTEMI or UA patient is high risk, what should be considered?
angioplasty
what should be started within 24hrs post NSTEMI, UA, STEMI
ACEi
what should be started for treatment of STEMI?
MONAH (BB once hemodynamically stable)
How long should anticoagulation be done in STEMI
start heparin in ER, continue for 48hrs or d/c at end of PCI procedure
what are some indications for PCI in STEMI
PCI facility available, cardiogenic shock, >75yrs, CI to thromboysis
if a thrombolysis is done for STEMI, what should be given after?
ACE, DAPT (ASA + clopi) F 1 yr, heparin for 48hrs, DVT prophylaxis until ambulatory
what are some post STEMI/NSTEMI management drugs?
ACEi, BB, HD statin
DAPT F1yr (clopi for thrombolysis, ticagralor for PCI)
which heparin is prefered in severe renal impairment
UFH
which LMWH is the DOC for STEMI w/ fibrinolysis
enoxaparin
which anticoagulant is the DOC for STEMI + PCI
UFH
which anticoagulant is the DOC for NSTEMI/UA as part of BMONAH
enoxaparin
which antiplatelets are reversible
clopi and prasugrel
clopi, ticagralor are metabolized by which CYP enzymes
clopi = 2C19
ticagralor = 3A4
what is an AE of clopidogrel
rash
what is an AE of ticagralor
dyspnea
what are the 2 high potency statins
rosuvastatin, attorvastatin
if a patient develops HIT and severe renal impairment, what is the best choice for anticoagulation in DVT?
argatroban- no renal adjustment required
PE sx
dyspnea, pleuritic pain, cough, syncope, tachypnea
what is elevated in PE and DVT
ESR/CBW and D dimer
what is heparin induced thrombocytopenia
low platelet blood counts due to heparin tx which predisposes pts to thrombosis (thrombin generation)
what is type 1 HIT + how to tx + onset
nonimmune mediated, onset 1-4d, observation only
what is type 2 HIT, onset, how to correct
immune mediated + platelets fall 30%
onset 5-10d after start of heparin
stop heparin + start alternative nonheparin anticoagulant agent (DOAC, fondaparinux, bivalirudin)
tx fro at least 4 wks if no thrombosis, 3mths if thrombosis
what is initial tx for VTE
any of the following; fondaparinux, apixaban, rivaroxaban, UFH, LMWH
what is ongoing tx for VTE if there is no malignancy
DOACs, warfarin
what is ongoing tx for VTE if there is malignancy
LMWH or DOACs
what are the LMWHs
dalteparin and enoxaparin
when to use UFH
severe renal impairment, high risk bleed who may require rapid reversal, recently received thrombolytic tx
what is the antidote for LMWH and UFH
protamine sulphate (not complete reversal in LMWH)
why is LMWH preferred to UFH
is more predictable anticoagulation dose response, loss HIT, less routine monitoring and major bleed risk
warfarin is metabolized by CYP ___(3)
2C9, 1A2, 3A4
what are some reversal agents for warfarin
vit K, octaplex, fresh frozen plasma
how to bridge warfarin
LMWH/UFH for at least 5 days + until INR at least 2 for 2 days in a row
what is dabigatran dosing
<80yrs: 150mg BID
=>80yrs or >75yr + =>1RF for bleed: 110mg BID po
what is the reversal agent for dabigatran
idarucizumab
how to switch from warfarin to apixaban or dabigatran
stop warfarin, start A or D when INR <2
how to switch from warfarin to edoxaban or rivaroxaban
stop warfarin, start E or R when INR <2.5
how to switch from UFH to DOAC
stop UFH infusion, start DOAC immediately (edoxaban = wait 4hrs)
how to switch from LMWH to DOAC and vice versa
start other at time of next scheduled dose
how long should anticoagulation tx be for after VTE or PE
3 months
which anticoagulants are preferred in pregancy
LMWH (preferred), UFH also safe
which anticoagulants are safe in post partum
warfarin, LMWH, UFH (not DOACs)
which anticoagulants are not safe in pregnancy
warfarin and DOACs
concurrent use of ____ and warfarin results in falsely elevated INR
argatroban
after orthopedic surgeries, what anticoagulants may be given as VTE prophylaxis + how long
LMWH, DOACs, fondaparinux, ASA 81 for 14-35d postop
after nonorthopedic surgeries, what anticoagulants may be given as VTE prophylaxis + how long
LMWH, UFH at least until discharge
which is not safe in postpartum: warfarin or DOACs
DOACs
which DOACs should be avoided if CrCL <15
DARE
what DOACs should be avoided if CrCL <30
dabigatran (ARE = renal adjustment)
which DOAC must be taken w/ food
rivaroxaban
reduce dabigatran dose to 110mg BID if
> 80yrs old or >75yrs + 1 RF for bleed
when to reduce edoxaban dose to 30mg?
if wt <60kg
which anticoagulant is not appropriate in both STEMI + PCI or severe renal impairment
fondaparinux
what is the HAS-BLED score stand for
HPTN, abnormal kidney or liver, hx stroke, hx bleed, hx labile INR, elderly >65yrs), drugs (NSAIDs, ASA)
in what kind of AF is warfarin 1st line
valvular AF or mod-severe mitral stenosis or presence of mechanical heart valve
when should you use OAC in AF pts
if =>65yrs, stroke, TIA, DM, HPTN, HF
when should you use only antiplatelet tx in AF pts
if only CAD or PAD
in elective PCI without high risk features for thrombosis, what is the tx?
clopidogrel + OAC for 1-12mths post PCI, then just OAC
in ACS w/ PCI or elective PCI w/ high risk features of thrombosis, what is the tx?
triple tx w/ ASA + clopi + OAC for 1d-1mth, then just clopidogrel + OAC for up to 12mths post PCI, then just OAC
in ACS (unstable angina) without PCI, what is the tx?
OAC + clopidogrel for 1-12mths post ACS, then just PAC
in persistent AF, what is the preferred start?
rate control (BB, ND-CCB)
when in AF is the preferred start rhythm control?
if recently dx AF <1yr, highly symptomatic or significant QoL impairment, multiple recurrences, difficulty achieving rate control, arrhythmia induced cardiomyopathy
what is used for rhythm control if LVEF =<40%? what if it is >40%
<40%: amiodarone only
>40% = amiodarone or sotalol
what may be used for rhythm control if pt does not have HF, but has CAD
sotalol, amiodarone, dronedarone
how to use the pill in pocket antiarrhythmic drug tx?
start w/ IR AV nodal blocker (diltiazem, verapamil, or metoprolol) 30 min before a class 1c antiarrhythmic (flecainide or propafenone)
remain seated for 4hrs or until episode resolves
what needs to be monitored for amiodarone tx
TSH at baseline and q3-6mths
CXR yearly due to pulmonary fibrosis
LFTs q6mths
HFrEF is mainly due to
not pumping enough, CAD problem
HFpEF is mainly due to
not filling enough, HPTN problem
which of the following HF meds are CI for T1DM; SGLT2i, BB, ARNIs
SGLT2i (empa/dapaglifloxin
T or F: ARNIs do not have a dry cough AE
T
what is the washout period from ACE to ARNI
36hrs
which 2 meds may reduce hospitalizations in HFpEF
candesartan and ARNI
which diuretic should be used if pt w/ HFrEF has sulfonamide allergies
ethanoynric acid
what to do in acute decompensation of HF
high dose loop diuretics (furosemide), start BB once stable or continue if already on
when to use ivabradine in HF
for HFrEF if HR >70 bpm despite quad tx and are in sinus rhythm
BB are CI in
> 1st degree heart block without a pacemaker
how to treat HFpEF patients?
may use ARNI/ARB/ACI for HPTN
candesartan and ARNI may reduce hospitalizations
loop diuretic may be used if reducing fluid retention
what is the tx algo for ischemic stroke?
within 4.5hrs? - yes = see if meets t-PA criteria + start alteplase (tenectaplase alt)
doesn’t meet criteria = EVT
>4.5hrs or not eligible for EVT = admit to stroke unit
T or F: EVTs can be performed in pts who have had alteplase tx
T
in tPA tx, ASA 160mg should be admin at least ___ hrs after alteplase, once _____________
24hrs
CT excludes intracranial hemorrhage
what is the target door to alteplase time
<60min
what is the tx BP fo pre-t-PA tx
SBP <185, DBP <110
which 3 agents are preferred to lower BP pre-t-PA
labetalol, hydralazine, NTG patch
during t-PA tx, if SBP > ____ or DBP > _____ for 2 or more readings, continue IV labetalol/ hydralazine/ nitro patch and add enalapril IV if needed
SBP >180
DBP >105
if the patient is not already on antiplatelet tx prestroke + not going to receive alteplase _____ should be done once CT excludes hemorrhage, then ________
AS 160mg loading dose, then LD ASA for secondary prevention
in acute, high risk TIA or minor ischemic stroke pts who are not at high risk of bleed, ________ may be considered for ________ followed by ___________ as post TIA management
DAPT w/ ASA and clopidogrel for 3-4wks, then ASA monotx
in pts receiving alteplase, how long must you wait before starting antiplatelet tx
24hrs post thrombolysis CT scan excludes intracranial hemorrhage
what medications should be started after stroke for secondary prevention
statins LDL <1.8
ACEi + thiazide diuretic once stable
antiplatelet tx
what antihypertensive class should be avoided in blacks
ACEi/ARBs
which combo is preferred: ACE + DHP CCB or ACE + thiazide/ thiazide like diuretic
ACE + DHP CCB
what is classified as a high risk patient for HPTN
=>50yrs and SBP >130 and => CV RF such as:
1. clinical or subclinical CVD
2. CKD (nondiabetic nephropathy, proteinuria, eGFR <60)
3. est 10yr global CV risk =>15%
4. =>75yrs
what is the target time for fibrinolysis
<30 min (ideally 90 min, ok 120min)
what is the time frame for t-PA
<4.5hrs
how to do perioperative warfarin management if high thromboembolic risk
bridging w/ LMWH for 3 days pre-op + stop 24hrs before, warfarin stopped 5 days pre-op, get INR value 24hrs before surgery
how to do emergent warfarin reversal
IV vit K + octaplex (reversal starts in 2hrs, full in 24hrs)
what to do if INR is <0.5 out of range for warfarin
see if you can identify cause, may increase or hold by 0.5-1 dose, then repeat INR in 1-2 wks
what is the target LDL for LDL =>5 on statin + what to add if not at target after max dose statin
LDL 50% reduction or =<2.5
if not = + ezetimibe
what is target LDL for DM and CKD + what to add if not at target after max statin dose
LDL =<2.0
if not = + ezitimibe
what is the target LDL for ACSVD + what to add if not at target after max statin dose
LDL <1.8
if LDL 1.8-2.2 = + ezetimibe
if LDL >2.2 = + PCSK9i
what is the most potent LDL lowering agent
LCSK9i (evolocumab, alirocumab)
what is the most potent TG lowering agent
fibrates
which dyslipidemia agents are not associated w/ myalgias
cholestyramine and bile acid sequestrants
which statins are metabolized by 3A4
SAL
which statins are metabolized by 2C9
RF
