Cardio Chronic Flashcards
HFrEF cutoff
EF < 40%
chemo agents that cause cardiomyopathy
5FU
Cytoxan high doses
anthracyclines
trastuzumab
mitoxantrone
HFpEF cutoff
> 50%
Five first line agents for HFrEF
ACE-I / ARB / ARNI
Beta Blockers
MRA (Spironolactone)
SGLT2A
Loops, then thiazides
HF type and problem
rEF = pumping problem (usually cardiac heart disease)
pEF = filling problem (usually HTN)
ACEI Mechanisms
prevents remodeling
vasodilation
ACEI Renal Harm
dilates renal arteries so if you dilate the arteries the blood flow is reduced and may temporarily harm kidneys
>30% increase is ok
ACEI Target Doses HFrEF
captopril 50mg TID
enalapril 10mg BID
lisinopril 20mg daily
Perindopril 8mg daily
ramipril 10mg daily
trandolapril 4mg daily
ARNI Dosing
97/103mg HFrEF target dose
ARB Dosing HFrEF
Candesartan 32mg daily
losartan 150mg daily
valsartan 160mg BID
sacubitril MOA
inhibits neprilysin to increases natural diuresis
washout period from ACE to ARNI
target dose ACEI requires a 36 hour washout period
Beta blockers used in heart failure
Toprol
Carvedilol
Bisoprolol
Beta Blocker Target Doses HF
Bisoprolol 10mg daily
carvedilol 25mg BID
carvedilol CR 80mg daily
toprol 200mg daily
Beta blocker MOA HF
decreased ventricular arrhythmias
decrease hypertrophy
decrease HR
carvedilol vasodilation to lower BP better
spironolactone EF cutoff and CrCl cutoffs, sCr cutoffs
EF < 35% and shouldn’t use if CrCl <30ml/min
men sCr <2.5, women sCr <2.0
MRA dosing and CrCl cutoffs
eGFR > 50:
eplerenone 50mg daily
spironol. 25mg daily or BID
eGFR<50:
eplerenone 25mg daily
spironolactone 12.5-25mg daily
SGLT2 eGFR cutoffs in HF
dapagliflozin >30
empagliflozin >20
SGLT2-I MOA in HF
diuresis
reduce arterial pressure
reduce heart hypertrophy and fibrosis
SGLT2-I Dosing
dapagliflozin and empagliflozin 10mg daily
Hydralazine/
Isosorbide dinitrate
indicated primarily for black people especially if cannot tolerate an ACE/ARB
reduced pulmonary congestion
hydralazine/
Isosorbide combo MOA
hydralazine arterial vasodilation
isosorbide venous vasodilation
BiDil dosing
37.5mg/20mg start 1 tab TID, goal 2 tab TID
hydralazine/Isosorbide worst ADR
drug-induced lupus
medication class for HFrEF that does not improve mortality rates
diuretics - symptom relief only
monitoring with loops when used for HF
K >4
Mag >2
bicarb for alkalosis
sCr and BUN
starting and max doses of loops in HF
lasix 20-40 daily or BID, max 600mg
bumetanide 0.5-1 daily or BID, max 10mg daily
torsemide 10-20mg daily, max 200mg
thiazides diuretics starting and max doses
HCTZ 25mg daily or BID, max 200
chlorthalidone 12.5-25mg daily, max 100
metolazone 2.5mg daily - 20mg
chlorothiazide 250-500mg daily or BID, max 1000mg
loop conversions
furosemide 40mg = bumex 1mg = torsemide 10-20mg = ethacrynic acid 50mg
ivabradine
use when all recommended agents are maxed (beta blockers esp.), reduces mortality is stable chronic symptomatic HF, in sinus rhythm and HR > 70 at rest
ivabradine site of action
SA node reduces conduction to decrease HR
ivabradine dosing
start at 5mg BID w/meals unless > 75yo
increase by 2.5mg until max 7.5mg BID
base dosing on HR if >60
ivabradine worst side effects
low BP and HR
arrhythmias
transient rings or spots of light in the visual field
digoxin place in HFrEF
add on after 2nd line
no increased mortality benefit
decreased hospitalizations
digoxin dosing
0.125mg daily, may do every other day in some cases:
- over 70 yo
- renal dysfunction
- low lean body mass
digoxin [x] increased by…..
clarithromycin, erythromycin
amiodarone (cut dose in 1/2)
dronedarone (cut dose in 1/2)
itraconazole, posaconazole
cyclosporine, tacrolimus
verapamil
digoxin goal serum [x]
0.5 - 0.9 ng/ml
measure trough or 6-8 hrs after last dose
electrolytes that increase digoxin levels
hypokalemia
hypomagnesemia
hypercalcemia
signs of digoxin toxicity
nausea
vomiting
vision changes
antiarrhythmics DOC for HFrEF
dofetilide or amiodarone
drugs to avoid in HFrEF
cilostazole, itraconazole
water and Na retention:
-NSAIDs, corticosteroids, minoxidil, TZD’s
negative inotropes:
- verapamil, diltiazem - Amlodipine and felodipine ok
- antiarrhythmics (except amiodarone or dofetilide)
amphetamines
metformin - increased lactic acidosis
lyrica
sodium goals in HF
<1500mg in A and B
<3000mg in C and D
fluid restrictions in HF
if serum Na is low in D
may restrict to 1.5 - 2 L/day
avoid non-DHP CCB’s if what disease state is present?
left ventricular systolic dysfunction
possible DOC in Afib if uncontrolled HR and decompensated HF
digoxin
cardio version of Afib and anticoag use
should do a TEE (prove no thrombus) OR treat with warfarin or DOAC’s x 3 weeks prior
then continue x 4 weeks after
List of I A anti-arrhythmics, channel and site of action
disopyramidine
quinidine
procainamide
sodium channels
atrial and ventricular
List of I B anti-arrhythmics, channel and site of action
Lidocaine
Mexilitene
ventricular only
sodium channels
List of I C anti-arrhythmics, channels and site of action
Flecainide
Propafenone
sodium channels
SVT use only
List of Class II Anti-arrhythmics
beta blockers
List of Class III Antiarrythmics, channels and site of action
Potassium Channels, Atrial and Ventricular
amiodarone
dofetilide
dronedarone
ibutilide
sotalol
List of Class IV anti-arrhythmics, channels, and site of action
verapamil
diltiazem
Ca channels
atrial and ventricular
anti-arrhythmics that can cause torsade’s and QT prolongation
Class I A and C Sodium Channel Blockers
anti-arrhythmics that cause decompensated HF
procainamide
disopyraminidine
I C channel blockers
dronedarone
adjust anti-arrhythmics for renal/hepatic dysfunction
procainamide
lidocaine
dronedarone
sotalol
dofetilide
typical classes for a fib
IC and III
flecainide
propafenone
amiodarone
dofetilide
dronedarone
ibutilide
sotalol
Class I C notes in Afib
should use with beta blockers or ca channel blockers for AV nodal blockade
contraindicated if structural heart disease
amiodarone drug interactions
digoxin - lower by 50%
warfarin - lower by 50%
simvastatin/lovastatin - do not exceed 20/40mg
bradycardia - beta blockers, Non DHP CCB, clonidine, ivabradine
sotalol notes
Class III anti-arrhythmic
renal change from BID - daily if CrCl <60ml/min
initiate in hospital
Contraindicated in any HF, CrCl <40ml/min, QTc >450, and 2nd/3rd degree heart block
for maintenance only, not cardioversion
dofetilide notes
starting dose is based on renal function: usual is 500mcg BID >60ml/min
contraindicated if QT >440, CrCl <20
cardioversion possible even in HF
dronedarone
amiodarone w/o iodine
less thyroid toxicity
400mg BIDM
slight scr increase-reversible
drug interactions w/dofetilide
Avoid: cimetidine, verapamil, conazoles, HCTZ, prochlorperazine, megestrol, dulotegravir, bactrim
3A4 inhibs watch: triamterene, metformin, amiloride
dofetilide renal dosing guidelines
CrCl >60 - 500mcg BID
40 - 60 - 250mcg BID
20 -39 - 125mcg BID
dofetilide dose adjustments in hospital
QTc > 500 (>550 ventricular conduction abnormalities) or baseline change >15% reduce by 50%
measure peak 2 to 3 hours after dose is administered
dronedarone contraindications
permanent afib
NY HF Class 1-3 w/recent hospitalization
HY HF Class 4
2nd/3rd degree heart block
sick sinus rhythm w/o pacemaker
severe liver impairment
HR < 50 bpm
CYP 3A4 inhibitors
QTc prolonging drugs
pregnancy
QTc >500 ms
dronedarone interactions
digoxin - decrease dig dose by 50%
beta blockers, nonDHP and clonidine - excessive bradycardia
diltiazem/verapamil - increase [x] of dronedarone
stations - use very low doses
dabigatran - decrease dose to 75mg BID
avoid CYP 3A4 inhibitors
rejection agents - increases [x] of these
stages of hypertensions
Normal 120/80
Stage 1: 130-139 / 80-89 mmHg
Stage 2: >140/>90
Urgency > 180, >120
blood pressure goals
less stringent with 2nd stroke and low risk of heart attack in next ten years (<10%)
<140/90 all others are <130/80
HTN agent first line based on disease state:
diabetes: ACEI/ARB, CCB or thiazide
CKD: ACEI/ARB if albuminuria
Stroke/TIA: thiazide, ACE/ARB
coronary disease: BB and ACE/ARB
HFrEF: ACE/ARB/ARNI BB, spironolactone and then loops
HFpEF: diuretic, ACE/ARB, BB
thiazide notes
hypo - Na, K
aids osteoporosis by blocking calcium loss
hyperglycemia risk
ACEI/ARB notes
hyper- K
can’t use if bilateral renal artery stenosis
direct renin antagonist notes
aliskiren
don’t use with ACE/ARB if CrCl <60
contraindicated with pregnancy
don’t use with ACE/ARB if diabetic (hypoTN, hyper-K, renal impair)
DHP CCB Notes
Amlodipine, felodipine, nifedipine XL
peripheral edema, reflex tachycardia, orthostatic hypotension
Non-DHP CCB Notes
indicated primarily with afib or stable angina
contraindicated in heart block and sick sinus syndrome
black people HTN first line
Thiazide and CCB are first line
ACE and BB can be used with comorbid conditions requiring
drugs that counteract anti-HTN meds
estrogen birth control
stimulants
sympathomimetics - pseudophed
nsaids
what drugs do you have to have on board if you do hydralazine or minoxidil for resistant BP?
beta blockers and diuretic
order of diuretics for HTN in resistance
thiazide is first until eGFR < 25-30
add spironolactone/eplerenone
switch to loops once CrCl <30
age to consider discontinuing statin if not tolerating well
75 years old
medications that increase LDL
amiodarone
diuretics
cyclosporine
glucocorticoids
medications that increase triglycerides
beta blockers
testosterone
atypical antipsychotics
cholesteramine
hormones
HIV
thiazides
raloxifene
statin dose for CVD risk
very high risk patients: high intensity, add ezetimibe if LDL still >70, add PCSK9 if LDL still >70 or nonHDL >100
statin dose for severe hypercholesteremia
considered LDL >190
max tolerated statin
add ezetimibe if LDL does not drop 50% or LDL still >100
add PCSK9 if baseline >220 or LDL still >130
statin dose for DM
<40 - no need unless high risk CVD
40 - 75 moderate unless multiple risk factors, add zetia if CVD risk >20%
>75 yo - continue or withdrawal based on risk/benefit
statin dose for primary CVD prevention
based on risks from calculator
<7.5% lifestyle changes or could do moderate if worth it
7.5 - 19.9% - moderate, can add zetia if need additional lowering but cannot tolerate increase, goal decrease 30-49%
>20% high intensity, goal decrease 50%
% decrease in triglycerides from different meds
Fish oil: 19 - 44%
statins: 7-30%
fibrates: 20-50%
niacin: 20-50%
ezetimibe: 5-11%
what level is severe triglyceridemia
> 500
coronary artery calcium risk and statin therapy
0 - no statin (unless family member w/early heard attack, DM, or smoker)
1-99: statin if >55yo
>100: statin
low intensity statin
simvastatin 10mg
lovastatin 20mg
pravastatin 20mg
fluvastatin 40mg
moderate intensity statin
simvastatin 20+
rosuvastatin 5-10
pravastatin 40+
lovastatin 40+
pitavastatin any dose
fluvastatin 80+
atorvastatin 10-20
high intensity statin
atorvastatin 40+
rosuvastatin 20+
statin drugs w/most interactions
lovastatin and simvastatin
statin w/fewest drug interactions
rosuvastatin
statin cutoff for MOST renal dosing
CrCl < 30ml/min
statin with no renal impairment
atorvastatin
PSCK9 mechanism of action
increase clearance from liver
PSCK9 drug names
aliroscumab and evolocumab
contraindications for bile acid sequestrants
bile duct obstruction
triglycerides >400
separate bile acid sequestrants from drugs by how many hours
1-2 hours before or 4 hours after bile sequestrants can you take other medications
fibrate drugs and precautions
gemfibrozil and fenofibrate
may raise LDL if TG’s are very high
may cause gallstones
Fish oil notes
icosapent ethyl Is not DHA component
good outcomes in LDL lowering
may raise LDL if TG are high
bempedoic acid
not as good of LDL lowering and raises HDL
causes gout, leukopenia, thrombocytopenia, tendon rupture
treatments for all patients with CHD
A = angina and ASA
B = beta blocker and blood pressure
C = cigarettes and cholesterol
D = diabetes and diet
E = exercise and education
goals for weight and exercises for Heart Disease
BMI <25 kg/m2
waist <40” males and 35” females
only P2Y12 indicated for stable ischemic heart disease
clopidogrel
stable ischemic heart disease, PCI w/bare metal stent
ASA 81mg daily
Plavix 1 mo but may extend if low risk of bleeding
stable ischemic heart disease, PCI w/ drug eluting stent
ASA 81mg daily
plavix for 1 year, 6 mo if bleed risk, 3 mo if severe bleed risk
Ranolazine for heart disease
inhibits sodium channels to reduce calcium influx, and decrease tension and oxygen consumption
use w/ beta blocker, CCB, and/or nitrates if others don’t manage symptoms
can add this when you cannot go up high enough on other meds
ranolazine warnings
3A4 substrate
not if hepatic dysfunction
max is 500mg BID if CCBs, fluconazole or grapefruit juice
stable angina medications
first line beta blockers (goal HR 55 - 60)
Non-DHP CCB contraindications
sick sinus syndrome w/o pacemaker
HFrEF
severe bradycardia
high degree AV block
use w/beta blockers (though sometimes necessary) may induce a heart attack
