Cardio Week 1 Flashcards
Examples of acute coronary syndrome?
Unstable angina
MI
Usual cause of coronary heart disease?
Atherosclerosis
Two other terms for coronary heart disease?
Coronary artery disease
Ischemic heart disease
Types of cardiovascular disease (7)?
Coronary heart disease
Cerebrovascular disease
Peripheral artery disease
Rheumatic heart disease
Congenital heart disease
DVT
PE
All-cause Mortality refers to?
Whether statin therapy Increases the risk of death from non-coronary causes more than it reduces coronary heart disease (CHD) death.
Major coronary events include?
Non-fatal MI
CHD
Secondary prevention using Statin therapy is most applicable to which patient population?
Those with acute coronary syndrome. History of unstable angina or MI.
Thiazide diuretics work here?
Distal convoluted tubule
Thiazide diuretics do this?
Inhibit tubular reabsorption of Na, Cl, K ions
Dilate the arterioles via direct relaxation
First line tx for hypertension? Dose?
HCTZ 12.5 mg OD
Dose that HCTZ reaches 80% of it’s effectiveness?
25mg OD
HCTZ treats this? (6)
Heart failure
Edema related to: Heart failure Renal dysfunction Cirrhosis Steroid therapy Estrogen therapy
Don’t use HCTZ for? (4)
Drug allergy
Anuria
Severe renal failure
Breastfeeding mothers
ADE of HCTZ?
dehydration electrolyte imbalances hyperuricemia insulin dose may need adjusting photosensitivity
Pts on HCTZ may need?
K supplementation
Serum electrolyte assessments
Insulin adjustments
Why is Chlorthalidone a pain in the butt?
Only comes in 5omg tabs
starting dose= 12.5mg (most effective SBP lowering)
25mg = most effective DBP lowering
Spironolactone is… (4)
Aldactone
a aldosterone receptor antagonist
a steroid
analogue (comparable to) aldosterone
Spironolactone works by:
inhibits aldosterone in collecting ducts
= loss of bicarbonate and calcium, conserves potassium and hydrogen (K sparing!)
Decreases Na reabsorption (water flows out of blood into tubules - follows Na)
Decreases K excretion (K sparing)
Spironolactone is…
A weak diurectic
A weak antihypertensive (compared to other diurectics)
Increases survival in HF
Potassium sparing
Drugs that can reach toxic levels if taken with diuretics ?
Digoxin
Lithium
This can lead to additive hypokalemia in pts taking thiazides diuretics?
Black licorice
Compound found in licorices root that causes increased Na and decreased K?
Glycyrrhetic acid
What do the adrenal glands secrete?
Aldosterone
Where does aldosterone exert its effect ?
Kidneys
Heart
Arteries
What does aldosterone do?
Increases BP by:
Increasing systemic vascular resistance (artery constriction)
Retains Na in the kidneys
Increased heart contractility, HR, BP
Ace inhibitors are the …?
“prils ”
Ramipril
Captopril
Lisinopril
Enalapril
ACEi lower BP by:
Reducing systemic vascular resistance
First line agents for BP tx?
Thiazide diurectics
ACE inhibitors
Captopril starting dose?
25mg daily
Capoten
Enalapril starting dose?
5mg daily
vasotec
Lisinopril starting dose?
10mg daily
Prinvil, Zestril
Ramipril starting dose?
2.5 mg daily
altace
Ace inhibitors such as ramipril reduce BP by what amount?
SBP = 8 DBP= 5
ACE inhibitors treat? (6)
First line for HTN
First line for heart failure (stopping aldosterone = decreased systemic resistance, decreased HR, decreased BP = lets the heart rest)
Cardio protection post MI
Renal protective in DM
Reduce GFR pressure
Reduce proteinuria = reduced diabetic nephropathy
BP meds not advised as 1st line in patients of African decent?
ACEi
ARBs
Who should not be given Vitamin K?
< 9 INR with no risk of bleeding
INR goal range and target for non-valvular atrial fib?
2.0- 3.0
Target= 2.5
Drugs associated with increased risk of bleeding for patients taking warfarin?
NSAIDS
antiplatelet agents
some antimicrobials
Some foods, herbal products
Recommended way of preventing drug/herbal interactions with warfarin?
check 2 drug resources
Antimicrobials that may interact with anticoagulants?
- amoxi-clav
- fluoroquinolones
- trimethoprim-sulfamethoxazale
- macrolides
- metronidazole
- azole antifungals
- tetracyclines
- rifampin
Cardiovascular medications that may react with anticoagulants?
amiodarone fenofibrate propafenone propranolol simvastatin
Cardiovascular medications that may react with anticoagulants?
amiodarone fenofibrate propafenone propranolol simvastatin
What CNS meds potentially react with anticoagulants?
Carbamazepine
SSRI
Tramadol
Risk factors for anticoagulant associated bleeding? (9)
Hx of GI bleed, thrombocytopenia, platelet dysfunction, active peptic ulcers
Uncontrolled hypertension
Renal or hepatic dysfunction
CV disease
Increased age
Labile or supratherapeutic INRs
Concomitant meds (NSAIDS, antiplatelets)
Excessive alcohol consumption
Malignancy
3 fold risk of bleeding when you take these 2 meds with warfarin?
ASA
Clopidogrel
Special circumstances where anticoagulants and antiplatelets are warrented?
1- intracoronary stent placement
2- acute coronary syndrome
What is a prescribing cascade?
A prescribing cascade occurs when a drug-related adverse event leads to the addition of a subsequent medication to treat
the adverse event
dihydropyridine Calcium channel blocker that studies show causes a 3-11% of peripheral edema?
Amlodipine
What is important to monitor for new oral anticoagulants?
Renal function
hepatic function
compliance
When to consider Warfarin? (9)
- Prosthetic heart valves or hemodynamically-significant valvular disease
- currently well managed on warfarin
- Stable coronary heart disease, placement of an intracoronary stent or acute coronary syndrome
- CYP- P450 3A4 and P‐glycoprotein drug interactions
- History of GI bleed
- Reversal needed
- Cost concerns
- Poor compliance
- Consider travel insurance
Transient Lifestyle changes that can affect INR levels?
Gastrointestinal illness
Missed or extra dose
Antibiotics
Recent increase of alcohol
Permanent changes that can cause fluctuations in INR?
Lifestyle change
Change in chronic medication
When should you not adjust warfarin doses?
previously stable INR for the last three months with a single INR that is within + or Minus 0.5 of therapeutic range
Recheck INR within 1 to 2 weeks
INR > 9.0
Urgently assess
Temporarily stop warfarin
Consider a vitamin K 2.5 mg orally, repeat in 24 hours if INR remains > 9
Once I know it is in therapeutic range of 2 to 3
Decrease weekly dose by 20%
INR < 1.5
Give one extra dose (equivalent to 20% of weekly dose).
Increase weekly dose by 10 to 20%
INR 1.5-1.9
Increase weekly dogs by 5 to 10%
INR 3.1- 3.5
Consider decreasing weekly dose by 5 to 10%
INR 3.6 to 4.9 (without bleeding)
Hold one dose
Decrease weekly dose by 10-20%
INR 5.0 - 9.0
Hold 2 doses
Decrease weekly dose by 10 to 20%
Which meds are dual action alpha and beta blockers?
Labetalol
Carvedilol
What does the alpha 1 receptor blockade cause?
Vasodilation
What does the beta 1 receptor blockade cause?
Decreased HR
2 drugs used for epilepsy, pain and anxiety that are calcium antagonists?
Pregabalin
Gabapentin
Cardiac drugs that are Ca antagonist?
Diltiazem
Verapamil
Nifedipine (dihydropyridines)
What does ASA do?
Tx suspected:
MI
TIA
Embolic stroke
Prevention of MI and STROKE in prosthetic heart valve
ASA is a 1st line :
Anti platelet option for secondary prevention in ischemic stroke
Clopidogrel dosing?
300 mg initial dose
Then 75mg daily
What drug may decrease effectiveness of clopidogrel?
Omeprazole
What class of enzyme might increase clopidogrel metabolites and increase bleeding risk?
CYP2C19 inducers
Normal aPTT?
Normal: 25-35 seconds
Therapeutic: 55-80 seconds
How long to stop plavix ahead of surgery?
5-7 days
How long to stop heparin prior to surgery?
24-48 hrs (pt dependent)
90 min half life.
Advantage of heparin over warfarin ?
Can be used in pregnancy. Warfarin cannot.
Used as bridging therapy for oral anticoagulants
What to monitor on patient on heparin?
Platelet count
aPTT
signs of bleeding
drug interactions
Tx and dose for PE, DVT, ACS?
Enoxaparin 1mg/kg BID
LMWH is sometimes preferred over heparin because: (6)
- Greater affinity for factor Xa than heparin
- Longer ½ life than heparin
- Higher bioavailability
- Predictable dose response
- Less risk of thrombocytopenia
- Preferred in pregnancy r/t less HIT and osteoporosis risk
Whats the antidote for heparin and LMWH?
Protamine Sulphate
Negative inotropic effect?
Weaken the force of the heartbeat
treat high blood pressure, chronic heart failure, arrhythmias, and angina
Positive inotropic effect?
Strengthen the force of the heart beat
Tx: congestive heart failure or cardiomyopathy
