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BCPS > Cardiology > Flashcards

Cardiology Flashcards

1
Q

TIMI Risk Score

A

Thrombolysis In Myocardial Infarction

0-2: low risk
3: intermediate risk
4+: high risk

Score of 3 or more have greater benefit from LMWH, GP IIb/IIIa inhibitors, and invasive strategies for NSTEMI

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2
Q

GRACE Risk Score

A

Global Registry of Acute Coronary Events

> 140: high score, qualifies for early invasive strategies

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3
Q

UA vs NSTEMI

A

NSTEMI has positive biomarkers (UA has none)
NSTEMI causes myocardial injury

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4
Q

Performance measure for time to PCI

A

90 minutes

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5
Q

Performance measure for fibrinolytic therapy

A

If PCI cannot be done within 120 minutes, then door-to-needle time of 30 minutes for fibrinolytic therapy

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6
Q

NSTEMI Ischemia Guided Antiplatelet & Anticoag regimen

A

Aspirin
Clopidogrel or Ticagrelor

Enoxaparin, fondaparinux, UFH

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7
Q

NSTEMI Invasive Management Antiplatelet & Anticoag regimen

A

Aspirin
Ticagrelor > Prasugrel > Clopidogrel
GP IIb/IIIa inhibitor if high risk

Enoxaparin, bivalrudin, UFH

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8
Q

STEMI PCI Antiplatelet &Anticoag management

A

Aspirin
Clopidogrel, prasugrel, or ticagrelor
GP IIb/IIIa inhibitor if high risk

UFH, bivalrudin

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9
Q

STEMI + Fibrinolytic Antiplatelet & Anticoag management

A

Aspirin
Ticagrelor > clopidogrel
GP IIb/IIIa inhibitor if high risk

UFH, enoxaparin, fondaparinux

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10
Q

Clopidogrel load, maintenance dose, surgery hold time

A

300-600mg load
75mg daily

5 days

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11
Q

Prasugrel load, maintenance dose, surgery hold time

A

60mg load
10mg daily
5mg daily if <60kg, >/= 75 y/o

7 days

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12
Q

Ticagrelor load, maintenance dose, surgery hold time

A

180mg load
90mg BID
May be reasonable to go to 60mg BID after 1 year

3-5 days

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13
Q

Clopidogrel box warning, contrainidications, pertinent DDI

A

BBW: CYP2C19 polymorphisms

CI: Active bleeding

DDI: esomeprazole/omeprazole (use pantoprazole, rabeprazole); increased bleeding w/ NSAIDs, OAC, O3FA

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14
Q

Prasugrel box warning, contraindications, pertinent DDI

A

BBW: age-related bleeding, CVA/TIA

CI: Active bleeding, CVA/TIA
*Do not give as load until know cardiac anatomy

DDI: increased bleeding with NSAIDs, OACs

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15
Q

Ticagrelor box warning, contrainidcations, pertinent DDI

A

BBW: aspirin dosing >100mg

CI: Active bleeding, ICH, severe hepatic disease

DDI: strong CYP3A4 inhibitors/inducers; DNE simva/lova 40mg; increased bleeding with NSAIDs, OACs

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16
Q

Cangrelor dosing

A

IV P2Y12 inhibitor
30 mcg/kg IV bolus followed by 4 mcg/kg/minute infusion

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17
Q

Eptifibatide dosing

A

180mcg/kg IV bolus x2 10 min apart, then 2mcg/kg/min for 18-24 hours. Initiate after first bolus.

CrCl < 50ml/min: reduce by 50%

Hemodialysis: avoid (not studied SCr >4)

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18
Q

Tirofiban dosing

A

25 mcg/kg IV bolus over 3 minutes, then 0.15 mcg/kg/min for 18 hours

CrCl </= 60 ml/min: reduce by 50%

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19
Q

UFH dosing NSTEMI

A

60 units/kg IV bolus (max 4000 units) then 12 units/kg/hr (max 1000 units/hr) for 48 hours

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20
Q

UFH dosing PCI with GP IIb/IIIa inhibitor

A

50-70 unit/kg bolus

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21
Q

UFH dosing PCI without GP IIb/IIIa inhibitor

A

70-100 units/kg IV bolus

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22
Q

Enoxaparin dosing NSTEMI

A

1mg/kg SC q12H
30mg/kg IV bolus

CrCl < 30 ml/min: 1mg/kg SC daily

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23
Q

Enoxaparin dosing NSTEMI PCI

A

If last dose > 8 hours ago, 0.3 mg/kg IV bolus

CrCl <30 ml/min: 1mg/kg daily

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24
Q

Enoxaparin dosing STEMI PCI

A

30mg IV bolus, followed immediately by 1mg/kg SC q12H (not to exceed 100mg on first two doses)

If > 75 y/o, omit bolus, 0.75mg/kg q12H (not to exceed 75mg on first two doses)

CrCl < 30 ml/min: 1 mg/kg daily

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25
Q

Fondaparinux dosing NSTEMI

A

2.5mg SC daily

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26
Q

Fondaparinux dosing PCI

A

Not recommended as sole anticoagulant

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27
Q

Fondaparinux dosing STEMI + PCI

A

2.5mg IV bolus then 2.5mg SC daily; not to be used as sole anticoagulant

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28
Q

Bivalrudin dosing NSTEMI, early invasive

A

0.1mg/kg IV bolus then 0.25mg/kg/hr IV

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29
Q

Bivalrudin dosing PCI

A

0.75mg/kg IV bolus then 1.75mg/kg/hr

CrCl < 30 ml/min: 0.75mg/kg bolus then 1mg/kg/hr

HD: 0.75 mg/kg bolus then 0.25mg/kg/hr

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30
Q

UFH contraindication

A

History of HIT

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31
Q

Enoxaparin contraindication

A

History of HIT

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32
Q

Fondaparinux contraindication

A

CrCl < 30 ml/min

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33
Q

UFH dosing with fibrinolytic

A

60 unit/kg bolus (max 4000 units), then 12 units/kg/hr (max 1000 units/hr) for at least 48 hours

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34
Q

Enoxaparin dosing with fibrinolytic

A

30mg IV (omit if > 75), followed by 1 mg/kg SC q12H for duration of hospitalization

Max 100mg (75mg if > 75) for first two doses

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35
Q

Fondaparinux dosing with fibrinolytic

A

2.5mg IV, followed by 2.5mg SC daily for hospitalization

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36
Q

Alteplase dosing

A

</= 67 kg: 15mg IVP over 1-2 minutes, then 0.75mg/kg IV over 30 minute (max 50mg), then 0.5 mg/kg (max 35mg) over 60 min

> 67: 15mg IVP over 1-2 minutes, then 50mg over 30 min, then 35mg over 1 hour (max 100mg total)

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37
Q

Reteplase dosing

A

10 units IVP x2 30 min apart

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38
Q

Tenecteplase dosing

A

<60 kg: 30mg IVP
60-69kg: 35mg IVP
70-79kg: 40mg IVP
80-89kg: 45mg IVP
>/=90kg: 50mg IVP

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39
Q

Relative Contraindication to Fibrinolytics

A

-BP > 180/110, poorly controlled HTN
-History of ischemic stroke >3 months before
-Recent major surgery <3 weeks before
-Traumatic or prolonged CPR (>10min)
-Recent internal bleeding (within 2-4 weeks)
-Active peptic ulcer
-Noncompressible vascular punctures
-Pregnancy
-Known intracranial pathology (dementia)
-OAC therapy

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40
Q

Absolute contraindications to fibrinolytic therapy

A

-Any prior hemorrhagic stroke
-Ischemic stroke within 3 months
-Intracranial neoplasm or ateriovenous malformation
-Active internal bleeding
-Aortic dissection
-Considerable facial trauma or closed-head trauma in past 3 months
-Intracranial or intraspinal surgery within 2 months
-Severe uncontrolled HTN

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41
Q

Duration of DAPT therapy after ACS
(ischemia guided or stent)

A

12 months

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42
Q

Duration of DAPT if SIHD, elective stent placement

A

6 months can be considered

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43
Q

Long-term DAPT

A

> 12 months if high ischemic risk and no bleeding while on therapy

Studies used clopidogrel mainly

DAPT score > 2 shows increased benefit for long DAPT

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44
Q

Beta-blocker after ACS

A

Indicated for all patients

Initiate in first 24 hours (if unable, reevaluate before discharge)

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45
Q

ACE-I after ACS

A

Indicated for all patients w/ EF <=40%, HTN, DM, CKD

CI: hypotension, pregnancy, bilateral renal artery stenosis

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46
Q

Aldosterone antagonist after ACS

A

Indicated in patients receiving ACE-I and BB, have EF <=40% AND symptomatic HF or diabetes

Administer ASAP

CI: Hyperkalemia, CrCl <30 ml/min, SCr >2.5 (men), 2.0 (women)

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47
Q

Statin after ACS

A

High intensity recommended within first 24 hours, preferably before PCI

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48
Q

LDL Treatment goal post ACS

A

LDL < 55
>50% reduction in LDL from baseline

If second CV event in 2 years, can consider LDL <40.

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49
Q

NSAID after ACS

A

Discontinue

May consider nonselective NSAIDs (naproxen)

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50
Q

Vaccination post ACS

A

Pneumococcal
Influenza

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51
Q

CABG management

A

Continue aspirin

Stop clopidogrel or ticagrelor for at least 24 hours prior

Stop GP IIb/IIIa inhibitor 2-4 hours before surgery

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52
Q

Triple therapy in AF undergoing PCI

A

Minimize

Discontinue aspirin at time of discharge

If stent thrombosis high risk, continue aspirin for 1 month

DOAC > Warfarin

Clopidogrel preferred

PPI

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53
Q

Congestion in ADHF

A

Elevated PCWP

-Dyspnea on exertion or rest
-Orthopnea, paroxysmal nocturnal dyspnea
-Peripheral edema
-Rales
-Early satiety, N/V
-Ascites
-Hepatomegaly, splenomegaly
-Jugular venous distention
-Hepatojugular reflux

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54
Q

Hypoperfursion in ADHF

A

Low CO

-Fatigue
-AMS, sleepy
-Cold extremities
-Worsening renal function
-Narrow pulse pressure
-Hypotension

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55
Q

Cardiac output equation

A

CO = SVR * HR

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56
Q

Cardiac index equation

A

CI = CO/BSA

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57
Q

MAP equation

A

MAP = DBP + [1/3(SBP - DBP)]

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58
Q

SVR equation

A

SVR = [(MAP - CVP)/CO] * 80

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59
Q

Warm and Dry background, management

A

Category I “compensated”
High CI > 2.2
Low PCWP 15-18

Optimize GDMT

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60
Q

Warm and Wet background, management

A

Category II “pulmonary congestion”

High CI > 2.2
High PCWP >18

IV diuretic +/- IV vasodilator (venous to relieve pulmonary congestion, arterial if no hypotension)

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61
Q

Cold and Dry background, management

A

Category III “hypoperfusion”
Low CI <2.2
Low PCWP 15-18

PCWP <15 = IVF
PCWP >= 15, SBP <90: IV inotrope
PCWP >= 15, SBP >=90: IV vasodilator (arterial) +/- IV vasopressor

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62
Q

Cold and Wet background, management

A

Category IV “pulmonary congestion & hypoperfusion”
Low CI <2.2
High PCWP >18

IV diuretic +/-
SBP >= 90: IV vasodilator (arterial)
SBP <90: IV inotrope +/- IV vasopressor

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63
Q

Loop diuretic equivalent dosing

A

Furosemide PO 40mg = bumex 1mg = torsemide 20mg = ethacrynic acid 50mg

PO:IV all 1:1 except furosemide is 2:1
Torsemide has no IV option

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64
Q

Drug of Choice for ADHF + Active Ischemia

A

Nitroglycerin

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65
Q

Vasodilator commonly used as venodilator

A

Nitroglycerin
Arterial @ high doses

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66
Q

Vasodilator commonly used as arterial vasodilator

A

Nitroprusside

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67
Q

Sodium nitroprusside dosing in ADHF

A

0.1-0.2 mcg/kg/min IV
Increase by 0.2-0.3 mcg/kg/min every 5 min
Max 10 mcg/kg/min

Not to be used for >10 min

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68
Q

Nitroglycerin dosing in ADHF

A

5 mcg/min IV
Increase by 5mcg/min every 5-10 min
Max 200 mcg/min

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69
Q

Favor milrinone

A

To avoid discontinuing home BB (no chronotropic effects)
High pulmonary arterial pressure

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70
Q

Favor dobutamine

A

Severe hypotension
Bradycardia
Thrombocytopenia
Severe renal impairment

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71
Q

Dobutamine dosing

A

2.5-5 mcg/kg/min
Max 20 mcg/kg/min

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72
Q

Milrinone dosing

A

0.125-0.25 mcg/kg/min
Max 0.75 mcg/kg/min

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73
Q

Tolvaptan indication, dosing, CI

A

Clinically significant hyponatremia associated with HF

15mg daily
Titrated to 30-60mg prn

CI: CYP3A4 inhibitors, CrCl <10, caution against use >30 days

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74
Q

Maximum sodium correction in 24 hours

A

8-10 mEq/L

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75
Q

Epinephrine dosing in CPR

A

1mg Q3-5 min

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76
Q

Amiodarone dosing in CPR

A

300mg IV/IO x1, then 150mg bolus

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77
Q

Lidocaine dosing in CPR

A

Only if amiodarone unavailable

1.5mg/kg IV, repeat 0.5-0.75mg/kg q5-10min

Max 3 mg/kg

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78
Q

Goal temperature in TTM

A

32-36C

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79
Q

Agents to reverse shivering In TTM

A

Meperidine
Buspirone
Clonidine
Dexmedetomidine
NMBA

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80
Q

Blood glucose goal during TTM

A

140-180

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81
Q

Symptomatic bradycardia DOC, second line

A

DOC: Atropine 1mg q3-5min, max 3 mg

If atropine fails:
dopamine 5-20mcg/kg/min
or epinephrine 2-10 mcg/min

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82
Q

Narrow QRS with regular ventricular rhythm management

A

SVT or sinus tachycardia

First line: vagal maneuvers or adenosine 6mg IVP, followed by 20 mL NS flush, then adenosine 12mg IVP

If both fail:
CCB or BB

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83
Q

Narrow QRS with irregular ventricular rhythm management

A

Atril fibrillation

Diltiazem, verapamil
BB
Sometimes digoxin

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84
Q

Pharmacologic options for cardioversion for AF

A

AF <7 days: flecainide, dofetilide, propafenone, ibutilide, amiodarone

AF >7 days: dofetilide, amiodarone, ibutilide

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85
Q

Wide complex QRS, VT

A

Regular & monomorphic: adenosine

IV procainamide, amiodarone, sotalol

Second line: lidocaine

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86
Q

DOC for Wolff Parkinson White syndrome w/ AF

A

Procainamide

*Avoid BB, diltiazem, verapamil, digoxin, sotalol, amiodarone, anything AV nodal blocking

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87
Q

Wide QRS with irregular VT

A

Unstable: defibrillation

Stable: IV magnesium 1-2gm bolus
Discontinue Class I & III antiarrhythmics
Assess for QTc prolonging drugs

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88
Q

Quinidine dosing

A

Class Ia Antiarrhythmic (Na blocker)

AF and VT Maintenance only
Sulfate: 200-400mg PO q6h
Gluconate (CR): 324mg q8-12H

CrCl <10: decrease by 25%

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89
Q

Quinidine pearls (AE, DI)

A

Class Ia Antiarrhythmic (Na blocker)

AE: N/V/D; TdP (first 72 hrs)

Do not use in AF conversion d/t GI AE

DI: Warfarin, digoxin, 2D6 or 3A4

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90
Q

Procainamide dosing

A

Class Ia Antiarrhythmic (Na blocker)

AF conversion: 1gm IV x30 min, then 2mg/min

VT conversion: 30 mg/min IV up to 17mg/kg, arrhythmia ceases, hypotension, QRS widens > 50%

VT maintenance: 1-4mg/min

No PO option

Reduce in liver, renal dysfunction

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91
Q

Procainamide pearls (AE, CI)

A

Class Ia Antiarrhythmic (Na blocker)

AE: hypotension, TdP

CI: LVEF <40%

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92
Q

Disopyramide dosing

A

Class Ia Antiarrhythmic (Na blocker)

AF conversion:
<50kg: 200mg q6h
>50kg: 300mg q6h

AF maintenance: 400-800mg/day
IR and CR options

<50kg, CrCl >40 OR hepatic dysfunction: max 400mg/day

CrCl 30-40 ml/min: 100mg IR q8h
CrCl 15-30 ml/min: 100mg IR q12h
CrCl <15 ml/min: 100mg IR q24h

VT: not used anymore

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93
Q

Disopyramide pearls (AEs, CI)

A

AE: anticholinergic, TdP, ADHF

CI: cardiogenic shock, long QT syndrome, 2nd-3rd degree AVB, glaucoma

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94
Q

Class Ia Antiarrhythmics

A

Na+ channel blocker

Quinidine, procainamide, disopyramide

Decrease conduction velocity
Increase refractory period

Increase QRS complex
Increase QT interval

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95
Q

Class Ib Antiarrhythmics

A

Na+ channel blocker

Lidocaine, mexiletine, phenytoin

Decrease conduction velocity
Inc/Dec refractory period

Decrease QT interval

Indication: Ventricular arrhythmia only

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96
Q

Class Ic Antiarrhythmics

A

Na+ channel blocker

Flecainide, propafenone

Major decrease in conduction velocity
No change on refractory period

Increase QRS complex

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97
Q

Class II Antiarrhythmics

A

Beta blockers

Metoprolol, esmolol, atenolol

Decrease conduction velocity
Increase refractory period

Decrease HR
Increase PR interval

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98
Q

Class III Antiarrhythmics

A

K+ channel blockers

Amiodarone, dronedarone, sotalol, dofetilide, ibutilide

No change on conduction velocity
Major increase in refractory period

Increase QT interval

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99
Q

Class IV Antiarrhythmics

A

Ca2+ channel blockers

Diltiazem, verapamil

Decrease conduction velocity
Increase refractory period

Decrease HR
Increase PR interval

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100
Q

Lidocaine dosing for antiarrhythmic

A

Class Ib Antiarrhythmic

VT maintenance: 1-4 mg/min

Reduce in hepatic disease, HF, renal dysfunction

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101
Q

Lidocaine pearls (AEs, CI)

A

AE: CNS related - perioral numbness, seizure, confusion, blurry vision, tinnitus

CI: 3rd degree AVB

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102
Q

Mexiletine dosing

A

Class Ib Antiarrhythmic

VT Maintenance: 200-300mg PO q8h
Max 1200mg/day

Reduce dose by 25-30% in hepatic impairment

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103
Q

Mexiletine pearls (AEs, CI)

A

AE: CNS (tremor, dizziness, ataxia, nystagmus)

CI: 3rd degree AVB

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104
Q

Propafenone dosing

A

Class Ic Antiarrhythmic

AF conversion: 600mg x1
Reduce to 450mg if <70kg

AF maintenance:
IR: 150-300mg q8-12h
SR: 225-425mg q12h

Reduce by 70-80% in hepatic impairment

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105
Q

Propafenone pearls (AE, DI, DI)

A

AE: metallic taste, dizziness, ADHF, bronchospasm, bradycardia, heart block

CI: NYHA III-IV HF, liver disease, TdP, CAD, MI

DI: Digoxin, warfarin

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106
Q

Flecainide dosing

A

Class Ic Antiarrhythmic

AF conversion: 300mg x1

AF maintenance: 50-150mg BID

CrCl <35 ml/min: reduce by 50%

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107
Q

Flecainide pearls (AE, CI, DI)

A

AE: Dizziness, tremor, ADHF, vagolytic, anticholinergic, hypotension

CI: HF, CAD, TdP

DI: Digoxin

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108
Q

Amiodarone dosing for arrhythmia

A

Class III Antiarrhythmic

AF conversion:
IV: 5-7mg/kg IV over 30-60 min, then 1.2-1.8g/day continuous IV (or divided PO dose until 6-10 gm load)
PO: 1.2-1.8 g/day in divided doses until 6-10 g

AF maintenance: 200-400mg

Stable VT: 150mg IV bolus for 10 min, then 1mg/min x6 hours, then 0.5mg/min (max 2.2 g/day)

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109
Q

Amiodarone pearls (AE, CI, DI)

A

AE: lungs (pulmonary fibrosis), thyroid (hyper/hypo thyroid), eyes (corneal deposits)
photosensitivity/blue-gray skin, TdP, heart block, neurologic toxicity, bradycardia

CI: iodine hypersensitivity, hyperthyroid, 3rd degree AVB

DI: warfarin, digoxin, statin (max simvastatin 20mg, lovastatin 40mg), phenytoin, lidocaine, etc.

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110
Q

Sotalol dosing

A

Class III Antiarrhythmic

AF maintenance:
CrCl > 60 ml/min: 80mg BID
CrCl 40-60 ml/min: 80mg daily

VT maintenance
CrCl > 60 ml/min: 80mg BID
CrCl 30-60 ml/min: 80mg daily
CrCl 10-30 ml/min: 80mg q36-48h
CrCl <10 ml/min: 80mg q48h

Not effective for AF conversion

111
Q

Sotalol pearls (AE, CI, BW)

A

AE: ADHF, bradycardia, AVB, wheezing, TdP (wihtin 72 hrs), bronchospasm

CI: Baseline QTc >440, LVEF <40%, 2nd/3rd degree AV block, Sinus sick syndrome

BBW: do not initiate if QTc >450. If Qtc >500 during therapy, reduce dose or discontinue.
–Initiate while in hospital

112
Q

Dofetilide dosing

A

Class III Antiarrhythmic

AF conversion & maintenance:
CrCl >60 ml/min: 500mcg BID
CrCl 40-60 ml/min: 250mcg BID
CrCl 20-39 ml/min: 125 mcg BID
*Use ABW for CrCl

CrCl <20 ml/min: not recommended

113
Q

Dofetilide pearls (AE, CI, BBW)

A

AE: TdP, diarrhea

CI: Baseline QTc >440 or intraventricular conduction delay with baseline QTc >500; CrCl <20

DI: CYP3A4 inhibitors, drugs renally excreted

BBW: hospitalization MANDATORY for initiation. Monitor QTc q2-3 hrs after each first 5 doses, reduce by 50% if Qtc increased by 15%. NTE QTc >500

114
Q

Ibutilide dosing

A

Class III Antiarrhythmic

AF conversion (can repeat after 10 min):
>=60kg: 1mg IV
<60kg: 0.01 mg/kg

115
Q

Ibutilide pearls (AE, CI, BBW)

A

AE: TdP, AV heart block

CI: Baseline QTc >440, LVEF <30%, concomitant AADs

BBW: Fatal arrhythmias (irregular VTs) - patients w/ chronic AF not preferred for converting

116
Q

Dronedarone dosing

A

Class III Antiarrhythmic

AF maintenance: 400mg BID

117
Q

Dronedarone pearls (AE, CI, BBW, DI)

A

AE: worsening HF, QT prolongation, hypokalemia/magnesemia, hepatic failure

CI: QTc>=500, PR >= 280, NYHA class IV HF (or II-III w/ recent ADHF hosp), severe hepatic impairment, 2nd/3rd degree AVB, HR <50

BBW: Risk of death is doubled when used with symptomatic HF. Use in patients w/ permanent AF doubles risk of death, stroke, hospitalization

Discontinue if QTc >= 500

DI: digoxin (reduce by 50%), BB, nonDHP CCB, clonidine, statins (simva 10mg, lova 20mg), dabigatran (reduce to 75 BID), strong CYP3A4 inhibitors/inducers

118
Q

Asymptomatic nonsustained VT managment

A

No treatment
If MI/HFrEF, BB

119
Q

Symptomatic nonsustained VT management

A

BB (NDHP CCB is alternative)

If still symptomatic: amiodarone, flecainide, mexiletine, propafenone, sotalol

120
Q

Sustained VT management

A

Pulseless: defibrillation
Pulse: synchronized cardioversion

ICD

121
Q

Hypertensive Emergency

A

BP >180/120 PLUS
Target-organ damage

122
Q

Hypertensive Urgency

A

BP >180/120
No target-organ damage
Treat with PO AntiHTNs

123
Q

Hypertensive Emergency Treatment Goals

A

1) Decrease MAP by 25% in first hour
2) SBP reduction to 160 and DBP to 100-110 over 2-6 hours
3) Normal BP over next 24-48 hours

124
Q

Hypertensive Emergency Treatment Goal - Acute Ischemic Stroke

A

Do not lower BP unless > 220/120
OR > 180/110 in thrombolysis candidates

125
Q

Hypertensive Emergency Treatment Goal - Preeclampsia, Eclampsia, Pheochromocytoma

A

SBP <140 in first hour

126
Q

Hypertensive Emergency Treatment Goal - Aortic dissection

A

SBP <120 and HR <60 in first hour

127
Q

Sodium nitroprusside dosing, onset, duration for hypertensive emergency

A

Vasodilator

0.3-0.5 mcg/kg/min
Increase by 0.5 mcg/kg/min to achieve BP target
Max 10 mcg/kg/min
30 min

Onset: immediate
Duration: 2-3 min

128
Q

Sodium nitroprusside pearls for HTN Emergency

A

Intra-arterial BP monitoring recommended

AE: Cyanide or thiocyanate toxicity

CI: renal/hepatic failure

129
Q

Nitroglycerin dosing, onset, duration for HTN Emergency

A

Vasodilator

5-10 mcg/min
Increase by 5mcg/min q3-5min
Max 200mcg/min

Onset: 2-5 min
Duration: 5-10 min

130
Q

Nitroglycerin pearls for HTN Emergency

A

AE: HA, nausea, vomiting, tachyphylaxis

Do not use in patients with ACS, pulmonary edema, volume depleted, right ventricular infarction

131
Q

Hydralazine dosing, onset, duration

A

Vasodilator

5-10mg IV q4-6hours
20mg max initial dose

Onset: 10 min, duration 1-4 hours

132
Q

Hydralazine pearls

A

AE: reflex tachycardia, HA, flushing

133
Q

Enalaprilat dosing, onset, duration

A

Vasodilator
0.625-1.25mg over 5 min
Increase to max of 5mg q6h

Onset: within 30 min
Duration: 12-24 hours

134
Q

Enalaprilat pearls

A

AE: renal insufficiency or failure, hyperkalemia

CI: pregnancy, bilateral renal artery stenosis, angioedema

Avoid in MI

Long half-life & unpredictable BP response makes unfavorable

135
Q

Fenoldopam dosing, onset, duration

A

Vasodilator

0.1-0.3 mcg/kg/min
Increase by 0.05-01 mcg/kg/min q15min
Max 1.6 mcg/kg/min

Onset: <5 min
Duration: 30 min

136
Q

Fenoldopam pearls (CI, AE)

A

CI: pts at risk of glaucoma, ICP, sulfite allergy

AE: HA, flushing, tachycardia, cerebral ischemia

137
Q

Nicardipine dosing, onset, duration

A

Vasodilator

5mg/hr
Increase by 2.5 mg/hr q15min
Max 15mg/hr

Onset: 1-5 min
Duration: 4 hours if prolonged infusion

138
Q

Nicardipine CI, AE

A

AE: reflex tachycardia, NV. HA, flushing
CI: advanced aortic stenosis

139
Q

Clevidipine dosing, onset, duration

A

Vasodilator

1-2 mg/hr
Double q90 seconds until target
Increase by less than double q5-10 min
Max 32 mg/hr for 72 hours

Onset: 2-4 min
Duration: 5-15 min

140
Q

Clevidipine pearls

A

CI: soy or egg allergy, severe aortic stenosis, defective lipid metabolism

Not studied in pts w/ renal or hepatic failure and older adults

Caution: HF, BB, reflex tachycardia, rebound HTN

141
Q

Esmolol dosing, onset, duration

A

Adrenergic inhibitor (BB)

Load 500-1000mcg/kg IV bolus over 1 min
Then 50mcg/kg/min infusion
Titrate by 50mcg/kg/min q5min
Max 200mcg/kg/min

Onset: 1-2 min
Duration: 10-30 min

142
Q

Esmolol pearls

A

AE: bronchospasm, HF exacerbation, bradycardia, heart block

CI: concurrent BB, bradycardia, ADHF

143
Q

Labetalol dosing, onset, duration

A

Adrenergic inhibitor (BB)

20-80mg q15min
Or initial 0.3-1mg/kg dose (max 20mg) q10min
Or 0.4-1 mg/kg/hr infusion with max 3mg/kg/hr

Onset: 5-10 min
Duration: 3-6 hours

144
Q

Labetalol pearls

A

CI: reactive airway disease, COPD

Caution: overtreatment can cause prolonged hypotension

145
Q

Phentolamine dosing, onset, duration

A

Adrenergic inhibitor

1-5mg IV bolus q10 min prn

Onset: 2 min
Duration: 15-30 min

146
Q

Phentolamine pearls

A

Use for catecholamine excess (pheochromocytoma, MAO-I intxns, cocaine toxicity, amphetamine overdose, clonidine withdrawal)

147
Q

Preferred agents for HTN crisis w/ acute aortic dissection

A

Labetalol
Esmolol

148
Q

Preferred agents for HTN crisis w/ ACS

A

Esmolol
Nitroglycerin
Labetalol
Nicardipine

149
Q

Preferred agents for HTN crisis w/ acute pulmonary edema

A

Clevidipine
Nitroglycerin
Nitroprusside

150
Q

Preferred agents for HTN crisis w/ acute renal failure

A

Clevidipine
Fenoldopam
Nicardipine

151
Q

Preferred agents for HTN crisis w/ eclampsia or preeclampsia

A

Labetalol
Nicardipine
Hydralazine

152
Q

Preferred agent for HTN crisis from perioperative HTN

A

Clevidipine
Esmolol
Nicardipine
Nitroglycerin

153
Q

Preferred agent for HTN crisis w/ excess catecholamines

A

Clevidipine
Nicardipine
Phentolamine

154
Q

Preferred agent for HTN crisis w/ acute intracranial hemorrhage

A

Most studied:
Nicardipine
Clevidipine
Labetalol

155
Q

Preferred agent for HTN crisis w/ acute ischemic stroke

A

No preference

156
Q

NYHA I

A

Either asymptomatic or symptomatic with no limitations caused by HF

157
Q

NYHA II

A

Symptomatic HF with slight limitation of physical activity; asymptomatic at rest

158
Q

NYHA III

A

Symptomatic HF with marked limitations in physical activity due to symptoms

159
Q

NYHA IV

A

Symptomatic HF where unable to carry out any physical activity
Symptoms at rest

160
Q

GDMT for HFrEF

A

ARNI
BB
MRA
SGLT2i
Diuretic

161
Q

GDMT but symptomatic, African American

A

Add hydralazine/isosorbide

162
Q

GDMT but symptomatic with HR >= 70, NYHA II & III

A

Add ivabradine

163
Q

GDMT but recent hospitalization, elevated NPs in NYHA II-IV

A

Add vericiguat

164
Q

GDMT but symptomatic HFrEF

A

Add digoxin

165
Q

GDMT but NYHA II-IV

A

Add PUFA (polyunsaturated fatty acid) – icosapent ethyl or EPA/DHA

166
Q

GDMT but hyperkalemia

A

Potassium binder (patiromer or sodium zirconium cyclosilicate)

167
Q

Captopril starting dose, target dose HF

A

6.25mg TID –> 50mg TID

168
Q

Enalapril starting dose, target dose HF

A

2.5mg BID –> 10mg BID

169
Q

Lisinopril starting dose, target dose HF

A

2.5-5mg daily –> 20mg daily

170
Q

Perindopril starting dose, target dose HF

A

2mg daily –> 8mg daily

171
Q

Ramipril starting dose, target dose HF

A

1.25-2.5mg daily –> 10mg daily

172
Q

Trandolapril starting dose, target dose HF

A

1mg daily -> 4mg daily

173
Q

Candesartan starting dose, target dose HF

A

4-8mg daily –> 32mg daily

174
Q

Losartan starting dose, target dose HF

A

25-50mg daily –> 150mg daily

175
Q

Valsartan starting dose, target dose HF

A

20-40mg BID –> 160mg BID

176
Q

Sacubitril-valsartan starting dose, target dose

A

Not currently on ACE/ARB or low dose, or CrCl <30 ml/min: 24/26mg BID

On standard dose ACE/ARB: 49/51mg BID

Target 97/103mg BID (double dose q2-4weeks)

177
Q

Bisoprolol starting dose, target dose HF

A

1.25mg daily –> 10mg daily

178
Q

Carvedilol starting dose, target dose HF

A

3.125mg BID –> 25mg BID (<85 kg) or 50mg BID (>85kg)

179
Q

Carvedilol CR starting dose, target dose HF

A

10mg daily –> 80mg daily

180
Q

Metoprolol succinate starting dose, target dose HF

A

12.5-25mg daily –> 200mg daily

181
Q

Eplerenone starting dose, target dose HF

A

CrCl >= 50ml/min:
25mg daily –> 50mg daily

CrCl 30-49 ml/min:
25mg every other day –> 25mg daily

182
Q

Spironolactone starting dose, target dose HF

A

CrCl >= 50 ml/min:
12.5-25mg daily –> 25mg daily or BID

CrCl 30-49 ml/min:
12.5mg daily or every other day –> 12.5-25mg daily

K must be <5.0

183
Q

K>5.5 in HF pt on MRA?

A

Decrease dose by 50% or discontinue

184
Q

Dapagliflozin dose in HF

A

CrCl >= 25 ml/min: 10mg daily

185
Q

Empagliflozin dose in HF

A

CrCl >= 20 ml/min: 10mg daily

186
Q

Hydralazine/isosorbide dosing HF

A

BiDil: hydralazine 37.5mg/isosorbide dinitrate 20mg - 1 tab TID –> 2 tabs TID

Hydralazine 70-300mg daily in 3-4 divided doses +
Isosorbide dinitrate 60-120mg daily in 3-4 divided doses

187
Q

Diuretic therapy goal for fluid-overloaded HF

A

0.5-1kg weight loss per day

Maintain euvolemic status

188
Q

Goal K and Mg in CVD

A

K >= 4.0
Mg >= 2.0

Minimize risk of arrhythmias

189
Q

Maximum loop diuretic doses

A

Furosemide: 600mg
Bumetanide 10mg
Torsemide: 200mg
Ethacrynic acid: 200mg

190
Q

Ivabradine starting dose, target dose

A

<75 y/o: 5mg BID
> 75 y/o: 2.5mg BID
Titrate based on HR

HR >=60: increase by 2.5mg to target 7.5mg BID
HR 50-60: continue current dose
HR <50 or s/s bradycardia: decrease by 2.5mg or discontinue

191
Q

Ivabradine MOA

A

Selectively inhibits If current in SA node, providing HR reduction

Must be at maximally tolerated BB dose before initiating

192
Q

Ivabradine CI

A

AHF
BP <90/50
resting HR <60 before initiation
SA block
Strong CYP3A4 inhibitors
Severe hepatic impairment

193
Q

Digoxin MOA for HF

A

Inhibit myocardial Na-K ATP
Decrease central sympathetic outflow by sensitizing cardiac baroreceptors
Decrease renal reabsorption of Na
Minimal increase in cardiac contractility

194
Q

Digoxin dosing, level in HF

A

No load
0.125mg/day (or every other day if >70, impaired renal function, low body mass)

Level: 0.5-0.9

195
Q

Digoxin DI

A

Clarithromycin, erythromycin
Amiodarone (reduce dig by 30-50%)
Dronedarone (reduce by 50%)
Itraconazole, posaconazole
Cyclosporine, tacrolimus
Verapamil

196
Q

Vericiguat MOA

A

Soluble guanylate cyclase stimulator that enhances production of cyclic guanosine monophosphate and enhances sensitivity to endogenous nitric oxide, resulting in smooth muscle relaxation and vasodilation

197
Q

Vericiguat starting dose, target dose, CI

A

2.5mg daily –> 10mg daily

Titrate based on BP:
SBP >=100: increase dose to target
SBP 90-99: continue current dose
SBP <90 or symptomatic: decrease dose or discontinue

CI: pregnancy

198
Q

Icosapent ethyl dosing HF

A

2gm BID

199
Q

EPA/DHA dosing HF

A

1000mg daily

200
Q

Patiromer MOA, monitor

A

Exchange calcium for potassium in GI tract, increasing K excretion
Monitor Mg

201
Q

Sodium zirconium cyclosilicate MOA, monitor

A

Exchange sodium and hydrogen for K in GI tract, increasing K excretion
Monitor edema

202
Q

Preferred Antiarrhythmic for HF

A

Amiodarone or dofetilide

203
Q

HFpEF managment

A

Control HTN
Diuretic if fluid overload
SGLT2i may be beneficial
MRA & ARNI/ARB

204
Q

Drugs that Exacerbate HF by Na/H2O retention

A

NSAIDs
Corticosteroids
Minoxidil
Thiazolidinediones (pioglitazone)

205
Q

Drugs that Exacerbate HF by negative inotropic effects

A

-Class I & III Antiarrhythmics (except amiodarone, dofetilide)
-CCBs (except amlodipine and felodipine)
-Itraconazole

206
Q

Drugs that Exacerbate HF, general

A

Metformin
Saxagliptin, alogliptin
Amphetamines
Pregabalin
Nutritional supplement
Cilostazol

207
Q

Paroxysmal AF

A

Spontaneous self-termination within 7 days of onset

208
Q

Persistent AF

A

Lasts more than 7 days

209
Q

Long standing persistent AF

A

Continuous duration of >12 months

210
Q

Permanent AF

A

Present all the time, unable to return to SR

211
Q

Nonvalvular AF

A

Absence of moderate-severe mitral stenosis, a mechanical or bioprosthetic heart valve, mitral valve repair

212
Q

Rate control options AF

A

BB (prefer in history of MI, HFrEF, htn control)
NonDHP CCB (verapamil, diltiazem) (preferred with asthma or COPD)
Digoxin (adjunct)
Amiodarone (refractory)

213
Q

Anticoagulant Recommendation for Cardioversion: Unstable AF

A

-Anticoagulate immediately prior to with parenteral therapy
->=4 weeks after

214
Q

Anticoagulant Recommendation for Cardioversion: Stable AF < 48 h

A

-Anticoagulate immediately prior to LMWH or UFH
->= 4 weeks after

Can also base on their risks from Chadsvasc

215
Q

Anticoagulant Recommendation for Cardioversion: Stable AF, duration >48 h

A

-3 weeks before
->= 4 weeks after

216
Q

Anticoagulant Recommendation for Cardioversion: Stable AF > 48 hours using TEE

A

-Anticoagulate at time of TEE with LMWH, UFH
->= 4 weeks after

-If thrombus on TEE, 3 weeks of anticoagulation required before cardioversion

217
Q

QTc > 500 OR >15% baseline managment with dofetilide

A

Decrease dose by 50%

If occur after doses 2-5, discontinue

218
Q

Antiarrhythmic preferred in CCD

A

Dofetilide, dronaderone, sotalol

Then amiodarone

219
Q

CHADS-VASc

A

CHF or LVEF = 40%
HTN
>=75 y/o (2)
Diabetes
Stroke, TIA, thromboembolism (2)
Vascular disease
65-74 y/o
Female

220
Q

CHADSVASc Score Recommendations

A

0 (men) or 1 (women): omit

1 (men) or 2 (women): consider anticoagulation

2 (men) or 3 (women): anticoagulation recommended

221
Q

White Coat HTN

A

Office BP: 130/80-160/100
Daytime ABPM or HBPM: <130/80

222
Q

Masked HTN

A

Office BP: 120-129/<80
Daytime ABPM or HBPM: >= 130/80

223
Q

Lifestyle modifications

A

-Maintain normal weight (BMI <25)
-DASH diet
-Reduce Na <1500mg/day
-Regular physical activity
-Reduce or omit alcohol

224
Q

Normal BP

A

<120/80
Reassess in 1 year

225
Q

Elevated BP

A

120-129/<80
Reassess in 3-6 months (lifestyle mods)

226
Q

Stage I HTN

A

130-139/80-89

ASCVD <10%: reassess in 3-6 mo
ASCVD >=10%: start therapy, reassess in 1 month

227
Q

Stage II HTN

A

> =140/>=90

Start therapy, reassess in 1 month
May use 2 drugs from 2 different classes if >20/10 above target

228
Q

BP med for diabetes

A

ACE-I/ARB (preferred in albuminuria)
CCB
Thiazide

229
Q

BP med for CKD

A

ACE-I/ARB with albuminuria

230
Q

BP med for stroke/TIA

A

Thiazide
ACE-I/ARB

231
Q

BP med for Coronary disease

A

BB + ACE-I/ARB

232
Q

BP med for HFrEF, HFpEF

A

ACE-I/ARB/ARNI
BB
MRA
Diuretic

233
Q

BB cautions for BP management

A

-Asthma or severe COPD
-Risk of developing diabetes
-Depression
-Masks hypoglycemia

234
Q

Thiazide cautions for BP management

A

-Worsen gout by increase uric acid
-Risk of developing diabetes
-Monitor hyponatremia, hypokalemia

235
Q

ACE-I/ARB contraindications

A

Pregnancy
Bilateral renal artery stenosis

236
Q

Aliskiren CI

A

Pregnancy
Diabetes (in combo with ACE-I/ARB)
Avoid w/ cyclosporine, itraconazole

237
Q

DHP vs NonDHP CCB preference in HTN

A

DHP: isolated systolic hypertension

NonDHP: comorbidities benefit from HR control

238
Q

Preferred antiHTN for pregnancy

A

Methyldopa
Nifedipine
Labetalol

239
Q

Resistent HTN Management

A

Office BP > 130/80 & on 3 antiHTN
Office BP < 130/80 but on 4 antiHTN

-Maximize diuretics
-Add MRA
-Alter dosing time
-If add hydralazine or minoxidil, must have BB and diuretic

240
Q

Statin Management for Very high risk ASCVD

A

History of several major ASCVD events or one major event + several high risk conditions

High intensity statin
Add ezetimibe if LDL >= 70 after statin
Add PCSK-9i if LDL >= 70 or non-HDL >=100 after statin

241
Q

Statin Management for Not very high risk ASCVD

A

</= 75: high intensity (goal to decrease LDL by 50%)

> 75: moderate or high-intensity statin

Add ezetimibe if LDL >= 70 after statin

242
Q

Statin Management for Severe hypercholesterolemia

A

LDL >=190 and 20-75

High intensity or maximally tolerated statin

Add ezetimibe of LDL decrease by less than 50% and/or LDL >= 100

Add PCSK9i if 30-75 with HeFH and LDL >=100 after statin, ezetimibe
Or
40-75 y/o with baseline LDL >=220 and LDL >=130

243
Q

Statin Management for Diabetes

A

40-75: moderate or high intensity statin
If ASCVD >= 20%, add ezetimibe

244
Q

Statin Management if ASCVD <5%

A

Lifestyle modifications only

245
Q

Statin Management if ASCVD 5-7.4%

A

Moderate intensity statin

246
Q

Statin Management if ASCVD 7.5-19.9%

A

Moderate intensity statin

If additional LDL lowering needed but unable to use high intensity statin, add ezetimibe or bile acid sequesterant

247
Q

Statin Management if ASCVD >20%

A

High intensity statin, goal decrease LDL by 50%

248
Q

High intensity statins

A

Decrease LDL by >=50%

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

249
Q

Moderate intensity statins

A

Decrease LDL by 30-<50%

Atorvastatin 10-20mg
Fluvastatin 80mg
Pitavastatin 1,2,4mg
Lovastatin 40-80mg
Pravastatin 40-80mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg

250
Q

Low intensity statins

A

Decrease LDL by <30%

Fluvastatin 20-40mg
Lovastatin 20mg
Pravastatin 10-20mg
Simvastatin 10mg

251
Q

Lipid lowering meds % decrease in TG

A

Statins: 7-30%
Fibrates: 20-50%
Ezetimibe: 5-11%
Omega-3 fatty acids: 19-44% (may inc LDL)

252
Q

Absolute contraindications to statins

A

Active liver disease
Pregnancy
Breastfeeding

253
Q

Fibrates + Statins

A

Increased risk of myopathy and rhabdomyolysis

Avoid gemfibrozil

254
Q

Niacin max dose with statins

A

1gm daily

255
Q

Statins of choice for HIV protease inhibitors

A

pravastatin, fluvastatin, pitavastatin

256
Q

Ezetimibe LDL lowering %

A

18-20%

257
Q

PCSK9 LDL lowering %

A

45-68%

258
Q

Evolocumab dosing

A

PCSK9i
HeFH: 140mg SC q2 weeks or 420mg SC monthly
HoFH: 420mg SC monthly

259
Q

Alirocumab dosing

A

PCSK9i
75mg SC q2 weeks or 300mg SC q4 weeks

May increase to 150mg SC q2 weeks

260
Q

Inclisiran LDL lowering, dosing

A

51%
284mg SC months 0, 3, then q6 months
not preferred due to no effects on CV morbidity/mortality

261
Q

Bile acid sequesterants LDL decrease

A

Cholestyramine, colestipol, colesevelam
15-27%
May increase trigs

262
Q

Fibrates CI, indication

A

CI: severe renal/hepatic dx, pre-existing gallbladder dx

Indication: TGs >= 500, especially if >=1000

263
Q

Bempedoic acid LDL lowering %

A

15-25%

264
Q

CCD Management

A

1st line: BB or CCB or long-acting nitrate

2nd line: BB or CCB or long-acting nitrate

3rd line: ranolazine

All: SL NG or NG spray

265
Q

Chronic Coronary Disease

A

-Stable outpatient with history of ACS or revascularization
-LV systolic dysfunction or cardiomyopathy
-Stable angina
-Vasospastic or microvascular angina
-Diagnosis from stress test, CT angiography

266
Q

BB effects for CCD

A

Decrease inotropy and HR = decreased O2 demand

267
Q

CCB effects for CCD

A

Decrease coronary vascular resistance and increase coronary blood flow = increase O2 supply

Negative inotrope = decrease O2 demand (nifedipine&raquo_space;> amlodipine/felodipine)

Decrease HR = decrease O2 demand (verapamil, diltiazem only)

268
Q

Nitrate effects for CCD

A

Endothelium-dependent vasodilation, epicardial arterial dilation, collateral vessels dilation = increase O2 supply

Decrease left ventricular volume b/c decreased preload d/t venodilation = decrease O2 demand

269
Q

Ranolazine effects for CCD

A

Decrease intracellular Na = Decrease Ca influx = reduced ventricular tension = decreased O2 consumption

Increase O2 efficiency

No effects on HR or BP

270
Q

Ranolazine dose if on verapamil, diltiazem

A

500mg BID

271
Q

Major ASCVD Events

A

ACS in past 12 months
History of MI
History of ischemic stroke
Symptomatic PAD

272
Q

High risk conditions for ASCVD

A

->= 65 y/o
-Familial hypercholesterolemia
-CABG or PCI (outside of major ASCVD)
-Persistent LDL >= 100, despite statin/ezetimibe
-DM
-HTN
-CKD
-CHF
-tobacco

273
Q

Vaccines for CCD

A

Pneumococcal
Flu
COVID19

274
Q

Epinephrine dosing in CPR

A

1mg Q3-5 min

BCPS (2 decks)

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