Cardiology Case wrap-up-Jaynstein (FINAL) Flashcards
Case A:
75 yo female with AF
-6 month FU
-CC: On Coumadin – inquiring about switching
A fib INR goal?
**2.0-3.0
for mech valve: 2.5-3.5
AFIB- COUMADIN FAILURE is defined as ?
=Thromboembolic event while on Coumadin at a therapeutic level
-You might hear people use this term for a patient who cannot maintain INR within the goal range
Afib coumadin dosing:
What dose of Coumadin was she on when this INR was obtained and if she took the days dose prior to the blood draw
Today, Thursday, INR 1.8
-Last INR 2.3
Current Coumadin dose: 4 mg M/W/F, 3 mg T/TH/S/S
she may need 4 mg every day
List meds that cause an increased bleeding risk independent of the INR:
NSAIDs, Aspirin, Plavix/ other antiplatelet drugs, gingko biloba, dong quai, fenugreek, chamomile.
Cephalexin and clindamycin have minimal interactions with warfarin
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AFIB-DIETARY COUNSELING
-what food items are high in vit K?
- Complete avoidance of spinach isn’t necessary
- Keep Vit K intake relatively constant over time
- Items very high in Vit K: Spinach, brussel sprouts, collard greens, turnip, mustard greens, kale
Medium Vit K foods: Asparagus, lettuce, cabbage, broccoli, peas, okra, Viactiv chews
Low Vit K foods: avocado, banana, chickpeas, fruit, oil, peppers, seaweed, tomatoes
- **green tea may alter VKA anticoagulation, and we generally advise patients to limit intake to one or two servings (or less) per day.
- Severely malnourished patients may be more sensitive to warfarin
- Weight loss diets: may lead to alterations in warfarin dose requirements due to changes in vitamin K intake or warfarin metabolism; individuals on weight-loss diets generally should have more frequent testing of the INR
Pros of Warfarin
Cheap
Best for severe or ESRD
Must use in valvular AF
Reversal agent exists
Cons of Warfarin
- Many food & drug interactions
- Narrow therapeutic window – need INR checks
Pros of DOACs
- Fewer interactions
- Less ICH and fatal bleeding events
- No monitoring needed
- Bridging not needed due to rapid onset/offset
**DOACs - Direct Thrombin Inhibitor and the Direct Factor Xa inhibitors
Cons of DOACs
- Some lack, or are difficult to obtain/costly, +/- reversal agents
- More expensive
- **Generally higher rate of GI bleeding
This patient’s CrCl: 29.47 mL/min; Cr 1.5 – pt requires renal dosing on all DOACs–so look at what would be the cheapest option, when can they be initiated
-list ex’s
-Dabigatran (Pradaxa): 75 mg PO BID (=Direct Thrombin Inhibitor) –> Start when INR <2.0
Rivaroxaban (Xarelto): 15 mg PO with evening meal (= Direct Factor Xa inhibitor)
–> Start when INR <3.0
Apixiban (Eliquis): 2.5 mg PO BID (=Direct Factor Xa inhibitor) –> Start when INR <2.0
Edoxaban (Savaysa): 30 mg PO daily (=Direct Factor Xa inhibitor)–>Start when INR ≤2.5
Which DOACs are reversible?
**Only Coumadin, pradaxa (praxbind), Eliquis and Xarelto (andexXa)
Describe normal dosing for various DOACs
-Pradaxa normal dosing: 150 mg PO BID
Xarelto normal dosing: 20 mg PO with evening meal
Eliquis needs lower dose if Cr ≥1.5 and either age ≥80 or weight ≤60 kg. Normal dosing is 5 mg BID
Savaysa: remember not to use in patients with a CrCl >95
CHA2DS2-VASC score
CHF- 1 hypertension- 1 age ≥ 75 years- 2 DM- 1 stroke or (TIA), - 2 vascular disease-1 age 65 to 74 years- +! sex category-F- +1
Our patient – HTN, Age > 75, Female
CHA2DS2-VASc score=
At which point do you need to anticoagulate?
4
Everybody agrees at 2.
Goals for resting HR (rate control)
- strict ventricular rate < ____
- lenient ventricular rate < ___
- <80
- <110
Goals for exertional HR:
- ventricular HR < ____
- list ex’s of meds that would work for this Pt
<115
-Current rate: 85
Current rate control med: Lopressor 50 mg PO BID
Other options: Toprol XL 50 mg daily, carvedilol (Coreg) 3.125 mg BID, Diltiazem (Cardizem) ER 120 mg daily, Verapamil ER 120-180 mg daily
When does a Pt require digoxin?
-Digoxin: probably not needed in this patient: she doesn’t have HFrEF, and her rate is adequately controlled with one agent (not even at max dosing)
Case A:
75 yo female with AF
-6 month FU
-CC: On Coumadin – inquiring about switching
Assessment and plan?
Meds: Continue Lopressor 50mg BID and MV
- D/C Coumadin
- Eliquis 2.5 mg PO BID – can start today
Diagnostics: None today
Patient Education: Bleeding prevention, ASA/NSAID use
Follow-up: within 4 weeks
Case B:
56yo AA male with HTN
H/O DM and Gout
Current meds: HCTZ, Norvasc, Metformin, Mucinex D
- Pt currently has BP of 154/94
- HCTZ can cause ?(list S/E)
Hyponatremia Hypokalemia Hypomagnesemia **Can precipitate gout -Caution in diabetics
(HCTZ- use in caution in patients with diabetes- can increase glucose levels)
Mucinex D (guaifenesin & pseudoephedrine): is assoc. with which S/E?
HTN
Norvasc can cause ________
peripheral edema
HTN + DM
- goal BP?
- ideal meds?
130/80
-Diuretics, ACE-I/ARB, CCBs
-For age >60: if either SBP or DBP is above these numbers, treat.
Age >60: Treating to a goal of <150/90 reduces stroke, CHF, and CHD (coronary heart disease).
-In the 30-59 group, there is actually only strong evidence for diastolic BP goals
Amlodipine (Norvasc)
- onset?
- duration?
- metabolism?
Onset: 24-48 hours
Time to peak: 6-12 hours
Duration: 24 hours (up to 72)
Metabolism: Hepatic
Amlodipine (Norvasc)
- life threatening S/E?
- common S/E?
angina/MI, hypotension, pulmonary edema
Use with extreme caution in patients with severe AS(aortic stenosis): can reduce coronary perfusion–> ischemia. Also in CHF patients: reduction in afterload can worsen sx
Common s/e: PERIPHERAL EDEMA, fatigue
Amlodipine (Norvasc):
-starting dose?
Max dose?
-2.5 mg (frail, already on other antihypertensives), or 5 mg (usual) daily
Max: 10 mg PO daily
-CCBs work better in AA patients
Lisinopril:
- onset?
- Duration?
- metabolism?
- 1 hour, peak at 6 hours
- duration: 24 hrs
not metabolized, excreted in urine as unchanged drug
Lisinopril:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
**Angioedema, cholestatic jaundice (can progress to fulminant hepatic necrosis), hyperkalemia, ARF, hypotension, severe hypersensitivity reactions
–>**Angioedema can also affect the gut, manifesting as abdominal pain. African Americans appear to be at increased risk.
Common s/e: hyperkalemia, increased creatinine, dizziness, cough
Starting dosage: 10 mg PO daily
Max: 40 mg daily
Lopressor (Metoprolol Tartrate):
- onset ?
- duration?
- metabolism?
- 1 hr, peaks 1-2 hrs
- duration variable, dose-related
- hepatic
Lopressor (Metoprolol Tartrate):
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
**AV block, bradycardia, CNS depression, hypotension
Common s/e: hypotension, bradycardia, dizziness
Starting dose: 50 mg BID
Max: 450 mg/day (usual up to 100 mg BID)
note:Can precipitate or worsen symptoms of Raynaud or peripheral vascular disease
Toprol XL (Metoprolol Succinate):
- onset?
- Duration?
- metabolism?
- peaks 6-12 hrs
- 24 hours
- hepatic
Toprol XL (Metoprolol Succinate):
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
AV block, bradycardia, CNS depression, hypotension,
Common s/e: hypotension, bradycardia, dizziness
Starting dose: 12.5- 25 mg daily
Max dose: 200 mg daily
Labetalol:
onset?
duration?
-metabolism?
- 20 min PO
- duration: 8-12 hrs
- hepatic
Labetalol:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
hypotension, hepatic injury
Common s/e: hypotension, orthostatic hypotension, dizziness, nausea
Starting dose: 100 mg PO BID
Max: 2400 mg/day
HCTZ:
- onsest?
- duration?
- metabolism?
- 2 hours
- duration: 6-12 hrs
- not metabolized
HCTZ:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
severe electrolyte disturbances, angle-closure glaucoma
Common s/e: hypokalemia, hyponatremia, hypomagnesemia, hypochloremic alkalosis, precipitation of gout
Starting dose: 12.5 – 25 mg PO daily
Max dosage: 50 mg daily (don’t do this! Stick with 25 mg)
There are multiple HCTZ combo drugs for consideration:
-list ex’s
- should not use HCTZ as monotherapy, typically given in combo form
- Losartan/HCTZ–> Hyzaar (ARB + Diuretic)
Benazepril/HCTZ –> Lotensin (ACE-I + Diuretic)
Lisinopril/HCTZ –> Zestoretic (ACE-I + Diuretic)
Metoprolol tartrate/HCTZ –> Lopressor HCT (BB + Diuretic)
Triamterene/HCTZ –> Dyazide or Maxzide (Potassium-sparing + thiazide diuretic)
Losartan (Cozaar):
onset?
duration?
-metabolism?
- 6 hrs, peaks in 1 hr
- metabolism: liver
Losartan (Cozaar):
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
angioedema, hyperkalemia, hypotension, renal function deterioration
Common s/e: cough, hyperkalemia, increased creatinine
Starting dose: 50 mg daily
Max dose: 100 mg daily
Clonidine:
- peaks?
- half life?
- metabolism?
- 1-3 hrs
- 1/2 life= 12-16 hrs w normal renal fx
- hepatic
Clonidine:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
bradycardia, CNS depression, hypotension
Common s/e: drowsiness, headache, fatigue, dizziness, transient skin rash, xerostomia**. (note: ppl crash v hard from this med)
Starting dose: 0.1 mg PO BID or transdermal patch 0.1 mg/24 hour patch applied weekly
Max: 2.4 mg/day
Diltiazem (Cardizem) ER:
- peak?
- 1/2 life?
- metabolism?
- 10-18 hrs
- 4-9 hrs
- hepatic
Diltiazem (Cardizem) ER:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
AV block, bradycardia, SJS, hypotension
Common s/e: peripheral edema, headache, bradycardia, dizziness
Starting dose: 120 – 240 mg daily (for ER capsule with once daily dosing)
Max: 480 mg/day
Hydralazine:
peaks?
1/2 life?
metabolism?
- 1-2 hrs
- 3-7 hrs
- liver
Hydralazine:
- Life-threatening s/e: ?
- common s/e?
-starting dose and max dose?
**drug-induced lupus-like syndrome, blood dyscrasias, contraindicated in those with CAD (implicated in MI), peripheral neuritis
Common s/e: earache, tachycardia, palpitations, angina, nausea/vomiting, diarrhea
Starting dose: 10 mg PO QID
Max: 300 mg/day
Life Style modifications- for HTN
Weight loss: DASH diet
Smoking cessation
Exercise
Alcohol in moderation
Case B:
56yo AA male with HTN
H/O DM and Gout
Current meds: HCTZ, Norvasc, Metformin, Mucinex D
Plan?
Meds:
- D/C HCTZ and Mucinex D
- Add Lisinopril 10mg QD
- Cont Norvasc 10mg QD and (*Metformin 500mg BID)
Diagnostics: No additional labs today
Patient Education: life style modifications
Follow-up: 1 week for BP check, labs
(Check potassium in 1 week!!!
Metformin– watch out, this pt has poor renal fx, may need to d/c metformin soon)
Case C:
55 yo male s/p AMI 2 wks ago with stent placement
?
Hyperlipidemia in CAD Pts:
-primary prevention?
Calculate baseline risk for CV events if LDL >100
- If 10 year risk ≥ 7.5-10% –> statin–>Statins reduce CV RR 20-30%
- If LDL ≥190
Primary prevention refers to the effort to prevent or delay the onset of ASCVD. Secondary prevention refers to the effort to treat known, clinically significant ASCVD, and to prevent or delay the onset of disease manifestations.
Hyperlipidemia in CAD Pts:
-secondary prevention?
Lifelong high intensity statin (regardless of LDL)
- -Atorvastatin (Lipitor) 40 or 80 mg
- -Rosuvastatin (Crestor) 20 or 40 mg
In secondary prevention, if they don’t tolerate, go to the maximum dose the patient will tolerate.
DOC for lowering LDL?
**statins
- A substantial reduction in LDL should occur at the usual starting dose – doubling of a dose produces only an additional 6% decrease.
- Consider this when deciding to increase a dose vs add an additional medication.
What labs should you obtain at baseline prior to starting statin therapy?
***LFTs at baseline, 6-12 weeks after initiation or any dose increase, then annually
Contraindications: Liver disease (alcohol abuse), pregnancy
Statins:
- list life-threatening S/E
- common s/e?
**Rhabdomyolysis, ARF, hepatotoxicity, hemorrhagic stroke
Common s/e: photosensitivity, arthralgia’s, GI upset - diarrhea, nasopharyngitis, elevated LFTs
Statin related myopathy
-risk factors?
-small body frame, multisystem diseases, multiple medications
**Routine monitoring of CPK levels is NOT recommended. Only consider in symptomatic patients.
Pts with DES (drug eluding stents) need at least ____ months of dual antiplatelet therapy (DAPT)
- 6-12 months
- -> If patients are free of major or moderate bleeding events at that time, continue for at least 18-24 more months
Long-term dual antiplatelet therapy=
-purpose?
DAPT- aspirin plus platelet P2Y12 receptor blocker) significantly lowers the risk of stent thrombosis. In addition, there is some evidence to support the idea that it also prevents ischemic events remote from the stented area.
-After 6-12 months of DAPT, the event rates for myocardial infarction, death, stent thrombosis, and major hemorrhage are relatively low and the benefits and risks are almost evenly balanced in most patients.
DAPT score predicts:
predicts combined ischemic and bleeding risk for patients being considered to continue DAPT therapy beyond 1 year
-DAPT trial showed that the benefit for prolonged DAPT is largely independent of stent type
BMS= (bare metal stent)–has Same recommendations
List dosing for DAPT
Clopidogrel (Plavix) 75 mg PO daily + ASA 81-325 mg daily
–>Reduces risk for stent thrombosis, MI, death
-ASA should be continued indefinitely in all stented patients
Plavix:
Life threatening s/e ?
common s/e?
Life threatening s/e: severe bleeding, Thrombotic thrombocytopenic purpura (TTP), agranulocytosis, hypersensitivity reaction, SJS/TEN, aplastic anemia, pancytopenia
Common s/e: Bleeding, pruritis
Daily ASA has been shown to reduce CV risk by up to _____%
25%
ASA:
- MOA?
- dosing?
MOA: inhibits platelet aggregation
FYI: ASA peak plasma conc can occur within 30 minutes of taking a non-enteric coated pill –can be up to 4 hours if enteric-coated!
Dosing: 325mg really only indicated for AMI and acute ischemic stroke. 81mg QD sufficient for daily use.
ASA:
- interactions?
- contraindications?
- *NSAIDs
- GI bleeds
Anti-Anginal Medications:
-list classes of meds
- BBs
- Nitrates
- CCBs
BBs:
- Reduce HR and ____
- the only anti-anginal med that is proven to improve _______
- contractility
- survival and prevent re-infarction in patients who have had MI
Nitrates are 1st line therapy for ______
**acute angina sx
CCBs cause coronary and peripheral vasodilation and reduce ______
contractility
–CCB usually used in combo with BB when monotherapy with BB not adequate
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