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
Slide 6
look
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
