Cardiovascular Flashcards
1
Q
Prasugrel (Effient) C/I
A
Hx of TIA/Stroke
2
Q
Time: fibrinolytics
A
Within 30 mins of admission
If at a hospital incapable of PCI and no other facility within 120 minutes
3
Q
Eptifibatide: brand name
A
Integrilin
4
Q
Ticagrelor (Brilinta) and aspirin
A
ASA doses > 100mg limit effectiveness of Brilinta
Loading doses of both okay to give however
5
Q
Avoid which medications in ACS
A
NSAIDS (except ASA)
Naproxen has the lowest risk
6
Q
When to start ACEI after MI
A
1 day
7
Q
When may you consider moderate intensity instead of high intensity statin post-ACS?
A
Patients 75yrs +
8
Q
Plavix: loading + maintenance dose
A
Loading dose: 300-600 mg
Maintenance: 75 mg daily
9
Q
Risk factors for ACS
A
- Age (men > 45 years of age, women > 55 years of age or with an early hysterectomy)
- Family history of coronary events before age 55 years (men) or before age 65 years (women)
- Smoking
- Hypertension
- Dyslipidemia
- Diabetes
- Known CAD
- Chronic angina
- Excessive alcohol use
- Sedentary lifestyle.
10
Q
Brilinta common, unique ADR
A
Dyspnea
11
Q
Ticagrelor (Brilinta) dosing
A
90 mg BID then 60 mg BID after 1 year
12
Q
Fibrinolytics MoA
A
Binds to fibrin
Converts plasminogen to plasmin
13
Q
Nifedipine IR and acute ACS
A
Inc. mortality risk
14
Q
Intrinsic pathway
A
Contact activation (minor)
aPTT (monitoring)
15
Q
Extrinsic pathway
A
Tissue factor activation (activated by tissue damage/trauma)
16
Q
UFH/LMWH MoA
A
Potentiate actions of antithrombin (inactivating Xa and IIa)
17
Q
Warfarin MoA
A
Inhibit factors II, VII, IX, and X by inhibiting Vit K synthesis
18
Q
Bivalirudin MoA
A
IIa (Thrombin) inhibitor
19
Q
What does Thrombin do?
A
converts Fibrinogen to fibrin (stable clot)
20
Q
When is warfarin preferred over DOACs?
A
- Moderate-severe mitral valve stenosis
- Mechanical heart valve
- Antiphospholipid syndrome
21
Q
Fondaparinux (Artixtra) MoA
A
Selective inhibition of factor Xa
22
Q
Hematoma with LMWH or DOAC
A
- LMWH: don’t rub after injection!
- Both: can have epidural or spinal hematoma in patients given neuraxial anesthesia or a spinal puncture
23
Q
UFH dosing: VTE ppx
A
5000 units Q8H SC
24
Q
UFH dosing: ACS/STEMI treatment
A
60 units/kg IV bolus then 12 units/kg/hr infusion
24
UFH dosing: VTE Tx
80 units/kg IV bolus then 18 units/kg/hr infusion
25
What weight to use when dosing UFH?
TBW
26
UFH: ADRs
Bleeding, thrombocytopenia, HIT, hyperkalemia, Osteoporosis (long-term), alopecia
27
UFH: monitoring
1. aPTT or anti-Xa (check 6 hrs after initiation then Q6H until therapeutic)
2. Platelets, Hgb, HCT daily (Dec in platelets > 50% = possible HIT)
28
UFH: aPTT therapeutic range
1.5-2.5x control
29
UFH vs LMWH difference in MoA
LMEWH has greater selectivity for the Xa binding
30
LMWH dosing: VTE ppx
30 mg SC BID or 40 mg daily
CrCl < 30: 30 mg daily
31
LMWH dosing: VTE/ UA/NSTEMI tx
1mg/kg SC BID or 1.5 mg/kg SC daily (only inpatient)
CrCl < 30: 1 mg/kg SC daily
32
LMWH dosing: Tx of STEMI in < 75 yr old
30 mg IV bolus then 1 mg/kg SC dose, followed by 1 mg/kg SC BID
CrCl < 30: 30mg IV bolus plus a 1 mg/kg SC dose followed by 1 mg/kg SC daily
33
LMWH dosing: Tx of STEMI in ≥ 75 yr old
0.75 mg/kg SC BID (no bolus). (Max 75 mg for the first 2 SC doses only)
CrCl < 30: 1mg/kg SC daily
**Use total body weight for dosing**
34
What weight do you use for dosing LMWH
TBW
35
When is monitoring (Anti-Xa) recommended for LMWH?
Pregnancy, renal insufficiency, extremes of body weight and age
36
Is aPTT used to monitor LMWH?
NO
only for UFH
37
When do you draw anti-Xa lvl for LMWH?
4 hrs post first SC dose
38
HIT: 4 T's
Thrombocytopenia: unexplained > 50% drop in PLTs
Timing: 5-10 days after start of UFH
Thrombosis: new or suspected or confirmed thrombosis
Other causes: rule our other probable causes
39
Management of HITT
1. Stop Heparin & LMWH
2. Stop warfarin and give Vit K
3. Argatroban
4. Do not start warfarin therapy until the platelets have recovered to > 150,000 cells/mm3
5. PCI required? Bival preferred
40
When is Eliquis dosed 2.5 mg BID?
If patient has 2+ of the following: age > 80 yrs, Body weight < 60 kg or SCr > 1.5 mg/dL
41
Treatment of DVT/PE : Eliquis
10mg BID x7 days then 5mg BID
42
Eliquis: Boxed warning
All pts receiving neuraxial anesthesia (Epidural, spinal) or undergoing spinal puncture are at risk of hematomas & subsequent paralysis
43
Edoxaban specific C/I
CrCl > 95
44
When are DOACs NOT recommended?
Prosthetic heart valves or antiphospholipid syndrome
45
Xarelto: AFib dosing
CrCl > 50 mL/min: 20 mg PO daily
CrCl 15-50 mL/min: 15 mg PO daily
46
Xarelto: treatment of DVT/PE
15mg BID x21 days then 20mg PO daily with food
CrCl < 30: avoid use
47
Edoxaban: treatment of DVT/PE dose
start after 5-10 days of parenteral anticoagulation
48
Fondaparinux: contraindications
Severe renal impairment (CrCl < 30)
49
DOACs D/I
Substrates of CYP3A4 and PgP
50
From warfarin to another oral anticoagulant, stop warfarin and convert to: READ
Rivaroxaban when INR is < 3
Edoxaban when INR is ≤ 2.5
Apixaban when INR < 2
Dabigatran when INR < 2
51
Conversion between dabigatran to warfarin
Start warfarin 1-3 days before stopping dabigatran (determined by renal function - refer to package labeling)
52
Pradaxa notes
Discard w/in 4 months of opening
Swallow capsules whole
When treating DVT/PE, start 5-10 days after parenteral anticoagulation
53
Bivalrubin: notes
Safe with active HIT or Hx of HIT
No antidote
54
Protein C and S
Natural anti-coagulants
55
When is the lower starting dose for warfarin recommended? (5 mg)
Elderly
Malnourished
Taking drugs that inc. level
Liver disease
Heart failure
High risk of bleeding
56
Warfarin: substrates
CYP2C9 (major)
57
Warfarin: C/I
Pregnancy (Except with mechanical heart valves)
58
CYP2C9 inhibitors
Amiodarone (Half dose of warfarin when starting)
Fluconazole
Metronidazole
TMP/SMX
59
Starting dose of warfarin in healthy outpatient
≤ 10 mg daily for the first 2 days
60
Warfarin: monitoring on stable INR
12 weeks
61
Protamine dose: heparin reversal
1 mg will reverse 100 units of heparin
**Reverse the amount of heparin given in 2-2.5 hours**
62
Protamine: max dose
50 mg
63
Protamine dose: Lovenox reversal
1mg of protamine per 1 mg of lovenox
64
When do you stop warfarin prior to surgery?
5 days prior
**Those at high VTE risk, bridge with LMWH or UFH**
65
Risk factors for VTE (Modifiable)
Acute medical illness
Immobility
Medications (SERMs, drugs containing estrogen, EPO)
Obesity (BMI ≥ 30)
Pregnancy & post-partum period
Recent surgery or major trauma
66
Risk factors for VTE (non-modifiable)
Inc. age
Cancer/Chemo
Previous VTE
Inherited or Acquired thrombophilia (Protein C/S deficiency)
Certain disease states (HF, nephrotic syndrome)
67
Treatment of VTE
3 months
For those without cancer: Dabigatran or DOAC preferred over warfarin
For those with cancer: DOACs over all
68
CHADS-VASc scoring system
C-CHF
H-HTN
A - age (≥ 75) 2
D- DM
S- prior stroke/TIA -2
Vascular disease (prior MI, PAD, aortic plaque) - 1
Age (65-74)
Sc- Sex category (Female = 1)
69
When is anticoagulation recommended?
CHADS over 2 for males and over 3 for females
70
Elemental Iron %
Gluconate - 12 %
Sulfate - 20%
Sulfate, dried - 30%
Fumarate - 33%
Carbonyl, polysaccharide, iron complex - 100%
71
When do sickled RBCs burst (hemolyze)?
after 10-20 days
72
Fetal hemoglobin (HgbF)
Blocks sickling of RBCs
73
What organisms are people with Sickle cell particularly at risk for?
Strep pneumo
H. influenzae
N. meningitis
74
Goal Hgb with SCD
≤ 10 post blood transfusion
75
Infants and SCD
Those who test positive for SCD at birth should be on ppx PCN BID until 5 yrs old
76
Hydroxyurea: when indicated?
≥ 3 moderate-severe pain crises in one year
77
Hydroxyurea: Boxed warnings
Myelosuppression
Fetal toxicity
Avoid live vaccine
78
Hydroxyurea: supplmentation
Folic acid to prevent macrocytosis
79
Voxelotor: MoA
stimulates production of hemoglobin S (HgbS) polymerization
80
Iron chelation treatment
Chelation therapy to remove excess iron
Oral agents: deferasirox and deferiprone
IV agent: deferoxamine (not used)
81
Metoprolol tartrate IV to PO
1: 2.5
82
Carvedilol: administration
Take with food
83
Beta-blockers: blood sugars
- Can mask S/Sx of Hypoglycemia
- Can dec insulin secretion leading to hyperglycemia
84
Hypertensive crisis BP threshold
≥ 180/120 mmHg
85
How much do you want to decrease the BP by in the first hour of a hypertensive emergency?
No more than 25%
86
Waist circumference target
< 35 inches (women)
< 40 inches (males)
87
Yosprala
Aspirin/Omeprazole
88
Ranolazine: contraindications
Liver cirrhosis
Do NOT use with strong CYP3A4 inhibitors or inducers
89
DAPT: SIHD
bare metal stent: at least one month
drug-eluting stent: 6+ months
post-CABG: 12 months
89
Ranolazine: warnings
QT prolongation!
**Not for acute treatment of chest pain**
90
NTEMI treatment
Medications alone OR
PCI
91
STEMI treatment
Requires PCI or fibrinolytic
92
PCI: timing
within 90 minutes of hospital arrival (optimal door-balloon time) or within 120 minutes of first medical contact (ex: ambulance)
93
FIbrinolytics: timing
If PCI is NOT possible within 120 minutes, fibrinolytic therapy is recommended and should be given within 30 minutes of hospital arrival (door-to-needle)
94
Drug treatment for ACS
MONA GAP BA
Morphine
Oxygen
Nitrates
Aspirin
GPIIb/IIa antagonists
Anticoagulants
P2Y12 inhibitors
Beta-blockers
ACEI
95
Prasugrel (Effient) contraindication
Bleeding
Hx of TIA or stroke
96
Ticagrelor weird ADR
Dyspnea (> 10%)
96
Ticagrelor (Brilinta) dosing
90 mg PO BID for 1 yr, then 60 mg BID
**Maintenance ASA should not exceed 100mg **
97
ACC/AHA HF staging system
A - at risk for HF but without symptoms, structural heart disease or elevated biomarkers
B - pre-HF: structural issues but without symptoms of HF
C - structural issues with symptoms
D - Advanced HF with severe symptoms or recurrent hospitalizations
98
NYHA Functional class
I - No limitation of ordinary activity
II - Comfortable at rest, ordinary physical activity causes symptoms
III - Minimal exertion = symptoms
IV - Symptoms at rest
99
Cardiac output
CO = SV X HR
100
Cardiac index
CI = CO/BSA
101
Natural products to help with HF
Omega-3 fatty acid
Hawthorn
CQ10
102
Drugs that worsen/cause HF
DI NATION
DPP4 inhibitors
Immunosuppressants
Non-DHP CCBs
Antiarrythmics
TZDs
Itraconazole
Oncology drugs
NSAIDs
103
When is Ivabradine added?
NYHA class II-III with HR > 70 on maximally tolerated dose of BB
104
Sacubitril/valsartan target dose
97/103
105
Coreg target doses
≤ 85 kg: 25mg BID
> 85: 50 mg BID
106
Spironolactone warning
do not initiate for HF if K+ > 5
107
Dapagliflozin: when not to initiate
eGFR < 25 mL/min
108
Jardiance: when NOT to initiate
eGFR < 20 mL/min
109
Loops: weird electrolytes
Inc. HCO3 (causing metabolic alkalosis)
Inc. UA
Inc. glucose
Inc. TG
Inc. Cholesterol
110
Loops: dose conversions
Furosemide 40mg = Torsemide 20mg = Bumetanide 1mg = Ethacrynic acid 50 mg
111
BiDil indication
African americans with NYHA III-IV who are symptomatic despite optimal treatment
112
Digoxin: MoA
Inhibits Na-K-ATPase pump
Positive inotrope
Negative Chronotrope
113
Digoxin: when is lower starting dose selected?
Renal insufficiency
Smaller
Older
Female
114
Digoxin: starting dose
0.125-0.25 mg
114
Digoxin: CrCl < 50 mL/min
dec dose or inc. frequency
115
Digoxin: IV to PO
Dec. dose by 20-25% when changing from PO to IV
116
Digoxin toxicity
Symptoms: N/V, loss of appetite, blurred/double vision, greenish-yellow halos, bradycardia, life-threatening arrhythmias
**Inc RISK with HYPOK+ HYPOmg+ and HYPERCa+
117
Potassium oral solution 10%
10% = 20 mEq/15 mL
