Cardiovascular Conditions * Flashcards
Drugs that inc LDL and TG
-protease inhibitors (-avir)
-atypical antipsychiatics
-steroids
-transplant drugs (cyclosporine, tacrolimus)
-diuretics
-Efavirenz
Drugs that increase LDL
-fibrates
-SGLT2 inhibitors
-thiazoliniesiones (-gliptins)
-fish oils
Drugs that increase TG
-IV lipid emulsions
-propofol
-clevidipine
-blie acid sequestrants
-alcohol
Friedewald equation
-to calculate LDL
LDL = Total cholesterol - HDL - (TG/5)
*cannot use if TG > 400 mg/dL
Managing myalgias with Statins
1: reduce the risk
-avoid drug interactions, including OTC products
-do not use simvastatin 80 mg/day
-do not use gemfibrozil + statin
2: if myalgias occur:
-hold statin, check CPK, investigate other possible causes
-after 2-4 weeks: re-challenge with same statin at same dose or lower dose
-ig myalgias return, d/c statin - use a low dose of diff statin
Drug interactions with Statins
–> G-PACMAN
G: grapefruit
P: protease inhibitors
A: azole antifungals
C: cyclosporine, cobicistat
M: macrolides (except azithromycin)
A: amiodarone (sim mdd 20, lova mdd 40)
N: non-DHP CCBs (sim mdd 10, lova mdd 20)
G-PACM: do NOT use with simvastatin or lovastatin
Statin general facts
MOA: inhibit rate-limiting step of cholesterol synthesis. (HMGO-reduc)
CI: active liver disease, pregos, breastfeeding, taking strong CYP3A4 (simva, lova)
SE: myalgias, arthralgias, myopathy, rhabdomyolysis, inc BG
–> reduce dose when crcl < 30 (except atorva)
–> when crcl < 60, reduce livalo dose
Statin equivalent doses
-Pitavastatin 2 mg
-rosuvastatin 5 mg
atorvastatin 20 mg
lovastatin 40 mg
pravastatin 40 mg
fluvastatin 80 mg
–> pitavastatin = most potent
–> rosuvastatin = most potent to lower LDL
Toxicities: hepatotoxicity, myalgias, myostitis, rhamdomyolysis, glucose changes
–> dosing in eveneings: simva, lova, fluvastatin
DDI with simvastatin
-max 10 mg/day w/ verapamil, diltiazem
-max 20 mg/day w/ amiodarone, amlodipine
DDI with Lovastatin
max 20-40 mg/day w/ diltiazem, verapamil, amlodipine, amiodarone
Ezetimibe (Zetia)
-use with a mod statin
Warning: avoid in mod-sev hepatic impairment, skeletal muscle effects
SE: URTI, diarrhea, arthalagias, sinusitis
combo product = Vytorin (eze/simva)
Bile acid Sequestrates
-bind bile acids and poop them out *do not use with TGs > 300
–> Cholestyramine: CI w/ complete biliary obstruction
–> Colesvalam: option for DM and pregos, CI w/ bowel obstruction, TG > 500
–> Colestipol
SE: constipation, abdominal pain, inc LFTs
DIs: seperate all drugs by 1-4 hrs before or 4-6 hrs after
Fenofibrates
-use when TGs are high
CI: severe liver disease, severe renal disease (crcl < 30), gallbladder disease, nursing mothers
SE: inc LFTs, myopathy, inc SCr
–> Gamfibrozol (lopid): give 30 mins before and after dinner, DO NOT use with repaglinide, ezetimide or statins
–> Fenofibrate (Antara, Ticor, Trilipix)
Niacin
-used to dec TGs
IR: Niacor = flushing (take ASA before dose)
ER: Niaspan = inc liver tox
CR: Slo-Niacin = inc liver tox
CI: active liver disease, active PUD, arterial bleeding
SE: flushing, pruritis, diarrhea, hyperglycemia, hyperurecemia
-monitor LFTs
-take w/ food, avoid hot liquids and spicy food
Fish oils for cholesterol
-indicated as an adjunt to diet in pts w/ TGs > 500
–> omega 3 acid: Lovaza
–> Iscosapent ethyl: Vascepa
–> omega-3 carboxylinc acid: Epanova
SE: prolonged bleeding time
L&E: eructation, dyspepsia, taste perversions
V: arthalgias
PCSK9 inhibitors
-use to inc LDL receptors
–> Alirocumab (Praluent): HeFH or ASCVD w/ max statin, 75-150 mg SC q 2 weeks
–> Evolocumab (Repatha): HeFH, HeFH, or prevention of cardio events in pt with ASCVD, 140 mg SC q 2 weeks, or 420 mg SC q month
SE: nasopharyngitis, injection site reaction, URTI, UTO, back pain (E) , inc LFT (A)
Drugs that can increase blood pressure
–> STIMULANTS
-ADHD meds (amphetamine, methylphenidate)
-Rec drugs (caffeine, cocaine)
-Decongestants (pseudoephedrine, phenylephrine)
-antidepressants (MAOIs, SNRIs, TCAs)
–> AGENTS THAT INCREASE SODIUM & WATER RETENTION
-NSAIDs (ibeu, naprox, melox)
-immunosuppressants (cyclosporine)
-systemic steroids
–> OTHERS
-ERSAs (spoetin, darbepoetin)
-high dose estrogen OCs
-select oncology agents (bevacizumab, sunitinib)
HTN guideline recommendations
When to start treatment:
–> stage 2 HTN ( > 140/>90)
–> stage 1 (130-130/80-89) and one of these
A. clinical CVD (stroke, HF or CAD)
B. 10 yr ASCVD risk > 10 %
BP goal: < 130/80
Initial drug selection:
non-black: ACE, ARB, thiazide, CCB
black: thiazide or CCB
stage 3 CKD: ACE/ARB
–> start 2 first line tx when BP > 150/90
Combination BP drugs: ACE/ARB + diuretic
-lisinopril/hctz (Zestoretic)
-losartan/hctz (Hyzaar)
-olmesartan/hctz (Benicar)
-valsartan/hctz (Diovan)
Combination BP drugs: ACE/ARB + CCB
-benazepril/amlodipine (Lotrel)
-valsartan/amlodipine (Exforge)
Combination BP drugs: BB + diuretic
-atenolol/chlorthalidone (Tenoretic)
-bisoprolol/hctz (Zlac)
Combination BP meds: K-sparing + thiazide like diuretics
triamterene/hctz (Maxzide)
HTN and Pregnancy
AVOID: ACE, ARB, Aliskiren
Threshold to tx: > 140/>90 (severe = >160/>110)
Goal BP = 120/139/80-89
TX:
1st line = labetalol, nifedipine ER
2nd line: methyldopa (sedation)
Severe TX:
1st line: IV labetolol or hydralazine
no IV access= nifedipine IR
Preeclampsia: screen BP, Risk Factors: HTN, renal disease, DM, hx in past prego, give ASA 81 mg at 14-20 weeks
Thiazide Diuretics
–> block NACl cotransporter in the distal convoluted tubule = inc excretion of Na, H2O, Cl, K
-Chlothalidone 12.5-25 qd (am)
-hctc 12.5-50 mg qd (am)
-metolazone: used in combo w/ loops for volume overload in renal impairment
CI: hypersensitivity to sulfanamide-derived drugs
SE: dec K, Na, Mg, inc Ca, uric acid (gout flare), BG, LDL & TG, photosensitivity, impotence
Dihydropyridine CCBs
Treat HTN, angina, raynauds
-amlodipine (Norvasc)
-nifedipine Er (Procardia) –> pregos, can leave ghost tab
-Nicardipine (Cardene) IV/PO
Warnings: hypotension, caution in HF
SE: peripheral edema, headache, flushing, palps + tachycardia, gingival hyperplasia
–> Clevidipine (Cleviprex) = lipid emulsion (2 kcal/ml) *must calculate caloric intake
CI: egg and soy/soybean allergy
Warnings: hypotension, reflex tachycardia, infections
SE: hypertriglyceridemia
Non-dihydropyridine CCBs
used to TX arrhythmias (afib), angina, HTN
-Diltiazem (Cardizem)
-Verapamil (Verelan)
CI: hypotension, 2nd or 3rd degree heart block
Warnings: HF, bradycardia
SE: edema (V), gingival hyperplasia, constipation (D)
–> DDI: use caution with BB, digoxin, clonidine, amiodaraon, simva, lova
When are ACE/ARBs preferred in select comorbid conditions?
–> CKD: eGFR < 60 and/or albuminuria
-slow progression of chronic kidney disease
-dec vasoconstriction of efferent arterioles, resulting in dec workload in glomeruli
–> Heart Failure: with EF < 40%
-reduction in mortality and morbidity
-dec ventricular remodeling that occurs secondary to angiotensin II
ACE inhibitors
-stop the conversion of angiotensin I to 2 & bradykinin conversion (= accumulation)
–> Benazepril (Lotensin)
–> Enalapril (Vasotec), Enalaprilat (Vasotec IV)
–> Lisinopril (Zestril)
–> Quinapril (Accupril)
–> Ramipril (Altace)
BBW: do not use in pregnancy due to fetal injury/death
CI: angioedema (DO NOT USE IF PT HAS HX), using within 36 hrs of valsartan (needs washout)
Warnings: hyperkalemia, hypotension/dizziness, renal impairment (do not use in bilateral renal stenosis)
SE: cough
ARBs
-block the angiotensin 2 receptor = inhibit vasoconstriction & aldosterone secretion
–> Irbesartan (Avapro)
–> Losartan (Cozaar)
–> Olmesartan (Benicar) –> Warning: Sprue-like enteropathy = severe, chronic diarrhea w/ weight loss
–> Valsartan (Diovan)
BBW: do not use in pregnancy due to fetal injury/death
Warnings: hyperkalemia, hypotension/dizziness, renal impairment (do not use in bilateral renal stenosis), angioedema (do not use if pt has hx)
–> less cough and no need for washout with Entresto
DDI with Ace/ARB
-lithium: renally excreted
*avoid with RAS inhibitors due to risk of dec clearance –> increase toxicity
Potassium sparing diuretics
-work in the collecting duct & inc excretion of sodium, water and dec K excretion
–>Spironolactone (Aldactone)
–>Eplerenone (Inspra)
–>Triamterene (+ HCTZ = Maxzide)
–>Amiloride
CI: hyperkalemia (K >5.5), severe renal impairment, Addison’s disease (spirono), strong CYP3A4 (eplere)
SE: inc serum creatinint, dizziness, gynecomastia, breast tenderness, impotence (spiron)
Indications for BB use
-Heart failure (Bisoprolol, Carvedilol, metoprolol succinate
-post myocardial infarction
-stable ischemic heart disease
-arrhythmias
-noncardiac (nonselective agents) –> migraine prophylaxis, variceal hemorrhage prophylaxis
Beta 1 selective BBs
–> Atenolol (Tenormin)
–> Esmolol (Brevibloc) IV
–> Meto tar (Lopressor) IV, PO (Po:IV - 1: 2.5)
–> Met Succ (Toprol)
–> Nebivolol (Bystolic) - also nitric oxide vasodilation
BBW: do not d/c abruptly
Warnings: use caution w/ pt: DM (masks symptoms of hypogly), bronchospastic idease, raynaud’s/peripheral vascular disease
SE: bradycardia, hypotension, CNS effects, impotence
Beta 1 & 2 selective BBS
–> proprabolol (inderal) - has inc lipid solubility (can cross BBB), so it is used fro non cardiac things - migraine ppx and tremor = inc CNS effects
–> Nadolol (corgard)
-all agents can be useful for pts w/ portal HTN to prevent veriacial hemorrhage
Beta-1, Beta-2 and Alpha -1 blocker BBs
–> Carvedilol (Coreg) - take all formulations with food
–> Labetalol: drugs of choice in PREGNANCY!
Centrally-Acting Alpha-2 Agonists
–> Clonidine (Carapres)
-Kapvay - for ADHD, also has a patch (skin rash, pruritus, eryhtema, change weekly, remove before MRI)
–> Guanfacine
-Intuniv - for ADHD
Warnings:do not d/c abruptly (rebound hypotension, sweating, anxiety)
SE: bradycardia, hypotension, CNS-related, dry mouth, constipation, Impotence
Centrally-Acting Alpha-2 Agonists: Methyldopa
CI: concurrent use with MAOi, liver disease
Warnings: risk of hemolytic anemia (positive coombs test) -d/c drug
SE: drug-induced lupus eythemtosus (DILE) - ANA testing
–> CANNOT be used in pregnancy
Direct vasodilators
–> Hydralazine: PO,IV
- Warning: DILE
-SE: peripheral edema, headache, flushing, tachycardia, palpitations
–>Minoxidil: PO, topical
-BBW: potent vasodilator, canc ause pericardial effusion and angina
-SE: hair growth, fluid retention, tachycardia
*use only for resistant hypertension and administer with a BB and diuretic
Alpha blockers
–> Doxazosin
–> Prazosin
–> Terazosin
-not rec for tx of HTN, have worse cardiac outcomes
–> can use if comirbid BPH
Key IV meds for HTN Emergency
D-CCBs: clevidipine, nicardipine
ACE inhibitors: Enalaprilat
BBs: esmolol, labetalol
Vasodilators: hydralazine, nitroglycerin, nitroprusside
Hypertensive Emergency
-acute organ damage present (encephalopathy, stroke, AKI, acute coronary syndrome)
–> treat w/ IV meds
–> dec BP by no more than 25% in first hour
–> dec BP to ~160/100 mmHg in the next 2-6 hrs
Hypertensive Urgency
-no acute organ damage, more severe, asymptomatic HTN
-treat with oral meds: home regimen or short acting meds (captopril, clonidine)
-dec BP gradually over 24-48 hrs
Treatment Approach for Stable Ischemic Heart Disease
A: anti-platelet and antianginal drugs
B: blood pressure and beta-blocker
C: Cholesterol (statins) and cigarettes (cessation)
D: Diet and diabetes
E: Exercise and education
Antiplatelet agents for chronic stable angina
–> Aspirin (Bayer) - 1st line - inhibits COX 1, preventing platelet aggregation
CI: salicylate allergy
Warnings: Reye’s syndrome (teens after viral infection)
SE: dyspepsia, heartburn, nausea, bleeding
(Yosprola = asa and omperazole combo- high GI bleed risk)
–> Clopidogrel (Plavix)
BBW: CYP2C19 active metabolism –> will not convert the drug to its active form (DDI w/ omeprazole/espoprazole - prevent conversion)
Warnings: serious bleeding, stop 5 days before surgery, thrombotic thromboytopenic purpura (TTP)
-do not use dual antiplatelets therapy unless a pt has a stent
When do you use dual antiplatelet therapy?
–> asa and clopidogrel
1) bare metal stent (at least 1 month)
2) drug-eluting stent (at least 6 months)
3) post-CABG (12 months)
-ASA is dosed 81 mg daily and is continued indefinitely
Different options for anti anginal treatment
-BBS (1st line): titrate to HR 55-60 BPM, do not stop abruptly
-CCBs: preferred for Prinzmetal’s angina, avoid Nifedipine IR, use D CCB if adding on to BB
-Nitrates: use for fast relief and for chronic symptoms
-Ranolazine: does not decrease HR or BP, QT prolongation, CYP3A4
Nitrates for chronic stable angina
-ALL are CI with PDE-5 inhibitors and riociguat
SE: HA, hypotension, flushing, dizziness
Short acting –> Nitroglycerin SL,
-give 3 doses at 5 min intervals
-keep SL in original bottle
-do not swallow or chew- let dissolve
Long acting–> ointment, isosorbide mononitrate- once daily (bi dil is combo with hydralazine) (used for chronic pain)
-pathc- requires 10-12 hr nitrate - free interval to dec tolerance
Comparing unstable angina, NSTEMI and STEMI
–> UA: chest pain, neg cardiac enzymes, no ECG changes, partial blockage
–>NSTEMI: chest pain, pos cardiac enzymes, no ECG changes, partial blockage
–> STEMI: chest pain, pos cardiac enzymes, ST segment elevation, completed blockage
Drug treatment for acute coronary syndrome
MONA-GAP-BA
M: morphine
O: oxygen
N: nitrates
A: aspirin
–> give right away
G: gplla (epitfibate, tirofiban)
A: anticoagulants
P: P2y12 inhibitors (clopidogrel, prasugrel, ticagrelor)
–> depends on PCI or not
B: beta blockers
A: ace inhibitors
–> give within 24 hrs
P2Y12 Inhibitors: Clopidogrel (Plavix)
BBW: prodrug (CYP2C19)
LD: 300-600mg
MD: 75 mg
Warnings: bleeding, do not use with omeprazole or esomeprazole
P2Y12 Inhibitors: Prasugrel (Effient)
*do not use in pts with hx of stroke or TIA
LD: 60 mg
MD: 10 mg
–> only for ACS pts receiving a PCI
-dispense in original container
P2Y12 Inhibitor: Ticagrelor (Brillinta)
*maintenance dose of asapirin must be less than 100 mg
LD: 180 mg
MD: 90 mg BID for 1 yr then 60 mg BID after
Glycoprotein IIB/IIA Receptor Antagonists
–> Abciximab (ReoPro)
–> Eptifibatide (Integrilin)
–> Tirofiban (Aggrastat)
-all IV, w/ short half lives, used in cath lab
CU: thrombocytopenia, active bleeding, uncontrolled HTN, recent surgery or trauma, HX of stroke (past 1 yr)
Fibrinolytics
*only used for STEMI (complete blockage)
MOA: bind to fibrin in the clot + convert plasminogen to plasmin
–> Alteplase (Activase) -also used for acute stroke
–> Tenecteplase (TNKase)
–> Reteplase (Retavase)
-PCI preferred (optimal time = 90 mins)
-If not able to recienve PCI within 120 mins = use fibrinolytics
-optimal door to needle time for fibrinolytic = 30 mins
CI: active bleeding, hx of recent stroke, uncontrolled HTN
SE: bleeding
Secondary Prevention after ACS
-Aspirin: 81 mg indefinitely
-P2Y12 inhibitor:
–> medically mananged: clopidogrel/ticagrelor + ASA fro 12 months
–> PCI: any oral med + ASA for at least 12 months
-NTG forever PRN
-Beta Blocker: target HR 50-60, for 3 yrs - forever
-ACE inhibitor: use for reduced EF, HTN, CKD or DM forever
-Aldosterone antagonist: reduced LVEF and systematic HF or DM
-statin: high intensity forever
Signs and Symptoms of Systolic HF (EF < 40%)
-inc BNP, inc NT-proBNP
-SOB: orthopnea- when you lay down, dyspnea- when you exert yourself
-cough
-weakness/fatigue
-reduced exercise capacity
-fluid overload: edema, ascites, jugular venous distention, hepatojugular reflux
drugs that cause or worsen HF* (DI NATION)
DPP-4 inhibitors (alogliptin)
Immunosuppressants (TNF, interferons)
Non-DHP CCBs (V,D)
Antiarrhythmics (quinidone, felcainide)
Thiazolidinediones (inc risk of edema)
Itraconazole
Oncology agents (doxorubicin)
NSAIDs
MOA; either increasing fluid retention or inc BP
Initial medications, recommended for all pts w/o CI for HF
-ARNI(entresto), ACE, or ARB: dec mortality (entresto is preferred over an ACE or ARB to further reduce morbidity and mortality)
-BB: met succ, carvedilol provide benefit in dec mortality, controlling HR and reducing arrhythmia risk
-ARA: spirno, dec morbidity and mortality in class 2-4 HF
-SGLT2: dec morbidity and mortality in pts with or w/o DM
-Loop diuretics: reduce blood volume, which dec edema and congestion; most HF pts need a loop diuretic for symptom relief
additional meds to add on to GDMT in select HF pts
-hydralazine and nitrate (BiDil): dec morbidity and mortality in self-identified black pts with class 3-4 HF when added to optimized initial meds
-Ivabradine (Corlanor): dec risk of hospitalization in stable class 2-3 HF with resting HR of > 70 BPM on max tolerated dose of a BB
-Digoxin: provides small increase in cardiac output, improves symptoms and decreases cardiac hospitalization; can be considered in pts who remain symptomatic w/ 1st line agents
-Vericiguat: dec risk of hospitalization and CV death after HF hospitalization or need for IV diuretics
loop diuretic dose conversions
PO: lasix 40 mg = 20 mg torsemide (demadex) = 1 mg bumex
IV: lasix 20 mg = 20 mg torsemide = 1 mg bumex
Loop diuretics used in HF:
-furosemide (lasix)
-bumetanide (bumex)
-torsemide
SEs:
–> dec Na, K, Mg, Cl, Ca
–> inc UA, BG, TG, Tc, HCO3
-monitor: renal function, fluid status, BP, electrolytes, audiology testing, s/sx of HF
-avoids NSAIDs
ACEi & ARBs in HF
-mortality benefit
BBW: pregnancy, hx of angioedema, ACE inhibitors require 36 hr washout period before starting Entresto
-titrate to target doses used in trials
-Enalapril (Vasotec): 10-20 mg BID
-Lisinopril (Zestril): 20-40 mg qd
-Quinapril (Accupril): 20 mg BID
-Ramipril (Altace): 10 mg qd
–
-Losartan (Cozar): 50-150 mg qd
-Valsartan (Diovan): 160 mg BID
ARNi in HF
-entresto (valsartan + sacubitril)
-indicated in NYHA class 2-4 to reduce hospitalization and death
-add on to other key therapies
SE: cough, hyperkalemia, inc SCR, hypotentsion
**washout period: DO NOT use within 36 hrs of an ACE inhibitor
BBs used for HF
-mortality benefit
-for all HF pts, do not abruptly BB, only stop in acute decompensated HF or hypotension or hypo perfusion is present
–> metoprolol succ (Toprol XL): 200 mg daily (1: 2.5 ratio IV:PO)
–> bisoprolol
–> Carvedilol (Coreg): 25-50 mg BID - nonselective, lowers HR a lot, take w/ food to reduce hypotension/dizziness
Aldosterone receptor antagonists in HF
-mortality benefit
–> spironolactone and eplerenone
-used in NYHA class 2-4 pts
do NOT start therapy in HF pts with:
- K > 5 meq/L
-eGFR < 30 ml/min or
-Scr > 2.5 in males and > 2 in females
-start low and titrate
Hydralazine/Isosorbide Dinitrates (BiDil)
-mortality benefit
-indicated for blacks with class 3-4 HF who are symptomatic despite optimal tx and other pts who cannot tolerate ACE/ARB
SE: hypotension, HA,
Warnings: DILE; drug induced lupus
-do not use with PP drugs (PDE5 inhibitors)
Digoxin for HF
-no mortality benefit
-therapeutic range: 0.5-0.9 ng/nL
antidote: digifab
-toxicity; N/V, see halos around objects, inc risk of hypo mag, kalemia and magnesia
Ivabradine (Corlanor)
no mortality benefit, reduced hospitalizations
Criteria for use:
-stable, symptomatic HF
-EF < 35%
-normal sinus rhythm and resting HR > 70
-taking max tolerated doses of BB or have CI to BB use
target resting HR: 50-60 BPM
Potassium oral supplementation in HF
-potassium chloride
SE: N/V/D, inc K
Formulations:
-Micro-K: can open capsules and sprinkle contents on food
-Klor-Con M: tablet can be cut in half or dissolved in 4 oz water
-Klor-Con, K-Tab: swallow whole
The hearts natural pacemaker and arrhythmias
-the rate and rhythm of the heartbeat are set by the rapidly firing cells in the SA note. The SA node is called the heart’s natural pacemaker
An arrhythmia is caused be a disruption somewhere in the conduction system:
-the SA node can be firing at an abnormal rate or rhythm
-scar tissue from a prior heart attack can block and divert signal transmission
-another part of the heart may be acting as the pacemaker
QT Prolongation risk factors
-higher doses
-multiple QT prolonging drugs taken at the same time
-reduced drug clearance
-electrolyte abnormalities
-other cardiac conditions
-female gender
Select drugs that can increase or prolong the QT interval
-antiarrhythmics
-abx: macrolindes, quinolones, lefamilin
-azole antifungals
-antimalarials (hydroxychloroquine)
-antidepressants: SSRI (citalopram, escitalopram), TCAs, mirtazapine, trazadone, venlafaxine
-antiemetics: 5-HT3 receptor antagonists, droperidol, metoclopramide, promethazine
-haloperidol, chloprpromazine, thioridazine)
-leuprolide, nilotinib, oxaliplatin
Vaughn-Williams Classification
Class 1: Sodium Channel Blockers
Ia: disopyramide, quinidine, procainamide
Ib: Lidocaine, mexiletine
Ic: fleccainide, propafenone
Class 2: BBs
Class 3: Potassium Channel Blockers
-Dronedarone, sofetilide, sotalol, ibutilidine, amiodarone
Class 4: calcium channel blockers
-verapamil, diltiazam
Afib: Rater vs Rhythm Control
Rate control: pt stays in Afib with rate control
–> BBs, non-DHP CCBs, sometimes digoxin
Rhythm Control: try to restore and/or maintain NSR
–> class Ia, Ic, or III antiarrhythmics
Storke Prophylaxis in Afib
-clots can form when a pt is in Afib, which can embolus when the pt returns to NSR
-for many pts it is safer to remain in AFIB with rate control, require anticoagulation with (based on chad score)
–DOAC
–Warfarin
Antiarrhythmics MOA
Class 1: na-channel blockers
Class 2: beta blockers
Class 3: K- channel blockers (Amiodarone)
Class 4: non-CCBs
Digoxin
Adenosine - used for PSVTs: proximal supraventicular tachyarythmias
Amiodarone (Nexterone, Pacerone)
*antiarrthymic drug of choice with HF!
–> infusions require a non-PVC container (Nexterone comes like that)
- T1/2 = 40-60 days
BBW: pulmonary toxicity, hepatotoxicity (pt must be hospitalized when loading dose is given)
CI: iodine hypersensitivity
Warnings: hypo/hyper thyroidism (monitor TSH), optic neuropathy, photosensitivity (blue skin tint)
SE: hypotension, bradycardia, corneal microdeposits, dizziness, ataxia, skin protection needed
IV use: 0.22 micron= filter needed, centeral line preferred
Aminodarone drug interactions
-interactions with:
Warfarin dec dose 30-50%
Digoxin: dec dose 50%
Statins: do not exceed 20 mg simva, 40 mg lova (use rosuva!)
-do not use with sofosbuvir
Class IV: used to slow ventricular HR
-Diltiazem (Cardizam)
-Verapamil (Calan SR)
–> only these can be used as antiarrthymics!
CI: HFrEF
SE: edema, HA, hypotension, arrthythmias, HF, constipation, gingival hyperplasia
DDI: grapefruit, 10-20 mg simva dose
Digoxin (Digitik, Lanoxin) for rate control in afib
-blocks Na-K-ATPase pump, inc contraction force (positive ionotrip) and dec HR (neg cornotrop)
–> therapeutic range: 0.125-0.25 mg = narrow therapeutic index drug
Toxicity: N/V, loss of appetite, blurred vision, green/yelow halos, bradycardia, life threatening arrhythmias
–> low K and Mg can increase risk of digoxin toxicity, high Ca and hypothyroidism can also inc toxicity
renally cleared
antidote = digifab
Other drugs for antiarrhythmics
-Disopyramide: anticholinergic AEs
-Quinidine: Cinhonism (tinnitus, hearing loss, blurred vision, headache, delirium) DILE
-Procainamide: NAPA drug, renally cleared –> can wipe out agranlocytosis, ANA+ = DILE
-Dronedrone: cardiovascule issues, liver toxicity, QT prolongation
-Sotalol: non- selective BB, use betapase AF
-Ibutilide: make sure K and Mg are normal
-Dofetilide: continuous ECG monitoring, assess crcl for min 3 days, very proarrhythmic
-Adenosine: drug for PSVTs!
Transient Ischemic Attack (TIA)
caused by a temporary clot, or block of blood flow in the brain
-does not last long enough to have perm. damage
-symptoms are the same as stroke, but resolve within mins or hours
-often a warning sign for future stroke
Signs and Symptoms of Stroke: FAST
F: face dropping
A: arm weakness
S: speech difficulty
T: time to call 911
Bleeding Risks with Alteplase
-alteplase breaks up existing clots
-before tx: evaluate for bleeding risk:
–> active bleed (intracranial hemorrhage)
–> conditions (uncontrolled HTN) or labs (INR > 1.7) that increase bleeding
–> additive risks (anticoagulant use)
Alteplase Contraindications (ABCD)
-Active Bleed: active internal bleeding (head CT to rule out)
-Conditions, labs or vitals that increase bleeding risk
–> hx of recent stroke or head trauma within last 3 months, intracranial hemorrhage, aneurysm
–> BP > 185/110
–> INR > 1.7, aPTT > 40 sec, platelets < 100,000
–> BG < 50
-Drug interactions with additive bleeding risk
–> tx dose LMWH (in past 24 hrs) - 1 mg or 1.5 mg/kg
–> direct thrombin inhibitor or direct factor Xa inhibitor (on past 48 hrs) - dibagatran, DOAC
Alteplase (Activase)
-door to needle time: within 60 min to hospital arrival (FDA approved within 3 hrs of last known well)
–> stroke dose = 0.9 mg/kg (Max 90 mg)- 10% as bolus (1 min), remainder administered over an hour
SE: major bleeding
Other tx for Ischemic Stroke
-ASA 162-325 mg PO within 24-48 hrs after a stroke
-BP management
–> before alteplase: BP must be < 185/110
–> during and after alteplase: maintain BP < 180/105 during and for at least 24 hrs after
–> permission HTN (> 220/120 may be treated)
-BG control: 140-180 mg/dL
-DVT prophylaxis : UF or LMWH can be started 24 hrs after alteplase
Ischemic Stroke: tx of modifiable risk factors
–> HTN: < 130/80, tx with thiazides, ACE/ARB
–> Dyslipidemia: high - intensity statin
–> DM: DM + ASCVD: glp-1 or sglt2
–> lifestyle: smoking cessation, nutrition, physical activity, weight reduction, reduce alcohol
Antiplatelet tx in Ischemic stroke
-ASA (Abyer, Bufferin, Durlaza-ER, Yosprala-DR)
-Clopidogrel (avoid parasagrul - if TIA)
-ASA/ER Dipyridamole (aggrenox)
–> ASA + clopidogrel can be used together for 21-90 days
Intracerebral Hemorrhage (ICH) tx
-reverse anticoagulation
-treat seizures
-decrease intracranial pressure (ICP)
–> elevation of head of bed
–> hypertonic saline, mannitol
Mannitol (Osmitrol, Resectisol)
CI: severe renal disease, severe hypovolemia, pulmonary edeam/congestion, active intracranial bleed
Warnings: CNS toxicity, extravasation, nephrotoxicity, fluid and electrolyte imbalances
SE: dehydration, headache, lethargy, inc or dec BP
–> inspect for crystals, use a filter
Acute Subarachnoid Hemmorrhage (SAH). tx
-surgical intervention
-prevent cerebral artery vasospasm
–> vasospasms occur 3-21 days after the bleed
–> ORAL nimodipine 60 mg Q4 h for 21 days
Nimodipine (Nynalize)
BBW: do not adminster IV = death
-label oral syringes for “oral use only)
CI: risk of hypotension with use of CYP2A4 inhibitors
SE: hypotension
