Cardiovascular Disorders Flashcards
What is first line therapy for stable ischemic heart disease?
BB and ACEI/ARB, may add DHP-CCB to beta blocker therapy for angina control
For a patient with DM what is first line therapy for hypertension?
All first-line hypertensive agents are useful, utilize ACEI/ARB in presence of albuminuria
Why is it important to give patients with CKD an ACEI/ARB?
To slow kidney disease progression with patients with stage 3 CKD or stage 1 and 2 with albuminuria
Albuminuria =>+ 300mg/day or >= 300 mg/g albumin-to-creatine ratio
Some data suggest that separating hypertensive agents may provide better blood pressure control t/f?
True
Explain pathophysiology of heart failure.
CAD -> event (MI) -> ischemia (lack of blood flow) to heart -> myocardial cell death -> reduce ability for heart to pump correctly
What is the difference between HFrEF and HFpEF?
HFrEF (EF <= 40%): heart failure with reduced ejection fraction: less blood is pumped out of ventricles because of weakened heart muscles that can’t squeeze well
HFpEF (EF >= 50%): heart failure with preserved ejection fraction: less blood fills the ventricle due to stiff heart muscles that cant relax normally causing ventricle area for blood filling is decreased
Name drugs that will exacerbate HF via negative inotropic effects (HFrEF only)
Antiarryhtmics agents (except amiodarone and dofetilide)
BB (do not start bb is wet or exacerbation; benefits with certain agents long term)
Non-DHP CCB (diltiazem, verapamil)
Itraconazole
- Inotropes act on your cardiomyocytes, the cells in your heart muscle. Positive inotropic drugs help your heart beat with more force. Negative inotropic drugs tell your heart muscles to contract with less force
What are some medications that induce/exacerbate HF by increasing sodium and water retention?
Androgens/estrogen
NSAIDs
COX-2 inhibitors
Glucocorticoids
Salicylates (high doses)
Thiazolidinediones (rosiglitazone, pioglitazone - avandia, actors)
T/F: DPP-4 inhibitors can exacerbate HF?
True: FDA warning for saxagliptin, alogliptin (Onlgyza, Nesina) - likely a class effect but studies do not show for other drugs
What stage of HF are most elderly patients?
Stage C (ACC-AHA)
What do we use NYHA functional classification for?
Classification of heart failure patients based on patient reports symptoms. (Bidirectional, patients can go in and out of the classes)
I, II, III, IV from no limitations/symptoms, slight limitations, marked limitation, symptomatic at rest
Why are guidelines for HF mainly focused on HFrEF and not HFpEF?
Limited data on hospitalizations and mortality for HFpEF
HFpEF recommendations currently surround treating HTN, controlling fluid overload, and treat co-morbid contributing disease states
*limited data on using aldosterone antagonists, SGLT-2 inhibitors, ARNi, or ARBs to decrease hospitalizations
What is the washout period when transition to Entrestro from ACEI?
ACEi = 36 hours before starting sacubtril/Valsartan
T/F. Entresto to has diuretic effects?
Yes, can cause angioedema, monitor potassium and renal function 7-14 days after initiation and dose adjustments.
*remember to adjust dose of diuretics
When treating HF with BB, we want to used evidence-based agents. Which BB are used in HF?
Carvedilol, metoprolol XL, bisoprolol
Initiate in STABLE patients with no or minimal evidence of fluid overload
Start low and double dose no more than every 2 weeks as tolerated, until the target or maximally tolerated dose is reached
*If hypotension occurs, separate BB and ACEi/ARB/ARNi by at least 2 hours
What are some steps to minimize HYPERKALEMIA in HF patients starting aldosterone antagonists (spironolactone)?
initiate at lower dose
D/C potassium supplements
Monitor K and renal function within 1 week of starting, then monthly for 3 months
What is the potency of loop diuretics form lowest to highest?
Furosemide 40mg > Torsemide 20mg > Bumetanide 1mg > Ethacrynic acid 50mg
Greater bioavailability with bumetanide and torsemide 80-100%, furosemide 10-100%
Torsemide longer half-life of 12-16 hrs vs 4-6 hours with furosemide or bumetanide
Ethacrynic acid should only be used in those with SULFA allergy
T/F: NSAID and diuretic interacts?
True
What are some facts about metolazone in older adults?
Be cautious with high dose, recommend 2.5mg twice to three times weekly.
Take with thiazide-like diuretic at the same time 30 min prior to the loop
Duration of action can be up to 72 hours in older adults
What happens when someone gets too much sun
They can get burned
What electrolytes need to be given when treating HF with loops diuretics?
20 mEq of potassium per 40 mg of furosemide
Mag loss can also be seen, recommend yearly mag levels
Aldosterone antagonist may be added to limit potassium loss
What SGLT-2 Inhibitors are used for HF?
Farxiga: dapagliflozin: 10mg daily (only HFrEF)
Jardiance: Empagliflozin: 10 mg daily (both HFrEF and recently HFpEF)
What are the side effects of SGLT-2 inhibitors?
Genital mycotic infections
UTI
Hypotension
Hyperkalemia
Volume depletion
Euglycemic diabetic ketoacidosis
What are some contraindications of the SGLT-2 inhibitors?
Must watch for kidney health
Dapagliflozin: eGFR<30, Empagliflozin eGFR<20
Which medication has more risk of hypotension in blood pressure carvedilol or metoprolol xl?
Carvedilol, counsel patients to take with food.
What are the dietary restrictions for sodium and fluid?
Sodium ~1500 mg/day to improve congestive symptoms
Fluid restrict 48-56 oz/day to improve congestive symptoms (amt not as important as WHAT they are drinking)
What is the max dose of digoxin for older adults?
0.125mg/day
What does Ivabradine do?
Beneficial in heart failure to reduce HF hospitalizations for patients with symptomatic HFrEF <=35 who are receiving GDMT, including BB at max tolerated dose, and who are in SINUS RHYTHM with a heart rate of >= 70 BPM
What medication is VERIGIGUAT?
Brand = Verquvo
Approve in 2021 for HFrEF (EF<=45%)
Place in therapy is patients with recent hospitalization or need for IV diuretics
Rarely used
New York Heart Association Classification (1-4)
Class 1: asymptomatic
Class 2: Become winded with exertion
Class 3: Trouble with regular activities
Class 4: Most severe, symptoms at rest
ACC/AHA Classification for heart failure
Class A: At Rieske for HF but no evidence of heart disease or symptoms of heart failure
Class B: Evidence of structural disease, but no signs and symptoms of heart failure
Class C: Structural heart disease with symptoms of heart failure
Class D: Refractory heart failure not responsive to treatments
When do you give metolazone with thiazide like diuretics and loop diuretics?
Same time with thiazide-like
30-60 min before loop diuretics
Digoxin for HF can reduce hospitalizations but has no mortality benefits. What else do we need to know about this medication?
Inc risk of hypokalemia (esp with duo-admin with loops and thiazide-like diuretics)
Target level for CHF is 0.5-0.8
Which patients can take ivabradine?
Patients with persistent heart failure symptoms already taking BB with resting HR of >70 and in sinus rhythm, likely reserved for refractory patients.
Contraindicated in patients with low BP/low HR (Bp <90/50, HR <60)
*$$$
How do you assess stroke risk in AF?
CHA2DS2-VASc
CHF -1
HTN -1
Age >=75 - 2
DM -1
Stroke or TIA or thromboembolism -2
Vascular disease (prior MI, PAD, or aortic plaque) - 1
Age 65-74 -1
Sex Category (F gender) -1
How do you use CHA2DS2-VASc to recommend agent for anti-coagulation?
AF plus 2 lol more NON gender risk factors, >=2 Men, >=3 Women —> strongly recommmend AG
AF plus 1 or more NON gender risk factors, 1 in men, 2 in women —> AG is preferred (no anti thrombotic therapy may be considered)
AF plus 0 NON gender risk factors, 0 in men, 1 in women, no anti thrombotic therapy preferred
What is the HASBLED scoring system?
Tool to identify reversible risk factors for bleeds
What are the anti coagulation options for non-valvular AFIB?
Direct oral anticoagulants (DOAC) and warfarin
What does non-valvular AFIB mean?
In AF the absence of moderate to servere mitral stenosis or presence of a mechanical heart valve
What is TTR with Warfarin in AF?
goal time in therapeutic range (TTR) should be >= 70%
If TTR ,65% consider DOAC strategies to improve TTR
*SAMe-TT2R2 score can be used to predict those whose might do better on warfarin
What are DOAC recommendations based on risk factors?
HIgh risk of bleeding: Eliquis (apixaban), Savaysa (edoxaban), dabigatran 110 (European)
High risk of GI bleeding: apixaban, dabigatran 110
High risk of stroke: dabigatran 150mg
**Recommend AGAINST anti platelet therapy alone for most patients (aspirin should not be used alone for AF)
Aspirin same bleed risk as apixaban, so bleed risk not a reason to choose aspirin over apixaban
What are the 4 DOACs? And what are there 4 indications
Apixaban, dabigatran, rivaroxaban, edoxaban
Non-valvular AFIB
VTE treatment
CAD/PAD (to reduce the risk of heart attack, stroke, and CV death)
VTE prophylaxis (TKR/THR FOR UP TO 35 DAYS OR REDUCTION IN THE RISK OF RECURRENT VTE FOLLOWING SURGERY UP TO 39 DAYS: XARELTO ONLY
Which is the only DOAC indicated for CAD/PAD and what is the dose?
Xarelto
2.5 mg PO BID plus ASA (75-100mg) QD
CrCl <15 avoid use
**only doses of 15/20 need to be taken with large meal
Which is the only DOAC indicated in non-valvular AFIB with ESRD/DIALYSIS patients?
Eliquis
5 mg PO BID
reduce to 2.5mg PO BID if age >=80, TBW <=60kg
Which DOAC has acidic core?
Dabigatran
Must store in original container, swallow whole do NOT crush
Which DOAC has real world data suggesting the highest association with higher rate of GI bleeds?
Xarelto, rivaroxaban
Which DOAC has the best safety profile with bleeding?
Eliquis, apixaban
Don’t forget to dose adjust in older APPROPRIATE adults —> if patient >=80yo, TBW <=60kg, SCr >=1.5 (must have two)
Which DOAC should NOT be used in patients with CrCL >= 95?
Savaysa, edoxaban
*dec efficacy with higher kidney function
*For patients with 50 < CrCl <95
Which DOAC has an antidote? And what are the names of the antidotes?
Praxbind, idarucizumab for Pradaxa, dabigatran
Anadexxa, andexanet alfa for factor Xa inhibitors (only FDA approved to be used with Apixaban and Rivaroxaban
Prothrombin complex concentrate (PCC)
For a patient with AF and CKD do we anticoag knowing that with CKD, risk for bleed is higher?
Yes, we still do for renal patients, as bleed risk does get higher, stroke risk is even higher for these patients.
Can valvular AFIB patients take DOACs?
NO. Warfarin is only option.
What if AF patients get cardio version. Do they still get anticoag?
Yes, OAC for >= 4 weeks, or even longer based on stroke risk per CHA2DA2-VASc score
For lipid panels, fasting is not necessary unless the patient’s triglycerides are over 400. T/F?
True. Test results become more inaccurate when triglycerides are high for LFTs. Fasting still recommended for full work up
Which agent should be used to lower TG in older patients?
Vascepa, Lovaza, fenofibrate
Between Vascepa and lovaza, Vascepa has more data to reduce CV event when used in addition to statin in those with TG >150 with CV disease or diabetes
Lovaza has more TG lowering effects
*vascepa is pure icosapent ethyl (highly purified fish oil), lovaza is a mixture
How do you calculate CHADS2Vasc?
Score of 2 or greater = anticoag
CHF = +1
HTN = +1
Age >65 = +1, >75 = +2
Diabetes = +1
Sex (Female) = +1
Vascular disease = +1
Stroke/TIA = +2
What is treatment goal for afib?
To prevent stroke.
Rate vs Rythym control
In afib what are the two options for treatment?
rate and rhythm control
In afib what are the two options for rhythm control?
Electrical or medication cardioversion
What are options for medication cardioversion?
flecainide, propafenone, dofetilide (Tikosyn), ibutilide, dronedarone (multaq)
In afib what are the options for rate control?
cardioselective BB: ie metoprolol
non-dhp CCB: verap, diltiazem (work to slow the heart rate)
digoxin
in afib, what is the medication used for rhythm control (not medication cardioversion)?
amiodarone
What boxed warning does amio have? what must you monitor with amio?
liver toxicity.
TSH, lung function, LFTs
QTC
T/F: digoxin can be used in both CHF and afib. In afib may have loading dose and target levels are higher.
True. levels are CHF vs afib = 0.5-0.8 vs 0.8-1.2
*can accumulate with worsening kidney function
What is TIMI risk scoring?
Used to determine the risk of ischemic events or mortality in patients who have unstable angina or NSTEMI, the higher the score, the more likely to use invasive strategies for revascularization with unstable angina and NSTEMI
What medications should patients be on for acute management of Acute coronary syndrome?
MONABS: morphine, oxygen, nitroglycerin, aspirin/antiplatelet, betablocker, statin
What medications should post MI patients be on?
acei/arb, BB, high intensity statin +/- ezetimibe, antiplatelet- mainly aspirin for secondary prevention, if aspirin not tolerated, clopidogrel, prasugrel, or ticagrelor
