Chronice Care in Cardiology Flashcards
What is the cut off for HFrEF?
40%
What are treatment options for HFrEF?
Loop diuretics, ACEi
What are the common adverse effects of ACEi?
Cough, Angioedema
What’s the initial daily dose of furosemide in HF?
20-40 mg/day or BID
What’s the target dosing for the ACEi in HF?
Captopril - 50 mg TID, Enalapril - 10 mg BID, Lisinopril - 20mg daily, Perindopril - 8 mg daily, Ramipril -10 mg daily, Trandolapril - 4 mg daily
What’s the hydrochlorothiazide initial daily dose?
25 mg/day or BID
What’s the target dosing for ARBs in HFrEF?
Candesartan 32 mg/day, Losartan 150 mg/day, Valsartan 160 mg BID
Do beta blockers need to be given to any patient with HFrEF?
YES
How to dose with beta blockers?
Add to existing ACE inhibitor therapy, start low and go slow. ONLY bisoprolol, carvedilol, and metoprolol succinate recommended.
What’s the target dosing for beta blockers in HFrEF?
Bisoprolol - 10 mg daily, Carvedilol - 25 mg BID (50 mg BID if weight is more than 85 kg), Carvedilol CR - 80 mg daily, Metoprolol succinate - 200 mg daily
When can you add aldosterone antagonists in HFrEF?
Recommend in NYHA class II-IV with LVEF <35% (patients in class II should have a history of CV hospitalization or elevated BNP), recommend in all patient after an acute MI with LVEF <40% with either signs and symptoms of HF or a history of DM.
What are the initiation parameters for aldosterone antagonists?
SCr < 2.5 in men or <2.0 in women or eGFR> 30. K <5.0
Are aldosterone antagonists dosed on SCr or eGFR?
eGFR > 50 is normal (12.5 spirono and 25 epler) and half if eGFR 30-49 (every other day)
What is the big ADR for aldosterone antagonists?
Gynecomastia (spironolactone).
Is there mortality reduction with digoxin?
No, improves symptoms and hospitalization.
What is the dose of digoxin?
0.125 mg/day.
What interactions would you see with digoxin?
Amiodarone (reduce by 30-50%), dronedarone (reduce by 50%), verapamil, itra and posaconazole, cyclosporine, tacrolimus, clarith and erythromycin.
When can you give hydralazine/isosorbide?
Add on therapy to ACEi and BB in African americans if HFrEF and Class 3 or 4 heart failure
What to know about Sacubitril/valsartan?
In HFrEF class 2 or 3 who tolerate ACEi or ARBs, replacement by entresto is recommended. Was better at composite end point of death and all cause moretality and or hospitlization for HF than enalapril monotherapy. Allow 36 hour washout time after ACEi/ARB use before starting due to angioedema
What to know about ivabradine?
Can be beneficial to reduce hospitalizations in NYHA class 2 or 3 patients with LVEF <35%. Resting HR more than 70 beats/min required. Monitor for bradycardia, halos of light in periphery (phosphenes), and afib.
What is the strict rate control for ventricular rate control?
<80 beats/min and lenient is <110/min
When are non-dhp CCB’s preferred for ventricular rate control?
Verapamil or diltiazem, preferred over bb if severe asthma/copd and useful to control HR increases with exercise
What to know about cardiovversion?
You HAVE to make sure there is no atrial thrombi via TEE or 3 weeks anticoagulation if in AF>48 hour; anticoagulation warranted
What drugs can be used for cardioversion up to 7 days? DIP-AF
Dofetilide, Ibutilide, Propapfenone, Amiodarone, or Flecainide
What drugs can be used for cardioversion after 7 days? DIA, diamonds last forever.
Dofetilide, ibutilide, amiodarone
How to remember the class 1 antiarrhythmic drugs?
3 classes. Class A disopyramide, quinidine (serious GI effects), procainamide (double quarter pounder), watch for TdP. Class B lidocaine and mexiletine (lettuce, mayo), Class C flecainaide (eye problems) and propafenone (fries please). Sodium channel blockers
How to remember the class 3 drugs antiarrhytmic drugs?
Amiodarone, Dronedarone, Dofetilide, Ibutilide, Sotalol. A DRooling DOg is scary. Potassium channel blockers.
What are the class 3 and 4 antiarrthymic drugs?
2 B- blockers, 4 - Ca channel blockers.
How to determine antiarrhythmic with renal function?
CrCl < 40 = any except sotalol
CrCl <20 = do not use dofetilide
Which antiarrhythmic can you not use if hypokalemic?
sotalol or dofetilide
Which antiarrhythmic can you not use if severe pulmonary disease?
amiodarone or dronedarone, caution with propafenone
Can you use sotalol in HFrEF?
NO
What key points to remember for acute AF?
Focus on ventricular rate, rate acceptable if asymptomatic and <110 BPM. If unstable, synchronized cardioversion and anticoagulation
What key points to remember for chronic AF?
Rate control - beta blockers and CCB preferred.
Rhythm control - choose agent based on concomitant disease state
Anticoagulation - based on CHADSVASc score
What to know about black adults with hypertension?
If they don’t have CKD or HF initial therapy should include a thiazide type or CCB.
What are the high intensity statin doses?
Atorvastatin at 40-80 mg and Rosuvastatin at 20-40 mg.
When do you give a diabetic patient a statin?
If older than 40 yes but if older than 75 continue previous therapy or see if statin therapy benefits outweigh risks.
What safety parameters with statins?
Alanine aminotransferase >3x upper limit of normal
What is 1st line treatment for HBP for a patient with HFpEF?
Diuretic
What is the primary goal of treating hypertriglyceridemia?
Prevent Pancreatitis. Severe is >500
What is a common side effect of Niacin and how do you reduce?
Flushing/hot flashes, take the medication prior to bed, take aspirin 30 minutes before the niacin dose, use extended release, start at a low dose (500 mg) and titrate to target dose by 500 mg each month (2000 mg). High dose niacin can increase uric acid levels and increase glucose levels
What drugs should be avoided in patients with WPW (wolf parkinson white)?
Non dihydropyridine CCBs. Especially if they present with A-Fib with RVR due to the risk of worsening the pulse instead of slowing it down.
How do you bridge to Warfarin when treating acute venous thromboembolism?
use therapeutic anticoagulation (bridge therapy) with low molecular weight heparin, fondaparinux, or unfractionated heparin. Typically need anticoagulation therapy for 3 months patients diagnosed with PE.
Do you do bridge therapy with the Xa inihibtors or dabigatran?
NO. Therapeutically active after 2 hours.
How do you treat gestational hypertension?
NEVER with ACEI or ARB. Angiotensin II is necessary for development of heart, kidneys, brain in fetal development. They are category X due to an increased risk of damage to the fetal kidneys. Methyldopa or labetalol are the go to’s. Beta blockers can cause low birth weight so no and thiazides are 2nd or 3rd line.
What is the CHADS-VASC parameters?
CHF history (1), HTN (1), Age (65-74 is 1, 75 and older is 2), Diabetes (1), Sex (female is 1), Vascular disease (1), Stroke/TIA/thromboembolism is 2.
What is the drug of choice for WPW syndrome and tachycardia?
Procainamide.
When is INR too high with warfarin?
3
When do you lower the starting dose of Entresto?
Severe renal impairment, patients not currently taking an ACEi/ARB or previously taking a low dose of these agents, and patients with moderate hepatic impairment
Can ranolazine increase the QTC interval?
YES
What are the CCS classification systems?
Class 1 - ordinary, Class 2 - slight limitation and occurs occasionally (angina), Class 3 - marked limitations, Class 4 - inability to carry physical activity without discomfort (anginal symptoms may be present at rest)
Which PSK9 is a monthly injection?
Evolocumab, Alirocumab is every 2 weeks.
How often do you change the patch for clonidine?
weekly
What are side effects of CCBs?
GERD and constipation
Does BNP elevate when taking Entresto?
YES
What is the boxed warning of lomitapide?
elevation in transaminase
Can class 3 antiarrhythmics cause QT interval prolongation?
YES, specifically Sotalol and amiodarone
Can bile acid binding resins (cholestyramine, colesevlam) raise TG’s while lowering LDL?
YES
Which anti platelet med is associated with agranulocytosis?
Ticlopidine
What is Xareltos dosing for DVT?
15 mg BID with food for 21 days then 20 mg QD with food
Is Ibutilide used for acute termination/cardioversion of afib or for the maintenance treatment of afib?
ACUTE
How long do you bridge with warfarin prior to cardioversion in someone with afib to prevent cardioembolic stroke?
3 weeks.
Can you give prasugrel before the cardiac cath lab in an NSTMI?
NO. No benefit, aspiring, clopidogrel, and ticagrelor are fine though.
How do you determine paroxysmal vs persistent afib?
Persistent is defined as greater than 7 days and easily cardioverted
Which ARBs can you use for pediatric hypertension?
Losartan, olmesartan, and valsartan
What’s the drug of choice for a positive acute vasodilator test in pulmonary hypotension?
Calcium Channel Blocker
What is contraindicated in beta blocker use?
hyperreactive airway disease (asthma)
