CVD Flashcards
Post-MI PCI tx
DAPT x1-3 years
BB x3 years
ACEi
Statin (high dose)
Post-STEMI no PCI tx
Clopidogrel x 30 days
ASA
ACEi
Nitrates for ischemia
Antiplatelets
ASA
P2Y12 Inhibitors: Clopidogrel, Ticagrelor, Prasugrel
DAPT
Dual Antiplatelet Therapy
ASA 81mg + Clopidogrel 75mg (or Ticagrelor 90mg BID)
PCI
Percutaneous Coronary Intervention
procedure used to open clogged heart arteries
pt may say they had angioplasty, catheter or stent put in
ASA for primary prevention
may use in ages 40-70yo at low risk of bleeding ie. pt doesn’t have history of bleeding, CKD, uncontrolled HTN, pt isn’t on NSAIDs, steroids, anticoagulants
HF triple therapy
ACEi BB MRA (spironolactone, eplerenone) Dapagliflozin now quadruple tx *all reduce hospitalizations and mortality
HF meds if sx despite triple tx
Entresto (Sacubatril/Valsartan) Ivabradine Hydralazine/Isosorbide Dinitrate Digoxin *all reduce hospitalizations (except digoxin) and mortality
Entresto
(Sacubatril/Valsartan)
for sx despite HF triple tx
need 36h washout from ACEi
CI in pregnancy
Ivabradine
for sx despite HF triple tx (NYHA II-III)
must be in sinus rhythm & HR >70bpm (bc it reduces HR)
AE: bradycardia, visual disturbances
Hydralazine/Isosorbide Dinitrate
for sx despite HF triple tx (NYHA III-IV) or alternative in ACE/ARB intolerant or Black pts
vasodilates, AE: hypotension, tachycardia, headache
Digoxin
for sx despite HF triple tx (NYHA III-IV)
dose based on age, wt, renal fxn & monitor levels in dehydrating illness, dose increases or toxicity
AE: delerium, n/v/d, visual disturbances
Statin indicated conditions
clinical atherosclerosis abdominal aortic aneurysm diabetes mellitus CKD LDL>5
Statin targets
LDL<2 or 50% reduction
Statins with CYP3A4 DDI
rosuvastatin, simvastatin, lovastatin
Bile acid resins
cholestyramine, cholestipol, colesevelam
2nd line for dyslipidemia, preferred in pregnancy (statins CI in pregnancy)
AE: GI (constipation, heartburn, bloating)
DDI: malabsorption of vitamins, seperate 1h before or 4-6h after)
Fibrates
gemfibrozil, fenofibrate, bezafibrate
used to lower TG or in combo with statins for dyslipidemia
AE: GI (take w food), renal dysfxn
Niacin (B3)
used to lower TG and LDL
do not combine with statin
AE: flushing, hyperglycemia
Ischemic stroke tx and secondary prevention
alteplase IV if <4.5h from stroke onset, otherwise antiplatelets: after ruling out hemorrhage
ASA (if not on it prior)
Clopidogrel
ASA/dipyridamole
ASA+Clopidogrel in 1st 21-30 days
anticoagulants: only if antiplatelets CI in ischemic stroke tx or for 2ndary prevention of cardiogenic stroke
angina tx
nitrate spray sl q5m max 3x for all pts
CCB 1st line
BB 1st line in HF or MI
long acting nitrates 2nd line
nitrates
nitrate spray sl q5m max 3x for all pts w angina
nitrates po or patch 2nd line for angina sx
10-12h nitrate free interval needed to prevent tolerance
AE: transient headache, hypotension, tachycardia, dizziness, flushing
traditional tx for VTE
LMWH (dalteparin, enoxaparin, nadroparin, tinzaparin)
LMWH or fondaparinux or UFH x5days/until warfarin INR>2
newer tx for VTE
Rivaroxaban
Apixaban
LMWH x5d then Dabigatran
LMWH x5d then Edoxaban
duration of VTE tx
provoked = 3mths
(obesity, surgery, hosp, cancer, thrombophilias, pregnancy, COCs)
unprovoked = 3-6mths to indefinite
duration of VTE prophylaxis
at least 10-14 days for total knee replacement, total hip replacement, hip fracture surgery, high risk general/abdominal surgery
VTE prophylaxis med options
LMWH or DOAC* x5d then switch to ASA
*rivaroxaban and apixaban demonstrated superiority over enoxaparin
Warfarin
for VTE tx: target INR 2-3 measured q3d-q3m
preferred when DOACs unsuitable due to renal failure (CrCl<30), valvular disease, DDI (PGP, 3A4) or unstable condition
AE: bleeding, hair loss, blue fingers, skin necrosis
reversal with vit K1, prothrombin complex concentrate
UFH
unfractionated heparin
IV or SC for VTE tx target aPPT 1.5-2.5xULN
preferred when unstable, planned invasive procedure, renal failure (CrCl<30), peri-thrombolytic
AE: 5% risk of HIT, hyperkalemia, osteoporosis
reversal with protamine sulfate
LMWH
low molecular weight heparin
for DVT tx or prophylaxis
SC and more predictable wt based dosing than UFH
AE: 1% risk of HIT, lower risk of osteoporosis
Fondaparinux
indirect factor Xa inhibitor
alternative to LMWH in VTE, can be used in HIT
SC wt based dosing
renally cleared
DOAC
direct factor Xa inhibitors: apixaban, edoxaban
direct thrombin inhibitors: rivaroxaban, dabigatran
for VTE tx, prophylaxis, afib
Amiodarone
most effective antiarrhythmic, used in vtach or afib (rhythm control)
AE: GI, derm, neuro, opth, thyroid abnormalities
DDI: digoxin
Rate control
used for afib
target HR<100
options: BB, Digoxin (except in CAD), CCB (except in HF)
Rate vs Rhythm control (CCS 2020 Guidelines)
in persistent (>7d) Afib:
rate control is 1st line
rhythm control preferred if diagnosed within 1y, highly sx, multiple recurrances, difficulty achieving rate control, arrhythmia induced cardiomyopathy)
When is pill-in-pocket used for arrhythmia?
paroxysmal (<7d) AF
or symptomatic tachycardias (diltiazem, verapamil, BB)
CCS Algorithm for Stroke Prevention in Afib
OAC indicated if: -age>65yo -prior stroke/TIA, HTN, HF, Diabetes ASA indicated if: -CAD or PAD
Afib + PCI or ACS tx
vs
Afib + PCI and ACS tx
Afib + PCI or ACS: OAC+Clopidogrel x1y then OAC
Afib + PCI and ACS: triple tx (ASA+OAC+Clopidogrel) x1d-6m then OAC+Clopidogrel x1y then OAC
DOACs doses for Afib vs VTE
AFIB:
Dabigatran 150 BID; 110 BID if >80yo or high bleed risk
Rivaroxaban 20mg; 15mg if CrCl 30-45
Apixaban 5 BID; 2.5 BID if 2 of: SCr>133, >80yo, <60kg
Edoxaban 60; 30 if <60kg, CrCl 30-50
VTE:
Rivaroxaban 15mg BID x3w then 20mg daily
Apixaban 10mg BID x7d then 5mg BID
LMWH x5d then Dabigatran 150mg BID; 110 if >75yo high bleed risk
LMWH x5d then Edoxaban 60mg OD; 30 if <60kg, CrCl 30-50
