CVD Part 2 Flashcards
What is afib?
Abnormal electrical conduction in the atria -> chaotic, uncoordinated contraction
What are the symptoms of afib (if not asymptomatic)? (4)
- Shortness of breath, fatigue
- Palpitations
- Chest discomfort
- Anxiety, sweating
What are two key clinical issues with afib?
- Significant ↑ risk of ischemic stroke (~5x)
- ANTICOAGULATION - ↑ Heart rate -> heart failure
- Need to control heart rate or rhythm
Manage stroke risk with? (2)
- Warfarin
- DOACs (dabigatran, rivaroxaban, apixaban, edoxaban)
Advanced age is a deterrent to anticoagulation, why? (3)
- Bleed risk
- Falls
- Drugs
- Medical conditions - Adherence, INR monitoring
- Cognitive impairment
- Limited mobility - Underestimation of benefit
What does the evidence for anticoagulation in older adults say?
Very good for stroke prevention
What to know about anticoagulation vs. ASA or ASA + Clopidogrel (2)
- ACTIVE-W Trial
- Aspirin + Clopidogrel vs Warfarin for stroke prevention in atrial fibrillation
- Trial terminated early due to superiority of warfarin (NNT = 47/1.3 years)
- NO difference in major bleeding rates between the two groups - ACTIVE-A Trial
- Aspirin vs aspirin plus clopidogrel in individuals unsuitable for warfarin
- Aspirin plus clopidogrel decreased the risk of stroke (NNT = 42/2.6 years)
- Also increased the risk of major bleeding (NNH = 42/2.6 years)
What are the advantages of DOACs? (4)
- > = Efficacy
- Less ICH
- No INR monitoring
- Fewer drug and food interactions
What are the disadvantages of DOACs? (6)
- Cost, EDS requirements?
- More GI bleeds
- Less long-term safety data
- Caution in renal impairment
- Contraindicated in severe renal impairment
- Not indicated with mechanical heart valves
Consider changing from warfarin to a DOAC when? (4)
- When starting on a medication with a significant DI with warfarin
- Practical considerations - can the pt get their blood work done as often as they need to?
- Basically all of the pros that we have talked about.
- Labile INRs - if you have someone with afib who has difficulty controlling INR, they should really be switched to a DOAC. Efficacy of warfarin drops dramatically below 2, and is doing basically nothing under 1.8 for stroke risk reduction. Bleed risk is big if above 3. So if consistently not within bounds then it’s a bitch to work with.
Warfarin is preferable when? (2)
- Severe renal dysfunction. Generally a CrCl <25, for sure CrCl <15 is when you would want to be on warfarin.
- Mechanical heart valves. DOACs not as effective in preventing strokes in these settings. Specifically, with a mechanical mitral heart valve, remember that’s when you need to target 2.5-3.5 INR and they need to be on aspirin.
Which DOAC to choose between dabigatran, rivaroxaban, edoxaban, and apixaban?
- Dabigatran – most GI upset, most highly renally eliminated
- Beer’s List drug if age > 75 - Rivaroxaban once daily dosing -> needs to be taken with food
- Beer’s List drug if age > 75 - Edoxaban once daily dosing
- Watch for drug interactions (↓ dose with strong P-GP inhibitors e.g. erythromycin, cyclosporine, dronaderone) - Apixaban best safety data (so far)
- Best choice when renal function is borderline
What are 4 considerations for anticoagulation in afib?
- Is there an indication for anticoagulation?
- Is there a high risk of bleeding or a contraindication to anticoagulation?
- Will the patient be able to adhere to therapy or monitoring requirements?
- Patient/family preferences?
According to the afib guidelines, what age patient is indicated for oral anticoagulation?
65+
HAS-BLED is a score to determine if there is a high risk of bleeding. What is it?
Hypertension
Abnormal renal or liver function
Stroke (caused by a bleed)
Bleeding
Labile INRs
Elderly (65+)
Drugs (ASA/NSAID) or alcohol (8+ drinks/week)
Caution if HAS-BLED score is >=_
3
When might we do anticoagulant + antiplatelet (3)
- Elective PCI without high risk features for thrombotic CV events
- ACS with PCI or elective PCI with high risk features for thrombotic CV events
- ACS without PCI
Will patients be able to adhere to the monitoring requirements of warfarin or DOACs? What to know?
- Warfarin:
- INR monitoring
- Ability to self-manage dosage adjustments? - DOACs:
- Consistent adherence is very important!
- Also need to check CBC, renal function ~q6months
What are factors to consider when deciding between rate vs. rhythm control? (3)
- Duration of afib
- Bothersome afib symptoms?
- Comorbid HF?
What is the main medication for rhythm control in afib?
Amiodarone
Likelihood of successful rhythm control _________ as afib duration increases
decreases
True or False? Regardless of rate or rhythm control, anticoagulation remains important
True
What are the adverse effects of amiodarone? (5)
- Optic neuropathy and neuritis
- Pulmonary and hepatic toxicity
- Hypo- or hyper-thyroidism
- Blue-grey skin discoloration
- Photosensitivity
What are the DIs of amiodarone? (4)
- Warfarin
- Digoxin
- Beta-blockers
- Non-DHP CCBs
What are the medications for rate control in afib? (4)
- Beta-blockers
- Non-DHP CCBs (diltiazem and verapamil)
Second-line - Digoxin (additive therapy)
- Amiodarone
When might beta-blockers be the preferred medication for afib rate control?
Preferred when concurrent CAD and HF
When might non-DHP CCBs be the preferred medication for afib rate control?
May be preferred in severe or poorly controlled asthma/COPD
When might digoxin be used for afib rate control? (4)
- Less effective – does not control heart rate during exercise
- Usually used as add-on therapy
- May be beneficial if concurrent symptomatic HF
- AFFIRM trial - ↑ mortality when digoxin used for AFib
What is target heart rate for afib pt in older adult?
< 100 bpm at rest
What should be monitored if pt is on digoxin for afib? (2)
- Monitoring for efficacy: Target HR
- Serum digoxin levels are not a “target” to aim for but a tool to avoid toxicity! - Monitoring for toxicity:
- Serum levels if concerned about adverse effects/toxicity, drug interactions, or if renal function ↓
- Digoxin adverse effects: Nausea, ↓appetite, vomiting, diarrhea, dizziness, confusion/delirium, blurred vision, “halos”
- Older adults much more susceptible to digoxin toxicity
- Ideally, maintain trough level < 1 nmol/L
- SHA reports “in-range” if 1.3-2.6nmol/L!
What are the 4 pillars of HFrEF medications?
- ARNI (or ACEi/ARB)
- Beta-blocker
- MRA
- SGLT2i
Medications for HFrEF: What to initiate and when?
Currently no consensus regarding which drug classes to start with when initiating treatment for HFrEF
- Start with one drug class and titrate up to max tolerated dose?
- Start with more than one drug class at smaller doses?
Medications for HFrEF: Decisions should be based on clinical characterstics of the patient. Such as? (5)
- Hemodynamic status
- Renal function
- Side effects/tolerability
- Cost
- Adherence
What to know about switching from ACEi to ARNI?
Requires a 36-hour washout period
What are some considerations for ACEi/ARB/ARNIs in HFrEF? (3)
- Monitor SCr, lytes within 1-2 weeks of initiation or titration
- < 30% ↑in SCr - Monitor sitting and standing BP
- Orthostatic hypotension may warrant dose ↓
- Use lowest required dose of diuretic - ARNI (valsartan/sacubitril)
- Accumulating evidence for initiating directly in new diagnoses of HFrEF in hospitalized patients
– Currently, EDS in SK requires patients to be on a stable dose of ACEI or ARB for > 4 weeks before initiating
- Frail older adults more susceptible to hypotension/orthostatic hypotension with ARNI vs. ACEI or ARB alone
What to monitor in pt using a beta-blocker? (2)
- Heart rate
- Blood pressure
What to monitor in pt using an MRA?
When to avoid?
- Potassium
- BEERS critera: avoid if CrCl < 30 mL/min
What to monitor in pt using SGLT2i? (2)
- Decreased eGFR ~15% on initiation
- Volume status - may need to decrease diuretic dose on initiation in euvolemic pts
What is the initiation regimen of SGLT2is for HFrEF? (2)
- Dapagliflozin 10 mg daily (eGFR > 30 ml/min)
- Empagliflozin 10 mg daily (eGFR > 20 ml/min)
What are 2 precautions for SGLT2is?
- ↓ BP ~1-2mmHg
- “Sick-day” medication
What are 3 tolerability considerations for SGLT2is?
- Increased risk of genital fungal infections
- ? increased UTIs
- ? increased DKA
When to use loop diuretic in HF?
Symptomatic treatment
- Used to manage SOB, fluid retention, increased weight
When might digoxin be used in HFrEF? (4)
- Add-on if symptoms persist despite optimized 1st and 2nd line meds
- May also help ↓ resting HR in AFib - 0.0625 – 0.125 mg daily
- Signs of toxicity: Nausea, vomiting, diarrhea, delirium, drowsiness, headache, vision changes (yellow or green halos, photophobia)
- Blood levels are not a target but a tool to avoid toxicity!
- Levels < 1nmol/L associated with ↓ mortality, hospitalizations
- Levels > 1.5 nmol/L associated with ↑ mortality
- Note: Therapeutic range for digoxin in SHA reported to be between 1.3-2.6 nmol/L
Treatment for HFpEF?
Perhaps empagliflozin
What are some risk factors for acquired TdP? (8)
- ↑ age
- Female
- Electrolyte abnormalities: Hypokalemia, hypocalcemia, hypomagesemia
- Liver or kidney disease
- Hypertension
- Smoking
- Arrhythmia, previous MI, cardiomyopathy
- DRUGS
What antiarrhythmics can prolong QT interval? (3)
- Amiodarone
- Sotalol
- Propafenone, procainamide, flecainide, others
What ADHD meds can prolong QT interval? (1)
Atomoxetine
What antiemetic drug can prolong QT interval? (1)
Domperidone
What antipsychotics can prolong QT interval? (5)
- Aripiprazole
- Haloperidol
- Pimozide
- Quetiapine > risperidone
- Clozapine
What SSRIs can prolong QT interval? (3)
- Sertraline
- Citalopram
- Escitalopram
What SNRIs can prolong QT interval?
Mirtazapine > venlafaxine
What TCAs can prolong QT interval?
All > nortriptyline
What antibiotics can prolong QT interval?
- Moxi- /gatifloxacin > ciprofloxacin or levofloxacin
- Clarithro/erythromycin > azithromycin
What antifungals can prolong QT interval?
Fluconazole > others
What misc drugs can prolong QT interval? (4)
- Donepezil
- Hydroxyzine
- Methadone
- Tramadol
