Drug Induced Cardiac Doses

Question 1

What is the diagnostic criteria for someone to have drug induced QT prolongation?

Answer 1

QT >500 or QT> 60 from baseline

Question 2

What are the common drug classes that cause QT prolongation?

ABCDEF

Answer 2

AntiArrythmics-amiodarone, dofetilide, sotalol
AntiBiotics-fluoroquinolones and macrolides
AntipsyChotics-first gen worse than second gen
AntiDepressants-citalopram and TCA
AntiEmetics-ondansetron
AntiFungals-azoles

Question 3

What are the non modifiable risk factors for torsades de pointes

Answer 3

Over 65
Female
Genetic predisposition
Cardiac disease

Question 4

What are the modifiable risk factors for torsades de pointes

Answer 4

Diuretic treatment
Electrolyte abnormalities
Taking More than one QT prolonging agent
Organ function

Question 5

What are some ways to approach Drug induced QT prolongation?

Answer 5

Avoid QT prolongating drugs in pts with pretreatment intervals> 450

Reduce dose or d/c prolonging agents if qt incr >/= 60 from baseline

D/c prolonging agent if qt incr to 500

Maintain k>4 and mg>2

Avoid concomitant administration of qt prolonging drugs

Avoid use of qt prolonging drugs in a pt with a history of drug induced torsades de pointes

Question 6

What is the general treatment regimen of drug induced qt prolongation

Answer 6

1. D/c offending agents
2. NO PULSE-give mg PUSH
   PULSE- give mg infusion
3. Transcutaneous pacing
4. Isoporoteronol infusion
5. Cardio version or defibrillation if pt is hemodynamically unstable

Question 7

What are some alternatives to isoproteronol

Answer 7

Epinephrine or atropine

Question 8

What are the three main causes of drug induced heart failure

Answer 8

1. Sodium and volume retention
2. Direct cardiotoxicity which can lead to cardiomyopathy
3. Negative ionotropy

Question 9

Drug classes that cause sodium and volume retention

Answer 9

NSAIDS
STEROIDS
THIAZOLIDINEDIONES-rosiglitazone and pioglitazone

Question 10

Drugs that cause cardiomyopathy

Answer 10

Chemo agents-anthracyclines (daunorubicin, doxorubicin) and alkylating agents

Biologics **trastuzumab
Alcohol-has direct toxic effect on myocardium

Question 11

Drugs that cause negative ionotropy

Answer 11

NON DHP CCB-diltiazem and verapamil
BETA BLOCKERS

Question 12

What drug class has a BBW to avoid in pts with NYHA CLASS III-IV

Answer 12

Thiazolidinediones

Question 13

Chemoprotectant that binds to TOP2B to prevent anthracycline binding

Answer 13

Dexaroxane

Question 14

Treatment related risk factors for anthracycline induced cardiotox/myopathy

Answer 14

Cumulative dose more than 400mg/ m2
Dosing schedules
Previous anthracycline therapy
Co-admin of potentially cardiotoxic agents

Question 15

Patient related risk factors of anthracycline induced cardiomyopathy

Answer 15

Age
Preexisting cardiovascular disease factors
Obesity
Smoking
Possibly gender

Question 16

What is the max lifetime dose of anthracyclines

Answer 16

550 mg/m2

Question 17

Risk factors for development of trastuzumab incduced cardiomyopathy

Answer 17

Advanced age
Prescence of CV comorbidities
Previous treatment with anthracyclines

Question 18

Is trastuzumab induced cardiomyopathy irreversible

Answer 18

NO ITS REVERSIBLE ONCE DRUG IS D/C

Question 19

What is trastuzumab BBW

Answer 19

Associated with symptomatic and asymptomatic LVEF and development of HF

Question 20

What monitoring parameter should you evaluate in all patients taking trastuzumab

Answer 20

LVEF

Question 21

Treatment regimen for trastuzumab induced cardiomyopathy

Answer 21

Adjust dose base on LVEF
Consider decr dose or D/C if HF develops
Consider HF meds during treatment if EF declines (ace/arb and b blockers)

Question 22

Who should avoid non dhp ccb

Answer 22

Pts with EF less than 40%

Question 23

Who should avoid beta blockers

Answer 23

Pts with acute hf exacerbation

Question 24

What drugs cause hf due to negative ionotropy

Answer 24

Non dhp ccb and beta blockers

Question 25

Drugs that cause increased myocardial oxygen demand
(increased hr and contractility)

Answer 25

**Cocaine, beta agonists, sympathomimetics, withdrawal of beta blockers, and potent vasodilators

Question 26

Drugs that cause decrease myocardial supply

Increased coronary resistance

Answer 26

**Cocaine and triptans

Question 27

Drugs that cause drug induced acs
(Coronary artery thrombosis)

Answer 27

**Cocaine, oral contraceptives, **NSAIDS, estrogens, anti migraine agents

Question 28

Drugs that cause drug induced acs
(Increased cardiovascular risk)

Answer 28

**Cocaine, estrogens, **NSAIDS, HIV AGENTS, oral contraceptives, rosiglitazone

Question 29

Treatment options for cocaine induced MI

Answer 29

1. Chest pain
   -Aspirin and benzos
   2.persistent HTN
   -benzos and IV nitroglycerin
2. Long term acs treatment
   -AVOID BETA BLOCKERS

Question 30

BBW that all NSAIDs have

Answer 30

Increased risk of severe cardiovascular thrombotic events, MI and stroke which can be fatal. This risk may increase with duration of use. Patients with cardiovascular disease may be at greater risk

Question 31

What are the risk factors for acute MI with NSAIDS

Answer 31

1.increased risk early on in therapy
2. Use of NSAIDS
3. HIGH DOSE=HIGH RISK
->1200mg/day of ibuprofen
->750mg/day of naproxen

Question 32

T/f non selective NSAIDs have increases risk of MI

Answer 32

FALSE there’s no diff btwn selective and non selective