Drug Induced Cardiac Doses Flashcards
What is the diagnostic criteria for someone to have drug induced QT prolongation?
QT >500 or QT> 60 from baseline
What are the common drug classes that cause QT prolongation?
ABCDEF
AntiArrythmics-amiodarone, dofetilide, sotalol
AntiBiotics-fluoroquinolones and macrolides
AntipsyChotics-first gen worse than second gen
AntiDepressants-citalopram and TCA
AntiEmetics-ondansetron
AntiFungals-azoles
What are the non modifiable risk factors for torsades de pointes
Over 65
Female
Genetic predisposition
Cardiac disease
What are the modifiable risk factors for torsades de pointes
Diuretic treatment
Electrolyte abnormalities
Taking More than one QT prolonging agent
Organ function
What are some ways to approach Drug induced QT prolongation?
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
What is the general treatment regimen of drug induced qt prolongation
- D/c offending agents
- NO PULSE-give mg PUSH
PULSE- give mg infusion - Transcutaneous pacing
- Isoporoteronol infusion
- Cardio version or defibrillation if pt is hemodynamically unstable
What are some alternatives to isoproteronol
Epinephrine or atropine
What are the three main causes of drug induced heart failure
- Sodium and volume retention
- Direct cardiotoxicity which can lead to cardiomyopathy
- Negative ionotropy
Drug classes that cause sodium and volume retention
NSAIDS
STEROIDS
THIAZOLIDINEDIONES-rosiglitazone and pioglitazone
Drugs that cause cardiomyopathy
Chemo agents-anthracyclines (daunorubicin, doxorubicin) and alkylating agents
Biologics **trastuzumab
Alcohol-has direct toxic effect on myocardium
Drugs that cause negative ionotropy
NON DHP CCB-diltiazem and verapamil
BETA BLOCKERS
What drug class has a BBW to avoid in pts with NYHA CLASS III-IV
Thiazolidinediones
Chemoprotectant that binds to TOP2B to prevent anthracycline binding
Dexaroxane
Treatment related risk factors for anthracycline induced cardiotox/myopathy
Cumulative dose more than 400mg/ m2
Dosing schedules
Previous anthracycline therapy
Co-admin of potentially cardiotoxic agents
Patient related risk factors of anthracycline induced cardiomyopathy
Age
Preexisting cardiovascular disease factors
Obesity
Smoking
Possibly gender
What is the max lifetime dose of anthracyclines
550 mg/m2
Risk factors for development of trastuzumab incduced cardiomyopathy
Advanced age
Prescence of CV comorbidities
Previous treatment with anthracyclines
Is trastuzumab induced cardiomyopathy irreversible
NO ITS REVERSIBLE ONCE DRUG IS D/C
What is trastuzumab BBW
Associated with symptomatic and asymptomatic LVEF and development of HF
What monitoring parameter should you evaluate in all patients taking trastuzumab
LVEF
Treatment regimen for trastuzumab induced cardiomyopathy
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)
Who should avoid non dhp ccb
Pts with EF less than 40%
Who should avoid beta blockers
Pts with acute hf exacerbation
What drugs cause hf due to negative ionotropy
Non dhp ccb and beta blockers
Drugs that cause increased myocardial oxygen demand
(increased hr and contractility)
**Cocaine, beta agonists, sympathomimetics, withdrawal of beta blockers, and potent vasodilators
Drugs that cause decrease myocardial supply
Increased coronary resistance
**Cocaine and triptans
Drugs that cause drug induced acs
(Coronary artery thrombosis)
**Cocaine, oral contraceptives, **NSAIDS, estrogens, anti migraine agents
Drugs that cause drug induced acs
(Increased cardiovascular risk)
**Cocaine, estrogens, **NSAIDS, HIV AGENTS, oral contraceptives, rosiglitazone
Treatment options for cocaine induced MI
- Chest pain
-Aspirin and benzos
2.persistent HTN
-benzos and IV nitroglycerin - Long term acs treatment
-AVOID BETA BLOCKERS
BBW that all NSAIDs have
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
What are the risk factors for acute MI with NSAIDS
1.increased risk early on in therapy
2. Use of NSAIDS
3. HIGH DOSE=HIGH RISK
->1200mg/day of ibuprofen
->750mg/day of naproxen
T/f non selective NSAIDs have increases risk of MI
FALSE there’s no diff btwn selective and non selective