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Su. Pharm 2 > Ex2 > Flashcards

Ex2 Flashcards

HTN Ischemic heart disease HF antithrombotics Clotting factors, trauma, blood disorders

1
Q

BP =

A

BP = CO x SVR

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2
Q

SVR is determined by

A

vascular tone of systemic vessels

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3
Q

most common CV pathology

A

HTN

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4
Q

HTN stage 1

A

SBP:130-139 mmHg
DBP: 80-89 mmHg

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5
Q

HTN stage 2

A

SBP: 140+ mmHg
DBP: 90+ mmHg

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6
Q

pts with preop HTN are

A

4x more likely to die from CV issue in surgery

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7
Q

causes of HTN

A

ANS
RAAS
impaired endothelial function

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8
Q

HTN renal SE

A

incr GFR
proteinurea
ESRD

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9
Q

HTN cancellectomy

A

SBP > 180
DBP > 100

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10
Q

pts on beta blockers prior to surgery should

A

continue beta blockers day of surgery

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11
Q

should pts who are not on beta blockers be given them day of surgery

A

no

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12
Q

should you continue ACe or ARBs day of surgery

A

discontinue unless HF pt

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13
Q

should you continue clonidine day of surgery

A

yes

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14
Q

what HTN drugs have acute withdrawal symptoms

A

clonidine
beta blockers

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15
Q

HTN pts have a _______ BP perioperatively and ____________ intraoperatively.

A

periop: volatile BP
intraop: hypotension

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16
Q

sympathetic activation during induction increases BP/HR: normotensive

A

BP: 20-30 mmHg
HR: 15-20 bpm

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17
Q

sympathetic activation during induction increases BP/HR: untreated HTN

A

SBP: 90 mmHg
HR: 40 bpm

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18
Q

causes of periop HTN

A

difficult to predict
multi-factoral

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19
Q

intraop HTN crisis

A

BP > 160/90
SBP elevation of 20%
persists for 15+ mins

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20
Q

goal of HTN crisis managment

A

halt vascular damage
reverse pathology
preserve organ function

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21
Q

edema

A

excessive vasoconstriction
impaired microcirculation

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22
Q

ischemia

A

increased risk of hypoperfusion

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23
Q

normal cerebral autoregulation

A

60-160 mmHg

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24
Q

when should you treat HTN

A

base on pts baseline
no consensus
- 20% baseline
- MAP > 65

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25
Q

HTN risk

A

organ ischemia risk

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26
Q

hTN risk

A

bp related bleeding risk

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27
Q

what surgeries require more tight BP regulation

A

cardiac

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28
Q

high baseline

A

BP: 80-110%
SBP: < 160 mmHg

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29
Q

normal baseline

A

BP: 90-110%
MAP: 65-95 mmHg

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30
Q

low baseline

A

BP: 100-120% baseline
MAP: > 60 mmHg

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31
Q

pts with intraop HTN should be managed with

A

IV antihypertensives until oral meds can be resume

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32
Q

CCB drugs

A

nicardipine
clevidipine

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33
Q

best drug for HTN

A

CCB
fast onset

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34
Q

which CCB has shorter half life

A

clevidipine

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35
Q

nicardipine CI

A

adv aortic stenosis

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36
Q

clevidipine CI

A

soy
egg
poor lipid metabolism

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37
Q

CCB dose adjustment for eldery

A

nicardipine: no
clevidipine: lower dose

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38
Q

vasodilators

A

nipride
NTG
hydralazine

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39
Q

nipride

A

venous/arterial vasodilator

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40
Q

NTG

A

venous/coronary artery vasodilator

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41
Q

hydralazine

A

direct vasodilator

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42
Q

which vasodilator requires art line

A

nipride

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43
Q

which vasodilator can cause tachyphylaxis and cyanide toxicity

A

nipride

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44
Q

which vasodilator is a bolus dose

A

hydralazine

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45
Q

which vasodilator is not potent enough alone to effectively lower bP

A

NTG

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46
Q

which vasodilator should you not use in renal dysfunction

A

nipride

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47
Q

which vasodilator requires lower dose for eldery

A

nipride

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48
Q

when do you use NTG

A

pts with ACS or acute pulm edema

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49
Q

which vasodilator is not a first line agent for HTN

A

hydralazine

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50
Q

adrenergic receptor blockers

A

esmolol
labetalol
phentolamine
fenoldapam
ACE inhibitor

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51
Q

esmolo

A

beta1 selective blocker

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52
Q

labetalol

A

alpha 1 blocker
non selective beta blocker

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53
Q

phentolamine

A

non selective alpha blocker

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54
Q

fenoldopam

A

dopa 1 receptor selective agonist

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55
Q

ACE inhibitor CI

A

pregnancty
acute MI
bilateral renal artery stenosis

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56
Q

is an ACE inhibitor useful intraoperatively

A

no

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57
Q

fenoldapam CI

A

incr ocular pressure
incr intracranial pressure
sulfite allergy

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58
Q

labetalol CO

A

reactive airway disease
COPD

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59
Q

esmolol CI

A

concurrent BB therapy
bradycardia
decompensated HF

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60
Q

avoid labetalol in

A

2nd/3rd degree Heart block
bradycardia

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61
Q

which drug can be used in HTN emegencies caused by catecholamine excess

A

phentolamine

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62
Q

which drug increases renal perfusion

A

fenoldapam

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63
Q

which drug is good for hyperadrenergic syndromes

A

labetolol

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64
Q

preferred drugs (4) for perioperative HTN

A

clevidipine
esmolol
nicardipine
NTG

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65
Q

acute post-op HTN

A

SBP: 180+ or 20% incr
DBP: 110+

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66
Q

acute post op HTN causes

A

failure to take beta blockers
hypervolemia (fluid overload)
overactive sympathertics

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67
Q

1st line acute post op HTN

A

esmolol
labetalol

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68
Q

2nd line acute post-op HTN

A

clevidipine
nicardipine

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69
Q

3rd line acute-post op HTN

A

ACE inhibitor
hydralazine

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70
Q

what should you resume after acute post-op HTN

A

resume oral antihypertensives

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71
Q

most important factor for ischemia

A

O2 demand/O2 supply balance

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72
Q

treatment goals of chronic coronary heart disease

A

prevent myocardial infarction
reduce symptoms of angina

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73
Q

Type 1 demand

A

thrombosis

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74
Q

Type 2 demand

A

non-thrombotic
Ischemic

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75
Q

reduce angina/ischemia symptoms

A

sublingual NTG
beta blockers
CCB
nitrates
ranolazine
PCI
CABG

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76
Q

how do beta blockers reduce ischemia/angina symptoms

A

decr HR
decr inotropy

DECR DEMAND

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77
Q

where do nitrates act

A

venous

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78
Q

how do nitrates reduce ischemia

A

incr capacitance
decr preload

WALL TENSION
DECR DEMAND

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79
Q

where do CCB work

A

arterial

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80
Q

how do CCB reduce ischemia

A

decr afterload
decr contractility
decr HR

DECR DEMAND

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81
Q

renolazine affects

A

decr angina without changing BP or HR

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82
Q

order of drugs for reducing ischemia

A

1st: beta blockers
2nd: CCB
3rd; nitrates
4th: ranolazine

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83
Q

drugs to prevent MI/death

A

aspirin
statins
beta blockers
ACEs
ARBS

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84
Q

statins mechanism

A

lower cholesterol
anti-inflammatory effect on vasculature

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85
Q

NSTE-ACS treatments

A

aspirin
NTG
anti-thrombotics
statins
beta blockers

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86
Q

aspirin dose

A

262-325 mg
81 mg indefinite dose

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87
Q

how should aspirin be taken

A

chew it

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88
Q

what is NTG function in NSTEMI

A

helps decr pain symptoms

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89
Q

NTG administration

A

sublingual every 5 mins
3 doses

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90
Q

DAPT

A

aspirin
+
P2Y12 inhibitor

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91
Q

common P2Y12 inhibitors

A

clopidogrel
prasugrel
ticagrelor

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92
Q

parenteral anticoagulant

A

UFH
LMWH

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93
Q

how many anithrombotics should be administered for NSTEMI

A

3 antithrombotics to stop the active clot from growing

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94
Q

statins short term function

A

reduce inflammation
improve endothelial function

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95
Q

statins long term function

A

cholesterol reduction

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96
Q

beta blockers function in NSTEMI

A

decr arrythmias
decr O2 demand
reduce progression

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97
Q

medical managment goal

A

decr demand

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98
Q

PCI goal

A

incr supply

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99
Q

CABG goal

A

incr supply

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100
Q

CABG indication

A

disease in left main coronary artery
disease in 3 or more coronary vessels
EF < 40%

101
Q

STEMI primary treatment goal

A

open vessel

102
Q

fibrinolysis protocol

A

30 mins

103
Q

PCI protocol

A

90 mins

104
Q

STEMI treatment

A

aspirin
NTG
antithrombotics
statins
beta blockers

105
Q

when is the risk of deaths due to CAD

A

closest to the event
- 33% in first 3 weeks
- 50% in first 3 months

106
Q

Post ACS big 5

A

aspirin
ACE/ARB
beta blocker
clopidogrel/prasugrel/ticagrelor
statins

107
Q

BIG 5 function

A

reduces 6 month mortality by up to 90% in pts with ACS

108
Q

MINS

A

elevated troponin < 30 days after non cardiac surgery

109
Q

MINS risk factors

A

recent MI
unstable angina
recent PCI
old age

110
Q

what will impact MINS risk

A

surgical and patient factors

111
Q

do you continue beta blockers for mINS

A

continue prior beta blockers

112
Q

do you continue statins for MINS

A

yes

113
Q

do you continue antiplt therapy for mins

A

patient and procedure specific

114
Q

do you continue ACE/ARB for MINS

A

continue for HF or poorly control HTN

115
Q

unstable CAD pt treatment

A

IV nitrates
IV heparin
arrythmias
intra-aortic baloon pump

116
Q

balloon is up during

A

diastole
blood back to heart

117
Q

balloon is down during

A

systole
blood sucked into syst circulation

118
Q

intraoperative Ischemia treatment: tachycardia

A

anesthetic
analgesic
beta blocker

119
Q

intraop ischemis treatment: afib/flutter

A

stable: BB or CCB
unstable: sync cardioversion

120
Q

when do you consider transfusion

A

HgB <7 g/dL

121
Q

what should you not give in post op for ischemia

A

NSAIDS
COX2 inhibitors
(Toradol)

*incr risk of thrombosis

122
Q

what drugs are commonly given for angina

A

ACE
ARB
BB
SGLT2 (diabetes)

123
Q

what drugs do you give for HFrEF: EF <40%

A

neprilysin inibitor (Valsartan/sacubitril)_
ACE
ARB
BB
MRA - spironolactone
SGLT2 - “flozin”
diuretics
hydral-nitrates (african american)

124
Q

what drugs do you give for HFmrEF: EF 41-49%

A

diuretics

maybe
SGLT2

125
Q

what drugs do you give for HFpEF: > 50%

A

diuretics

maybe
SGLT2

126
Q

when should diuretics be prescribed in HF

A

all patients with evidence of fluid retention

127
Q

which diuretics are better for HF

A

loop diuretics are better than thiazide

128
Q

do diuretics slow progression of HF

A

no - they just decrease symptoms

129
Q

should you continue BB perioperatively for HF

A

yes -continue BB in HF pts

130
Q

do you continue or stop ACE/ARB/ARNI in HF pts perioperatively?

A

continue if EF < 50%
consider stopping if risk of hypotension
or just dont take dose in AM of surgery

131
Q

do you continue or stop aldosterone antagonists in HF perioperatively?

A

continue aldo antagonists if renal function is stable

132
Q

do you continue or hold SGLT2i in HF pts perioperatively?

A

hold due to incr risk of post-op euglycemic ketoacidosis

133
Q

treat intraop severe HTN in HF pts

A

vasodilator (nitroprusside)

134
Q

treat intraop fluid overload/pulm edema in HF pts

A

NTG
diuretic

135
Q

treat intraop low CO in HF pts

A

inotrope
vasodilator

136
Q

treat intraop arrythmias in HF pts

A

amiodarone
lidocaine

137
Q

treat intraop hypotension in HF pts

A

vasopressor (phenylephrine)
NOT fluid bolus

138
Q

warm

A

CI > 2.2

139
Q

wet

A

PCWP > 18 mmHg
(preload)

140
Q

cold

A

CI < 2.2

141
Q

dry

A

PCWP < 18 mmHg
(preload)

142
Q

warm and wet

A

want to reduce preload:
give diuretic
NTG

143
Q

cold and wet

A

inotropes
diuretics
NTG

144
Q

if they have low BP and are cold and wet avoid:

A

milrinone
dobutamine

145
Q

use diuretics

A

when pt is fluid overloaded
preferrably loops

146
Q

BMS reendotheliazation

A

1-3 months

147
Q

DES reendothelization

A

1 year

148
Q

risk of thrombosis with stents is highest

A

closest to stent placement

149
Q

which stent type requires longer course of antithrombotics

A

DES

150
Q

DES thrombotic prohphylaxis for SIHD

A

6 months clopidogrel

151
Q

DES thrombotic prophylaxis for ACS

A

12 months
- clopidogrel
- prasugrel
- ticagrelor

152
Q

BMS thrombosis prophylaxis

A

1 month clopidogrel

153
Q

hemorrhagic risk is determined by

A

surgery

154
Q

stop clopidogrel

A

5 days before

155
Q

resume clopidogrel

A

24-72 hrs

156
Q

stop prasugrel

A

7 days prior

157
Q

low hemorrhagic risk
+
low thrombotic risk

A

continue aspirin
stop clopidogrel

158
Q

med hemorrhagic risk
+
low thrombotic risk

A

continue aspirin
stop clopidogrel

159
Q

high hemorrhagic risk
+
low thrombotic risk

A

Stop aspirin
Stop clopidogrel

160
Q

low hemorrhagic
+
mod thrombotic

A

continue aspirin
continue clopidogrel

161
Q

mod hemorrhagic
+
mod thrombotic

A

continue aspirin
stop clopidogrel

162
Q

high hemorrhagic
+
mod thrombotic

A

continue aspirin
stop clopidogrel

163
Q

low hemorrhagic
+
high thrombotic

A

continue aspirin
continue clopidogrel

164
Q

mod hemorrhagic
+
high thrombotic

A

continue aspirin
stop clopidogrel
bridge

165
Q

high hemorrhagic
+
high thrombotic

A

continue aspirin
stop clopidogrel
bridge

166
Q

bridge therapy drugs

A

GPiib/iiia inhibitors

167
Q

high thrombotic risk: heart valves

A

mitral valve prosthesis
ball/disc aortic valves
recent stroke
recent TIA

168
Q

mod thrombotic risk: heart valves

A

bileaflet aortic valve
+ afib
+ stroke
+ TIA
+ HTN
+ diabetes
+ CHF
+ 75+ years old

169
Q

low thrombotic risk: heart valve

A

bileaflet aortic valve with no additional risk factors

170
Q

high thrombotic risk: afib

A

CHAD score >=7
thrombembolism w/in 3 mos
rheumatic valvular disease

171
Q

mod thrombotic risk: afib

A

CHAD score 5-6
thromboelmbolism > 3 months

172
Q

low thrombotic risk: afib

A

CHAD score: 0-4
no thromboembolism

173
Q

if your risk risk of stroke is greater than ____%, pts should be taking ______

A

if risk of stroke is > 2%, pts should take anticoagulation meds

174
Q

CHAD score

A

1 point:
CHF
EF<40%
HTN
diabetes
vascular disease
65-74 years old
female

2 points:
75+ years old
stroke
TIA
thromboembolism

175
Q

high thrombotic risk: venous

A

VTE < 3months
severe thrombophilia

176
Q

mod risk: VTE

A

VTE 3-12 months
non-severe thrombophilia
recurrent VTE
cancer w/in 6 months

177
Q

low risk: VTE

A

VTE > 12 months ago
no additional risk factors

178
Q

what HAD-BLED is high risk of bleeding

A

> = 3

179
Q

HAS-BLED mod risk bleeding

A

2

180
Q

HAS-BLED low risk bleeding

A

0-1

181
Q

when do you interrupt anticoagulation therapy

A

intermediate surgical bleeding risk
high surgical bleeding risk

182
Q

when do you consider interrupting anticoagulation therapy

A

low surgical risk
+
pt related bleeding factors

183
Q

when should you not interrupt anticoagulation therapy

A

low bleeding risk surgery
absence of pt related factors

184
Q

pt related bleeding factors

A

major bleed w/in 3 months
PLT abnormality
aspirin use
high INR
prior bleed w/bridging

185
Q

what should you check for pts on warfarin

A

INR day of surgery

186
Q

normal INR

A

<1.2

187
Q

pt is on warfarin
INR prior to surgery is >3

A

discontinue warfarin 5+ days prior

188
Q

pt is on warfarin
INR prior to procedure is 2-3

A

discontinue 5 days prior

189
Q

pt is on warfarin
INR is <2 prior to surgery

A

discontinue 3-4 days prior

190
Q

which DOAC has renal impacts

A

dabigatran

191
Q

which DOACs have less renal impacts

A

apixaban
edoxaban
rivaroxaban

192
Q

what is DOAC interruption based on

A

renal function

193
Q

do you bridge DOACs

A

no

194
Q

do you bridge warfarin

A

potentially

195
Q

do you bridge warfarin with low thrombotic risk

A

no bridge

196
Q

do you bridge warfarin with mod thrombotic risk

A

increased bleed: no bridge
prior stroke: bridge
no prior stroke: no bridge

197
Q

do you bridge warfarin with high thrombotic risk

A

bleed w/in 3 months: no bridge

all others: bridge

198
Q

when should you stop UFH

A

4 hrs prior

199
Q

monitor UFH residual effect with

A

ACT
PTT

200
Q

stop LMWH prior to procedure

A

24 hrs

201
Q

monitor residual effects of LMWH

A

antifactor 10a

202
Q

when do you start pre-op bridging

A

INR<2
(typically 2-3 omitted doses)

203
Q

restart warfarin post-op

A

12-24 hrs

204
Q

how long does anticoag effect take after restarting warfarin

A

2-3 days

205
Q

start LMWH/UFH bridge: low bleeding risk

A

24 hrs post op

206
Q

start LMWH/UFH bridge: high bleeding risk

A

48-72 hrs post op

207
Q

when do you discontinue post-op bridge

A

INR>2

208
Q

DOAC onset time

A

2-3 hrs

209
Q

restart DOAC: low bleeding risk

A

<24 hrs

210
Q

restart DOAC: high bleeding risk

A

48-72 hrs

211
Q

what should you monitor when restarting DOAC

A

renal function

212
Q

stop heparin before neuraxial

A

6 hrs

213
Q

restart heparin after neuraxial

A

2 hrs

214
Q

LMWH before neuraxial

A

high dose: 24 hrs
low dose: 12 hrs

215
Q

LMWH restart neuraxial: low risk

A

4 hrs

216
Q

LMWH restart: mod-high risk neuraxial

A

12 hrs

217
Q

stop fondiparinux before neuraxial

A

4 days

218
Q

restart fondaparinux before neuraxial

A

6-24 hrs

219
Q

stop warfarin before neuraxial

A

5 days
INR < 1.2

220
Q

restart warfain after neuraxial

A

next day

221
Q

desmopressin (DDAVP) mechains

A

incr endothelial release of Factor VII and vWF
incr tissue plasminogen activator
incr plasmin

222
Q

Desmopressin indications

A

mild hemophilia A w/FVIII >5%
vWF disease

223
Q

Desmopressin CI

A

SIADH
GFR < 50 ml/min

224
Q

Desmopressin SE

A

antidiuretic (water retention)
hypotension
premature labor
thrombosis

225
Q

warfarin reversal options

A

vit K (phytonadione)
PCC
FFP

226
Q

PCC contain

A

vit-K dependent clotting factors

227
Q

what must you give with PCC

A

vit K

228
Q

DOAC reversals

A

idarucizumab (dabigatran)
andexanet alfa (apixaban/rivaroxaban)

229
Q

apixaban
rivaroxaban reversal

A

1st: andexanet
2nd: PCC
3rd: activated charcoal

230
Q

bextrixaban
edoxaban
reversals

A

1st: andexanet
2nd: PCC
3rd: activated charcoal

231
Q

TXA mechansims

A

blocks binding of plasminogen to fibrin
prevents activation of plasminogen to plasmin

232
Q

TXA indications

A

reduce surgical blood loss
reverse fibrinolytics
treat traumatic hemorrhage

233
Q

TXA SE

A

theomboembolism
seizures

234
Q

EACA SE

A

renal dysfunction
thromboembolisms

235
Q

what is used as replacement of fibrinogen in hypofibrinogenemia

A

cryoprecipatate

236
Q

cryo contains (5)

A

fibrinogen
vWF
Factor 8
Factor 13
fibronectin

237
Q

PCC indications (5)

A

reversing warfarin (unactivated)
reversing fondaparinux (activated)
reversing DOAC
bleeding (cardiac, hepatic, trauma)
bleeding hemophilia A/B (activated)

238
Q

PCC SE

A

thrombosis

239
Q

which PCC contain heparin

A

unactivated 4 factor

240
Q

what should you give to pts with thrombotic thrombocytopenic purpura?

A

FFP

241
Q

FFP indication (3)

A

surgery w/abnormal coag
warfarin reversal
thrombotic thrombocytopenic purpura

242
Q

1 mL of FFP =

A

1 unit of coag factor activity

243
Q

how much FFP

A

15-20 mL/kg for 20-30% increase

244
Q

how to treat factor VIII deficiency

A

give factor VIII

245
Q

how to ID factor VIII deficiency

A

prolonged aPTT
normal PT

246
Q

rFVIIa indication (2)

A

prevent csurgical bleeding w/hemophillia (F8/9)
uncontrollable bleeding

247
Q

rFVIIa SE

A

serious arterial/venous thrombosis events

248
Q

what does hydralazine isosorbide do

A

decr afterload
decr prelaod

Su. Pharm 2 (6 decks)

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