Exam 1 Flashcards
Treatment goal for dyslipidemia
Greater than or equal to 50% reduction in LDL
Preferred treatment for dyslipidemia
-Lifestyle modifications
-Low (<7%) saturated fat; Low (<200 mg/dL) C
-Moderate-High intensity statin
Treatment goal for HTN
BP < 130/80 mmHg
Preferred treatment for HTN
-Lifestyle modification
-Therapy based on compelling indications with BB, ACEi, ARBs + others as needed
Treatment goal for DM
HbA1c < 7%
Treatment preferred for DM
-Individualize to reach goal
-T2DM with ASCVD: SGLT2 or GLP-1
Treatment goal for smoking
Complete smoking cessation/exposure
Preferred treatment for smoking
Systematic strategy, pharmacotherapy
Treatment goal for weight management
-BMI: 18.5-24.9
-Waist circumference: 40 for men and 35 for women
-Wt loss 5-10% initially
Preferred treatment for weight management
Diet/lifestyle counseling; printed educational materials and encourage
Treatment goal for physical activity
~30-60 min mod intensity activity 5-7 days/wk
~cardiac rehab/supervised
Preferred treatment for physical activity
Brisk walking, swimming, cycling; increased daily activities
Why is it not recommended to give low-dose ASA in patients who have no risk of CAD?
Greater risk of developing hemorrhagic stroke (risk outweighs potential benefit)
Which P2Y12 inhibitor is indicated following ACS
Cangrelor or Prasugrel
Which P2Y12 inhibitor is indicated following ACS or prior MI
Ticagrelor
What is the purpose of enteric coated ASA?
Protect gastritis/stomach ulcer irritation
For a patient having an MI, take ____ in addition to NGL
1 ASA tablet (can chew and swallow to help it be absorbed faster)
____-dose ASA reduces risk of future ____ substantially
Low; MACE
Which P2Y12 inhibitors are pro-drugs
Clopidogrel and Prasugrel
What is the time to peak inhibition for clopidogrel
4-5 h (300 mg); 2-3 h (600 mg)
What is the time to peak inhibition of prasugrel
2-4 h
What is the time to peak inhibition of ticagrelor
2-4 h
What is the time required for effect dissipation for clopidogrel?
5 d
What is the time required for effect dissipation for prasugrel?
7 d
What is the time required for effect dissipation for ticagrelor?
5 d
Can 2 antiplatelets be used together? Why or why not?
Yes; they have different MOA
P2Y12 agents add additional benefit to ASA in specific situations, but also significantly increase ____
Bleeding risk
Why must an antiplatelet be given after stent placement?
If there was a mistake, blood may bind to the area thinking it is damaged and we do not want blood to accumulate there.
ASA dose MUST be ___ 100 mg with _____
Less than or equal to; ticagrelor
Do RAS inhibitors improve symptomatic ischemia?
NO! They decrease cardiovascular events
ACEi/ARB should be considered for ___
All patients with CCD (especially those with LVEF < 40%, HTN, DM, and CKD)
Which ACEi were studied for people with CCD?
Ramipril 10 mg/d
Perindopril 8 mg/d
Which ARB was studied for people intolerant to ACEi with CCD?
Telmisartan 80 mg/d
When should a statin be used?
When LDL > 100
Do nitrates have an effect on the natural history of a disease?
NO! They treat symptoms, but do not keep people alive
What is a challenge with nitrates?
Poor dexterity: grabbing small tablet or pushing down on spray
Efficacy of nitrates
They are all the same!
Advantage of NTG spray
Longest shelf life
Storage of NTG
Must keep in original container
Instructions for NTG
- Sit down
- Place 1 tablet under the tongue (don’t swallow; no H2O)
- If still experiencing chest pain after 5 min, call 911 and take another tablet
What should and should not be used for a HA while a patient is taking NTG?
Should take: Tylenol
Should NOT take: ASA or anti-inflammatory meds
What medication class must be used with extreme caution with nitrates?
PDEi due to hypotension and may lead to death
Explain risk of combined agents
What should a patient do if they took a PDE-i and experience chest pain, but they are still in the time frame that NTG should be avoided?
Stop action and hope the pain resolves
How long should you wait after taking Avanafil to take NTG?
12 h
How long should you wait after taking Sildenafil or Vardenafil to take NTG?
24 h
How long should you wait after taking Tadalafil to take NTG?
48 h
Which beta blockers are lipid soluble?
Propranolol
Carvedilol
Which beta blockers are water soluble?
Atenolol
Bisoprolol
Adverse cardiac effects with beta blockers
Sinus bradycardia
Sinus arrest
AV block
Goal HR while on BB
50-60 bpm at rest
<100 bpm when exercising
Which CCB are DHP?
Amlodipine
Which CCB are non-DHP?
Diltiazem and verapamil
**Act like BB
What are the examples of short-acting DHPs? Can short-acting DHP’s be used for CAD? Why?
Nicardipine and Nifedipine
NO; they cause substantial tachycardia
Which CCB are C/I in HF?
Verapamil and Diltiazem
Monitoring for DHPs
BP and edema
Monitoring for non-DHPs
Constipation
HR (goal: 50-60 at rest and <100 during exercise)
Do you get nitrate protection overnight?
Nope; that’s the nitrate-free period
NTG patch dosing
On @ 7 AM and take off 7-9 PM (put on in AM and take off in PM)
ISDN tablet dosing
10 mg TID (8,12,4 or 7,12,5)
ISMN tablet dosing
20 mg BID (8,3 or 8,4)
ISMN SR tablet dosing
30 mg QD in AM (8)
When should Ranolazine monotherapy be utilized?
When BP/HR are too low with other first-line agents
Which drug classes can be used for stable angina?
BB, CCB, nitrates
Should BB and non-DHP CCB be used together in stable angina?
No–b/c of HR lowering effect and negative conduction abnormalities
First line options if NSAIDs are to be used with ASA
Ibuprofen or naproxen
Which NSAID should be avoided with ASA use?
Diclofenac
Prinzmetal’s angina/vasospastic angina usually occurs (during exercise/at rest)?
At rest
Vasospastic angina is associated with ECG __-segment (elevation/depression)?
ST; elevation
When do ischemic episodes occur most frequently in vasospastic angina?
Early morning hours
Treatment options for vasospastic angina
CCB (1st line)
Nitrates
Combo tx (CCB + nitrate)
Define unstable angina
A little bit of an occlusion
Define NSTEMI
Some blood flowing through
Define STEMI
Full occlusion; no blood passing through
Type 1 acute coronary syndrome
Spontaneous MI; atherosclerotic plaque ruptures
Type 2 acute coronary syndrome
MI secondary to ischemic imbalance (oxygen supply and demand mismatch to heart)
Diagnosing ACS: All patients should receive an ECG within __ minutes of arriving to the ED facility
10
What condition is described: persistent ECG ST elevation; Q wave changes
STEMI
What condition is described: ST depression or new T wave inversion; Q wave changes are unlikely
NSTEMI
Units of high sensitivity troponin
ng/L
Units of conventional troponin
ng/mL
Levels of high sensitivity troponin that detect myocardial injury
Greater than 14 ng/L
Levels of conventional troponin that detect myocardial injury
Greater than 0.05 ng/mL
Which part of the heart is the strongest and pumps blood out to the rest of the body?
Left ventricle
If initial ECG is not diagnostic, but symptoms persist, how often should serial ECG’s be performed?
q15-30min for the first hour
Why should NSAIDs be avoided during hospitalization for UA, NSTEMI, or STEMI?
Lead to sodium and water retention which increases risk of MACE
When is supplemental oxygen needed?
When O2 sat is less than 90%
What are the names of the fibrinolytics learned in class? Which disease state are they used for? Which ones are weight based?
Names: tenecteplase, Reteplase, Alteplase
Disease: STEMI
Weight based: Tenecteplase and Alteplase
Which STEMI patients should get reperfused? Which type of reperfusion is preferred?
ALL patients whose symptoms began in previous 12h; PCI is preferred over fibrinolytic
Door-to-needle time (Fibrinolytics)
within 30 minutes of hospital arrival
Door-to-balloon time (PCI/stent)
within 90 minutes of hospital arrival
How long is DAPT recommended for UA/NSTEMI/STEMI patients?
12 months
The loading dose of clopidogrel is 300-600 mg. Most of the time 600 mg is used. In which situation would 300 mg be used?
If pt is on a fibrinolytic
What is prasugrel not recommended for?
ischemia guided strategy, pt 75+ years old, less than 60 kg, or at high bleed risk
What is a contraindication for prasugrel?
Patient has a hx of stroke/TIA
In the acute/early phase of switching from one P2Y12 inhibitor to another, is washout needed? Is loading dose needed?
Washout of 24h is NOT needed, but a loading dose is needed
In the late phase of switching from one P2Y12 inhibitor to another, is washout needed? Is loading dose needed?
24h washout is needed, but a loading dose is not needed.
Which P2Y12i is preferred for ischemia guided tx?
Clopidogrel or ticagrelor
Which P2Y12i is preferred with a fibrinolytic?
Clopidogrel
Which P2Y12i is preferred for PCI?
Ticagrelor or prasugrel
Adverse event with ticagrelor
SOB
Major s/sx of bleeding
Blood in urine/stool; coughing up blood; cut that won’t stop bleeding after pressure is applied for ~10 min
Does ASA need to be held before a CABG?
NO
How long do the P2Y12i need to be held before elective CABG?
Ticagrelor: 3d
Clopidogrel: 5d
Prasugrel: 7d
GPIIb/IIIa inhibitors include
Abciximab, eptifibatide, and tirofiban
**Given in addition to ASA and P2Y12 inhibitor if needed
Which drug class can be used as “bail out”?
*Used during PCI if thrombus develops or low blood after stenting
GPIIb/IIIa
What are the names of the two screening tests available for HIT?
Enzyme-linked immunosorbent assay (ELISA) and Serotonin release assay (SRA)
What should you do if a patient tests positive for ELISA test?
STOP heparin and send off SRA to lab to verify the positive reading
What is UFH dosing based on?
aPTT (activated partial thromboplastin time) or ACT (activated clotting time)
What drug class does enoxaparin belong to? What should be checked before giving a pt enoxaparin?
LMWH; CrCl
What drug class does bivalirudin belong to?
Direct thrombin inhibitor
Can bivalirudin be used with GPIIb/IIIa inhibitors?
NO–except when used for “bail out”
What drug class does fondaparinux belong to?
Factor Xa inhibitor
When is fondaparinux mainly used?
If pt has a hx of HIT
Is fondaparinux the DOC if planning on a PCI?
NO–need to give UFH or bivalirudin also
When is fondaparinux C/I?
When CrCl < 30 ml/min
When should a BB be utilized in ACS?
Within 24h
Which BB should be used for pts with HFrEF?
Metoprolol succinate, carvedilol, or bisoprolol
What should you do if a patient is using cocaine and needs a BB?
Use a non-selective BB, such as carvedilol for alpha blockade as well
Is it okay to start or increase a BB in a patient with acute HF exacerbation?
No
Is it okay to continue giving a patient their BB during acute HF exacerbation?
Yes
Which sign of hypoglycemia do BB not mask?
Cold sweats
Blood pressure and heart rate that are too low for BB
BP< 90/60 mmHg
HR<50-60 bpm
If a patient has recurrent ischemia and they are contraindicated to BB, what should be used next?
Non-DHP CCB (diltiazem or verapamil)
Which patients should be on a statin?
ALL! **High-intensity
Which patients should be on an ACE inhibitor?
ALL–especially those with HFrEF, DM, or CKD
When should an ACE inhibitor be added to regimen?
Use cautiously in first 24h of MI because it may result in hypotension/renal dysfunction
Which ACE inhibitors are indicated for ACS?
captopril, enalapril, lisinopril, ramipril, and trandopril
Monitoring parameters for ACE-i
BP (decreases)
K+ (increases)
SCr (increases)
Angioedema (swelling of face and lips)
Counseling point if patient experiences angioedema
STOP taking med and seek medical attention
How many sprays does it take to prime nitrolingual?
5
How many sprays does it take to prime Nitromist?
10
Which patients should get nitroglycerin?
ALL; they should get 0.3-0.4 mg for under the tongue 15min for chest pain….max 3 doses
Which type of ischemia (supply or demand) is Printzmetal’s?
Supply
Which type of ischemia (supply or demand) is fixed stenosis?
Demand
Which type of ischemia (supply or demand) is unstable angina?
Supply
Cause of stable angina ischemia
Fixed obstruction in epicardial artery
Cause of stable angina pectoris
Myocardial ischemia and associated disturbances in myocardial function WITHOUT myocardial necrosis
What is the definitive test of coronary anatomy?
Cardiac catherization and coronary angiography
Do nitrates impact supply or demand?
decrease preload=decrease demand
Do beta blockers impact supply or demand?
decrease demand
Do CCB impact supply or demand?
decrease demand
Side effects of BB
Sinus bradycardia
Sinus arrest
AV block
Monitoring of DHPs
Edema and BP
Monitoring of non-DHPs
Constipation and HR
MOA of nitrates
ALDH2 inactivation in mitochondria
Adverse events of nitrates
BP reduction; reflex tachycardia
MOA of ranolazine
Inhibit late sodium channel to prevent an increase in intracellular sodium and calcium increase
Which drug class should ranolazine NOT be used with?
CYP3A inhibitors and inducers
With moderate CYP3A inhibitors (diltiazem and verapamil), ranolazine should be dosed at ____.
500 mg BID
What is a contraindication for DHP and non-DHP CCB?
HFrEF
What should be used in combination with nitrates to blunt nitrate induced increase in HR?
Non-DHP CCB or BB
When do MIs occur most of the time?
At rest
Atypical s/sx of MI
Indigestion, epigastric pain, increasing dyspnea in absence of CP
If a patient has elevated troponin, is it conclusive that they have a STEMI/NSTEMI?
NO–other conditions can cause elevated troponin. Check ECG as well!
