Exam 1 review Flashcards by Morgan Evans

What is the primary prevention for ACS?

Aspirin 81 mg PO daily (not used routinely)

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What is the secondary Tx for ACS?

“DAPT (dual antiplatelet therapy) with Aspirin plus a P2Y12 inhibitor is indicated for most patients treated for ACS for a minimum of 12 months regardless of whether the patient was medically managed or if the patient undergoes some type of revascularization”

(i.e. ASA 81 mg PO daily + Clopidogrel 75 mg once daily)

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How do you dose nitroglycerin for ACS?

0.4 mg q5 min, up to 3 doses PRN

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What is the primary prevention for stroke?

Oral anticoagulation is the treatment of choice for the prevention of stroke in patients with atrial fibrillation

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What is the secondary prevention for stroke?

“Antiplatelet therapy is the cornerstone of antithrombotic therapy for the secondary prevention of noncardioembolic ischemic stroke.”
“Oral anticoagulation is recommended for the secondary prevention of cardioembolic (atrial fibrillation) stroke in moderate-to-high risk patients.”

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Differentiate your parenteral (IV) anticoagulants and when you can substitute for HIT (heparin induced thrombocytopenia)

1) Heparin: binds to endogenous anticoagulant antithrombin(AT) increase PTT (measure every 6 hr until in therapeutic range)
2) Low molecular weight heparin: lovenox aka enoxaparin. Don’t need to monitor unless peds, pregnant, obesity, CrCl<30. LOWER INCIDENCE OF THROMBOCYTOPENIA COMPARED TO HEPARIN, BUT NOT CONSIDERED A SAFE ALTERNATIVE IN PT THAT DEVELOP HIT FROM HEPARIN (UFH).
3) Fondaparinux: binds to AT, only inhibiting factor Xa. For use in patients with a history of HIT due to no antibody cross-reactivity. Side effect: catheter related thrombosis compared to enoxaparin.
4) Bivalirudin: direct thrombin inhibitor

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How do you dose unfractionated heparin for fibrinolytic reperfusion (stemi) and both of the nstemi strategies?

60 units/ kg (max initial bolus = 4000 units), followed by 12 units/kg/hr (max initial infusion rate = 1000 units/ hr) unfractionated heparin

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How do you dose unfractionated heparin and enoxaparin for Percutaneous coronary intervention (PCI) (coronary angioplasty) (Stemi)

1) No GP (glycoprotein) IIb/IIIa: 70-100 units/kg IV bolus heparin to achieve therapeutic ACT
2) GP IIb/IIIa (glycoprotein): 50-70 units/ kg IV bolus heparin to achieve therapeutic ACT
3) Enoxaparin: 0.5mg/ kg one time IV bolus

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How do you dose Enoxaparin for stemi?

Enoxaparin: 1mg/kg SC Q12 hours until PCI
a) An initial 30mg IV bolus can be given
b) CrCl <30mL/min (.5ml/s): 1mg/kg SC Q24 hours

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Clopidogrel 75 mg once daily. Metabolized by ____________. Discontinue this drug 5 days before surgery. Caution use with omeprazole.

CYP2C19

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P2Y12 inhibitors for ACS:
1) Describe presugrel
2) Describe ticagrelor

1) Prasugrel 10 mg once daily, weight less than 60 kg =5mg daily. Discontinue 7 days before surgery. Contraindicated with history of stroke or TIA.
2) Ticagrelor (Brilinta) 90mg PO BID. Strong inducers or inhibitors of CYP3A4. Daily ASA doses > 100 mg, higher doses of aspirin reduce the benefit of ticagrelor. D/c 5 days before surgery.

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1) What are the adverse effects of P2Y12 inhibitors?
2) What about ticagrelor specifically?
3) Which 2 are prodrugs?

1) Adverse effects: bleeding, rash.
2) Ticagrelor can have dyspnea, ventricular pauses, bradycardia.
3) Both clopidogrel and prasugrel

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1) Bad total cholesterol is __________
2) LDL >________is almost a sure sign you need to be on a coreductase inhibitor like rosuvastatin.

1) >200.
2) >190

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With heart disease we talked abt nitrogylcerin; know a community setting dose and know counseling.

All patients with SIHD should receive sublingual nitroglycerin for acute treatment and should receive education regarding its proper use. Sublingual is not the same as PO!!!!. Example sig code: dissolve one tablet by mouth at onset of chest pain; may repeat every five minutes for up to three doses
NTG is indicated for angina, uncontrolled HTN, acute HF. Contraindicated if SBP less than 90 or greater than 30 below baseline, avoid. Avoid if recent sildenafil or tadalafil (or any -fil med bc they are PDE5 inhibitors). Use with caution if infarct suspected, wean gradually off of it!. Dose: SL .3-.4 mg every 5 min, up to 3 doses PRN. IV: 10mcg/min titrated to symptom relief + desired BP. May cause fluting, headache, hypotension, tachycardia

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Recommend doses for isosorbide nitrate and dinitrate. What is the goal for both?

1) Isosorbide dinitrate: TID, take a dose every 4 to 5 hours. Initial oral dose: 5-20mg TID
2) Isosorbide mononitrate: BID, dosed 7 hours apart. Initial immediate release dose: 20mg BID. Initial extended-release dose: 30-60mg Qday.
Goal for both: ensure a 10 to 14-hour nitrate-free interval every day (or it’ll stop working).

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Give counseling points for isosorbide nitrate and dinitrate.

Keep in a dark place
Do not store in the bathroom (keep dry)
Sit down when you take it
Tablets last 6 months after opening; spray lasts 3 yrs after opening
Remove the cotton plug

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RAAS: ACEis act on__________ ARBs act on ________________

angiotensin I; angiotensin II

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What does angiotensin II do?

Pressor effects include direct vasoconstriction, stimulation of catecholamine release from the adrenal medulla, and centrally mediated increases in sympathetic nervous system activity. Stimulates aldosterone synthesis from the adrenal cortex, leading to sodium and water reabsorption that increases plasma volume, TPR, and ultimately BP

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Why can ACEis/ ARBs through ANG2 and RAAS be renally protected but also cause an acute decomp in renal function? (has to do with efferent arteriole)

1) For pts with type 2 diabetes and CKD the progression of kidney disease has shown to be significantly reduced with ARB therapy. When giving an ACEi the starting dose will be half that or normal in someone with CKD.
2) Severe bilateral renal artery stenosis or unilateral artery stenosis of a solitary functioning kidney renders the pts dependent on the vasoconstrictive effect of ang II on the efferent arteriole of the kidney, this explains why pts are susceptible to AKI from an ACEi. GFR will also decrease slightly because the drug is inhibiting ang IIs vasoconstrictive properties. Both also cause hyperkalemia.

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Let’s say I’m on ramipril (ACEi), and I develop angioedema. Can I switch to an ARB?

Yes

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If someone has a cough with ACEi, can you switch to an ARB?

Yes, bc bradykinin buildup isn’t an issue with ARBs because it works at the angiotensin receptor, not in the lungs

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CKD, sodium, licorice, or use of a monoamine oxidase inhibitor (PD meds) with tyramine containing food, or certain drugs can all cause what?

HTN crisis

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What is prazosin used for?

Nightmares, BPH, HTN, and PTSD

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Nondihydropyridines (verapamil and diltiazem) may also treat what?

Supraventricular tachyarrhythmias (e.g., atrial fibrillation)

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What is the 1st line option for patients with DM + HTN?

ACEis

SGLT2 inhibitor empagliflozin (Jardiance) can be used for _________ in SIHD and for HF

What would be preferred in SIHD patients with chronic obstructive pulmonary disease, peripheral arterial disease, DM, dyslipidemias, and sexual dysfunction?

β1-selective agents (i.e Metaprolol)

What drug class increases lithium?

ACEis

What drugs are good for isolated systolic HTN in older patients?

Thiazides and long-acting dihydropyridine CCB

Which blockers have mixed alpha and beta receptor activity? Which beta blockers are cardioselective?

Mixed alpha and beta receptors: Carvedilol Beta-1 selective blockers: Metoprolol

What is the most common Tx for preeclampsia?

IV Hydralazine

Define gestational HTN

new-onset HTN after 20 weeks of gestation

What are recommended for chronic HTN in pregnancy (pre-established) as FIRST LINE agents due to favorable safety profile?

Labetalol, long-acting nifedipine, or methyldopa

True or false: Instant-release nifedipine is Teratogenic

True

What drug is shown to cause intrauterine growth retardation?

Atenolol

What 3 drug classes are known teratogens and are ABSOLUTELY CONTRAINDICATED in pregnancy?

ACEis, ARBs, and direct renin inhibitors

What drug class significantly reduces LDL-C levels (20%-60%), modestly increases HDL-C (6%-12%) and decreases TG levels (10%-29%)?

Statins

Cholesterol absorption inhibitors: 1) ______________ has a modest reduction in LDL-C of 15% to 24%. 2) The bile acid sequestrants (BAS), such as _______________, modestly reduce LDL-C (13%-20%) and reduce cardiovascular events.

1) Ezetimibe (Zetia) 2) colesevelam

What drug class reduces LDL-C by as much as 60% when added to background statin therapy?

The PCSK9 inhibitors (e.g., alirocumab)

Adenosine triphosphate-citrate lyase inhibitors: Bempedoic acid (Nexletol)- what do they do to LDL?

Modest reductions in LDL-C (15-20%) when combined with statin therapy or used as monotherapy in patients who are unable to tolerate statins

What drug class may lower TG by 20-50% & may raise HDL-C by 10-15% ?

Fibric acid derivatives (Fibrates):

What drug class significantly reduces TG and VLDL cholesterol levels (20%-50%) [with lesser effects on other lipoproteins]?

Omega-3 polyunsaturated fatty acids (PUFA

What drug increases HDL-C (5%-30%); lowers TG (20%-50%) and LDL-C (5%-20%)?

Niacin (Vitamin B3)

Can you be on simvastatin, Repatha, and robinamide?

Yes

If you don’t have ACS, goal LDL is <100. If you do, goal is <______.

<70

If you need <50% reduction in LDL, what med would you use? What’s an alternative?

You can use Evolocumab (Repatha) (injection) or ezetimibe which would only get you to about a 25% reduction, but it’s “better than nothing”

Which statins are contraindicated with strong CYP3A4 inhibitors?

Lovastatin + Simvastatin (so avoid Gemfibrozil & caution use with cyclosporin or ART (HIV meds))

When a pt is taking amlodipine, what is their max Simvastatin dose?

20mg

Which statin does NOT require renal dosing?

Atorvastatin

What is a big side effects of taking statin drugs?

Rhabdomyolysis (+ myalgia large muscle group pain, CK >10x ULN)

What are some of the less common risks with statins?

Some say brain fog (not cognition), rare risk of DM.

1) What do you do when triglycerides go over 500? 2) Can you add gemfibrozil to crestor?

1) Fibrates (Fibric acid derivatives) 2) NO (or lewis will hunt you down)

1) Statins work in the _______ 2) Cholesterol absorption inhibitors work in the _______________

1) liver 2) small intestine

1) What bind bile acids in the intestinal lumen? 2) Where do fibrates act?

1) BAS (bile acid sequestrants) 2) Liver (gemfibrozil) PPARa receptor (fenofibrate)

1) What is the MOA of PUFAs? 2) Where does niacin (B3) act?

1) Activating PPARa and inhibiting apoprotein C-III 2) Liver

What drug class is the recommendation for those with DM and HTN?

Statins

1) Statins are contraindicated in patients with decompensated cirrhosis or acute __________ 2) Alcoholics most at risk for what?

1) liver failure. 2) hypertriglyceridemia.

What are the 2 most common adverse effects with CCBs?

Constipation and edema (The peripheral edema and other side effects associated with vasodilation occur more frequently with dihydropyridines rather than non-dihydropyridines)

1) What drugs should you use for HFrEF? 2) What about for HFpEF?

1) 3-4 drugs consisting of an ACEi or ARB + diuretic + beta blocker and maybe a mineralocorticoid receptor 2) Use of a beta blocker or an ACEi or ARB but if edema is present they need a diuretic

How do you Tx HTN And SIHD?

Beta blockers are the 1st line, an ACEi or ARB is also effective as an add on to a b-blocker, alternative to b-blocker: nondihydropyridine CCB (diltiazem, verapamil) ; pt’s with ongoing sx: dihydropyridine CCB (amlodipine, felodipine)

________________ can mask the sx of hypoglycemia in pts with well controlled DM, because the sx of hypoglycemia go thru sympathetic NS. *sweating still occurs during hypoglycemia episodes*

Beta blockers

Describe secondary stroke prevention with HTN

Thiazide either in combination with an ACEi or as monotherapy

Metformin, beta blockers, and nondihydropyridines can all exacerbate what?

What drug class works on the distal convoluted tubules?

Thiazides

What 4 groups of OTC meds can be used for dyslipidemias?

1) Omega-3 polyunsaturated fatty acids (PUFA) 2) Red Yeast Rice 3) Phytosterols 4) Soluble fiber and psyllium

When should you caution use of Omega-3 polyunsaturated fatty acids (PUFA)?

Pts on anticoagulants (may prolong bleeding time)

Bile acid sequestrants and fibrates can be used for what?

Diabetes

What drug class can cause impaired absorption of fat-soluble vitamins A, D, E, K; GI obstruction; and reduced availability of drugs such as warfarin, levothyroxine, and phenytoin?

Bile Acid Sequestrants (BAS) (Drug-drug interactions may be avoided by taking other meds 1 hour before or 4 hours after BAS)

Fibric acid derivatives (Fibrates): Differentiate between Gemfibrozil and Fenofibrate based on MOAs

1) Gemfibrozil→ increases the activity of LPL and somewhat reduces the secretion of VLDL from the liver 2) Fenofibrate→ increases LPL activity, and reduces apoprotein C-III by activating peroxisome proliferator-activated receptor a (PPARa)

True or false: Fibrates require renal dose adjustments

True

1) Muscle related side effects of fibrates are more common when used with what? 2) List 2 fibrate contraindications

1) Statins 2) Statins (rhabdo) and warfarin (can increase INR)

What do you consider if a patient who went through PCI doesn't have a high bleed risk?

Dual Antiplatelet Therapy (Clopidogrel and Aspirin)

What does a pt need to take before a PCI?

Clopidogrel 75 mg Qday BEFORE PCI, Aspirin 325 mg at least 2 hours (but preferably 24 hours) BEFORE PCI

Differentiate between medicating for a bare metal stent or a drug eluting stent

1) Bare metal stent→ one month of DAPT (high risk of bleeding consider only 2 weeks…think solid organ transplant here) 2) Drug eluting stent→ Six months (high risk of bleeding, only 3 months) Drug eluting stents: sirolimus, paclitaxel, zotarolimus, or everolimus

What are the 2 orphan drugs for dyslipidemias? What do they have a BBW for?

Mipomerson (Kynamro) (reduces LDL by 25% ish) Lomitapide (Juxtapid) (reduces LDL by 40% ish) Severe hepatotoxicity; are only available through REMS programs

Recc. monitoring parameters for ACEis and ARBs (hint: 3 tests)

ACEi→ BP, BUN/SCr, SK+ ARB→ BP; BUN/SCr, SK+

Recc. monitoring parameters for beta blockers and CCBs (hint: 2 tests)

B-Blocker→ BP; HR CCB→ BP; HR

Recc. monitoring parameters for mineralocorticoid receptor antagonists (MRAs) and thiazides

1) MRA→ BP; BUN/SCr, SK+ (K and Kidney function checked @ 3 days and 1 week) 2) Thiazide→ BP; BUN/SCr, Serum Electrolytes (K+, MG2+, Na+) Uric acid

What drugs should you take while sitting down bc they're associated w first dose syncope?

Selective α1-receptor blockers

Constipation, bloating, epigastric fullness, nausea, and flatulence are potential side effects of what?

Bile acid sequestrants

What are assoc. with injection site rxns, allergic rxns, infections, and post shot “flu-like” symptoms?

PCSK9 Inhibitors

1) Hyperuricemia and tendon rupture (inhibits OAT2 involved in uric acid uptake) 2) Risk of myopathy if used with simvastatin >20 or pravastatin >40 (AVOID) This describes what drug class?

ATP-Citrate lyase Inhibitors

"Hard on the liver, cutaneous flushing and itching that can be reduced by taking ASA. Alcohol/hot drinks could exacerbate flushing and pruritus" This describes what?

Niacin

Recommend a dose for alteplase (tPA) for a stroke patient

0.9 mg/kg given as 10% bolus over 1 minute, then 90% left over 1 hour; max dose of 90 mg

What do you need to monitor for alteplase (tPA) use?

Monitor patient closely (q 15 min) for: elevated BP, neurologic status, and hemorrhage (increased risk of hemorrhagic stroke) D/C tPA and obtain CT if patient develops s/s of cerebral edema of intracranial bleeding

When can you use alteplase (tPA)?

>18 y/o, dx of ischemic stroke w/ neurologic deficit, and onset time less than 4.5 hours ago

How do you control BP in stroke patients? (hint: 3 first line drugs)

Labetalol, nicardipine, and clevidipine are often first-line agents If refractory HTN, consider nitroprusside, but be mindful of potential cyanide toxicity

Recommend first line reversals for the following oral anticoagulants: 1) Warfarin 2) Dabigatran 3) Rivaroxaban 4) Apixaban

1) Warfarin → Vitamin K and 4-factor Prothrombin Complex concentrate (4PCC) 2) Dabigatran → Idarucizumab 3) Rivaroxaban → Andexanet alfa 4) Apixaban → Andexanet alfa

What 2 drugs can be reversed with Andexanet alfa?

Rivaroxaban + Apixaban

Recommend an antiplatelet dose for aspirin and plavix for secondary stroke prevention.

ASA 81 mg PO daily Clopidogrel (plavix)75 mg once daily

Recommended doses for Rivaroxaban, dabigatran, and Apixaban (Eliquis)

1) Rivaroxaban (Xarelto) → 20 mg PO Qpm w/meal; reduce dose to 15mg Qpm with meal if CrCl ≤ 50 mL/min 2) Apixaban (Eliquis) → 5 mg PO BID; reduce dose to 2.5 mg BID if 2 or more of the following (age ≥80, weight ≤ 60 kg, sCr ≥ 1.5 mg/dL) 3) Dabigatran (Pradaxa) → 150 mg PO BID; reduce dose to 75 mg BID if CrCl = 15-30 mL/ min

Nitroglycerin can cause severe _______________

headaches

Why does Edoxaban suck so much?

Edoxaban is contraindicated with CrCl > 95 mL / min + increased risk of stroke when compared to warfarin