Exam 2 - high yield Flashcards
Tx for stable CAD?
A=ASA, ACEI/ARB B=Beta blocker (Metoprolol) C=Cholesterol and Cigarettes D= Diet E=Exercise
PAD treatments? (Hint: Three)
- ASA
- Clopidogrel if ASA allergy
- Cilastazol w/IC
VTE prophylaxis in gen med PT and if trauma patient? Dose? Renal?
Gen med:
- UHF 5000U SC (good for renal)
- Enox 40mg SC or 30mg SC if Cr below 30
- Fonda 2.5mg SC or not if Cr less than 30.
Trauma: Enox
Fondapirinux dose for DVT prophylaxis and VTE tx? Renal concerns?
DVT Proph: 2.5mg SC daily. If CrCl less than 30 don’t give.
VTE: 5-10mg daily SC between 50kg and 100kg.
Enoxaparin dose for DVT prophylaxis and VTE Tx? Renal concerns?
DVT Proph: 40mg SC. CrCl less than 30 then 30mg.
VTE Tx: 1mg/1kg q12h SC -or- 1.5mg/kg q24h
Tx of Acute VTE? If bad kidney? Goal?
- Enoxaparin 1mg/kg. (Best, CrCl 20 no)
- Fondapirinux 5mg to 10mg. (CrCl 20 no)
- UFH.
Bad kidney=UFH.
Goal=transition to PO Warfarin with INR of 2-3.
Tx for VTE if kidney good? If kidney bad? Duration? INR goal?
Good kidney=LMWH daily or q12h (Enox 1mg/kg or Fonda 5-10mg)
Bad kidney= IV UFH x5 days
1st occurrence= Warfarin x3 months
2nd occurrence= Warfarin lifelong
INR=2-3 (2.5 ideal)
In Acute VTE which medication to use if renal impairment is an issue?
If CrCl less than 20 do not use LWMH (Enox or Fonda)! Use UFH to reduce bleeding
Tx of choice for Pulmonary Embolism? Shock with low bleed risk? Small PE?
Acute PE=5-10mg Fondaparinux or 1mg/kg Enodaparin
or IV UFH
Shock with low bleed risk= Thrombolytic
Small PE= Alteplase
Tx for high-risk PE? Renal impairment? High risk bleeding?
IV UFH is agent of choice.
High -risk bleeding=Apixaban (less bleeding)
Renal impairment= Warfarin is gold standard and then Apixiban
AFib/AFlutter stroke prevention? (Hint: three)
- Warfarin 5mg if healthy, 2.5 older than 75 or hepatic dysfunc
- Dabigitran
- Oral Xa
Tx for Secondary Stroke Prevention if from cardioembolic stroke (Afib/Aflut)? INR?
Warfarin aka Coumadin. INR 2-3.
Tx for NSTEMI? What if going for PCI?
Morphine Oxygen Nitrates ASA Heparin Beta-Blocker PCI=Prasugruel (P2Y12-inhib)
What is reversal agent for Indirect Thrombin Inhibitors (LMWH and UFH/Enox)?
Protamine Sulfate IV.
UFH= 1mg:100U
Enox=1mg:1mg 60-70% effective
None for Fonda.
Tx for Acute Ischemic Stroke? When to use what? What are two major exclusion criteria?
- IV t-PA within 4.5hr
- ASA 325mg PO 12-24h after t-PA
Exclusion: SBP 185 or DBP 100, 80+
Secondary stroke prevention if not from cardioembolic? (Hint: 3)
- ASA
- ASA + Dipyridamole ER
- Clopidogrel if cannot tolerate ASA
What are the 4 main anti-platelets? MOAs?
- ASA (COX-inhib)
- Clopidogrel (ADP P2Y12-inhib)
- Cilostazol (PDE-inhib)
- Dipyridamole (Adenosine + PDE-inhibitor)
(ACCD)
What are the indications for the 4 main anti-platelets?
- ASA=PAD, CVA/TIA prevention and treatment
- Clopidogrel=PAD
- Cilostazol=PAD with intermittent claudication
- Dipyridamole=Secondary CVA/TIA prevention
What is intermittent claudication? What is it a sign of?
Cramping in legs. Sign of PAD.
What is the class and mechanism of ASA? Side-effects? Contraindications?
Class: Antiplatelet
MOA: Irreversibly inhibits prostaglandin cyclooxygenase (COX-1) in platelets. Prevents formation of Thromboxane A2 (TXA2).
SE: GI upset and/or bleeding
Contras: Active bleeding, hemophilia, thrombocytopenia
What is the class and mechanism of Dipyridamole? Side-effects? Contraindications?
Class: Antiplatelet
MOA: Inhibits platelet aggregation via adenosine and PDE inhibition.
SE: Angina, HA, dizziness, hypotension, dyspnea
Contras: Active bleeding, CAD (“coronary steal syndrome”)
What is the class and mechanism of Cilostazol? Side-effects? Contraindications?
Class: Anti-platelet
MOA: Phosphodiesterase inhibitor; suppresses platelet aggregation; direct artery vasodilator
SE: Fever, infection, tachycardia
Contras: All CHF patients. They’ll die quicker.
What is the class and mechanism of Clopidogrel? Side-effects? Contraindications?
Class: Anti-platelet
MOA: Inhibits binding of ADP to analogues to platelet receptor causing irreversible inhibition of platelets
SE: Chest pain, purpura (purple rash spots d/t bleeding)
Contras: Active pathologic bleeding (peptic ulcer, intracranial bleed)
What is CHA2DS2-VASc Score assess? Score of 0, 1, and 2 mean for treatment?
Assesses stroke risk.
0=don’t give anticoagulant even if have afib.
1=ASA (anti-platelet)
2 or above=Anticoagulant like Warfarin or new novel anticoagulants.
What does HAS-BLED calculate? What to consider if score is 3 or higher?
Risk of bleeding vs clot from anticoagulant or ischemic stroke.
3 or higher=consider alternative to anticoagulant warfarin. Not valid for other anticoags.
What is tx for of AFib/AFlutter if has CHA2DS2-VAS2c of 0, 1, or 2?
0=No antithrombotic
1=ASA
2=Warfarin or the “-bans” (oral Direct Xa Inhibitors “ARE”)
Two treatments for Acute Ischemic Stroke? Timing?
- IV t-PA. Within 3h, up to 4.5h.
- ASA 325. 24-48h after t-PA.
No anti-thrombitics for 24h after t-PA.
What is SBP and DBP exclusion criteria for Acute Ischemic Stroke? Others?
SBP over 185
DBP over 110 at time of treatment
Others: Active bleeding, bleeding within 3 weeks, recent anticoagulation, recent surgery.
4 treatments for Secondary Stroke Prevention?
- Statins
- BP reduction below 140/90
- Stop smoking
- Antiplatelet (ASA, Clopidogrel, Dipyridamole). Anticoagulatant if cardioembolic.
Warfarin (Coumadin) class and MOA? Use? Monitor test? Adverse effects?
Class: Direct Thrombin (Factor II) inhibitor.
MOA: Antagonized VitK to inhibit SNOT/1972 and proteins C, S
Use: DVT/PE, prevent CVA/TIA in AFib with heart valve replacement
Monitor: INR
Adverses: Bleeding, bruising
What three tx choices of antiplatelets for Secondary Stroke Prevention? (Hint: one is a combo)
- ASA
- Clopidogrel
- ASA + Dipyridamole
Fibrinolytics: MOA and indication?
Convert plaminogen to plasin to lyse thrombi. In acute ischemic stroke. NOT IN NSTEMI!
GP IIb/IIIa, PAR-1, PDE, COX, and ADP P2Y12 inhibitors are all what drug class?
Antiplatelet drugs
UFH dose for VTE prophylaxis?
5000U SC q8-12h, usually TID
Warfarin for initiation? Kidney issues? Goal?
Init: 5mg if healthy, 2.5mg if older than 75 or hepatic dysfunction.
INR: 2-3
What are the three Direct Thrombin Inhibitors? Which are IV and oral? What is the factor and pathway? Reversal agent?
DTI=ABD. Inhibitor Factor 2a in common pathway.
Agratroban- IV only
Bivalirudin- IV only (CrCl 30 reduce)
Dabigatran-PO only (AFib 15-30 reduce; AFib 15 no; VTE 30 no)
Reversal: Praxbind/Idarucizumab
What are the three Ora Direct Xa Inhibitors? What is the factor and pathway? Reversal agent? Kidney?
"ORAL are A.R.E." Apixiban Rivaroxaban (CrCl 50 reduce; 30 dont give) Edoxaban Reversal: None!
Which are the Indirect Xa inhibitors? Renal issues? Reversal?
- UFH
- LMWH/Enox (Cr 30 reduce, 20 don’t use!)
- Fondaparinux (Cr 50 reduce, 30 DON’T USE BLACK BOX)
Reversal for Heparin and Enox=Protamine. None for Fondaparinux.
What severe condition can UFH cause? Around when in treatment? What will notice on labs? Tx?
HIT. 5-10 days into treatment. 50% platelet drop. Stop UFH and give IV Direct Thrombin IIa Inhibitors (Agatroban and Bivalirudin).
What are 5 general CIs for anticoagulants?
- Active major bleed
- Hemophilia
- Severe liver dz
- Severe thrombycytopenia
- Malignant HTN
What three labs to check at baseline before starting anti-coagulants?
- CBC w/platelets (#1)
- SrCr
- LFTs
What is the length of time for “bridge to Warfarin”.
Around 5 days.
Which med not used in hepatic dysfunction?
Agatroban (Direct 2a Inhib IV)
Which meds increase INR while on Warfarin?
TEAM Cipro
What to check post Heparin infusion?
aPTT
What is Virchow’s Triad?
Hypercoagulable state, Stasis, Vessel wall injury. Risk factors for VTE.
Which are the three Novel Oral Anticoagulants? What factor? When are they contraindicated?
-xabans. Factor Xa=A.R.E.
Contraindicated in renal dysfunction.
If PT on Cipro which NOAC can you only use?
Edoxaban. Not a CYP3A4 interaction.
Clopidogrel has a Drug-Drug Interaction which what class? What to use instead?
DDI with PPIs (omerprazole). D/C omerprazole and give ranitidine.
Which is the only P2Y12 agent that is reversible?
Ticagrelor
Which 3 Beta-blockers to use in stable HF?
- Carvedilol
- Metoprolol
- Bisoprolol
Which Beta-blocker to use in hypertensive emergencies? MOA?
Labetelol. Nonselective Beta, selective alpha 1.
If PT cannot tolerate BB and need to reduce HR what to use?
Non-DI CCBs (verapamil, diltiazem)
Which nitrate to use for short acting and long acting?
Short=NTG. Develops tolerance. Lasts 20-30min.
Long=Isosorbide Mononitrate. No tolerance.
When to never give nitrates? When PT is on ____ or ____.
EtOH or PDE-inhibitors like Viagra.
Conservative TX for NSTEMI?
ASA, Clopidogrel, and Enoxaparin
Invasive Tx for NSTEMI?
ASA, Clopidogrel, Enoxaparin, and PCI. Can give Pasugrel and GP-inhibitors with PCI.