Heart Attack, Stroke Flashcards

1
Q

Signs and Symptoms of Heart Failure

A

Decreased Perfusion: Dyspnea, Fatigue, Weakness, decreased exercise capacity

Pulmonary Congestion: Cough, rales, S3 gallop

Systemic Congestion: Peripheral edema, ascites, hepatomegaly

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2
Q

Diagnosis criteria of Heart Failure

A

Lab:
BMP > 100
Echo (preferred)

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3
Q

Heart failure categories

A

HFpEF: >= 50%
HFrEF: <= 40%

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4
Q

Heart Failure Classification

A

Staging:
A: At risk
B: Structural Changes, No Symptoms
C: Structural Changes, Symptoms
D: Severe, recurrent hospitalization

NYHA Functional Class: (After is diagnosed)
Class 1: No symptoms; Normal activity
Class 2: Symptoms; Slight limitation of physical activity
Class 3: Symptoms; Minimal exertion causes symptoms
Class 4: Symptoms; Symptoms at rest

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5
Q

What are some Natural Products that may be beneficial in Heart Failure?

A

1) Omega-3 fatty acids
2) Coenzyme Q10
3) Hawthorne

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6
Q

What are some drugs that may worsen heart failure?

A

DI NATION
D - DPP4i (Gliptins)
I - Immunosuppressants (TNF inhibitors)
N - Non-DHP CCB (verapamil, diltiazem)
A - Antiarrhythmics
T - Thiazolidinediones (Pioglitazone)
I - Itraconazole
O - Oncology: Anthracyclines (Doxorubicin, Daunorubicin)
N - NSAIDs

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7
Q

First-line medications for HFrEF

A

1) ACE/ARB alone, OR ANRI (Preferred)
2) Aldosterone Receptor Blocker
3) Beta Blocker (Metoprolol succinate, Bisoprolol, Carvedilol)
4) SGLT2i (Dapa, Epagli)

+- Loop Diuretic

*Titrate all 4 drug classes to target doses

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8
Q

What are the optional add-on medications for HFrEF?

A

Based on symptomatic or worsening HF, we can add the following for specific groups:
1) Hydralazine & Nitrate (Black patients)
2) Ivabradine (HR >70 on max BB dose)
3) Digoxin
4) Vericiguat (Worsening HF)

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9
Q

Switching from an ACE to ARNI

A

36 washout period to decrease risk of Angioedema

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10
Q

What is the target dose of Sacubitril/Valsartan (Entresto)?

A

97/103 mg BID

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11
Q

What is the MAX target dose of ACEi?

A

Ramipril (Altace): 10 mg QD
Enalapril (Vasotec): 20 mg BID
Quinapril (Accupril): 20 mg BID
Lisinopril (Zestril): 40 mg QD

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12
Q

What is the target dose of ARB?

A

Losartan (Cozaar): 150 mg QD
Valsartan (Diovan): 160 mg BID

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13
Q

What are the target dose of Beta Blockers used in HFrEF?

A

1) Metoprolol succinate (Toprol XL) 200 mg QD
2) Bisoprolol
3) Carvedilol (Coreg)
IR:
< 85 kg: 25 mg BID
> 85 kg: 50 mg BID

XL: 80 mg QD

*Do not discontinue abruptly, taper off over 1-2 weeks
*Caution with use in patients with DM1: it can mask symptoms
*Caution with use in patients with COPD and Asthma. Metoprolol and Bisoprolol preferred since these are B1 selective. Carvedilol is non-selective (B1, B2, A1).

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14
Q

What are the Aldosterone Receptor Blockers?

A

Spironolactone (Aldactone): 25-50 mg QD
Eplerenone

*These increase potassium retention in the body.
*Contraindication: Addison’s disease

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15
Q

What are the target doses of SGLT2i in HFrEF?

A

Dapagliflozin (Farxiga) 10 mg daily
Empagliflozin (Jardiance) 10 mg daily

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16
Q

What are the Loop Diuretics used in HFrEF?

A

1) Bumetanide (Bumex) - most potent!
2) Torsemide
3) Furosemide (Lasix)
4) Ethacrynic Acid

17
Q

Loop Diuretic IV:PO conversion

A

1) Bumetanide (Bumex) 1 mg (1:1)
2) Torsemide 20 mg
3) Furosemide (Lasix) 40 mg (1:2)

*These 3 agents have SULFA Allergy! Ethacrynic acid is expensive and is reserved for patients who have a true sulfa allergy to the above medications.
*Ototoxicity

18
Q

What are the side effects of Loop Diuretics?

A

-Decreased: Na, K, Cl, Mg, Ca
-Increased: TG, cholesterol, bicarbonate, Uric Acid, BG
-Photosensitivity

19
Q

Mechanism of Action of Hydralazine/Isosorbide dinitrate (BiDil)

A

Hydralazine is an arterial vasodilator.
Isosorbide Dinitrate is a venous vasodilator.

*Shows benefit in Black patients

20
Q

What is Digoxin MOA?

A

It inhibits Na/K ATPase pump to overall improve symptoms.

Typical Dose: 0.125-0.25 mg PO daily
Reduced Dose: 0.125 mg PO daily

21
Q

What is the therapeutic range of Digoxin?

A

0.5 - 0.9

22
Q

Symptoms of Digoxin toxicity

A

Antidote: Digifab

GI: N/V, loss of appetite
Visual: Blurred, double
Heart: Bradycardia, Arrythmias

23
Q

What is the preferred potassium supplementation in patients with Hypokalemia?

A

Potassium Chloride

24
Q

Types of Stroke

A

Ischemic (88%) - Due to blockage
Hemorrhagic - Due to breakage of BP, usually HTN caused

25
Q

What are the modifiable risk factors of Stroke?

A

1) Hypertension
2) Smoking
3) Diabetes
4) Dyslipidemia
5) Sedentary Lifestyle

26
Q

What are the non-modifiable risk factors of Stroke?

A

1) Age > 55
2) Sex: Females>Males
3) Atherosclerosis
4) Prior stroke or TIA
5) Sickle Cell Disease

27
Q

Stroke Symptoms: FAST

A

F: Face drooping
A: Arm weakness
S: Speech difficulty
T: Time to call 911

Upon arrival to the hospital, brain imaging (CT or MRI) is usually done within 20 mins to assess whether there has been bleeding. (hemorrhage)

28
Q

How does Alteplase (Activase) work?

A

[Fibrinolytic]

Alteplase is a recombinant tissue plasminogen activator (tPA). It binds to fibrin in a thrombus (clot) and converts plasminogen to plasmin, resulting in fibrinolysis.

Tenecteplase is sometimes used off-label.

29
Q

When can we use Alteplase?

A

1) If there is no bleeding, and
2) Symptoms onset is within 3 hours, and
3) Alteplase is administered within 60 minutes of hospital arrival

Do not administer if there is a current active bleed.

If the patient has severe HTN (BP > 185/110), lower BP first.

30
Q

Alteplase Contraindications

A

1) Active Bleed
2) History of recent stroke or head trauma within the last 3 months
3) BP > 180/110
4) INR > 1.7, aPTT > 40 sec, Platelets < 100,000, BG < 50
5) Treatment dose LMWH in past 24 hrs
6) Direct thrombin or direct Xa inhibitor in past 48 hrs

31
Q

What is the dose of Alteplase for Stroke Patients?

A

0.9 mg/kg (MAX 90 mg)

10% is given as a bolus, and the remainder is given over an hour

32
Q

Other treatment for Stroke

A

1) Aspirin 162-325 mg PO within 24-48 hours after a stroke. Do NOT give it within 24 hour after a fibrinolytic.

2) Blood pressure management. Those that didn’t receive alteplase, permissive hypertension is allowed.

3) Blood glucose control

4) DVT Prophylaxis

33
Q

Secondary Prevention/Treatment of Modifiable risk factors

A

Treatment in the outpatient chapter:

1) BP target <130/80 [Thiazides, ACE/ARB]
2) Dyslipidemia [High intensity statin]
3) Diabetes [GLP1/SGLT2i]
4) Antiplatelet Med [ASA/Plavix/ASA-Dipyridamole ER]
*DAPT can be used together for 21-90 days

Antiplatelet therapy is continued for life. There is no benefit of increasing the dose of aspirin if the patient was previously on it before the stroke.

34
Q

What is the mechanism of action of Aspirin?

A

COX 1 & 2 inhibitor leading to decreased prostaglandin and thromboxane A2.

35
Q

Contraindication of Aspirin

A

1) NSAID or Salicylate Allergy
2) Children and teens with viral infection

36
Q

What are the drugs which gives an additive bleed risk?

A

Anticoagulants
NSAIDs
SSRI
SNRI

37
Q

What are the treatment options for a Hemorrhagic Stroke?

A

1) Reverse anticoagulation
2) Treat seizures
3) Decrease ICP by bed elevation, hyperosmolar therapy (Mannitol, Hypertonic Saline]