Heart Attack, Stroke

Question 1

Signs and Symptoms of Heart Failure

Answer 1

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

Pulmonary Congestion: Cough, rales, S3 gallop

Systemic Congestion: Peripheral edema, ascites, hepatomegaly

Question 2

Diagnosis criteria of Heart Failure

Answer 2

Lab:
BMP > 100
Echo (preferred)

Question 3

Heart failure categories

Answer 3

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

Question 4

Heart Failure Classification

Answer 4

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

Question 5

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

Answer 5

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

Question 6

What are some drugs that may worsen heart failure?

Answer 6

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

Question 7

First-line medications for HFrEF

Answer 7

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

Question 8

What are the optional add-on medications for HFrEF?

Answer 8

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)

Question 9

Switching from an ACE to ARNI

Answer 9

36 washout period to decrease risk of Angioedema

Question 10

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

Answer 10

97/103 mg BID

Question 11

What is the MAX target dose of ACEi?

Answer 11

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

Question 12

What is the target dose of ARB?

Answer 12

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

Question 13

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

Answer 13

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).

Question 14

What are the Aldosterone Receptor Blockers?

Answer 14

Spironolactone (Aldactone): 25-50 mg QD
Eplerenone

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

Question 15

What are the target doses of SGLT2i in HFrEF?

Answer 15

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

Question 16

What are the Loop Diuretics used in HFrEF?

Answer 16

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

Question 17

Loop Diuretic IV:PO conversion

Answer 17

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

Question 18

What are the side effects of Loop Diuretics?

Answer 18

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

Question 19

Mechanism of Action of Hydralazine/Isosorbide dinitrate (BiDil)

Answer 19

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

*Shows benefit in Black patients

Question 20

What is Digoxin MOA?

Answer 20

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

Question 21

What is the therapeutic range of Digoxin?

Answer 21

0.5 - 0.9

Question 22

Symptoms of Digoxin toxicity

Answer 22

Antidote: Digifab

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

Question 23

What is the preferred potassium supplementation in patients with Hypokalemia?

Answer 23

Potassium Chloride

Question 24

Types of Stroke

Answer 24

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

Question 25

What are the modifiable risk factors of Stroke?

Answer 25

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

Question 26

What are the non-modifiable risk factors of Stroke?

Answer 26

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

Question 27

Stroke Symptoms: FAST

Answer 27

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)

Question 28

How does Alteplase (Activase) work?

Answer 28

[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.

Question 29

When can we use Alteplase?

Answer 29

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.

Question 30

Alteplase Contraindications

Answer 30

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

Question 31

What is the dose of Alteplase for Stroke Patients?

Answer 31

0.9 mg/kg (MAX 90 mg)

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

Question 32

Other treatment for Stroke

Answer 32

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

Question 33

Secondary Prevention/Treatment of Modifiable risk factors

Answer 33

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.

Question 34

What is the mechanism of action of Aspirin?

Answer 34

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

Question 35

Contraindication of Aspirin

Answer 35

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

Question 36

What are the drugs which gives an additive bleed risk?

Answer 36

Anticoagulants
NSAIDs
SSRI
SNRI

Question 37

What are the treatment options for a Hemorrhagic Stroke?

Answer 37

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