Heart Attack, Stroke Flashcards by Navita Ramdin

Signs and Symptoms of Heart Failure

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

Pulmonary Congestion: Cough, rales, S3 gallop

Systemic Congestion: Peripheral edema, ascites, hepatomegaly

How well did you know this?

Not at all

Perfectly

Diagnosis criteria of Heart Failure

Lab:
BMP > 100
Echo (preferred)

How well did you know this?

Not at all

Perfectly

Heart failure categories

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

How well did you know this?

Not at all

Perfectly

Heart Failure Classification

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What are some drugs that may worsen heart failure?

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

How well did you know this?

Not at all

Perfectly

First-line medications for HFrEF

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

How well did you know this?

Not at all

Perfectly

What are the optional add-on medications for HFrEF?

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)

How well did you know this?

Not at all

Perfectly

Switching from an ACE to ARNI

36 washout period to decrease risk of Angioedema

How well did you know this?

Not at all

Perfectly

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

97/103 mg BID

How well did you know this?

Not at all

Perfectly

What is the MAX target dose of ACEi?

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

How well did you know this?

Not at all

Perfectly

What is the target dose of ARB?

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

How well did you know this?

Not at all

Perfectly

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

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).

How well did you know this?

Not at all

Perfectly

What are the Aldosterone Receptor Blockers?

Spironolactone (Aldactone): 25-50 mg QD
Eplerenone

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

How well did you know this?

Not at all

Perfectly

What are the target doses of SGLT2i in HFrEF?

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

How well did you know this?

Not at all

Perfectly

What are the Loop Diuretics used in HFrEF?

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

Loop Diuretic IV:PO conversion

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

What are the side effects of Loop Diuretics?

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

Mechanism of Action of Hydralazine/Isosorbide dinitrate (BiDil)

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

*Shows benefit in Black patients

What is Digoxin MOA?

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

What is the therapeutic range of Digoxin?

0.5 - 0.9

Symptoms of Digoxin toxicity

Antidote: Digifab

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

What is the preferred potassium supplementation in patients with Hypokalemia?

Potassium Chloride

Types of Stroke

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

What are the modifiable risk factors of Stroke?

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

What are the non-modifiable risk factors of Stroke?

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

Stroke Symptoms: FAST

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)

How does Alteplase (Activase) work?

[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.

When can we use Alteplase?

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.

Alteplase Contraindications

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

What is the dose of Alteplase for Stroke Patients?

0.9 mg/kg (MAX 90 mg) 10% is given as a bolus, and the remainder is given over an hour

Other treatment for Stroke

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

Secondary Prevention/Treatment of Modifiable risk factors

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.

What is the mechanism of action of Aspirin?

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

Contraindication of Aspirin

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

What are the drugs which gives an additive bleed risk?

Anticoagulants NSAIDs SSRI SNRI

What are the treatment options for a Hemorrhagic Stroke?

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