Heart Attack, Stroke Flashcards
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
Diagnosis criteria of Heart Failure
Lab:
BMP > 100
Echo (preferred)
Heart failure categories
HFpEF: >= 50%
HFrEF: <= 40%
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
What are some Natural Products that may be beneficial in Heart Failure?
1) Omega-3 fatty acids
2) Coenzyme Q10
3) Hawthorne
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
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
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)
Switching from an ACE to ARNI
36 washout period to decrease risk of Angioedema
What is the target dose of Sacubitril/Valsartan (Entresto)?
97/103 mg BID
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
What is the target dose of ARB?
Losartan (Cozaar): 150 mg QD
Valsartan (Diovan): 160 mg BID
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).
What are the Aldosterone Receptor Blockers?
Spironolactone (Aldactone): 25-50 mg QD
Eplerenone
*These increase potassium retention in the body.
*Contraindication: Addison’s disease
What are the target doses of SGLT2i in HFrEF?
Dapagliflozin (Farxiga) 10 mg daily
Empagliflozin (Jardiance) 10 mg daily
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]
