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PHM601 UB Pharmacy > Ischemic Heart Disease (CCD, ACS, PAD) > Flashcards

Ischemic Heart Disease (CCD, ACS, PAD) Flashcards

1
Q

P2Y12 inhibitor that is reversible

A

Ticagrelor

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2
Q

Oral P2Y12 inhibitors with the quickest onset of action (2)

A

Ticagrelor, Prasugrel

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3
Q

Primary metabolism pathway for Ticagrelor

A

3A4

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4
Q

P2Y12 inhibitors that are prodrugs (2)

A

Clopidogrel, Prasugrel

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5
Q

P2Y12 inhibitors that are irreversible

A

Clopidogrel, Prasugrel

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6
Q

Clopidogrel and Prasugrel bind at what receptor

A

ADP-binding

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7
Q

Absolute contraindication for prasugrel

A

history of stroke/TIA

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8
Q

Absolute contraindication for ticagrelor

A

history of cerebral bleed and severe liver disease

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9
Q

Clopidogrel is metabolized by

A

a 2-step process involving 2C19

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10
Q

When should you discontinue clopidogrel before surgery?

A

5 days before

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11
Q

When should you discontinue prasugrel before surgery?

A

7 days before

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12
Q

Clopidogrel loading dose

A

300-600 mg

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13
Q

Clopidogrel loading dose with lytic

A

/< 75 years: 300 mg
> 75 years: 75 mg

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14
Q

What is the maintenance dose of Clopidogrel?

A

75mg daily

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15
Q

Ticagrelor loading dose

A

180 mg

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16
Q

Ticagrelor maintenance dose

A

90 mg twice daily

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17
Q

Prasugrel loading dose

A

60 mg

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18
Q

Prasugrel maintenance dose

A

10 mg daily

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19
Q

Prasugrel relative contraindications

A

< 60 kg, > 75 years of age

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20
Q

O (acute treatment)

A

Oxygen- provide if O2 sat <90%

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21
Q

S (acute/chronic treatment)

A

Statin- start or continue a high intensity statin (Atorvastatin 40-80 mg or Rosuvastatin 20-40 mg)

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22
Q

N (acute/chronic treatment)

A

Acute - Nitroglycerin- SL NTG every 5 minutes for 3 times and if chest pain is still ongoing then we can consider IV NTG
Chronic - send home with Rx for sublingual nitroglycerin

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23
Q

A (acute/chronic treatment)

A

Aspirin- loading dose of 162-325 mg should be given in a chewable non-enteric coated tablet

24
Q

A (acute ONLY treatment)

A

Anticoagulant- IV unfractionated heparin for 48 hours or until PCI can be performed or SQ Enoxaparin for the duration of hospitalization or until PCI is performed

25
Q

P (acute/chronic treatment)

A

P2Y12 inhibitor LOAD (acute)- Ticagrelor (180 mg), Prasugrel (60 mg), Clopidogrel (300-600 mg) are given as loading doses in acute treatment
P2Y12 inhibitor MAINTENANCE (chronic) - ticagrelor 90 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily

26
Q

B (chronic treatment)

A

Beta Blockers (Longterm Treatment) Patient on Beta Blocker at least 3 years/Indefinitely
All beta blockers are okay
Heart Failure With reduced Ejection Fraction: Metoprolol Succinate, Carvedilol, Bisoprolol

27
Q

A (chronic treatment)

A

ACE/ARB (Longterm Treatment): Patient is on indefinitely
If possible, all patients
Patients with LVEF <40%
Patients with HTN, DM, stable CKD

28
Q

M (chronic treatment)

A

Mineralocorticoid Receptor Antagonist (Longterm Treatment): Should be on indefinitely
Drugs: Spironolactone or Eplerenone
Patients with EF <40% (on ACE and Beta Blocker)
Contraindications: Serum Creatine: >2.5 mg/dl men and women >2.0 mg/dL-Potassium: >5mEq/L

29
Q

Medications with Cardiovascular and Diabetes benefit

A

GLP1 Agonists
SGLT2 inhibitors

30
Q

Chronic coronary disease includes what patients?

A
  1. Patients with stable angina
  2. Patients discharged after ACS
  3. Patients with atherosclerosis diagnosed via screening
31
Q

What is the goal of therapy for patients diagnosed with CCD?

A

Prevent development of major adverse cardiovascular event (MACE) like a myocardial infarction (ACS), stroke, or death due to cardiovascular causes

32
Q

What non-pharmacological management should occur for patients with CCD?

A
  1. Multidisciplinary approach
  2. Individualized education
  3. Assessment of SDOH
  4. Diet and physical activity
  5. Tobacco cessation
  6. Alcohol limitations
  7. Attempt to avoid - cocaine, methampheatmines, opioids, marijuana
33
Q

What lipid therapy should occur for patients with CCD not at very high risk?

A
  1. High intensity statin, LDL-C reduction at least 50%
  2. If high-intensity is not tolerate, moderate intensity is recommended
  3. Max statin and LDL-C > 70 > add ezetimibe
  4. On max tolerated statin and LDL-C < 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
34
Q

What lipid therapy should occur for patients with CCD at very high risk?

A
  1. High intensity statin, LDL-C reduction at least 50%
  2. Max statin and LDL-C > 70 > add ezetimibe
  3. On max tolerated statin and LDL-C < 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
  4. If on max LDL-C lowering therapy and LDL-C 70 or greater or non-HDL above 100, a PCSK9 inhibitor can be beneficial
35
Q

What antiplatelet therapy should a patient with CCD and no history of PCI receive?

A

Aspirin 81 mg daily

36
Q

What antiplatelet therapy should a patient with CCD and a PCI receive?

A

DAPT for 1-6 months, then SAPT

37
Q

What antiplatelet therapy should a patient with CCD and a CABG receive?

A

DAPT

38
Q

Use this for intermittent anginal symptoms

A

SL Nitroglycerin

39
Q

How do Beta-blockers work to decrease anginal pain?

A

Decreases HR and contractility, which results in a decrease in O2 demand (GOAL: HR: 50-60bpm; exercise HR: 100bpm)
Antiarrhythmic and slow progression of plaque

40
Q

Beta-blockers adverse effects

A

bradycardia, heart block, worsening HF, bronchospasm, cold extremities, fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence

41
Q

Beta-blocker pearls

A

Must be tapered upon discontinuation
Mortality benefit in HFrEF: bisoprolol, metoprolol succinate, carvediol
Do not initiate while a heart failure exacerbation
Reduce dose if pt experiencing exacerbation (try not to discontinue)

42
Q

How to CCBs work for anginal symptoms?

A

Both DHP and non-DHP work
Non-DHP: decreased HR and contractility → decreased O2 demand
DHP: decreased afterload → decrease O2 demand

43
Q

Avoid Non-DHP CCB in these scenarios

A

Concomitant beta-blocker, Severe LV dysfunction

44
Q

When do you use ranolazine for angina?

A

Add on therapy or Patients who need an anti-anginal that has no impact on HR/BP

45
Q

Ranolazine MOA

A

MOA: inhibits persistent/late inward Na+ current in the ventricles; also has anti-ischemic activity related to reduced accumulation of intracellular calcium.

46
Q

Ranolazine adverse effect

A

QT prolongation

47
Q

Ranolazine metabolism

A

CYP3A4, 2D6, pGp

48
Q

How do we diagnose PAD?

A

ABI (ankle brachial index) -> ratio of blood pressure in ankles:arms < 0.9

49
Q

When is Cilostazol recommended in PAD?

A

To manage symptoms and improve walking distance

50
Q

What are the adverse effects of cilostazol? Why does this happen?

A

Headache GI upset/diarrhea= lots of vasodilation

51
Q

How long does Cilostazol take to work

A

2-4 weeks or up to 12 weeks.

52
Q

Cilostazol BBW

A

Contraindicated in patients with heart failure

53
Q

For long-term treatment of PAD what drugs should be given to ALL patients?

A
  1. Statin
  2. BP control (ACEI/ARB preferred)
54
Q

When is DAPT recommended in PAD?

A

After revascularization (aspirin + clopidogrel)

55
Q

What medication should be given to all patients with acute limb ischemia?

A

Heparin

PHM601 UB Pharmacy (6 decks)

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