Module 13: Angina, Arrythmias & Anticoagulation (b)

Question 1

ACC/AHA 2019 Guideline’s for Stable Ischemic Heart Dz

Answer 1

1. All Pt’s w/ SIHD should be on:
   - Anti-platelet therapy
   - Address modifiable risk factors — smoking, weight loss, exercise
2. Optimize therapy for:
   - HTN
   - Dyslipidemia
   - DM

Question 2

ACC/AHA 2019 Guideline Overview

-Angina Sx Mgmt

Answer 2

1. Patients w/ Angina:
   - UNIVERSAL — Anti-platelet therapy & Short acting nitroglycerin for relief of acute episodes
   - FIRST LINE — Beta blocker if no contraindication — Compelling indications include — MI & Heart Failure

• SECOND LINE — If Sx’s persist or there is a contraindication to BB — Sub for CCB and/or long acting nitrate
• THIRD LINE — Ranolazine (Ranexa) — antianginal which inhibits late sodium current; significant drug-drug interactions. *

Question 3

Angina

-Goals of therapy

Answer 3

1. Short term — Relief of ACUTE angina — Use NITRATES
2. Long Term — Nitrates, BBs, CCBs, anti-platelets
   - Prevention of angina episodes
   - Prevent progression of atherosclerosis
   - Reduce risk of MI
   - Improve functional capacity
   - Prolong survival

Question 4

Antiplatelet Therapy — 2021 USPSTF REC

-ASA

Answer 4

1. Adults aged 40-59 years
   - Consider use of low-dose ASA (75-100mg PO qDay) if at higher risk for ASCVD, but not at increased bleeding risk
2. Adults aged >60 years
   - Do not routinely administer for prevention of ASCVD

Question 5

Rapid Acting Nitrate

-Nitroglycerin NTG

Answer 5

1. Onset is 1-5 minutes
2. Half life 3-4 minutes
3. Duration is 30-60 minutes

-Can hasten onset by sitting, leaning forward, breathing deeply, & valsalva

Question 6

Angina First-Line Tx

-Beta Blockers

Answer 6

1. Decrease cardiac workload and myocardial O2 demand
2. Particularly helpful for exertional angina/exercise tolerance
3. Complimentary to long acting nitrates — potentiate MOA and help correct rebound tachycardia

Question 7

Beta Blockers Reminders*

Answer 7

1. Mortality benefit for post-MI and CAD
2. Caution in HF exacerbation; pulmonary disease
3. AVOID abrupt discontinuation

Question 8

Angina Second-Line Tx

-CCBs

Answer 8

1. Relaxation of smooth muscle, primarily arteries — CCBs DO NOT reduce preload**
2. May also assist w/ exertional angina/exercise tolerance
3. Dihydropyridine CCBs — Good for patient who needs concomitant BP control
   —Non-DHPs — Good for patient who needs RATE control of arrhythmia
4. AVOID in heart failure
   - Watch for edema
   - Watch for cumulative bradycardia effect w/ BBs

Question 9

Angina Second-Line Tx

-Long Acting Nitrates

Answer 9

1. Start w/ low dose — advance dose q1-2 weeks

2. Some Nitrate S/Es will abate after 1-2 wks of therapy — rebound tachycardia may occur

Question 10

Angina Second-Line Tx

-Long acting Nitrate meds?

Answer 10

1. Isosorbide Mononitrate (Imdur)
   —Extended release, less frequent dosing
   —Take on an empty stomach (1-2 hrs after food)
2. OFF TIME**
   - To prevent tolerance, make sure pt has 10-12 hours nitrate free per 24 hours
   - Continuous nitrate use can lead to tolerance

Question 11

Atrial Fibrillation

-Rate Vs Rhythm control?

Answer 11

1. Rhythm Control — Associated w/ SIGNIFICANT A/Es w/ need for frequent monitoring
2. Rate Control — Beta blockers and Non-DHP CCBs — safer and easier to prescribe/take **

Question 12

Arrhythmia Tx

-Amiodarone (Cardorone)

Answer 12

1. Class 3 on the Vaughan Williams classifications — Potassium channel blocker
2. Used for supra-ventricular and ventricular arrhythmia — Safe for structural heart disease
3. Pt’s undergo “Loading” inpatient, then take Maintenence doses
4. Drug can accumulate and cause A/Es systemically — check TSH, LFT’s q6 months
5. MANY drug/drug interactions — Can increase INR by 200% when taking warfarin — Review ALL Rx’s prior to starting **

Question 13

Arrhythmia Tx

-Sotalol (Betapace)

Answer 13

1. Class III — Potassium channel blocker
2. Treats supra-ventricular and ventricular arrhythmia — May reduce arrhythmia and device d/c in ICD patients
3. Significant QT prolongation — EKGs between cards appointments — Avoid meds that prolong QT interval
4. Renal elimination — Follow Renal function and electrolytes (Potassium/magnesium)

Question 14

Arrhythmia Tx

-Digoxin

Answer 14

1. Not included in Vaughan Williams Taxonomy
2. Works at AV node and may provide rate control in Atrial Fib.
3. Positive inotrope —can be good fit w/ HF
4. Relatively narrow therapeutic window
5. Toxicity s/Sx’s — Heart block, ventricular arrhythmia, visual disturbance, dizziness, weakness, N/V/D, anorexia
6. Toxicity affected by Metabolism (frequent drug-drug interactions) & elimination (renal; caution w/ CKD or AKI)

Question 15

Anticoagulation

-Indications?

Answer 15

1. Primary & secondary prevention of MI and CVA
2. Arrhythmia — CVA prevention — Annual failure rate of rhythm/rate control can be as high as 35-60% — ALL should have Anticoagulation
3. Mechanical heart valve/valvular disease
4. Thromboembolism
5. Post-stenting

Question 16

Anticoagulation

-ASA

Answer 16

1. Irreversibly modifies and binds COX enzyme; this has the effect of inhibiting prostaglandin synthesis
2. Can cause dyspepsia, heartburn, tinnitus

A/Es

• ASA increases upper GI bleed risk 2-to-4-fold.
• Enteric coated is NO better for bothersome GI effects

Question 17

Anticoagulation

-Secondary Prevention ASA

Answer 17

1. ALL patients post-MI and post-CVA should take ASA for secondary prevention
   - Lower doses are just as effective as higher doses

Question 18

Anticoagulation

-Primary Prevention of ASCVD w/ ASA

Answer 18

1. Benefits
   - A little ASCVD/MI/CVA reduction
   - A little cancer prevention, particularly colorectal
2. Risks
   - GI bleed
   - Beer’s criteria for patients over 80 y/o d/t bleed risk and uncertain benefit

Question 19

Anticoagulation

-Clopidogrel (Plavix)

Answer 19

1. Class P2Y12 receptor blocker — Inhibits adenosine DI phosphate which promotes PLT receptor binding
   —A/Es — Dyspepsia N/D
2. Dual Anti-platelet therapy w/ ASA and clopidogrel for
   - Post-stent w/ bare metal or drug eluding stents for 12 months or more
   - Secondary prevention of ACS/CVA
3. Use Clopidogrel alone in
   - Secondary prevention of ACS/CVA
4. DO NOT use PPIs w/ clopidogrel — Risk for coronary events which was DISPROVEN — OKAY now to take both
5. DO NOT use Plavix in patient with platelet reactivity on genetic test

Question 20

Anticoagulation

-P2Y12 receptor blocker examples

Answer 20

1. Prasugrel (Effient)
2. Ticagrelor (Brilinta)
3. Ticlopinide (Ticlid)

• ALL are indicated for stent-related thrombus prevention post-stenting
• Alt for Pt’s w/ poor anti-platelet activity w/ Plavix

Question 21

Anticoagulation

-Warfarin (Coumadin)

Answer 21

1. Competitively binds to vitamin K, inhibiting Vit K dependent coagulation — Antidote is VITAMIN K
2. Coumadin is highly protein bound w/ narrow therapeutic index
3. FREQUENT monitoring of
   - Blood levels (INR)
   - Adherence to medication/diet
   - Risk of bleeding vs benefit

Question 22

Anticoagulation

-Warfarin (Coumadin) Therapeutic Targets

Answer 22

1. INR targets
   - A Fib — Hx of VTE: INR 2.0-3.0
   - Most prosthetic heart valves: INR 2.5-3.5
2. D/t pharmacokinetics/Narrow therapeutic index — Use BRAND product for consistency
   —Dose at BEDTIME to minimize drug/food interactions
3. Contraindications
   - Pregnancy
   - Hemorrhage (recent)
   - Risk of major bleed
   - Recent Trauma

Question 23

Anticoagulation

-Warfarin (Coumadin) Initiating Therapy

Answer 23

1. Start w/ 4-5 mg
2. First check 3-5 days; titrate to target IRN
3. Constant adjustment throughout treatment required — Think “total weekly dose” when adjusting dose

Question 24

Anticoagulation

• Direct Oral Anti-Coagulats (DOACs)
• Novel Oral Anti-Coagulants (NOACs)

Answer 24

1. Dabigatran (Pradaxa)
2. Apixaban (Eliquis)
3. Rivaroxaban (Xarelto)
4. Edoxaban (Savaysa)

In 2019, ACC/AHA suggest DOACs/NOACs be used as FIRST LINE therapy for thrombus prevention in A-fib

Question 25

Anticoagulation

-Apixaban (Eliquis)

Answer 25

1. Factor Xa inhibition
2. Indicated for — Non-valvular Afib, VTE, DVT, PE
3. Contraindicated for CrCl <30
4. Reversal agent — Andexanet (Andexxa)

Question 26

Anticoagulation

-Rivaroxaban (Xarelto)

Answer 26

1. Factor Xa inhibition
2. Indicated for NON-Valvular Afib, VTW, DVT, PE & DVT prophylaxis knee/hip replacement
3. Contraindicated for CrCl <15 — Administer w/ meal
4. Reversal agent — Andexanet (Andexxa)

Question 27

Anticoagulation

-Dabigatran (Pradaxa)

Answer 27

1. Directly and reversible inhibits thrombin **
2. Indicated for NON-Valvular Afib, VTE, DVT, PE
3. Reversal agent — Idarucizumab (Praxbind)
4. Requires renal dosing and contraindicated for CrCl <15

**LEAVE MED in original bottle (Opaque white bottle) ** Can be easily denatured by the light

Question 28

Anticoagulation

-Edoxaban (Savaysa)

Answer 28

1. Factor Xa Inhibition
2. Indicated for NON-valvular AF, VTE, DVT, PE
3. DO NOT USE w/ CrCl >95*** or <15
4. Reversal agent — Andexanet (Andexxa)

Question 29

Anticoagulation

-For Venousthromboembolism (VTE), DVT and/or PE

Answer 29

1. Current Standard — Use lovenox followed by DOAC or warfarin
   —Or use DOAC in office
2. Duration of therapy
   - First event known cause - 3 months
   - First event, idiopathic or cancer >3 months and refer out
   - Recurrent - Use indefinitely