Pharm Cardiology Exam 2 Flashcards
Weight loss lowers SBP in HTN by
5 mmhg
Healthy Diet lowers SBP in HTN by
11 mmhg
DASH
Reduced sodium lowers SBP in HTN by
5/6 mmhg
Aerobic physical activity lowers SBP in HTN by
5/8 mmhg
Lowering alcohol intake lowers SBP in HTN by
4 mmhg
1st line HTN Meds
ABCD ACE/ARB Beta Blocker (only if HFrEF, MI or CAD) CCB (dipines) (amlodipine) Diuretics (low dose HCTZ)
Angiotensinogen pathway
RAAS
Liver makes angiotensinogen Kidney makes Renin Renin makes angiotensin I Lungs make ACE Ace makes Angiotensin II Angiotensin II Receptor Vessels, Heart, Kidneys, CNS
Renin inhibitor,
ACE inhibitor,
Angiotensin II receptor blocker (ARB)
Amlodipine
Norvasc (CCB)
HTN
5mg QD
Contra:
Obstructive coronary disease, aortic stenosis, CHF
Interactions
May be potentiated by CYP3A inhibitors
Adverse:
Edema, Fatigue, drowsiness, palpitations, dizzy, nausea, flushing, abdominal pain
HCTZ
HTN (thiazide diuretic)
25mg QD
Contra:
Anuria, sulfa allergy
Warning:
Renal/hepatic impairment, arrhythmia, DM, Gout
Interactions
Digitalis, Lithium toxicity
Adverse
Electrolyte imbalance, hypokalemia, hyperkalemia, hyperuricemia
HCTZ vs Chlorthalidone
HCTZ has shorter half life
10-12 hours
Alpha 1 blockers
Associated with orthostatic hypotension
-zosin
Used in BPH
Alpha 2 agonists
stimulates alpha 2 in brain
decreases CO and PVR
Clonidine, methyldopa
Should be last line due side effects, cant discontinue suddenly
Clonidine
Sympatholytic Alpha 2 agonist for HTN, ADHD, anxiety, Withdrawal, migraine, menopausal flushing, diarrhea
Methyldopa
Pro drug used as sympathoplegic
Alpha 2 agonist
Gestational HTN
Significant side effects are Rebound HTN depression Sexual dysfunction Memory impairment tolerance
Direct acting vasodilators
Hydralazine
Sodium Nitroprusside
associated with sodium and water retention
Need to be used with diuretic and BB
Aliskiren
Direct renin inhibitor
HTN
Contraindications
ACE/ARB in diabetics
Warning
Fetal Toxicity
Indications for Systolic heart failure
ACE/ARB
BB
Diuretic
Aldosterone ag
Indications for Post MI
ACE
BB
ARB
Aldosterone ag
Indications for proteinuric CKD
ACE/ARB
Indications for Angina
BB,
CCB
Indications for A fib Rate control
BB,
CCB (Diltiazem/verapamil)
Indications for A flutter rate control
BB,
CCB (Diltiazem/verapamil)
Contraindications for Angioedema
ACE
Contraindications for Bronchospastic disease
BB
Contraindications for Depression
Reserpine
Contraindications for Liver disease
Methyldopa
Contraindications for Preganancy
ACE
ARB
Renin inhib
Contraindications for 2nd/3rd AV block
BB,
CCB (Diltiazem/verapamil)
Mean arterial pressure (MAP) reduction in HTN emergencies
Should be reduced by 10 - 20 percent in first hour then gradually during next 23 hours to a total of 25% of baseline
Otherwise can worsen organ ischemia
Common cause of HTN Emergency
Drugs that produce hyperadrenergic state Cocaine amphetamine PCP MAOI recent discontinuation of clonidine
Meds to use in HTN emrgencies
Sodium nitroprusside or nitro
CCB (clevidipne) (ultra short acting) (nicardipine)
Dopamine agonist - fenoldopam
BB - labetalol, esmolol, metoprolol
Nitroprusside indications
Vasodilator
HTN emergency
Caution with High ICP or azotemia
Nicardipine indications
CCB
HTN emergency
Not with acute heart failure
Caution with coronary ischemia
Nitro indications
Vasodilator
Coronary ischemia
Fenoldopam indications
Dopamine 1 agonist
HTN emergency
Caution with glaucoma
Hydralazine indications
Direct vasodilator
eclampsia
Fenoldopam
Dopamine Receptor agonist
Peripheral arteriolar dilator
for HTN Emergencies
For the in-hospital, short-term (up to 48 hours) management of severe hypertension when rapid, but quickly reversible, emergency reduction of blood pressure is clinically indicated, including malignant hypertension with deteriorating end-organ function.
Children: for the in-hospital, short-term (up to 4 hours) reduction in blood pressure.
Avoid in patients with glaucoma (Increased IOP)
Interactions: Avoid with BB
given with continuous IV infusion
Adverse
Reflex tachycardia, HA, Flushing
HTN in black patients
Monotherapy = CCB or thiazide
Dual therapy = CCB + ACE/ARB
If patient has edema or hypervolemia
ACE/ARB +Thiazide
If CCB+ Ace/ARB not working, add thiazide
next add spironolactone / eplerenone
HTN in pregnancy
Contraindicated Meds
ACE
ARB
direct renin inhibitors
HTN in pregnancy
For acute HTN lowering
IV labetalol or hydralazine
Treatment should begin when SBP >160
Classes
Labetalol class
Alpha and beta blocker
Hydralazine
Peripheral vasodilator
Nifedipine
CCB (dihydropyridine)
Methyldopa
Central acting alpha agonist
HTN in elderly
1st line Thiazide CCB ACE ARB
CCB & Thiazide works best in elderly
Treatment for orthostatic HTN
Fludrocortisone
Starting with low-dosefludrocortisone(0.1 mg/day) for patients with volume depletion and disabling symptoms despite nonpharmacologic measures.
A sympathomimetic pressor agent, such asmidodrineordroxidopa, can be added or substituted in patients who remain symptomatic on or cannot tolerate fludrocortisone.
Fludrocortisone
Corticosteroid
0.1 mg QD
up to
0.3 mg QD
Up titrate0.1mg every week as needed
Max dose 1mg per day
Taken with high salt diet and plenty of fluid
Adverse
Hypokalemia, ankle edema, CHF
Midodrine
Symptomatic orthostatic hypotension
Alpha adrenergic agonist
10mg TID
during daytime hours
Staring does is 2.5mg
Contra:
Severe heart disease, acute renal disease, urinary retention, Pheochromocytoma, thyrotoxicosis, excessive supine hypertension
Adverse
Paresthesia, piloerection, dysuria, pruritis, supine hypertension
MOA midodrine
Rapidly absorbed after PO
Metabolized in liver/ tissues
Activates a1 receptor causing vasoconstriction increased SBP/DBP while standing, sitting, supine
For postural hypotension after non pharm fails
Shock Tx
Vasopressors (alpha 1)
Norepi, epi, phenylephrine, dopamine
ADH Vasopressin: Pitressin, vasostrict
Inotrope Beta 1: Dobutamine
Inotrope PDE 3 inhib: Milrinone
Vasopressors
Alpha 1 adrenergic
Norepi (levophed)
Epi
Phenylephrine
Dopamine
Norepi
Levophed
Sympathomimetic
Contra:
Hypotension due to blood volume deficits except in emergencies, mesenteric or peripheral vascular thrombosis
Adverse:
Ischemic injury, Reflex bradycardia, arrhythmias, anxiety
EPI
Increase MAP in hypotension with shock
Sympathomimetic
Adverse
Anxiety, apprehensiveness, tremors, weakness, dizzy, sweating, palpitations
Phenylephrine
Hypotension resulting from vasodilation in the setting of anesthesia
Sympathomimetic
Adverse
NV, HA, vasoconstriction, ischemia, severe bradycardia, renal toxicity
Dopamine
Dopamine receptor and beta 1
at low dose it constricts vessels other than in kidney and brain
at high does it constricts all vessels
increases cardiac contractility and increases SBP
Used for shock related to under perfusion and reflex vasoconstriction
Used in renal failure with shock
Vasopressin
Vasostrict
Synthetic vasopressin
contra
Chlorobutanol allergy
Adverse
Decreased CO, bradycardia, tachyarrhythmias, hyponatremia, ischemia
Dobutamine
Dose = 2-20 mcg/kg/min (max 40)
Receptors B1, B2, A1
Adverse
Tachyarrhythmias, HTN, Hypotension, Nausea, HA
Milrinone
Reduces left ventricular filling pressure in chronic heart failure patients
May be the preferred inotropic drug for patients receiving BB as it does not use the Beta receptor to drive cardiac contractility.
(unlike dopamine and dobutamine)
Through its enhancement of cAMP may reduce pulmonary artery pressure via a vasodilator mechanism and therefore may improve right heart failure due to pulmonary hypertension
Statins
Atorvastatin Fluvastatin Lovastatin Pitavastatin Pravastatin Rosuvastatin Simvastatin
High intensity statins
Rosuvastatin 20-40mg
Atorvastatin 40-80mg
> 50% LDL reduction
Rosuvastatin, atorvastatin and simvastatin cause the greatest reduction in LDL
Atorvastatin
HMG-COA reductase inhibitor
Contraindications Active liver disease Unexplained elevated serum transaminases Pregnancy Nursing mothers
Bile acid sequestrants
Colesevelam binds with bile acids in the intestine to form an insoluble complex that is eliminated in feces.
This increased excretion of bile acids results in an increased oxidation of cholesterol to bile acid and a lowering of the serum cholesterol.
colesevelam
Pregnancy cat B
Contra
Hx of bowel obstruction, Serum TGL over 500, Hx of hyperTGL induced pancreatitis
Adverse
Constipation, nausea, dyspepsia, dysphagia, pancreatitis
Fibrates
Fenofibrate, Gemfibrozil
Adverse
Liver function tests increased (dose related; 3% to 13%; ALT/AST increased >3 x ULN: 5% to 13%)
Abdominal pain-5%; URI-6%
Can lower serum TGL up to 50% and
Raise serum HDL up to 20%
Fenofibrate
hypertriglyceridemia
Fibrate
Contra:
Hepatic/renal dysfunction, primary biliary cirrhosis, gallbladder disease
Adverse
myopathy, abnormal LFT’s, elevated CPK
Warnings
renal impairment, monitor CBC for 1 yr, monitor LFT’s, discontinue if >3 x normal
Interactions
Avoid statins, potentiates oral coags
Ezetimibe
Zetia (10mg QD)
Cholesterol absorption inhibitor
Interaction
Other fibrates except feonfibrate
Contra
with statin in active liver disease or unexplained elevations in serum transaminases
Adverse
Diarrhea 4%, Arthralgia 3%, URI 4%
Ezetimibe MOA
Cholesterol absorption inhibitors that impair dietary and biliary cholesterol absorption at the brush border of the intestine without affecting the absorption of triglycerides or fat soluble vitamin.
Statins in pregnancy
Statins are contraindicated in
pregnancy and nursing mothers
Lipid regulating agents
Omega 3 acid ethyl esters (Lovaza)
Icosapent ethyl (vascepa)
Omega 3 acid ethyl esters
(Lovaza)
Adjunct to diet to reduce very high TGL (>500)
Lipid regulating agent
Interaction
May potentiate anti coagulants (monitor)
Adverse
Eructation, dyspepsia, rash, taste perversion,
Increased ALT,AST,LDL
Icosapent ethyl
(vascepa)
Lipid regulating agent
Increased risk of bleeding with antithrombotics (ASA, Clopidogrel, warfarin etc.)
Adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adults with elevated triglyceride (TG) levels (≥150mg/dL) and established cardiovascular disease (CVD), or diabetes plus ≥2 additional CVD risk factors.
The effect of Vascepa on the risk for pancreatitis in patients with severe hypertriglyceridemia has not been determined.
Nicotinic acid
Niacin
Raises HDL up to 30-35%
by reducing lipid transfer of cholesterol from HDL to VLDL and by delaying HDL clearance
NO flush doesn’t work
Can use ASA 325mg 30 min / NSAID 200mg 60 min prior to reduce flush (reduce prostaglandin effect)
Sustained release can lead to Hepatotoxicity
Niacin Adverse
Can increase glucose levels worsening uncontrolled DM
Worst with Extended release tablets
Can cause hyperuricemia and lead to gout
can cause hypotension if on vasodilators and worsen unstable angina
can cause bleeding in patients with bleeding issues
PCSK9 Inhibitor
Proprotein convertase subtilisin/kexin type 9
Can lower LDL by 60% in patient on statins
Can reduce risk of CVA or MI
Alirocumab (praluent), Evolocumab (reptha)
PCSK9 inhibitor MOA
Proprotein convertasesubtilisin/kexintype 9 (PCSK9) is an enzyme produced in the liver.
PCSK9 binds to the low density lipoprotein receptor on the surface of hepatocytes,
leading to its degradation and higher plasma LDL-cholesterol (LDL-C) levels.
Blocking PCSK9 with antibodies leads to lower plasma LDL-C levels.
Alirocumab
PCSK9 Inhibitor
Warnings
2nd and 3rd trimester
Hypertriglyceridemia
All such patients should have LDL-C lowered with statin therapy if indicated.
Statins typically lower TG levels by 5 to 15 percent; however, high-intensity statin therapy can lower TGs by 25 to 30 percent
Hypertriglyceridemia over 885
For patients with TG levels persistently >885 mg/dL (10 mmol/L) after nonpharmacologic interventions,
we suggest starting drug therapy to lower the risk of pancreatitis.
We start treatment with a fibrate, which may lower TGs by up to 70 percent .
We choosefenofibraterather thangemfibrozildue to the likelihood of either concurrent or later use of a statin.
Gemfibrozil has a higher risk of muscle toxicity, especially when administered with many statins.
Hypertriglyceridemia between 150 and 885
if already taking statins
add icosapent ethyl (vascepa)
Which of the below HTN medications is not contraindicated in pregnant patients?
aliskiren (Tekturna)
lisinopril (Zestril)
valsartan (Diovan)
methyldopa (Aldomet)
methyldopa (Aldomet)
Which electrolyte disorders is sometimes associated with HCTZ?
Hypernatremia
Hypokalemia
Hyperkalemia
Hyponatremia
Hypokalemia
Which is not considered a first-line parenteral medication for HTN emergencies?
sodium nitroprusside (Nitropress)
clonidine (Catapress)
fenoldopam (Corlopam)
labetalol (Trandate)
clonidine (Catapress)
What is the common dosage for the drug flurdrocortisone (Florinef) for the initial treatment of orthostatic hypotension?
0.1 mg-0.2 mg once a day
0.2 mg-0.4 mg once a day
0.4 mg-0.8 mg once a day
1-2 mg once a day
0.1 mg-0.2 mg once a day
Which of the below medications is not considered a vasopressors (alpha-1 adrenergic?
norepinephrine (Levophed)
dobutamine (Dobutrex)
phenylephrine (Biorphen or Neo-Synephrine)
dopamine (Inotropin)
dobutamine (Dobutrex)
Which of the vasopressors is generally used for patients with shock and renal failure?
norepinephrine (Levophed)
dobutamine (Dobutrex)
phenylephrine (Biorphen or Neo-Synephrine)
dopamine (Inotropin)
dopamine (Inotropin)
Which of the following medications is considered a medication for high-intensity statin therapy for HLP?
pravastatin (Pravachol)
rosuvastatin (Crestor)
simvastatin (Zocor)
lovastatin (Mevacor)
rosuvastatin (Crestor)
Which drug is contraindicated for pregnant patients with hyperlipidemia?
atorvastatin (Lipitor)
omega-3 (Lovaza)
niacin (Niaspan)
colesevelam (Welchol)
atorvastatin (Lipitor)
Which drug is considered a cholesterol absorption inhibitor for HLP?
atorvastatin (Lipitor)
icosapent ethyl (Vascepa)
lomitapide mesylate (Juxtapid)
ezetimbe (Zetia)
ezetimbe (Zetia)
Which of the following is not a contraindication for the drug fenofibrate (Tricor)?
Hepatic dysfunction
Primary biliary cirrhosis
History of myocardial infarction
Gallbladder disease
History of myocardial infarction
Congenital disorders
Mostly surgical repair for all
Tetralogy of Fallot
Pulmonary atresia
Hypoplastic left heart syndrome
Transposition of great vessels
Prostaglandin E1 threrapy
Relaxes arterial smooth muscle, producing vasodilation
Helps keep Ductus open
If ductus is large
PGE1 can be started at low dose of
0.01mcg/kg per min
Alprostadil
Prostaglandin E1 (PDE1) Keep ductus arteriosus open
Warning
apnea, only use if ventilator is readily available
not recommended in respiratory distress syndrome
Adverse
Apnea, Hypotension, tachycardia, necrotizing enterocolitis, Deterioration, Transfer (apnea)
Tetralogy of Fallot (TOF)
4 components
VSD
Overriding aorta
Pulmonary (RV) outflow tract obstruction
RVH
Management of TOF
Severe RVOT obstruction – Neonates with severe RVOT obstruction may require intravenous prostaglandin therapy (alprostadil), ductal stenting, or palliative shunt placement to maintain adequate pulmonary blood flow pending surgical repair.
Heart failure symptoms – Patients with minimal obstruction and increased pulmonary blood flow may develop symptoms of heart failure and require pharmacologic treatment
(loop diuretic therapy anddigoxin).
NO ACE or ARB
Indomethacin
Indocin
Closes ductus
Adverse
Renal failure, electrolyte imbalance, GI bleed
MOA
NSAID
Accelerates maturation of germinal matrix microvasculature
Closes PDA by inhibiting COX enzyme that catalyzes prostaglandin precursor formation from arachidonic acid (70% of patients)
Acute infective endocarditis bug
Staph aureus and staph epidermis
Subacute infective endocarditis bug
Strep viridans
Infective endocarditis
Duke criteria
Major
Positive blood cultures of
S.Aureus, Strep viridans, Strep gallolyticus, HACEK, community acquired enterococcus
Persistently positive blood culture
New valvular regurgitation murmur
Coxiella burneti infection
Echo positive for vegetation
Prosthetic valve endocarditis Treatment
Synergistic interaction of a cell wall active agent (penicillin,ampicillin, orvancomycin)
and
an aminoglycoside (gentamicinorstreptomycin) if possible
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Oral
Amoxicillin
Oral
Amoxicillin
2G PO
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Unable to take oral meds
Ampicillin
Unable to take oral meds
Ampicillin
2G IM/IV
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Unable to take oral meds
Ceftriaxone/cefazolin
Unable to take oral meds
Ceftriaxone/cefazolin
1 Gm IM/IV
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
Cephalexin
Allergic to penicillin
Cephalexin
2gm PO
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
Clindamycin
Allergic to penicillin
Clindamycin
600mg PO
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
Azithromycin/clarithromycin
Allergic to penicillin
Azithromycin/clarithromycin
500mg PO
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
And unable to take oral medication
Cefazolin/Ceftriaxone
Allergic to penicillin
And unable to take oral medication
Cefazolin/Ceftriaxone
1 G IM/IV
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
And unable to take oral medication
Clindamycin
Allergic to penicillin
And unable to take oral medication
Clindamycin
600 mg IM/IV
Prevention of endocarditis prior to dental or respiratory procedure
Med/Dose
Allergic to penicillin
And unable to take oral medication
Vancomycin
Allergic to penicillin And unable to take oral medication Vancomycin 15-20 mg/kg IV 2g max
Acute pericarditis tx
In cases of pericarditis due to an identifiable cause (eg, bacterial infection or malignancy),
management is focused upon the underlying disorder and, if necessary, drainage of an associated pericardial effusion.
For nearly all patients with acute idiopathic or viral pericarditis, we recommend combination therapy withcolchicineplus nonsteroidal anti-inflammatory drugs (NSAIDs) rather than NSAIDs alone.
Ibuprofen or ASA + Colchicine
If glucocorticoid is needed
we suggest the use of moderate initial dosing (eg, 0.2 to 0.5 mg/kg/day ofprednisone) followed by a slow taper
Colchicine
Recurrent pericarditis
0.6mg PO BID-TID
Contra
Renal/hepatic impairment with use of CYP3A or P-glycoprotein inhibitors
Adverse
GI upset, abdominal pain
Pericardial effusion
US guided Pericardiocentesis
If reappears, repeat pericardiocentesis
Aortic aneurysm
for asymptomatic
control HTN with BB
Can use ACE/ARB if BB not tolerated
Can also add statin to help reduce aortic expansion
Arterial embolism/thrombosis
For those who present with acute limb ischemia, anticoagulation typically with a heparin (bolus followed by infusion)
and
intravenous fluid therapy should be immediately initiated prior to making plans for intervention.
Arterial embolism/thrombosis
with afib
Patients with ongoing atrial fibrillation and a prior embolic event are at a significantly increased risk of stroke or other embolic event and often warrant lifelong anticoagulation unless there is some other compelling factor.
For patients with coronary heart disease equivalents, treatment withaspirinand statins should be a component of their medical therapy.
Giant cell arteritis (GCA)
Glucocorticoid treatment is central to the management of giant cell arteritis (GCA, also known as Horton disease, cranial arteritis, and temporal arteritis).
If vision is intact at the time appropriate glucocorticoid treatment is initiated, the risk of sight loss is reduced to less than 1 percent.
Treatment should be initiated promptly once the diagnosis is confirmed or there is a high index of suspicion for GCA.
For patients without visual loss at presentation:prednisone1 mg/kg or equivalent, not to exceed 60 mg, given in a single daily dose
IF GCA relapses add tocilizumab
tocilizumab (Actemra)
Giant cell arteritis (Interleukin 6 antagonist)
in combination with steroids
Warning
Serious risk of infection
Interactions
Avoid live vaccines
Peripheral artery disease PAD
Claudication is associated with an increased risk of coronary, cerebrovascular, and renovascular disease, and peripheral artery disease (PAD) is considered to be a coronary heart disease risk equivalent.
To reduce the risk for cardiovascular disease progression and complications, we recommend a secondary prevention strategy that includes
antiplatelet therapy (aspirin75 to 162 mg/day orclopidogrel75 mg/day),
smoking cessation, control of blood sugar and blood pressure, lipid-lowering therapy, and dietary modification (as needed) to achieve the goals set in national guidelines.
For most patients with lifestyle-limiting claudication who do not have an improvement in symptoms with risk modification and exercise therapy, we suggest a therapeutic trial of naftidrofuryl
Cilostazol
Pletal (PDE-3 inhibitor)
for intermittent claudication
Contra
HF
Warning
HF, Tachycardia, palpitation, tachyarrhythmia, hypotension, exacerbating angina or MI inpatients with ischemic heart disease
Interactions
CYP3A inhibitors
Adverse
HA, GI, diarrhea, abdominal pain
MOA
PDE 3 inhibitor, prevents cAMP degradation which prevents platelet aggregation and promotes vasodilation
Venous thrombosis
Anticoagulation administered immediately and for up to 10 days following a diagnosis of DVT to provide protection from recurrent thrombosis in this period of highest risk.
Long-term (finite) anticoagulation is administered for a minimum of three months and extended for 6 to 12 months in some cases.
A small population of patients will require indefinite anticoagulation
(LMW) heparin, subcutaneousfondaparinux, the oral factor Xa inhibitorsrivaroxabanorapixaban, orunfractionated heparin(UFH).
For most patients with a first episode of DVT (provoked and unprovoked, proximal and distal), anticoagulants should be administered forthree months
Pregnant with DVT
LMWH (Lovenox) be selected as the initial and long-term anticoagulant
Anticoagulation in Cancer
LMWH (lovenox)
Anticoagulation in renal disease
Cr clearance <30
Vitamin K dependent antagonist
Warfarin
Anticoagulation in CAD
Vitamin K dependent antagonist
Warfarin
rivoroxaban
apixaban
edoxaban
Anticoagulation in Pregnancy
LMWH (lovenox)
Warfarin
Coumarin anticoagulant. Vitamin K antagonist
for Venous thrombosis. Pulmonary embolism. Thromboembolic complications from atrial fibrillation and/or cardiac valve replacement. Reduce risk of death, recurrent MIs, and thromboembolic events (eg, stroke, systemic embolization) post-MI.
Dose Individualize. ≥18yrs: Initially 2–5mg once daily
Warnings
Risk of major or fatal bleeding. Monitor INR frequently. History of GI bleed. Hypertension. Cerebrovascular disease. Anemia. Malignancy. Trauma.
Dabigatran
Pradaxa (Direct thrombin inhibitor)
To reduce risk of stroke and systemic embolism in non-valvular atrial fibrillation (AF). Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients treated with parenteral anticoagulant for 5–10 days. To reduce risk of recurrent DVT/PE in patients who have been previously treated. Prophylaxis of DVT/PE after hip replacement surgery.
Contra
Active bleeding. Mechanical prosthetic heart valve.
Warning
Premature discontinuation increases the risk of thrombotic events. Spinal/epidural hematoma
Adverse
Gastritis-like symptoms (eg, GERD, esophagitis, erosive gastritis, gastric hemorrhage, ulcer),
Rivaroxaban
Xarelto (Factor Xa inhibitor)
To reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Treatment of deep vein thrombosis (DVT),
Contra
Active bleeding
Warning
Premature discontinuation increases the risk of thrombotic events. Spinal/epidural hematoma
Interactions
Increased risk of bleeding with concomitant aspirin, clopidogrel, enoxaparin, warfarin, chronic NSAIDs
idarucizumab
Praxbind
Reversal of the anticoagulant effects of dabigatran in emergency surgery/urgent procedures and in life-threatening or uncontrolled bleeding.
Venous insuffciency
For patients who are unable to tolerate, are not compliant with, or in whom compression therapy is contraindicated (eg, occlusive arterial disease),
we suggest horse chestnut seed extract. A typical dose is 300 mg (standardized to 50 mg of escin) twice daily.
Use horse chestnut extract as a dietary supplement for chronic venous insufficiency (when the veins of the lower leg are unable to send blood back toward the heart), hemorrhoids, and swelling after surgery. Preparations made from the tree’s bark are applied to skin sores.
side effects, include itching, nausea, gastrointestinal upset, muscle spasm, or headache.
