Some Heart and Some Blood Things Flashcards
A TG level above ______ can cause acute pancreatitis
500
Please name 6 drugs that increase LDL and TG:
Diuretics
Efavirenz
Steroids
Immunosuppressants
Atypical Antipsychotics
Protease Inhibitors
What dyslipidemia drug is known to slightly elevate LDL?
Fish Oils
Name 3 drugs that increase TG only
Propofol
IV lipid emulsion
Bile Acid Sequestrates
Friedewald Equation
LDL = TC - HDL - TG/ 5
What are intensity does a diabetic patient that is 42 and an LDL of 120 require?
Moderate intensity!
Diabetic patient: 40 - 75
LDL: 70 - 189
With no ASCVD risk factors
What are intensity does a diabetic patient that is 42 and an LDL of 120 with ASCVD risk factors require?
High Intensity!
Diabetic patient: 40 - 75
LDL: 70 - 189
With ASCVD risk factors
A patient that is between 40 - 75 with an LDL between 70 - 189 and ASCVD risk score between 7.5 - 19.9% requires a…
Moderate intensity
Name the two high intensity statins and their doses
Atorvastatin 40 - 80
Rosuvastatin 20 - 40
What is the Pitavastatin Moderate intensity dose range?
2- 4 mg
Low: 1 mg
What is Simvastatins Moderate intensity dose range?
20 - 40 mg
Low: 10 mg
What is the moderate intensity dose range for pravastatin?
40 - 80 mg
Low: 10 - 20 mg
What is the moderate intensity dose range for Lovastatin?
40 mg
Low: 20 mg
What is the moderate intensity dose range for Fluvastatin?
40 mg BID / 80 QD XL
Low: 20 - 40
How do we reduce the risk of statin based Myalgia?
Avoid DDI
Do not exceed simvastatin 80 mg/d
Do not use gemfibrozil with a statin
How to manage Myalgia from a statin?
Hold, Check CPK
After 2 - 4 weeks rechallenge with the same statin or decrease the dose.
If myalgia returns d/c statin. Once muscle sx’s resolve a low dose statin can be started with a gradual increase
What statins can be taken at any time of day? (5)
Crestor
Lipitor
Livalo
Lescol XL
Pravachol
What are the lipid effects of statins?
Decrease LDL by 20 - 55%
Increase HDL by 5 - 15%
Decrease TG by 10 - 30 %
What are the significant DDI with Statins?
G <3 PACMAN
G: grapefruit
P: Protease inhibitors
A: Azoles
C: Cyclosporine
M: Macrolides (except Zpak )
A: Amio
N: Non DHP CCB
Do not use Simvastatin or Lovastatin in G - M
Statins MOA:
inhibit HMG CoA reductase. Rate limiting step in cholesterol synthesis
Ezetimibe MOA:
inhibits absorption of cholesterol in the small intestine
MOA of PCSK 9 Inhibitors:
PCSK9 = enzyme that increases LDL receptor degradation
the Inhibitors at MAbs that block the ability of PCSK 9 to bind to the LDL receptor.
(dramatic decrease in LDL)
Alirocumab
Praluent - SC
- HeFH or ASCVD
- PCSK9 - I
Evolocumab
Repatha - SC
*HeFH or ASCVD
* HoFH
Bile Acide Séquestrants MOA:
bind bile acids in the intestine forming a complex that is excreted in the feces. Prevents BA reabsorption
Welchol, a BA sequestrate has three important things:
- Take with a meal and liquid
- Also approved for glycemic control in type 2 DM (~0.5%)
- Can be used in pregnant patients
What are the 3 CI of Welchol?
- TG > 500
- history of HyperTg induced pancreatitis
- bowel obstruction
What do BA do to the TG level?
Increase ~5%
Fibrate MOA:
PPAR alpha activators, up regulate the expression of apolipoprotein C2 (apoC-2) which increases lipoprotein lipase activity, leads to increased catabolism of VLDL particles
(decreases TG A LOT)
Contraindications for Fibrates (Gemfibrozil - Lopid, and Fenofibrate)
Severe liver disease (including primary biliary cirrhosis
Gall bladder disease
What is a side effect of gemfibrozil?
Dyspepsia
What is a SE and Warning of Fibrates?
Can increase LFTs
increased myopathy with administered with a statin
Gemfibrozil should not be given with ___ and ____
Ezetimibe and Statins ( increases risk of myopathy)
Fibrates ___ the effects of sulfonylureas and warfarin
increase!
Niacin MOA:
decreases rate of hepatic VLDL and LDL synthesis.
- decreases LDL and TG
When the TG are high fibrates can…
increase LDL
Nicotinic acid = Niacin = ____
Vitamin B 3
If a patient has just taken Welchol (BA), how long must you wait to take Niacin?
4 - 6 hours
Thiazide MOA:
inhibit sodium reabsorption in the DCT causing increased excretion of Na, Cl, H20, and K
What is the dosing of Chlorithalidone
12.5 - 25 mg QD
What is the dosing of HCTZ
12.5 - 50 mg QD
Patients with a _____ hypersensitivity are CI in thiazides.
Sulfonamide derived drug sensitivity
What electrolytes/labs do thiazides increase?
UA, Ca, LDL, TG, BG
Billie Joe has a CrCl of 28. What evidence is there with him starting a thiazide?
It has been shown to be ineffective in CrCl < 30
DHP CCB MOA
inhibit Ca ions from entering the vascular smooth muscle and myocardial cells. Leading to peripheral arterial vasodilation and coronary artery dilations.
The peripheral vasodilation leads to sx’s: reflex tachy, palpitations, headaches, flushing, peripheral edema
Nifedipine ER can be used in ___ patients (not pregnant)
Raynouds - to help prevent peripheral vasoconstriction
Bella has an allergy to Soy and Eggs. What DHP can she not use?
Cleviprex
Hypertriglyceridemia can occur with which DHP?
Clevidipine
How many calories are in the lipid emulsion of Clevidipine?
2kcal/ ml
STRICT aseptic technique needs to be utilized. Vial is only good for 12 hours after puncture
Non DHP CCB MOA:
inhibit Ca ions from entering the vascular smooth muscle and myocardial cells
* more selective for the myocardial than DHP CCB*
the decrease in BP is from the negative ionotropic and the decreased HR is from negative chronotropic effects
ACE inhibitors should not be used within ___ hours from entresto?
36 hours
ACE MOA:
block the conversion from Ang 1 to Ang 2 (decrease vasoconstriction and aldosterone secretion)
also believed to block the degradation of bradykinin (vasodilatory effects)
ARB MOA:
Block Ang2 from binding to AT1 receptor (prevents vasoconstriction)
What is a warning associated with Benicar?
Olmesartan is associated with Sprue - like enteropathy
(can occur at any time)
Direct Renin Inhibitor, Aliskiren MOA:
direct inhibitor of Renin, which is responsible for the conversion of Angiotensinogen to Ang 1.
What is a CI of Aliskiren?
Do not use with ACE/ARB in a Diabetic patients
Tekturna:
Aliskiren
difference between spironolactone and eplerenone
Spironolactone: non selective aldosterone receptor antagonists that also blocks androgen
Eplerenone: selective aldosterone receptor antagonist that DOES not exhibit the endocrine SE of Aldactone
What BB have ISA (intrinsic sympathomimetic activity)?
Acebutolol , Penobutolol, pindolol
- not recommended post MI
Name the Beta 1 selective BB:
Atenolol - tenormin
Esmolol - Brevibloc - inj
Metoprolol
Acebutolol
Betaxolol
Bisoprolol
Metoprolol Tartate IV to PO:
1 : 2.5
Name the 1 BB that is beta 1 selective blocker with nitric oxide dependent vasodilation
Nebivolol - Bystolic
Non Selective BB 1 and 2:
Nadolol (corgard)
Propranolol
Pindolol, Timolol
What is a big point with propranolol
high lipid solubility!!! More CNS SE - migraine prophy
Non selective BB with Alpha 1 blocking
Labetolol and Coreg
Inutiv is associated with what serious SE?
DILE
Guanfacine
Minoxidil BBW:
potent antihypertensive can cause pericardial effusion and angina exacerbations
HTN Emergency:
Acute target organ damage
Stroke, AKI, ACS, Encephalopathy
HTN Urgency:
No evidence of acute target organ damage
- treat with PO med okay
- Decrease BP gradually over 24 - 48 Hours
Prinzmetals Angina:
can be variant or vasospastic
Chest pain caused via Vasospasm
(DHP = DOC)
What are the ABCDE of SIHD?
A: antiplatelets + antianginals
B: BB + BP meds
C: Cholesterol and Cigs
D: Diet and diabetes
E: exercise and education
When would Yosprala be indicated?
With chronic ASA use PPI can be used to help protect the gut. This is a combo product with ASA and Prilosec
How long will DAPT be for Bare metal Stent?
1 month
How long with DAPT be for drug- eluting stent?
at least 6 months
How long with DAPT be for post CABG?
at least 12 months
BB MOA in SIDH
reduce myocardial oxygen demand: decrease HR, contractility, and left ventricular wall tension
CCB MOA in SIDH:
non DHP : decrease HR and contractility
DHP: decrease after load (SVR)
All CCB’s increase myocardial O2 supply
Nitrates MOA in SIDH:
reduce myocardial O2 demand, decrease preload, produces vasodilation of the veins
Ranolazine (Ranexa) big points:
not for acute Chest pain
Qt prolonging
A LOT OF DDI
A PCI is preferred in STEMI when…
Patient presents within 90 minutes or 120 minutes of first medical contact
If a PCI is not possible, what is the timeline to induce fibrinolytic therapy?
30 minutes within hospital arrival (door to needle time)
What is the MONA-GAP-BA for ACS management?
M- morphine
O- oxygen
N - nitrates
A- ASA
G - IIb/IIa antagonists
A: anticoagulant
P: P2Y12 inhibitors
B: BB
A: Ace inhibitors
What are the contraindications of Effient
Prasugrel is CI in active serious bleeding
AND: history of stroke or TIA
glycoprotein IIb/IIIa receptor antagonist:
Abciximab (reopro) only for patients undergoing PCI
Eptiflibatide (integrillin)
Loop Diuretics MOA:
block reabsorption in the thick ascending limb in the LOH. increase excretion of Na, K, Cl, Mg, Ca, and H2O
DO NOT IMPROVE SURVIVAL in HF
What labs do Loops increase:
HCO3 (metabolic alkalosis)
UA, BG, TG’s, TC
Please give the dosing conversions for loops
Lasix 40
Torsemide 20
Bumex 1
Ethacrynic Acid: 50
Lasix IV to PO
1: 2
Ivabardine (Corlanor)
Funny Channel = decrease HR
indicated if BB is maxed out or unable to be tolerate and the resting HR is > 70
GOAL: 50 - 60
Digoxin MOA:
inhibits Na/K/ATP-ase pump = positive ionotropic effects. (increases CO)
- which leads to a decrease in HR (negative chronotropic)
Digoxin Therapeutic level in HF:
0.5 - 0.9
Digoxin dose change when going PO to IV?
Decrease by 20 - 25%
Vericiguat
Verquvo
Soluble guanylate cyclase stimulator which increased cyclic GMP and leads to smooth muscle relaxation.
DO NOT USE WITH Riociguat
KCl 10% = x mEq/ 15 ml
20 mEq/15 ml
Holter Monitor is a…
Ambulatory ECG Device
The SA Node is _____
the hearts natural pacemaker
The SA node cells have ____ which allows them to initiate their own action potential unlike other myocytes.
Automaticity
When is Phase 0 of the cardiac action potential initiated?
When there is a rapid ventricular depolarization due to an influx of Na ions… causes contraction
In the cardiac action potential Phase 1 is….
Early rapid repolariation (Na channels close)
In the cardiac action potential In Phase 2 there is a plateau response to ________
an influx of Ca and efflux of K
cardiac action potential Phase 3 is the….
Rapid depolarization the occurs in response to an efflux of K and this leads to ventricular relaxation. Resulting in Phase 4 which is the resting membrane state.
What class of antiarrhytmics prolong the QTc?
Class 1a, 1c, and 3
What Anti-infective agents prolong QTc? (5)
- Antimalarials (hydroxychloroquine)
- Azoles (except isavuconazonium)
- Macrolides
- Quinolones
- Lefamulin
What 3 oncology based meds prolong QTc?
Androgen Deprived therapy (leuprolide)
Tyrosine Kinase Inhibitors (nilotinib)
Oxaliplatin
Classifying drugs with Vaufhan Williams.
“Double Quarter Pounder, Lettuce Mayo, Fries Please, Because, Dieting During Stress is Always, Very Difficult”
1a: Disopyramide, Quinidine, Procainamide
1b: Lidocaine, Mexiletine
1c: Flecainide, Propafernone
2: BB
3: Dronedarone, Dofetilide, Sotalol, Ibutilide, Amiodarone
4: Verapamil, Diltiazem
AF rate control Agents?
BB or NON DHP are used and sometimes digoxin
AF rhythm control agents?
Class 1a, 1c, or 3
if AF is permanent avoid this strategy with antiarrhythmics . R>B
Digoxin Arrhythmia Concentration:
0.8 - 2 ng/mL
Starting dose 0.125 - 0.25 mg QD
Norpace
Disopyramide (class 1a)
Quinidine Class 1A should be…
Taken with food to decrease GI upset.
Can cause DILE
What is Quinidine Cinchonism?
overdose. Tinnitus, hearing loss, blurred vision, headache, delirium
What is Procainamide, Class 1a Active metabolite?
N-acetyl procainamide = recalled cleared. Watch out in slow acetylators
Class 1C Propafenone Brand + one SE
Rythmol
Taste Disturbance (metallic)
CI: HF and MI
Flecainamide a Class 1c is CI in these two heart conditions…
HF and MI
Class 3 Multaq has what BBW?
Dronedarone
BBW: increased risk of death, stroke, and HF in patients with decompensated HF or permanent AF
Has little effects on thyroids.
Class 3 Dofetilide ( Tikosyn) BBW:
must be initiated in a setting with continuous ECG monitoring. Need to assess CrCl a minimum of 3 days. (QT prolongation)
DOC In HF ( so is amio)
Adenosine Injection Is indicated for:
paroxysmal supraventricular tachycardia (PSVT)
SHORT 1/2 Life 10 seconds
Alteplase MOA:
tissue plasminogen activator.
Binds to fibrin in the thrombus and converts plasminogen to plasmin. Resulting in fibrinolysis.
ONLY FDA approved fibrinolytic to treat acute ischemic stroke
Due to the bleeding risk with tPA, what are three categories they are contraindicated in?
- Active bleed
- Labs or Conditions that increase bleeding (severe HTN, INR >1.7)
- Drug interactions with bleeding risks (anticoagulant)
LMWH ~ last 24 hours
DOAC ~ last 48 hours
Alteplase is CI in severe uncontrolled HTN. What is that range?
> 185/110
Can decrease BP with labetalol, cleviprex, or Cardene to get patient below this
When should ASA be given in stroke?
ASA 162 - 325 should be given within 24 - 48 hours after stroke onset
DVT prophylaxis in stroke?
Usually Mannual should be used if the patient is receiving tPA
If a LMWH is started it should be started > 24 hours post injection
What is the goal BP for a person post stroke?
< 130/80
What is Na restriction post stroke?
< 2.4 g
or
<1.5 g for optimal BP reduction
In pateints with a NON cardioembolic stroke, is anticoagulation warranted?
No, it is recommended that a patient utilize antaplatelet therapy.
ASA, Aggrenox, or Plavix
If a patient was already on ASA 81 prior to the stroke, is there a benefit in increasing there dose to the 162-325 dose range ?
No, there has been no proven benefit if a patient was on statin therapy prior to the stroke.
ASA moa:
irreversibly inhibits COX-1 & 2 leading to decreased prostaglandin and TXA 2
Aggrenox MOA:
ASA + Dypyridamole
ASA same
Dipyridamole: inhibits the uptake of adenosine into platelets and increases cAMP levels (inhibits platelet aggregation)
Plavix is a ____ drug that _____
Prodrug; that irreversibly inhibits P2Y12
If a patient comes in with an intracerebral hemorrhage (ICH) that is on anticoagulant therapy what should be done?
Patients should be considered for reversal of the anticoagulant. IF there is also evidence of seizures then patients should be placed on AED treatment dosing
What is the main complication with ICH?
Increased intracranial pressure
Mannitol MOA:
produces osmotic diuresis by increasing osmotic pressure of the glomerular filtrate in the kidneys. Inhibiting tubular reabsorption of water and electrolytes and increases urinary output.
AKA: reduced ICP by withdrawing water from the brain parenchyma and excreting it via the urine
What is a CI for mannitol?
Severe renal disease!! (pulmonary edema, hypovolemia)
What are some warnings with Mannitol?
- vesicant
- nephrotoxic
- can cause rebound ICP if used for prolonged time frame (intermittent blouses are preferred)
- fluid and electrolyte imabalnces (DEHYDRATION)
When looking at Mannitol administration what are two big counseling points to the nurse?
- inspect for crystals! if they are present warm the solution
- filter should be used for admin
Other than Mannitol what other IV can be used for ICH?
HypER tonic saline can be used
Why is Nimodipine used in Acute Subarachnoid Hemorrhage (SAH)?
used to prevent vasospasm (which can occur 3 - 21 days after a bleed)
Nymalize BBW:
Nimodipine should NOT be admin IV!!!! (death, serious life threatening events!!!)
Name the direct Factor Xa inhibitors.
Edoxaban
Apixaban
Rivaroxaban
What factors does Warfarin inhibit?
2, 7, 9, 10
Direct thrombin inhibitors names
IV: Argatroban, Bivalirudin
PO: Dabigatran
Indirect Factor Xa inhibitor name:
Fondaparinux
When looking at Key points, when is oral anticoagulants appropriate?
- AF and DVT/PE
- Xarelto and ELiquis r not indicated for the acute management of ACS when platelet aggregation is the main target of therapy
When looking at Key points, what is Fibrinolytics appropriate?
used to break down existing clots.
Used to immediately treat an acute ischemic stroke or STEMI
When looking at Key points, when is antiplatelet therapy appropriate?
in CAD and to help prevent recurrent stroke/TIA
DAPT: common in patients who have had an ACS.
Heparin treatment dosing for VTE:
80 U/kg bolus
18 u/kg/hr infusion
Heparin treatment dosing for ACS/STEMI:
60 U/kg bolus
12u /kg/ hr infusion
When do you check anti-xa and aPTT levels in heparin ?
6 hours after starting and every 6 hours until therapeuitc.
aPTT: 1.5 - 2.5 x control
Anti-xa: 0.3 - 0.7
Lovenox dosing for STEMI in pt < 75
30 mg IV bolus + 1mg/kg SC dose
followed by BID
LMWH BBW:
patients receiving neuraxial anesthesia are at risk for hematomas and subsequent paralysis
HIT is when:
Platelets drop > 50 % from baseline with no other underlining cause
If a patient develops HIT while on Heparin and was also receiving warfarin what should be done?
patient should be stopped on both the heparin and the warfarin (increased risk of necrosis) and Vitamin K should be administered.
When can warfarin be started/restarted after a patient develops HIT?
Until Platelets are at least 150,000
Antidote for Apixaban and Xarelto?
Adexanet alfa (Andexxa)
What is the dose of Xarelto that can be used for reduction in the risk of major CVD events in CAD/PAD?
2.5 mg PO BID with ASA 81
Savaysa
Edoxaban
Savaysa AF CrCl cutoffs
> 95: DO NOT USE
< 15: do not use
When do you start savaysa therapy in DVT/PE treatment?
Edoxaban should be 60 mg QD started 5 - 10 days after parental anticoagulation
Arixtra
Fondaparinux
What is a CI when using Pradaxa (what type of heart thing)
CI in use of a mechanical prosthetic heart valve
Angiomax
Bivalirudin
What are SE to Jantoven other than bleeding?
Skin Necrosis and Purple toe Syndrome
what agents decrease INR?
2C9 inducers: carbamazepine, phenobarbital, phenytoin, rifampin (drastic), St. Johns wart
Agents that increase INR:
2C9 inhibitors: Metronidazole, amiodarone, fluconazole, TMP/SMX
What are the five G’s of supplements tht increase INR?
Ginger
Ginkgo
Ginseng
Glucosamine
Garlic
What are the warfarin tablet colors?
Pink - 1 mg
Lavender - 2 mg
Green - 2.5 mg
Brown/tan - 3 mg
Blue - 4 mg
Peach - 5 mg
Teal - 6 mg
Yellow - 7.5 mg
White - 10 mg
Please Let Greg Brown Bring Peaches To Your Wedding
What agent is used for UFH/LMWH reversal?
Protamine!
UHF: 1 mg will reverse 100 U of heparin
LMWH: 1mg per 1 mg of protamine
Idarucizumab aka Praxbind is the _____
Dabigatran reversal agent
For a patient that is set to undergo a cardio version. If their AFib duration is unknown how long should anticoagulant therapy be utilized?
For 3 weeks prior and for 4 weeks after
MCV < 80 = Microcytic. What is the likely cause?
Iron Deficiency
MCV 80 - 100 = Normocytic what is the likely cause?
Acute blood loss
CKD
Bone Marrow Failure ( aplastic anemia)
Hemolysis
MCV> 100 = Macrocytic. What is the likely cause?
Vitamin B 12 or Folate deficiency
What laboratory findings are best associated with iron anemia?
Decreased: Hgb, MCV, RBC production (low reticulocyte count)
Decreased: serum from, ferritin, and TSAT
Increased:TIBC
What is the goal with treating iron anemia?
increase serum Hgb ~1g/dL Q2-3 weeks and continue treatment for 3 - 6 months after anemia has resolved
% of elemental iron in Ferrous Gluconate
12%
% of elemental iron in Ferrous Sulfate
20%
% of elemental iron in Ferrous Sulfate DRIED
30 %
% of elemental iron in carbonyl iron, polysaccharide iron complex, ferric mall
100%
BBW with Oral Iron
Accidental OD of iron containing products leading to overdose in children
What can be given with oral iron and why?
Docusate to prevent Constipation
What can iron be taken with to slightly enhance the absorption of it?
Vitamin C
BBW with Feruxytol (feraheme) and Iron Dextran (INFEdD)
serious anaphylaxis concern. Present with all but noted with these two.
A patient should receive a test dose of iron dextran before actually recieving it
What is unique about Triferic?
Ferric Pyrophosphate Citrate is only indicted for iron replacement in patients with hemodialysis dependent CKD
Should be added to bicarb concentrate of the hemodialysate
Nascobal is:
A intranasal B12. Given in one nostril every week
Prolonged use of Metformin, H2RA, or PPIs can lead to:
Vitamin B12 deficiency (2 yrs)
When do you initiate Procrit in patients of Normocytic anemia that have cancer or CKD?
When Hgb is < 10
What is the admin frequency for Epoetin Alfa (Epogen/procrit)?
3x/wk
IV or SC
What is the admin frequency for Aranesp?
IV or SC weekly for Darbepoetin
What is the Hgb goal in patients with Sickle Cell?
10!
What is considered the only cure for sickle cell?
Bone Marrow Transplant
Droxia MOA:
stimulated the production go HgbF.
Indicated in adults with >/= 3 moderate to severe pain crises in one year.
Considered in all children > 9 months
What are two warnings with Hydrea/Droxia/Siklos/Hydroxyurea?
Fetal toxicity
Avoid Lie Vaccines (Myelosuppression BBW)
What supplementation is recommended with hydroxyurea?
Folic acid to help avoid macrocytosis
Oxbryta MOA:
Voxelotor: inhibiting hemoglobin S polymerization (cause of SCD)
Tablet form
What is the antidote for Iron toxicity?
Deferoxamine
What are the current oral formulation utilized to chelating iron in SCD patients.
Exjade, Jadenu (Desferasirox)
Ferriprox (deferiprone)
