Stable Ischemic HD, ACS, and HF Flashcards
cardiac stress test medications
adenosine, dipyridamole, dobutamine or regadenoson (Lexiscan)
Non-drug treatment for SIHD
BMI 18.5-24.9
waist circumference of < 35 in in females and < 40 in males
drug regimen for SIHD
aspirin 81 mg and beta blockers (clopidogrel if allergy to aspirin)
when do you suggest clopidogrel + aspirin
history of bare metal stent placement (DAPT 1 month), drug-eluting stent (DAPT 6 month) or CABG (DAPT 12 months)
alternatives when beta-blockers are contraindicated in patients
CCB (both DHP and non-DHP), long-acting nitrates, ranolazine (in addition or instead of)
SIHD preventative medications
- SLNG for immediate relief
- high intensity statin
-antihypertensives with HTN, HF, and DM
how long should aspirin be used in patients with SIHD
indefinitely - use non-enteric coated chewable aspirin
Clopidogrel
avoid use with omeprazole and esomeprazole
ranolazine
not for acute treatment of chest pain
has little to no effect on HR and BP
QT prolongation
nitroglycerin
hypotension, headache, tachyphylaxis
ISDN + hydralazine
preferred combo for HFrEF
nitrates
do not use with PDE-5s and riociguat
-avanafil in the past 12 hours
-sildenafil or vardenafil in the past 24 hours
- tadalafil in the past 48 hours
NG TL Spray
do not shake
spray onto or under the tongue
do not inhale the spray or try to swallow
do not spit or rinse mouth for 5-10 min after
Unstable angina (UA)
chest pain
negative cardiac enzymes
none/transient ischemic changes in ECG
partial blockage
NSTEMI
chest pain
positive cardiac enzymes
none/transient ischemic changes in ECG
partial blockage
STEMI
chest pain
positive cardiac enzymes
ST-segment elevation on ECG
complete blockage
NSTEMI-ACS
can be treated with medications alone or with PCI
STEMI
PCI or fibrinolytic
Time to PCI
90 minutes (door to balloon time) or within 120 minutes of first medical contact
Time to fibrinolytic
30 minutes
MONA-GAP-BA
MONA: morphine, oxygen, nitrates, asa
GAP: GPIIb/IIIa antagonists, anticoagulants, P2Y12 inhibitors
BA: beta-blockers, ACEi
when not to use IV nitroglycerin in ACS
SBP < 90 mmHg
when should beta-blockers be given post ACS?
within 24 hours to increase long term survival
P2Y12 inhibitors
prodrugs that irreversibly bind to the P2Y12 receptor
*not ticagrelor
Clopidogrel
LD: 300-600 mg (600 mg PCI)
MD: 75 mg
-bleeding risk (stop 5 days prior to surgery) di not use with omeprazole or esomeprazole
Prasugrel
LD: 60 mg (no later than 1 hour after PCI)
MD: 10 mg (5 mg < 60 kg)
-dispense in original container
-do not initiate if CABG is likely - stop at least 7 days prior to elective surgery
Ticagrelor
LD: 180 mg
MD: 90 mg BID x 1 year then 60 mg BID
- do not exceed 100 mg of ASA
-avoid use when CABG likely, stop 5 days before any surgery
SSRIs and SNRIs
increase the risk of bleeding when used with P2Y12
GIIb/IIIa receptor antagonists
Abciximab (ReoPro), Eptifibatide (Integrillin)
-bleeding, thrombocytopenia
PAR-1 antagonist
Vorapaxar (Zontivity)
Fibrinolytics
cause fibrinolysis by binding to fibrin and converting plasminogen to plasmin
-used only for STEMI
Alteplase (Activase) | Tenecteplase (TNKase)
contraindications: active internal bleeding, hx of a recent stroke, ICH, severe controlled HTN
Secondary prevention: ASA
indefinitely (81 mg/day) unless contraindicated
Secondary prevention: P2Y12 inhibitor
-medical therapy: ticagrelor or clopidogrel with asa 81 mg for at least 12 months
-PCI-treated patients: clopidogrel, prasugrel, or ticagrelor with asa for 12 months
Secondary prevention: BB
3 years - continue indefinitely in patients with HF or if needed for management of HTN
Secondary prevention: ACEi
indefinitely in patients with EF < 40%, HTN, CKD, or diabetes; consider for all I patients with no CI
Secondary prevention: aldosterone antagonist
indefinitely in patients with EF < 40% and symptomatic HF or DM receiving target doses of an ACEi and BB
-CI: significant renal impairment or hyperkalemia
Secondary prevention: statin
indefinitely high statin for most people (those > 75 can consider moderate or high intensity)
HFrEF
EF < 40% (systolic dysfunction)
impaired ability to eject blood during systole
HFmrEF
EF 41-49%
HFpEF
EF > 50%
HFimpEF
< 40% at baseline then > 10% increase and second F > 40%
Lab/biomarkers of HF
increased BNP (normal < 100)
increased NT-proBNP (normal is < 300)
BNP and proBNP are used to distinguish between cardiac and non-cardiac causes of dyspnea
Left-sided S/Sx
orthopnea: SOB when laying down
Paroxysmal nocturnal dyspnea: nocturnal cough and SOB
Bibasilar rales: crackling lung sounds heard on lung exams
S3 gallop
hypoperfusion (renal impairment, cool extremities)
General S/Sx of HF
dyspnea (SOB at rest or upon exertion)
cough
fatigue, weakness
reduced exercise capacity
Right-sided S/Sx
peripheral edema
ascites: abdominal fluid accumulation
JVD
HJR
hepatomegaly
cardiac output
CO = HR x SV
cardiac index
CI - CO/ BSA
Drug Information NATION (drugs that cause or worsen HF)
DPP4-inhibitors
Immunosuppressants/TNF inhibitors
Non-DHP CCB/diltiazem and verpamil
Antiarrhythmics (class 1 agents)
Thiazolidinediones
Itraconazole
Onc drugs
NSAIDs
Initial medications for HF (w/o CI)
ARNI, ACEi, or ARBs
BB
Loop diuretics
Which HF medications decrease mortality
ARNI/ACEi/ARBs
BB
ARAs, SGLT-2 (NYHA II-IV)
Secondary medications for HF in select patients
ARA
SGLT-2
BiDill
Ivabradine
Which HF medications decrease morbidity
ARAs, SGLT-2, Bidill
Additional medications for HF
Dig, vericiguat
BB in HF
bisoprolol, carvedilol (IR and ER), metoprolol succinate (ER)
-only discontinue during acute decompensated HF
carvedilol CR and IR dose conversion
Coreg 3.125 mg BID = Coreg CR 10 mg daily
Loop diuretics
- do not use in those with sulfa allergies
- decrease K, Mg, Na, Cl, Ca
- increase HCO3, UA, BG, TG, TC
- ototoxicity
- orthostatic hypotension, photosensitivity
- keep at room temperature
oral loop diuretic coversion
furosemide 40 mg = torsemide 20 mg = bumetanide 1 mg - ethacrynic acid 50 mg
furosemide IV:PO
1:2 (20 mg IV = 40 mg PO)
ARA in HF
do not initiate for HF if K > 5
Ivabradine
bradycardia, increased risk of QT prolongation and ventricular arrhythmias
-side effects: bradycardia, HTN, AFib
Target: resting HR between 50-60 BPM
digoxin level target
< 1 ng/mL in HF (0.5-0.9 ng/mL)
magnesium and potassium levels in those on digoxin
> 2 and 4-5
digoxin
-0.125-0.25 mg PO QD
-LD not used in HF
-CrCl < 50 mL/min decrease dose or freq
-decrease dose 20-25% when switching from PO to IV
digoxin toxicity
blurred/double vision, greenish-yellow halos
digoxin and amiodarone/dronedarone
reduce digoxin dose by 50%
KCl ER capsules
capsule contents can be sprinkled on a small amount of applesauce or pudding
KCl ER Tab
K-Tab, Klor-Con: swallow whole; do not chew, crush, cut or suck on tablet
Klor-Con M: can be cut in half or dissolved in water; do not chew, crush, or suck on the tablet
KCl oral packet
dissolve contents in water and drink immediately
