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OU Module Cardio Spring 2018 > Therapeutics of Coronary Artery Disease > Flashcards

Therapeutics of Coronary Artery Disease Flashcards

1
Q

pathophysiology and diagnosis of a STEMI

A
  • Total Occlusion of Coronary Artery -> Unstable plaque causing infarction
  • EKG Manifestations: ST segment elevation, NEW left bundle branch block (LBBB)
  • Signs/Symptoms: Chest pain, Intense sweating, N/V
  • Presence of biomarkers
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2
Q

patients who are candidates for PCI

A
  • First medical contact device time ≤ 90
  • Superior to fibrinolytic therapy if availability of skilled interventional cardiology department
  • High Risk of Mortality: Cardiogenic shock or severe HF must get PCI right away
  • High Bleed risk
  • Diagnosis of STEMI in doubt
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3
Q

patients who are candidates for Fibrinolytics

A
  • Administer within 30 min of arrival if first medical contact device time > 120 min
  • More appropriate option in institutions with lack of availability of skilled interventional cardiology department
  • Low bleed risk
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4
Q

pharmacotherapeutics for PCI

A
  • antiplatelet

- anticoagulation

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5
Q

What are the antiplatelets for PCI?

A
  • ASA (if not already given)
  • P2Y12 receptor inhibitor
  • GP IIb/IIIa Inhibitors
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6
Q

P2Y12 receptor inhibitors for PCI

A
  • Clopidogrel
  • Prasugrel
  • Ticagrelor
  • Cangrelor
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7
Q

Clopidogrel dose for PCI

A

600 mg LD

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8
Q

Prasugrel dose for PCI

A

60 mg

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9
Q

Ticagrelor dose for PCI

A

180 mg

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10
Q

Cangrelor dose for PCI

A

30 mcg/kg IV bolus prior to PCI followed immediately by an infusion of 4 mcg/kg/minute continued for at least 2 hours or for the duration of the PCI

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11
Q

What are the anticoag therapies for PCI?

A
  • UFH
  • Enoxaparin
  • Fondaparinux
  • Argatroban
  • Bivalirudin
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12
Q

UFH dose for PCI and Fibrinolysis

A
  • After PCI, a weight-adjusted, continuous, IV infusion is administed for 48 hours or until revascularization
  • 12 U/kg/hour (maximum 1000 U/hour)
  • aPTT of 1.5 to 2.0 times control
  • Drug of choice when renal function is unknown
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13
Q

Enoxaparin dose for PCI and Fibrinolysis

A
  • IV bolus, followed in 15 minutes by SQ injection for the duration of hospitalization, up to 8 days or until revascularization
  • If age < 75 years: 30-mg IV bolus, followed in 15 min by 1 mg/kg SQ every 12 hours (maximum 100 mg for the first 2 doses)
  • If age ≥ 75 years: no bolus, 0.75 mg/kg SQ every 12 hours (maximum 75 mg for the first 2 doses)
  • Regardless of age, if CrCl < 30 mL/min: 1 mg/kg SQ every 24 hours
  • Consider using this in pts who has history of HITT
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14
Q

Fondaparinux dose for PCI and Fibrinolysis

A
  • NOT recommended as sole anticoagulant for PCI
  • Increased risk of catheter thrombosis when used as monotherapy
  • Contraindicated in patients with CrCl < 30 mL/min
  • Consider using this in pts who has history of HITT
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15
Q

Argatroban use for PCI and Fibrinolysis

A
  • Useful when anticoagulation needs to be extended past PCI
  • Dose adjust in hepatic dysfunction
  • Useful option in patients with renal dysfunction
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16
Q

Bivalirudin dose for PCI and Fibrinolysis

A
  • Monotherapy anticoagulation in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist
  • Monotherapy anticoagulation
  • 0.75-mg/kg IV bolus, then 1.75–mg/kg/hour IV infusion
  • if CrCl < 30 ml/min = 1 mg/kg/hour
  • Consider using this in pts who has history of HITT
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17
Q

When to use Glycoprotein IIb/IIIa Receptor Antagonists in PCI?

A
  • begin treatment with an IV GP IIb/IIIa receptor antagonist at the time of primary PCI in selected patients with STEMI who are receiving unfractionated heparin (UFH)
  • Used in special cases: Thrombectomy, High-troponin, Complex lesions, Large thrombi, “Bail-out” Therapy
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18
Q

What are the Glycoprotein IIb/IIIa Receptor Antagonists for PCI?

A
  • Abciximab
  • Tirofiban
  • Eptifibatide
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19
Q

Abciximab dose for PCI

A

0.25 mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min) x 12 hours

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20
Q

Tirofiban dose for PCI

A
  • 25 mcg/kg IV bolus, then 0.15 mcg/kg/min x 18-24 hours
  • In patients with CrCl ≤ 60 mL/min, reduce maintenance dose by 50% x 18 hours
  • Contraindicated in patients on hemodialysis
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21
Q

Eptifibatide dose for PCI

A
  • 180 mcg/kg IV bolus [max: 22.6 mg] (repeat 10 minutes later), then 2 mcg/kg/min (max: 15 mg/hour) x 18-24 hours
  • n patients with CrCl < 50 mL/min, reduce maintenance dose by 50%
  • Contraindicated in patients on hemodialysis
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22
Q

Therapy for fibrinolysis

A
  • fibrinolytics
  • antiplatelets
  • anticoags
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23
Q

fibrinolytics

A
  • Alteplase
  • Reteplase
  • Tenecteplase
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24
Q

What are the antiplatelet therapies for PCI?

A
  • ASA

- P2Y12 Receptor Antagonist

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25
Q

ASA for fibrinolysis

A

325mg before fibrinolytics and then ASA 81mg once daily thereafter

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26
Q

P2Y12 Receptor Antagonist for fibrinolysis

A

Clopidogrel

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27
Q

Clopidogrel dose for fibrinolysis

A
  • 300 mg loading dose for patients ≤75 years of age

- 75 mg dose for patients >75 years of age (don’t get a loading dose because it increases risk for bleeding)

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28
Q

GP IIb/IIIa Antagonists in fibrinolysis

A

not recommended -> Combination of IIb/IIIa antagonist and fibrinolysis associated with high rates of bleeding and ICH

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29
Q

Anticoagulation During Fibrinolysis

A
  • UFH
  • Enoxaparin
  • If history of HITT -> Fondaparinux, Bivalirudin
  • Patients with STEMI undergoing reperfusion with fibrinolytics therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of hospitalization, up to 8 days or until revascularization if performed.
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30
Q

TIMI Flow Grade

A
  • 0: No perfusion (no antegrade flow beyond occlusion)
  • 1: Penetration without perfusion (contrast material passes beyond the area obstruction but fails to opacify the entire coronary bed distal to obstruction)
  • 2: Partial reperfusion (delayed flow with complete filling of distal area)
  • 3: Complete perfusion
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31
Q

TIMI Risk Score: factors

A
  • for NSTE-ACS
  • ≥65 y of age
  • ≥3 risk factors for CAD
  • Prior coronary stenosis ≥50%
  • ST deviation on ECG
  • ≥2 angina events in prior 24 hours
  • Use of aspirin in prior 7 days
  • Elevated cardiac biomarkers
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32
Q

TIMI Risk Score: percentages

A
  • 0-1: 4.7%
  • 2: 8.3%
  • 3: 13.2%
  • 4: 19.9%
  • 5: 26.2%
  • 6-7: 40.9%
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33
Q

Relative contraindications for fibrinolytic therapy

A
  • History of chronic, severe, poorly controlled HTN
  • Severe uncontrolled HTN on presentation: SBP > 180 mm Hg; DBP > 110 mm Hg
  • Traumatic or prolonged (> 10 min) CPR
  • Major surgery ( < 3 weeks)
  • Recent internal bleeding (within 2-4 weeks)
  • Prior ischemic stroke in > 3 months
  • Dementia or any known intracranial pathology not covered in absolute contraindications
  • Non-compressible vascular punctures
  • Pregnancy
  • Active peptic ulcer disease (PUD)
  • Current use of anticoagulants (Higher INR = Higher risk)
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34
Q

Absolute contraindications for fibrinolytic therapy

A
  • Active bleeding or bleeding diathesis (Excluding menses)
  • Any prior intracranial hemorrhage (ICH)
  • Ischemic stroke within 3 months (EXCEPT acute ischemic stroke within 4.5 hours)
  • Structural cerebrovascular lesion
  • Presence of malignant intracranial neoplasm
  • Significant closed head or facial trauma within last 3 months
  • Intracranial or intraspinal surgery within 2 months
  • Severe uncontrolled HTN that is unresponsive to emergency therapy
  • Aortic dissection
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35
Q

Monitoring of Perfusion After Fibrinolysis

A
  • Monitor over 1 - 3 hours after initiation of fibrinolytic therapy
  • Pattern of ST elevation
  • Cardiac rhythm
  • Clinical symptoms
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36
Q

for Fibrinolysis, what are we looking for in pattern of ST elevation?

A

reduction of at least 50% of the initial ST-segment elevation injury pattern on a follow-up ECG

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37
Q

for Fibrinolysis, what are we looking for in cardiac rhythm?

A

Maintenance or restoration of hemodynamic and/or electrical stability

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38
Q

for Fibrinolysis, what clinical symptoms are we looking for?

A
  • want to monitor for Intracranial Hemorrhage (ICH)
  • Usually occurs within first 24 hours of therapy
  • Fibrinolytic, antiplatelet, and anticoagulant therapies should be discontinued until brain imaging scan shows no evidence of ICH
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39
Q

What are the presenting features of ICH?

A
  • Acute change in level of consciousness
  • Focal neurological deficits
  • New/severe headache
  • Nausea/vomiting
  • Seizures
  • Acute hypertension
  • Drowsiness
  • Coma
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40
Q

What is NSTE-ACS?

A
  • Partial thrombus occlusion of coronary vasculature

- Plaque stability dictates whether patient will have ischemic or infarction

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41
Q

What falls under NSTE-ACS?

A
  • Unstable Angina (UA)

- Non ST segment Elevation MI (NSTEMI)

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42
Q

Unstable Angina (UA)

A
  • ST segment depression
  • Absence of ST segment elevation
  • Absence of Biomarkers
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43
Q

Non ST segment Elevation MI (NSTEMI)

A
  • ST segment depression
  • Absence of ST segment elevation
  • Presence of Biomarkers
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44
Q

Ischemia-Guided Strategy

A
  • Patients receive optimal anti-ischemic/anti-thrombotic medical therapy
  • Not getting angiography
  • Criteria: Low TIMI risk score (0-1), Low risk Tn (-) patients
  • MONA-BAAS
  • Maximize angina treatment
  • In patients with NSTE-ACS (i.e., without ST elevation), IV fibrinolytic therapy should not be used!!!!!
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45
Q

Antiplatelet for Ischemia-Guided Strategy

A
  • Clopidogrel: 300-600 mg LD

- Ticagrelor: 180 mg LD

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46
Q

Anticoag for Ischemia-Guided Strategy

A
  • UFH
  • Enoxaparin
  • Dalteparin
  • Fondaparinux
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47
Q

UFH dose for Ischemia-Guided Strategy

A
  • Initial loading dose 60 IU/kg (max 4,000 IU) with initial infusion 12 IU/kg/hour (max 1,000 IU/hour)
  • Use for 48 hours or until PCI is performed; aPTT of 1.5 to 2.0 times control
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48
Q

Enoxaparin dose for Ischemia-Guided Strategy

A
  • IV bolus, followed by SQ injection for the duration of hospitalization, up to 8 days or until PCI performed
  • 30-mg IV bolus then 1 mg/kg SQ every 12 hours
  • Regardless of age, if CrCl < 30 mL/min -> 1 mg/kg SQ every 24 hours
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49
Q

Dalteparin dose for Ischemia-Guided Strategy

A

120 units/kg body weight SQ (maximum dose: 10,000 units) every 12 hours for up to 5-8 days

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50
Q

Fondaparinux dose for Ischemia-Guided Strategy

A
  • Initial dose 2.5 mg IV, then 2.5 mg SQ daily starting the following day, for the durations of hospitalization, up to 8 days or until revascularization
  • not recommended for monotherapy
  • CI with CrCl < 30 mL/min
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51
Q

Early Invasive Strategy

A

MONA-BAAS

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52
Q

Antiplatelet for Early Invasive Strategy

A
  • P2Y12 Receptor Antagonists

- GP IIb/IIIa Receptor Antagonist

53
Q

P2Y12 Receptor Antagonists in Early Invasive Strategy

A
  • Clopidogrel
  • Ticagrelor
  • Prasugrel
  • Cangrelor
54
Q

Clopidogrel dose for Early Invasive Strategy

A

300-600 mg LD

55
Q

Ticagrelor dose for Early Invasive Strategy

A

180 mg LD

56
Q

Prasugrel dose for Early Invasive Strategy

A

60 mg LD

57
Q

Cangrelor dose for Early Invasive Strategy

A

30 mcg/kg IV bolus prior to PCI followed immediately by an infusion of 4 mcg/kg/minute continued for at least 2 hours or for the duration of the PCI

58
Q

GP IIb/IIIa Receptor Antagonist for Early Invasive Strategy

A
  • Use in pts that has NSTE-ACS and high-risk features and not adequately pretreated with clopidogrel or ticagrelor
  • Can use if pre-treated adequately with clopidogrel plus ASA (DAPT)
  • Eptifibatide
  • Tirofiban
59
Q

Eptifibatide dose for Early Invasive Strategy

A
  • 180 mcg/kg IV bolus [max: 22.6 mg] (repeat 10 minutes later), then 2 mcg/kg/min (max: 15 mg/hour) x 18-24 hours
  • Remember: In patients with CrCl < 50 mL/min, reduce maintenance dose by 50%
  • Contraindicated in patients on hemodialysis
60
Q

Tirofiban for Early Invasive Strategy

A
  • 25 mcg/kg IV bolus, then 0.15 mcg/kg/min x 18-24 hours
  • Remember: In patients with CrCl ≤ 60 mL/min, reduce maintenance dose by 50% x 18 hours
  • Contraindicated in patients on hemodialysis
61
Q

Anticoagulation for Early Invasive Strategy

A
  • UFH
  • Enoxaparin
  • Dalteparin
  • Fondaparinux
  • Bivalirudin
  • Argatroban
62
Q

UFH dose for Early Invasive Strategy

A
  • Initial loading dose 60 IU/kg (max 4,000 IU) with initial infusion 12 IU/kg/hour (max 1,000 IU/hour)
  • Use for 48 hours or until PCI is performed
  • aPTT of 1.5 to 2.0 times control
63
Q

Enoxaparin dose for Early Invasive Strategy

A
  • IV bolus, followed by SQ injection for the duration of hospitalization, up to 8 days or until PCI performed
  • 30-mg IV bolus then 1 mg/kg SQ every 12 hours
  • Regardless of age, if CrCl < 30 mL/min -> 1 mg/kg SQ every 24 hours
64
Q

Dalteparin dose for Early Invasive Strategy

A

120 units/kg body weight SQ (maximum dose: 10,000 units) every 12 hours for up to 5-8 days

65
Q

Fondaparinux dose for Early Invasive Strategy

A
  • Initial dose 2.5 mg IV, then 2.5 mg SQ daily starting the following day, for the durations of hospitalization, up to 8 days or until revascularization
  • not recommended for monotherapy
  • CI with CrCl < 30 mL/min
66
Q

Bivalirudin dose for Early Invasive Strategy

A
  • Prior to angiography
  • 0.75-mg/kg IV bolus, then 1.75–mg/kg/hour IV infusion
  • Dose adjust for patients with renal dysfunction -> CrCl < 30 ml/min = 1 mg/kg/hour
67
Q

Argatroban dose for Early Invasive Strategy

A
  • direct thrombin inhibitor
  • dose adjust with liver dysfunction
  • good for pts with renal dysfunction
68
Q

Invasive Strategy

A
  • Diagnostic coronary angiography

- MONA-BAAS

69
Q

What has to happen before invasive strategy is considered?

A
  • Fail medical therapy
  • Objective evidence of ischemia by non-invasive stress testing
  • Hemodynamic or electrical instability
  • Very high prognostic risk -> High TIMI/GRACE scores
70
Q

What is the criteria for invasive strategy?

A
  • Patient experiencing refractory/recurrent angina
  • Electrical instability
  • Hemodynamically unstable: Hypotensive, Change in mental status
  • Troponin elevation
  • TIMI score ≥ 2
71
Q

antiplatelet for invasive strategy

A
  • P2Y12 Receptor Antagonists

- GP IIb/IIIa Receptor Antagonist

72
Q

P2Y12 Receptor Antagonists for invasive strategy

A
  • Clopidogrel

- Ticagrelor

73
Q

Clopidogrel dose for invasive strategy

A

300-600 mg LD

74
Q

Ticagrelor dose for invasive strategy

A

180 mg LD

75
Q

Anticoagulation for invasive strategy

A
  • UFH
  • Enoxaparin
  • Dalteparin
  • Fondaparinux
  • Bivalirudin
76
Q

UFH dose for invasive strategy

A
  • Initial loading dose 60 IU/kg (max 4,000 IU) with initial infusion 12 IU/kg/hour (max 1,000 IU/hour)
  • Use for 48 hours or until PCI is performed
  • aPTT of 1.5 to 2.0 times control
77
Q

Enoxaparin dose for invasive strategy

A
  • IV bolus, followed by SQ injection for the duration of hospitalization, up to 8 days or until PCI performed
  • 30-mg IV bolus then 1 mg/kg SQ every 12 hours
  • Regardless of age, if CrCl < 30 mL/min -> 1 mg/kg SQ every 24 hours
78
Q

Dalteparin dose for invasive strategy

A

120 units/kg body weight SQ (maximum dose: 10,000 units) every 12 hours for up to 5-8 days

79
Q

Fondaparinux dose for invasive strategy

A
  • Initial dose 2.5 mg IV, then 2.5 mg SQ daily starting the following day, for the durations of hospitalization, up to 8 days or until revascularization
  • not recommended for monotherapy
  • CI with CrCl < 30 mL/min
80
Q

Bivalirudin dose for invasive strategy

A
  • Prior to angiography
  • 0.75-mg/kg IV bolus, then 1.75–mg/kg/hour IV infusion
  • Dose adjust for patients with renal dysfunction -> CrCl < 30 ml/min = 1 mg/kg/hour
81
Q

GP IIb/IIIa Receptor Antagonist for invasive strategy

A
  • Eptifibatide

- Tirofiban

82
Q

Eptifibatide dose for invasive strategy

A
  • 180 mcg/kg IV bolus [max: 22.6 mg] (repeat 10 minutes later), then 2 mcg/kg/min (max: 15 mg/hour) x 18-24 hours
  • Remember: In patients with CrCl < 50 mL/min, reduce maintenance dose by 50%
  • Contraindicated in patients on hemodialysis
83
Q

Tirofiban dose for invasive strategy

A
  • 25 mcg/kg IV bolus, then 0.15 mcg/kg/min x 18-24 hours
  • Remember: In patients with CrCl ≤ 60 mL/min, reduce maintenance dose by 50% x 18 hours
  • Contraindicated in patients on hemodialysis
84
Q

Secondary Prevention post-ACS

A
  • DAPT Considerations
  • High-intensity statin therapy
  • Beta Blockers
  • RAAS Blockade
85
Q

DAPT Considerations for Secondary Prevention post-ACS

A
  • ASA 81mg indefinitely

- P2Y12 Receptor antagonists: Clopidogrel, Prasugrel, Ticagrelor

86
Q

Clopidogrel dose for Secondary Prevention post-ACS

A

75 mg PO once daily

87
Q

Prasugrel dose for Secondary Prevention post-ACS

A

10 mg PO once daily

88
Q

Ticagrelor dose for Secondary Prevention post-ACS

A

90 mg PO BID

89
Q

How long should you use P2Y12 Receptor antagonists in Secondary Prevention post-ACS patients?

A
  • if no stent: 1 year; bleeding concerns -> 14days - 1month
  • BMS/DES stent: 1 year; bleeding concerns -> 6 months
  • favorable DAPT score to extend, after 1 year of Ticagrelor 90mg BID, change to Ticagrelor 60mg BID
90
Q

What is the favorable DAPT scores to continue P2Y12 Receptor antagonist therapy?

A
  • Score ≥2 – favorable benefit/risk ratio for extending DAPT
  • Score < 2 – Unfavorable benefit/risk ratio
  • excludes patients who are on oral anticoagulation and/or patients with a high bleed risk
91
Q

triple anti-thrombotic therapy

A
  • Two antiplatelets + one anticoag

- Warfarin + ASA+ P2Y12 receptor antagonist

92
Q

managing triple anti-thrombotic therapy

A
  • Consider temporariliy holding the ASA therapy
  • Add ASA back when P2Y12 receptor antagonist or warfarin can be discontinued
  • Use clopidogrel as P2Y12 receptor antagonist
  • Target INR goal of 2-2.5
93
Q

Vorapaxar

A
  • Indicated for Secondary Prevention of MI but increases risk of bleeding
  • NOT to be used during AMI
  • Place in therapy is currently unknown
94
Q

ARA (Aldosterone Receptor Antagonists)

A
  • Should be added to patients stabilized on ACE-I (ARB) / Beta Blocker who have EF ≤ 40% AND EITHER symptomatic HF OR DM
  • Decreases risk of mortality
95
Q

ACE-I (ARB)

A
  • Will prevent cardiac remodeling
  • administered within 24 hours and continue indefinitely
  • mortality benefit
  • ARB’s should be given to pts who cannot take ACEI
96
Q

Beta Blockers in Secondary Prevention post-ACS

A
  • Oral agent should be initiated in the first 24 hours
  • Continued indefinitely
  • Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after ACS
  • non-ISA
  • treatment of SIHD, ALL beta blockers are equally efficacious
97
Q

Relative contraindications of beta blockers

A
  • prolong PR interval
  • asthma
  • COPD
98
Q

Absolute contraindications of beta blockers

A
  • 3rd degree or complete AV block

- cardiogenic shock

99
Q

CSA (chronic stable angina)

A
  • Stable coronary plaque
  • Angina precipitated by exertion or emotional stress and relieved by rest
  • Lack of biomarkers
  • Transient ST-segment changes that develop during symptomatic episodes that resolves when the patient becomes asymptomatic
100
Q

Pharmacotherapy to Prevent MI & Reduce Mortality

A
  • ASA
  • Clopidogrel is ADA is CI
  • Beta blockers
  • RAAS blockade
101
Q

In patients that have LV systolic dysfunction (EF ≤ 40%) with heart failure or prior MI, which beta blockers should be used?

A
  • carvedilol
  • metoprolol succinate
  • bisoprolol
102
Q

Pharmacotherapy to Relieve Ischemic Symptoms

A
  • Nitrates
  • Beta Blockers
  • Calcium Channel Blockers
  • Ranolazine
103
Q

Nitrates: effects on SIHD

A
  • Improve exercise tolerance
  • Improves time to angina onset
  • Improves time to ST-segment depression
104
Q

Short-Acting Nitrates

A
  • for ALL patients
  • Tablet: Max of 1.2 mg within 15 minutes; discard 6-12 months after opening
  • Spray: 1-2 sprays onto or SL
105
Q

Long-Acting Nitrates

A
  • when beta blockers are contraindicated or cause unacceptable side effects or, in combination with beta blockers, for relief of symptoms when initial treatment with beta blockers is unsuccessful
  • better in combination
  • Patch: 0.1-0.6 mg/hr, Allow 10-12 hour patch-free interval
106
Q

Nitrate Adverse effects

A
  • Dyspepsia
  • Headache
  • Flushing
  • Dizziness
  • Hypotension
  • Tachycardia
  • Tachyphylaxis
107
Q

Contraindications to Nitrates

A
  • Hypotension: SBP <90 mm Hg or ≥30 mm Hg below baseline
  • Tachycardia
  • Bradycardia
  • PDE5 inhibitors: Tadalafil / Cialis within 48 hours; Vardenafil / Levitra or Sildenafil / Viagra for 24 hours
108
Q

Calcium Channel Blockers

A
  • Non DHP helps with demand
  • DHP helps with increase in supply
  • Reduce angina symptoms
  • Increase exercise duration
  • Reduce SL nitroglycerin use
  • NO MORTALITY BENEFIT
109
Q

Ranolazine

A
  • Inhibitor of late sodium ion channels -> prevent influx of Ca into the cells
  • 500-1000 mg PO twice daily
  • Substitute for beta blocker
  • Can be added as background therapy
  • Reduces angina frequency
  • Improves exercise tolerance
110
Q

Monitoring for signs/symptoms of bleeding

A
  • Hypotension
  • Thrombocytopenia
  • aPTT
111
Q

When should you give prasugrel?

A

Only give at time of PCI for patients with NSTEMI

112
Q

What happens after clinician receives angiography results?

A

Will decide if pt gets medical therapy, PCI, or CABG

113
Q

When should you discontinue P2Y12 Receptor Antagonist for procedures?

A
  • Clopidogrel – 5 days prior
  • Ticagrelor – 5 days prior
  • Prasugrel – 7 days prior
114
Q

Outpatient Check-list for ACS patients

A
  • DAPT
  • ACEI or ARB
  • Beta blocker
  • Statin
  • Nitrate
  • Select patients: ARA, Vorapaxar
115
Q

Risk Factor Modification for cardiovascular diseases

A
  • Lipid Management
  • Blood Pressure Management
  • Diabetes Mellitus Management
  • Physical Activity
  • Weight Management
  • Smoking Cessation
  • Alcohol Moderation
116
Q

What is the BP target for pts with SIHD and HTN?

A

130/80 mmHg

117
Q

Isosorbide Mononitrate, IR

A
  • Monoket®

- 10-20 mg tablets give BID (7 hours apart)

118
Q

Isosorbide Mononitrate, ER

A
  • Imdur®

- 30, 60, 120 mg tablets given once daily in the AM

119
Q

Isosorbide Dinitrate, ER

A
  • Dilatrate SR®

- 40 mg once daily (If using BID: 18 hour dose-free interval )

120
Q

Isosorbide Dinitrate, IR

A
  • Isordil®

- 5-40 mg BID-TID (14 hour dose-free interval)

121
Q

Adverse effects of Ranolazine

A
  • Nausea / constipation
  • Headache
  • Dizziness
  • Hypotension
  • QTc Prolongation
122
Q

Contraindications of Ranolazine

A

cirrhosis

123
Q

Precautions of Ranolazine

A
  • In patients with history of malignancy

- Intestinal tumorigenesis

124
Q

Drug interactions of Ranolazine

A
  • Major CYP3A4 Substrate; cannot take with inducers or inhibitors of this enzyme
  • avoid grapefruit
  • do not exceed 20mg simvastatin daily
  • minor CYP2D6 substrate -> Dose adjust tricyclic antidepressants
  • P-glycoprotein inhibitors
125
Q

Why should you avoid use of short-acting nifedipine?

A

can cause reflex tachycardia

126
Q

CCB drug interactions

A
  • CYP3A4 Substrate; do not exceed 20mg simvastatin w/ amlodipine; do not exceed 10mg simvastatin w/ non DHP CCB
  • beta blockers
127
Q

CCB comorbid conditions

A
  • HFrEF

- Cardiac conduction deficits: tachy or brady cardia

128
Q

non DHP CCB adverse effects

A
  • bradycardia

- constipation

129
Q

DHP CCB adverse effects

A
  • peripheral edema
  • flushing
  • headache

OU Module Cardio Spring 2018 (16 decks)

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