C&R E2 Flashcards
SIHD ACS PAD HF (148 cards)
1
Q
Antithrombotic therapy is ____ + ____
A
Anticoagulant
Antiplatelet
2
Q
Antiplatelets therapies are
A
Aspirin
P2Y12 inhibitors (ticagrelol, prasugrel, ,clopidogrel)
G2a/3b inhibitors
3
Q
P2Y12 inhibitors are
A
ticagrelor, prasugrel, clopidogrel
4
Q
Anticoagulant therapies are
A
Heparin
Enoxaparin
Bivalirudin
Argatroban
Fondaparinux
5
Q
SIHD therapy goal
A
prevent future rupture, so Antiplatelet agents 1 -2
6
Q
ACS therapy goal
A
Stop the current process, so antiplatelet agents 2 -3 and anticoagulant
Prevent exacerbation in the future, so antiplatelet agents 1 - 2
7
Q
Order of PO P2Y12i therapies? what is it antiplatelet or anticoagulant? what used for?
A
antiplatelets, used for both SIHD and ACS
pretty tiger cubs
prasugrel + ticagrelor > clopidogrel
8
Q
when is an anticoagulant used?
A
only ACS
9
Q
Prasugrel Dosing and what use?
A
PCI only
Load: 60mg
Maint: 10mg QD, 5mg only if less than 60kg or over 75 yo
10
Q
GP 2b/3a’s biggest side effect?
A
acute profound thrombocytopenia
11
Q
Clopidogrel what used for?
A
Medical Management, PCI, and STEMI with thrombolytics
12
Q
Ticagrelor what used for?
A
PCI and medical management only
13
Q
pt has stemi with thrombolytics, what kind of p2y12 can you use?
A
clopidogrel only
14
Q
pt needs PCI, what kind of p2y12 can you use?
A
Prasugrel, Ticagrelor, and clopidogrel
15
Q
pt needs medical management, what kind of p2y12 can you use?
A
Ticagrelor and clopidogrel
16
Q
Clopidogrel PCI Dosing
A
Load 600 mg ASAP
MD 75mg QD
17
Q
Clopidogrel Medical Management Dosing
A
Load 300 - 600mg
MD 75 mg QD
18
Q
Clopidogrel STEMI with thrombolytics
A
Load 300mg, 75 if greater than 75 yo
MD 75mg QD
19
Q
Ticagrelor PCI dosing?
A
load 180mg
MD, 90mg BID then 60mg BID after 12 months
20
Q
Ticagrelor Medical management dosing?
A
same as PCI dosing
load 180mg
MD, 90mg BID then 60mg BID after 12 months
21
Q
Prasugrel
How long D/C prior to surgery
ADE
Contraindications
A
D/C 7 days prior
ADE bleeding
Contra is hx of stroke/tia with less than 60kg and older than 75 yo being relative contra
22
Q
Ticagrelor
How long D/C prior to surgery
ADE
Contraindications
DDI
A
D/C 5 days prior
ADE dyspnea, bradycardia, bleeding
contra is hx of cerebral bleed, and severe liver disease
DDI is to avoid concomitant strong CUP3A4 inhibitors and inducers, max ASA dose is 100mg QD
23
Q
Clopidogrel
How long D/C prior to surgery
ADE
Contraindications
A
D/C 5 days prior
ADE bleeding
NO CONTRA
thats why pkpd is terrible but still keep because it has no contra and its the only one that can be used with fibrinolytic on board
24
Q
Anticoagulation recommendations?
A
ACS event? immediately place an anticoag rx (heparin or enoxaparin)
Medical management: Heparin for 48hrs and enoxaparin for 7 days
early invasive: until the procedure is done
25
Ranolazine DDI with which enzyme and which P2y12 inhibitor?
DDI with CYP3A4, 2D6, and pGp
therefore, can not be used with ticagrelor because tig is meta by 3A4
26
which CCB can be used with BB?
DHP can (amlodipine, nifedipine ER)
27
which CCB can NOT be used with BB?
non DHP can NOT be used (Diltiazem ER)
28
G2a3b MOA and pearl?
potent antiplatelet agents that block the binding site for fibrinogen
Increases bleed risk, especially in combination with aspirin, a P2Y12 inhibitor and an anticoagulant
29
MRA initiation is contraindicated in what?
GFR
SCR
K
GFR < 30ml/min
SCR > 2.5 (M), > 2 (F)
K > 5 (hyperkalemia)
30
MRA initiation is okay when?
GFR
SCR
K
GFR > 30ml/min
SCR < 2.5 (M) or < 2 (F)
K < 5
31
Fibrinolytic therapy should be used when....
door to balloon is greater than 90mins
32
Fibrinolytic therapy should be used in caution when....because of increased bleed risk
when you have an ASA, P2Y12, and an anticoag on board
33
Clopidogrel is useful because....
only P2Y12 inhibitor that can be used with a fibrinolytic (which will be used if door to balloon is greater than 90 mins)
AND NO CONTRA
34
Fibrinolytics/thrombolytic therapy examples and their corresponding specificity:
Alteplase (tpa) -- least specific, so high bleed risk
Reteplase
Tenecteplase -- most specific, so low bleed risk
35
What is cilostazol used for?
for symptomatic relief of PAF and to increase walking distance in patients with claudication
36
Cilostazol MOA
inhibits phosphodiesterase III and inhibits vascular smooth muscle cell proliferation
37
Cilostazol takes how long to work?
effect on walking is within 2 - 4 wks but may take up to 12 weeks
38
Cilostazol BBW
Contra in patients with HF
39
Cilostazol ADE and DDI?
HA and GI upset/diarrhea
many DDI
40
What is HF?
It is a decrease in cardiac output such that the cardiac output isn't able to meet the demands of the body
41
What is HFrEF
Your heart pump doesn't work so <40% of the blood in the ventricle leaves when it contracts
EF <40%
42
What is HFpEF
Your LV isn't filling properly but does contract. So the same % of the blood is leaving the ventricle but from a smaller starting volume.
EF >50%
43
what type of HF has EF >50%
HFpEF
44
what type of HF has EF <40%
HFrEF
45
Morbidity and Mortality reducing drugs for HF
BB
RAAS Inhibition
MRA
SGLT2
Vaso/Veno dilators
46
Morbidity-reducing drugs for HF
Ivabradine
Soluble guanylate cyclase stimulators
Digoxin
Diuretics
47
Sacubitril/valsartan brand name?
Entresto
48
Sacubitril/valsartan contraindications
Prego and hx of angioedema
49
Sacubitril/valsartan MOA
Sacubitril: blocks breakdown of BNP resulting in natriuresis and vasodilation
Valsartan: blocks angiotensin receptor
50
Sacubitril/valsartan drug interactions
ACE inhibitors (36 hr washout)
51
Sacubitril/valsartan monitoring
Blood pressure (because the ARNI will drop bp more than ACE/ARB)
Electrolytes and renal function 2 - 4 weeks after initiating therapy or changing disease
52
Sacubitril/valsartan ADE
hyperkalemia
53
Sacubitril/valsartan pearls
Do not initiate if K >5.5 and D/C rx if > 5.6
Protects the myocardium from remodelling/hypertrophy in patients with HF
Do not use RAAS drugs in combination
54
ACEi Contra
Prego
hx of angioedema
No use within 36 hrs of an ARNI
55
ACEi monitoring
electrolytes and renal function 2 - 4 weeks post initiation
56
ACEi Pearls
Target organ protection, drug of choice in pts with DM/HF/Post MI, stroke and or CKD
Do not initiate if K > 5 and D/C rx if > 5.6
Protects the myocardium from remodelling/hypertrophy in patients with HF
Do not use RAAS drugs in combination
57
Enalapril brand name
Vasotec
58
Lisinopril brand name
Prinivil/Zestril
59
Entresto target doses?
97/103 mg BID
60
Entresto starting doses?
24/26 mg - 49/51mg BID
61
Lisinopril doses starting?
2.5 - 5mg QD
62
Lisinopril doses target?
20 - 40mg QD
63
ARB contraindications
prego ONLY
64
ARB Monitoring
electrolytes and renal function 2 - 4 weeks post initiation
65
ARB Monitoring
electrolytes and renal function 2 - 4 weeks post initiation
66
ARB ADE
hyperkalemia
67
ARB Pearls
target organ protection...
Do not initiate if K > 5 and D/C if K > 5.6
Do not use RAAS drugs in combination
No wash out period needed with ARNI
Less dry cough/angioedema vs ACE
68
Losartan Brand?
Cozaar
69
Valsartan Brand?
Diovan
70
Losartan Dose starting
25 - 50 QD
71
Valsartan Dose starting?
40mg BID
72
BB MOA
decreases HR and myocardial contractility, which is why only used in chronic HF pts
If in acute decompensated hf, will need to increase CO to compensate
73
BB Contra
Severe Bradycardia
74
BB ADE
Bradycardia, bronchospasm
75
BB Pearls
Must be tapered on D/C
Only carvedilol, bisoprolol, and metoprolol succinate have mortality benefit in HF
DO NOT INITIATE WHEN IN EXACERBATION (ADHF), JUST TRY TO REDUCE THE DOSE IN EXACERBATION -- TRY NOT TO D/C COMPLETELY (possible rebound htn)
76
Which bb in hf?
Carvedilol
Bisoprolol
Metoprolol Succinate
77
Bisoprolol Brand?
Zebeta
78
Metoprolol succinate brand?
Toprol XL
79
Carvedilol brand?
Coreg
80
Cardioselective BB
Bisoprolol and Metoprolol Succinate
81
Non-cardioselective BB (alpha and B blockade)
Carvedilol, therefore can help push bp down lower
82
Bisoprolol dose starting and target dose?
start 2.5 QD, target is 10mg QD
83
Metoprolol succinate starting and target dose?
12.5 - 25mg QD
200mg QD
84
Carvedilol dose starting and target dose?
3.125 - 6.25mg BID
25mg BID but if > 85kg then 50mg BID m
85
MRA Contra
Hyperkalemia (K > 5), anuria, and CrCl < 30ml/min
86
MRA DDI
Eplerenone is a CYP3A4 substrate
87
MRA Monitoring
monitor electrolytes and renal function at 2 -3 days following initiation, then 7 days after initiation/titration, then check monthly for 3 months then every 3 months afterwards
88
MRA ADE
dehydration, hyponatremia, dizziness
Spironolactone: gynecomastia, breast tenderness, impotence
89
Eplerenone starting and target dose?
25mg QD - 50mg QD
90
Spironolactone starting and target dose?
12.5 - 50mg QD
91
MRA for HF is ---- than MRA for HTN
LOWER
92
SGLT2i Contra
Dapagliflozin GFR < 30
Empagliflozin GFR < 20
93
SGLT2i Monitoring
500ml UO
94
SGLT2i ADE
Genetical mycotic infections/UTI
Dehydration
95
SGLT2i pearls
may require adjustment to loop diuretic doses
96
Dapagliflozin and Empagliflozin dose?
10mg QD, only titrate up if for DM control
97
Direct Vasodilators Monitoring
BP/HR and drug induced lupus
98
Direct vasodilators ADE
reflex tachycardia, peripheral edema, palpitations, DILE
99
Direct venodilators CONTRA
Concomitant use with PDE5 inhibitors
100
Direct Venodilators Monitoring
BP and HR
101
Direct Venodilators Pearls
Isosorbide dinitrate + Hydralazine (BiDil) is approved for HFrEF
Need to prevent nitrate tolerance by providing a 10 - 14 hour nitrate free exposure (usually in sleep because chronic therapy decreases efficacy)
102
Hydralazine Brand?
Apresoline
103
Hydralazine starting dose?
25mg TID
104
Hydralazine target dose?
75mg TID
105
Isosorbide dinitrate starting?
20mg TID
106
Isosorbide dinitrate target?
40mg TID
107
Loop diuretics CONTRA
hypersensitivity to sulfa drugs
108
Loop diuretics DDI
NSAID use/drugs that retain water
109
Loop diuretics monitoring
electrolytes and renal function REGULARLY
110
loop diuretics ADE
hypokalemia, hypocalcemia, hyperuricemia
KAU
111
loop diuretics pearls
consider ethacrynic acid if pt has a true sulfa allergy
May need K supplementation if hypokalemia too much
112
Ivabradine brand?
Corlandor
113
Vericiguat brand?
verquvo
114
Ivabradine MOA
impacts the funny channel in the SA node and only decreases HR (not bp)
Hence why the requirement is HR > 70 only
115
Ivabradine CONTRA
sever hepatic impairment, acute decompensate HF, HYPOtension, abnormal heart rhythm
116
Ivabradine monitoring
heart rate and rhythm
117
Ivabradine ADE
bradycardia, afib
118
Ivabradine pearl
Morbidity drug only
decreases HF hospitalizations NOT Mortality
119
Morbidity and mortality rx HF
BB
RAASi
MRAs
vaso/venodilators
SGLT2s
120
Morbidity rx HF only
Ivabradine
Vericigut (soluble guanylate cyclase stimulator)
Digoxin
Diuretics
121
Vericiguat contra?
PREGO
122
vericiguat DDI?
Do not use with PDE5 inhibitors
123
vericiguat Monitoring
negative prego test (that's how much prego is contra) and bp
124
vericiguat pearl
decreases HF hospitalizations, not HF mortality
125
Digoxin DDI
PgP and CY3A4
126
Digoxin Monitoring
HR and rhythm
Serum concentrations ideally a trough of 0.5 - 0.9
127
Digoxin Pearls
Beers Criteria
decrease HF hospitalization, not HF mortality
128
Losartan target dose?
150mg QD
129
Valsartan target dose?
160mg BID
130
IV NTG Drug Class
Vasodilator
131
IV NTG CONTRA
Concurrent use with PDE5 inhibitors (-fil ending)
concurrent use with soluble guanylate cyclase stimulators
132
IV Nitroprusside drug class
vasodilator
133
IV Nitroprusside vs IV NTG
Nitroprusside has more bp impact than NTG
Therefore only use if bp is high enough to be dropped
134
IV Nitroprusside Monitoring
BP, cyanide and thiocyanate toxicity (especially if on for more than 3 days for > 3mcg/kg/min)
135
IV Dobutamine drug class?
Inotrope
136
IV Dobutamine drug interactions
increases arrhythmogenic potential in combination with other proarrhythmic agents
137
IV Dobutamine ADE
Increase or decrease in BP, increased HR, arrhythmia
138
IV Dobutamine Pearls
HIGH RISK OF ARRHYTHMIA
low risk of hypotension
139
IV Milrinone Drug Class
Inotrope therefore might have an impact on arrhythmia potential
140
IV Milrinone DDI
Anagrelide is category X
141
IV Milrinone Pearls
Moderate risk of arrhythmia
HIGH RISK OF HYPOTENSION
Renally eliminated (more renal dysfunction, the more drug exposure and concerns for hypotension)
142
Norepinephrine drug class?
Vasopressors
143
Epinephrine drug class?
vasopressors
144
Dopamine drug class?
vasopressors
145
Vasopressors DDI
Increases arrhythmogenic potential in combination with other pro-arrhythmic agents
146
Vasopressors ADE
Increases BP, increased HR, arrhythmia, extravasation (may cause necrosis of tissue if outside IV site)
147
Vasopressors ADE
Increases BP, increased HR, arrhythmia, extravasation (may cause necrosis of tissue if outside IV site)
148
Vasopressors ADE
Increases BP, increased HR, arrhythmia, extravasation (may cause necrosis of tissue if outside IV site)
