Cardiology Flashcards
(274 cards)
1
Q
TIMI Risk Score
A
Thrombolysis In Myocardial Infarction
0-2: low risk
3: intermediate risk
4+: high risk
Score of 3 or more have greater benefit from LMWH, GP IIb/IIIa inhibitors, and invasive strategies for NSTEMI/UA only!
Only use for NSTEMI/UA!
2
Q
GRACE Risk Score
A
Global Registry of Acute Coronary Events
> 140: high score, qualifies for early invasive strategies
3
Q
UA vs NSTEMI
A
NSTEMI has positive biomarkers (UA has none)
NSTEMI causes myocardial injury
4
Q
Performance measure for time to PCI
A
90 minutes
5
Q
Performance measure for fibrinolytic therapy
A
If PCI cannot be done within 120 minutes, then door-to-needle time of 30 minutes for fibrinolytic therapy
6
Q
NSTEMI Ischemia Guided Antiplatelet & Anticoag regimen
A
Aspirin
Clopidogrel or Ticagrelor
Enoxaparin, fondaparinux, UFH
7
Q
NSTEMI Invasive Management Antiplatelet & Anticoag regimen
A
Aspirin
Ticagrelor > Prasugrel > Clopidogrel
GP IIb/IIIa inhibitor if high risk
Enoxaparin, bivalrudin, UFH
8
Q
STEMI PCI Antiplatelet &Anticoag management
A
Aspirin
Clopidogrel, prasugrel, or ticagrelor
GP IIb/IIIa inhibitor if high risk
UFH, bivalrudin
9
Q
STEMI + Fibrinolytic Antiplatelet & Anticoag management
A
Aspirin
Ticagrelor > clopidogrel
GP IIb/IIIa inhibitor if high risk
UFH, enoxaparin, fondaparinux
10
Q
Clopidogrel load, maintenance dose, surgery hold time
A
300-600mg load
75mg daily
5 days
11
Q
Prasugrel load, maintenance dose, surgery hold time
A
60mg load
10mg daily
5mg daily if <60kg, >/= 75 y/o
7 days
12
Q
Ticagrelor load, maintenance dose, surgery hold time
A
180mg load
90mg BID
May be reasonable to go to 60mg BID after 1 year
3-5 days
13
Q
Clopidogrel box warning, contrainidications, pertinent DDI
A
BBW: CYP2C19 polymorphisms
CI: Active bleeding
DDI: esomeprazole/omeprazole (use pantoprazole, rabeprazole); increased bleeding w/ NSAIDs, OAC, O3FA
14
Q
Prasugrel box warning, contraindications, pertinent DDI
A
BBW: age-related bleeding, CVA/TIA
CI: Active bleeding, CVA/TIA
*Do not give as load until know cardiac anatomy
DDI: increased bleeding with NSAIDs, OACs
15
Q
Ticagrelor box warning, contrainidcations, pertinent DDI
A
BBW: aspirin dosing >100mg
CI: Active bleeding, ICH, severe hepatic disease
DDI: strong CYP3A4 inhibitors/inducers; DNE simva/lova 40mg; increased bleeding with NSAIDs, OACs
16
Q
Cangrelor dosing
A
IV P2Y12 inhibitor
30 mcg/kg IV bolus followed by 4 mcg/kg/minute infusion
17
Q
Eptifibatide dosing
A
180mcg/kg IV bolus x2 10 min apart, then 2mcg/kg/min for 18-24 hours. Initiate after first bolus.
CrCl < 50ml/min: reduce by 50%
Hemodialysis: avoid (not studied SCr >4)
18
Q
Tirofiban dosing
A
25 mcg/kg IV bolus over 3 minutes, then 0.15 mcg/kg/min for 18 hours
CrCl </= 60 ml/min: reduce by 50%
19
Q
UFH dosing NSTEMI
A
60 units/kg IV bolus (max 4000 units) then 12 units/kg/hr (max 1000 units/hr) for 48 hours
20
Q
UFH dosing PCI with GP IIb/IIIa inhibitor
A
50-70 unit/kg bolus
21
Q
UFH dosing PCI without GP IIb/IIIa inhibitor
A
70-100 units/kg IV bolus
22
Q
Enoxaparin dosing NSTEMI
A
1mg/kg SC q12H
30mg IV bolus
CrCl < 30 ml/min: 1mg/kg SC daily
23
Q
Enoxaparin dosing NSTEMI PCI
A
If last dose > 8 hours ago, 0.3 mg/kg IV bolus
CrCl <30 ml/min: 1mg/kg daily
24
Q
Enoxaparin dosing STEMI PCI
A
30mg IV bolus, followed immediately by 1mg/kg SC q12H (not to exceed 100mg on first two doses)
If > 75 y/o, omit bolus, 0.75mg/kg q12H (not to exceed 75mg on first two doses)
CrCl < 30 ml/min: 1 mg/kg daily
25
Fondaparinux dosing NSTEMI
2.5mg SC daily
26
Fondaparinux dosing PCI
Not recommended as sole anticoagulant
27
Fondaparinux dosing STEMI + PCI
2.5mg IV bolus then 2.5mg SC daily; not to be used as sole anticoagulant
28
Bivalrudin dosing NSTEMI, early invasive
0.1mg/kg IV bolus then 0.25mg/kg/hr IV
29
Bivalrudin dosing PCI
0.75mg/kg IV bolus then 1.75mg/kg/hr
CrCl < 30 ml/min: 0.75mg/kg bolus then 1mg/kg/hr
HD: 0.75 mg/kg bolus then 0.25mg/kg/hr
30
UFH contraindication
History of HIT
31
Enoxaparin contraindication
History of HIT
32
Fondaparinux contraindication
CrCl < 30 ml/min
33
UFH dosing with fibrinolytic
60 unit/kg bolus (max 4000 units), then 12 units/kg/hr (max 1000 units/hr) for at least 48 hours
34
Enoxaparin dosing with fibrinolytic
30mg IV (omit if > 75), followed by 1 mg/kg SC q12H for duration of hospitalization
Max 100mg (75mg if > 75) for first two doses
35
Fondaparinux dosing with fibrinolytic
2.5mg IV, followed by 2.5mg SC daily for hospitalization
36
Alteplase dosing
Acute MI Dosing
67: 15mg IVP over 1-2 minutes, then 50mg over 30 min, then 35mg over 1 hour (max 100mg total)
37
Reteplase dosing
Indicated for acute MI only
10 units IVP x2 30 min apart
38
Tenecteplase dosing
<60 kg: 30mg IVP
60-69kg: 35mg IVP
70-79kg: 40mg IVP
80-89kg: 45mg IVP
>/=90kg: 50mg IVP
39
Relative Contraindication to Fibrinolytics
-BP > 180/110, poorly controlled HTN
-History of ischemic stroke >3 months before
-Recent major surgery <3 weeks before
-Traumatic or prolonged CPR (>10min)
-Recent internal bleeding (within 2-4 weeks)
-Active peptic ulcer
-Noncompressible vascular punctures
-Pregnancy
-Known intracranial pathology (dementia)
-OAC therapy
40
Absolute contraindications to fibrinolytic therapy
-Any prior hemorrhagic stroke
-Ischemic stroke within 3 months
-Intracranial neoplasm or ateriovenous malformation
-Active internal bleeding
-Aortic dissection
-Considerable facial trauma or closed-head trauma in past 3 months
-Intracranial or intraspinal surgery within 2 months
-Severe uncontrolled HTN
41
Duration of DAPT therapy after ACS
(ischemia guided or stent)
12 months
42
Duration of DAPT if SIHD, elective stent placement
6 months can be considered
43
Long-term DAPT
>12 months if high ischemic risk and no bleeding while on therapy
Studies used clopidogrel mainly
DAPT score > 2 shows increased benefit for long DAPT
44
Beta-blocker after ACS
Indicated for all patients
Initiate in first 24 hours (if unable, reevaluate before discharge)
45
ACE-I after ACS
Indicated for all patients w/ EF <=40%, HTN, DM, CKD
CI: hypotension, pregnancy, bilateral renal artery stenosis
46
Aldosterone antagonist after ACS
Indicated in patients receiving ACE-I and BB, have EF <=40% AND symptomatic HF or diabetes
Administer ASAP
CI: Hyperkalemia, CrCl <30 ml/min, SCr >2.5 (men), 2.0 (women)
47
Statin after ACS
High intensity recommended within first 24 hours, preferably before PCI
48
LDL Treatment goal post ACS
LDL < 55
>50% reduction in LDL from baseline
If second CV event in 2 years, can consider LDL <40.
49
NSAID after ACS
Discontinue
May consider nonselective NSAIDs (naproxen)
50
Vaccination post ACS
Pneumococcal
Influenza
51
CABG management
Continue aspirin
Stop clopidogrel or ticagrelor for at least 24 hours prior
Stop GP IIb/IIIa inhibitor 2-4 hours before surgery
52
Triple therapy in AF undergoing PCI
Minimize
Discontinue aspirin at time of discharge
If stent thrombosis high risk, continue aspirin for 1 month
DOAC > Warfarin
Clopidogrel preferred
PPI
53
Congestion in ADHF
Elevated PCWP
-Dyspnea on exertion or rest
-Orthopnea, paroxysmal nocturnal dyspnea
-Peripheral edema
-Rales
-Early satiety, N/V
-Ascites
-Hepatomegaly, splenomegaly
-Jugular venous distention
-Hepatojugular reflux
54
Hypoperfursion in ADHF
Low CO
-Fatigue
-AMS, sleepy
-Cold extremities
-Worsening renal function
-Narrow pulse pressure
-Hypotension
55
Cardiac output equation
CO = SVR * HR
56
Cardiac index equation
CI = CO/BSA
57
MAP equation
MAP = DBP + [1/3(SBP - DBP)]
58
SVR equation
SVR = [(MAP - CVP)/CO] * 80
59
Warm and Dry background, management
Category I "compensated"
High CI > 2.2
Low PCWP 15-18
Optimize GDMT
60
Warm and Wet background, management
Category II "pulmonary congestion"
High CI > 2.2
High PCWP >18
IV diuretic +/- IV vasodilator (venous to relieve pulmonary congestion, arterial if no hypotension)
61
Cold and Dry background, management
Category III "hypoperfusion"
Low CI <2.2
Low PCWP 15-18
PCWP <15 = IVF
PCWP >= 15, SBP <90: IV inotrope
PCWP >= 15, SBP >=90: IV vasodilator (arterial) +/- IV vasopressor
62
Cold and Wet background, management
Category IV "pulmonary congestion & hypoperfusion"
Low CI <2.2
High PCWP >18
IV diuretic +/-
SBP >= 90: IV vasodilator (arterial)
SBP <90: IV inotrope +/- IV vasopressor
63
Loop diuretic equivalent dosing
Furosemide PO 40mg = bumex 1mg = torsemide 20mg = ethacrynic acid 50mg
PO:IV all 1:1 except furosemide is 2:1
Torsemide has no IV option
64
Drug of Choice for ADHF + Active Ischemia
Nitroglycerin
65
Vasodilator commonly used as venodilator
Nitroglycerin
Arterial @ high doses
66
Vasodilator commonly used as arterial vasodilator
Nitroprusside
67
Sodium nitroprusside dosing in ADHF
0.1-0.2 mcg/kg/min IV
Increase by 0.2-0.3 mcg/kg/min every 5 min
Max 10 mcg/kg/min
Not to be used for >10 min
68
Nitroglycerin dosing in ADHF
5 mcg/min IV
Increase by 5mcg/min every 5-10 min
Max 200 mcg/min
69
Favor milrinone
To avoid discontinuing home BB (no chronotropic effects)
High pulmonary arterial pressure
70
Favor dobutamine
Severe hypotension
Bradycardia
Thrombocytopenia
Severe renal impairment
71
Dobutamine dosing
2.5-5 mcg/kg/min
Max 20 mcg/kg/min
72
Milrinone dosing
0.125-0.25 mcg/kg/min
Max 0.75 mcg/kg/min
73
Tolvaptan indication, dosing, CI
Clinically significant hyponatremia associated with HF
15mg daily
Titrated to 30-60mg prn
CI: CYP3A4 inhibitors, CrCl <10, caution against use >30 days
74
Maximum sodium correction in 24 hours
8-10 mEq/L
75
Epinephrine dosing in CPR
1mg Q3-5 min
76
Amiodarone dosing in CPR
300mg IV/IO x1, then 150mg bolus
77
Lidocaine dosing in CPR
Only if amiodarone unavailable
1.5mg/kg IV, repeat 0.5-0.75mg/kg q5-10min
Max 3 mg/kg
78
Goal temperature in TTM
32-36C
79
Agents to reverse shivering In TTM
Meperidine
Buspirone
Clonidine
Dexmedetomidine
NMBA
80
Blood glucose goal during TTM
140-180
81
Symptomatic bradycardia DOC, second line
DOC: Atropine 1mg q3-5min, max 3 mg
If atropine fails:
dopamine 5-20mcg/kg/min
or epinephrine 2-10 mcg/min
82
Narrow QRS with regular ventricular rhythm management
SVT or sinus tachycardia
First line: vagal maneuvers or adenosine 6mg IVP, followed by 20 mL NS flush, then adenosine 12mg IVP
If both fail:
CCB or BB
83
Narrow QRS with irregular ventricular rhythm management
Atril fibrillation
Diltiazem, verapamil
BB
Sometimes digoxin
84
Pharmacologic options for cardioversion for AF
AF <7 days: flecainide, dofetilide, propafenone, ibutilide, amiodarone
AF >7 days: dofetilide, amiodarone, ibutilide
85
Wide complex QRS, VT
Regular & monomorphic: adenosine
IV procainamide, amiodarone, sotalol
Second line: lidocaine
86
DOC for Wolff Parkinson White syndrome w/ AF
Procainamide
*Avoid BB, diltiazem, verapamil, digoxin, sotalol, amiodarone, anything AV nodal blocking
87
Wide QRS with irregular VT
Unstable: defibrillation
Stable: IV magnesium 1-2gm bolus
Discontinue Class I & III antiarrhythmics
Assess for QTc prolonging drugs
88
Quinidine dosing
Class Ia Antiarrhythmic (Na blocker)
AF and VT Maintenance only
Sulfate: 200-400mg PO q6h
Gluconate (CR): 324mg q8-12H
CrCl <10: decrease by 25%
89
Quinidine pearls (AE, DI)
Class Ia Antiarrhythmic (Na blocker)
AE: N/V/D; TdP (first 72 hrs)
Do not use in AF conversion d/t GI AE
DI: Warfarin, digoxin, 2D6 or 3A4
90
Procainamide dosing
Class Ia Antiarrhythmic (Na blocker)
AF conversion: 1gm IV x30 min, then 2mg/min
VT conversion: 30 mg/min IV up to 17mg/kg, arrhythmia ceases, hypotension, QRS widens > 50%
VT maintenance: 1-4mg/min
No PO option
Reduce in liver, renal dysfunction
91
Procainamide pearls (AE, CI)
Class Ia Antiarrhythmic (Na blocker)
AE: hypotension, TdP
CI: LVEF <40%
92
Disopyramide dosing
Class Ia Antiarrhythmic (Na blocker)
AF conversion:
<50kg: 200mg q6h
>50kg: 300mg q6h
AF maintenance: 400-800mg/day
IR and CR options
<50kg, CrCl >40 OR hepatic dysfunction: max 400mg/day
CrCl 30-40 ml/min: 100mg IR q8h
CrCl 15-30 ml/min: 100mg IR q12h
CrCl <15 ml/min: 100mg IR q24h
VT: not used anymore
93
Disopyramide pearls (AEs, CI)
AE: anticholinergic, TdP, ADHF
CI: cardiogenic shock, long QT syndrome, 2nd-3rd degree AVB, glaucoma
94
Class Ia Antiarrhythmics
Na+ channel blocker
Quinidine, procainamide, disopyramide
Decrease conduction velocity
Increase refractory period
Increase QRS complex
Increase QT interval
95
Class Ib Antiarrhythmics
Na+ channel blocker
Lidocaine, mexiletine, phenytoin
Decrease conduction velocity
Inc/Dec refractory period
Decrease QT interval
Indication: Ventricular arrhythmia only
96
Class Ic Antiarrhythmics
Na+ channel blocker
Flecainide, propafenone
Major decrease in conduction velocity
No change on refractory period
Increase QRS complex
97
Class II Antiarrhythmics
Beta blockers
Metoprolol, esmolol, atenolol
Decrease conduction velocity
Increase refractory period
Decrease HR
Increase PR interval
98
Class III Antiarrhythmics
K+ channel blockers
Amiodarone, dronedarone, sotalol, dofetilide, ibutilide
No change on conduction velocity
Major increase in refractory period
Increase QT interval
99
Class IV Antiarrhythmics
Ca2+ channel blockers
Diltiazem, verapamil
Decrease conduction velocity
Increase refractory period
Decrease HR
Increase PR interval
100
Lidocaine dosing for antiarrhythmic
Class Ib Antiarrhythmic
VT maintenance: 1-4 mg/min
Reduce in hepatic disease, HF, renal dysfunction
101
Lidocaine pearls (AEs, CI)
AE: CNS related - perioral numbness, seizure, confusion, blurry vision, tinnitus
CI: 3rd degree AVB
102
Mexiletine dosing
Class Ib Antiarrhythmic
VT Maintenance: 200-300mg PO q8h
Max 1200mg/day
Reduce dose by 25-30% in hepatic impairment
103
Mexiletine pearls (AEs, CI)
AE: CNS (tremor, dizziness, ataxia, nystagmus)
CI: 3rd degree AVB
104
Propafenone dosing
Class Ic Antiarrhythmic
AF conversion: 600mg x1
Reduce to 450mg if <70kg
AF maintenance:
IR: 150-300mg q8-12h
SR: 225-425mg q12h
Reduce by 70-80% in hepatic impairment
105
Propafenone pearls (AE, DI, DI)
AE: metallic taste, dizziness, ADHF, bronchospasm, bradycardia, heart block
CI: NYHA III-IV HF, liver disease, TdP, CAD, MI
DI: Digoxin, warfarin
106
Flecainide dosing
Class Ic Antiarrhythmic
AF conversion: 300mg x1
AF maintenance: 50-150mg BID
CrCl <35 ml/min: reduce by 50%
107
Flecainide pearls (AE, CI, DI)
AE: Dizziness, tremor, ADHF, vagolytic, anticholinergic, hypotension
CI: HF, CAD, TdP
DI: Digoxin
108
Amiodarone dosing for arrhythmia
Class III Antiarrhythmic
AF conversion:
IV: 5-7mg/kg IV over 30-60 min, then 1.2-1.8g/day continuous IV (or divided PO dose until 6-10 gm load)
PO: 1.2-1.8 g/day in divided doses until 6-10 g
AF maintenance: 200-400mg
Stable VT: 150mg IV bolus for 10 min, then 1mg/min x6 hours, then 0.5mg/min (max 2.2 g/day)
109
Amiodarone pearls (AE, CI, DI)
AE: lungs (pulmonary fibrosis), thyroid (hyper/hypo thyroid), eyes (corneal deposits)
photosensitivity/blue-gray skin, TdP, heart block, neurologic toxicity, bradycardia
CI: iodine hypersensitivity, hyperthyroid, 3rd degree AVB
DI: warfarin, digoxin, statin (max simvastatin 20mg, lovastatin 40mg), phenytoin, lidocaine, etc.
110
Sotalol dosing
Class III Antiarrhythmic
AF maintenance:
CrCl > 60 ml/min: 80mg BID
CrCl 40-60 ml/min: 80mg daily
VT maintenance
CrCl > 60 ml/min: 80mg BID
CrCl 30-60 ml/min: 80mg daily
CrCl 10-30 ml/min: 80mg q36-48h
CrCl <10 ml/min: 80mg q48h
Not effective for AF conversion
111
Sotalol pearls (AE, CI, BW)
AE: ADHF, bradycardia, AVB, wheezing, TdP (wihtin 72 hrs), bronchospasm
CI: Baseline QTc >440, LVEF <40%, 2nd/3rd degree AV block, Sinus sick syndrome
BBW: do not initiate if QTc >450. If Qtc >500 during therapy, reduce dose or discontinue.
--Initiate while in hospital
112
Dofetilide dosing
Class III Antiarrhythmic
AF conversion & maintenance:
CrCl >60 ml/min: 500mcg BID
CrCl 40-60 ml/min: 250mcg BID
CrCl 20-39 ml/min: 125 mcg BID
*Use ABW for CrCl
CrCl <20 ml/min: not recommended
113
Dofetilide pearls (AE, CI, BBW)
AE: TdP, diarrhea
CI: Baseline QTc >440 or intraventricular conduction delay with baseline QTc >500; CrCl <20
DI: CYP3A4 inhibitors, drugs renally excreted
BBW: hospitalization MANDATORY for initiation. Monitor QTc q2-3 hrs after each first 5 doses, reduce by 50% if Qtc increased by 15%. NTE QTc >500
114
Ibutilide dosing
Class III Antiarrhythmic
AF conversion (can repeat after 10 min):
>=60kg: 1mg IV
<60kg: 0.01 mg/kg
115
Ibutilide pearls (AE, CI, BBW)
AE: TdP, AV heart block
CI: Baseline QTc >440, LVEF <30%, concomitant AADs
BBW: Fatal arrhythmias (irregular VTs) - patients w/ chronic AF not preferred for converting
116
Dronedarone dosing
Class III Antiarrhythmic
AF maintenance: 400mg BID
117
Dronedarone pearls (AE, CI, BBW, DI)
AE: worsening HF, QT prolongation, hypokalemia/magnesemia, hepatic failure
CI: QTc>=500, PR >= 280, NYHA class IV HF (or II-III w/ recent ADHF hosp), severe hepatic impairment, 2nd/3rd degree AVB, HR <50
BBW: Risk of death is doubled when used with symptomatic HF. Use in patients w/ permanent AF doubles risk of death, stroke, hospitalization
Discontinue if QTc >= 500
DI: digoxin (reduce by 50%), BB, nonDHP CCB, clonidine, statins (simva 10mg, lova 20mg), dabigatran (reduce to 75 BID), strong CYP3A4 inhibitors/inducers
118
Asymptomatic nonsustained VT managment
No treatment
If MI/HFrEF, BB
119
Symptomatic nonsustained VT management
BB (NDHP CCB is alternative)
If still symptomatic: amiodarone, flecainide, mexiletine, propafenone, sotalol
120
Sustained VT management
Pulseless: defibrillation
Pulse: synchronized cardioversion
ICD
121
Hypertensive Emergency
BP >180/120 PLUS
Target-organ damage
122
Hypertensive Urgency
BP >180/120
No target-organ damage
Treat with PO AntiHTNs
123
Hypertensive Emergency Treatment Goals
1) Decrease MAP by 25% in first hour
2) SBP reduction to 160 and DBP to 100-110 over 2-6 hours
3) Normal BP over next 24-48 hours
124
Hypertensive Emergency Treatment Goal - Acute Ischemic Stroke
Do not lower BP unless > 220/120
OR > 180/110 in thrombolysis candidates
125
Hypertensive Emergency Treatment Goal - Preeclampsia, Eclampsia, Pheochromocytoma
SBP <140 in first hour
126
Hypertensive Emergency Treatment Goal - Aortic dissection
SBP <120 and HR <60 in first hour
127
Sodium nitroprusside dosing, onset, duration for hypertensive emergency
Vasodilator
0.3-0.5 mcg/kg/min
Increase by 0.5 mcg/kg/min to achieve BP target
Max 10 mcg/kg/min
30 min
Onset: immediate
Duration: 2-3 min
128
Sodium nitroprusside pearls for HTN Emergency
Intra-arterial BP monitoring recommended
AE: Cyanide or thiocyanate toxicity
CI: renal/hepatic failure
129
Nitroglycerin dosing, onset, duration for HTN Emergency
Vasodilator
5-10 mcg/min
Increase by 5mcg/min q3-5min
Max 200mcg/min
Onset: 2-5 min
Duration: 5-10 min
130
Nitroglycerin pearls for HTN Emergency
AE: HA, nausea, vomiting, tachyphylaxis
Do not use in patients with ACS, pulmonary edema, volume depleted, right ventricular infarction
131
Hydralazine dosing, onset, duration
Vasodilator
5-10mg IV q4-6hours
20mg max initial dose
Onset: 10 min, duration 1-4 hours
132
Hydralazine pearls
AE: reflex tachycardia, HA, flushing
133
Enalaprilat dosing, onset, duration
Vasodilator
0.625-1.25mg over 5 min
Increase to max of 5mg q6h
Onset: within 30 min
Duration: 12-24 hours
134
Enalaprilat pearls
AE: renal insufficiency or failure, hyperkalemia
CI: pregnancy, bilateral renal artery stenosis, angioedema
Avoid in MI
Long half-life & unpredictable BP response makes unfavorable
135
Fenoldopam dosing, onset, duration
Vasodilator
0.1-0.3 mcg/kg/min
Increase by 0.05-01 mcg/kg/min q15min
Max 1.6 mcg/kg/min
Onset: <5 min
Duration: 30 min
136
Fenoldopam pearls (CI, AE)
CI: pts at risk of glaucoma, ICP, sulfite allergy
AE: HA, flushing, tachycardia, cerebral ischemia
137
Nicardipine dosing, onset, duration
Vasodilator
5mg/hr
Increase by 2.5 mg/hr q15min
Max 15mg/hr
Onset: 1-5 min
Duration: 4 hours if prolonged infusion
138
Nicardipine CI, AE
AE: reflex tachycardia, NV. HA, flushing
CI: advanced aortic stenosis
139
Clevidipine dosing, onset, duration
Vasodilator
1-2 mg/hr
Double q90 seconds until target
Increase by less than double q5-10 min
Max 32 mg/hr for 72 hours
Onset: 2-4 min
Duration: 5-15 min
140
Clevidipine pearls
CI: soy or egg allergy, severe aortic stenosis, defective lipid metabolism
Not studied in pts w/ renal or hepatic failure and older adults
Caution: HF, BB, reflex tachycardia, rebound HTN
141
Esmolol dosing, onset, duration
Adrenergic inhibitor (BB)
Load 500-1000mcg/kg IV bolus over 1 min
Then 50mcg/kg/min infusion
Titrate by 50mcg/kg/min q5min
Max 200mcg/kg/min
Onset: 1-2 min
Duration: 10-30 min
142
Esmolol pearls
AE: bronchospasm, HF exacerbation, bradycardia, heart block
CI: concurrent BB, bradycardia, ADHF
143
Labetalol dosing, onset, duration
Adrenergic inhibitor (BB)
20-80mg q15min
Or initial 0.3-1mg/kg dose (max 20mg) q10min
Or 0.4-1 mg/kg/hr infusion with max 3mg/kg/hr
Onset: 5-10 min
Duration: 3-6 hours
144
Labetalol pearls
CI: reactive airway disease, COPD
Caution: overtreatment can cause prolonged hypotension
145
Phentolamine dosing, onset, duration
Adrenergic inhibitor
1-5mg IV bolus q10 min prn
Onset: 2 min
Duration: 15-30 min
146
Phentolamine pearls
Use for catecholamine excess (pheochromocytoma, MAO-I intxns, cocaine toxicity, amphetamine overdose, clonidine withdrawal)
147
Preferred agents for HTN crisis w/ acute aortic dissection
Labetalol
Esmolol
148
Preferred agents for HTN crisis w/ ACS
Esmolol
Nitroglycerin
Labetalol
Nicardipine
149
Preferred agents for HTN crisis w/ acute pulmonary edema
Clevidipine
Nitroglycerin
Nitroprusside
150
Preferred agents for HTN crisis w/ acute renal failure
Clevidipine
Fenoldopam
Nicardipine
151
Preferred agents for HTN crisis w/ eclampsia or preeclampsia
Labetalol
Nicardipine
Hydralazine
152
Preferred agent for HTN crisis from perioperative HTN
Clevidipine
Esmolol
Nicardipine
Nitroglycerin
153
Preferred agent for HTN crisis w/ excess catecholamines
Clevidipine
Nicardipine
Phentolamine
154
Preferred agent for HTN crisis w/ acute intracranial hemorrhage
Most studied:
Nicardipine
Clevidipine
Labetalol
155
Preferred agent for HTN crisis w/ acute ischemic stroke
No preference
156
NYHA I
Either asymptomatic or symptomatic with no limitations caused by HF
157
NYHA II
Symptomatic HF with slight limitation of physical activity; asymptomatic at rest
158
NYHA III
Symptomatic HF with marked limitations in physical activity due to symptoms
159
NYHA IV
Symptomatic HF where unable to carry out any physical activity
Symptoms at rest
160
GDMT for HFrEF
ARNI
BB
MRA
SGLT2i
Diuretic
161
GDMT but symptomatic, African American
Add hydralazine/isosorbide
162
GDMT but symptomatic with HR >= 70, NYHA II & III
Add ivabradine
163
GDMT but recent hospitalization, elevated NPs in NYHA II-IV
Add vericiguat
164
GDMT but symptomatic HFrEF
Add digoxin
165
GDMT but NYHA II-IV
Add PUFA (polyunsaturated fatty acid) -- icosapent ethyl or EPA/DHA
166
GDMT but hyperkalemia
Potassium binder (patiromer or sodium zirconium cyclosilicate)
167
Captopril starting dose, target dose HF
6.25mg TID --> 50mg TID
168
Enalapril starting dose, target dose HF
2.5mg BID --> 10mg BID
169
Lisinopril starting dose, target dose HF
2.5-5mg daily --> 20mg daily
170
Perindopril starting dose, target dose HF
2mg daily --> 8mg daily
171
Ramipril starting dose, target dose HF
1.25-2.5mg daily --> 10mg daily
172
Trandolapril starting dose, target dose HF
1mg daily -> 4mg daily
173
Candesartan starting dose, target dose HF
4-8mg daily --> 32mg daily
174
Losartan starting dose, target dose HF
25-50mg daily --> 150mg daily
175
Valsartan starting dose, target dose HF
20-40mg BID --> 160mg BID
176
Sacubitril-valsartan starting dose, target dose
Not currently on ACE/ARB or low dose, or CrCl <30 ml/min: 24/26mg BID
On standard dose ACE/ARB: 49/51mg BID
Target 97/103mg BID (double dose q2-4weeks)
177
Bisoprolol starting dose, target dose HF
1.25mg daily --> 10mg daily
178
Carvedilol starting dose, target dose HF
3.125mg BID --> 25mg BID (<85 kg) or 50mg BID (>85kg)
179
Carvedilol CR starting dose, target dose HF
10mg daily --> 80mg daily
180
Metoprolol succinate starting dose, target dose HF
12.5-25mg daily --> 200mg daily
181
Eplerenone starting dose, target dose HF
CrCl >= 50ml/min:
25mg daily --> 50mg daily
CrCl 30-49 ml/min:
25mg every other day --> 25mg daily
182
Spironolactone starting dose, target dose HF
CrCl >= 50 ml/min:
12.5-25mg daily --> 25mg daily or BID
CrCl 30-49 ml/min:
12.5mg daily or every other day --> 12.5-25mg daily
K must be <5.0
183
K>5.5 in HF pt on MRA?
Decrease dose by 50% or discontinue
184
Dapagliflozin dose in HF
CrCl >= 25 ml/min: 10mg daily
185
Empagliflozin dose in HF
CrCl >= 20 ml/min: 10mg daily
186
Hydralazine/isosorbide dosing HF
BiDil: hydralazine 37.5mg/isosorbide dinitrate 20mg - 1 tab TID --> 2 tabs TID
Hydralazine 70-300mg daily in 3-4 divided doses +
Isosorbide dinitrate 60-120mg daily in 3-4 divided doses
187
Diuretic therapy goal for fluid-overloaded HF
0.5-1kg weight loss per day
Maintain euvolemic status
188
Goal K and Mg in CVD
K >= 4.0
Mg >= 2.0
Minimize risk of arrhythmias
189
Maximum loop diuretic doses
Furosemide: 600mg
Bumetanide 10mg
Torsemide: 200mg
Ethacrynic acid: 200mg
190
Ivabradine starting dose, target dose
<75 y/o: 5mg BID
> 75 y/o: 2.5mg BID
Titrate based on HR
HR >=60: increase by 2.5mg to target 7.5mg BID
HR 50-60: continue current dose
HR <50 or s/s bradycardia: decrease by 2.5mg or discontinue
191
Ivabradine MOA
Selectively inhibits If current in SA node, providing HR reduction
Must be at maximally tolerated BB dose before initiating
192
Ivabradine CI
AHF
BP <90/50
resting HR <60 before initiation
SA block
Strong CYP3A4 inhibitors
Severe hepatic impairment
193
Digoxin MOA for HF
Inhibit myocardial Na-K ATP
Decrease central sympathetic outflow by sensitizing cardiac baroreceptors
Decrease renal reabsorption of Na
Minimal increase in cardiac contractility
194
Digoxin dosing, level in HF
No load
0.125mg/day (or every other day if >70, impaired renal function, low body mass)
Level: 0.5-0.9
195
Digoxin DI
Clarithromycin, erythromycin
Amiodarone (reduce dig by 30-50%)
Dronedarone (reduce by 50%)
Itraconazole, posaconazole
Cyclosporine, tacrolimus
Verapamil
196
Vericiguat MOA
Soluble guanylate cyclase stimulator that enhances production of cyclic guanosine monophosphate and enhances sensitivity to endogenous nitric oxide, resulting in smooth muscle relaxation and vasodilation
197
Vericiguat starting dose, target dose, CI
2.5mg daily --> 10mg daily
Titrate based on BP:
SBP >=100: increase dose to target
SBP 90-99: continue current dose
SBP <90 or symptomatic: decrease dose or discontinue
CI: pregnancy
198
Icosapent ethyl dosing HF
2gm BID
199
EPA/DHA dosing HF
1000mg daily
200
Patiromer MOA, monitor
Exchange calcium for potassium in GI tract, increasing K excretion
Monitor Mg
201
Sodium zirconium cyclosilicate MOA, monitor
Exchange sodium and hydrogen for K in GI tract, increasing K excretion
Monitor edema
202
Preferred Antiarrhythmic for HF
Amiodarone or dofetilide
203
HFpEF managment
Control HTN
Diuretic if fluid overload
SGLT2i may be beneficial
MRA & ARNI/ARB
204
Drugs that Exacerbate HF by Na/H2O retention
NSAIDs
Corticosteroids
Minoxidil
Thiazolidinediones (pioglitazone)
205
Drugs that Exacerbate HF by negative inotropic effects
-Class I & III Antiarrhythmics (except amiodarone, dofetilide)
-CCBs (except amlodipine and felodipine)
-Itraconazole
206
Drugs that Exacerbate HF, general
Metformin
Saxagliptin, alogliptin
Amphetamines
Pregabalin
Nutritional supplement
Cilostazol
207
Paroxysmal AF
Spontaneous self-termination within 7 days of onset
208
Persistent AF
Lasts more than 7 days
209
Long standing persistent AF
Continuous duration of >12 months
210
Permanent AF
Present all the time, unable to return to SR
211
Nonvalvular AF
Absence of moderate-severe mitral stenosis, a mechanical or bioprosthetic heart valve, mitral valve repair
212
Rate control options AF
BB (prefer in history of MI, HFrEF, htn control)
NonDHP CCB (verapamil, diltiazem) (preferred with asthma or COPD)
Digoxin (adjunct)
Amiodarone (refractory)
213
Anticoagulant Recommendation for Cardioversion: Unstable AF
-Anticoagulate immediately prior to with parenteral therapy
->=4 weeks after
214
Anticoagulant Recommendation for Cardioversion: Stable AF < 48 h
-Anticoagulate immediately prior to LMWH or UFH
->= 4 weeks after
Can also base on their risks from Chadsvasc
215
Anticoagulant Recommendation for Cardioversion: Stable AF, duration >48 h
-3 weeks before
->= 4 weeks after
216
Anticoagulant Recommendation for Cardioversion: Stable AF > 48 hours using TEE
-Anticoagulate at time of TEE with LMWH, UFH
->= 4 weeks after
-If thrombus on TEE, 3 weeks of anticoagulation required before cardioversion
217
QTc > 500 OR >15% baseline managment with dofetilide
Decrease dose by 50%
If occur after doses 2-5, discontinue
218
Antiarrhythmic preferred in CCD
Dofetilide, dronaderone, sotalol
Then amiodarone
219
CHADS-VASc
CHF or LVEF = 40%
HTN
>=75 y/o (2)
Diabetes
Stroke, TIA, thromboembolism (2)
Vascular disease
65-74 y/o
Female
220
CHADSVASc Score Recommendations
0 (men) or 1 (women): omit
1 (men) or 2 (women): consider anticoagulation
2 (men) or 3 (women): anticoagulation recommended
221
White Coat HTN
Office BP: 130/80-160/100
Daytime ABPM or HBPM: <130/80
222
Masked HTN
Office BP: 120-129/<80
Daytime ABPM or HBPM: >= 130/80
223
Lifestyle modifications
-Maintain normal weight (BMI <25)
-DASH diet
-Reduce Na <1500mg/day
-Regular physical activity
-Reduce or omit alcohol
224
Normal BP
<120/80
Reassess in 1 year
225
Elevated BP
120-129/<80
Reassess in 3-6 months (lifestyle mods)
226
Stage I HTN
130-139/80-89
ASCVD <10%: reassess in 3-6 mo
ASCVD >=10%: start therapy, reassess in 1 month
227
Stage II HTN
>=140/>=90
Start therapy, reassess in 1 month
May use 2 drugs from 2 different classes if >20/10 above target
228
BP med for diabetes
ACE-I/ARB (preferred in albuminuria)
CCB
Thiazide
229
BP med for CKD
ACE-I/ARB with albuminuria
230
BP med for stroke/TIA
Thiazide
ACE-I/ARB
231
BP med for Coronary disease
BB + ACE-I/ARB
232
BP med for HFrEF, HFpEF
ACE-I/ARB/ARNI
BB
MRA
Diuretic
233
BB cautions for BP management
-Asthma or severe COPD
-Risk of developing diabetes
-Depression
-Masks hypoglycemia
234
Thiazide cautions for BP management
-Worsen gout by increase uric acid
-Risk of developing diabetes
-Monitor hyponatremia, hypokalemia
235
ACE-I/ARB contraindications
Pregnancy
Bilateral renal artery stenosis
236
Aliskiren CI
Pregnancy
Diabetes (in combo with ACE-I/ARB)
Avoid w/ cyclosporine, itraconazole
237
DHP vs NonDHP CCB preference in HTN
DHP: isolated systolic hypertension
NonDHP: comorbidities benefit from HR control
238
Preferred antiHTN for pregnancy
Methyldopa
Nifedipine
Labetalol
239
Resistent HTN Management
Office BP > 130/80 & on 3 antiHTN
Office BP < 130/80 but on 4 antiHTN
-Maximize diuretics
-Add MRA
-Alter dosing time
-If add hydralazine or minoxidil, must have BB and diuretic
240
Statin Management for Very high risk ASCVD
History of several major ASCVD events or one major event + several high risk conditions
High intensity statin
Add ezetimibe if LDL >= 70 after statin
Add PCSK-9i if LDL >= 70 or non-HDL >=100 after statin
241
Statin Management for Not very high risk ASCVD
75: moderate or high-intensity statin
Add ezetimibe if LDL >= 70 after statin
242
Statin Management for Severe hypercholesterolemia
LDL >=190 and 20-75
High intensity or maximally tolerated statin
Add ezetimibe of LDL decrease by less than 50% and/or LDL >= 100
Add PCSK9i if 30-75 with HeFH and LDL >=100 after statin, ezetimibe
Or
40-75 y/o with baseline LDL >=220 and LDL >=130
243
Statin Management for Diabetes
40-75: moderate or high intensity statin
If ASCVD >= 20%, add ezetimibe
244
Statin Management if ASCVD <5%
Lifestyle modifications only
245
Statin Management if ASCVD 5-7.4%
Moderate intensity statin
246
Statin Management if ASCVD 7.5-19.9%
Moderate intensity statin
If additional LDL lowering needed but unable to use high intensity statin, add ezetimibe or bile acid sequesterant
247
Statin Management if ASCVD >20%
High intensity statin, goal decrease LDL by 50%
248
High intensity statins
Decrease LDL by >=50%
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
249
Moderate intensity statins
Decrease LDL by 30-<50%
Atorvastatin 10-20mg
Fluvastatin 80mg
Pitavastatin 1,2,4mg
Lovastatin 40-80mg
Pravastatin 40-80mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg
250
Low intensity statins
Decrease LDL by <30%
Fluvastatin 20-40mg
Lovastatin 20mg
Pravastatin 10-20mg
Simvastatin 10mg
251
Lipid lowering meds % decrease in TG
Statins: 7-30%
Fibrates: 20-50%
Ezetimibe: 5-11%
Omega-3 fatty acids: 19-44% (may inc LDL)
252
Absolute contraindications to statins
Active liver disease
Pregnancy
Breastfeeding
253
Fibrates + Statins
Increased risk of myopathy and rhabdomyolysis
Avoid gemfibrozil
254
Niacin max dose with statins
1gm daily
255
Statins of choice for HIV protease inhibitors
pravastatin, fluvastatin, pitavastatin
256
Ezetimibe LDL lowering %
18-20%
257
PCSK9 LDL lowering %
45-68%
258
Evolocumab dosing
PCSK9i
HeFH: 140mg SC q2 weeks or 420mg SC monthly
HoFH: 420mg SC monthly
259
Alirocumab dosing
PCSK9i
75mg SC q2 weeks or 300mg SC q4 weeks
May increase to 150mg SC q2 weeks
260
Inclisiran LDL lowering, dosing
51%
284mg SC months 0, 3, then q6 months
not preferred due to no effects on CV morbidity/mortality
261
Bile acid sequesterants LDL decrease
Cholestyramine, colestipol, colesevelam
15-27%
May increase trigs
262
Fibrates CI, indication
CI: severe renal/hepatic dx, pre-existing gallbladder dx
Indication: TGs >= 500, especially if >=1000
263
Bempedoic acid LDL lowering %
15-25%
264
CCD Management
1st line: BB or CCB or long-acting nitrate
2nd line: BB or CCB or long-acting nitrate
3rd line: ranolazine
All: SL NG or NG spray
265
Chronic Coronary Disease
-Stable outpatient with history of ACS or revascularization
-LV systolic dysfunction or cardiomyopathy
-Stable angina
-Vasospastic or microvascular angina
-Diagnosis from stress test, CT angiography
266
BB effects for CCD
Decrease inotropy and HR = decreased O2 demand
267
CCB effects for CCD
Decrease coronary vascular resistance and increase coronary blood flow = increase O2 supply
Negative inotrope = decrease O2 demand (nifedipine >>> amlodipine/felodipine)
Decrease HR = decrease O2 demand (verapamil, diltiazem only)
268
Nitrate effects for CCD
Endothelium-dependent vasodilation, epicardial arterial dilation, collateral vessels dilation = increase O2 supply
Decrease left ventricular volume b/c decreased preload d/t venodilation = decrease O2 demand
269
Ranolazine effects for CCD
Decrease intracellular Na = Decrease Ca influx = reduced ventricular tension = decreased O2 consumption
Increase O2 efficiency
No effects on HR or BP
270
Ranolazine dose if on verapamil, diltiazem
500mg BID
271
Major ASCVD Events
ACS in past 12 months
History of MI
History of ischemic stroke
Symptomatic PAD
272
High risk conditions for ASCVD
->= 65 y/o
-Familial hypercholesterolemia
-CABG or PCI (outside of major ASCVD)
-Persistent LDL >= 100, despite statin/ezetimibe
-DM
-HTN
-CKD
-CHF
-tobacco
273
Vaccines for CCD
Pneumococcal
Flu
COVID19
274
Epinephrine dosing in CPR
1mg Q3-5 min
