Cardiovascular Flashcards
In a patient with both CV disease and T2DM, which agents are associated with decreasing risk for CV events. Select all that apply.
a. Metformin
b. Liragluutide, a GLP-1 receptor antagonist
c. Selected SGLT-2 inhibitors - canaglifolozn and empagliflozin
d. Beta-blocker
e. ACEi
f. Statins
a. Metformin
c. Selected SGLT-2 inhibitors - canaglifolozn and empagliflozin
e. ACEi
f. Statins
Data around ACEi and ARBs is a moving target, the 2018 meta-analysis by Zhang et al in Medicine concluded “that treatment with ACEi showed a significant CV protection for all-cause mortality, CV death, and major CV events, whereas ARBS had no benefits on these outcomes ecept MI. In conisderation of high mortality and morbidity, ACEi was preferable than ARBs on patients with hypertension and T2DM.”
A beta blocker can be associated with increased baseline glucose, however, it should not be withheld in someone with ACS (pick one that is more beta-1 selective or use a low dose).
What should you do to optimize medications for a patient with stable coronary artery disease?
a. Switch patients on metformin to empagliflozin
b. Confirm that patietns are taking at least 162 mg of aspirin daily
c. Ensure patients have a rapid acting nitrate to administer as needed.
d. Veryify that patients are receiving a low intensity statin
c. Ensure patients have a rapid acting nitrate to administer as needed.
High intensity statin
Aspirin 81-120 mg
Continue on metformin - it has potential benefits in regard to CV event reduction
Some say every patient with CAD should have a SAAB (statin, aspirin, antiplatelet, and beta blocker)
What should you consider before you recommend aspirin for priamry prevention of CV events?
a. The bleeding risk may offset any CV benefit, especially in older adults
b. Stopping it in this population will increase for stroke and MI
c. Aspirin is recommended for patients with high risk for CV events but it should not be used routinely or for low-to-moderate risk patients
d. The preferred dose is 325 mg
c. Aspirin is recommended for patients with high risk for CV events but it should not be used routinely or for low-to-moderate risk patients
Dual antiplatelet therapy is rarely beneficial in patietns post PCI.
a. True
b. False
b. False
Dual aspirin and DOAC is also indicated short-term for patients following TIA, stroke, and post MI
Triple anticoagulant therapy (i.e. dual anti-platelets plus another clotting factor disruptor) is beneficial to patietns with coronary artery stents who also have afib.
a. True
b. False
a. True
Adding soemthing like LMWH or warfarin to aspirin and a DOAC increase bleeding risk without reducing subsequent CV events.
Which antithrombotic would you use first to reduce stroke risk for most patients with atrial fibrillation who receive a mechanical valve?
a. Warfarin, a vit K anticoagulant
b. Apixiban, a DOAC
c. Clopidogrel, an ADP inhibitor for platelets
d. Aspirin, a platelet activatin inhibitor
a. Warfarin, a vit K anticoagulant
DOACs reduce stroke risk and cause slightly less intracranial bleeding and require less monitoring compared to warfarin. All DOACs are similar in terms of stroke risk reduction, but Eliquis (apixiban) appears to have less bleeding risk. A missed dose can be more problematic in a DOAC compared to warfarin.
Aspirin alone does not lower stroke risk in afib patients (most recent data) and has bleeding risk.
DOACs are first one for all patients with non-mechanical valves.
Which of the following statements are true?
a. Never use heparin in a neonate due to its bleeding risk
b. Watch for low serum potassium if using TMP/SMX and a ACEi for patient management
c. Adherence is not considered when deciding between a DOAC and warfarin to manage a thrombophilic disease
d. Taper off a benzo, if possible, for most patients using an opioid
d. Taper off a benzo, if possible, for most patients using an opioid
Missing a dose of long-acting warfarin (4 days) has less serious risk for clotting than missing a dose of a DOAC (daily variation)
Heparin is useful in managing lines in neonates - keeping lines patent/without fibrin sheath buildup. Be careful of dose. Immature immune systems means less HIT.
High K with ACE and some abx - be careful in pts with established CKD stages 2-4.
Among older adults taking a DOAC, the risk of hemorrhage is higher with which antibiotic?
a. Azithromycin
b. Clarithromycin
b. Clarithromycin
While the overall risk is low, it is elevated in clarithromycin (0.77% vs 0.43%) due to DDI due to CYP450 metabolism.
How long after an acute MI should beta-blockers be prescribed?
a. 3 years
b. Indefinitely
c. 6 months
d. As long as the patient does not receive definitive therapy such as a stent or CABG surgery
a. 3 years
Consider weaning after 3 years. Recall that one does not want to stop a beta-blocker abruptly.
Of course, therapy should be invidualized - if the patient continues to have angina or symptomatic cardiac disase or develops HF, continue the BB indefinitely.
What is the general indication for the duration of use for proton pump inhibitors?
a. 2 weeks
b. 2 years
c. 2 months
d. Indefinitely
a. 2 weeks
PPIs are widely prescribed, rarely deprescribed, and commonly purchased OTC.
They have been linked to serious ADRs including c diff infections, AKI, pna, CKD, dementia, upper GI cancer, and death.
Generally, prescribe for 2 weeks, then stop - unless there is an ongoing indication (such as antiplatelet or NSAID administration)
What is the rationale for deprescribing antimuscarinic drugs for an “overactive” bladder? Select all that apply.
a. These drugs are not especially effective
b. These drugs have a high rate of adverse events
c. Long-term use is associated with increased risk for cognitive impairment in older adults.
d. These drugs inhibit the WBC response to infection, causing immunosuppression
a. These drugs are not especially effective
b. These drugs have a high rate of adverse events
c. Long-term use is associated with increased risk for cognitive impairment in older adults.
Antimuscarinics restore continence in less than 10% of patients. Most report no difference in symptoms on or off the treatment.
These drugs are also associated with mortality in older adults, the risk for falls, dry mouth, new caries, constipation, somnolence, dizziness, and blurred vision.
Benzodiazepines and related “Z” drugs - zolpidem (Ambien, eszopiclone (Lunesta), and zaleplon (Sonata) - are sedative-hypnotics commonly prescribed to manage anxiety, mood disorders, depression, insomnia, and seizures. What defines chronic use of these drugs?
a. Greater than 120 days
b. Greater than 14 days
c. Greater than 6 months
d. Greater than 1 year
a. Greater than 120 days
Over 5-12% of US adults are on one of these sedative-hypnotics. Prescription use of thse drugs has doubled from 2003 to 2019.
Misuse of benzos is common - patients take these drugs in a way not prescribed by their HCP - take more frequently, without a prescription, in higher doses, or for longer than intended.
Benzos are intended to be used for fewer than 14 days, but many older adults are prescribed these drugs from more than 120 days (indicating chronic use).
Benzo misuse is strongly associated with opioid misuse.
There are evidence-based guidelines available to help clinicians de-prescribe benzos.
Everyone reports that antibiotics are overprescribed. According to the CDC, of the estimated 154 million antibiotic prescriptions written annually in the US, about how mnay are unnecessary?
a. 30%
b. 10%
c. 50%
d. 0%
a. 30%
Likewise, 20-50% of inpatient/acute care antibiotics are unnecessary or inappropriate.
More than 70% of bacteria responsible for the 2 million infections acquired in the US hospitals each year are resistant to at least one commonly prescribed antibiotic.
Overprescription of antibiotics leads to risks for which of the following? Select all that apply.
a. Increases in disease severity
b. Increased disease length
c. Health complications
d. More adverse drug effects
e. Greater mortality risks
f. Increased healthcare costs
g. Rehospitalization
h. More medical treatment for health problems that might have otherwise resolved on their own
a. Increases in disease severity
b. Increased disease length
c. Health complications
d. More adverse drug effects
e. Greater mortality risks
f. Increased healthcare costs
g. Rehospitalization
h. More medical treatment for health problems that might have otherwise resolved on their own
Statins should be prescribed for the primary prevention of cardiovascular disease for low-risk patients.
a. True
b. False
b. False
While this is somewhat controversial, there is limited evidence on the effectiveness of using statins for all patients for the primary prevention of CVD.
More than 2/3 of Americans who take statins take them for primary prevention. In one study, researchers found that the number needed to prevent one major vascular event was 400 for low-risk patients compared with </= 25 for high -risk patients.
Statins have a role in the secondary and tertiary prevention of CVD.
