Drug Induced Cardiovasc Disease Flashcards
What can elicit a hypertensive crisis?
How To treat : If SBP >180 and or DBP>120, and signs of organ damage such as (AKI, alt ment status, retinpathy, chest pain)
- YEs they have signs of this, what drug do you use? (2)
b. What should you reduce the BP to?
c. WHat should u re-start? - if NO, what do u do?
- If their home clonidine was a PATCH, how would u go about re-starting their home dosage while in hospital?
Abrupt clonidine withdrawal
- Nicardipine IV 2.5-5 mg/h
-Titrate it by 2.5 mg/h q5mins , max 15mg/h
OR
Clevidipine IV 1-5 mg/h
-Double rate every 2 mins
-max 30 mg/H
1b. Reduce BP by max 25% over 1st hour, then to 160/110-100 mmHg over next 2-6hrs then to normal over 24-48 hrs
c. restart clonidine at home dose and wean off IV meds
- Restart Clonidine at home dose
- Since patches take 3 days to work
DAY1 : place patch + admin 100% of dose as oral
DAY2 : Continue patch, decr oral dose to ~50%
DAY3: COntinue patch, decr oral dose to ~25%
DAy 4: Contine patch, no more ORAL !
How to prevent Abrupt Clonidine Withdrawal
- If taking IR oral , how would you taper the oral dose every 2-4 days? (Describe day 1-day 9)
- If patient is on a patch, how would you taper them down to avoid withdrawal?
- DAY1 : 100% of oral dose
DAY3: Decr oral dose to 50%
DAY6: Decr oral dose to 25%
DAY 9 : discontinue completely - You stop the patch , and taper the oral dose every 2-4 days. Its the same titration as above, but on day1, just stop the patch completely and administer 100% of that dose as an oral dose
What are some other drug classes that INCR BP and how do you prevent/Treat a drug induced event ? (3)
- Triptans (Sumatriptan)
Prevention : Avoid use in uncontrolled HTN, hx of MI, cerebral vasc disease
Migraine : sub with tylenol or prn NSAIDS; consider botulinum toxin injections
TX : Discontinue drug and treat as HTN crisis if SBP >180 and or DBP >120
- MAOI’s (Phenelzine, Rasagiline, Selegiline)
Prevent : Avoid use with sympathomimetics, triptans, SNRI’s and TCA’s, + high tyramine foods (beer, cheese, cured meats)
TX : Discontinue drug and tx as HTN crisis if SBP >180 and/or DBP >120
- Sympathomimetics (Amphets, pseudoephed, cocaine)
Prevention : Avoid use in uncontrolled HTN, HX of MI, Cerebral vasc disease
TX : discontinue drug and tx as HTN crisis if SBP >180 and/or DBP >120
- Which drugs can decrease O2 supply ? (3)
- Which drugs can increase O2 demand? (5)
- Sympathomimetics
-Ergot Alkaloids
-triptans
ALL thru coronary vasospasms - Nifedipine IR
-Sympathomimetics
-Ergot Alkaloids (Ergotamine)
-Triptans
-ABrupt B Blocker withdrawal
TX of Drug Induced ACS : Standard ACS
- What meds do you start with in the ED (3)
A. If its STEMI or high risk NSTE-ACS, what do u do from here?
B. In standard post-ACS tx, what beta blocker should u use if the drug inducing ACS was caused by cocaine, amphet, methamphet?
C. In addition to standard POST ACS tx, what should the pt receive ?
D. If its LOW RISK N-STE-ACS, whats the regimen ?
- Nitroglycerin 0.4 mg SL prn 5 min up to 3 doses, aspirin 324 mg PO, Heparin 60 units/kg –> 12 units/kg/hr
A. Cardiac Catherization
B. Carvedilol
C. Drug abuse counseling
D. Standard med management using carvedilol and Drug abuse counseling
Summary of Drugs inducing Myocardial Ischemia Prevention + TX see Chart
See chart
Drug Induced BRADYCARDIA/AV BLOCKADE from OD
- What drug to use immed?
A. If they’re found to be hemodynamic STABLE (SBP > 90) what should u do?
B. If Hemodynamically UNSTABLE (SBP <90, High degree heart block)
-What drug should u give
-If that doesnt work, what drugs/methods can u start ? (3)
- Activated charcoal 50-100 gm PO once
A. Monitor VS and let them metab the drug in body
B. Atropine 0.5 mg IV q3-5 mins, max 3 mg
+/- EPI IV 0.01-0.3 mcg/kg/min
+/- DOPAMINE IV 2-10 mcg/kg/min
+/- Temp pacemaker device
Drug Specific TX Of Beta blocker or NON-DHP CCB’s OD
- Use a combo of these 3 drugs (C, G, I)
B. If ineffective, what drug should u give?
- Calc Chloride/Gluconate
-1gm IV over 2-5 mins, repeat 3-4x prn - Glucagon
-3-10 mg IV bolus, repeat q10 min prn
-Can start infusion at 3-5 mg/h if still sx’s - Insulin
-1unit/kg IV bolus fb 0.5-10IU/kg/h infusion w/dextrose infusion to maintain BG between 100-200 mg/dL
B. Lipid emulsion 20% (1.5 mL/kg IV bolus fb 0.25 mL/kg/Min)
Which drugs can exacerbate existing HF? (3)
-How do u prevent these ?
- NSAIDS
-Use Tylenol for pain in pt’s with HF, 81 mg aspirin ok - Steroids (Avoid if possible)
- Thiazolidinediones (Avoid in pt’s with HF! consider SGLT2I)
TX of drug induced HF mirrors Standard HF TX
- What are the 4 types of acute decomp HF that u could treat related to OD?
- What would be the tx for drug induced HF in terms of chronic HF with reduced ejection fraction?
- Warm and wet , warm and dry, cold and wet, cold and dry
- Bblockers, MRA’s, SGLT2’s, ACEI’s/ARBS/ARNI’s
Many Drugs Can prolong QTc : State an example of each drug class
- Antiarrhythmics (3)
- Abx
- Antidepressants (4)
- Antiemetics (5)
- Antifungals
- Antipsychotics (7)
- Opioids (1)
- Class 1A, Class 1c, Class 3
- Erythro>Clarithro>Azithro
Moxi>Cipro=fluoro - Citalopram >= 40 mg, lexapro
-Amitriptyline, notriptyline - Chlorpromazine, droperidol, metoclopramide, zofran, prochlorper
- azoles
- Haloperiodl, ziprasidone, seroquel (high risk)
-Zyprexa, risperdal, lurasidone, paliperidone - Methadone
Risk for Developing TdP involves more than drugs : WHat are the other risk factors that may exist? (6)
- HFrEF
- Female
- > 65 yo
- hx of MI
- Hypomag, hypokalemia
- Bradycardia
Prevention of TdP
1. Avoid use when
2. Discontinue when ?
3. monitor electrolytes to maintain normal mag and potass levels of?
4. If using azithro for pneumo, switch to?
5. If using citalopram , avoid ….
6. If using haloperidol, consider __
- baseline QTc> 450 ms.
- QTc> 500 ms.
- Mag > 2 mg/dL , potass > 4 mEq/L
- Doxycycline
- doses > 20 if >60yo, hepatic impair, use of 2c19 inhibs and PM of 2c19
- ZYprexa
TX of TdP :
1) If they’re hemo stable (SBP>90) what should u do?
B. If after, their HR is < 60 bpm and refractory TdP…. what do u give?
2) If hemodym UNSTABLE (SBP<90 or loss of heart pulse) … what should u do?
-After, Give what drug ?
B. If HR is < 60 bpm and refractory TdP…. what do u give?
- Mag Sulfate 2gm IV over 30 mins fb 1-4 gm/hr to target serum Mg > 2 mg/dL
B. Isoproterenol 2-20 mcg/min IV targeted to HR > 60 bpm
- Cardioversion if SBP < 90
Defibrillation if no Heart pulse
-Mag Sulfate 2gm IV over 30 mins fb 1-4 gm/hr to target serum Mg > 2 mg/dL
B. Isoproterenol 2-20 mcg/min IV targeted to HR > 60 bpm
