exam 1 Flashcards
(94 cards)
1
Q
aspirin dosing
A
75-162 mg qd
2
Q
ticlodipine dosing in CAD
A
250 mg BID
antiplatelet
Ticlid
3
Q
clopidogrel dosing in CAD
A
75 mg QD
antiplatelet
plavix
4
Q
prasugrel dosing in CAD
A
10 mg daily
ONLY indicated following ACS
antiplatelet
Effient
5
Q
Ticragrelor dosing in CAD
A
90 mg BID
ONLY indicated following ACS
antiplatelet
Brilinta
6
Q
Cangrelor dosing in CAD
A
IV only
antiplatelet
Kengreal
7
Q
aspirin AEs
A
bleeding (GI and hematologic)
8
Q
increases O2 consumption
A
increased HR, contractility, after load or preload
9
Q
decreases O2 supply
A
vasospasm, fixed stenosis, thrombus
10
Q
angina risk/CAD factors
A
age (45 men, 55 women) family history (primary man 55, woman 65) smoking DM HTN low HDL CKD obesity sedentary lifestyle
11
Q
cardio selective BB
A
atenolol
metoprolol
acebutolol
12
Q
non selective BB
A
propranolol
carvedilol
pindolol
labetolol
13
Q
antiplatelet examples
A
aspirin P2Y12 inhibitors (clopidogrel, ticlodipine, prasugrel, ticragrelor, cangrelor)
14
Q
anginal combination therapy algorithem
A
1) nitrate + BB (used in stable angina)
2) CCB + BB (used when refractory to 1)
3) CCB + nitrate (used when refractory or in printzmetals)
4) nitrates + BB + CCB (when other combos fail)
15
Q
drugs used in stents
A
paclitaxel (taxol) and sirolimus (rapamycin)
inhibit cell cycle progression
16
Q
ALL patients with a history of CHD should be on…
A
ASA 75-162 mg indefinitely
clopidogrel 75 mg if CI
17
Q
if a stent is put in, initiate ___
A
DAPT
ASA + clopidogrel (12 mo unless high risk)
(canuse anticoag as 3rd agent if required or if ASA/P2Y12 allergy)
18
Q
pharmacotherapy to relieve acute ischemia and angina Sx
A
nitrates
19
Q
pharmacotherapy to prevent recurrent ischemia and angina symptoms
A
BB, CCB, nitrates
20
Q
atenolol dosing
A
50-100 mg QD
21
Q
carvedilol dosing
A
25-50 mg BID
22
Q
Metoprolol tartrate dosing
A
50-100 mg BID
23
Q
metoprolol succinate dosing
A
100-200 mg QD
24
Q
propranolol LA dosing
A
80-160 mg QD
25
nifedipine dosing
10-20 TID (NEVER used to treat CAD)
26
nicardipine dosing
20-40 mg TID
27
amlodipine dosing
5-10 mg QD
28
nifedipine XL or CC dosing
30-60 mg QD
29
nifedipine ER dosing
20-40 QD
30
Verapamil dosing
60-90 mg TID-QID
31
verapamil SR dosing
240 mg QD
32
diltiazem dosing
80-120 mg TID
33
diltiazem SR dosing
60-120 mg BID
34
diltazem CD dosing
180-360 mg QD
35
diltiazem XR dosing
180-540 mg QD
36
diltazem ER dosing
180-360 mg QD
37
DHP AE
hypotension, flushing, HA, dizziness, peripheral edema (cannot be treated w diuretics, only dec. dose), reduced myocardial contractility
38
non-DHP AE
reduced myocardial contractility, bradycardia and AV block, hypotension, HA, dizziness, constipation (V>D)
39
ISDN tabs
5-40 mg PO 2-3 times daily
40
ISMN tabs
10-20 mg PO BID 7 hours apart
41
ISDN SR tabs/caps
40-80 mg PO QD-BID
42
ISMN SR tabs
30-240 mg PO QD
43
MONA
used in treatment of ALL ACS
Morphine - 2-4mg IV repeated every 5-30 minutes in increments of 2-8mg for pain relief and patient comfort
Oxygen - administer if O2 less than 90%
Nitrates - use of PDEI w/in 24-36 hrs? SL 0.4mg q 5 min, evaluate for IV NTG
Aspirin - 162-325mg chewed and swallowed
44
IV nitrates rule
start w 5 mcg/min, increase by 5 every 5 minutes (usually to 75-100, max 200)
45
IV nitrates CI
SBP 30 mmHg from baseline, HR 100
46
"other" ACS treatments
anxiolytics - lorazepam
| stool softeners
47
if patient presents within 12 hours of STEMI
primary PCI
48
door to balloon time
90 min
49
door to needle time
30 min
| needle = IV fibrinolytic therapy
50
drugs used in primary PCI
anti platelets and anticoags
antiplatelets: aspirin, P2Y12 inhibitors, (IV GP IIb/IIIa receptor antagonists)
anticoag: UFH (LMWH), bivalirudin
51
aspirin use in primary PCI
325 chewed and swallowed as soon as ACS
| stent: 81 mg po qd indefinitely
52
clopidogrel use in primary PCI
600 mg once before then 75 mg po QD for at least 12 months (longer w DES, duration depends on bleeding risk)
- D/C 5 days prior to elective CABG and 24 hours before urgent CABG
- never D/C w/o discussion w CV
53
Prasurgel use in primary PCI
P2Y12 inhibitor
60 mg load, 10 mg PO QD for > 12 mo, longer w DES, duration depends on bleeding risk
-d/c 7 days prior to elective CABG
-AVOID IN PATIENTS OVER 75 unless DM w MI Hx
-DO NOT USE IN PTS W A Hx OF TIA/STROKE
-no discontinuation w/out discussion w CV
54
Ticagrelor use in primary PCI
P2Y12 inhibitor
180 mg load, 90 mg BID maintenance for > 12 mo, longer w DES
-no greater than 100 mg ASA/day
-D/C 7 days prior to elective CABG
-D/C 24 hours before urgent CABG
-reasonable to choose over clopidogrel, more effective
55
Cangrelor use in primary PCI
30 mcg/kg IV blous followed by 4 mcg/kg/min when PCI is performed, continue for at least 2 hours or duration of infusion, whichever is longer
- higher blleding risk
- cannot be used with GP IIb/IIIa inhibitor
56
GP IIb/IIIa inhibitor examples and use in primary PCI
abciximab, eptifibitide, tirofiban
used in STEMI only if primary PCI is preformed
generally only used when a P2Y12 inhib are not given, during a bailout situation, or is thrombotic complications occur
57
abciximab
GIIb/IIIa ihibitor
not preferred
0.25 mg/kg IV bolus then 0.125 mcg/kg/min (max 10) continued up to 12 hours after PCI
58
eptifibitide
GIIb/IIIa inhibitor
preferred in tx of PCI
180 mcg/kg IV bolus 2 mcg/kg/min IV blus (10 m after bolus)
continue 18-24 hours after PCI
59
tirofiban
GIIIb/IIIa inhibitor
preferred in tx of PCI
25 mcg/kg IV bolus 0.1 mcg/kg/min infusion
continue 18-24 hours after PCI
60
G IIb/IIIa inhibitors CI
-active bleed, major surgery, stroke
61
anticoagulant use in PCI
heparin or bivalirudin
| required bc we want to prevent anticoag at site of catheter
62
UFH dosing
50-70 units/kg if ACT is 250-350 s
70-100 units/kg if ACT is 200-250 s
continue only until end of PCI
LMWH heparin may be used as an alternative
63
medical reperfusion in treatment of STEMI
fibrinolytics
antiplatelets
anticoag
64
reteplase dosing
fibrinolytic
10 units IV
10 units IV 30 minutes later
65
tenecteplase dosing
```
fibrinolytic
under 60 kg: 30 mg IV
60-69.9 kg: 35 mg IV
70-79.9 kg: 40 mg IV
80-89.9 kg: 45 mg IV
over 90 kg: 50 mg IV
```
66
ABSOLUTE CI to fibrinolytics
any prior intracranial hemmorhage
structural cerebral vascular lesion
malignant IC neoplasm
ischemic stroke within 3 months
suspected aortic dissection
active bleeding or bleeding diatheiss (excludes menses)
significant closed-head of facial trauma within 3 months
67
fibrinolytic choice
single bolus - tenecteplase
| non-weight based (extremely obese) - reteplase
68
clopidogrel dose in reperfusion
300 mg LD, 75 mg MD
NO LD in over 75
use up to 1 year
69
bivalirudin dosing
0.75 mg/kg IV bolus followed by 1.75 mg/kg/hr until end of PCI
can continue at 0.25 mg/kg/hr if desired
70
adjunctive anticoagulant therapy
with tPA, reteplase and tenecteplase:
| heparin, LMWH, fondaparinux
71
heparin used as an anticoag for fibrinolysis
60 units/kg bolus (max 4000), followed by 12 units/kg/hr infusion (max 1000/hr)
-aPTT maintained between 50-70s (1.5-2 x control)
72
LMWH used as an anticoag for fibrinolysis
Enoxaparin 30 mg IV bolus then 1 mg/kg SQ q12h until discharge
- only studied w tenecteplase
- generally max 100 mg for first 2 doses
- exceptions: CrCl 10-29 mL/min, 1 mg/kg q24h, over 75 yo: 0.75 mg/kg q12h (max 75 for first 2 doses)
73
fonaparinux uses as an anticoag for fibrinolysis
2. 5 mg IV bolus followed by 2.5 mg SQ QD starting on day 2 up to 8 days or until revascularization
- caution if CrCl 30-50; CI if CrCl
74
UFH monitoring
- signs of bleeding
- baseline aPTT, INR, CBC and platelet count
- aPTT q6h until target and then q24h
- daily CBC
- platelet count every 2-3 days from days 4-14 until heparin is stopped
75
LMWH monitoring
- signs of bleeding
- baseline aPTT, INR, CBC, platelet count and SCr (CrCl)
- daily CBC and SCr
- platelet count only required if "recent" (~3 months) UFH used
76
fondaparinux monitoring
- signs of bleeding
- baseline SCr, aPTT, INR, CBC and platelet count
- daily CBC and SCr
77
bivalirudin monitoring
- signs of bleeding
- baseline SCr, aPTT, INR, CBC and platelet count
- daily CBC and SCr
78
STEMI treatment summary
reperfusion with PCI:
antiplatelets: ASA + clopidogrel, prasugrel, ticagrelor
parenteral anticoag: UFH (LMWH), bivalirudin
parenteral antiplatelets: cangrelor, abciximab, aptifibitide
medical reperfusion with fibrinolysis:
antiplatelets: ASA + clopidogrel
parenteral anticoag: UFH, LMWH, fondaparinux
parenteral antiplatelets: only used in PCI
79
BB doses used in 2nd prevention of STEMI
metoprolol: 25-50 mg q6h
propranolol: 40-80 mg q6-8h
atenolol: 50-100 mg daily
carvedilol: 25-50 mg BID
IV metoprolol: 5 mg q5m for 3 doses, then 50 mg PO q6h
IV atenolol: 5 mg then again in 5 min, then 50-100 mg PO QD
80
BB monitoring
BP, RR, HR, 12 lead ECG, and s/s of HF (IV q5 min, oral every shift during hospitalization)
81
ACE inhibitors rationale w STEMI
used to reduce ventricular remodeling and occurance of HF
82
ACE inhibitors patient selection
administer within first 24 hours of STEMI to patients with LVEF
83
ACEI examples and doses
captopril: start 6.25-12.5 mg; target 50 mg BID-TID
lisinopril: start 2.5-5 mg; target 10-20 mg QD
enalapril: start 2.5-5 mg; target 10 mg BID
ramipril: start 1.25-2.5 mg; target 5 mg BID-10 mg QD
trandolapril: start 1.0 mg; target 4 mg QD
84
ARB agents and doses
candasartan: start 4-8 mg; target 32 mg QD
valsartan: start 40 mg; target 160 mg
losartan: start 12.5-25 mg; target 150 mg QD
85
aldosterone antagonists
- used in addition to ACEI (ARB) in patient with LVEF 2.5 (2.0 in women) or CrCl 5 or receiving K sparing siuretic
- unless K
86
aldosterone antagonists agents and doses
eplerenone: start 25 mg; target 50 mg QD
spironolactone: start 12.5 mg; target 25-50 mg QD
87
Misc. therapies considereing in STEMI
magnesium (low mag = inc. arrythmias)
glycemic control
CCBs if ischemic pain doesn't subside w nitrate, BB and morphine
88
UA/NSTEMI goals of therapy
prevent MI/death by inhibiting extension of the thrombus
| reverse ischemia and relieve CP by increasing myocardial O2 supply and/or decreasing myocardial O2 demand
89
UA/NSTEMI treatment
MONA, BB, ACE/ARB and AA, CCB
| fibrinolytics are not used because we do not need to open the artery
90
UA/NSTEMI treatment
1. ASA
2. p2Y12 inhibitor (clopidogrel or ticarelor)
3. anticoag (UFH, enoaparin, fondaparinux, bivalirudin (only invasive))
(4. if plan on invasive, consider GIIb/IIIa inhib)
if effective: discharge with ASA and P2Y12 inhib
if NOT effective: PCI with stenting (ASA + P2Y12 + GPI (unless bivalirudin was used) + anticoag (enoxaparin, bivalirudin, fondaparinux, UFH)) or CABG (ASA, D/C P2Y12 inhibitor 5-7 days before, or 24 hours before urgent CABG, D/C GPI 2-4 hours before (or >12 if abciximab))
91
UFH dosing differences
ischemia guided: 60 U/kg bolus (max 4000), 12 U/kg/hr infusion (max 1000)
invasive: with GPI, 50-70 U/kg, without GPI, 70-100 U/kg, continue until end of PCI
92
enoxaparin dosing differences
ischemia guided and early invasive: 1mg/kg SQ q12h, CrCl 10-29 1 mg/kg q24h
early invasive only: 30 mg IV load may be used if the time since last dose is 8-12 hours or if received less than 2 therapuetic doses
93
bivairudin early invasive only
dose for invasive: 0.75 mg/kg blous followed by 1.75 mg/kg/hr until PCI or angiography
reduce dose to: 1 mg/kg/hr if CrCl
94
fondaparinus ischemic gusided vs. invasive
ischemic guided: 2.5 mg SQ QD up to 8 days
| invasive: NOT WELL STUDIED, should not be sole AC in PCI, must ass UFH or bival
