TEST 2 Flashcards
African American patient
-thiazides are preferred over ACE for HTN
-HTN + DM = CCB, diuretic
-HF = ACE, BB -> stage C -> hydralazine/isosorbide
CCB
-indication- HTN, angina, atrial arrhythmias (non-DHP), migraine, raynauds disease
-precautions- peripheral edema, reflex tachycardia, non-DHP with BB
-Non-DHP CI- hypotension, cardiogenic shock, SSS, 2/3 heart block
-ADR: constipation, bradycardia, flushing, reflex tachycardia
-ADR for non-DHP- heart block, CHF, hypotension
beta blockers
-Indications: HTN, angina, post MI, specific agents for arrhythmias, migraine, glaucoma, CHF (specifically carvedilol and metoprolol succinate XL)
-Contraindications: bradycardia, > 1st degree heart block, uncompensated cardiac failure, cardiogenic shock, SSS, severe PAD, Asthma
-ADRs- bradycardia, CHF, hypotension, bronchoconstriction, sexual dysfunction, fatigue, dizziness, cold extremities (reflex peripheral vasoconstriction), hypercholesterolemia, CNS side effects like confusion, nightmares (w/ lipid soluble BB)
-titrate HR to 50-60 in angina
which drugs can you not take with PDE-5
-nitroglycerin
-alpha 1
-side note- alpha 1 can cause fluid retention so its usually given with diuretic
alpha 2: centrally acting agents
-ADR- bradycardia, heart block, impotence, dry mouth, sedation
-clonidine
-methyldopa- coombs + hemolytic anemia
-guanethidine and reserpine
HTN emergency
-BB- esmolol and labetalol
-sodium nitroprusside (SNP) - PVR
-nitroglycerin (NTG) - AMI or HF
-Hydralazine
-dopamine receptor agonist- Fenoldopam- good for renal dysfunction
-CCB- nicardipine (encephalopathy and stroke) and clevidipine (before CABG)
-ACE- enalaprilat -> HTN with HF
causes of HF
-MC cause of systolic HF -> MI
-non-cardiac causes:
-diet- low K and Ca
-anemia
-drugs- chemo agents (doxorubicin), COX-2, NSAIDs, thiazolidinediones (for DM)
HF med process
-1ST LINE- ACEi/ARB
-Add beta blocker -> pref carvedilol (once it HF is more advanced - caution bc it decreases contractility)
STAGE C CONSIDERATIONS:
-diuretics- sx of volume overload
-aldosterone antagonist
-d/c ACE or ARB and start ARNI
-hydralazine/isos- first line in AA
-ICD
-ivatradine
-HCN channel blocker- HR must be < 70 and EF < 35%
-digoxin
ARNI
-valsartan/sacubitril
-decrease fibrosis
-decrease morbidity and mortality
-SE- hypotension, hyperkalemia, cough, dizzy, acute renal failure
hyrdalazine/isosorbide
-hydralazine- arterial relax
-isosorbide dinitrate- venous relax
-preferred for AA in stage C
-reduce morbidity and mortality
-can be used for pts with ACE/ARB intolerance
HCN blocker
-Ivabradine
-reduces rate
-reduces hospitalizations in symptomatic HF with LVEF < 35% and HR >= 70
-must be on max BB or contraindicated
-ADR- bradycardia, HTN, afib, luminous phenomena (phosphenes) or brightness
-CI- acute decompensated HF, BP < 90/50, SSS, SA block, 3rd degree AV block, resting heart rate < 60, hepatic impairment, pacemaker dependence,
digoxin
-0.5-2 ng/mL - must monitor!!!!
-positive iontrope
-indications- CHF, atrial arrythmias, shock
-IV dose is 20-25% less than PO
-if CrCl <50 -> reduce dose by 50%
-digitoxin- metabolized in liver, excreted in feces
-ADR- GI, brady, arrythmias, AV block, weakness, fatigue, dizzy, AMS, visual disturbance
-precaution in hypomagnesaemia, hypercalcemia*, hypokalemia
-overdose- K, lidocaine, digibind
IV inotropes for acute decompensated HF
-adrenergic agonist- dobutamine
-selective beta agonist for contractility
-mild vasodilative effect
-phosphodiesterase (PDE) inhibitor- amrinone and milrinone
-long term use -> thrombocytopenia and ventricular arrythmias
-increase mortality
IV vasodilators for acute decompensated HF
-nesiritide- B-type human natriuretic peptide
-give to pts with dyspnea at rest
-CI in pts with shock or hypotension
-nitroprusside- arterial and venous dilation via nitric oxide
-nitroglycerin- venous dilation > arterial
-used in the ABSCENCE of hypotension
angina tx
-1st line for typical angina -> beta blocker- beta 1 selective
-add DHP CCB for further treatment -> NOT NON-DHP CCB
-if BB is contraindicated (asthma, DM) -> non-DHP CCB
-if bradycardia/heart block- DHP CCB
-nitrates- nitroglycerin, amyl nitrate, isosorbide
-ranolazine
-1st line for variant angina -> non-DHP CCB
-occasional episodes- SL nitroglycerin
ADJUNCT:
-antiplatelet- aspirin, clopidogrel, prasugral (UA), ticagrelor (UA) -> slow progression to acute coronary syndrome
-ACE- in all CAD pts to slow progression
specific CCB used for angina
-Non-DHPs
-Verapamil (Calan, Isoptin)
-Diltiazem (Cardizem, Tiazac)
-DHPs
-Amlodipine (Norvasc)
-Felodipine (Plendil)
-Nifedipine (Procardia XL) – avoid IR formulation
nitrites and nitrates
-venous dilation (arterial at higher doses)
-contraindications- aortic valve stenosis, cerebral hemorrhage, anemia, hypotension <90, PDE-5, angle-closure glaucoma
-reflex tachy
-long term use in addition to BB and CCBs
-Amyl nitrate (INH) (X)
-nitroglycerin
-isosorbide
nitroglycerin
-IV, PO, SL, buccal, topical, transdermal
-SL and buccal form- Deteriorates in sunlight -> Replace every 3-6 months after open
-Ointment- messy only inpatient
-Patch -> 12 hr intervals to prevent tolerance
-PO– must be QD or BID to minimize tolerance
-IV– contains propylene glycol, need special tubing
-cool dry place, fridge, keep in container
-0.4mg every 5mins (3 doses max) - sublingual
-if no relief after first dose -> call 911
isosorbide: angina
-dinitrate form- PO or SL, give TID (8, 1, 6)
-mononitrate form- PO only -> BID or QD
ranolazine
-used for chronic stable angina in combo with CCB, BB, or nitrates
-CI- QT prolongation, hypokalemia, hepatic failure
-torsades
acute STEMI tx
-aspirin- 162-325 STAT, then 81-325
-nitroglycerin- for first 24-48 hrs -> do NOT give if hypotension <90 or HR <50
-analgesics- morphine every 5 mins
-beta blockers- ASAP and continue after
-ACE- post MI for pts with LV dysfunction and/or HF
-CCB- for pts intolerant to BB
-weight based unfractionated heparin
-LMWH (enozaparin/dalteparin)
-bivalrudin
-fondaparinux
-P2Y-12 inhibitors- clopidogrel, prasugrel or ticagrelor
-fibrinolytics
-statins- post MI
fibrinolytics: contraindications and examples
-Absolute Contraindications in pts with MI*:
-Previous hemorrhagic stroke
-Other strokes or CVA within 1 year
-Intracranial neoplasm
-Suspected aortic dissection
-relative contraindications in pts with MI*:
-Severe uncontrolled HTN (> 180/110)
-Recent trauma, head trauma or major surgery
-Recent internal bleeding
-Pregnancy
-Active peptic ulcer
-History of chronic severe HTN
-Streptokinase – 1.5 million units over 30-60 minutes
-Alteplase (TPA) – 100 mg over 90 minutes total
-Reteplase (Retavase) – 10 units x 2 doses over 30 minutes total
-Anistreplase (Eminase) – 30 mg over 5 minutes total
-Tenecteplase (TNKase) - 30-50 mg (based on pt weight) over 5 seconds* -> time is tissue
NSTEMI/UA
-PCI– stent placement
-some pts require CABG -> antiplatelets should be held for 5-7 days if possible*
-ASA
-BBs
-Nitrates
-Antithrombotic regimens
-Anticoagulants - Options include:
-Weight-based unfractionated heparin
-LMWH
-Bivalrudin
-fondaparinux
-Antiplatelets
-ASA
-P2Y12 inhibitor (Clopidogrel, Prasugrel or Ticagrelor)
-IV Glycoprotein IIb/IIIa inhibitors (not used much bc of P2Y 12 inhibitors + anticoagulants*)
-On discharge: Dual oral antiplatelet therapy with aspirin and a P2Y12 inhibitor depending on type of stent placed
-Statins – long term to delay progression, improve mortality
-ACE inhibitors – long term to delay progression, improve mortality
-A major difference in therapy between STEMI and NSTEMI is that fibrinolytics are NOT used in NSTEMI patients
good fat
-Monounsaturated fatty acids (MUFA)
-Aka oleic acid
-found in olive oil, canola oil, safflower oil and sunflower oil
-Also found in walnuts, almonds, peanuts and sesame seeds and olives and avocados
-Polyunsaturated fatty acids (PUFA)
-Linoleic acid (omega-6) – found in vegetable oils (soybean, safflower, sunflower and corn)
-alpha-linoleic acid (omega-3) – found in certain fish, marine oils, flaxseed and linseed oils
