Cardio (Tsu) - E4 STUDY

Lecture 1: Acute Coronary Syndromes

Acute Coronary Syndromes

• STEMI

  • Increased troponin levels

  • ST elevation

• NSTEMI

  • Increased troponin levels

  • ST depression or T wave inversions

• Unstable Angina

  • ST depression or T wave inversions

Initial Treatment in ER (MONA)

• Morphine: 2-4mg IV PRN

• Oxygen:

• Nitroglycerin: for ONGOING chest pain

  • 0.4 mL SL x 3 doses —> IV

• Aspirin: 162-325 mg tab - chew

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• BB: within 24 hours if no CI

Fibrinolytics vs. PCI for STEMI

STEMI

• PCI: do if current location is within 2 hours away from hospital

  • Door to needle: 90 min

• Fibrinolytics: given if too far from hospital that can do PCI (2+ hrs away)

  • Door to needle: 30 min

  • CI:

    • Intracranial hemorrhage

    • Cerebral vascular lesion

    • Malignant intracranial neoplasm

    • Ichemic stroke within 3 mo

    • Aortic dissection

    • Active bleeding

    • Closed-head or facial trauma within 3 mo

    • Intracranial or intraspinal surgery within 2 mo

    • Severe uncontrolled HTN: SBP>180 or DBP >110

Thrombolytics & Adjunct Therapy

Thrombolytics

• Alteplase

• Reteplase

• Tenectaplase

Adjunct

• Anticoags:

  • UFH: 60 units/kg then 12 units/kg/hr

  • Enoxaparin: 1 mg/k SC q12h

• Anti-Platelet:

  • Aspirin: 81-325 mg QD indefinitely

  • Clopidogrel: 300-600mg x 1, then 75mg daily for 14 days-1 year

    • (Prasugrel or ticagrelor NOT recommended with fibrinolytics)

What is done with PCI?

• Cardiac catherterization

• Coronary angiography

PCI

• Stent

  • BMS

  • DES

  • Dual anti-platelet therapy - 12 mo

    • (decrease stent thrombosis)

• Balloon Angioplasty

PCI in STEMI Therapy

• Anticoag

  • UFH

  • LMWH

  • Fondaparinux

  • Bivalirudin

• Anti-platelet

  • Aspirin

  • GP 2b/3a inhibitors

    • Eptifibatide

    • Tirofiban

  • ADP receptor antagonists

    • Ticagrelor or Prasugrel

NSTEMI TIMI Score

TIMI —> NSTEMI

• Low Risk

  • Conservative

• Medium

  • Conservative or Invasive

• High

  • Invasive

NSTEMI Therapy

INVASIVE

• Anticoag: prevent thrombosis/clotting

  • UFH (60 to 12)

    • D/C immediately AFTER PCI

    • Easy bedside monitoring

  • LMWH (1 q12) - Enoxaparin

    • Renally adjust

  • Fondaparinux (2.5 mg QD)

    • AVOID in CrCl <30mL/min

    • DNU during PCI

  • Bivalirudin (0.75 then 1.75 IV) → Direct Thrombin Inhibitor

    • CrCL<30mL/min —> reduce dose

    • Indication:

      • Concern for HIT (heparin-induced thrombocytopenia)

  • Warfarin

• Anti-Platelet:

  • Aspirin

  • ± GP 2b/3a

    • Eptifibatide:

      • CrCl < 50 mL/min —> reduce to 1 mcg/kg/min

      • 18-24 hr

      • Monitor platelets

    • Tirofiban:

      • CrCl < 30 mL/min —> decrease by 50%

      • 12-24 hr

  • ADP receptor antagonists/P2Y12 receptor antagonists

    • Prasugrel

      • Hold 7 days prior to CABG

      • 60 mg → 10 mg

      • CI: Transient Ischemic Attack or Stroke

        • Caution: 75+ yo or <60 kg

      • STEMI and diabetic pt

    • Ticagrelor

      • Hold 3-5 days prior to CABG

      • 180mg → 90 mg BID

      • CI: > 100 mg ASA, CYP3A4, ICH (intracerebral hemorrhage)

      • SE: Dyspnea

    • Clopidogrel

      • 300-600g → 75 mg

      • Hold 5 days prior to CABG

      • CI: CYP2C19

    • Cangrelor: IV only

      • 30 mcg/kg IV → 4 mcg/kg/min

      • Indication:

        • PCI

        • Bridge therapy for CABG

• CABG: d/c GP2b/3a and P2Y12 (so just be on anticoags)

• PCI: continue same meds

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CONSERVATIVE

• Stress Test

• Anticoag

  • UFH

  • LMWH (Enoxaparin)

  • Fondaparinux

• Anti-Platelet

  • ASA (indefinitely)

  • P2Y12 (12 mo)

    • Clopidogrel

    • Ticagrelor

Discharge Medications Post-MI

• ASA: 81 mg (indefinitely)

  • On arrival & discharge

• P2Y12 (12 mo aka 1 year with ASA)

  • Clopidogrel/Prasugrel/Ticagrelor

• BB (within 24 hr of admit, for 1 year)

• ACEI/ARB

  • if EF < 40% anterior MI, diabetes, HTN

• Statin (high-intensity statin, indefinitely)

  • Target LDL < 70 mg/dL

• MRA (Spirinolactone, Eplerone)

  • if EF < 40% or diabetes

• Nitroglycerin SL (PRN)

Secondary Prevention of CV Events

• High-Intensity Statins

  • Atorvastatin: 40-80 mg

  • Rosuvastatin: 20-40 mg

  • Long-term target LDL < 70 mg/dL

Triple Therapy: DAPT with Oral Anticoag Therapy

• Indication:

  • Post-MI or CAD

    • Afib

    • VTE

    • VHD (must be on warfarin)

  • Clopidogrel is pregerred for triple therapy

  • D/C ASA 1-4 weeks post-PCI

ACS Diagram

LOOK OVER

CABG Indication

• Indication

  • Multi-vessel (>3) disease

  • Left anterior descending artery (LAD)

  • Failed primary PCI

  • Cardiogenic shock

CABG Therapy

• Prior to CABG

  • Clopidogrel hold x 5 days

  • Prasugrel hold x 7 days

  • Ticagrelor hold x 3-5 days

• During CABG

  • UFH - HIGH DOSES

  • Bivalirudin (alternative to heparin) - history of HIT

• Post-op

  • Monitor post-op AF

    • BB given 24 hr PRIOR to CABG

    • Control BG - continuous IV insulin for BG < 180 mg/dL

    • Monitor mediastinal infection: pre-op antibiotics

• Discharge

  • Aspirin +/- Clopidogrel

  • Secondary Prevention

    • HTN- BB and ACEI

    • Hyperlipidemia: ASCVD high potency statin

    • HR- BB

    • Smoking Cessation

Lecture 2: Heart Failure

Heart Failure Types

Echocardiogram:

• HFrEF (systolic): <40%

  • Larger than normal ventricular volume

  • Insufficient CO output

  • Increase in BNP

  • Congestion symptoms

  • Thin, weak heart muscle

  • Males

• HFpEF (diastolic): >50%

  • Insufficient cardiac output

  • Long-standing HTN

  • Thick, fibrosed ventricular walls

  • Females or older age

  • Diastolic HF

  • Increase in BNP

  • Congestion

NYHA HF Classification

• Class I: no limitation of physical activity

• Class II: ordinal physical activity, symptoms of HF

• Class III: less then ordinal activity

• Class IV: any physical activity

ACCF HF Classification

• A: high risk, no symptoms

• B: structural heart disease, no symptoms

• C: structure heart disease, symptoms

• D: refractory HF - need intervention

Clinical Presentation

• Congestion

  • Fluid overload

    • Rales/crackles in lungs

    • Peripheral edema

    • GI discomfort

    • Weight gain

• Hypoperfusion

  • Cold extremities

  • Fatigue

  • Poor appetite

  • Worsened renal function

• BNP = elevated in HF

  • Cannot be used to diagnose

Medications that Induce/Exacerbate HF

• Negative Inotropic Agents

  • Anti-arrhythmics

  • BB

  • CCB

• Alcohol

• Anthracyclines

• Sodium and Water Retention

  • Androgens

  • COX-2 Inhibitors

  • Estrogens

  • NSAIDs

  • TZDs

• Osmotic Agents

  • Albumin

  • Blood products

Inpatient Restrictions

• Sodium: <2 g/day

• Fluid: <2L/day

Forrester Classification

• Cardiac Index (CI)

  • Cl > 2.2 = hyperperfused (warm)

  • Cl < 2.2 = hypoperfused (cold)

• PCWP

  • PCWP > 18 = congestion (wet)

  • PCWP < 18 = congestion (dry)

Bolus vs. Continuous Infusion

• Continuous: constant delivery to renal tubule

• Bolus:

  • High levels → ototoxicity and nephrotoxicity

Diuretics for HF

• Loop Diuretics

  • Furosemide

  • Torsemide

  • Bumetanide

  • Ethacrynic Acid —> ok for sulfa allergy

• Monitor: Scr, I/O, K/Mg, BP

• Considerations:

  • Admin IV

  • Increase bolus

  • Admin continuous infusion

  • Add diff class diuretic

  • Titrate to relief of symptoms and adequate urine output without intravascular depletion

  • Vasopressins

  • Ultrafiltration

Vasopressin Antagonists

Indication:

• Hypoatremia (low Na)

• Volume overload → remove excess fluid

Vasopressins:

• Conivaptan

• Tolvaptan

Vasodilators - 1st Line

MUST NOT HAVE HYPOTENSION (SBP > 90mmHg)

• Nitroglycerin: lower doses = vasodilation

  • Preferred in ACS

  • Monitor:

    • Tachyphylaxis when >24hr infusion

    • Headache

    • Hypotension

• Nitroprusside: venous and arterial vasodilation

  • Risk of Toxicity:

    • Hepatic dysfunction → cyanide toxicity

    • Renal dysfunction → thiocyanide toxicity

  • Monitor:

    • Hypotension

    • Hepatic and renal dysfunction

    • Mental status changes

    • Metabolic or lactic acidosis

Inotropes - 2nd Line

• Dobutamine

  • Increase CO, decrease SV

  • Monitor:

    • Tachyphylaxis, hypotension, arrhythmias

• Milrinone

  • PDE Type-3 Inhibitor

  • Monitor:

    • Renal function

      • CrCl < 50 mL → adjust dose

    • Hypotension

    • Arrhythmias

• Indication:

  • Improve end-organ function

  • SBP < 90 mmHg

  • Symptomatic hypotension despite adequate filling pressures

  • Unresponsive or intolerant to vasodilators

• ADE:

  • Arrythmias

  • Hypotension

  • MI

HF Treatment Algorithm

• HFrEF (<40%)

  • 1. Diuretics - PRN

    • Symptom control

  • 2. SGLT2 (-flozin)

    • With or without diabetes

  • 3. ACEI/ARB/ARNI (ARNI is preferred)

    • ACEI: titrate to target dose when BB uptitrating

    • ARB: rec if ACEI ADE like angioedema or coughing

  • 3. BB (Metoprolol Succinate/Toprol XL)

    • BB: titrate to target dose when ACEI/ARB uptitrating

      • Titrate in 2-week intervals

      • 3-10 day intervals in pt → after newly diagnosed MI

    • Avoid Non-DHP CCBs in HFrEF

  • 3. MRA (Spirinolactone, Eplerone)

    • Target doses

  • Select Populations

    • Digoxin

      • Target: 0.5-0.8 ng/mL

    • Hydralazine/Isosorbide Dinitrate (African Americans)

      • Increase nitric oxide bioavail

      • Approved for high CrCl

    • Ivabradine

      • Reduce hospitalizations HFrED NYHA Class II-III while taking BB at max dose (resting HR > 70 bpm)

    • Vericiguat: oral soluble GC stimulator

      • Adjunct therapy

      • ADE: hypotension

• HFpEF (>50%)

  • 1. Diuretics

    • Symptom control

  • 2. SGLT2 Inhibitors (-flozin)

    • With or without diabetes

  • 3. ARNI (lower range, EF 50-60%)

  • 3. MRA

  • 3. ARB

ARNI

Valsartan/Sacubitril (Entresto)

• ADE:

  • Hypotension

  • Hyperkalemia

  • Cough

  • Renal failure

• CI:

  • ACEI within 36 hours

  • Do not use with BB

  • Hx of angiodema

• NYHA Class II or III: can substitute for ACEI or ARB

Device Therapy

• Pacemakers (PPM): symptomatic bradycardia or AV block

  • Single chamber or dual chamber

• Implantable Cardioverter Defibrillator (ICD)

  • Prevent sudden cardiac death (VF or VT)

• Biventricular Pacemaker

  • No anti-thrombotic therapy needed

  • Long-term use

• Intra-aortic Balloon Pump (IABP)

  • Refractory or intolerant to inotropes

  • ADE: severe bleeding, limb ischemia, systemic embolization, pseudoaneurysm of femoral artery

• Ventricular Assist Devices (VAD)

  • Replace falling left ventricle

  • Bridge to heart transplant

  • ADE: infection, arrhythmias, anemia, thrombosis, GI bleeding, right heart failure, critical bleeding

• Percutaneous Mechanical Support → Impella

  • Smaller than VAD → short-term

    • Hospital only

    • Need anticoagulation