PHRD 619: Final Exam

Collaterals

Small alternative blood vessels that act as detours around a narrowed or blocked artery

Preload

The amount of blood sitting within the heart

Afterload

The resistance to the heart pushing blood out

T-wave inversion or ST segment depression

UA or NSTEMI

Acute ST segment elevation

STEMI

Troponin T Normal

<14

Troponin T indication of MI

>20% increase at 2h

LDL Goal for CCD

<70

<55 for very high risk

BP Goal for CCD

<130/80

Exercise goal for CCD

150-300 mins/week (moderate) or 75-150 mins/week (high-intensity)

Diabetes goals for CCD

A1C <7 or <6.5

No PCI Antithrombotic Treatment

Aspirin 81 mg

Clopidogrel or Ticagrelor if aspirin is contraindicated

Recent PCI Antithrombotic Treatment

DAPT - Aspirin and P2Y12i for 6 months

Followed by SAPT

Recent PCI + Pt requires anticoagulation Antithrombotic Treatment

DAPT for 1-4 weeks

Followed by Clopidogrel alone for 6 months

Previous MI and low risk of bleeding Antithrombotic Treatment

Extended DAPT beyond 12 months for up to 3 years

Non-cardioselective beta-blockers

Propranolol, Nadolol, Timolol, Sotalol

Cardioselective Beta-Blockers

Metoprolol, Atenolol, Acebutolol

Intrinsic Sympathomimetic Activity Beta-Blocker

Acebutolol, Pindolol, Oxyprenolol

Lipophilicity Beta-Blockers (most to least)

Propranolol > Metoprolol > Atenolol

Low TIMI Risk

Score 0-1, 2

Intermediate TIMI Risk

Score 3-4

High TIMI Risk

Score 5, 6-7

Alteplase STEMI dose

15 mg IV bolus, then 0.75 mg/kg (max 50 mg) over 30 mins, then 0.5 mg/kg (max 35 mg) over 60 minutes. Total dose should not exceed 100 mg.

Tenecteplase STEMI dose

<60 - 30 mg

60-70 - 35 mg

70-80 - 40 mg

80-90 - 45 mg

> 90 - 50 mg

Alteplase brand

Activase

Tenecteplase brand

TNKase

Nitroglycerin Dose ACS Stabilization

SL or Spray: 0.3 or 0.4 mg q5 min PRN up to a total of 3 doses

IV Drip: Start at 10 mcg/min and titrate to pain relief

Morphine Dose ACS Stabilization

2-4 mg IV push q5-15 min PRN pain

Fentanyl Dose ACS Stabilization

25-50 mcg IV push q5-15 min PRN pain

Notable CI for Nitroglycerin

Concurrent use of PDE-5 inhibitors (Sildenafil - 24 hours+; Tadalafil - 48 hours+)

Aspirin Dose ACS

LD: 162-325 mg PO x1

MD: 75-100 mg PO QD

P2Y12i Examples

Clopidogrel, Prasugrel, Ticagrelor, Cangrelor

Clopidogrel brand

Plavix

Prasugrel brand

Effient

Ticagrelor brand

Brilinta

Cangrelor brand

Kengreal

Clopidogrel Medical Management of ACS dose

LD: 300 mg PO x1

MD: 75 mg PO QD

Clopidogrel Fibrinolytic ACS Dose

LD: 75 years or younger 300 mg PO QD (75+ no LD)

MD: 75 mg PO QD

Clopidogrel PCI ACS Dose

LD: 600 mg PO x1

MD: 75 mg PO QD

Clopidogrel Hold before CABG

5 days before surgery

Clopidogrel BBW

Diminished effectiveness in poor metabolizers of CYP2C19

Prasugrel PCI ACS Dose

LD: 60 mg PO x1

MD: 60+ kg - 10 mg PO QD; Less than 60 kg - 5 mg PO QD

Prasugrel Hold before CABG

7 days before surgery

Prasugrel BBW

Not recommended in pts 75+ years old due to increased risk of fatal and intracranial bleeding and uncertain benefit

Prasugrel CI

History of transient ischemic attack or stroke

Clopidogrel indication ACS

Medical Management, Fibrinolytic, PCI

Prasugrel indication ACS

PCI

Ticagrelor indication ACS

Medical Management, PCI

Cangrelor indication ACS

PCI

Ticagrelor Medical Management ACS Dose

LD: 180 mg PO x1

MD: 90 mg PO BID, can continue with 60 mg PO BID after 1 year

Ticagrelor Hold before CABG

3-5 days before surgery

Ticagrelor CI

Severe hepatic impairment, history of intracranial hemorrhage

Ticagrelor BBW

Maintenance dose of aspirin >100 mg reduces the effectiveness of ticagrelor

Cangrelor Hold before CABG

1 hour prior to surgery

Ticagrelor indication

Patients with ACS undergoing a PCI who are unable to receive or tolerate a PCY12i

Med Selection for Reperfusion Therapy - PCI

Aspirin + Ticagrelor/Prasugrel (use clopidogrel when unavailable or contraindicated)

Med Selection for Reperfusion Therapy - Fibrinolytic

Aspirin + Clopidogrel

Med Selection for Medical Management ACS

Aspirin + Ticagrelor

GP IIb/IIIa Inhibitors

Eptifibatide, Tirofiban

Eptifibatide CI

Patients on hemodialysis

Unfractionated Heparin ACS Dose

60 units/kg IV bolus (Max 4000 units), then 12 units/kg/hr infusion (max 1000 units/hr) for 48 hours or until end of PCI

Low Molecular Weight Heparin NSTE-ACS Dose

1 mg/kg SC q12 hours

Low Molecular Weight Heparin STEMI Dose

Younger than 75: 30 mg IV bolus, then 1 mg/kg SC q12 hours

Older than 75: No bolus, then 0.75 mg/kg SC q12 hours

Alternative Anticoagulant Indication

Patient hx of HIT or development of HIT

Alternative Anticoagulants that are renally cleared

Bivalirudin, Fondaparinux

Alternative Anticoagulants that are hepatically cleared

Agatroban

Alternative Anticoagulants that are used in PCI patients

Bivalirudin, Fondaparinux

GP IIb/IIIa Inhibitor Hold before CABG

2-4 hours

UFH hold before CABG

Continued during CABG

Enoxaparin hold before CABG

12-24 hours, start UFH

Fondaparinux hold before CABG

24 hours, start UFH

Bivalirudin hold before CABG

3 hours, start UFH

Atorvastatin Secondary Prevention ACS Dose

40-80 mg PO QD

Rosuvastatin Secondary Prevention ACS Dose

20-40 mg PO QD

Statin indication ACS

All patients with ACS

Non-statin indication ACS

Patients who are on maximally tolerated statin + LDL > 70 (>55 if high-risk) or statin intolerant

LDL 55 ACS

Continue high intensity statin

LDL 55-69 ACS

Add non-statin LDL-lowering therapy if patient is very high risk

LDL 70 ACS

Add non-statin LDL lowering therapy

Statin intolerant or refusing statin therapy ACS

Add non-statin LDL lowering therapy

Not on statin or on low-moderate intensity statin ACS

Initiate high-intensity statin

Beta blocker indication ACS

Within 24 hours in all patients with ACS

ACEi/ARB indication ACS

All patients with ACS

Aldosterone indication ACS

Patients with ACS with LVEF <40% with HF sx and/or DM

Bradycardia

Slow heart rate, less than 60 bpm

Drugs that affect SA node function (may cause bradycardia)

Beta Blockers

Non-DHP Calcium Channel Blockers

Clonidine

Hypoperfusion HF sx

Fatigue, Weakness, Malaise, Depression, CNS Disturbances, Pallor, Tachycardia

Congestion Right-Sided HF sx

Jugular Venous Distention, Hepatomegaly, Hepatojugular Reflux, GI Congestion, Anorexia, Ascites, Peripheral Edema

Congestion Left-Sided HF sx

Pulmonary congestion, pulmonary edema, Orthopnea, Paroxsymal Noctunral Dyspnea, Dyspnea, Rales, Pleural Effusion, Cough, S3 Extra Heart Sound

B-Type Natriuretic Peptide (BNP) Acute HF Cutoff

<100 pg/mL

B-Type Natriuretic Peptide (BNP) Non-Acute HF cutoff

<35 pg/mL

N-Terminal Pro-BNP (NT-proBNP) Acute HF cutoff

<300 pg/mL

N-Terminal Pro-BNP (NT-proBNP) Non-Acute HF cutoff

<125 pg/mL

Stage A HF management

ACEi/ARB in appropriate pts for vascular disease/DM

SGLT2i in pts with type 2 diabetes+CVD or high-risk CVD

Statins as appropriate

Stage B HF management

ACEi/ARB

Beta-blocker

Stage C HF management

Diuretics for volume management

4 Pillars of GDMT to improve survival

1. ACEi or ARB or ARNI

2. Beta-blocker

3. MRA

4. SGLT2i

Sometimes additional therapies added

ARNI Starting Dose HF

"100 mg” 49/51 mg (s/v) BID. Double the dose after 2-4 weeks as tolerated

ARNI Max/Target Dose HF

“200 mg” 97/103 mg (s/v) BID

ARNI Reduced Dose HF

“50 mg” 24/26 mg (s/v) if…

1. Patient is not currently taking an ACEi or ARB or previously on low dose

2. Severe renal impairment (eGFR <30)

3. Moderate hepatic impairment (Child-Pugh Class B)

Loop diuretic with longest duration of action

Torsemide