Cardio Exam 3L Simplified Tsu (VHD/Shock/IHD)

Stenosis = ______

Regurgitation = ______

______ is by far the most common type of valvular disorder

narrowing or tightening, insufficiency or leaking, aortic valve stenosis

Surgical Treatment & Procedures

• Balloon Valvuloplasty

  • ______

  • pre-procedureal ______ to rule out ______ formation

  • ______ if pt is ______-risk for ______

• Valve repair

  • Valve repair ______ replacement

• Valve replacement: Open-heart cardiac surgery, Transcatheter aortic valve implantation (TAVI)

  • ______ replacement

    • ______ BUT ______ (need replacement in ______)

    • Best for RFs for ______ and pt refuses or C/I to ______

    • Ex.

      • ______

      • ______

  • Mechanical replacement

    • ______ BUT ______ → ______ AND ______

    • Best for ______

    • Ex.

      • 1st Gen: ______

      • 2nd Gen: ______ tilting disk

      • 3rd Gen: ______ tilting disk

Mitral stenosis, TEE, thrombus, aortic stenosis, too high, cardiac surgery, preferred over, Bioprosthetic, less thrombogenic, low durability, 5-10 years, bleeding, anticoags, Porcine (Pig), Bovine (Cow), Mechanical, High durability, highly thrombogenic, lifelong anticoag, clicking sound, young pts, Ball and Cage, Single, Bileaflet

Antithrombotic Therapy Summary

• Aortic

  • BioProsthetic (Porcine or Bovine)

    • ASA: ______

    • Warfarin: ______

  • Mechanical (Any Generation)

    • ASA: ______

    • Warfarin: ______

Baby ASA (add clopidogrel if transcatheter), NONE, NONE, INR 2.5-3.5 for 3 months only

Antithrombotic Therapy Summary

• Mitral

  • BioProsthetic (Porcine or Bovine)

    • ASA: ______

    • Warfarin: ______

  • Mechanical (Any Generation)

    • ASA: ______

    • Warfarin: ______

Baby ASA if additional TE RFs, INR 2-3, Baby ASA if additional TE RFs, INR 2.5-3.5

Use of DOACs in valvular disease

• ______ (DARE)

• Use is C/I with ______

• Studies show increased risk of ______ compared to ______

Dabigatran, Apixaban, Rivaroxaban, and Edoxaban, mechanical heart valves, TE and bleeding, Warfarin

Pregnancy and VHD

• ______ generally preferred

• If mother is willing, ______ could be continued in ______ if daily dose is ______

• Most choose to use ______

  • It ______ cross placenta

  • ______

Bioprosthetic Vavle, Warfarin, 1st trimester, <5 mg, LMWH injection, does not, BID SQ injections

Shock

• ______ of ______

• ______ mmHg OR reduction of at least ______ mmHg from ______ with ______

inadequate perfusion, critical organs, SBP <90, 40, baseline, perfusion abnormalities

Goals and Monitoring of Shock (KNOW)

• MAP ______ mmHg

• Adequate perfusion to critical organs

• perfusion and oxygenation of entire body

• systemic BP, oxygen tension, lactate

• organ-specific oxygen delivery and utilization

• coagulation abnormalities, impaired renal or hepatic dysfunction, cool extremities, cardiac ischemia, etc.

>65

Types of Shock

• ______

• ______

• ______

• ______

Cardiogenic, Obstructive, Hypovolemic, Distributive

Types of Shock

• Cardiogenic

  • Heart ______

  • Ex. ______

  • General Treatment: ______

fails to pump out blood, HF and Valve dysfunction, Increase CO and Inotropes

Types of Shock

• Obstructive

  • Heart ______

  • Ex. ______

  • General Treatment: ______

pumps well, but outflow is obstructed, PE and Tamponade, Treat obstruction

Types of Shock

• Hypovolemic

  • Heart ______

  • Ex. ______

  • General Treatment: ______ (______)

pumps well, but not enough blood volume to pump, blood and fluid loss, IV fluids, crystalloids, colloids, and blood

Types of Shock

• Distributive

  • Heart ______

  • Ex. ______

  • General Treatment: ______

pumps well, but there’s peripheral vasodilation, Anaphylaxis and Sepsis, IV fluids, then vasopressors

Review of Receptor Physiology

• Blood Vessels

  • Alpha-__ → ______

  • Beta-__ → ______

• Heart

  • Beta-__ → ______

• Other

  • Beta-__ → ______

  • DA → ______

  • Vasopresin

    • V1 → ______

    • V2 → ______

1, Vasoconstriction, 2, Vasodilation, 1, Increased inotropy and chronotropy, 2, bronchodilation, vasodilation in kidneys, vasoconstriction, Reabsorption water in kidneys

Vasopressors to treat Shock (treat ______ shock (______) AFTER ______)

• ______

• ______ (Levophed)

• ______

• ______ (Neo-Synephrine)

• ______

distributive, anaphylaxis and sepsis, IV fluids, EPI, NE, DA, Phenylephrine, Vasopressin

Vasopressors to treat Shock (treat distributive shock (anaphylaxis, sepsis) AFTER IV fluids)

• EPI

  • ______ agonist

  • ______

  • ______ activity

  • Most common vasopressor used in ______ situations (______, pt is ______)

alpha-1, beta-1, and beta-2, Vasoconstriction, Increased inotopic/chronotropic, life-threatening, cardiac arrest, dead

Vasopressors to treat Shock (treat distributive shock (anaphylaxis, sepsis) AFTER IV fluids)

• NE (______)

  • Primarily ______ agonist, secondarily ______ agonist

  • ______

  • ______ activity

  • Preferred vasopressor in ______

    • Most common vasopressor in ______

Levophed, alpha-1, beta-1, vasoconstriction, increased inotropic/chronotropic, sepsis, ICU

Vasopressors to treat Shock (treat distributive shock (anaphylaxis, sepsis) AFTER IV fluids)

• DA

  • ______ agonist (depends on dosing!)

  • ______ (______ dose)

  • ______ activity (______ dose, for ______)

  • ______ (______ dose)

  • Primarily used for ______

DA, beta-1, and alpha-1, increased renal blood flow, low, increased inotropic/chronotropic, medium, bradycardia, Vasoconstriction, high, cardiogenic shock in ICU

Vasopressors to treat Shock (treat distributive shock (anaphylaxis, sepsis) AFTER IV fluids)

• Phenylephrine (______)

  • ______ agonist

  • ______

  • ______ vasopressor IF ______ from ______

Neo-Synephrine, pure alpha-1, Vasoconstriction, Alternative, tachyarrhythmias, NE or DA

Vasopressors to treat Shock (treat distributive shock (anaphylaxis, sepsis) AFTER IV fluids)

• Vasopressin

  • ______ to ______ in ______ (NOT as ______)

  • ______

Adjunctive agent, NE, sepsis, monotherapy, Vasoconstriction

General Adverse Effects of Vasopressors

• ______

• ______

• ______, Especially ______ → ______

Arrhythmias, Tachycardia, Tissue Ischemia, digit ischemia, long-term (ICU)

Stable Ischemic Disease

• ______-acting nitrates

  • ______

  • Indications:

    • ______ (______)

    • ______

      • Taken ______ to activity

• ______-acting nitrates

  • ______

  • Indications:

    • ______ therapy to ______ if ineffective

    • ______ only if ______ C/I or intolerable

    • Will cause compensatory ______

Short, sublingual tablets or spray, infrequent attacks, few times a month, Prophylaxin, 5-10 mins prior, Long, Oral or transdermal patches, add-on, BB or CCB, Monotherapy, BB or CCB, tachycardia

Stable Ischemic Disease

• Monitoring: ______

• Counseling

  • ______

  • ______ interval at least ______

  • ______

    • Keep in ______ (______ canister)

    • Call 911 if ______

      • Newer recommendations to call after 911 after ______ IF NO relief of Sxs

• Interventional

  • ______

  • ______

BP and HR (reflex tachycardia), Headache, Nitrate-Free, 8 hours every day, Sublingual Tablets, original container, brown, persistent chest pain after 3 tablets/sprays, 5 mins of 1st dose, PCI, CABG

KNOW IMAGE

Nitrates = increase HR + greatly decrease LV Volume

BBs and Verapamil WILL decrease myocardial contractility

Nifedipine may or may not decrease systolic P

BBs WILL Increase LV Volume

KNOW IMAGE

Ranolazine

• ______ in ischemic myocyte by inhibiting ______ (Ina)

• C/Is

  • Pre-existing ______

  • ______

  • ______

• Reserved for pts with inadequate response to other ______

• Does NOT affect ______, ______, ______, or ______

• Monitor ______

Reduces Ca, late Na current, QT prolongation and QT-prolonging meds, liver impairment, Potent 3A4 inhibitors, anti-anginal meds, HR, inotropy, hemodynamics, coronary blood flow, QT prolongation

A 58 year-old male presents to your pharmacy with a new prescription for nitroglycerin SL tablets. Fill in the following instructions regarding nitroglycerin.

• Place 1 tablet (______ mg) under your ______ at start of chest pain.

• You can repeat this ______ times, ______ mins apart.

• Keep your tablets in the ______ container

• Do not take within ______ hours of erectile dysfunction medications.

• If you are using this to prevent chest pain prior to exercise, take ______ mins before activity

0.4, tongue, 2, 5, original, 24-48, 5-10