Cardiac Meds for HESI

Dyslipidemia

• Lifestyle

• Statins: Reduce LDL + total mortality

  • 30%. with low-intensity, 50% with high intensity

• Add Ezetimibe to reduce LDL another 20%

• Add PCSK9 inhibitor (-mab)

Dyslipidemia Meds

• Statins

• Ezetimibe

• Evolocumab

• Bile Acid Sequestrant

• Niacin/Nicotinic Acid

• Gemfribozil

Statins

HMH-CoA reductase inhibitors: Reduces cholesterol synthesis

• Reduce LDL + total mortality 30%. with low-intensity, 50% with high intensity

Teratogenic

Dosing: Once daily (QD) in evening

Monitor: LFTs (all cholesterol drugs are hepatotoxic)

FIRST LINE FOR DYSLIPIDEMIA

Statin Side Effects

• Myalgia

• Myopathy

• Rhabdomyolysis

Ezetimibe

Added to statin to reduce LDL by another 20%

MOA: Inhibit cholesterol absorption

Side Effect: HA and rash

Max out on statins, then add this**

Evolocumab

PCSK9 inhibitor: Lowers bad LDL

ADDED TO STATIN + EZETIMIBE

• Lowers LDL 50-60%

• Increase cholesterol clearance from the liver

Side Effects:

• SQ site reaction

• Respiratory infection

Cholestyramine

Bile Acid Sequestrant!!!!!!

Removes bile acid from your body and decreases the amount of bad cholesterol (such as LDL) in your blood

• Takes 2 hours before or 6 hours after all drugs (alters absorption)

• Decreases fat soluble vitamin absorption → Take Vit powder with water (cloudy)

Colesevelam

Bile Acid Sequestrant!!!!!!

Works by binding to bile acids in the digestive tract, which helps reduce cholesterol levels, particularly LDL (bad) cholesterol.

• Decreases LDL

Side Effects:

• Constipation

• TAKE WITH FULL GLASS OF WATER

Niacin/Nicotinic Acid

• Best for increasing HDL

Side Effects:

• Intense skin flushing = pretreat with 325 mg ASA 30 minutes before

• Increased blood glucose and gouty arthritis

Gemfibrozil

BEST FOR LOWERING TRIGLYCERIDES

• Increased risk of bleeding with warfarin (monitor PTT/INR)

• ^ risk of rhabdomyolysis with statin

Side Effects:

• Gallstones

• Rash

• Myopathy

Anticoagulants/Platelets

• Heparin

• Enoxaparin (Lovenox)

• Bivalrudin

• Warfarin

• Dabigatran

• Apixaban

• Aspirin (ASA)

• Clopidogrel

• Abciximab

• Alteplase (TPA)

Heparin

Reduces fibrin production to prevent coagulation (promotes bleeding)

• SQ for prophylaxis, IV tx of clots

• Rapid onset, short duration (Hep! Hep! Hep me!)

• Dosed based on body weight

• No effect on placenta or BF

Monitor: aPTT = 60-80 secs is goal

Heparin Contraindications

Contraindications

• Uncontrolled bleeding

• Thrombocytopenia

• Eye/brain/spinal cord surgery

Heparin Side Effects

• Hemorrhage

  • ANTIDOTE = PROTAMINE SULFATE

• HIT: Heparin induced thrombocytopenia

  • USE BIVALIRUDIN

Enoxaparin (Lovenox)

Low molecular weight heparin

Only SQ, do not need to monitor PTT Q4

• Tx + prophylaxis for DVT

• Prevent ischemic complications (MI, angina)

Enoxaparin (Lovenox) Side Effects

• Sever neuro injury with epidural/spinal

• HIT

• Bleeding

ANTIDOTE = PROTAMINE SULFATE

Dabigatran

Direct Thrombin Inhibitor

Swallow WHOLE with FULL GLASS OF WATER

• Discard after 4 months

ANTIDOTE = IDARUCIZUMAB

5 benefits of Dabigatran over Warfarin

• Fewer drug interactions

• No monitoring

• Rapid onset

• Decreased risk of major bleed

• Predictable response (no personalized dose)

Apixaban

PO, safe for pregnancy***

• Rapid onset

• Decreased risk of bleeding

• Prevent stroke and emboli with A-fib

• Selective inhibitor of CF Xa

Aspirin (ASA)

IRREVERSIBLE inhibitor of COX for platelet’s whole life (10 days)

• Increased risk of GI bleed and hemorrhagic stroke

• Used to treat TIA, MI, CVA, stent, and angina

• Chew a 325mg ASA if think having an MI

Clopidogrel

IRREVERSIBLE ADP receptor antagonist

• Prevents stent blockage and decreases CV events

Abciximab

NEVER USE WITH ALTEPLASE (TPA)

• Super aspirin!!!!!!!

• Glycoprotein 2b/3a antagonist

• Used in Percutaneous Coronary Intervention (PCI) and Acute Coronary Syndrome (ACS)

Alteplase (TPA)

Thrombolytic drug used in STEMI when PCI is not possible within 2 hours

• MANY contraindications

• NEVER USED WITH ABCIXIMAB

STEMI: coronary artery is completely blocked,

• MONA B

• SAAB/C

• Nitroglycerin

MONA B

• Morphine: For severe pain

• Oxygen: if SpO2 < 95%

• Nitroglycerin: Sublingual, vasodilation

• Aspirin: Chew 325 mg, prevent further platelet aggregation

• Beta Blocker: Decrease the workload of the heart and increase O2 supply

SAAB/C

FOR ALL POST-MI PTs

• Statin: To reduce LDLs

• ACEI/ARB: To reduce BP

• ASA/Clopidogrel: Dual antiplatelet therapy

• Beta Blocker/CCB: Reduce worklaod of the heart via vasodilator or HR reduction

Nitroglycerin

Promotes vasodilation to decrease preload

Usually SUBLINGUAL

• ORTHOSTATIC HYPOTENSION, HA, flushing, reflex tachycardia

• Need an 8 hour nitrate free period

• Hold if SBP < 90 mmHg

• DO NOT TAKE WITH Erectile Dysfunction drugs

• Keep in dark, glass bottle

• Tablet will FIZZ

• Remove old paste; use special IV tubing

• Take patch off before shocking pt (contains aluminum)

Heart Failure Meds

• Sacubitril/Valsartan

• Digoxin

Heart Failure

• ACEI/ARB = Sacubitril/Varsartan

• Beta Blocker

• Spironolactone

• Furosemide if fluid overload

• Digoxin if HR > 60bpm

• Hydralazaline/Isosorbide if African American

• Empagliflozin

ACEI/ARB

Both used reduce BP

• ACE inhibitor/ACEI: Block the conversion of angiotensin 1 to 2; REDUCES MORTALITY

• Angiotensin 2 Receptor Blocker/ARB: Block angiotensin 2 (a vasoconstrictor) from binding to its receptors

Beta Blocker

Slow HR; Reduce force of heart contractions

• REDUCES MORTALITY

Beta 1: Heart + Kidneys = Crucial for regulating heart rate, contractility, and renin release

Beta 2: Lungs + Blood vessels = Bronchodilation, vasodilation, insulin release

Spironolactone

K+ sparing diuretic (water pill)

• REDUCES MORTALITY

• Precent ^ absorbtion of salt and keeps K+ levels from getting too low

• Manages excess fluid and salt retention by blocking aldosterone

Furosemide

Loop Diuretic

• Helps treat fluid retention (edema) and swelling caused by CHF

Digoxin

Cardiac Glycoside

• Positive Ionotrope: Increases heart contractility

• Negative Chronotrope: Decreases HR

Hydralazaline/Isosorbide

Used for HF for African American patients

• REDUCES MORTALITY

• Relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing workload

Empagliflozin

Works in kidneys to prevent absorption of blood sugar level and helps treate TYPE 2 DIABETES

• REDUCES MORTALITY

• Helps reduce HF with reduced ejection fracture

• Reduces risk of cardiovascular death + hospitalization

Calcium Channel Blocker

Block entry of calcium into the cells of the heart and blood vessels. Calcium plays a role in muscle contraction, so blocking causes the blood vessels to relax and widen, lowering BP

Can also slow down HR and reduce contraction force

• Angina

• Arrhythmias

• High BP

Verapamil + Diltaizem

HF contraindicated

• Calcium Channel Blocker: Verapamil + Diltiazem

• Pregabalin: Control seizure + pain, exacerbate HF

• NSAID: ^ BP and fluid retention

• Class 1 and 3 antiarrhythmics : Potential for pro-arrhythmic effects + negative ionotrope to decrease heart force

Sacubitril/Valsartan

Replaces ACEI/ARB; cannot be used if developed angioedema

• Need a 36 hour washout period between ACEI/ARB and SV

  • If not = angioedema

Digoxin

Positive Ionotrope + Negative Chronotrope (increase force, decrease rate)

• Alleviates s/s but NOT IMPACT ON MORTALITY

• Narrow TI: Keep < 0.1 in HF pt

Dig Toxicity

HALOS*****

• PVC: Premature Ventricular Contraction

• Death

• Hallucinations

• Psychosis

• Confusion

• Worsened with hypo/hyperkalemia

TX of Dig Toxicity

STOP DIG + K-WASTING DIURETICS

• Stat dig level

• Give PHENYTOIN OR LIDOCAINE. for arrythmias; Digibind if severe

• Lower dose in elderly + renal or hepatic dysfunction

• Drug Interactions: Amiodarone, Verapamil

• Can be cardiotoxic, ESPECIALLY WITH HYPOKALEMIA

Dysrhythmia

• Na Channel Blockers

• Beta Blockers

• K Channel Blockers

• Ca Channel Blockers

• Adenosine

Quinidine

Na Channel Blockers

• Torsade de Pointe (SERIOUS V-Tach)

• For V rhythms

Lidocaine

Na Channel Blockers

• 2nd line for V tach; Dig toxicity

Propafenone

Na Channel Blockers

• SVT

• Use with rate control agent to decrease the paradoxical rate increase

  • Increases dig and warfarin levels

Beta Blockers Prototypes

• Propranolol

• Atenolol

• Metoprolol

• Esmolol

• Sotalol

Pretty Angry, My Ex Sucks

Amiodarone

K Channel Blockers

• Most Effective for A-fib

• Adverse Reaction:

  • Pulmonary fibrosis

  • QT prolongation

  • Hepatotoxicity

  • Corneal deposits

  • Neuropathy

  • Photosensitivity

  • Skin pigmentation

  • Thyroid disorders

*********NO KIDNEY EFFECTS******

Monitoring

• Every 12 months: CXR, PFT, EKG

• Every 6 months: LFT, TSH, T4

Verapamil + Diltiazem

Calcium Channel Blockers

• Diphenhydrapyradines only work peripherally

Adenosine

Only for Supraventricular Tachycardia (SVT)

Pt will temporarily flatline

Given central line or peripheral IV

• Slam the drug, slam the saline, raise the arm