SCOPE Objectives - HF and Ischemic Stroke

describe the MOA of digoxin

inhibits Na+/K+ ATPase pump on cardiac myocytes → increases Na+ intracellular and Ca2+ = increase contraction

list ADRs for digoxin

• N/V

• vision disturbances

• AV nodal block

• ventricular arrhythmias

• fatigue

describe the MOA of spironolactone

blocks aldosterone to decrease fibrosis and increase pumping effectiveness

list ADRs for spironolactone

• N/V/D

• gynecomastia

• irregular menses

• impotence

• hypokalemia (esp. if combined with ACE or ARB)

• hyperkalemia if combined with digoxin

describe the MOA of milrinone

prevents breakdown of cAMP to AMP = inhibits PDE-3 and enhances the effects of SNS to increase FOC

list ADRs of milrinone

• hypotension

• arrhythmias

• thrombocytopenia

describe the MOA of nesiritide

activates guanylyl cyclase to increase cGMP causing an increase in natriuresis and diuresis (decreases TPR and preload)

list ADRs for nesiritide

• hypotension

• GI upset

describe the MOA of vasopressin

binds to GPCR causing peripheral vasoconstriction and water absorption in the renal collecting duct; also increases blood flow to the heart and brain

list the ADRs for vasopressin

• N/V

• abdominal cramps

describe the MOA of ADH antagonists

blocks ADH to reduce volume overload

(Tolvaptan is V2 selective; Conivaptan blocks V1a and V2)

list ADRs for ADH antagonists

Tolvaptan: dry mouth, thirst, urinary frequency, constipation, and hyperglycemia

Conivaptan: orthostatic hypotension, fever, hypokalemia, and injection site reactions

describe the MOA of ivabradine

within the SA node, selectively inhibits the HCN channel to inhibit the funny channel → decreases heart rate

list ADRs for ivabradine

• bradycardia

• HTN

• increased risk for Afib

• vision disturbances

• avoid in severe hepatic impairment

describe the MOA of Entresto

the sacubitril inhibits the enzyme neprisylin to decrease degradation of atrial and brain natriuretic peptides and valsartan inhibits AT1 receptors

list ADRs for Entresto

• angioedema

• hypotension

• hyperkalemia

• cough

• dizziness

• renal failure

• avoid in severe hepatic impairment

list the eligibility requirements to receive thrombolytics for acute ischemic stroke

• LKN < 4.5 hrs

• disabling stroke

• BP <185/110

• dual antiplatelet therapy is not contraindicated

• BG normalized (50-400mg/dL)

list contraindications for thrombolytics

• Hx of intracerebral hemorrhage

• AIS within the last 3 months

• severe head trauma in last 3 months

• GI/GU bleed within 21 days

• intracranial neoplasm

• aortic arch dissection

• coagulopathy

• use of DOAC within 48 hrs or LMWH within 24 hrs

• active internal bleeding

• infective endocarditis

thrombolytic agents dosing and form

alteplase: IV bolus over 1 min, infuse over 60min; dosing = 0.9mg/kg IV (max = 90mg)

tenecteplase: single bolus dose over 5-10 secs; dosing = 0.25mg/kg IV bolus (max = 25mg)

what is the initial ASA dose for patient post AIS or TIA

162-325mg start immediately (within 24-48hrs onset OR >24hrs post thrombolytic therapy

what is the recommended antiplatelet regimen post minor AIS/TIA with cardioembolic source (i.e. A.fib)

start DOAC 2-14 days post stroke → follow with either single antiplatelet therapy or dual antiplatelet therapy

criteria for single antiplatelet therapy

if TIA was not high risk or AIS was not caught early or if NIHSS was not < 3

criteria for dual antiplatelet therapy

if TIA was high risk or AIS was caught early AND NIHSS < 3

• start with DAPT 0-90 days → transition to single going forward

what is the dosing scheme for plavix in DAPT

300-600mg load then 75mg po QD

what is the dosing scheme for ASA in DAPT

50-325 po QD

what is the dosing scheme for ticagrelor in DAPT

180mg load then 90mg po BID for 30 days

what is the dosing scheme for ASA when used with ticagrelor for DAPT

300-325mg load then 75-100mg QD x 30 days