pharm- cardio 3 (Ischemic Heart disease)

ABCDEs of ischemic heart disease treatment

-A(aspirin, antiaginal)

-B(BP management, beta blockers)

-C(cholesterol management, cessation of smoking)

-D(diabetes control, diet)

-E(exercise, education)

what class of meds has been shown to decrease mortality in MI patients?

beta blockers

what class of meds improves angina symptoms but not mortality?

nitrates

what class of meds reduces progression/mortality of atherosclerosis/CAD?

statins and aspirin

what medications are antiplatelet meds?

-aspirin

-dipyridamole

-clopidogrel

-prasugrel

-ticagrelor

-abciximab

-eptifibatide

-tirofiban

aspirin MOA

-nsaid

-inhibits COX1 enzyme to inhibit thromboxane-> inhibiting platelet aggregation(for the entire lifetime of the platelet)

aspirin indications

first line in ACS and stroke prevention

aspirin contraindications

-GI bleed

-bleeding disorders

-children

aspirin SE

-GI complications (GERD, GI bleed)

-tinnitus

-toxicity can be fatal

how to decrease GI complications when giving aspirin?

give enteric coated-> absorbs in small intestine rather than stomach

dipyridamole MOA

-PDE inhibitor + blocks adenosine reuptake

-coronary vasodilation + decreases platelet aggregation

dipyridamole indications

-second line for prevention of ischemic stroke

(aspirin is favored)

dipyridamole contraindications

-active PUD

-hypotension

dipyridamole SE

-hypotension

-GI sx

-headache/dizziness

dipyridamole downside

dosed 4x daily-> pill burden

clopidogrel moa

-prevents platelet aggregation (P2Y12 inhibitor)

-prodrug-> takes 2-3 days to be fully converted

clopidogrel indications

secondary prevention for MI, stroke, PAD, ACS, post-PCI

clopidogrel DDis

omeprazole and esomeprazole

clopidogrel SE

-TTP

-bleeding/bruising

prasugrel moa

-prevents platelet aggregation (P2Y12 inhibitor)

-prodrug (faster onset than clopidogrel)

prasugrel vs clopidogrel

-very similar moa, but prasugrel is faster and more predictable

-prasugrel also much more expensive(brand)

-both irreversible(lifetime of platelet)

-prasugrel has better anti thrombotic event efficacy, but worse bleeding outcomes

prasugrel indications

-ACS

-reduction of thrombotic CV events

prasugrel contraindications

-hx of stroke of TIA

-active bleeding

prasugrel SE

-TTP

-bleeding/brusing

-HTN

ticagrelor moa

-prevents platelet aggregation(P2Y12 inhibitor)

-reversible

-not a prodrug(does not require metabolic activation)

which 3 drugs are P2Y12 inhibitors?

which is reversible?

-clopidogrel, prasugrel, ticagrelor

-ticagrelor

ticagrelor indications

ACS

unstable angina

post-PCI

secondary prevention of MI

ticagrelor contraindications

-active bleed

-ICH

-severe hepatic impairment

ticagrelor SE

-dyspnea

-bradycardia

-hyperuricemia

what food to avoid with ticagrelor?

-grapefruit (CYP3A4)

which antiplatelet meds are commonly combined with low dose aspirin?

-ticagrelor

-prasugrel

-clopidogrel

-dipyridamole( as aggrenox)

cilostazol moa

-decreases platelet aggregation(PDE3 inhibitor)

-vasodilation

cilostazol indications

intermittent claudication in PAD

cilostazol contraindications

CHF

cilostazol SE

-Afib/aflutter

-thrombocytopenia/bleeding

-peripheral edema

what food to avoid in cilostazol?

grapefruit (CYP3A4)

ivabradine moa

reduces heart rate

ivabradine indications

Heart Failure with Reduced Ejection Fraction(HFrEF)

ivabradine goal HR?

how do we achieve this?

50-60BPM. after 2 weeks->

-decrease by half if

ivabradine contraindications

-decompensated CHF

-hypotn/bradycardia

-liver failure

-pregnancy

ivabradine SE

-visual disturbances

-prolonged QT

-afib/bradycardia

ivabradine DDIs

-grapefruit (CYP3A4)

-non-DHPs

which antiplatelet meds are glycoprotein inhibtiors specifically?

-abciximab

-eptifibatide

-tirofiban

(IV only!!)

abciximab moa

-monoclonal antibody to GP 2b/3a

-inhibits platelet aggregation

-irreversible

eptifibatide moa

-inhibits platelet aggregation via GP 2b/3a

-reversible

is eptifibatide or tirofiban more renal toxic?

-eptifibatide

-it needs an adjustment at CrCL

tirofiban moa

inhibits fibrinogen

-reversible

glycoprotein inhibitor indications

ACS, PCI

glycoprotein inhibitor contraindications

-active bleed

-hx of stroke

-major surgery within 6 weeks

-platelets

glycoprotein inhibitor SE

-bleeding/thrombocytopenia

-injection site rxn/hypersensitivity

-hypotn

which glycoprotein inhibitor is safer in pregnancy?

eptifibatide/tirofiban

which glycoprotein inhibitor is irreversible, meaning it would need to be held longer before surgery?

abciximab

nitrates MOA

-prodrug of nitric oxide

-relaxes smooth muscle cells (dilates veins/arteries)

-reduces preload and cardiac demand

-inhibits platelet aggregation

nitroglycerin indications

-immediate chest pain symptomatic relief

-ACS pain relief

-acute HF with pulmonary edema

nitroglycerin dosing

3 doses sublingual every 5 mins

(call 911 after the first dose!!!)

nitrate class contraindications

-PDE5 inhibitors (little blue pill)

-high ICP

-cardiogenic shock

-hypotn

-right ventricular (inferior) MI

nitroglycerin SE

-severe HA

-reflex tachycardia

-flushing/syncope

which is the only form of nitroglycerin that actually reduces mortalitiy, not just symptoms?

IV only been shown to improve mortality in acute ischemia

isosorbide dinitrate/isosorbide mononitrate indications

-angina prophylaxis

-HF adjunct

(this is used in stable patients and for prevention, whereas nitroglycerin is used for immediate relief in acute situations)

isosorbide dinitrate/isosorbide mononitrate SE

-basically same as nitroglycerin

-HA, hypotn, reflex tachy, dizziness, etc.

tolerance to nitrate class is common (T/F)

true

how to reduce tolerance to nitrates

-avoid high doses

-utilize drug free hours (ex- avoid nighttime dosing)

ranolazine moa

inhibits sodium channels to reduce calcium overload in cardiac cells -> relaxes heart

ranolzaine indications

chronic, stable angina

ranolzaine contraindications

-QT prolongation

-hepatic impairment

ranolzaine SE

-QT prolongation

-palpitations/syncope

-GI

what meds are fibrinolytics

-alteplase

-tenecteplase

-reteplase

fibrinolytics moa

-convert plasminogen to plasmin to break down fibrin clots

fibrinolytics contraindications

-active bleed

-hx of stroke

-severe HTN

-major surgery or trauma within 3 weeks

-AV malformation

-aortic dissection

indications for all fibrinolytics

STEMI

fibrinolytics SE

-reperfusion arrythmias

-bleeding

-allergic rxn/angioedema

additional indications for alteplase(TPA)

-ischemic stroke

-massive PE

additional indications for tenecteplase

ischemic stroke