860 Exam 2

unstable angina

ischemia without necrosis

arteries are not fully occluded

no-biomarkers present

NSTEMI

non-transmural myocardial necrosis

significantly occluded artery

troponin will be elevated

STEMI

transmural myocardial necrosis

fully occluded artery

troponin elevated

ST will be elevated

typical symptoms of ACS

pressure type chest at rest or with minimal exertion

pain is located in the retrosternal areal with radiation to both arms and back

atypical symptoms of ACA

diaphoresis

fatigue

nausea/vomiting

syncope

epigastric pain/indigestion

what patient population usually presents with atypical symptoms of ACS

women

older adults

diabetics

what is immediately done when a patient presents to the ER with suspected ACS

labs including troponin, K, Mg, and SCr

12 lead ECG within 10 minutes of presentation

what is an elevated troponin level

greater than or equal to 0.02 ng/Ml

what are the short term goals of care for ACS

early restoration of blood flow to artery

prevent infarction expansion or complete occlusion

prevent MI in unstable angina

prevent death

prevent re-occlusion

what are the long term goals of care for ACS

control CV risk factors

prevent additional CV events like MI stroke or HF

improve quality of life

what are the three phases of care in ACS

early hospital care

intervention

post intervention

what medications are involved in early hospital care

Morphine

Oxygen

Nitrates

Aspirin

Betablocker

what is the purpose of morphine in early hospital care

decrease pain and pain induced sympathetic/adrenergic tone

may induce vasodilation

describe the role of oxygen in early hospital care

relieve chest pain induced from hypoxia

only used when patients sat is under 90%

describe the role of nitrates in early hospital care

relieves chest pain

cause vasodilation

when is the use of nitrates contratindicated

if the patient has used a PDE recently

low blood pressure

describe the role of aspirin in early hospital care

every patient who presents with ACS should chew and swallow one 324 mg aspirin immediately

describe the role of beta blockers in early hospital care

given within 24 hours of admission

should generally be cardioselective

what is the first line treatment for STEMI

primary PCI or CABG within 12 hours

when is fibrinolysis used

only when the patient is not within 120 minutes of a PCI facility

what drugs are given pre- PCI or CAGB

anti-platelet

anti-coagulant

aspirin loading dose if not already administered

what are the three anti-platelet drugs used pre-PCI and their doses

clopidogrel 300-600 mg (not preferred)

ticagrelor 180 mg (5 day washout)

prasugrel 50 mg (7 day washout)

what are the anti-coagulant therapies used pre-PCI

IV unfractionated heparin

bivalirudin if UFH contraindicated

what are the 5 drugs given post PCI

81 mg aspirin

P2Y12 for 12 months

can use GP IIb/IIIa inhib if not responding to P2Y12

beta blocker within 24 hours

ACE or ARB

high intensity statin

what are the P2Y12 inhibitors and their doses

clopidogrel 75 mg PO QD

ticagrelor 90 mg PO BID

Prasugrel 10 mg PO BID

what drugs are used for fibrinolysis

alteplase

tenecteplase

reteplase

what drugs are given pre fibrinolysis

clopidogrel 300 mg

IV UFH

what drugs are given post fibrinolysis

aspirin 81 mg PO daily

clopidogrel 75 mg PO daily for 12 months

beta blocker within 24 hours

high intensity statin

ACE or ARB

what are the two strategies in NSTEMI

early invasive strategy

ischemia guided strategy

what medications are given during the early invasive strategy

anti-platelet therapy

anti- coagulant therapy

what medications are given during late hospital care in the early invasive strategy when a PCI is performed

aspirin 81 mg PO QD

P2Y12 for 12 months

beta blocker within 24 hours

ACE or ARB

high intensity statin

what medications are given during late hospital care in the early invasive strategy when a PCI is NOT performed

aspirin 81 mg PO QD

clopidogrel 75 mg PO QD x 12 months

beta blocker within 24 hours

high intensity statin

ACE or ARB

what medication are given in early hospital care in the ischemia guided strategy for an NSTEMI

anti-platelet

anti-coagulant

what medications are given in late hospital care in the ischemia guided strategy for an NSTEMI

aspirin 81 mg PO daily

clopidogrel 75 mg PO daily x 12 months

beta blocker within 224 hours

high intensity statin

ACE or ARB

what are the secondary prevention medications given to EVERY patient post intervention

aspirin 81 mg

P2Y12 for 12 months

high intensity statin

beta blocker

ACE

aldosterone antagonist when LVEF <40%

SL NTG PRN

what are the PQRST of Ischemic heart disease

Precipitation factors: some level of activity

Palliative measures: relieved by rest ± SL NTG

Quality of pain: squeezing, heaviness, tightness

Region: substernal

Radiation: left or aright arm, back, down ab, up neck

Severity: 5+ on a 10 pt scale

Timing: <20 min usually relieved in 5-10 min

what medications do all patients with Ischemic heat disease recieve

81 mg aspirin

mod-high intensity statin

ACE

SL NTG

what medications are used in vasospastic angina

DHP-CCB or long acting nitrate

what is the first step for patients who present with non- vasospastic angina and ischemic heart disease

beta blocker

non-DHP CCB if beta blocker is contraindicated

what medication is given if the angina is not resolved by a beta blocker

add DHP-CCB if BP is over >140/90

ass ranolazine or a long acting nitrate if BP <140/90

what if the angina is not resolved by a DHP CCB or ranolazine or long acting nitrate individually

ass agent not yet used

what if all three classes of post-beta blocker administration are not sufficient to resolve angina

PCI or CABG should be performed

describe the role of aspirin in IHD

decreased CV events by 1/3

clopidogrel can be used if an aspirin allergy

when is Dual Anti - Platelet Therapy used

in high risk patients

-prior MI, stroke, or PAD

describe the role of ACE inhibitors in SIHD

stabilize plaque

no symptomatic improvement

what is the role of beta blockers in SIHD

initial symptomatic therapy

HF specific BB when LVEF < 40% or prior MI

decrease o2 demand increase o2 supply and reduced remodeling

goal HR is 55-60 bpm

what is the role of NON-DHP CCB in SIHD

increase o2 supply and decrease o2 demand

heart specific are verapmil and diltiazem

what is the role of DHP CCB in SIHD

increase o2 supplu

symptomatic relief

what is the role of long acting nitrates in SIHD

increase o2 supply and decrease o2 demand

preferred in vasospastic angina

provide symptomatic relief

what is the role of ranolazine in SIHD

symptomatic relief

what are the most common causes of HF

SIHD

myocardial infarction

HTN

valvular disease

what is the equation for ejection fracture

EF=SV/EDV

what are the normal vital values in heart failure

CO = 4-8 L/min

HR = 60-100 bpm

SV = 60-100 ml

what are the classifications of heart failure

HFrEF: reduced ejection fracture

LVEF < 40

HFimpEF: improved ejection fracture

LVEF < 40 then LVEF > 40

HFmrEF: mildly reduced injection fracture

LVEF 41-49

HFpEF: preserved ejection fracture

LVEF > 50

what are the symptoms of HF

dyspnea and fatigue

fluid retention

swelling of the feet and legs

increase nighttime urination

confusion

issues sleeping

cough with frothy sputum

what are the signs of heart failure

elevated jujular venous distension

third hear sound (gallop rhythm) or murmur

weight gain of over 2 kg a week

pulmoary rales

cold extremities

what is stage A HF

at risk for HF

no sx but high risk like ASCVD, heart disease, HTN

obesity, family hx of HD

what is stage B HF

pre-HF

no symptoms but one of the following:

decreased LVEF

decreased systolic function

ventricular hypertrophy

valvular heart disease

wall motion abnormality

chamber enlargement

what is stage C HF

symptomatic HF

structural heart disease with current or previous

heart failure symptoms

what is stage D HF

advanced HF

marked HF symptoms that interfere with daily life

despite intervention

what is class 1 HF

no symptoms with normal activity

normal functional status

what is class 2 HF

mild symptoms with normal activity, comfortable at rest

slight limitation of functional status

what is class 3 HF

moderate symptoms with less than normal activity

comfortable only at rest

marked limitation of functional status

what is class 4 HF

sever symptoms with features of HF with minimal activity and at rest

sever limitation of functional status

what is treatment of HF based on

staging and classing

what are the steps of treatment for stage A Hf

manage other disease states

HTN - optimize BP

T2DM - SGLT2i

CVD - optimize CVD tx

Family Hx - genetic counseling

HF risk - BNP screening

what are the steps of treatment for stage B HF

when LVEF is less than or equal to 40 %

-HF specific beta blocker

-ACE or ARB

HFrEF treatment

ARNi (preferred) or ACE or ARB

beta blocker

MRA

SGLT2i

diuretics as needed

consider hydralnitratrates in AA pts

HFmrEF treatment

diuretics as needed

SGLT2i

ARNi (preferred) or ACE or ARB

MRA

HF specific beta blocker

HFimpEF treatment

continue GDMT even is asymptomatic

HFpEF treatment

diuretics as needed

SGLT2i

ARNi or ARB

MRA

manage symptoms with loop diuretic and control hypertension

what is the role of ARNi or ACE or ARB in HF

provide morbidity and mortality benefit in HFrEF

what are the HF preferred ACEs

lisinopril

captopril

enalapril

what are the HF preferred ARBs

losartan

candesartan

valsartan

what are the important features of ARNis

entresto

must have a 36 hour wash out period from ACE

to transition from ARB stop ARB and replace with ARNi

do not use in angioedema

needs renal dosing

what is the role of beta blockers in HF

provide morbidity and mortality benefit in HFrEF

what are the HF specific beta blockers

bisoprolol

carvedilol

metoprolol SUCCINATE

what is the role of aldosterone antagonists in HF

morbidity and mortality benefit in HFrEF

spironolactone eplerenone

may cause hyperkalemia

SCr must be > than 2.5 in men and 2.0 in women

what is the role of SGLT2 inhibitors in HF

provide morbidity and mortality benefit in HFrEF with or without DM

dapagliflozin, empagliflozin

indicated in HFrEF class 2-4

cannot use in T1DM because increased risk of DKA

cannot use in pts on dialysis

caution with GFR < 30 in dapag and <20 in empag or AKI

what is the role of If channel inhibitors in HF

ivabradine

no mortality benefit but decreases hospitalizations

indicated in LVEF < 35% class II-III with max dose beta blocker and a HR >70 bpm

contraindicated in HFpEF, HR , 60 and Afib

what is the role of digoxin in HF

no mortality benefit but decreases hospitalizations

does not effect BP

what is the role of loop diuretics in HF

no mortality benefit

what medications can cause or exacerbate HF

corticosteroids and NSAIDS

class 1 and 3 antiarrhythmics

itraconazole

TZDs (pioglitazone)

CCBs (especially non DHP)

cilostazol

amphetamines

what is acute decompensated heart failure

clinical syndrome with worsening signs or symptoms of HF that require hospitalization

what are factors that precipitate ADHF

ACS

uncontrolled HTN

Afib and arrythmias

acute infarction

non-adherance

anemia

hyper/o thyroidism

pulmonary embolism

what are medications that exacerbate or cause HF

NSAIDS (most common)

lithium

anti-diabetics (TZD and DPP4)

TNF alpha inhibitors

stimulants

chemotherapy

illicit drugs (amphetamines)

what are the goals of therapy in ADHF

address precipitating factors

restore hemodynamics and increase perfusion

improve symptom management

optimize GDMT

prevent hospitalizations

what is the cardia output formula

CO = HR x SV

what is relevant to understand about SVR

increased SVR = hard work = increased afterload

describe preload and afterload

preload = end diastolic volume

afterload = resistance

what is the cardiac index equation

CI = CO/BSA

what are the three parameters that decrease cardiac output and their compensatory mechanisms

increased preload = decreased CO = increased SVR

increased afterload = decreased CO = increased HR

decreased contractility = decreased CO = increased SVR

what are the signs and symptoms of ADHF

congestion = dyspnea, increased o2 requirements, weight gain, peripheral edema

poor perfusion = poor renal function, shock liver, altered mental status, hypotension, cool extremities

what are the markers for poor renal function

increased SCr

decreased urine output

what are the markers for shock liver

increased liver enzymes

increased INR

what are the four types of ADHF

type 1: warm and dry Cl > 2.2 PCWP < 18

type 2: warm and wet Cl > 2.2 PCWP > 18

type 3: cold and dry Cl <2.2 PCWP < 18

type 4: cold and wet Cl <2.2 PCWP > 18

warm = perfusion

wet = fluid loss or overload

what are the usual drugs needed to treat type 2 ADHF

diuretics ± vasodilator

what are the usual drugs needed to treat type 3 ADHF

inotropes ± vasodilator if SBP > 90

what are the usual drugs needed to treat type 4 ADHF

diuretics ± inotropes ± vasodilators if SBP > 90

what is the role of diuretics in ADHF

get fluid off

given immediately at 2-2.5 x home dose

20-40 mg IV furosemide is given when home dose is unknown