Cardio Exam 4

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217 Terms

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palliative care

whole-person care for people with serious illness

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whole-person care

holistic care that addresses well-being as defined by individuals, their families, and communities

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serious illness

health condition that carries a high risk of mortality and either negatively impacts a person’s daily functioning or quality of life or excessively strains their caregivers

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no

should you wait until heart failure stage D for palliative care?

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mortality and rehospitalizations

what does palliative care NOT change?

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treat underlying cause, palliate

symptom management approach in serious illness

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drug side effect

any symptom in an older adult should be considered a ______ until proved otherwise

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NSAIDs

what is the most common cause of uncontrolled (and reversible) dyspnea in heart failure

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decompensation, death, increase in systolic blood pressure and MAP

what do systemic NSAIDs increase risk of?

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NSAIDs cause vasoconstriction of the afferent arteriole, which increases sodium and fluid retention

how do systemic NSAIDs worsen dyspnea in heart failure?

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NSAIDs constrict the afferent arteriole, which leads to reduced glomerular pressure, which causes an acute kidney injury

how do systemic NSAIDs cause acute kidney injury?

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NSAIDs prevent aspirin from binding to COX-1, making aspirin ineffective

how do NSAIDs affect antiplatelets when administered together?

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increase risk of GI bleeding

what risk does NSAIDs and anticoagulants have when administered together?

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life expectancy, values, preferences

what three things should someone think about when deprescribing medications?

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mortality, hospitalizations, high risk medications, and polypharmacy

benefits of deprescribing

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collect history

c in CEASE

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evaluate risk

first e in CEASE

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5

number of medications that is a predictor for drug induced harm

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assess each drug

a in CEASE

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sort (ranking drugs from high to low harm)

s in CEASE

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eliminate

second e in CEASE

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aspirin, amiodarone, statins, anticoagulants, HF meds (keep as long as tolerated)

potentially inappropriate cardiovascular medications in serious illness, frailty, or older adults

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indication, time to benefit, adverse effects, half-life

key factors for deprescribing decisions in serious CVD

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yes

end of lockman material

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group 1

who classification for pulmonary hypertension (PAH)

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group 2

who classification for PH with left heart disease

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group 3

who classification for PH with lung diseases or hypoxemia

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group 4

who classification for PH due to chronic thrombotic or other obstructions

29
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idiopathic PAH; connective tissue disorders

two most common reasons for PAH

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1

who functional class for no limitation of usual physical activity

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2

who functional class for mild limitation of physical activity with no discomfort at rest

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3

who functional class for marked limitation of physical activity with no discomfort at rest

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4

who functional class where PH symptoms are present at rest and have visible signs of right ventricular heart failure

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who functional class, 6 minute walk distance, BNP

three best indicators of survival rates in pulmonary hypertension

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clinical suspicion (ex: high BNP), echocardiogram, confirm with right heart catheterization

three steps in the PH diagnosis algorithm

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right heart catheterization

what is the diagnostic test needed in order to diagnose PH?

37
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greater than 20mmHg at rest

what is the mPAP minimum to be diagnosed with PH?

38
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CCBs

a patient that has a positive vasodilator test (idiopathic responder) can be put on what medication?

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idiopathic, hereditary, drug induced PH

what three groups of PH can you perform a vasodilator test on?

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who functional class 4

which group of patients does not need to go through a vasodilator test because CCBs are not an option to begin with?

41
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nifedipine, amlodipine, diltiazem, felodipine

what are the four options for beta blockers for PH?

42
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tadalafil

which PDE-5 inhibitor can’t be used in a patient with poor renal function?

43
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nitrates

what drug class is contraindicated in PDE-5 inhibitors?

44
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riociguat

what is the singular SGC inhibitor?

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who functional class 1 and 4

which patients are riociguat approved in?

46
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PDE-5 inhibitors and nitrates

what drug classes are contraindicated in SGC inhibitors?

47
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macitentan

what is the only endothelin receptor antagonist to decrease mortality and morbidity rate?

48
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ambrisentan

what is the only endothelin receptor antagonist to be selective for ETa?

49
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endothelin receptor antagonists

which PH drug class can cause fetal toxicity and requires monthly pregnancy tests?

50
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bosentan, macitentan, ambrisentan

what are the three endothelin receptor antagonists?

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epoprostenol

which prostacyclin has the best survival rates in PH?

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treprostinil

which prostacyclin has a long half life, is easiest to titrate, and works the fastest?

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iloprost

which prostacyclin must be inhaled 6-9 times a day?

54
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flolan

epoprostenol formulation that is unstable at physiological pH and temperatures

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veletri

epoprostenol formulation that is thermostable

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treprostinil

epoprostenol formulation that is an IV formulation associated with higher risk of gram-negative blood infections than epoprostenol

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selexipag

selective ip receptor agonist

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better as combination therapy

are tadalafil and ambrisentan better as a combination therapy or monotherapies?

59
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better as macitentan and tadalafil only

are macitentan and tadalafil and selexipag better as a combination therapy or monotherapies?

60
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yes

end of wessel material

61
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diet, drugs, diseases, disorders of metabolism

four secondary causes of hyperlipidemia

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retinoic acid and anabolic steroids

which drugs caused significantly elevated triglycerides?

63
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pancreatitis

biggest concern of significantly elevated triglycerides

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statins

1st line cholesterol medications in all patients without contraindications

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myalgias and rhabdomyolysis

two most common adverse effects for statins

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active liver disease, pregnancy

statin contraindications

67
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myalgia

muscle pain and weakness without CK elevation from statins

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myopathy

myalgias with CK that has 10 times the upper normal limit

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rhabdomyolysis

myopathy or weakness or CK that has 10,000 times the upper normal limit

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elderly, women

risk factors for muscle pain

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CK over 10 times the upper normal limit

what level of creatinine clearance is the minimum to stop statin

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Co-Q10

OTC medication that improves statin-associated muscle symptoms

73
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azole antifungals, macrolide, gemfibrozil, cyclosporine (diltiazem and verapamil over 10mg)

drugs that are contraindicated with simvastatin

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gemfibrizol

which fibrate is contraindicated in statins?

75
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40-80mg

high intensity dose range of atorvastatin

76
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20-40mg

high intensity dose range of rosuvastatin

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clinical ASCVD and secondary prevention patients

which patients should get high intensity statins?

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PSCK9 inhibitors

what drug class is preferred in very high risk patients if statins/ezetimibe do not lower LDL enough?

79
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high intensity statin

recommendations for primary prevention patient with LDL>190

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moderate intensity statin (high intensity if other risk factors)

recommendations for primary prevention patient with LDL<190 and diabetes and 40-75 years old

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lifestyle modifications

recommendations for primary prevention patient who is 0-19 years old

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lifestyle modifications

recommendations for primary prevention patient who is 20-39 years

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risk and benefits discussion

recommendations for primary prevention patient who is over 75 years old

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dependent on 10-year ASCVD risk (same recommendations as in Jacobsen lecture)

recommendations for primary prevention patient who is 40-75 years old with elevated LDL (still below 190) and no diabetes

85
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coronary artery calcium (CAC)

non-invasive CT scan of the heart to measure calcified plaque in coronary arteries

86
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LDL greater than 190

what is the LDL range for severe primary hypercholestrolemia?

87
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moderate intensity statin/high intensity statin with risk factors, no other non-statins recommended

primary prevention in those with diabetes

88
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GI issues

what are bile acid sequestrants more likely to be used for instead of hypercholesterolemia?

89
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statins, levothyroxine, warfarin, digoxin, vitamins

bile acid sequestrant drug interactions

90
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constipation

most common side effect with bile acid sequestrants

91
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250

bile acid sequestrants can’t be used if triglycerides are over what value?

92
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fibric acid

drug of choice when triglycerides are over 500mg and LDL is normal

93
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gemfibrozil

which specific fibrin cannot be used with statins?

94
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fenofibrate

which specific fibrin cannot be used with cyclosporine?

95
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ezetimibe

which cholesterol drug should not be used as a monotherapy due to not being effective in low HDL or high triglyceride patients?

96
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inhibits ATP citrate lyase (higher up in statin pathway)

mechanism of action for bempedoic acid (nexletol)

97
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reduces hepatic production of VLDL and reduces clearance of HDL

niacin mechanism of action

98
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flushing, liver disease

niacin side effects

99
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inhibitor of lipoprotein and endothelial lipase (lower levels of ANGPTL3 have lowered LDL and triglycerides)

example drug: evinacumab

mechanism of action for angiopoietin-like 3 drugs

100
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50%

LDL reduces by how much when a PCSK9 inhibitor is used with a max dose statin