Cardio Exam 4

palliative care

palliative care

whole-person care for people with serious illness

whole-person care

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

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

no

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

mortality and rehospitalizations

what does palliative care NOT change?

treat underlying cause, palliate

symptom management approach in serious illness

drug side effect

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

NSAIDs

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

decompensation, death, increase in systolic blood pressure and MAP

what do systemic NSAIDs increase risk of?

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

how do systemic NSAIDs worsen dyspnea in heart failure?

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?

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

how do NSAIDs affect antiplatelets when administered together?

increase risk of GI bleeding

what risk does NSAIDs and anticoagulants have when administered together?

life expectancy, values, preferences

what three things should someone think about when deprescribing medications?

mortality, hospitalizations, high risk medications, and polypharmacy

benefits of deprescribing

collect history

c in CEASE

evaluate risk

first e in CEASE

5

number of medications that is a predictor for drug induced harm

assess each drug

a in CEASE

sort (ranking drugs from high to low harm)

s in CEASE

eliminate

second e in CEASE

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

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

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

key factors for deprescribing decisions in serious CVD

yes

end of lockman material

group 1

who classification for pulmonary hypertension (PAH)

group 2

who classification for PH with left heart disease

group 3

who classification for PH with lung diseases or hypoxemia

group 4

who classification for PH due to chronic thrombotic or other obstructions

idiopathic PAH; connective tissue disorders

two most common reasons for PAH

1

who functional class for no limitation of usual physical activity

2

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

3

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

4

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

who functional class, 6 minute walk distance, BNP

three best indicators of survival rates in pulmonary hypertension

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

three steps in the PH diagnosis algorithm

right heart catheterization

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

greater than 20mmHg at rest

what is the mPAP minimum to be diagnosed with PH?

CCBs

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

idiopathic, hereditary, drug induced PH

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

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?

nifedipine, amlodipine, diltiazem, felodipine

what are the four options for beta blockers for PH?

tadalafil

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

nitrates

what drug class is contraindicated in PDE-5 inhibitors?

riociguat

what is the singular SGC inhibitor?

who functional class 1 and 4

which patients are riociguat approved in?

PDE-5 inhibitors and nitrates

what drug classes are contraindicated in SGC inhibitors?

macitentan

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

ambrisentan

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

endothelin receptor antagonists

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

bosentan, macitentan, ambrisentan

what are the three endothelin receptor antagonists?

epoprostenol

which prostacyclin has the best survival rates in PH?

treprostinil

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

iloprost

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

flolan

epoprostenol formulation that is unstable at physiological pH and temperatures

veletri

epoprostenol formulation that is thermostable

treprostinil

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

selexipag

selective ip receptor agonist

better as combination therapy

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

better as macitentan and tadalafil only

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

yes

end of wessel material

diet, drugs, diseases, disorders of metabolism

four secondary causes of hyperlipidemia

retinoic acid and anabolic steroids

which drugs caused significantly elevated triglycerides?

pancreatitis

biggest concern of significantly elevated triglycerides

statins

1st line cholesterol medications in all patients without contraindications

myalgias and rhabdomyolysis

two most common adverse effects for statins

active liver disease, pregnancy

statin contraindications

myalgia

muscle pain and weakness without CK elevation from statins

myopathy

myalgias with CK that has 10 times the upper normal limit

rhabdomyolysis

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

elderly, women

risk factors for muscle pain

CK over 10 times the upper normal limit

what level of creatinine clearance is the minimum to stop statin

Co-Q10

OTC medication that improves statin-associated muscle symptoms

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

drugs that are contraindicated with simvastatin

gemfibrizol

which fibrate is contraindicated in statins?

40-80mg

high intensity dose range of atorvastatin

20-40mg

high intensity dose range of rosuvastatin

clinical ASCVD and secondary prevention patients

which patients should get high intensity statins?

PSCK9 inhibitors

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

high intensity statin

recommendations for primary prevention patient with LDL>190

moderate intensity statin (high intensity if other risk factors)

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

lifestyle modifications

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

lifestyle modifications

recommendations for primary prevention patient who is 20-39 years

risk and benefits discussion

recommendations for primary prevention patient who is over 75 years old

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

coronary artery calcium (CAC)

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

LDL greater than 190

what is the LDL range for severe primary hypercholestrolemia?

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

primary prevention in those with diabetes

GI issues

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

statins, levothyroxine, warfarin, digoxin, vitamins

bile acid sequestrant drug interactions

constipation

most common side effect with bile acid sequestrants

250

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

fibric acid

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

gemfibrozil

which specific fibrin cannot be used with statins?

fenofibrate

which specific fibrin cannot be used with cyclosporine?

ezetimibe

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

inhibits ATP citrate lyase (higher up in statin pathway)

mechanism of action for bempedoic acid (nexletol)

reduces hepatic production of VLDL and reduces clearance of HDL

niacin mechanism of action

flushing, liver disease

niacin side effects

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

50%

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