CARDIO OBJECTIVES

  1. For the medications listed below, you are responsible for reviewing the following information from your module notes, class notes and appropriate drug references (as directed):
    Review the slides

  2. Recognize electrolyte changes associated with different diuretics (i.e. potassium, magnesium, calcium).

    1. Thiazides: (-) Na, K/Mg —— (+) Ca, glucose, uric acid

    2. Loops: (-) K/Mg, Na, Ca (+) uric acid

    3. Potassium sparring: Hyperkalemia, hyper uricemia

  3. Identify medications or conditions that may be exacerbated by diuretic therapy secondary to electrolyte loss.

    1. Conditions: Gout, diabetes, sulfa allergy, photosensitivity

    2. Medications: Digoxin (K+ wasting), lithium (increased Li levels), dofetilide (QTc), NSAID (prevents sodium loss)

  4. Identify beta-blocker agents that are lipophilic (cross the blood brain barrier).

    • Everything except tenormin and labetolol

  5. Contrast adverse effect profiles for calcium channel blocker agents.

    1. DHP (nifedipine, felodipine, amlodipine): peripheral edema (nifedipine), flushing, headache

    2. Non-DHP: Negative inotrope/chronotrope, constipation (verapamil)

  6. Recognize the purpose for and method(s) of providing a nitrate-free interval according to dosage form.

    1. Isosorbide dinitrate (14 hours): TID every 4-5 hours. Give at 7-12-5

    2. Isosorbide dinitrate ER (18 hours) : BID every 6 hours. Give at 8am-2pm

    3. Isosorbide mononitrate: once daily in morning

  7. Calculate dose conversions between the loop diuretics: furosemide, torsemide, and bumetanide.

    • Furosemide IV 20 = lasix 40 oral = demadex 20 oral = bumex 1 oral

  8. Demonstrate knowledge of specific calculations. (e.g. creatinine clearance, ideal bodyweight).

    1. IBW = 45.5/50 + (2.3*inch over 60)

    2. AjBW = IBW + 0.4(ABW-IBW)

    3. CrCl = [(140-age)(IBW or AjBW)] / 72 * SrCr] x .85 if woman

  9. Coronary artery disease (CAD): recommend appropriate therapy for chronic stable angina, including agents appropriate for first line/monotherapy and second line/add-on therapy.

    1. 1st line: Beta-blockers or any CCBs (unless they have HF. Then fuck NDHPs)

      • Beta-blockers > CCBs, if: LV systolic dysfunction (aka EF <40%) with Hf or prior MI

    2. 2nd line: Long-acting nitrates or Ranolazine as an ADD on therapy if the maximum dose of 1st line is achieved (ranolazine shouldn’t be used alone)

  10. Recommend appropriate pharmacotherapy post-ACS with or without PCI (e.g. statin, beta- blocker, etc.). (See cardiology module notes)

    1. With PCI:

      1. Beta-blocker

      2. DAPT (At least 1 yr of p2y12)

      3. Statin

      4. NTG

      5. + ACE/ARB (DM/prior MI and HF/anterior/HTN/CKD,Prior MI)

      6. + MRA (On ACE/ARB with rEF and DM or HF)

    2. Without PCI:

      1. Beta-blocker

      2. DAPT (up to 1 yr of p2y12)

      3. Statin

      4. NTG

      5. + ACE/ARB (DM/prior MI and HF/anterior/HTN/CKD,Prior MI)

      6. + MRA (On ACE/ARB with rEF and DM or HF)

  11. Dysrhythmias/Anticoagulation: Recommend appropriate antiplatelet or anticoagulant therapy based on indication and patient characteristics (e.g. indication, contraindications, drug interactions, renal/hepatic function, etc.)

    1. DOACs:

      • Pradaxa:

        • DVT prophylaxis & treatment: 5-10 days of parenteral anti cog → BID (<30 CrCl not recommended)

        • Afib: BID (<15 CrCl not recommended. Renal adjustment for 15-30)

      • Rivaroxaban:

        • DVT prophylaxis: 10mg QD (<30 CrCl not recommended)

        • DVT treatment: 15 BID x21 days →20 QD (<30 CrCl not recommended)

        • Afib: 20 QD (<15 CrCl not recommended. Renal adjustment for 15-50)

      • Xarelto:

        • DVT prophylaxis: 2.5mg QD

        • DVT treatment: 10mg BID x7 days → 5mg QD

        • Afib: 5mg BID (unless <60kg, 80+ yrs, SrCR 1.5… then 2.5mg)

      • Sarvaysa:

        • DVT treatment: 5-10 days of parenteral anticoagulant… then → Once daily (avoid in CrCl <15 and >95, reduce dose if <60kg, dose adjust in 15-50ml/min)

    2. Warfarin: Only recommended if valvular disease OR if cannot do Apixaban and CrCl <15

    3. In AFIB: Bridge when:

      1. history of stroke, TIA, or thromboembolism

      2. CHA2DS2VASC >5

      3. Mechanical heart valve

  12. Recognize the target range for oral anticoagulation with warfarin for patients with atrial fibrillation, deep vein thrombosis, and mechanical prosthetic heart valves (mitral position)

    1. AF/DVT: 2-3

    2. Mechanical valves/Mitral stenosis: 2.5-3.5

  13. Select an appropriate rate control strategy for a patient with atrial fibrillation.

    1. <80 BPM: Surgery, hyperthyroidism, HF, CAD, or symptomatic… <110BPM for all others

    2. 1st Beta-blockers: GOOD for CHF ;

    3. 1st NDHP (watch for drug interactions): BAD for CHF ; Verapamil is more constipating

    4. 2nd Digoxin: Good for patients with hypotension and AFIB.

    5. + Amiodarone

  14. Evaluate when a rhythm control strategy should be considered for a patient with atrial fibrillation.

    1. Reduced LV function + persistent/high burden AF

    2. Patient is younger

    3. Symptomatic AF

    4. Recent diagnosis (<1 yr)

    5. has HF too

    6. Difficult to control HR (if their rate control isn’t so good)

    7. (possible preferences due to toxicities)

      1. Amiodarone or dofetalide: Good for HF and CAD

      2. Dronedarone: not too good... but no renal or hepatic dose adjust

      3. Sotaltol: good for CAD

      4. Flecainide: Avoid in HF

  15. Determine whether or not anticoagulation for atrial fibrillation is warranted based on the CHADS2VASc score.

    1. They must meet CHA2DS2VASc

      • C - CHF

      • H - HTN

      • A2 - 75+

      • D - DM

      • S2 - Stroke

      • V - Vascular disease

      • A - 65-74

      • Sc - Female

    2. If >2 (M) or >3 (F) → Anticoagulate

  16. Heart Failure (reduced ejection fraction): Distinguish between medications with a mortality benefit in the setting of heart failure with reduced ejection fraction (HFrEF) and medications that only provide symptomatic improvement or reduce hospitalizations and be able to optimize a therapeutic regimen accordingly.

    • Mortality:

      1. Beta-blockers

      2. ACE-i/ARNi'

      3. MRA

      4. SLGT-2

      5. ***Hydralazine/Ivabradine in AA patients

      6. Ivabradine monotherapy (if on max BB, sinus rhythm and HR >70)

    • Symptomatic:

      1. Loop/Thiazide diuretics

      2. Ivabradine monotherapy

      3. Digoxin

  17. Identify target doses for ACE-inhibitors, angiotensin II receptor blockers (ARBs), beta- adrenergic blockers, SGLT2 inhibitors, and aldosterone antagonists for patients with HFrEF and recognize when dose optimization is needed. (see dosing table)

    • Beta-blockers:

      1. Carvedilol - 25mg/50mg BID

      2. Coreg SR - 80mg QD

      3. Toprol XL - 200mg QD

      4. bisoprolol 10mg QD

    • ACE-i/ARNI:

      1. Altace (rami) - 10mg QD

      2. Vasotec (enala) - 10-20mg BID

      3. Zestil (Lisinopril) - 40mg QD

      4. Entresto (Sacubatril/Valsart)

        1. 23/26 → If CrCl <30 OR vasotec 10mg = lisinopril 10mg = valsartan 160mg = losartan 50mg

        2. 49/51 → 97/103

    • MRA:

      1. Aldactone: 25mg QD

      2. Inspira: 50mg QD

    • SGLT2:

      • Empagliflozin (Jardiance), Dapagliflozin (Farxiga): 10mg QD

  18. Identify and select appropriate blood pressure treatment goals, considering individual patient characteristics:

    • 130/80

  19. Recommend appropriate antihypertensive therapy based on patient-specific factors

    1. HFrEF: BB, Entresto/Ace/Arb, MRA

    2. CAD: BB, CCB, ACE/ARB,

    3. DM: ACE/ARB (hyperalbuminemia >30)

    4. CKD: ACE/ARB (hyperalbuminemia >300)

    5. asthma/COPD: Not a beta blocker

    6. AFIB: ACE/ARB

  20. Dyslipidemia: Recognize the four major statin benefit groups for prevention of ASCVD

    1. LDL > 190 → High intensity (Goal <100)

    2. ASVD → High intensity (Goal <70)

    3. 40-75 + LDL >70 + ASCVD >7.5% → Moderate intensity (30-50%)

    4. 40-75 + LDL >70 + DM → Moderate intensity (50%)

  21. Identify the expected percentage of LDL-C lowering based on statin intensity

    1. High → >50%

    2. Moderate → 30-49%

    3. Low → <30%

  22. Identify appropriate stepwise therapy in a patient with clinical ASCVD, including when to consider non-statin therapy

    • Target <70:

      1. Add Zetia if not meeting goals

      2. Add PCSK9 if still not

      3. Add bempedoic acid or inclisran

    • Target <55:

      1. Add Zetia OR PCSK9 if not meeting goals

      2. Add bempedoic acid or inclisran

  23. Determine when it is appropriate to use non-statin, triglyceride-lowering agents (i.e. BAS, fibrates, icosapent ethyl) (assumed on highest statin, optimized glycemic and diet)

    • ASCVD w/ TGs 150-499

      1. If LDL high (>100): Do non-statin therapy 1st (Zetia)

      2. If LDL low (<70): Icosapent ethyl

        • (Vascepa preferred in ASCVD or diabetes w/ 2+ risk factors for ASCVD)

    • DM 40+ yrs old w/ TGs 150-499

      1. DM, If no additional ASCVD risk factors → LDL-c

      2. DM, 50+ with >1 ASVD risk → Vascepa

      3. TGs >1000 → Add fibrates, vascepa, or lovasa