Term
| What is the typical cause of acute coronary syndromes? |
|
Definition
|
|
Term
| What are the steps of clot formation (3 A's) |
|
Definition
| 1) adherence 2) activation 3) aggregation |
|
|
Term
| What two drugs might be used for chest pain associated w/ MI? |
|
Definition
|
|
Term
| What differentiates Non-STEMI? |
|
Definition
| Normal to increased CK and minor troponin increase. No ST elevation |
|
|
Term
|
Definition
| Increase in CK and troponins as-well-as ST segment elevation |
|
|
Term
| What differentiates Unstable Angina? |
|
Definition
| Larger lipid core in atherosclerotic lesion, more inflammatory cells, thin fibrous cap. No CK elevation at all (no cell death) |
|
|
Term
| What is the 5 drug trail mix for post MI? |
|
Definition
| 1) ASA 2) BB 3) ACE (LVD, HTN, Diabetic neuropathy) 4) Statin 5) Plavix |
|
|
Term
| What is the primary goal of treating UA or MI? |
|
Definition
|
|
Term
| Post MI remodeling is seen on ECHO by dilation of left ventricle. What drug prevents this via the neurohormonal pathway? |
|
Definition
|
|
Term
| What is the TIMI risk score? |
|
Definition
| A classification system for people w/ similar chest pain aids in differentiation |
|
|
Term
| What are TIMI risk factors? |
|
Definition
| Age >65, more than 3 CAD RF, Coronary stenosis, ST elevation, Severe angina (>2 in last day), Daily ASA in last 7 days, Elevated CK |
|
|
Term
|
Definition
| Evaluate risk in Unstable Angina vs Non-STEMI |
|
|
Term
| What is the preferred treatment for STEMI? PCI or Fibrinolytic? |
|
Definition
| PCI, opens the blockage the majority of the time, Fibrinolytics are only about 75% of the time |
|
|
Term
| Early drug thereapys in ACS consists of 4 drugs |
|
Definition
ASA- 160-325mg first dose chewed
NTG- SL then IV
Plavix- 600mg LD then 75mg
Lovenox/LMWH/Fondoparinux |
|
|
Term
| What is the dosing associated w/ IV NTG? |
|
Definition
| Start at 5mcg/min increase by 5mcg every 5min until pain is resolved. Max of 200mcg, but has seen up to 400. |
|
|
Term
| What irreveribly binds P2Y12 receptors to block them? |
|
Definition
| Plavix and Effient(prasugrel) |
|
|
Term
| What are the pros and cons of Effient (prasugrel) |
|
Definition
Strong, better MI prevention, No PPI/P450 problems
Serious bleeds/intracranial hemorrages |
|
|
Term
| What is a revesible P2Y12 inhibitor that's not yet FDA approved? |
|
Definition
|
|
Term
| What pathway is shared by Plavix and most PPI's? |
|
Definition
|
|
Term
| What injectable anticoagulent has renal dosing protocol? |
|
Definition
|
|
Term
| What do you do if you have a patient that gets HIT? |
|
Definition
| DC immediately and switch to a direct thrombin inhibitor (bivalrudin, hirudin, desrudin, argatroban, dabigatran[pradaxa]) |
|
|
Term
| If MI Sx have been for less than 12h what do you do? |
|
Definition
|
|
Term
| Which heparinoind doesn't need renal adjustment? |
|
Definition
|
|
Term
| What is the dose of UFH in HF pt? |
|
Definition
Bolus 60U/kg Infusion of 12U/kg/hr
NOT full dose (prophylactic) |
|
|
Term
| What dosing considerations do you have to make with UFH? |
|
Definition
| Pt >60yo may req lower doses |
|
|
Term
| LMWH (Enoxaparin) dosing considerations |
|
Definition
| Dec dose by 50% by increasing interval to 24h if CrCl<30ml/min |
|
|
Term
| What dosing considerations need to be made for Eptifibatide? |
|
Definition
| Decrease infusion by 50% to 1ug/kg/min if CrCl<50ml/min or SrCr 2-4mg/dL |
|
|
Term
| What class of drug is Eptifibatide? |
|
Definition
| Glycoprotein (GP) IIb/IIIa inhibitor |
|
|
Term
| How do you know fibrinolytics are working in a patient? |
|
Definition
Chest pain goes away
ST elevation goes down |
|
|
Term
|
Definition
|
|
Term
Which drugs might you give for a NSTEMI?
Clopidogrel, ASA, TPA |
|
Definition
Clopidogrel
ASA
NOT TPA!!! no fibrinolytics for NSTEMI!!! |
|
|
Term
| When might you give a fibrinolytic? |
|
Definition
ONLY for STEMI pt
When PCI is not readily available |
|
|
Term
| Heparin dose DVT and dosing for ACS |
|
Definition
80U/kg- (17u/kg/hr infusion) no additional drugs
60u/kg- (12u/kg/hr infusion) Giving ASA, clopidogrel etc so you don't need as much w/ ACS. Be sure to know ACS heparin dose |
|
|
Term
| What is the ACS heparin dose? |
|
Definition
| 60u/kg (infusion rate 12u/kg/hr) |
|
|
Term
| Require renal dosing (Heparinoid and GP2B3A inhib) |
|
Definition
| Enoxaparin Integrelin (eptifibitide) |
|
|
Term
|
Definition
|
|
Term
| Why is enoxaparin (lovenox) preffered |
|
Definition
| Better outcomes in trials |
|
|
Term
| 5 drugs in the fibrinoltyic class |
|
Definition
| TPA, TNK-t-PA, reteplase, altaplase, RPA |
|
|
Term
| What is the benefit of RPA? |
|
Definition
| One bolus for 30min, good because can be admin by EMT |
|
|
Term
| What if a pt got one bolus of RPA and sx has been relieved? |
|
Definition
| Still give them the second bolus |
|
|
Term
| Why is anticoagulation inportant with fibrinolytics? |
|
Definition
| After the clot is busted, the original cause of the clot is normally still there (Plaque rupture etc). |
|
|
Term
| What is good about streptokinase? |
|
Definition
| It's CHEAP and you don't have to anticoagulate |
|
|
Term
| What drug therapy is recomended for pt who've been Sx for over 12h with MI? |
|
Definition
| ASA, Plavix, BB, Ace, Statin, Aldosterone antagonist |
|
|
Term
| What lab findings are present in UA? |
|
Definition
CK- no
ECG early- ST depression, T wave inversion
ECG late- no q wave |
|
|
Term
| What lab findings do you see with NTEMI? |
|
Definition
CK- yes
ECG early- ST dep T wave inversion
ECG late- No q wave |
|
|
Term
| What are the lab findings for STEMI? |
|
Definition
CK- Yes
ECG early- ST elevation
ECG late- Q wave developes |
|
|
Term
| What is the effect of MI on LDL? |
|
Definition
| Decreases LDL for up to 4 mo. Don't be fooled keep your statin onboard |
|
|
Term
| What is the most sensative way of detecting Mi? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
Muscle- (statins)
Brain-
Myocardial |
|
|
Term
| Most commonly used test to monitor UFH Tx |
|
Definition
| aPTT (activated partial thromboplastin time) |
|
|
Term
| A quantitative measure of fibrin breakdown on serum (marker for thrombotic activitiy) |
|
Definition
|
|
Term
| monitoring parameter to manage warfarin |
|
Definition
|
|
Term
| drug used to reverse over anticoagulation or warfarin overdose |
|
Definition
|
|
Term
| The majority of thrombi begin where? |
|
Definition
|
|
Term
| Once pt is stabilized on warfarin monitoring should be performed _________ |
|
Definition
|
|
Term
| What is the most common adverse event associated with antithrombolytic drugs? |
|
Definition
|
|
Term
| What is the only available factor Xa inhibitor available in the US |
|
Definition
|
|
Term
| VTE factors can be categorized as one off the three elements of ________ triad |
|
Definition
|
|
Term
| What invasive test is the gold standard for diagnosing DVT? |
|
Definition
| Venography (Although it's not commonly used) |
|
|
Term
| How does APAP taken with warfarin affect the pt's INR? |
|
Definition
|
|
Term
| What can be used to reverse the effects of UFH and partially reverse the effects of LMWH's |
|
Definition
|
|
Term
| How should warfarin dosing changes be made? |
|
Definition
|
|
Term
| Overlap of parenteral anticoagulation and warfarin should last at least ______ |
|
Definition
|
|
Term
| What class of drug is considered the treatment of choice in pt w/ history of HIT? |
|
Definition
| Direct Thrombin Inhibitors (DTI)such as Argatroban, Dabigatran (Pradaxa), Hirudin, Bivalrudin (Angiomax) etc |
|
|
Term
| What is the strongest known risk factor for DVT or PE? |
|
Definition
| Prior history of PE or DVT |
|
|
Term
| Thrombolytics are reserved for whom? |
|
Definition
|
|
Term
| What is the most commonly used test to diagnose PE? |
|
Definition
|
|
Term
| Due to improved pharmacodynamics/pharmacokinetics of LMWH pt's usually don't require _______ |
|
Definition
|
|
Term
| Initial treatment of VTE includes a parenteral anticoagulation (UFH/LMWH) overlapped with warfarin for alteast 5 days until INR is greater than _______ |
|
Definition
| Two, INR must be greater than two to get maximum benefit from warfarin |
|
|
Term
| What is the name of the recently approved oral DTI? |
|
Definition
|
|
Term
| This drug appears to be as effective as LMWH for prevention of VTE in highest risk population but requires frequent monitoring and dosing adjustment |
|
Definition
|
|
Term
| LMWH have an improved side effect profile compared to UFH including a lower incidence of this platelet disorder _________ |
|
Definition
| HIT, if a patient experiences HIT while on UFH though you need to go straight to using a DTI |
|
|
Term
| Activated ________ resistance is the most common genetic disorder of hypercoagulability |
|
Definition
|
|
Term
| When should you use a DTI? |
|
Definition
|
|
Term
| 9% of this ethnic group possesses SCT and 1:600 is homozygous for sickle cell |
|
Definition
|
|
Term
| The sickle Hb gene is protective against what infection? |
|
Definition
| Plasmodium falciparum (Malaria) |
|
|
Term
| Coagulation disorders are common in SCD in addition the ____________ dosen't function properly increasing suceptability to infections caused by encapsulated organisms like Strep pneumoniae |
|
Definition
|
|
Term
| There are two vaccines available to protect SCD patients from infections. What are they and when should they be given? |
|
Definition
PCV7 given at infancy PPV23 given after age 2
Both are Pneumococcal vaccines |
|
|
Term
| _______ can benefit SCD patients through multiple mechanisms including inc HbF |
|
Definition
|
|
Term
| What is the dosing for Hydroxyurea? |
|
Definition
| 10-15mg/kg/d max of 35mg/kg/day |
|
|
Term
| How is hydroxyurea supplied? |
|
Definition
| 200, 300, 400, 500mg caps |
|
|
Term
| How much of a change can Hydroxyura have on HbF? |
|
Definition
|
|
Term
| _____ is an injectabl NSAID which is useful in vasooclclusive pain crisis affecting BONE and JOINTS |
|
Definition
|
|
Term
| How many days can Ketorolac be used and why? |
|
Definition
5 days
because of GI bleeds and ADRs |
|
|
Term
| What type of Hb do we want to induce production in SCD pt? (Esp those in frequent crisis) |
|
Definition
|
|
Term
| What supplement might be given to SCD pt (esp those hemolysing, pregnant and other certain Tx) |
|
Definition
|
|
Term
| What catalizes the conversion of fibrinogn to fibrin? |
|
Definition
|
|
Term
| What is the most common inherited bleeding disorder? |
|
Definition
|
|
Term
| Vaccination against what disease is recommended in all pt w/ vWF (von willibrands factor) deficiency |
|
Definition
| Hepatitis (A and B currently no effective HepC vaccine) |
|
|
Term
| What do clotting factors II, VII, IX, X depend on? |
|
Definition
|
|
Term
| What class of drug should be avoided in Pt w/ hemophilia to treat pain due to binding w/ plts and inc bleeding risk |
|
Definition
|
|
Term
| What disorder does factor IX deficency result in |
|
Definition
|
|
Term
| What drug can be used to treat DIC |
|
Definition
| Heparin, but it's contraindicated in Pt w/ serious or life-threatening bleeding |
|
|
Term
| This class of drugs can be used in combination w/ PEX to treat TTP (Thrombotic thrombocytopenia pupura) |
|
Definition
| Corticosteroids, because of their immunosuppresive effects |
|
|
Term
| What dose purpura look like? |
|
Definition
|
|
Term
| What is the primary treatment for RICDs? |
|
Definition
| Single donor fresh frozen plasma |
|
|
Term
| Name two fibrinolysis inhibitors |
|
Definition
aminocaproic acid
Tranexamic acid |
|
|
Term
| Hemophilias often result in a symptom that causes bleeding into joint space, what is this symptom called? |
|
Definition
|
|
Term
| Excessive and unregulated generation of thrombin leads to agressive and compensitory ____________ in DIC |
|
Definition
|
|
Term
| Hemophilia A is a deficiency in what? |
|
Definition
|
|
Term
| This is the present treatment for TTP |
|
Definition
| Plasma exchange (NOT for pregnancy) |
|
|
Term
| Most patients with mild to moderate hemophillia A can be treated with what? |
|
Definition
|
|
Term
| Treatment of ITP (idiopathic thrombocytopenic purpura) is based on this |
|
Definition
|
|
Term
|
Definition
Infectious- Mennengitis
Obsetric- amniotic fluid in blood stream
Tissue injury (burn, crush etc) |
|
|
Term
|
Definition
| Aggressively treat underlying illness |
|
|
Term
| If treating DIC for bleeding or clotting how do you treat them? |
|
Definition
| Which ever is most urgent you would treat |
|
|
Term
| How would you administer heparin in a DIC pt? |
|
Definition
| prophylactic dose, NOT full therapeutic dose |
|
|
Term
| Therapeutic heparin is dosed how |
|
Definition
|
|
Term
| Prophylactic doses of heparin (used in DIC) is dosed how? |
|
Definition
|
|
Term
| fibrinogen in FFP can cause pt to what? |
|
Definition
|
|
Term
| ITP (immune thrombocytopenic purpera) is acquired how? |
|
Definition
|
|
Term
| Why wouldn't you treat a child that has ITP? |
|
Definition
| Often times ITP in children resolves spontaniously |
|
|
Term
|
Definition
| Nose bleeds, gum bleeds, peteci, purpera |
|
|
Term
| Whats the difference in petechia and purpura? |
|
Definition
Petechia is petite (smaller)
Purpura is larger |
|
|
Term
| Should adults with ITP be treated? |
|
Definition
|
|
Term
| What is the purpose of splenectomy in ITP? |
|
Definition
Removes immunogenic factor of ITP (antibody production)
Also sequesters AB attacked cells |
|
|
Term
| WHen the spleen is removed what is important to do? |
|
Definition
|
|
Term
| How is vaccination preffered in ITP in relation to splenectomy |
|
Definition
| 2wks prior to splenectomy |
|
|
Term
| What drug might you use in ITP? |
|
Definition
Corticosteroids
Azothioprine
Cyclophosphamide
(pg1134)immunosuppression |
|
|
Term
|
Definition
Low ptlt count AND making clots (counterintitive)
Fever, hemolytic anemia, neurologic symptoms (HA, speach, etc) |
|
|
Term
| What is the PT and PTT for TTP? |
|
Definition
| Both are normal oddly enough |
|
|
Term
| What drugs might cause TTP? |
|
Definition
Anti-neoplastic drugs
Ticlid
Plavix
Antibiotics
Immunosupressants
Table 67.10 |
|
|
Term
| What is the preffered treatment of TTP? |
|
Definition
| Single donor Plasma exchange |
|
|
Term
| What is a potential problem with plasma exchange? |
|
Definition
|
|
Term
| What is the pathophysilogic mechanism of ACS? |
|
Definition
|
|
Term
| How is lovenox eliminated? |
|
Definition
| Renally, important because it has to be renally dosed otherwise the bleed out |
|
|
Term
|
Definition
| Anticoagulant (LMWH, UFH, DTI) Nitro IV and SL Clopedigrel ASA |
|
|
Term
| When might you try to open a blood vessel up even after 12h? |
|
Definition
|
|
Term
| What is the LDL goal in MI? |
|
Definition
|
|
Term
| What drug is under-utilized for HF/post-MI and useful when EF <40 |
|
Definition
Aldosterone antagonist (Spronolactone or eplerenone)
May be a trailmix add-on |
|
|
Term
|
Definition
| ASA Plavix Statin ACE/ARB BB (Spironolactone good addition) |
|
|
Term
| Which should be used in ACS? Plavix or ASA? |
|
Definition
| BOTH! Combo antiplatelet therapy ASA and Plavix better than ASA alone in ACS |
|
|
Term
| If EF is fairly normal and no other reason to be on an ACE, drop the ACE if you have to drop one |
|
Definition
|
|
Term
| Both LMWH and Eptifibitide require what? |
|
Definition
Renal adjustment
UFH DOESN"T! |
|
|
Term
|
Definition
|
|
Term
| Which fibrinolytic is best per Dr. Bottorff? |
|
Definition
| RPA, recombinant TPA that is not wt based dosing and can be administered in 2 boluses 30min apart |
|
|
Term
| What is TNKTPA's benefit and cheviot? |
|
Definition
|
|
Term
| Why is anticoagulation important w/ fibrinolytics? |
|
Definition
| Cause of thrombus is still present |
|
|
Term
| What is the treatment of NSTEMI ? |
|
Definition
Same as STEMI minus the fibrinolytic
ASA, clopedigrel, IV nitro, Heparin |
|
|
Term
| Abciximab (Reapro) andEptifibitide (Intergrolyn) is what? |
|
Definition
Glycoprotein IIa/IIIb inhibitor
If you're at a hospital w/ a cathlab, if you're highrisk on the TIMI, add a GPIIaIIIB |
|
|
Term
| How does MI affect liver? |
|
Definition
| Switches to acute phase reactants and quits making LDL so LDL will drop massively w/in 24h and stay that way for 2-4mo |
|
|
Term
| Leg clots are usually unilateral, swelling, and palpible |
|
Definition
|
|
Term
| What are the three main risk factors associated w/ VTE? (Virchows triad) |
|
Definition
Venoustasis
Hypercoagulable states
Vascular injury |
|
|
Term
| what is the signifigance of virchows triad? |
|
Definition
| If you have more than one leg of the triangle you are at very high risk of VTE |
|
|
Term
|
Definition
Age over 40
Sitting long times (over 5hr)
Acute MI
General anesthesia
Prostetic valves
Malignancy
High dose estrogen
Endstage renal disease |
|
|
Term
| Extrinsic pathway of hypercoagulability (clotting) |
|
Definition
| Tissue factor, tissue damage |
|
|
Term
| What clotting factors are most important? |
|
Definition
|
|
Term
| Hemophilia involves which factors? |
|
Definition
| 8(a) or 9(b) either one depeding on type |
|
|
Term
| Intrinsic pathway of clott formation |
|
Definition
| drug induced/chemical (too much estrogen) |
|
|
Term
| which two factors are the most important? |
|
Definition
| 2(prothrombin) and 10. they are involved in both pathways. So if drug knocks out either one then it will stop the cascade no matter how it got started |
|
|
Term
| Clotting factors only work when they are ACTIVATED. other wise they are always there, just not active |
|
Definition
|
|
Term
| what do you look for in labs w/ clott? |
|
Definition
VQ Scan- lung mainly
Ultrasound- only noninvasive look for a clot |
|
|
Term
|
Definition
Inhaling a radioactive material and imaging
Cannot determine clot, not diagnosable, this is for evidence
Can clot rule out, not in |
|
|
Term
| What guidelines are used for clotts? |
|
Definition
|
|
Term
| People in ICU are what level of risk? |
|
Definition
| VERY high, most pt (unless reason not to) should have clot prophylaxis (lovenox daily) |
|
|
Term
|
Definition
Moderate-risk: 40mg q24h (SubQ)
High-risk: 30mg q 12h
Morbidly-obese: 30mg q 12h |
|
|
Term
| Mechanical venoustasis prevention |
|
Definition
Graduated compression stocking
Inflatable leg cuffs |
|
|
Term
| Lovenox/LMWH is very important in joint replacement/orthopedic surgery VERY HIGH RISK for VTE |
|
Definition
|
|
Term
| if a clot is found you begin heparin/heparinoids |
|
Definition
|
|
Term
| How do you determine which heparin/heparinoid to use in DVT? |
|
Definition
| Cost- UFH is cheaper but LMWH might get them out faster |
|
|
Term
| what treatment might you use for leg clot? |
|
Definition
| 1mg/kg lovenox SQ and start them on warfarin |
|
|
Term
| what is the antidote for warfarin? |
|
Definition
|
|
Term
| Weekly dose adjustment of warfarin in what % range? |
|
Definition
|
|
Term
| What is therapeutic target and range for VTE? |
|
Definition
|
|
Term
| What are the chest guidelines for INR being too high? INR 3.1-5 |
|
Definition
| 3.1-5: Omit next few warfarin doses and/or restart at lower dose when INR. No dose rdxn required |
|
|
Term
| Soy is a major vitamin K food! Watch w/ coumadin |
|
Definition
|
|
Term
| INR 5.1-9 with no bleeding |
|
Definition
| Omit next 1–2 doses, restart at lower dose when INR approaches target |
|
|
Term
| INR 5.1-9 with need for proceedure |
|
Definition
| Vitamin K1 2–4 mg orally (expected reversal within 24 hours); give additional1–2 mg if INR remains high at 24 hours |
|
|
Term
| INR 9.1-20 with no bleeding |
|
Definition
Stop warfarin
give vitamin K1 3–5 mg repeat if needed |
|
|
Term
| INR >20 or serious bleeding |
|
Definition
Stop warfarin
vitamin K1 10mg
repeat vitamin K1 every 12h plasma transfusion or prothrombin complex prn heparin until pt responsive to warfarin |
|
|
Term
| Life threatening bleed due to warfarin |
|
Definition
prothrombin complex concentrate
10 mg of vitamin K1 |
|
|
Term
| Will pts on therapeutic INR bruise easier? |
|
Definition
|
|
Term
|
Definition
When pt stops coumadin for proceedure (OK for DVT not for mechanical valves)
Start LMWH (lovenox) 5 days before proceedure and stop coumadin then stop for proceedure and start as soon as you're done w/ proceedure and switch over to coumadin again |
|
|
Term
| In the short term what does alcohol do to INR? |
|
Definition
|
|
Term
| In the long term how does alcohol effect INR? |
|
Definition
| Decreases (need to inc coumadin) |
|
|
Term
| Heparin (esp UFH) osteopenia/osteoporos/dec bone mass |
|
Definition
| Is pt pregnant? This makes it even worse. DVT in preg be ware of this, make sure plenty of Ca and minimize heparin exposure |
|
|
Term
Which would you DC in a HF pt?
Norpace/disopyramide
Actos/pioglitazone
Nsaid
Acetaminophen |
|
Definition
| All except APAP can contribute to HF |
|
|
Term
| Things that can cause a stable HF pt to become unstable |
|
Definition
New ischemia
Poorly controlled HTN
Worsening renal fxn
#1 is NONCOMPLIANCE |
|
|
Term
| Orthopnea, inability to sleep due to HF often prop themselves up with several pillows at night |
|
Definition
|
|
Term
| PND- paroxymismal nocturnal dyspenia |
|
Definition
| shortness of breath that woke me up related to HF |
|
|
Term
| What does a BNP of 100 or less indicate? |
|
Definition
|
|
Term
| What does a BNP of 100-300 indicate? |
|
Definition
|
|
Term
| What does a BNP of 300-600 indicate? |
|
Definition
|
|
Term
| What does a BNP of 600-900 indicate? |
|
Definition
|
|
Term
| What does a BNP of more than 900 indicate? |
|
Definition
|
|
Term
| What are the goals of therapy in HF? |
|
Definition
Improve Sx/fxnal class
Slow progression- determined by hospital visit decrease
Improve survival |
|
|
Term
| do loop diuretics improve survival? |
|
Definition
|
|
Term
| What diuretic is the best to use to remove fluid in HF? |
|
Definition
|
|
Term
| What is the target wt of a HF pt called with respect to fluid management |
|
Definition
|
|
Term
| What diruetic is notriously poorly bioavailable/eratic? |
|
Definition
| Lasix, if having a hard time controling dry wt and keep changing lasix dose switch to torsemide |
|
|
Term
| HF pt are more sensitive to hypokalemia, what treatment might be used to offset this? |
|
Definition
|
|
Term
| In two days after changing lasix dose you take a potassium showing no change in potassium what do you do? |
|
Definition
| Wait 3 more days, it takes up to 5 days to see a change when messing with lasix |
|
|
Term
| What systolic dysfunxn pt should be on an ACE? |
|
Definition
| EVERYONE (except, preg, angioadema, bilateral renal artery stenosis) |
|
|
Term
| Which ACE is used the most in HF and why? |
|
Definition
|
|
Term
| What sort of starting dose do you use for lisinopril? |
|
Definition
| 2.5 or 5 if high BP and good renal go 10 start low if K is high and/or poor renal etc |
|
|
Term
| When switching ace inhibitors you need to look at the min dose and max dose and use a 7:1 ratio and look for the closest one to what your current dose is |
|
Definition
|
|
Term
|
Definition
|
|
Term
| CrCl of 2.5-3 is a relative contraindication, why? |
|
Definition
| Because practically people don't accept it, but in literature there is no CrCl that is to high for ACE in HF |
|
|
Term
| Where is the most benefit w/ ACE? |
|
Definition
| Low end, so some is much better than none, but push as High as you can if not limited |
|
|
Term
| What might you do for pts on loops but not responding adequately? |
|
Definition
| At a thiazide- prevents Na reabsorption at the tubule |
|
|
Term
| When should you not use a thiazide? |
|
Definition
CrCl<30
Then you can use a thiazide-like drug Metalazone |
|
|
Term
| What is a thiazide like drug that doesn't require filtration? |
|
Definition
|
|
Term
| What are the cons of ACE in HF? |
|
Definition
Renal concerns
Hyperkalemia
Hypotension |
|
|
Term
| When are the side effects of an ACE most prominent? |
|
Definition
|
|
Term
| Using BOTH ACE and ABR will improve what? |
|
Definition
| Hospitalization, no effect at all on survival |
|
|
Term
| What are the types of HF? |
|
Definition
1) CAD (Ischemic)
2) hypertension/inc workload causes hardening/thickening Dilated cardiomyopathy |
|
|
Term
| Neurohormonal HF is caused by |
|
Definition
| Sympathetic nervous system (SNS) and rennin angiotensin-aldosterone system (RAAS) |
|
|
Term
| RAAS system makes AT2 which is a potent vasoconstrictor that inc intraglomerular pressure how does this affect HF? |
|
Definition
AT2 causes aldosterone release which causes Edema (Na/H2O retention) which worsens ventricular filling
As well as increases BP |
|
|
Term
| What drugs can be used to combat the RAAS system's negative effects in HF? |
|
Definition
Spironolactone
Epleronone
(Aldosterone antagonists) |
|
|
Term
| How is spironolactone dosed in HF? |
|
Definition
| 1qd (not qid like diuretic) |
|
|
Term
| What might you treat a pt w/ to combat SNS contributions to HF? |
|
Definition
| BB, SNS tries to increase HR to compensate for dec in fxn, but ends up worsening HF at some point, slow down HR, increase filling |
|
|
Term
| What negative effects can the neurohormonal response to HF have? |
|
Definition
Inc preload
Vasoconstriciton
Tachycardia
Ventericular hypertrophy/remodeling |
|
|
Term
| What is the difference in Systolic and diastolic dysfxn |
|
Definition
EF
Diastolic HF EF >40
Systolic HF EF <40 |
|
|
Term
| Why does renal insuficency worsen HF? (Cardio renal model) |
|
Definition
| Lose CO to kidney the kidney changes by increasing AT2 to compensate the kidney which causes an increase in aldosterone and increase in edema etc |
|
|
Term
| What treatment targets the cardio-renal model? |
|
Definition
| Lasix to dry up edema and ACE to prevent glomerular changes |
|
|
Term
| What treatment targets the cardio-renal model? |
|
Definition
| Lasix to dry up edema and ACE to prevent glomerular changes |
|
|
Term
| When you put a HF pt on lasix and ACE you can expect to see what lab changes? |
|
Definition
| BUN and Cr rise, decrease in fluid volume and decrease in glomerular pressure so decreaed excretion |
|
|
Term
| What are some exacerbating factors for HF? |
|
Definition
| ischemia, arrhythmia, endocarditis, myocarditis, pulmonary embolus, uncontrolled HTN, valvular disorder, anemia, infxn, pregnancy, worsened renal fxn, cocain, alcohol, amphetamines, sympathomimetics |
|
|
Term
| What drugs might exacterbate HF? |
|
Definition
| NSAIDs, COX-2, steroids, lithium, BB, CCB, antiarrythmics, alcohol, thiazolidineiones (TZD) |
|
|
Term
| What negative inotropes might exacerbate HF? |
|
Definition
| Flecainide, disopyromide, CCB, itraconazole, terbiafine |
|
|
Term
| What cadriotoxic drugs much exacerbate HF? |
|
Definition
| doxirubicin, daunomycin, cyclophasphamide |
|
|
Term
| What drugs might effect Na/Water retention and exacerbate HF? |
|
Definition
| NSAID, COX2, androgens, estrogens, steroids, salicylates, NA drugs, rosiglitazone(avandia)/pioglitazone (TZD) |
|
|
Term
| What CCB might exacerbate HF? |
|
Definition
| Non-dihydropyradines (Dilt, Verap) |
|
|
Term
| What signs and sx might you see that are unique/indicative of HF? |
|
Definition
| JVD, HJR (hepato-jugular reflex), tachycardia, cough, BNP, S3 gallop, enlarged liver, Railes(sp) |
|
|
Term
| What dietary changes might cause decompensation of HF? |
|
Definition
| Increased Na intake (wolfies synd) |
|
|
Term
| What do half of HF pts die from? |
|
Definition
|
|
Term
| NYHA classification (N/A, 1, 2, 3, 4) |
|
Definition
N/A: high risk, no changes
I: no limits to activity
II: slight limitation (angina, dyspnea)
III: marked limitation less than ordinary exercise
IV: inability of physical activity w/o discomfort |
|
|
Term
| What are our objectives in HF? |
|
Definition
Early: RF management
Early-med: pharmacologic Tx slow prog
Late-med: additional Tx dec morbidity
Late: QOL |
|
|
Term
| What might be a serious consideration with lasix/loops? |
|
Definition
| Hypokalemia, which HF pt are particularly sensative too |
|
|
Term
| How many days does it take K, BUN and Cr to respond to a lasix dose change? |
|
Definition
|
|
Term
| What is the role of hydralazine in HF? |
|
Definition
| reduces afterload through ARTERIAL relaxtation and a rdxn in nitrate tolerance |
|
|
Term
| What is the role of Isosorbid dinitrate in HF? |
|
Definition
| Rdxn in preload by venous vasodilation |
|
|
Term
| What is the role of Dig in HF? |
|
Definition
| positive inotropic effects used in short term for decompensated HF, or AFib. |
|
|
Term
| What are the contraindications of ACE important to HF? |
|
Definition
Pregnancy
Angioedema
Bilateral renal stenosis |
|
|
Term
| Which ARBs have best data for HF? |
|
Definition
|
|
Term
| Which two beta blockers have the strongest data in HF? |
|
Definition
| Metoprolol and carvedolol |
|
|
Term
|
Definition
| Highest tolerated dose or Max dose which ever comes first |
|
|
Term
| When would you consider giving more than 25mg Carvedolol BID? |
|
Definition
| Pt wt>85kg(170lb) give 50mg BID |
|
|
Term
| How do you know Pt has to much beta blocker? |
|
Definition
| JVD/edema, SOB, BP/Pulse very low |
|
|
Term
| How long does it take to get past the phase in which a BB might make HF worse? |
|
Definition
|
|
Term
| What do you do to treat hypotension and SOB in a properly medicated HF pt? |
|
Definition
|
|
Term
| If you are titrating onto a BB and you get SOB, Edema problems etc what do you do? |
|
Definition
| lower/hold BB or ad diuretic |
|
|
Term
| Every HF pt needs to be on what two drugs with very few exceptions? |
|
Definition
|
|
Term
| When can you NOT give spironolactone and what should you do? |
|
Definition
| CrCl <2.5 change to epleronone |
|
|
Term
| What is the downside of using isosorbid or hydralazine? |
|
Definition
| Has no effect on neurohormonal exacerbation |
|
|
Term
| When do you use Isosorbid and/or hydralazine in HF? |
|
Definition
When CrCl is not good. Good for people who have lost the ability to be on an ACE
Contradicts himself about the ACE.... |
|
|
Term
| What population responds better to nitrates than most? |
|
Definition
|
|
Term
| What is one of the main problems with isosrbid and hydralazine? |
|
Definition
| Compliance, two pills QID has poor adherence |
|
|
Term
| What is an odd side effect of hydralazine that is dose dependant? |
|
Definition
| Lupus effect (seen w/ 400mg or more qd) |
|
|
Term
| What two things does Dig do? |
|
Definition
NaK ATPase pump inhibitor/blocker, increases intracellular Na causing an increase in CO
Stimulates vaugal tone thus decreaseing HR and AV conduction |
|
|
Term
| What type of pt would not be able to get heartblocked by Dig? |
|
Definition
| heart transplant because no vaugal inervation |
|
|
Term
| What dosing do we use for dig? |
|
Definition
| 0.125 almost ALWAY gets the job done, better to under dose than over dose |
|
|
Term
| How is dig excreted? what signigance? |
|
Definition
| Renally, poor renal fxn = high serum concentration |
|
|
Term
| Why might you consider anticoagulation in HF pt? |
|
Definition
| Only if Pt needs it for another reason, no benefit in HF |
|
|
Term
| Diastolic dysfxn you have to slow the HR down do ensure proper filling |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What drugs do we use to help with preload in HF? |
|
Definition
| diuretics, venous vasodilators (NTG) |
|
|
Term
| What positive inotropes do you use in HF? |
|
Definition
| dig, dobutamin, milrinone |
|
|
Term
| What drugs do you use to help with afterload in acute HF? |
|
Definition
| Arterial vasodilators (nitroprusside) high dose IV NTG |
|
|
Term
| Positive innotropes should only be used in AHF no CHF |
|
Definition
| These are like dobutamine and milronone |
|
|
Term
| When is dobutamine useless/not work |
|
Definition
| when a pt is on BB it fxns on the beta receptor |
|
|
Term
| Which drug is useful even in Pt on beta blocker to work as a postive ionotrope? |
|
Definition
| Milronone- it breaks down cyclic AMP (phosphodiesterase inhibitor) |
|
|
Term
| Can dobutamine and mlironone be used together? |
|
Definition
| Yes, they work on two seperate pathways |
|
|
Term
| What is normal cardiovascular index? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| what is normal pulmonary artery occlusion pressure (wedge pressure)? |
|
Definition
|
|
Term
| what is normal pulmonary artery occlusion pressure (wedge pressure)? |
|
Definition
|
|
Term
| how do you measure SVR, wedge pressure and CI? |
|
Definition
|
|
Term
| What are the downside of ACE in HF? |
|
Definition
Declining renal fxn
Hyperkalemia
Hypotension |
|
|
Term
| Very important to monitor K in pts |
|
Definition
|
|
Term
| What is dosing for spironolactone |
|
Definition
|
|
Term
| What drug is used for prophylaxis in sickle cell pt? |
|
Definition
| PenV (prevention of strep pneumo) qd or shot in the hip once monthly |
|
|
Term
| Patients with SCD should be on folic acid ESP when on hydroxyurea |
|
Definition
|
|
Term
| When would you not use hydroxyurea in SCD pt? |
|
Definition
| PREGNANCY/sexually active |
|
|
Term
|
Definition
Pneumococcal vaccine (PCV7 and PPV23)
Penicillin prophylaxis for children <5yo
Annual flue vaccine |
|
|
Term
| SCD induction of fetal hemoglobin (HgF)drug therapy |
|
Definition
Hydroxyurea is primary agent
also butyrides, decitabin, clotrimazole and erythropeitin |
|
|
Term
| Chronic tranfusion therapy of SCD pt |
|
Definition
Indicated for stroke prevention in pediatrics
may reduce pain crisis |
|
|
Term
| SCD pain crisis treatment |
|
Definition
|
|
Term
| SCD fever and infxn treatment |
|
Definition
|
|
Term
| What are some factors that affect cell sickling? |
|
Definition
rapid temp change
Smoking
Alcohol
Hydration |
|
|
Term
| When does RBC tend to sickle the most? |
|
Definition
|
|
Term
|
Definition
| Broad spec AB (cefotaxime, ceftriazone, clindamycin(alt to cephalosporin), VANC for resistant staphy and pneumo infxn |
|
|
Term
| How do you treat acute chest synd in SCD? |
|
Definition
| broad spec AB, bronchodilator (airway), fluids, pain management, transfusion |
|
|
Term
| Stroke treatment in SCD pt |
|
Definition
| apap/buprofen for fever, exchange transfusion, chronic transfusion therapy |
|
|
Term
| SCT (sickle cell trait) is carrier usually asymptomatic |
|
Definition
|
|
Term
| Monitor hydroxyurea in SCD pt for what? |
|
Definition
|
|
Term
| How high must a fever be in a SCD pt to consider AB treatment? |
|
Definition
|
|
Term
|
Definition
| Arteriole clot, primarily formed by clumping platelets |
|
|
Term
|
Definition
| veinous clots caused by coagulated blood cells |
|
|
Term
| What is the loading dose of warfarin? |
|
Definition
| IT SHOULDN"T BE LOADING DOSED! |
|
|
Term
| What drug inhibits factor X? |
|
Definition
|
|
Term
| How long does it take warfarin to be effective? |
|
Definition
|
|
Term
| How dose binge drinking affect INR? |
|
Definition
|
|
Term
| How does chronic alcohol consumption affect INR? |
|
Definition
|
|
Term
| What DTI doesn't requre renal adjustment? |
|
Definition
|
|
