BCPS 2013: Cardiology II

More of what I was studying last week: Acute Coronary Syndromes

UA NSTEMI STEMI
CP +

CE –

ECG +

CP +

CE +

ECG + (ST depress, T wave ∆s)

CP +

CE +/– (90 min door to balloon, may not have dmg)

ECG + (ST elevation > 1 mm)

Risk factors → cath

Stress test

Cath 12-24 hrs Cath 90 min

Chest pain → atypical, typical (exertional, relief from SL nitro, shorter (min-hr), substernal, radiating left)

Cardiac enzymes → troponin, CK-MB

ECG changes → ST or T wave ∆s

Therapeutic goals

UA/NSTEMI: prevent total occlusion, control chest pain and other symptoms

STEMI: restore patency of infacted artery, prevent complications (e.g. arrhythmias), control CP and Sx

  UA NSTEMI STEMI
Morphine 1-5 mg IV

Oxygen (if O2 sat < 90%)

Nitroglycerin

Aspirin (chew 162-325 mg)

x x x
Beta blocker     x
Anticoagulation x x x
Antiplatelet x x x
IIb/IIIa If PCI If PCI If PCI
Fibrinolysis     If no PCI

 

UA/NSTEMI

  Early invasive (PCI < 12 hr) Delayed PCI (> 12 hrs) Early conservative (no PCI)
Anticoagulant UFH, enox, bival,

fonda (+ UFH w/ PCI)

UFH, enox, bival,

fonda (+ UFH w/ PCI)

Enox, fonda
Antiplatelet Clopidogrel or prasugrel

Abciximab or eptifib w/ PCI

Clopidogrel or prasugrel

Eptifib or tirofib w/ PCI if high or moderate risk

Clopidogrel

Abcix or eptifib w/ PCI if +stress test

 

STEMI PCI (w/in 90 min) Fibrinolysis (w/in 30 min, up to 12 hrs)
Anticoagulation UFH w/ abciximab (or eptifib or tirofib)

Bivalirudin alone

UFH 48 hrs or

Enoxaparin 8 days or

Fondaparinux 8 days

Antiplatelet Clopidogrel or prasugrel Clopidogrel

 

Dosing and duration of antiplatelet

  ASA Clopidogrel/Prasugrel
Initial 162-325 mg chewed CLO 300-600 mg LD (300 mg if w/ fibrinolytics)
Pre-PCI 75-325 mg CLO 300-600 mg LD or PRA 60 mg LD
No stent 75-162 mg/day indefinitely CLO 75 mg for 14 d to 1 yr

BMS

DES

 

162-325 mg 1 month

3 mo (siro), 6 mo (paclitaxel)

Then 75-162 mg/day infef.

CLO 75 mg/day or PRA 10 mg/day (5 mg if < 60 kg)

for 12-15 mo

 

See Table 8, 9, 10 for IIb/IIIa, anticoagulants, thrombolytics. See Table 11 for contraindications to thrombolytics.

Post ACS:

1. Beta blockers,

2. ACEi or ARB,

3. ASA + CLO or warfarin,

4. Statin (LDL < 70-100 mg/dL)

 

Peripheral Artery Disease: vascular insufficiencies in noncoronary arteries 2/2 atherosclerotic occlusions

  1. Functional – due to spasms of vessels
  2. Organic – structural changes e.g. fatty buildup

Age > 50                 HTN

Smoking                 # homocysteine

Diabetes                                High sensitivity-CRP

HL                            Male

Family Hx

Symptoms: leg or hip pain, cold legs and feet, changes in skin color, pain reduced w/ resting, numbness or tingling

Ankle brachial index = ankle SBP ÷ arm SBP                  PAD risk factors

1-1.29 Normal
0.91-0.99 Borderline
0.41-0.9 Mild to moderate
0-0.4 Severe

 

Treatment: reduce risk factors

Diet, exercise, smoking cessation, HL drugs (goal LDL < 70), antihypertensives (goal BP < 140/90 or 130/80 if diabetic), diabetes control ( A1C < 7%), homocysteine, folic acid and B12, antiplatelet (ASA 75-325 or CLO 75)

Treatment of claudication: cilostazol 1st line, pentoxifylline 2nd line, IR for angioplasty or stents

Dyslipidemia

Fasting lipid panel (9-12 hrs)

LDL < 100

100-129

130-159

160-189

> 190

Optimal

Above optimal

Borderline high

High

Very high

HDL < 40

> 60

Low

High

TC < 200

200-239

> 240

Desirable

Borderline high

High

TG < 150

150-199

200-499

> 500

Normal

Borderline high

High

Very high

 

LDL goal

CHD risk equivalents: CHD (MI, CABG, PCI, ACS), atherosclerotic dx (PAD, AAA, carotid), DM, > 20% Framingham

Positive risk factors: smoking, HTN, low HDL, family Hx premature CHD (55m, 65w), Age (45m, 55w)

Negative risk factors: high HDL

 

Risk category LDL goal LDL to start Rx
CHD risk equiv, Fram > 20% < 100 (optional < 70) > 130, opt > 100 or < 100?
2+ risk factors, Fram 10-20% < 130 (optional < 100) > 130, opt > 100
2+ risk factors, Fram < 10% < 130 > 160
0-1 risk factor < 160 > 190, opt > 160

Non HDL goal = 30 + LDL goal

Lifestyle changes: weight loss, exercise, diet (plant sterols, soluble fiber, low cholestrol)

Low HDL: TG < 200, niacin safer combo w/ statins than fibrates, smoking cessation, exercise

TG 200-499 target non-HDL, TG > 500 target TG

High TG > 500: goal prevent pancreatitis

Low fat diet, fibrates or niacin, reduce TG before LDL

Pharmacotherapy

Statins (HMG-CoA reductase inhibitors)

$ LDL 24-60%, $ TG 7-40%, # HDL 5-15%. Reduce coronary events, CHD mortality, stroke, total mortality

AE: myopathy, elevated LFTs (check baseline, 3 month, yearly)

DI: SAL (simvastastin, atorvastatin, lovastatin) are CYP3A4. Fluva 2C9, Rosu 2C19, Pita 2C9. Avoid with inhibitors.

Myopathy risk higher with gemfibrozil than fenofibrate. Niacin lower risk than fibrates (careful if > 1g/day).

Efficacy

  5 mg 10 mg 20 mg 40 mg 80 mg
Fluvastatin     24 30 36
Pravastatin   24 30 36 40
Lovastatin   24 30 36 40
Simvastatin 24 30 36 42 48
Atorvastatin   36 42 48 54
Rosuvastatin 42 48 54 60  

Pitavastatin (1 mg = 30%, 2 mg = 36%, 4 mg = 42%). About 6% with each dose doubling and rank.

Bile acid sequestrants – inhibits bile acid recirculation. Liver converts cholesterol to bile acid

$ LDL 15-26%, # HDL 3-6%, reduce coronary events and CHD mortality.

Names: cholestyramine, cholestipol, colesevelam

AE: GI distress, constipation, may increase TG.

DI: decreased absorption of drugs (e.g. warfarin, BB, thiazides)

Niacin – inhibits mobilization of FFA from perif adipose tissue, reduces VLDL synthesis

$ LDL 15-26%, $ TG 20-50%, # HDL 15-26%, reduces coronary events, possibly reduces mortality

Formulations: IR Niacin, ER Niaspan, SR Slo-Niacin

AE: flushing, hyperglycemia, hyperuricemia, GI distress, hepatotoxicity (check LFTs base, q6-12wks, yearly)

Sustained release more hepatotoxic, less flushing (can give ASA 30 min prior to reduce flushing)

Fibrates – reduce lipogenesis in liver

$ LDL 5-20% (normal TG, may # TG up to 45% w/ high TG), $ TG 30-55%, # HDL 18-22%, reduce coronary events and progression of coronary lesions

Names: gemfibrozil, fenofibrate

AE: dyspepsia, gallstones, myopathy, # LFTs (check q3mo for 1st year, then yearly)

Ezetimibe – inhibits cholesterol absorption. Adjunct with statins.

$ LDL 18-20%, $ TG 7-17%, may # HDL 1-5%

AE: HA, rash

Omega-3 (Lovasa) – unknown mechanism

(may # LDL up to 45% w/ high TG), $ TG 26-45%, may # HDL 11-14%

AE: GI (burping, dyspepsia), inhibit plt aggregation, bleeding

Purple heart in the hands

 

BCPS 2013: Cardiology I

A little in the past on my study schedule, but what I'm studying this past week. Acute Decompensated Heart Failure

Parameter Normal ADHF  
MAP 80-100 60-80  
HR 60-80 70-90  
CO/CI 4-7 / 2.8-3.6 2-4 / 1.3-2 Low cardiac output
PCWP 8-12 18-30 Congestion
SVR 800-1200 1500-3000  
CVP 2-6 6-15 Fluid up

*want PCWP 15-18 for optimal filling pressure

Signs and symptoms

Congestion (PCWP) Hypoperfusion (CO)
Dyspnea Fatigue
Peripheral edema Cold extremities
Rales Narrow pulse pressure
Ascites Hypotension
Jugular venous distention Worsening renal function
Hepatomegaly, splenomegaly Hyponatremia

 

Subsets and Therapy

  Warm (CI > 2.2) Cold (CI < 2.2)
Wet (PCWP > 18) Congestion

IV diuretics + IV vasodiliators (venous)

Congestion and Hypoperfusion
MAP < 50 Dopamine
MAP > 50 Inotrope* or vasodilator (V or A)
Dry (PCWP < 18) Normal

Optimize oral meds

Hypoperfusion
PCWP < 15 IV fluids
PCWP > 15, MAP < 50 Dopamine
PCWP > 15, Map > 50 Inotrope* or vasodilator (arterial)

*SBP < 90, hypotension, worsening renal function

Home HF meds in ADHF

  • ACEi – caution with uptitration during diuresis and if Scr # more than 0.5 mg/dL above baseline
  • BBlockers – Do not discontinue if stable prior to admission, do not start until euvolemic, hold if hemodynamically unstable
  • Digoxin – goal conc 0.5-0.8 ng/mL, avoid discontinuation, caution if renal function worsens

Drugs for ADHF

Diuretics – congestion

Loop Furosemide 40 PO = Furosemide 20 IV = Bumetanide 1 mg = Torsemide 10 mg
Thiazide Not effective if CrCl < 30, used as adjunct

HCTZ 12.5-25 mg PO, metolazone 2.5-5 mg PO

Chlorothiazide 250-500 mg IV if GI edema (expensive)

Resistance to diuretics Fluid and sodium restriction

Increase dose, frequency, cont infusion

Add thiazide

 

Inotropes – hypoperfusion

Dobutamine

B1 agonist: inotropic, lusitropic, chronotropic

Dose: 2.5-20 mcg/kg/min

AE: tachycardia, arrhythmia, myocardial ischemia

Consider if hypotension

Milrinone

PDE inhibitor: inotropic, lusitropic

 

AE: arrhythmia, hypotension

Dose: 0.1-0.75 mcg/kg/min

Consider if on B-blocker

 

Vasodilators – congestion, (Venous $ PCWP for dyspnea), (Arterial  $ SVR for $ CO)

Nitroprusside

Arterial = venous

Doses: 0.3-3 mcg/kg/min

AE: hypotension, cyanide/thiocyanate toxicity

Nesiritide

# Na excretion, UOP, CI

$ PCWP, SVR, NE, aldosterone

Doses: 0.01 mcg/kg/min

AE: hypotension, some tachycardia

Nitroglycerine

Venous > arterial (art w/ high doses)

Doses: 5-200 mcg/min

AE: hypotension, reflex tachycardia, HA

 

Arrhythmias

Drug therapy overview

  • Check thyroid function, K 4-5 mmol/L, Mg > 2 mg/dL, QTc < 500 ms
  • Potential drug causes: QTc prolongation, bradycardia, AV block

 

See figures on last page.

See Table 9.

Treatment of arrhythmias

Pulseless VT/VF Epinephrine, Vasopressin, Amiodarone, Lidocaine, eval reversible causes
PEA Epinephrine, Vasopressin, eval reversible causes
Sx Bradyarrhythmia If unstable: atropine 0.5-1.0 mg IV, repeat up to 3.0 mg
Sx Tachycardia If unstable: cardioversion

If stable: narrow/regular (SVT) – Vagal maneuvers, adenosine, β blockers, CCB, ablation

Note: avoid CCB and digoxin if WPW, adenosine 6/12 mg (caution in severe CAD)

Afib (narrow/irregular)
  1. Control ventricular rate (β blockers, CCB (diltiazem, verapamil), digoxin)
  2. Rate (leave in AF) OR rhythm control (restore sinus rhythm)
  • Rate control with drugs listed above
  • Rhythm control with electric cardioversion or antiarrhythmic drugs

IA (quinidine, procainamide), IC (flecainide, propofenone), III (amiodarone, sotalol, ibutalide, dofetilide)

  1. Anticoagulation
  • Rate control: chronic anticoagulation ASA or warfarin (INR goal 2-3) (CHADS2 score)
  • Rhythm depends on timing
    • < 48 hrs AF, no anticoagulation needed  prior to cardioversion
    • > 48 hrs AF, anticoagulation for 3 wks prior and 4 wks after CV
  1. Consider long term antiarrhythmics if pt still symptomatic despite rate control
Vtach, Vfib Cardiovert (shock) patients, give Epi or vasopressin as needed

Consider amiodarone or lidocaine during CV and after for prophy

Patients with LVEF < 30 to 40% should have implantable cardioverter defibrillator (ICD)

Torsades Mg
Special populations HF – amiodarone and dofetilide (LV dysfxn post MI) neutral effect on mortality

Post MI – ecainide, flecainide, moricizine, 1A meds # mortality

Dofetilide neutral mortality LV dysfxn post MI

 

Pulmonary Arterial Hypertension

Signs and symptoms

Dyspnea w/ exertion, fatigue, chest pain, syncope, weakness, orthopnea, peripheral edema (fluid backs up), liver congestion, ascites, hemodynamics (mPAP > 25, PCWP < 15, PVR > 3), RV hypertrophy

Treatment

Goal: relieve acute dyspnea, improve exercise capacity and QOL

Vasodilator response testing: epoprostenol, inhaled nitric oxide, IV adenosine

Initial treatment algorithm

Supportive care
Oxygen
Anticoagulation: warfarin goal INR 1.5-2.5 to prevent catheter thrombosis, VTE
Immunizations
Birth control
Oral CCB
If no sustained response to CCB:
Low risk High risk
1st line: ERA or PDEIs (oral)

Alt: epoprostenol, treprostinil (IV)

iloprost (inhaled), treprostinil (SC)

1st line: epoprostenol, treprostinil (IV)

Alt: ERA or PDEIs (oral)

iloprost (inhaled), treprostinil (SC)

ERA: endothelin receptor antagonist (e.g. sentans)                      PDEIs (e.g. sildenafil)

Prostacyclin analogs (e.g. epoprostenol)

See Table 16.

Hypertensive Crises (Urgency and Emergency)

HTN urgency: acute elevation in BP > 180/120 without organ damage

HTN emergency: HTN with organ damage (encephalopathy, intracranial hemorrhage, angina or MI, pulm edema, aortic dissection, retinopathy, $ UOP or AKI, eclampsia)

Treatment

Urgency: goal to $ BP within 24 hrs

Agents (Table 18): captopril, clonidine, minoxidil, nifedipine, labetalol

 

Emergency: goal to $ MAP 25% or diastolic BP to 100-110 mmHg within 30-60 min

Agents (Table 17): sodium nitroprusside, esmolol, labetalol, nicardipine, nitroglycerin, hydralazine, enalaprilat, fenoldopam, clevidipine

Preferred agents for crises based on comorbidities

Acute aortic dissection Esmolol alone or w/ nicardipine or nitroprusside

(BB first!)

Acute HF Nitroprusside, nitroglycerin, nesiritide, ACEi with diuretics if pulm edema (no BBs)
Stroke (ischemic, hemorrhagic) Labetalol, nicardipine
Acute MI BB with nitro, if HR < 70 nicardipine, clevidipine
Acute pulm edema Nesiritide, nitroglycerin, nitroprusside
AKI Fenoldopam, nicardipine, clevidipine
Eclampsia Hydralazine, labetalol, nicardipine
HTN encephalopathy Nitroprusside, labetalol, fenoldopam, nicardipine
Perioperative HTN Clevidipine, esmolo, nicardipine, nitro
Sympathetic crisis Nicardipine and such (avoid unopposed BB)

 

 

Cardiac Muscle

cardiology