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At what point should and IHD patient be given a moderate statin dose vs. a high intensity dose?
- >75 = Moderate dose
- < 75 = High Intensity
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What constitutes a High intensity atorvastatin dose?
40-80 mgs
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What constitutes a High intensity Rosuvastatin dose?
20-40mg
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What Statins are used for high intensity treatments?
Rosuvastatin and Atorvastatin (long half lives)
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What Statins can be taken any time of day?
Rosuvastatin and Atorvastatin
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What time of day do you need to give all Statins other than Rosuvastatin and Atorvastatin?
Bedtime
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What are the CYP3A4 statins?
Lovastatin, Simvastatin and Atorvastatin
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What is the MOA for NTG?
- Nitric oxide as the mediator:
- ↑ in O2 supply
- Coronary vasodilation
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What are the normal side effects of NTG?
HA, flushing, postural hypotension (take sitting down), reflex tachycardia, nausea
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How should NTG be dispensed?
With an easy open cap
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When would you give CCBs for IHD?
Only given when BB are contraindicated, not tolerated, or as add-on therapy for angina pain
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What kind of CCBs would you use for IHD?
Long-acting Non-DHP (Verapamil or diltiazem)
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What are your main choices for treating high TG?
- Fibrate (first line)
- Nicotinic acid (niacin)
- Fish oil may help also
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What is the dosing for Isosorbide dinitrate (Isordil)?
- 5-40 mg QID
- OR
- 40 mg BID-TID
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What is the dosing for Isosorbide mononitrate (Imdur)?
- 5-20 BID
- OR
- 30-60 QD
- Max 240 mg QD
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What are the ADP inhibitors:
Clopidogrel, prasugrel, or ticagrelor
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What are the CIs for Aspirin?
Anaphylaxis, bronchospasm and serious bleeding
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NTG is CI in what patients?
- SBP < 90 or ≥ to 30 below baseline
- Severe bradycardia (< 50 bpm)
- Tachycardia (> 100 bpm)
- PDE5 inhibitor for erectile dysfunction within last 24 hours (48 hours for tadalafil - Cialis)
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What are the CIs for morphine in IHD?
Hypotension, respiratory depression and confusion
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What are the extra effects (other than analgesia) of Morphine?
- Peripheral arterial dilation
- ↓systemic vascular resistance
- ↓afterload and O2 demand
- ↓catecholamines
- Prevent arrhythmias
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When should you caution use of BBs in IHD?
- SEVERE heart failure
- Low output
- Increased risk for cardiogenic shock
- Bradycardia
- 2nd or 3rd degree HB
- PR interval > 0.24 sec
- SEVERE asthma/COPD
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What are the Benefits of taking a BB?
- ↓ RISK OF REINFARCTION
- ↓ RISK OF VENTRICULAR ARRHYTHMIAS
- IMPROVES MI MORTALITY
- ↓chest pain
- ↓infarct size
- ↓ left ventricular wall stress
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What is the MOA of Heparin?
Binds to antithrombin and then inhibits activity of factors Xa and IIa (thrombin)
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Glycoprotein inhibitors should never be used in combo with what?
Angiomax/Bivalirudin
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What are the CIs for Heparin?
- HIT
- Serious active bleeding
- Recent CVA or stroke
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What are the CIs for Enoxaparin?
Previous HIT, serious active bleeding, Going to CABG, or recent CVA
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What is the MOA of enoxaparin?
Binds to antithrombin and inhibits activity of factors Xa and IIa (preferentially Xa)
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In certain special populations, what would you monitor when giving enoxaparin?
Platelets, Renal function for dosing, and Anti-1oa
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What is the MOA of Bivalirudin?
Direct thrombin (factor IIa) inhibitor
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What are the CIs for Bivalirudin?
Active bleeding, severe bleeding risk
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What is the MOA of Clopidegrel?
Inhibits platelet aggregation through the ADP receptor
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What DDI does Clopidegrel have?
PPIs educe the efficacy
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What group is Prausegrel CI/not recommended in?
- Pts > 75 years
- History of TIA or CVA due to ↑ risk of bleed
- Consider lowering maintenance dose to 5 mg if pt < 132 lbs (60 kg)
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How does Prausegrel compare to Clopidegrel?
- Increased risk of bleed
- Decrease in Death, MI and Stroke
- No PPI interaction
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Prausegrel is reserved for what group?
Younger patients with high risk
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What group should you not use prausegrel in and why?
Over 75/History of Stroke or TIA, had greatest risk of bleeds
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