-
treating myopathy and the pt has severe muscle symptoms or fatigue
D/C statin get CK, urinalysis for myoglobinuria, creatine
-
treating myopathy and the pt has mild/moderate symptoms
D/C statin, look for other risk factors (hypothyroidism, reduced renal/hepatic fxn, rheum disorders, vitamin D deficiency, primary muscle dx)
-
when would you check FLP after stain initiation
4-12 wks, if LDL reduction less than expected, asses adherence & secondary causes of hyperlipidemia
-
when would you consider reducing the dose of a statin in regards to LDL level
< 40 mg/dL
-
what advantages does aspirin have in primary prevention of cardiovascular events in men and women
-
risk factors for CHD
- smoking
- HTN
- albuminuria
- dyslipidemia
- family history of CHD
-
if a pt is having an ACS event which marker is the most accurate for early onset
myoglobin
-
a pt is in the ER with suspected ACS event, what is appropriate to start while acutely working up the pt
- MONAB
- morphine - optional, only if they are having refractory pain
- oxygen - optional, if they are < 90%
- nitroglycerin - sublingual, total of 3 doses in 5 minute intervals (NOT if HoTN)
- aspirin - full dose, chew it up
- beta blocker - w/I the first 24 hrs. if they are tachycardia and hypertensive. oral if they are HoTN (metoprolol)
antiplatelet - UFH, full Tx dose at least until you get a plan. enoxaparin 1mg/kg/day
-
what are the contraindications of fibrinolytic therapy
- active bleeding
- history of ICH
- pregnancy
- oral anticoagulant use
- high risk for bleeding
- recent trauma
- recent major surgery
- severe uncontrolled hypertension 185/105
-
post MI CI for beta blockers
- low baseline HR
- severe bradycardia
- preexisting high-degree AV block
- sick sinus syndrome (w/no pacemaker)
- refractory heart failure
-
recommended levels of activity for management of IHD
- 30-60 minutes of moderate intensity at least 5 days/wk + increase in lifestyle activity
- resistance training 2 days/week
- cardiac rehab
-
6 lifestyle elements that could influence prognosis of IHD
- maintain BMI of 18.5-24.9
- waist circumference M < 40, F <35
- lipid management
- BP control
- smoking cessation
- individualized diabetes mgmt. plan
-
diet considerations for the mgmt. of IHD
- saturated fats < 7% of total calories
- trans fats < 1% of total calories
- cholesterol < 200 mg/day
high in fruits/vegetables, whole grains and reduced sodium intake
-
when do we initiate aspirin as primary prevention of CHD
- M = 45-79 yo if benefit of MI > GI bleed
- F = 55-79 yo if benefit of stroke > GI bleed
-
when do we initiate statins for the primary prevention of CHD
- LDL > 190 mg/dL
- 40-75 yo + DM
- 10 year ASCVD risk of > 7.5%
-
symptoms of ACS
squeezing, tightness, pressure that comes on gradually and intensity will wax and wane over several minutes. discomfort that doesn't change with breathing or position
-
symptoms other than chest pain that are considered "angina equivalent"
- dyspnea
- N/V
- diaphoresis
- unexplained fatigue
-
what could cause troponin levels to be falsely elevated
it is renally cleared, CKD
-
invasive strategy
- cath lab for coronary angiography
- assess need for PCI or CABG
-
conservative strategy
- observe
- follow symptoms and cardiac biomarkers
- cath lab only if these worsen
- consider stress testing
-
Tx guidelines for anticoagulants in a pt whose has a stint placed
discontinue
-
Tx guidelines for unfractionated heparin if a pt is medically managed
continue for 48 hours
-
Tx guidelines for enoxaparin and fondapainux if a pt is medically managed
continue for the duration of the hospitalization
-
if a pt goes in for a CABG what do you do with the enoxaparin, fondaparinux, clopidogrel and UFH
- enoxaparin - discontinue 12-24 hrs prior
- fondaparinux - discontinue 24 hrs prior
- clopidogrel - discontinue 5 days prior
- UFH - hold 2 hrs prior
-
3 P2Y12 ADP receptor antagonists
- clopidogrel - plavix
- Prasurgrel - effient
- ticagrelor - brilinta
-
which P2Y12 ADP receptor antagonist is reversible
ticagrelor - brilinta
-
which P2Y12 ADP receptor antagonist can be used upstream of catheterization
clopidogrel - plavix
-
compare antiplatelet therapy of clopidogrel vs prasurgrel
- TRITON-TIMI 38 trial
- equal mortality difference secondary to cardiovascular
- prasurgrel has increased mortality secondary to bleeding
-
compare antiplatelet therapy of clopidogrel vs ticagrelor
- PLATO study
- decreased risk of mortality w/ ticagrelor but CI if there is a history of hemorrhagic stroke
-
3 GP IIb/IIIa inhibitors
- eptifibatide - integrilin
- tirofiban - aggrastat
- abciximab - reopro
-
which anticoagulant is preferred during PCI in cath lab if the pt has a high bleeding risk
bivalrudin - angiomax
-
stent restenosis
- renarrowing of coronary artery at the site of stent placement due to tissue growth
- occurs 3-6 months later
-
stent thrombosis
- acute thrombosis at the site of the stent that can cause a rapid and complete occlusion of the coronary artery
- occurs 0-30 days later
-
which stents have a higher likelihood of restenosis
bare-metal stent
-
which stents have a higher likelihood of thrombosis
drug-eluding
-
when are BP IIb/IIIa inhibitors used
typically only for pts undergoing PCI with UFH and up to 18 hours after PCI
-
absolute CI's to fibrinolysis
- any previous ICH
- known structural cerebrovascular lesion
- known malignant intracranial neoplasm
- ischemic stroke w/I 3 mo
- suspected aortic dissection
- active bleeding
- severe closed-head or facial trauma w/I 3 mo
-
CI to nitrates as home meds
- systolic BP < 90 or 30+ below baseline
- bradycardia (<50bpm) or tachycardia >100bpm
- phosphodiesterase inhibitor w/I last 24-48 hrs
- severe anemai
-
CI to beta blockers as home meds
- systolic BP < 90 or 30+ below baseline
- bradycardia (<50bpm) or tachycardia >100bpm
- phosphodiesterase inhibitor w/I last 24-48 hrs
-
CI to ACEI as home meds
pregnancy
-
CI to CCBs as home meds
- left ventricular dysfunction
- sick sinus syndrome
- hypotension
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