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DSM: AC and AFib (pogge) E3

Terms in this set (52)

CV exam:

Pulse: rate? Rhythm?

Heart sounds: S3? S4?

Carotid bruits?
Tachycardia; irreg irreg

S3 volume overload; S4 increased resistance to filling

Murmur-like sound in the carotid artery due to narrowing
Types of stroke: ischemic

Arterial vs cardiac?
Arterial: related to the process of atherosclerosis

Cardiac: emboli formed and released due to a cardiac issue
Types of stroke: hemorrhagic

Generally caused by?
High BP or aneurysms

Arteries in the brain leak blood or rupture
AFib: duration

Paroxysmal?

Persistent?

Long standing persistent?

Permanent?

Valvular?
Terminated within 7 days

Longer than 7 days

Longer than 12 months

No longer attempt to restore normal sinus rhythm

Mod to severe mitral stenosis or presence of mechanical heart valve
Management approach: 3 areas of focus?
Reduced clinical ASCVD risk factors

Initiate antithrombotic therapy

Initiate rate or rhythm control
Focus 1: reduce ASCVD

Step 1: determine 10 year risk of ASCVD for adults ______ years of age

Reminder: ASCVD risk estimator can est 10 risk defined as what?
40-75

Nonfatal or fatal ACS or fatal or non fatal stroke
Focus 1: reduce ASCVD

Step 2: dietary changes should be implemented

Replace ____ fat with dietary ___ and ____ fats
Saturated

Monounsaturated and polyunsaturated (liquid at room temp!!!!)
Focus 1: reduce ASCVD

Step 3: physical activity?
At least 150 minutes per week of mod intensity or 75 min per week of vigorous aerobic activity
Focus 1: reduce ASCVD

Step 4: special pop?
Rec weight loss in overweight or obese individuals

T2DM; metformin 1st line; SGLT2i and/or GLP1
Focus 1: reduce ASCVD

Step 5: initiate what?
Pharmacotherapy for co morbities: hyperlipidemia, HTN, smoking cessation
Focus 2: antithrombotic for primary prevention NO AF

Use of ____ for primary prevention: low dose for select adults _____ yo who are at higher ASCVD risk but not at increased bleed risk

NOT recommended on a routine basis for primary prevention among adults >____ yo
ASA; 40-70 yo

>70
Focus 2: antithrombotic for secondary ASCVD prevention

Secondary prevention for ischemic stroke: use what?

Acceptable options for initial therapy? (3)
AntiPLT not AC

ASA, ASA+dipyridamole, clopidogrel
Focus 2: antithrombotic for primary or secondary prevention for stroke in AF

In patients with non valvular AF, what do we assess?
CHADSVASc
Focus 2: antithrombotic for primary or secondary prevention for stroke in AF

In patients with AF, what do we assess for bleed risk?
HASBLED
Focus 2: antithrombotic for primary or secondary prevention for stroke in AF

What is high risk HASBLED score?
>3
Focus 2: antithrombotic for primary or secondary prevention for stroke in AF

What is high risk CHADSVASc?
>2 males

>3 females
AC recommendations based on risk factors:

High risk of bleeding? (3)
Apix

Edox

Dabigatran 110mg
AC recommendations based on risk factors:

Prior GI bleeding? (2)
Apix

Dabigatran 110mg
AC recommendations based on risk factors:

High risk of stroke?
Dabigatran 150mg
AC recommendations based on risk factors:

End stage CKD (CrCl<15) or on dialysis?
Apix or warfarin
AC recommendations based on risk factors:

Mechanical heart valves or mod to severe mitral stenosis?
Warfarin (INR 2-3 OR 2.5-3.5)
_____ and ____ function should be evaluated before initiation of a DOAC and should be reevaluated at least _____
Renal and hepatic

Annually
A SAMe-TTR score of >2 indicates what?
Patients are considered better candidates for DOACs
Dabigatran: AF

AF dose?

Dose adj?

Not recommended in CrCl<_____
150 mg BID with or w/o food

15-30 ml/min: 75 mg BID

15ml/min
Rivarox: AF

AF dose?

Dose adj?

Not recommended in CrCl<_____
20 mg QD with a large meal

15-50ml/min: 15 mg QD WF

<15 ml/min
Apixaban: AF

AF dose?

Dose adj? (3)

Not recommended in CrCl<_____
5 mg BID with or w/o food

Age>80 yo, weight<60kg, SCr>1.5: 2.5 mg BID with 2 or more RF

N/A: can use in ESRD
Edoxaban: AF

AF dose?

Dose adj?

Not recommended in CrCl<_____
60 mg QD with or w/o food

15-50ml/min: 30 mg QD

>95 OR <15 ml/min
Which DOAC is superior in preventing stroke or systemic embolism AND major bleed vs warfarin?
Apixaban
Which DOAC is inferior to warfarin at preventing stroke/systemic embolism AND rates of major bleed?
Rivaroxaban
Which DOACs are used cautiously in >75yo? (2)
Dabigatran and rivarox (BEERS criteria)
All DOACs are CI in what? (2)
Mod to severe mitral stenosis OR mechanical heart valve due to increased stroke risk

Warfarin should be used!!!
Do not use DOACs in mild to mod ______ impairment
Liver
Antibiotics and warfarin:

Which ABX have no DDI? (4)
Amox/augmentin

Cephal

Clindamycin

Nitrofurantoin
Antibiotics and warfarin:

Which decrease INR/increase clot? (2)
Rifampin

Dicloxacillin, Nafcillin, cloxacillin
Warfarin DDI with seizure meds? (2)
Phenytoin (inc or dec INR)

Carbamazepine (dec INR)
DOAC DDI: increase level

Strong Pgp inhibitors and 3A4? (7)
Amiodarone

Clarithromycin

Dilt/verapamil

Dronedarone

Cyclosporine/tacrolimus

HIV protease inhibitors

Ketocon/itraconazole
DOAC DDI: decrease level

Pgp inducers and 3A4? (7)
Carbamazepine

Levetiracetam

Phenytoin/phenobarbital

Rifampin

St. John's wort

Valproic acid

Primidone
DOAC DDI:

For most DDI with strong inhibitors, recommended using ____ or _____

For inducers, recommend ____
Caution or avoiding

Avoiding
All DOACs are _____ substrates
Pgp
DOAC: initiation of therapy

In patients sufficiently healthy to be treated as an outpatient, suggest initiation of warfarin ____ for the first ____ days followed by dosing based on INR
10 mg QD

2
Monitoring: blood sampling

How often?
4 months /year

If crcl <60 recheck at interval CrCl/10
Rate or rhythm control:

Which is preferred in most patients?
Rate control
Rate or rhythm control:

Rhythm control is appropriate based on patients _____; _____ age; _____ tolerance, cant control heart rate to goal, or patient preference
Sx; younger; exercise
Rate or rhythm control:

Drugs used for rate control?(4)
BB

Non DHP CCBs

Digoxin

Amiodarone
Rate or rhythm control:

Goal HR in patients with normal EF?
80-110
Rate or rhythm control:

Drugs most commonly used for rhythm control? (6)
Amiodarone

Propafenone

Dofetilide

Flecainide

Sotalol

Dronedarone
Which BB are used? Dose? (4)
Metoprolol tartrate: 25-100 mg BID

succinate: 25-200 mg/day

Atenolol: 50-100 mg/day

Carvedilol: 3.125-25 mg BID
What non DHP are used? Dose?
120-360 mg/day

Verapamil ER and diltiazem ER
Digoxin drug level in AF?
1-1.5
Amiodarone dose?
600 mg to 1.8 g/day in divided doses until 10 grams is given then 200-400 mg/day maintenance
Dofetilide:

Dose: CrCl >60? 40-60? 20-40? <20?
500 mcg BID

250 mcg BID

125 mcg BID

CI in <20
Dofetilide: BBW?
Initiate in facility with continuous EKG and renal fxn monitoring and ability to resuscitate for at least 3 days
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