Therapeutics IHD 2
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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
What constitutes a High intensity atorvastatin dose?
What constitutes a High intensity Rosuvastatin dose?
What Statins are used for high intensity treatments?
Rosuvastatin and Atorvastatin (long half lives)
What Statins can be taken any time of day?
Rosuvastatin and Atorvastatin
What time of day do you need to give all Statins other than Rosuvastatin and Atorvastatin?
What are the CYP3A4 statins?
Lovastatin, Simvastatin and Atorvastatin
What is the MOA for NTG?
- Nitric oxide as the mediator:
- ↑ in O2 supply
- Coronary vasodilation
What are the normal side effects of NTG?
HA, flushing, postural hypotension (take sitting down), reflex tachycardia, nausea
How should NTG be dispensed?
With an easy open cap
When would you give CCBs for IHD?
Only given when BB are contraindicated, not tolerated, or as add-on therapy for angina pain
What kind of CCBs would you use for IHD?
Long-acting Non-DHP (Verapamil or diltiazem)
What are your main choices for treating high TG?
- Fibrate (first line)
- Nicotinic acid (niacin)
- Fish oil may help also
What is the dosing for Isosorbide dinitrate (Isordil)?
- 5-40 mg QID
- 40 mg BID-TID
What is the dosing for Isosorbide mononitrate (Imdur)?
- 5-20 BID
- 30-60 QD
- Max 240 mg QD
What are the ADP inhibitors:
Clopidogrel, prasugrel, or ticagrelor
What are the CIs for Aspirin?
Anaphylaxis, bronchospasm and serious bleeding
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)
What are the CIs for morphine in IHD?
Hypotension, respiratory depression and confusion
What are the extra effects (other than analgesia) of Morphine?
- Peripheral arterial dilation
- ↓systemic vascular resistance
- ↓afterload and O2 demand
- Prevent arrhythmias
When should you caution use of BBs in IHD?
- SEVERE heart failure
- Low output
- Increased risk for cardiogenic shock
- 2nd or 3rd degree HB
- PR interval > 0.24 sec
- SEVERE asthma/COPD
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
What is the MOA of Heparin?
Binds to antithrombin and then inhibits activity of factors Xa and IIa (thrombin)
Glycoprotein inhibitors should never be used in combo with what?
What are the CIs for Heparin?
- Serious active bleeding
- Recent CVA or stroke
What are the CIs for Enoxaparin?
Previous HIT, serious active bleeding, Going to CABG, or recent CVA
What is the MOA of enoxaparin?
Binds to antithrombin and inhibits activity of factors Xa and IIa (preferentially Xa)
In certain special populations, what would you monitor when giving enoxaparin?
Platelets, Renal function for dosing, and Anti-1oa
What is the MOA of Bivalirudin?
Direct thrombin (factor IIa) inhibitor
What are the CIs for Bivalirudin?
Active bleeding, severe bleeding risk
What is the MOA of Clopidegrel?
Inhibits platelet aggregation through the ADP receptor
What DDI does Clopidegrel have?
PPIs educe the efficacy
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)
How does Prausegrel compare to Clopidegrel?
- Increased risk of bleed
- Decrease in Death, MI and Stroke
- No PPI interaction
Prausegrel is reserved for what group?
Younger patients with high risk
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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