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: Infectious Diseases

BCPS 2013: Cardiology I