BP = SVR x CO
Name the thresholds for elevated BP, stage 1 hypertension, and stage II hypertension
How high is 120/<80, 130/80, and 140/80 mmHg
List the 4 pharmacologic pillars of HFrEF, recommended for all patients without a contraindication
ACEi/ARB/ARNI; MRA, BB (3 BBs with evidence to reduce mortality in HF), and SGLT-2 inhibitors
What are your high intensity statins? (Drug and dose)
Rosuvastatin 20-40 mg, atorvastatin 40-80 mg
What factors can increase the likelihood of a drug cause qtc prolongation?
Higher doses, reduced drug clearance, DDIs, coadministration with other drugs which prolong qtc, hypokalemia, hypomagnesemia, hypocalcemia,
This serious side effects of heparins may present with abrupt decline in platelets (50% or more) which occurs 5-10 days after heparin exposure (or within 24 hours if recent heparin exposure) and may or may not be accompanied with a new thrombus
What is heparin induced thrombocytopenia
List 5 thiazide-like or thiazide-type diuretics (Generics first, then brand names)
HCTZ (Microzide), chlorthalidone (Thalitone), metolazone (Zaroxolyn), indapamide (Lozol), chlorothiazide(Diuril)
Your patient was recently started on spironolactone for HF. What do you counsel your patient on and when do we need to check a potassium?
Check potassium in 1 week (then 4 weeks, then 6 months), hyperkalemia (muscle cramps, abnormal heart beat), diarrhea, dizziness (signs of low blood pressure), gynecomastia (if male) abnormal menses (if female of child-bearing age)
Name your two PCSK9 inhibitors and name one important storage requirement patients should be counselled on.
Evolocumab (Repatha) and alirocumab (Praluent), must be stored in fridge
What's typical loading dose for amiodarone?
5-10 grams, administered over 1-2 weeks or longer
You're dispensing dabigatran. What do you counsel your patient on? (Side effects and storage requirements)
May cause GI upset (take with full glass of water) and take with food if GI upset occurs, increased risk of bleeding (anywhere - brain, gums, GI tract, menses), must dispense in original manufacturer bottle and discard 4 months after opening, protect from moisture, brand name Pradaxa
What are first line options for a patient diagnosed with stage II hypertension with a blood pressure of 141/89 mmHg?
Combination single pill agents with a thiazide/ACE inhibitor, thiazide/ARB, ACEi/CCB, or ARB/CCB are preferred (CCB/thiazide, BB/thiazide, CCB/BB, thiazide/potassium-sparing diuretic are second line) ACEi/BB, ARB/BB, clonidine/BB are less effective
Your patient was admitted to the hospital in decompensated heart failure and described as "warm and wet" what do you recommend?
Current medications include:
Lisinopril 20 mg qday
Farxiga 10 mg qday
Spironolactone 25 mg qday
Carvedilol 25 mg BID
Furosemide 20 mg qday
Hold BB (patient in decompensated HF), and double furosemide to 40 mg qday (realistically 20 mg IV)
Brand name Lipitor, side effects - GI side effects, myopathies, risk of hepatoxicity but rare
Name all drugs in the vaughn william's class 1 category, including Ia, Ib, and IC agents.
what is disopyramide, quinidine, procainamide, lidocaine, mexiletine, propafenone, flecainide (Remember Double Quarter Pounder, Lettuce, Mayo, Fries please!
Name each oral DOAC (brand/generic) and its reversal agent (brand/generic)
Apixaban (Eliquis) - andexanet alfa (Andexxa)
Rivaroxaban (Xarelto) - andexanet alfa (Andexxa)
Edoxaban (Savaysa) - (off label) andexanet alfa (Andexxa)
Dabigatran (Pradaxa) - idarucizumab (Praxbind)
A patient has a prescription for Zestoretic. What do you counsel your patient on?
Lisinopril/HCTZ - hyperkalemia or hypokalemia (cramps, abnormal heart beat), dry cough, dizziness, electrolyte abnormalities in general b/c of thiazide, photosensitivity (more with long term use, but sunscreen is recommended for people in general), risk of angioedema (d/c if lip, facial, or throat swelling occur) and must use contraception if of child bearing age
Hypotension and cyanide toxicity
Your patient's total cholesterol is 250, the HDL is 45, the TGs are 170, what is the patient's LDL using the friedewald equation?
LDL = TC - HDL - TG/5 = 171 mg/dL
Tikosyn must be initiated in hospital. Please list how long patients must be hospitalized for, what is monitored, and why monitoring is required.
3 days, EKGs after each dose (BID drug), electrolytes (mag and potassium), and renal function (risk of qtc prolongation and torsades)
Your patient has a VTE and is started on unfractionated heparin. What is the initial bolus and maintenance dose and what do you monitor?
80 units/kg bolus followed by 18 units/kg/hr x 6 hours (check aPTT and adjust dose accordingly)
Please come to the board and list all Ace inhibitors, ARBs, CCBs, and thiazides
Thiazides: metolazone, indapamide, HCTZ, chlorthalidone, chlorothiazide
ACEi:lisinopril, quinapril, ramipril, fosinopril, enalapril, benazepril, captopril, moexipril, perindopril, trandopril
ARB: Losartan, valsartan, candesartan, azilsartan, eprosartan, irbesartan, telmisartan, olmesartan
CCB: Amlodipine, felodipine, nifedipine, nisoldipine (and diltiazem and verapamil)
Your patient has an ejection fraction of 25. They currently take lisinopril 20 mg qday, metoprolol succinate 100 mg qday, empagliflozin 10 mg qday, spironolactone 25 mg qday, and furosemide 40 mg qday.
His HR is 53 bpm and his blood pressure is 115/72 mmHg.
What recommendation do you make to improve compliance to GDMT? And how do you counsel your patient on this medication change?
Switch lisinopril 20 mg qday to sacubitril/valsartan 24/26 mg BID (49/51 mg BID also accepted). Must wait 36 hours after stopping lisinopril to start Entresto. Side effects are similar - can lower blood pressure (may feel dizzy), cause hyperkalemia (muscle cramps, abnormal heart beat), and has some risk of angioedema (may cause swelling of lips/face/throat)
Your patient is on rosuvastatin 40 mg qday. They've been taking this regimen for 3 months. Their LDL is currently 120 mg/dL with a goal of 70 mg/dL. What do you recommend?
Ezetimibe is a recommended next step for patients on maximized statin therapy not at goal (typically 10 mg qday) with an expected drop in LDL up to 20%. Patient is not expected to be at goal with the addition of this medication. Can reevaluate lifestyle modifications (DASH diet, exercise, weight loss, etc.) and recheck lipids in 1-3 months) or could consider a PCSK9 inhibitor which lower LDL by about 50-60%
Please list short term use side effects of amiodarone and long term use side effects (toxicities) associated with amiodarone use.
Short term use: bradycardia, hypotension, photosensitivity, nausea, phlebitis (IV)
Long term use: pulmonary toxicity (BBW), hepatotoxicity (BBW), ocular toxicities, thyroid dysfunction, dermatologic toxicities, peripheral neuropathy (Remember THOPPD)
Spinal hematomas may cause serious side effects such as paralysis. Which anticoagulant should be used if anticoagulation is required for a patient with an epidural?
Heparin (most other agents have warning or BBW against the use in patients receiving neuraxial anesthesia - epidural or spinal - due to risk of spinal hematomas)