A) Ihd

Front 1

ReoPro
1)duration of effect
2)renal elimination
3)renal dosing adjustment

Back 1

abciximab
1)>12h (can be reversed by a platelet infusion)
2)No
3)No

Front 2

Integrilin
1)duration of effect
2)renal elimination
3)renal dosing adjustment

Back 2

eptifibatide
1)4-8h
2)Yes
3)Yes

Front 3

Aggrastat
1)duration of effect
2)renal elimination
3)renal dosing adjustment

Back 3

tirofiban
1)4h
2)Yes
3)Yes

Front 4

GPIIb/IIIa receptor inhibitors
1)allergic rxn
2)contraindications

Back 4

1)abciximab may produce allergic rxn with repeated exposure
2)active bleeding, PLT <100,000, stroke w/in past 30 days, hemorrhagic stroke, BP>180/110, major surgery within past 6 weeks, SCr >4 or dialysis dependent (eptifibitide only), hx of neoplasms, AV malformations, aneurysm

Front 5

ReoPro indication

Back 5

adjunct to PCI or when PCI is planned within 24 hours

Front 6

Integrilin indication

Back 6

adjunct to PCI; patients w/ ACS managed w/ or w/o PCI

Front 7

Aggrastat indication

Back 7

adjunct to PCI; patients w/ ACS managed w/ or w/o PCI

Front 8

Heparin dosing
1)UA/NSTEMI
2)STEMI

Back 8

1)60-70units/kg (max 5000 units) IV bolus, 12-15units/kg/h (max 1000units/h) infusion titrated to an aPTT 1.5-2x normal
2)(in combination w/ tPA, rPA, or TNK), 60units/kg (max 4000units) IV bolus, 12units/kg/h (max 1000units/h) infusion titrated to an aPTT of 1.5-2x control for 48 hours

Front 9

Reverses the effects of Heparin

Back 9

Protamine
1mg of protamine neutralizes 100 units of heparin

Front 10

LMWH's

Back 10

Lovenox (exoxaparin)
Fragmin (dalteparin)

Front 11

enoxaprin dosing
dalteparin dosing

Back 11

1mg/kg SC q12 (Crcl <30: 1mg/kg SC q24h)

120 IU/kg q12h (max 10,000 IU q12h)

Front 12

Advantages of LMWH over Heparin

Back 12

better bioavailability
more predictable response
ease of administration
fewer SE's
No recommended monitoring
(Stronger inhibitor of thrombin, factor Xa)

Front 13

LMWH warnings

Back 13

patients with recent or anticipated epidural or spinal anesthesia are at risk of hematomoa and subsequent paralysis

Front 14

Enoxaparin
1)half life
2)Anti-Xa: Anti-IIa
3)Renal elimination

Back 14

1)4.5h
2)2.7 : 1
3)Yes

Front 15

dalteparin
1)half life
2)Anti-Xa: Anti-IIa
3)Renal elimination

Back 15

1)3-5h
2)2 : 1
3)Yes

Front 16

UFH
1)half life
2)Anti-Xa: Anti-IIa
3)Renal elimination

Back 16

1)1h
2)1:1
3)No

Front 17

Thrombolytics

Back 17

Alteplase (tissue plasminogen activator, tPA)
Retevase (reteplase, rPA)
Steptase (streptokinase, SK)
TNKase (tenecteplase)

Front 18

Thrombolytic dosed by weight

Back 18

TNK (<60kg give 30mg IV bolus, >90kg give 50mg IV bolus, 35mg, 40mg, 45mg)

tPA (15mg IV bolus, followed by 0.75mg/kg IV infusion over 30mins (max 50mg); then 0.5mg/kg IV infusion over 60mins (max 35mg)

Front 19

Thrombolytics requiring IV bolus

Back 19

tPA (15mg IV bolus)
rPA (10 U IVP over 2 mins, followed in 30mins by a repeat 10 U IV bolus over 10 mins)
Bolus given over 5 seconds

Front 20

Streptokinase dosing

Back 20

1.5million units in 50mL NS or D5W given over 60 mins

Front 21

Clopidogrel and Ticlopidine (Thienopyridines) MOA

Back 21

blocks ADP mediated activation of PLTS by selectively and irreversibly blocking ADP activation of gpIIb/IIIa complex

Front 22

Clopidogrel dosing

Back 22

loading dose: 300-600mg PO
Maintenance doses:
75mg daily combined w/ ASA for up to 9 months in pts who did not undergo cardiac cath

75mg daily combined w/ ASA for at least 1 month with BMS, 3 months for sirolimus-coated and 6 months for paclitaxel-coated stents

75mg daily for life in pts w/ ASA allergy

Front 23

Ticlopidine dosing

Back 23

Loading dose: 500mg PO
Maintenance dose: 250mg BID

Front 24

When should ticlopidine by discontinued

Back 24

ANC <1200 or PLT <80,000

Front 25

Thienopyridine contraindications

Back 25

active bleeding
severe liver disease
Ticlopidine: neutropenia, thrombocytopenia

Front 26

Thienopyridine drug interactions

Back 26

CYP450-2CP substrates (phenytoin, fluvastatin, NSAIDs, losartan, irbesartan, valsartan) may increase serum levels

Front 27

Nitrostat, Nitroquick
1)Route
2)Onset
3)duration of action
4)dose

Back 27

nitroglycerin sublingual tablet
1)sublingual
2)1-3mins
3)30-60mins
4)0.2-0.6mg q5mins. Seek emergency treatment if chest pain is unrelieved after 1 dose

Front 28

Nitrolingual
1)Route
2)Onset
3)duration of action
4)dose

Back 28

nitroglycerin spray
1)translingual
2)2 mins
3)30-60mins
4)0.4mg q5mins. Seek emergency treatment if chest pain unrelieved after 1 spray

Front 29

Nitroguard
1)Route
2)Onset
3)duration of action
4)dose

Back 29

nitroglycerin transmucosal tablets
1)buccal
2)1-2mins
3)3-5h
4)insert 1 tablet into cheek q3-5h

Front 30

Nitrobid, Nitrol
1)Route
2)Onset
3)duration of action
4)dose

Back 30

nitroglycerin ointment
1)topical
2)30-60mins
3)2-12hours
4)1-2 inches q8h up to 4-5inches every q4h

Front 31

Nitrodur, Nitrek, Nitrodisc, Deponit, Minitran
1)Route
2)Onset
3)duration of action
4)dose

Back 31

nitroglycerin transdermal patches
1)topical
2)30-60mins
3)up to 24h
4)0.2-0.4mg/h. Apply and allow patch to say in place for 12h. Remove the patch after 12h

Front 32

Nitrong, Nitroglyn, Nitro-Time
1)Route
2)Onset
3)duration of action
4)dose

Back 32

nitroglycerin sustained-release tabls/caps
1)oral
2)20-45mins
3)3-8h
4)2.5mg tid-qid

Front 33

Tridil, Nitro-BID
1)Route
2)Onset
3)duration of action
4)dose

Back 33

nitroglycerin intravenous
1)IV
2)1-2mins
3)3-5mins
4)5mcg/min

Front 34

Ismo, Monoket
1)Route
2)Onset
3)duration of action
4)dose

Back 34

isosorbide mononitrate
1)oral
2)30-60mins
3)no data
4)20mg bid (given 7 hours apart)

Front 35

Imdur, Isotrate ER
1)Route
2)Onset
3)duration of action
4)dose

Back 35

isosorbide mononitrate, extended-release
1)oral
2)30-60mins
3)no data
4)30-60mg QD (max 240mg QD)

Front 36

Isordil Titradose, Sorbitrate
1)Route
2)Onset
3)duration of action
4)dose

Back 36

isosorbide dinitrate
1)oral
2)20-40mins
3)4-6 hours
4)5-20mg q6h (max 40mg q6h)

Front 37

Isordil Tembids, Dilatrate-SR
1)Route
2)Onset
3)duration of action
4)dose

Back 37

isosorbide dinitrate, sustained release
1)oral
2)up to 4h
3)6-8h
4)40mg q8h. max 80mg q8-12h

Front 38

Oral properties of nitrates

Back 38

Isosorbide dinitrate (ISDN) and NTG undergo extensive first-pass metabolism when given orally

Mononitrate does not and is completely bioavailable

Front 39

IV properties of nitrates

Back 39

achieves highest concentrations; usually used only 24hours to avoid developing resistance

Front 40

SL tablet/spray for immediate-release properties

Back 40

spray does not degrade when exposed to air like tablets

half life 1-5mins regardless of route

Front 41

Nitrate Drug-disease interactions

Back 41

glaucoma (IOP may increase use with caution)
HOCM
severe aortic stenosis

Front 42

Nitrate contraindications

Back 42

sildenafil and vardenafil use within 24hours
tadalafil use within 48hours

Front 43

SL tablet patient instructions

Back 43

-keep tabs in their original container
-dissolve tab under tongue. lack of tingling doesn't indicate lack of potency
-take one tab at first sign of chest pain, if unrelieved, seek emergency medical attention

Front 44

translingual spray patient instructions

Back 44

-spray under tongue or onto tongue
-hold spray nozzle as close to the mouth as possible
-do not inhale spray or use near heat, open flame, or while smoking
-close mouth immediately after spraying
-avoid eating, drinking, or smoking for 5-10mins
-if pain does not go away after 1 spray, seek medical attention

Front 45

transmucosal tablets patient instructions

Back 45

-place between cheek and gum; do not chew tablet; allow to dissolve over a 3-5 hour period
-touching tab with tongue or hot liquid may increase release of medication

Front 46

Ointment patient instructions

Back 46

-measure correct amount using the papers provided w/ the product
-use papers for application, not fingers
-apply to chest or back

Front 47

Transdermal patches patient instructions

Back 47

-apply to hairless area and rotate sites
-remove patch approximately 12-14hours after placing it on every day
-store patches at room tempin a closed container,away from heat, moisture, and direct light
-do not refrigerate

Front 48

Sustained release tabs patient instructions

Back 48

-take atsame time each day as directed
-do not chew or crush tabs/caps

Front 49

When to use abciximab, eptifibatide, tirofiban

Back 49

abciximab or eptifibatide: use if PCI anticipated <4 hours after presentation

tirofiban: reserve for patients treated medically during the first 48 hours

abciximab should not be used in patients who are conservatively managed w/o plans for PCI

Front 50

Goal door-to-ballon time

Back 50

90mins or less

Front 51

When should long-term aldosterone blockade with eplerenone or spironolactone be considered

Back 51

Post-STEMI patients w/o contraindications w/ an LVEF <40% and having either symptomatic heart failure or DM

Front 52

Aldosterone blockers contrainidcations

Back 52

SCr >2.5mg/dL in men or >2mg/dL in women

hyperkalemia (K>5 mEq/L)

Front 53

ARBs that have established efficcacy for POST-STEMI indication

Back 53

valsartan, candesartan

Front 54

Indications for ACEI therapy post-STEMI

Back 54

patients w/in first 24 hours of suspected MI or with clinical HF w/o contraindications

all other patients w/o contraindications should receiver ACEI within first 24 hours

Front 55

Heparin use in STEMI

Back 55

-adjunct w/ fibrinolytics for prevention of recurrent coronary thrombosis
-IV UFH or LMWH or dalteparin in patients at high risk for systemic emboli
-UFH with streptokinase may increase risk of bleedind d/t SK's long half life
-patients at high risk for systemic emboli should have UFH helf for 6 hours (postthrombolytic) and aPTT monitoring begun at that time. After 48 hours a change to SC heparin, warfarin or ASA alone should be considered

Front 56

LMWH use in STEMI

Back 56

-alterative to UFH for patients <75 yearos of age w/o significant renal dysfunction (men: SCR >2.5, women: >2) who are receiving fibrinolytic therapy (enoxaparin 30mg IV bolus, 1mg/kg SC q12 until discharge + TNK

-should not be used in patients >75 years of age or in patients <75 with renal dysfunction

Front 57

Use of fibrinolytic therapy in STEMI

Back 57

-ST segmant elevation >1mm in two or more contiguous leads or LBBB
-presentation w/in 12 hours or less of symptom onset
-can be used in STEMI when time to therapy is 12-24 hours if chest pain is ongoing
-should not be used if time to therapy is >24 hours, and the ischemic pain is resolved
-should not be used for ST depression
-patients age >75 may be useful and appropriate

Front 58

Door-to-needle time

Back 58

<30 minutes

Front 59

Nitrate use in STEMI

Back 59

-first 24 hours in all patients w/ MI who do not have hypotension, bradycardia, tachycardia
-insignificant reductions in mortality beyound 48 hours, use is reserved for patients w/ large AMIs, persistent chest discomfort, HF, HTN, or persistent pulmonary congestion
-cautions: Inferior wall MI because of its frequent association w/ RV infarction. Such patients especially dependent on RV preload to maintain CO and can experience profound hypotension during nitrate administration

Front 60

Criteria for diagnosis of MI

Back 60

Chest Pain (>30mins)
ECG changes (ST segment elevation)
Cardiac isoenzymes (troponin T or I elevation, CK-MB elevations)

Must have two our of three

Front 61

LDL-lowering therapy in UA/STEMI

Back 61

-in patients w/ documented or suspected CAD or CHD risk equivalents and LDL >100mg/dL

Front 62

LMWH use in UA/NSTEMI

Back 62

LMWH or heparin in combination w/ ASA and clopidogrel should be given to all patients

enoxaparin may be superrior to heparin in these patients

Front 63

Heparin use in UA/NSTEMI

Back 63

-heparin continued for total of 24-48 hours or unitl a PCI procedure is completed
-In patients with a planned CABG within 24 hours, heparin use is preferred to LMWH

Front 64

GPIIb/IIIa receptor inhibitor use in UA/NSTEMI

Back 64

-in addition to heparin, ASA, and clopidogrel should be given to all patients w/ a planned PCI procedure. GPI can be given during the interventional procedure just before stent deployment or angioplasty

-eptifibitide or tirofiban should be given in combo w/ ASA and LMWH/UFH to patients w/ ACS who will not undergo a PCI procedure

Front 65

Clopidogrel use in UA/NSTEMI

Back 65

-should be combined w/ ASA in patients undergoing stent implantation for at least 1-6months depending on type of stent used and possibly up to 1yr

-clopidogrel should be continued w/ ASA in patients w/o planned PCI procedure for up to 9 months

Front 66

ACEI use in UA/NSTEMI

Back 66

-not indicated for immediate treatment of UA/NSTEMI
-recommended for patients w/ HF, DM, patients with high-risk CAD and in pateints with persistent HTN not controlled by BB or nitrates

Front 67

Acronym for management of UA/NSTEMI

Back 67

MONA
morphine
oxygen
nitrates
aspirin

Front 68

Morphine cautions and contraindications

Back 68

produces a vagotonic effect that may be C/I in patients w/ bradycardia

Front 69

When can meperidine by used?

Back 69

patients who are intolerant to morphine

Has vagolytic effects and is analgesic of choice in patients who are bradycardic