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103 Cards in this Set
- Front
- Back
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Total cholesterol formula
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TC = HDL + LDL + (TG/5)
Only usable if patient's TC is <400mg/dL |
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Normal Lipid Panel Values
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TC: <200
LDL-C: 100-129 HDL-C: >40 men; >50 women TG: <150 |
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Fasting Lipid Panel
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TC
HDL TG Requires a 9-12 hour fast |
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Lipid Screenings
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Primary w/o diabetes: Q5 years if >20 yrs old
Secondary/Diabetes: Every year!! High Risk Children with + family history of CVD or TC >240 b/w 2-10 yrs old |
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Syndrome X
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Metabolic Syndrome
Patients that have multiple risks Goal: raise HDL-C |
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ATP III: Major AVD Risk Factors
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Cigarette smoking
HTN Low HDL-C FH of premature CHD |
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Non HDL-C goal
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30mg/dL higher than the patient's LDL goal
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LDL-C goals according to risk category
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VERY high risk: <70
High risk: <100 Moderate/moderate high: <130 Low risk<160 |
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Initiating drug therapy according to risk category
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High risk: >100
Moderate high risk >130 Moderate risk >160 Low risk > 190 |
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TLC
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Dietary:
-plant sterols/stanols (2g/day) -Soluble fiber (10-25g/day) -increased fatty fish intake Others: -increased aerobic activity -weight reduction if overweight -Smoking cessation if applicable Measure FLP in 6 weeks to determine LDL |
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DOC's for specific TC reduction
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Statins: LDL C decrease
Nicotinic Acid: HDL increase and TG decrease Fibrates: DOC for TG decrease |
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Recommended percent reduction goals of LDL-C
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Moderately high, high, and very high: 30-40%
Very high: If <70 is not attainable, aim for at least a 50% reduction |
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Available OTC cholesterol tests
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Kits are not recommended b/c they're non-HDL testers
Cholestech LDX and Cardiocheck use FRS scores and can be used! |
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Statins
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HMG-CoA reductase
DOC for decreasing LDL-C Side effects: GI upset, headache, hepatotoxicity, muscle related |
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Signs of hepatotoxicity
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Jaundice
hepatomegaly increased indirect bilirubin elevated PTT Increased creatine kinase |
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Rhabdomyolosis
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>10 x ULN of tramsaminase levels
Myoglobin Brown urine |
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Risk factors for statin induced myopathy
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Age >80
CKD stage 4 or 5 Impaired liver function Perioperative periods Alcohol abuse Grapefruit juice Drug Interactions |
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Statin Monitoring Tests
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Fasting lipid panel
LFTs CK measurement (may not need) |
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Statin drug interactions
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-Inc. myopathy risk w/ fibrate/niacin
-Strong CYP 3A4 Inhibitors (inc. concentration causing myopathy and rhabdomyolysis) Azole antifungals, erythromycin, clarithromycin, HIV protease inhibitors, grapefruit juice -Weak CYP3A4 inhibitors Amiodarone/verapamil, cyclosporine, gemfibrozil |
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Statin contraindications
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Pregnancy
ACTIVE liver disease |
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Statin Rank Potency
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RATSILOPRAF
Highest to lowest |
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Zetia
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Ezetimibe (10mg daily ONLY)
Cholesterol Absorption Inhibitor in the GI. Commonly used as add-on to statin Side effects: diarrhea, abdominal pain (unusual) Monitor: FLP LFTs (only in combo with statin) No contraindications |
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Vytorin
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Ezetimibe and Simvastatin
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Bile acid sequestrants
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Colestipol (Cholestid), Cholestyramine (Questran), Colesevelam (WelChol)
Non-systemic Side effects: (common) GI upset and constipation Monitor: FLP Colestipol and Cholestyramine bind drugs: administer 2hr after/before other drugs Contraindications: Hx of severe constipation and TG > 300mg/dL DOC: Colesevelam b/c there's no binding interactions, best tolerated, also indicated for Type II DM |
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Niacin
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Inhibits synthesis of LDL and VLDL
ALWAYS TITRATE 2nd line of therapy for elevated LDL; DOC for raising HDL Side effects: Hepatotoxicity, rhabdomyolysis, GI upset, flushing, itching (common with IR) Monitor: FLP, LFT's, uric acid, fasting glucose Interactions: Inc. myopathy w/ statin/fibrate Contrainidications: ACTIVE liver disease, ACTIVE peptic ulcer disease, ACTIVE gout,k POORLY CONTROLLED diabetes. USE LOWER DOSES FOR CKD patients!!! |
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Niacin Products
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IR: Poorly tolerated. Low hepatotoxicity. (start at 100mg bid or tid; inc. by 100/week to 1500/3000)
ER (Niaspan): Best tolerated. Low hepatotoxicity (Start at 500mg QHS; inc by 500/week till 1000-2000) |
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Fibrates
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DOC:severe hypertriglyceridemia
Much more effective as add-on to statin Side effects: GI upset, hepatotoxicity, rhabdomyolysis Monitor: FLP, LFTs, and CK (only if signs of myositosis or combined w/ statin or niacin) Interactions: Warfarin (inc. bleeding) Rhabdomyolysis mostly with gemfibrozil Contraindications: ACTIVE liver disease, gallbladder disease, severe CKD (CrCl <30) Fenofibrate is preferred!! Dosed QD, lowers LDL, less potential to interact w/ statin, and doesn't commonly cause rhabdomyolysis |
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Fibrates (Doses/Brands)
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Fenofibrate Acid DR (Trilipix)
Fenofibrate (Tricor/Triglide) Micronized fenofibrate (Lofibra/Antara) 43-200mg QD Gemfibrozil (Lopid) 600mg BID |
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Combination therapies for Dyslipidemia
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Vytorin (ezetimibe & simvastatin)
10/10, 10/20, 10/40, or 10/80mg Advicor (ER Niacin & lovastatin) 500/20, 750/20, 1000/20 Simcor (ER Niacin & simvastatin) 500/20, 750/20, 1000/20 |
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Fish Oil
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Omega 3 Fatty Acids
May inc. bleeding risk with ASA or warfarin. Dyspepsia may occur Omacor (only Rx product) 465mg DHA & 375mg EPA Used for hypertriglyceremia Usual dose: 4g QD or BID w/food OTC products contain less than 1/3 of active ingredients than Rx |
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Criteria to determine Metabolic Syndrome presence
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Need at least 3 out of 5
-Abdominal obesity -Triglycerides >150 -Low HDL-C -BP >130 or >85 -Fasting glucose >100 OR on drug treatment for any of these medical problems |
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Type II DM and Dyslipidemia
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-High risk of AVD
-LDL goal: <100 (<70 w/ diabetes AND AVD or baseline LDL <100) -Avoid niacin if glucose is poorly controlled -most have syndrome x -statin/fibrate or statin/niacin is best in high risk patients |
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Chronic Kidney Disease & Dyslipidemia
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1)Patient specific risk for AVD
2)Goals and Targets of therapy 3)Lifestyle Habits 4)Rule out Secondary Dyslipidemia Controversies: -NKF recommends LDL goal of <100 for moderate-severe CKD -CHD risk reducing effects of statin or fibrates may not be b/c of lipid modification -Lab tests that measure LDL particle size and number, different subtypes of HDL, CRP. -OTC statins |
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Venous vs. Arterial Thrombosis (Types and Composition)
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Venous: DVT & PE
fibrin > platelets Arterial: Stroke & ACS platelets > fibrin |
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Define ACS
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MI
Clot in the coronary artery on top of a ruptured artherosclerotic plaque |
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Steps of Normal Hemostasis Coagulation
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1)Vasoconstriction (endothelin and EPI)
2)Platelet activation (collagen and PAF from endothelium) 3)Platelet adhesion (vWF from endothelium via GP1b receptors) 4)Platelet aggregation (ADP exposes IIb/IIIa receptors on platelets for fibrinogen to bind) |
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Activation of the coagulation cascade
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Extrinsic pathway: act on TF bearing cell to produce enough thrombin to start
Inactive clotting factor (substrate) Enzyme (activates factor) Co-factor These components are assembled on surface and held together by calcium. |
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Thrombin
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Promotes coagulation and anticoagulation
Cleaves fibrin from fibrinogen Activates platelets and factors XI, V, VIII. Inhibits fibrinolysis Activates protein C which inactivates factors Va and VIIIa Antithrombin and heparin HCII inhibits thrombin on endothelium |
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Virchow's Triad
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3 basic reasons clots form:
-Circulatory stasis -Thromboembolism -Hypercoagulable state |
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Anti-platelet vs Anti-coagulant drug
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Anti-platelet prevents platelet activation/aggregation
Anti-coagulant prevents formation of fibrin by inactivation coagulation factors |
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Different types of Antithrombotics
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-Thrombomodulin binds to thrombin to activate Protein C
-Protein C inactivates factor Va and VIIIa -Protein S is a required cofactor for Protein C -Tissue factor pathway inhibitor is released from the endothelium to inhibit tissue factor -Tissue plasminogen activator (Alteplase) -Antithrombin (ATIII) inactivates thrombin adn factor Xa -Nitric oxide and Prostacyclin (PGI-2) are vasodilators that inhibit platelet aggregation. |
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LMWH
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Enoxaparin
Dalteparin Tinzaparin Specific for factor Xa |
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Indirect acting factor Xa inhibitors
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Fondaparinux
Idrabiotaparinux Binds to antithrombin III |
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Direct acting factor Xa inhibitors
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Investigational; oral
Rivaroxaban Apixaban |
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Direct thrombin inhibitors
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Argatroban
Lepirudin Bivalirudin Dbigatran (investigational) |
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Pregnancy and Anticoagulation
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Warfarin is contraindicated! Category X
Heparin/LMWH doesn't cross placenta |
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Normal range of aPTT vs Heparin therapy
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Normal: 25-40 sec
During therapy: should be above normal range |
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UFH Therapeutic range
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VTE: Determined by nomogram of aPTT vs heparin level or protamine titration; patient specific.
Arterial Thromboembolism: ACS/MI aPTT: 50-70 sec |
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UFH Initial Dosing for VTE
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NO MAX
80units/kg IV bolus 18units/kg/hr IV infusion |
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UFH Initial Dose for ACS
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60units/kg IV bolus (MAX IS 4000)
12units/kg/hr IV infusion (MAX IS 1000) |
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UFH Dose Adjustment
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-Check aPTT every 4-6 hours from when dose is given till therapeutic range is reached
In general, if aPTT is too high, lower maintenance dose; if aPTT is too low, give bolus |
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Dosage adjustment for DVT/PE vs ACS
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DVT/PE:
<35 sec: 80U/kg Bolus, inc. by 4U/kg 36-50: 40U/kg Bolus, inc. by 2U/kg ACS: <35: 60U/kg Bolus, inc. by 4U/kg 36-50: 30U/kg Bolus, inc. by 2U/kg For both: 70-102: Decrease by 2U/kg/hr >102: Hold for 1 hr, decrease by 3 U/kg/hr |
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UFH Monitoring
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-CBC baseline
-Daily Hg/Hct -Platelet baseline, w/in 30 min. of bolus, and every 2-3 days once within therapeutic range. -aPTT baseline and every 4-6 hours. Daily when goal aPTT reached. Watch out for hyperkalemia and osteoporosis |
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UFH Reversal
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1mg Protamine reverses about 100 units UFH per hour or dose.
MAX IS 50mg IV over 10min. MUST REASSESS |
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LMWH
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Binds to factor Xa so monitor anit-Xa levels
Indicated for pts > 150kg, renal insufficiency (CrCl <30), and pregnant QD SQ injections Not completely reversible by protamine. |
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Fondaparinux
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Contrainidicated in pts <50kg or CrCl <30.
ONLY INDICATION IS INTRACRANIAL HEMORRHAGE No antidote; must give blood transfusion No monitorable lab value |
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Heparin Induced Thrombocytopenia Cause/Intro
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DO NOT USE LMWHs and FONDAPARINUX
Allergic response to heparin Lower platelet count b/c platelets are clumped in clots Type II: DEADLY Binds to platelet factor 4 to promote platelet aggregation via IgG mediated allergy pathways |
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Clinical Diagnosis of HIT (4 Ts)
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-Thrombocytopenia
-Timing of platelet count decrease -Thrombosis -Other causes for thrombocytopenia (2B3a inhibitors related infections cause low platelet count) |
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Laboratory tests to determine HIT presence
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ELISA
Platelet factor 4 antibody test (gold standard) |
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Treatment of HIT according to severity
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Low risk:
Continue heparin or switch to fondaparinux/lepirudin for prophylaxi Moderate to high risk: D/c heparin Start IV DTI -Lepirudin (renally eliminated) -Argatroban (hepatically eliminated) Reduce dose in pts with CHF, PO fluid overload, poorly dialyzed CKD. CONTINUE THERAPY TILL PLATELET COUNT RECOVERS! |
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Normal AST/ALT levels
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ALT: 5-40
AST: 5-30 |
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Normal Potassium Level
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3.5-5
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Normal Platelet count
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140,000-400,000/mm^3
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Monitoring Platelets for Prophylactic Anticoagulation administration
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Post/operative; risk>1%: measure every other day till d/c heparin
Medical/OB, UFH, or LMWH PO; risk 0.1-1%: Every 2-3 days till d/c heparin |
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Thrombus prophylaxis in patients with drug-eluting stents
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Warfarin w/ ASA and clopidogrel
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Which factors does warfarin inhibit the production of?
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Proteins C & S
Factors II, VII, IX, X |
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R-warfarin vs S-warfarin
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S-warfarin is the more potent anticoagulant. Substrate for CYP 2C9
R-warfarin is a substrate for CYP 1A2 and CYP3A4. |
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CAM interactions with warfarin
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Garlic, gingko biloba, ginger, ginseng, fish oil increase effect of warfarin.
Green Tea and St.John's Wort decrease effect of warfarin. |
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Factors influencing warfarin dose
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Vitamin K
VKORC1 or CYP2C9 mutations Hereditary warfarin resistance Factor IX pro-peptide mutation inc. bleeding risk Older age Smoking Wt/ht |
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What subtypes of VKORC1 and CYP2C9 require lower doses of warfarin compared to "normal"?
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VKORC1 - A allele (-1639) and T allele (-1739)
CYP2C9 - 2* and 3* alleles |
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INR targets
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2.0-3.0 for VTE treatment
2.5-3.5 for thromboprophylaxis for mechanical heart valve <1.8: increased possibility of thrombosis >3.0 increased possibility of bleeding |
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Diseases that affect warfarin clearance
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Decrease clearance, increase effect
-CHF (dec. metabolism) -Diarrhea (dec. Vitamin K) -Hyperthyroidism (dec. metabolism) |
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Warfarin skin necrosis
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W/in 3-8 days of warfarin initiation
Predisposed: Large loading doses >10mg Protein C/S deficiency Local pain w/ petechial rash and black ecchymosis Bridging w/ heparin should prevent this! |
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Warfarin Reversal Protocol
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Oral: 2.5mg po reversal in 24 to 48 hrs. Use if INR is 5.0-9.0 and no bleeding
IV: Phytonadione -- 0.5-1.0mg reversal in 6 to 24 hrs. SERIOUS BLEEDING: IV 10 mg Also used for the reversal of INR for invasive procedures |
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Warfarin Dosing Protocol
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Check INR in 2-5 days with any change or initiation. Then check weekly for 2 weeks. Then check every two weeks. Then, monthly. IF UNSTABLE INR, back to step 1 after adjusting.
CHECK INR DAILY IF OVERLAPPED WITH OTHER ANTICOAGULANT Initiate w/ 5mg or previously well tolerated dose Adjusting: If INR is too high: dec. dose by 5-20% If INR is too low: inc. dose by 5-20% |
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Warfarin Monitoring
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Baseline INR/aPTT
Bleeding signs CBC (Hg/Hct) Platelet count INR appropriately Compliance Diet CAM Genetics? |
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Where is DVT most common?
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Lower extremity veins such as popliteal, femoral, and iliac.
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Mechanism of post-phlebitic syndrome
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An acute thrombus causes damage to venous valves causing venous valve insufficiency due to inflammation. This causes venous hypertension.
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Drug-Associated VTE
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Tamoxifen
Estrogen Cancer therapy with angiogenic inhibitors, gemacitabine, and L-aspariginase in ALL KIDS) ESAs |
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ACCP VTE Guidelines for ASA use and Mechanical methods
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Mechanical methods are used for high risk pts or as an adjunct to anticoagulant therapy
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ACCP VTE Guidelines for ASA use and Mechanical methods
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Mechanical methods are used for high risk pts or as an adjunct to anticoagulant therapy
ASA use alone is not recommended |
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Moderate risk and High risk: define and DOC for VTE prophylaxis
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Moderate (no malignancy): LMWH, LDUH BID, or fondaparinux until hospital discharge
High (malignancy or prior VTE): LMWH, LDUH TID, or fondaparinux continue w/ LMWH for up to 28 days after discharge |
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ACCP VTE Prophylaxis in pts w/ thoracic surgery
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LMWH, LDUH (5000Units) BID, fondaparinux
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ACCP VTE Prophylaxis in pts with CABG surgery
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LMWH, LDUH BID, bilateral GCS or IPC
LMWH IS PREFERRED |
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VTE Prophylaxis in pts w/ THR or Hip Fracture Surgery
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LMWH (enox 40mg SC QD or 30mg SC BID; Dalteparin 5000units QD)
Fondaparinux 2.5mg VKA INR target 2.5 (2.0-3.0) At least 10 days but should be extended up to 35 days LMWH is DOC for THR Fondaparinux is DOC for Hip Fracture Surgery |
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ACCP VTE Prophylaxis for pts w/ TKR
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LMWH, Fondaparinux, VKA, IPC
At least 10 days but should be extended to 35 days. LMWH IS PREFERRED |
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ACCP VE Prophylaxis for pts w/ Major Trauma
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LMWH is preferred!
Don't use a IVCF. Use IPC or GCS till safe to use anticoagulant if contraindicated At least through hospital discharge. Extend to rehab using LMWH or Warfarin |
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Risk factors for VTE in Medical patients
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CHF
Severe respiratory disease COPD Asthma Pneumonia Confined to bed w/ either active cancer, previous VTE, sepsis, Acute neurological disease, IBD. |
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Signs and symptoms of DVT
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Pain
Swelling Tenderness Leg Edema Skin Discoloration Skin Warmth Palpable cord Homan's sign (pain on dorsiflexion of foot) |
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Venography vs. Other lab tests for DVT
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Gold standard
Invasive Painful Contrast dye Venous ultrasound is less sensitive but more commonly used D-dimer test (negative: rule out VTE) Partial b/c other factors can cause d-dimer elevation |
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Diagnostic Tests for PE
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Pulmonary angiogram is the gold standard
If avoiding contrast dye is necessary, use VQ scan CT scan is most common but less sensitive (also uses dye) D-dimer and Venous US are other options |
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Goals of Therapy for PE and DVT Treatment
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Resolve signs and symptoms, prevent recurrence.
DVT: prevent PE and lower extremity ischemia. PE: prevent sudden death and pulmonary HTN! Monitor: aPTT for UFH, platelet count for HIT, Bleeding, and SCR if enoxaparin or Fondaparinux used. |
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Treatment of DVT
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Bedrest, elevate leg, anticoagulant therapy (UFH/LMWH/fondaparinux followed by warfarin), IVC in pts who are bleeding severely and those w/ repeat VTE.
Thrombolytic therapy only if limb amputation is threatened; use alteplase if PE w/ shock. Throboectomy only if limb amputation is threatened AND pt cannot receive thrombolytic therapy |
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Treatment of PE
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Bedrest
oxygen anticoagulation (same as DVT) Thrombolysis only if shock present Thromboectomy if shock AND contraindication to thrombolysis |
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Signs of shock
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low BP
poor oxygenation |
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VTE Treatment Guidelines
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Injectable anticoagulant from Day 1! d/c when INR >2 for 24 hrs
Target INR (2.0-3.0) Elastic compression stockings for every pt! LMWH is preferred w/ DVT or nonmassive PE UFH is preferred for massive PE |
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Obese pts w/ VTE
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Use same weight based dosing.
Fondaparinux is capped Monitor anti-Xa levels |
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Severe CKD pts w/ VTE
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Use UFH over LMWH
Fondaparinux:Contraindicated If LMWH is used, reduce dose by 50% Monitor anti-Xa levels 3-5 hrs after dose |
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Normal anti-Xa levels
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0.5-1.0 units/mL
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Duration of Treatment for VTE
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W/ transient reversible risk factors:
3 mths of warfarin Idiopathic VTE: Minimum duration; consider repeat US at 3mths |
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Cancer pt w/ VTE
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Use LMWH the first 3 to 6 mths
Use VKA, Dalteparin, enoxaparin indefinitely or until cancer resolved |
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Risk factors for idiopathic bleeding/VTE
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Renal/hepatic failure
Concomitant antiplatelet therapy Hx of bleeding Hx of non-cardioembolic stroke Poor INR control w/ VKA >75 yrs old. |
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Risk factors for Idiopathic VTE recurrence
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recurrent event
positive D-dimer positive US clot PE as first event Pulmonary HTN Male Thrombophilia |
