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CARDIOLOGY Antithrombotic Therapies

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CARDIOLOGY Antithrombotic Therapies CARDIOLOGY Antithrombotic Therapies Anticoagulants: for Vitamin K antagonists Warfarin (Coumadin) -Impairs hepatic synthesis of thrombin, 7, 9, and 10 treatment of venous -Interferes with both clotting and anticoagulation = need to use another med for first 5 days of therapy clots or risk of such -Must consume consistent vit K as factor V Leiden -Pregnancy X disorder, other -Monitor with INR and PT twice weekly until stable, then every 4-6 weeks clotting disorders, Jantoven -Rarely used, usually only if there is a warfarin allergy post PE, post DVT Marvan Waran Anisindione (Miradon) Heparin -IV or injection -Short half-life of 1 hour -Monitored with aPTT, platelets for HIT -Protamine antidote LMWH Ardeparin (Normiflo) -Inhibit factors 10a and thrombin Dalteparin (Fragmin) -Injections can be done at home Danaparoid (Orgarin) -Useful as bridge therapy from warfarin prior to surgery Enoxaparin (Lovenox) -Monitor aPTT and watch platelets initially for HIT, then no monitoring needed once goal is reached? Tinzaparin (Innohep) -Safe in pregnancy Heparinoids Fondaparinux (Arixtra) -Direct 10a inhibitor Rivaroxaban (Xarelto) -Only anticoagulant that does not affect thrombin Direct thrombin Dabigatran (Pradaxa) -Monitor aPTT inhibitors Lepirudin (Refludan) Bivalirudin (Angiomax) Antiplatelets: used COX inhibitors Aspirin -Blocks thromboxane A-2 = only 1 platelet pathway blocked = weak antiplatelet for arterial clots or -Only NSAID where antiplatelet activity lasts for days rather than hours risk of such as ADP receptor inhibitors Ticlopidine (Ticlid) -No monitoring needed stroke, TIA, -May ease migraines atherosclerosis, Clopidogrel (Plavix) -Needs monitoring during initiation due to risk of blood count abnormalities CAD, MI, angina, Ticagrelor (Brilinta) PVD, post PCI, post Prasugrel (Effient) CABG, a-fib PPD inhibitors Cilostazol (Pletal) -Contraindicated in CHF -May be useful in PVD as it widens leg arteries -Pregnancy X Glycoprotein IIB/IIIA Abciximab (ReoPro) -IV only inhibitors Eptifibatide (Integrilin) Tirofiban (Aggrastat) Defibrotide Adenosine reuptake Dipyridamole (Persantine) -Strong treatments for prevention of recurrent stroke inhibitors 1 CARDIOMYOPATHIES -A group of diseases of the myocardium associated with mechanical or electrical dysfunction that usually exhibit ventricular hypertrophy or dilation -Current major society definitions of cardiomyopathies exclude heart disease secondary to CV disorders such as HTN, CAD, or valvular disease -Etiologies may be genetic, inflammatory, metabolic, toxic, or idiopathic Type Info Signs & Symptoms Workup Management Prognosis Dilated Cardiomyopathy: -Common etiologies: viral, -CHF -Treat CHF symptoms dilation and impaired contraction genetic, alcoholism -Arrhythmias -ICDs of one or both ventricles -Systolic dysfunction -Sudden death -Eval for transplant -Exercise intolerance -Fatigue or weakness -Dyspnea Hypertrophic Cardiomyopathy: -Caused by genetic mutations -Varied presentation, may be asymptomatic -Differential: athlete’s -β-blockers to reduce O2 -Annual disorganized hypertrophy of left -Diastolic dysfunction -CHF heart (physiologic LVH), demand mortality of 1% ventricle and occasionally right -Usually asymptomatic until -DOE: the most common sx HTN, aortic stenosis -CCB to reduce -May progress ventricle childhood or adolescence -Orthopnea and PND -Valsalva will increase contractility and improve to dilated -Athletes with underlying -Exertional chest pain HCM murmur and diastolic relaxation cardiomyopathy HOCM at greater risk for lethal -Atypical chest pain decrease aortic stenosis -Pacer or AICD arrhythmia during exertion -Syncope and presyncope murmur -Surgical myectomy, -May have abnormal SAM -Palpitations -EKG: prominent Q mitral valve surgery, or movement of mitral valve -Postural hypotension waves, P wave ethanol ablation to -Fatigue abnormalities, LAD destroy thickened -Edema -Echo septum -Arrhythmias -Holter monitor -Harsh crescendo systolic murmur ± mitral -Exercise stress test regurg -Screen relatives -S4 -Displaced apical impulse or thrill -Sudden death -Stroke Restrictive Cardiomyopathy: -Etiologies: scleroderma, -R CHF as pulmonary pressures must increase to -Differential: constrictive diastolic dysfunction normal amyloidosis, genetic, HOCM, deliver blood pericarditis contractility but rigid and stiff DM, chemo, HIV ventricular walls -Uncommon in US Arrhythmogenic Right -Genetic cause -Ventricular arrhythmias Ventricular Cardiomyopathy/Dysplasia: RV wall replaced with fibrous tissue Unclassified Cardiomyopathies -Includes stress-induced cardiomyopathy and left ventricular noncompaction 2 ARRHYTHMIAS AND CONDUCTION DISORDERS Atrioventricular Block Type Signs & Symptoms/Info/Workup Management EKG First degree -Asymptomatic -Treat reversible -EKG showing lengthened PR interval causes such as -Determine site of block using EKG ischemia, increased findings, atropine, exercise, or vagal vagal tone, or meds maneuvers -Pacemaker usually not recommended Second Wenckebach -Typically asymptomatic -Treat reversible degree (Mobitz type I) -EKG shows progressive PR causes such as prolongation for several beats prior to ischemia, increased nonconducted P wave vagal tone, or meds -Beats classically occur in ratios of 3:2, -Pacemaker if there is 4:3, or 5:4 symptomatic -Can be a result of inferior MI bradycardia Mobitz type II -May be asymptomatic or have signs of -Treat reversible hypoperfusion or HF causes such as -PR interval remains unchanged prior to ischemia, increased a nonconducted P wave vagal tone, or meds -Most patients will require a pacemaker Third degree -May have dizziness, presyncope, syncope, v-tach, v-fib, worsening HF, or angina -P waves don’t correlate to QRS -Escape rhythm takes over for QRS (junctional or ventricular) 3 Bundle Branch Block -Occurs when block in left or right BB delays depolarization Differential Workup to a ventricle -Any BBB: ventricular rhythm or ventricular pacing -RBBB: if asymptomatic and no other evidence of cardiac -Variation is “intermittent Mobitz” where there is a RBBB or -RBBB: Brugada syndrome disease, no further w/u indicated LBBB plus intermittent BBB of opposite side can progress -LBBB needs further w/u for cardiac cause to 3° AV block BBB and acute MI -LBBB interferes with dx of ventricular hypertrophy, myocardial Management Causes ischemia, and acute MI because of associated Q waves (early -Permanent pacemaker insertion for symptomatic BBB or -Structural heart disease: cor pulmonale, pulmonary ventricular depolarization is affected) as well as ST changes progression to AV block embolism, MI or ischemia (both branches receives blood (ventricular repolarization is affected) supply from LAD), myocarditis, HTN, congenital heart -RBBB usually does not interfere with dx of Q wave MI (early Prognosis disease ventricular depolarization is not affected) but can inflict ST -LBBB in older individuals associated with increased mortality -Iatrogenic: R heart cath, ethanol ablation segment changes EKG -Joined QRS’s or “rabbit ears” -May have accompanying ST or T wave change due to altered sequence of repolarization -RBBB will be prominent on R heart leads (V1 and V2) -LBBB will be prominent on L heart leads (V5 and V6) Sick Sinus Syndrome -A combination of unhealthy SA that stops pacing Signs & Symptoms Management intermittently + unresponsive supraventricular foci -Lightheadedness -May eventually need pacemaker -Seen in the elderly with heart disease and in kids with -Presyncope or syncope congenital and acquired heart disease after corrective -DOE Workup cardiac surgery -Worsening angina -Appears as sinus bradycardia -Palpitations -May also see intermittent SVT Causes bradycardia-tachycardia syndrome -SA node tissue becomes replaced with fibrous tissue -Compromised blood supply to SA node (atherosclerosis, inflammation, emboli) -Lyme disease -Drugs causing depressed SA node function: β-blocker, clonidine, methyldopa, digitalis, Li, amiodarone 4 Ventricular Tachycardia Torsades de pointes is a Signs & symptoms Management EKG polymorphic form of VT -Can remain alert and stable with -Torsades: remove offending med, use short runs anti-arrhythmics Ventricular flutter is a rapid (240- -Prolonged runs hypotension, -Treat if > 30 s with antiarrhythmics 280) unstable form of VT that can myocardial ischemia, syncope, (amiodarone, lidocaine, procainamide) deteriorate to VF chest pain, dyspnea -Cardioversion if pt remains unstable -Sudden cardiac death Causes -Electrolyte imbalances -Acid/base abnormalities -Hypoxemia -MI -Drugs Ventricular Fibrillation Causes Signs & Symptoms Management -Underlying ischemia or -Can remain alert and stable with short -Treat underlying cause LV dysfunction runs -Electric defibrillation -Prolonged runs hypotension, myocardial ischemia, syncope, chest pain, dyspnea -Sudden cardiac death Atrial Fibrillation -Associations: valvular disease, Acute management Subsequent management dilated cardiomyopathy, ASD, -Hemodynamically stable rate and -Cardioversion w/ antiarrhythmic maintenance vs.
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