Jennifer Carlquist PA-C, ER CAQ

Community Hospital Of Monterey Peninsula, Central Coast Cardiology

CHF Margarita

Cointreau(Spironolactone)

TEQUILA(Furosemide)

Margarita mix(BB)

LIME(ACEI)

Adjust to taste

“I am worried about her 16o systolic”

Objectives

AF treatment strategies

CHF tips and tricks

Common medication side effects

Cocktails the Kill!

They are buying what you are selling.

“Broccoli not beta blockers.”

No stress

Exercise

Meditate

Eat better

Say no

“Free lunch” - Lifestyle wins

As compared with the control diet with a high sodium level, the DASH diet with a low sodium level led to a mean systolic blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5 mm Hg lower in participants with hypertension.

N Engl J Med 1990;322:569-574

Case #1: 65 year old male attorney

Strategy

Stable? Unstable? Acute? Chronic?

Rate vs Rhythm.

1. Diltiazem is the premier drug for rate control

(NO HF)

2. BB

3. Verapamil

More on him….

He received Diltiazem 120 mg and converted.

He was discharged on Multaq and Eliquis

Labs: TSH, CBC, trop all normal

“This Multaq is too expensive. There HAS GOT TO be something else.”

Things to rule out

Post op, coPd, Partying

Infiltrative myxoma

Rheumatic valvular disease

Acute MI

Thyroid

Toxins

Environmental

Get you know your customer

Obese? Sleep apnea

Echo – LAE

Lexiscan – ischemic substrate

Bleeding issues?

HRTF?

Beer

How do you choose a drug?

How symptomatic?

How long to stay in it – perioperative?

Bleeder?

How likely to stroke?

How much are they in it?

WHAT DO THEY WANT TO DO

Simple?

Insert chart about this

“The second time you want to be a zero…”

1 - strong consideration for AC

2 and up- “No brainer”

BUT - 1 from female (< 65 years old without other risk factors) NO AC

Pick your poison

Warfarin – (target 2-3)

Rivaroxaban, Apixiban, Dabigitran, Edoxaban(non-valvular)

ASA

To bleed or not to bleed…

Factor 10 Coumadin

No monitoring

No reversal agents

No medication interactions

No food interactions

Expensive up to $12/day

Needs monitoring

Reversal possible

Medication interactions

Food interactions

Renal insufficiency

Inexpensive

AC

AC Rate RhythmSotolol

Flecainide

Propafenone

Dronedarone

Amiodarone

Calls back: “I read the side effects on amiodarone…”

“What else can I be on?”

Sometimes the choice is between bad and worse

Final answer?

Ablate him!

Omeprazole. The new villain?

Can make Plavix less potent

Can lead to bone loss

Probably not that bad but……lawyers

What ever happened to 14 days?

Caviat: Should be on PPI if on coumadin

“My doctor said to ask you about my labs…”

CR 2.2 - _____________, ________________

TSH 10.1 - ________________

HA1c 7 - ___________

What’s wrong with this patient?

Lisinopril Atorvastatin

CarvedilolFurosemide

Metformin

DM, HTN, CHF, Hyperlipidemia

What is missing? What is the dx?

NTG

LisinoprilFurosemide

Dronededarone

Carvedilol

AC/AF

What’s wrong with this picture?

ApixibanK ASA

Metoprolol

Carvedilol

Forgot to take off ASA!

What are they at risk for?

FurosemideCelecoxib

ASA

Ginko

Apixiban

Too Many Blood Thinners

What labs do they need?

Spironolactone Lisinopril K

Warfarin

Digoxin

Digoxin, INR, BMP

What is wrong here?

NTGAsa

Sildenafil Lisinopril

Carvedilol

Nitrate + Viagra =

What medication should we take him off of?

“I am getting all these bruises”

Ticagrelor, ASA, Atorvastatin, Carvedilol, Fish oil, Ginko

“I ache”

Med list: Simvastatin Clopidogril Metoprolol

CoQ 10, qod, Pitavastatin (Livalo)

“My feet can’t fit in my shoes”

Actos (Pioglitazone), ASA, HCTZ, Losartan

Take away Actos, use ted hose, elevate, make sure not unilateral, look for venous stasis, look for HF, dry weight

“Lipidema”

“Not everything that swells is cardiac”

Don’t make it worse

NSAIDS

Glitazones

Diltiazem

Verapamil

Nifedipine

Sotolol

Dronaderone

What medication should we take him off of?

76.1% with spironolactone vs 67.1% with eplerenone

What is the treatment?

“I have this cough…” ACEI vacation

Prilosec (Omeprazole)

Claritin (Loratadine)

Albuterol

“I’m constipated.”

Verapamil, cholestyramine, Ranexa (Ranolazine)

“I have this rash…”

Put on gloves.

Ok, “What?”

Take away all non essentials

Killer Cocktails

“Low Ball Spritz”

Imdur (Isosorbide)

Lasix (Furosemide)

Clonidine

Verapamil

“Long Island Cutie (QT) “

Terfenadine, astemizole

Class I or III antiarrhythmic agent

Macrolide antibiotic

Grapefruit juice

Kill My Kidneys Blast

ACE inhibitor

Diuretic

NSAID

“Kill Your Kidneys Cocktail”

Insulin

Oral hypoglycemic agent

Beta blocker

“Cops Gonna Think You Drunk” Cocktail

Digoxin

Amiodarone

Quinidine

Verapamil

Propafenone

“Mellow Yellow Cocktail”

Aspirin

Clopidogrel

Warfarin

Ginkgo biloba

Vitamin E

“Bloody Mary”

Digoxin

Beta blocker

(Diltiazem, Verapamil)

Amiodarone

“Slow Your Roll”

Case # 3

The Cardiology “Happy Meal”

BB

ACEI

Statin

ASA/Antiplatelet

“FixIt

All”

The Happy Meal: Not so happy?

“I feel dizzy now”

“I don’t want to be on all these medications”

Phase II Cardiac Rehab

Aspirin Tidbits

25% reduction of MI/death

Drinkers and bleeders watch out

No benefit in primary prevention in women under 65

BBA1

HZTZCCBACEI

Nitrates

Induce coronary vasodilation

Dilate peripheral veins – reduce venous return –decreases o2 demand

Refractory Angina

Ranolazine

Isosorbide

Amlodipine

ASAACEIStatin

Car

ved

ilol

Clopidogrel $

Prasugrel $$

Ticagrelor $$

+If stent

BB

Met

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Ato

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Ram

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“Where’s the bathroom?”

I have to wear this??

2013 – He was sent for echo

“Presented in 2007 with burning in the throat, began several days prior to MI; had BMS to RCA and LAD for acute anteroseptal MI.

Was on Atorvastatin, Ramipril and metoprolol; not taking any longer. Hasn't been feeling well for the past month, with fatigue dyspnea, effort intolerance, and throat/chest discomfort.”

Final read

Severely reduced LV systolic function with anterior, septal and apical akinesis. Severe hypokinesis in remaining segments. EF is 25-30%.

Moderate LV enlargement with mild LA enlargement.

CHF Treatment Tree

3rd Line

Sacubitril/Valsartan Ivabradine

Second Line

Bidil (Isorsorbide/HCTZ) K sparing

First line

BB ACEI/ARB/Diuretics

ACEI pearls

Lisinopril, Ramipril, Enalapril

Check K, CR and BP within one week of initiation or dosage increase in the elderly, and within one to two weeks of initiation or dose

Reduces mortality and morbity

Beta blocker Bits

Hypotension? Stagger or decrease diuretic dose

TAPER

Use Metoprolol Succinate (Toprol XL, Coreg)

No QT

Break it on Dowwwwnn…

Thiazides-HCTZ

Loop diuretics-Lasix, Bumex, Torsemide

K Sparing- Aldactone

Metalazone 30 min before loop shuts down whole tubule

Diuretic Bits

Loops preferred, but thiazides can be considered for patients with hypertension and mild fluid retention.

Furosemide: initial 20 to 40 mg qd/bid

Bumetanide: initial 0.5 to 1 mg qd/bid, max total daily dose 10 mg

Torsemide: initial 10 to 20 mg qd (gut edema)

Potassium Sparing Diuretics

Players: Spironolactone/Eplerenone (aldosterone antagonist)

“Weak diuretics”Help maintain KRarely used alone and are often combined with thiazide or loop diuretics to offset urinary potassium loss.

ACE inhibitor+loop+/- digoxin= improved CHF

“Entresto”, “Corlanor”

“CHF Alcoholics”

Corlanor

(Ivabradine)Entresto(Sacubitril/Valsartan)

Corlanor (Ivabradine))

HCN blocker in SA node (inhibits cardiac pacemaker current to decrease HR)

Lowers HR lowers CHF admissions

Use when maxed out BB, EF less than 35%

Will decrease HR 10-15

Needs to be in sinus to work

No affect on BP

Why do we care about HR in HF?

Entresto (Sacubitril/Valsartan)

Class II-IV HF

Breaks down neprilysin decreases BNP degredation -> valsartan antagonizes angiotensin receptors

EF under 40%

Hypotension, hyper K, renal failure, arthralgias can be seen

Jcarlquist.com