Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo...
Transcript of Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo...
![Page 1: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/1.jpg)
Jennifer Carlquist PA-C, ER CAQ
Community Hospital Of Monterey Peninsula, Central Coast Cardiology
![Page 2: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/2.jpg)
CHF Margarita
Cointreau(Spironolactone)
TEQUILA(Furosemide)
Margarita mix(BB)
LIME(ACEI)
Adjust to taste
![Page 3: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/3.jpg)
“I am worried about her 16o systolic”
![Page 4: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/4.jpg)
Objectives
AF treatment strategies
CHF tips and tricks
Common medication side effects
Cocktails the Kill!
![Page 5: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/5.jpg)
![Page 6: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/6.jpg)
![Page 7: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/7.jpg)
They are buying what you are selling.
![Page 8: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/8.jpg)
![Page 9: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/9.jpg)
![Page 10: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/10.jpg)
“Broccoli not beta blockers.”
No stress
Exercise
Meditate
Eat better
Say no
![Page 11: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/11.jpg)
“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
![Page 12: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/12.jpg)
![Page 13: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/13.jpg)
Case #1: 65 year old male attorney
![Page 14: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/14.jpg)
Strategy
Stable? Unstable? Acute? Chronic?
Rate vs Rhythm.
1. Diltiazem is the premier drug for rate control
(NO HF)
2. BB
3. Verapamil
![Page 15: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/15.jpg)
More on him….
He received Diltiazem 120 mg and converted.
He was discharged on Dronaderone and Apixiban
Labs: TSH, CBC, trop all normal
“This Dronaderone is too expensive. There HAS GOT TO be something else.”
![Page 16: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/16.jpg)
Things to rule out
Post op, coPd, Partying
Infiltrative myxoma
Rheumatic valvular disease
Acute MI
Thyroid
Toxins
Environmental
![Page 17: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/17.jpg)
Get you know your customer
Obese? Sleep apnea
Echo – LAE
Lexiscan – ischemic substrate
Bleeding issues?
HRTF?
Beer
![Page 18: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/18.jpg)
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
![Page 19: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/19.jpg)
Simple?
![Page 20: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/20.jpg)
Insert chart about this
![Page 21: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/21.jpg)
“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
![Page 22: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/22.jpg)
Pick your poison
Warfarin (Couamdin®) – (target 2-3)
Rivaroxaban, Apixiban, Dabigitran, Edoxaban(non-valvular)
ASA
![Page 23: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/23.jpg)
To bleed or not to bleed…
Factor 10 Warfarin (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
![Page 24: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/24.jpg)
AC
![Page 25: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/25.jpg)
AC Rate RhythmSotolol
Flecainide
Propafenone
Dronedarone
Amiodarone
![Page 26: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/26.jpg)
Calls back: “I read the side effects on amiodarone…”
“What else can I be on?”
Sometimes the choice is between bad and worse
![Page 27: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/27.jpg)
Final answer?
Ablate him!
![Page 28: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/28.jpg)
Omeprazole. The new villain?
Can make Clopidogrel 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 Warfarin (Coumadin®)
![Page 29: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/29.jpg)
![Page 30: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/30.jpg)
“My doctor said to ask you about my labs…”
CR 2.2 - _____________, ________________
TSH 10.1 - ________________
HA1c 7 - ___________
![Page 31: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/31.jpg)
What’s wrong with this patient?
LisinoprilAtorvastatin Carvedilol
Furosemide
Metformin
DM, HTN, CHF, Hyperlipidemia
![Page 32: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/32.jpg)
What is missing? What is the dx?
NTG
LisinoprilFurosemide
Dronededarone
Carvedilol
AC/AF
![Page 33: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/33.jpg)
What’s wrong with this picture?
ApixibanK ASA
Metoprolol
Carvedilol
Forgot to take off ASA!
![Page 34: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/34.jpg)
What are they at risk for?
FurosemideCelecoxib
ASA
Ginko
Apixiban
Too Many Blood Thinners
![Page 35: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/35.jpg)
What labs do they need?
Spironolactone Lisinopril K
Coumadin
Digoxin
Digoxin, INR, BMP
![Page 36: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/36.jpg)
What is wrong here?
NTGAsa
Sildenafil Lisinopril
Carvedilol
Nitrate + Viagra =
![Page 37: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/37.jpg)
![Page 38: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/38.jpg)
What medication should we take him off of?
![Page 39: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/39.jpg)
“I am getting all these bruises”
Ticagrelor, ASA, Atorvastatin, Carvedilol, Fish oil, Ginko
![Page 40: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/40.jpg)
“I ache”
Med list: Simvastatin Clopidogril Metoprolol
CoQ 10, qod, Pitavastatin (Livalo)
![Page 41: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/41.jpg)
“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”
![Page 42: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/42.jpg)
Don’t make it worse
NSAIDS
Glitazones
Diltiazem
Verapamil
Nifedipine
Sotolol
Dronaderone
![Page 43: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/43.jpg)
What medication should we take him off of?
76.1% with spironolactone vs 67.1% with eplerenone
![Page 44: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/44.jpg)
What is the treatment?
![Page 45: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/45.jpg)
“I have this cough…” ACEI vacation
Prilosec (Omeprazole)
Claritin (Loratadine)
Albuterol
![Page 46: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/46.jpg)
“I’m constipated.”
Verapamil, cholestyramine, Ranexa (Ranolazine)
![Page 47: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/47.jpg)
“I have this rash…”
Put on gloves.
Ok, “What?”
Take away all non essentials
![Page 48: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/48.jpg)
Killer Cocktails
![Page 49: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/49.jpg)
“Low Ball Spritz”
Imdur (Isosorbide)
Lasix (Furosemide)
Clonidine
Verapamil
![Page 50: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/50.jpg)
“Long Island Cutie (QT) “
Terfenadine, astemizole
Class I or III antiarrhythmic agent
Macrolide antibiotic
Grapefruit juice
![Page 51: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/51.jpg)
Kill My Kidneys Blast
ACE inhibitor
Diuretic
NSAID
“Kill Your Kidneys Cocktail”
![Page 52: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/52.jpg)
Insulin
Oral hypoglycemic agent
Beta blocker
“Cops Gonna Think You Drunk” Cocktail
![Page 53: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/53.jpg)
Digoxin
Amiodarone
Quinidine
Verapamil
Propafenone
“Mellow Yellow Cocktail”
![Page 54: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/54.jpg)
Aspirin
Clopidogrel
Coumadin
Ginkgo biloba
Vitamin E
“Bloody Mary”
![Page 55: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/55.jpg)
Digoxin
Beta blocker
(Diltiazem, Verapamil)
Amiodarone
“Slow Your Roll”
![Page 56: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/56.jpg)
![Page 57: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/57.jpg)
Case # 3
![Page 58: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/58.jpg)
The Cardiology “Happy Meal”
BB
ACEI
Statin
ASA/Antiplatelet
“FixIt
All”
![Page 59: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/59.jpg)
The Happy Meal: Not so happy?
“I feel dizzy now”
“I don’t want to be on all these medications”
Phase II Cardiac Rehab
![Page 60: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/60.jpg)
Aspirin Tidbits
25% reduction of MI/death
Drinkers and bleeders watch out
No benefit in primary prevention in women under 65
![Page 61: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/61.jpg)
BBA1
HZTZCCBACEI
![Page 62: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/62.jpg)
Nitrates
Induce coronary vasodilation
Dilate peripheral veins – reduce venous return –decreases o2 demand
![Page 63: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/63.jpg)
Refractory Angina
Ranolazine
Isosorbide
Amlodipine
![Page 64: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/64.jpg)
ASAACEIStatin
Car
ved
ilol
Clopidogrel $
Prasugrel $$
Ticagrelor $$
+If stent
BB
Met
op
rolo
l
Ro
uva
stat
in4
0
Ato
rvas
tati
n 8
0Si
mvi
stat
in
81
Ram
ipri
l
Lisi
no
pri
l
![Page 65: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/65.jpg)
“Where’s the bathroom?”
![Page 66: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/66.jpg)
I have to wear this??
![Page 67: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/67.jpg)
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.”
![Page 68: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/68.jpg)
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.
![Page 69: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/69.jpg)
![Page 70: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/70.jpg)
CHF Treatment Tree
3rd Line
Sacubitril/Valsartan Ivabradine
Second Line
Bidil (Isorsorbide/HCTZ) K sparing
First line
BB ACEI/ARB/Diuretics
![Page 71: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/71.jpg)
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
![Page 72: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/72.jpg)
Beta blocker Bits
Hypotension? Stagger or decrease diuretic dose
TAPER
Use Metoprolol Succinate (Toprol XL, Coreg)
No QT
![Page 73: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/73.jpg)
Break it on Dowwwwnn…
Thiazides-HCTZ
Loop diuretics-Lasix, Bumex, Torsemide
K Sparing- Aldactone
Metalazone 30 min before loop shuts down whole tubule
![Page 74: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/74.jpg)
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)
![Page 75: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/75.jpg)
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
![Page 76: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/76.jpg)
“Entresto”, “Corlanor”
![Page 77: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/77.jpg)
“CHF Alcoholics”
Corlanor
(Ivabradine)Entresto(Sacubitril/Valsartan)
![Page 78: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/78.jpg)
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?
![Page 79: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/79.jpg)
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
![Page 80: Jennifer Carlquist PA-C, ER CAQ Community Hospital Of Monterey … · 2013 –He was sent for echo “Presented in 2007 with burning in the throat, began several days prior to MI;](https://reader034.fdocuments.in/reader034/viewer/2022050323/5f7c2fcdf5c1fb07df5e6b12/html5/thumbnails/80.jpg)
Jcarlquist.com