Professional Documents
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Hypertension
BP = CO x PR
Why do we want to lower blood pressure? To decrease risk of complications from HTN (stroke,
heart attack, etc.)
**Anti-hypertensive drugs used in mild hypertension (140-159/90-99) have not been shown to
reduce mortality or morbidity! Low risk = low benefit
Drugs that increase BP:
-NSAIDs (vasoconstriction)
-Decongestants (vasoconstriction)
-Alcohol
-Estrogen
4 things to consider when picking an anti-hypertensive:
-Efficacy – similar efficacy
-ADR - see table
-Convenience – all once daily or BID dosing
-Cost – similar, perindopril is $$, thiazides are cheap
Class ADR’s Cautions Comments
Thiazides -dizziness -Hx gout, diabetes, Biochemical
-increased urination hypokalemia, abnormalities are
1st line in (generally short lived hyponatremia less with lower doses
uncomplicated HTN, 2-4 weeks)
isolated systolic -increasing sun-
HTN, elderly, black sensitivity -Elderly
-hypokalemia, -Black
hyponatremia,
increased lipids, *thiazides increase
increased uric acid, uric acid and glucose
increased glucose levels
-muscle cramps
ACEi -DRY COUGH -Hx bilateral renal
-increase K+, artery stenosis,
1st line in diabetes in increased serum NSAID use
kidney disease creatinine (if it goes
higher than 40%
increase, stop ACEi
ARB -increase K+, -Hx bilateral renal
increased serum artery stenosis,
creatinine (if it goes NSAID use
higher than 40%
increase, stop ACEi
BB -cold extremities Hx asthma, severe **Not generally used
-fatigue PAD, heart block, age for lone HTN.
-decrease HR over 60
-decrease exercise Only used as first line
tolerance if CHF or angina or as
-vivid dreams option for A. fib
-impotence
CCB -DHP: flushing ankle Hx heart failure (for
edema, headache non-DHP)
*1st line for ppl who
don’t want to do lab -non-DHP: flushing -Add-on therapy
tests ankle edema,
headache, decrease
HR, heart block,
worsened HF,
constipation
(verapamil,
diltiazem)
Monitoring:
Thiazides -Check Na+ and K+ levels
-In about 2 weeks
-For SE (dizziness)
ACEi -Check kidney function
-Check K+ and SCr levels
-Check these in a couple of weeks
-Warn about dry cough
ARB -Check kidney function
-Check K+ and SCr levels
-Check these in a couple of weeks
BB -No labs
-Monitor for hypotension, decreased HR,
fatigue, insomnia, dizziness
-Affects lipids and glucose
CCB -No labs
-Monitor for flushing, headache, edema
*For those without kidney disease, ACEi and ARB reduce likelihood of developing
microalbuminuria, but not doubling of SCr or ESRD.
*For those with diabetic kidney disease, ACEi and ARB both delay progression of nephropathy
to ESRD
Use of 1 antihypertensive drug at bedtime reduced CV events more than use of all drugs in
the morning in CKD.
1) Intro: “Hi, my name’s Sam, I’m the pharmacist on duty, did you want to have a seat and we
can discuss this further? Just so you know everything here is private and confidential.”
2) MAPPL
-Medical conditions and how long they’ve had them
-Allergies & Type of reaction
-Prescription Meds, Herbals, OTC/Vitamins
-Pregnant/Breastfeeding
-Lifestyle
3) SCHOLAR
-Symptoms
-Characteristics
-History
-Onset
-Location
-Aggravating factors
-Relieving factors
5) Other questions:
-Seen a Doctor, Diagnosed?
-Tried anything yet?
-Patient preferences ?
8) Monitoring:
-BP within target
-Side effects
9) Follow-up
-In a week for side effects
-Should start seeing a consistent effect within 1 month of BP meds
Healthy values:
TChol < 5.2 mmol/L
LDL < 3.4 mmol/L
HDL > 1.0 (men)
HDL > 1.3 (women)
TG < 1.7 mmol/L
Myositis:
-CK levels > 2-4x ULN but < 10 x ULN
-D/C Statin
Rhabdomyolysis:
-Severe muscle pain and weakness
-CK > 3-10x ULN and marked SCr
-D/C statin & hospitalization for supportive treatment
-May later re-challenge w low dose of different statin
1) Intro: “Hi, my name’s Sam, I’m the pharmacist on duty, did you want to have a seat and we
can discuss this further? Just so you know everything here is private and confidential.”
2) MAPPL
-Medical conditions and how long they’ve had them
-Allergies & Type of reaction
-Prescription Meds, Herbals (st. john’s wort), OTC/Vitamins
-Pregnant/Breastfeeding
-Lifestyle
3) SCHOLAR
-Symptoms
-Characteristics
-History
-Onset
-Location
-Aggravating factors
-Relieving factors
5) Other questions:
-Seen a Doctor?
-Tried anything yet?
-Patient preferences ?
Statin-induced myopathy questions:
-Bilateral or unilateral ? If bilateral, more likely statin-induced
-Brought on by exercise ?
-Worsened with exercise ?
-Has this happened before?
-When did it start ?
-Which muscles are affected? (starts in larger muscles)
-Anything that makes it better or worse ?
-Any change in urine color ? (if yes, sign of rhabdomyolysis)
8) Monitoring:
-LDL levels (below 2 mmol/L or 50% reduction)
-Monitor Lipid Levels, CK, and LFTs: Baseline, 6-8 weeks after initiation, then every 6 months
Side effects:
-Muscle pains (10%)
-GI upset
-sleep disturbances (less than 1%)
-dark urine, ab pain, yellowing of eyes or skin (indicative of liver damage) (less than 1%)
9) Follow-up
Hypoglycemia:
Early Signs: Sweating, hunger, shakiness, palpitations
-If untreated, may progress to: Blurred vision, confusion, slurred speech, convulsion, coma,
death
-Can be brought on by vigorous exercise, skipping meals, overdose of antihyperglycemics
Treatment: 15, 15, 15 Rule
-Take 15 grams of carbs
-Wait 15 minutes and test BG again
-If still under 4 mmol/L, ingest another 15g of carbs
-Make sure BG rises above 4 mmol/L
-If next meal is over an hour away, have a snack.
Diabetic Ketoacidosis:
-HYPERglycemia puts patients at risk for DKA.
-This condition develops when your body can’t produce enough insulin.
-Without insulin, your body starts to break down fat as a fuel bc it can’t break down sugar.
-When fat breaks down, ketones can be present in urine and blood.
-Treatment: Insulin
Type 1 Diabetes:
Initial dosing:
-0.5-1 units/kg per day
-50% basal
-50% rapid acting
For Hyperglycemia:
In most cases, insulin adjustments should approximate a 10% increase to the insulin (long-
acting) causing the effect. If it’s short or rapid acting, you can use the correlation factor.
For Hypoglycemia:
The insulin causing the low level should be typically decreased by 10%
-Used for hyperglycemia to determine how much insulin to increase in order to reduce BG
-Used for figuring out how much insulin to inject for extra carbs
Type 2 Diabetes:
Gestational Diabetes:
Exercise & Diabetes:
-SMBG should be done before, during & after exercise to determine how individual’s BG varies
in response to exercise
-Exercise should be avoided if BG is below target OR > 14 mmol/L and ketones in urine or
ketones > 0.5 mmol/L in blood
-Young children often need extra food bc activities are unplanned
-As activity becomes planned, adjusting insulin is preferred
-Hypoglycemia can be prevented by decreasing insulin dose or adding food
-Always carry a source of fast-acting glucose when exercising
-Hypoglycemia can occur during or after exercise (Up to 36 hours post exercise)
1) Intro: “Hi, my name’s Sam, I’m the pharmacist on duty, did you want to have a seat and we
can discuss this further? Just so you know everything here is private and confidential.”
2) MAPPL
-Medical conditions and how long they’ve had them – Ask if it’s Type 1 or 2, and ask about
kidney function
-Allergies & Type of reaction
-Prescription Meds, Herbals, OTC/Vitamins
-Pregnant/Breastfeeding
-Lifestyle
3) SCHOLAR
-Symptoms
-Characteristics
-History
-Onset
-Location
-Aggravating factors
-Relieving factors
Targets:
Age A1C (%) FPG (mmol/L) 2hr after meal Comments
(mmol/L)
<6 <8 6-10
6-12 <7.5 4-10
13-18 <7 4-7 5-10
(5-8 if A1C not
met)
Elderly <8.5 5-12
Pregnancy
5) Other questions:
For insulin adjustments for exercise:
-What type of exercise
-How long they will exercise for and how often
-You are going to be reducing insulin dose for exercise!
7) Non-pharms:
1) Weight management
-BMI 18.5-25
-Waist circumference (<100 cm males & <90 cm in females)
-Goal of 5-10% weight reduction
2) Physical exercise
-individualized according to patients’ current exercise status
-Goal 30-60 min of moderate activity/day
3) Counsel on hypoglycemia
4) Counsel on how to use insulin pens and storage
5) Counsel on ketone testing if they’re nausea, vomiting, ab pain or if FPG > 14 mmol/L
8) Monitoring:
-Monitor that BG is within targets (see above)
-Hypoglycemic symptoms
9) Follow-up
ACS – NSTEMI or STEMI (not angina)
3 types of ACS:
-UA – unstable plaque, plaque disruption and platelet aggregation
-NSTEMI – mostly platelets, partial occlusion
-STEMI – a lot of fibrin, complete occlusion
UA NSTEMI STEMI
Troponin - + +
ST elevation - - +
CK-MB:
-Detectable in serum within 3-6 hours after MI, peaks in 12-24 hours, stays elevated for 2-3
days
Troponin:
-Detectable in serum within 4-12 hours after MI onset, peaks in 12-48 hours, and stays elevated
for 7-10 days
*Biomarker assays should be done STAT on presentation, then repeated q4-6 hours for the first
12-24 hours, then periodically
*For diagnosis of STEMI or NSTEMI, at least 2 elevated CK-MB or 1 TnT exceeding the upper
reference range is needed (usually 2 successive blood samples)
Diagnosis of STEMI:
-signs and symptoms
-ECGs
-cardiac biomarkers of cell death (CK-MB and TnT)
Symptoms:
-central chest pain (typically radiating to shoulder, down the left arm, to the back or jaw)
-shortness of breath
-nausea or vomiting
-diaphoresis (sweating)
-CAN BE SILENT TYPE (NO SYMPTOMS)
Elderly, diabetic and women are less likely to have classic symptoms.
On average, women experience longer time interval than men between symptom onset and
Emergency Department (ED) Care.
Signs:
-syncope
-bradycardia (inferior infarction), tachycardia (increased sympathetic activity, decreased cardiac
output), other arrhythmias
-elevated or low BP
-diffuse rales, wheezing or respiratory distress usually indicate pulmonary edema and CHF
-jugular venous distention indicates right atrial hypertension, usually from RV infarction or
elevated LV filling pressure
Reperfusion:
-Time is muscle in STEMI
-Priority is to re-establish blood flow to the occluded artery as quickly as possible
-2 types of reperfusion strategies in STEMI:
1) Primary percutaneous coronary intervention (PCI)
2) Fibrinolytics
Choice of reperfusion strategies dependent on geographical location, availability of PCI-capable
facilities, onset of symptoms.
Primary PCI:
-Diagnostic catheter is placed and advanced through the femoral artery to the aorta and the
coronary arteries
-Contrast dye is injected once the catheter is in place. X-rays are taken to locate the exact
location of coronary occlusion.
-A balloon catheter (with or without a stent mounted) is advanced to the blockage site. Once at
the site, the balloon is inflated for a few seconds to open the blocked coronary artery.
-The stents are left in place to keep the coronary vessel open.
-Once the balloon has deflated, or when stent is in place, repeat x-rays are taken with contrast
dye to ensure optimal coronary blood flow has been achieved:
TIMI grade flow: adopted scoring system of 0-3 referring to the level of coronary blood
flow assessed during PCI
Want to achieve TIMI 3 flow (complete perfusion)
-Angioplasty without stenting is rarely used in the setting of ACS now
-PCI procedures will almost always involve a bare metal stent (BMS) or drug eluting stent (DES)
-Drug eluting stent have Antiproliferative drugs coated on the stent scaffold, which is released
slowly over time to prevent restenosis.
-DES have been shown to reduce restenosis rates compared to BMS and is commonly used in
NSTEMI/STEMI patients undergoing PCI
-Patients who received DES will require dual-antiplatelet therapy for a minimum of 1 year
Fibrinolytics:
-Benefit of fibrinolytics is directly related to the time from MI onset
-Greatest mortality reduction is achieved when fibrinolytics is given within 0-2 hours.
-Target 30 mins within arrival
**Fibrinolytics not administered to NSTEMI/UA patients bc there is not much fibrin, mostly
made up of platelets
-Tenecteplase (TNK) is the fibrinolytic of choice
-5 second single bolus
-Weight-tired dosing
-Major concern of fibrinolytic therapy is bleeding complications
-CI’s to fibrinolytic use must be evaluated to minimize major bleeding risk
Antithrombotics:
-Antithrombotics (antiplatelets, anticoagulants) are the cornerstone therapy in STEMI
management
Maintenance dose:
-ASA 81-162 mg PO daily
PLUS
-P2Y12 receptor inhibitor at maintenance dose should be continued
-Clopidogrel 75mg daily
-Prasugrel 10mg daily
-Ticagrelor 90mg BID
Heparin:
-Use in patients > 149 kg (little evidence to support LMWH in these patients)
-For those with renal impariemtn, CrCl < 30
-Use UFH 60 units/kg IV load, followed by 12 units/kg/hr IV infusion
-Target aPTT 49-65 seconds
Antiplatelets in STEMI:
-ASA 162-325 mg PO x 1 for all STEMI patients (unless CI)
-ASA + Clopidogrel was the conventional DAPT regimen for patients undergoing PCI in ACS
-New P2Y12 antagonists emerged 5 years ago (prasugrel and ticagrelor)
-Both drugs are more favorable than clopidogrel in terms of pharmacokinetics and
pharmacodynamics properties
-Clinical trials suggest better efficacy profile with ASA+prasugrel or ASA+ticagrelor compared to
ASA+clopidogrel in patients with STMEI undergoing primary PCI
-Prasugrel should not be used in patients with history of stroke or TIA due to higher rates of
major bleeding in these population
Triple therapy (DAPT + Warfarin) may be indicated in STEMI patients with low ejection fraction
or has concurrent AF
STEMI Complications:
1) Heart Failure
-LV myocardium may be ischemic, stunned, hibernating or irrevocably injured after MI
-ECG is warranted to assess LVEF (want it >40%)
-Medical therapy with diuretics, vasodilators and inotropic may be required based on
symptoms and echo results
2) Cardiogenic shock
-Decreased CO & evidence of tissue hypoxia in presence of adequate intravascular
volume
-Often due to extensive LV infarction
-Can be due to systolic, diastolic, or valvular dysfunction
3) Arrhythmias
-may arise post MI due to ischemia and severe HF
-ventricular arrhythmias more probable in the peri-infarction period; leading cause of
sudden cardiac death in the setting of STEMI
-implantable cardioverter-defibrillator (ICD) is indicated before discharge in patietns
who develop sustained VT/VF more than 48 hours after STEMI
-Atrial Fibrillation or other conduction defects also possible
4) Pericarditis
-Uncommon and usually presents within 72 hours post MI
-Symptoms usually resolve within 3-4 days
-Tx with ASA 650 mg po QID or NSAIDs
Risk Stratification:
TIMI Risk Score All-cause mortality, new or recurrent MI, or
severe recurrent ischemia requiring urgent
revascularization through 14 d, %
0-1 4.7
2 8.3
3 13.2
4 19.9
5 25.2
6-7 40.9
1 point is given for each of the following: >65, >3 risk factors for CAD (ex. HTN, DM, smoker),
prior coronary stenosis > 50%, ST deviation on ECG, >2 anginal events in prior 24h, use of
aspirin in prior 7 days, elevated cardiac biomarkers
3) CABG
-High risk patients with multivessel disease may be referred for CABG (hold DAPT 5-7 `
days prior to surgery if possible)
Antiplatelets:
Loading Dose Maintenance Dose
ASA 160-325 mg STAT (chewed) 80-325 mg daily
Ticagrelor 180 mg 90mg BID
Clopidogrel 150-300 mg 75 mg
Prasugrel 60 mg 10 mg
DAPT:
-UA/NSTEMI patients who underwent early invasive strategy with PCI should receive DAPT as
outlined for STEMI patients
-For patients with ischemia-guided strategy (medical management), current guidelines
recommend DAPT with ASA plus ticagrelor or clopidogrel
-DAPT x 1 year for all ACS patients
LMWH – standard
-Enoxaparin 1mg/kg SC q12h (max 100mg) until PCI or hospital discharge shown to decrease
risk of death, MI and stroke
-Advantage: easier to give, no monitoring, lower incidence of HIT (heparin induced
thrombocytopenia)
-Disadvantage: long acting, renal elimination
Fondaparinux
-Indirect-acting factor Xa inhibitor
-2.5mg SC once daily (until PCI or hospital discharge)
-Non-inferior to enoxaparin
-Lower rate of major bleeding
-Increased risk of thrombus formation post-PCI
-Give UFH bolus during PCI
-May be preferable in patients at higher risk of bleeding
1) Intro: “Hi, my name’s Sam, I’m the pharmacist on duty, did you want to have a seat and we
can discuss this further? Just so you know everything here is private and confidential.”
2) MAPPL
-Medical conditions and how long they’ve had them
-Allergies & Type of reaction
-Prescription Meds, Herbals, OTC/Vitamins
-Pregnant/Breastfeeding
-Lifestyle
3) SCHOLAR
-Symptoms
-Characteristics
-History
-Onset
-Location
-Aggravating factors
-Relieving factors
5) Other questions:
-Is this your first heart attack?
7) Non-pharms:
1) Weight management
-BMI 18.5-25
-Waist circumference (<100 cm males & <90 cm in females)
-Goal of 5-10% weight reduction
2) Physical exercise
-individualized according to patients’ current exercise status
-Goal 30-60 min of moderate activity
3) ICD – Implantable Cardioverter/defibrillator assessment for patients with ongoing LV
dysfunction
8) Monitoring:
1) Efficacy
-Signs and symptoms of ongoing chest pain, ECG changes, serial monitoring of
biomarkers
-Stent thrombosis
-Complications: arrhythmias, HF, pericarditis
2) Safety
-Major and minor bleeding complications, Hbg, platelets
-Clinical signs of bleeding including bloody stools, melena, hematuria, hematemesis,
bruising, and oozing from arterial or venous puncture sites
9) Follow-up