Updates in the Management of Cardiovascular Diseases · ACEI Hyperkalemia, ↑SCr, cough, angioedema, hypotension ... What’s New in 2013 Guidelines? Focus on reduction of cardiovascular

Anna Nogid, PharmD, BCPS

Associate Professor of Pharmacy Practice

LIU Pharmacy

Updates in the Management of

Cardiovascular Diseases

Objectives

Discuss updates in treatment recommendations for

patients with cardiovascular disorders

Develop a treatment plan for a patient with

cardiovascular disorders

Provide patient education with regard to disease

state and drug therapy for patients with CV

disorders

Go A S et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Prevalence of CV Disease in Adults

Go A S et al. Circulation. 2014;129:e28-e292Copyright © American Heart Association, Inc. All rights reserved.

Deaths and Hospital Discharges

Attributable to CV Disease

Deaths Hospital Discharges

Go A S et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Leading Diagnoses for Direct Health

Expenditures

Updates in CV Disease Timeline

June 2013 Heart failure

October 2013 Secondary prevention of atherosclerotic disease

November 2013

High blood pressure

High cholesterol

ASCVD risk assessment

February 2014 JNC 8

March 2014 Atrial fibrillation

May 2014 secondary stroke prevention

Managing High Blood Pressure

Go A S et al. Circulation. 2014;129:e28-e292Copyright © American Heart Association, Inc. All rights reserved.

Awareness, Treatment, and Control of

High Blood Pressure

What’s New in JNC 8?

No definition for hypertension

Increased SBP threshold for drug treatment initiation in patients > 60 years of age

Similar treatment goals defined for most hypertensive patients

Emphasis on lifestyle modifications

Recommended selection among 4 specific mediation classes

Specific medication classes recommended for racial, diabetic, and CKD patient groups

Treatment goals

General population

Age 60 years or older: < 150mmHg/90 mmHg

Age < 60 years: < 140mmHg/ 90 mmHg

CKD: < 140 mmHg/90 mmHg

Diabetes: < 140mmHg/90mmHg

Lifestyle Modifications

Modification ~ SBP

Weight reduction

Attain & maintain BMI < 25 kg/m2

5-20 mm Hg/10kg

Adopt DASH eating plan

Fruits/vegetables

Low-fat dairy products

Reduce saturated fat & cholesterol

8-14 mm Hg

Physical activity

> 30 min/day most days of the week

4-9 mm Hg

Dietary sodium restriction

< 2.4g/day (< 1.5 g/day)

2-8 mmHg

Moderate alcohol consumption

< 2 drinks/d (men); < 1 drink/d (women)

2-4 mm Hg

Go AS, et al. Hypertension 2014;63;878-885

Approach to Treatment: JNC 8

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

Approach to Treatment: JNC 8 (cont)

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

Approach to dosing

Initiate with 1 or 2 agents from recommended drug

class

If goal BP is not reached within 1 month, increase

dose or add another agent

Continue increasing the dose until goal BP is

attained

Consider alternative antihypertensive agents if

needed

Avoid ACEI + ARB whenever possible

Adverse Effects of Commonly Utilized

Blood-Pressure Lowering Agents

Class Adverse effects

DHP CCB Peripheral edema, flushing, reflex tachycardia

Non-DHP CCB Constipation (verapamil), bradycardia

Diuretics Electrolyte disturbances, hyperuricemia, hyperglycemia,

hyperlipidemia

ACEI Hyperkalemia, ↑ SCr, cough, angioedema, hypotension

ARB Hyperkalemia, ↑ SCr, angioedema, hypotension

Patient Education

Blood pressure monitoring

Every 2-4 weeks until controlled, then every 3-6 months

Self-monitoring for select patients

Importance of adherence

Lifestyle modifications

Summary

Higher BP goals for most patients

Beta blockers are no longer preferred initial agents

in the general population

Main objective is to attain and maintain goal BP

Combine drug therapy with lifestyle modifications

Patient Profile

18

Patient Name: BE Address: 75 Dekalb Ave, Brooklyn, NY 11201

Age: 62 Height: 5’8” Weight: 251 lb Sex: F Phone: (800) 249-4957

Medication Profile

Date Rx No. Physician Drug/Strength Qty Sig Refills

5/30 112555 Davis Carvedilol 25mg 60 1 bid 2

5/30 111002 Davis Furosemide 40mg 30 1 daily 2

5/30 111003 Davis Fosinopril 40mg 30 1 daily 1

5/30 111004 Wonder Glipizide XL 10mg 30 1 daily 4

5/30 111005 George Tramadol 50mg 60 1 bid 1

4/27 111001 Davis Carvedilol 12.5mg 60 1 bid 2





Patient Case: Additional Information

Ethnicity: Caucasian

PMHx: DM x 15 years; CAD x 10 years (MI in 1999 and 2001), heart failure, and osteoarthritis

Social Hx: tobacco use

OTC: aspirin 81mg daily, ibuprofen PRN

BP: 144mmHg/85mmHg

Patient Case

According to JNC 8, what is the BP target for this

patient?

< 140/90 mmHg

What recommendations for therapy, if any, would

you make in this patient?

Provide patient education with regard to

hypertension and drug therapy for this patient

Managing Elevated Cholesterol

What’s New in 2013 Guidelines?

Focus on reduction of cardiovascular risk: 4 statin

benefit groups

A new perspective on treatment goals

Global risk assessment for primary prevention

Safety recommendations

4 Defined Statin Benefit Groups

Clinical ASCVD

LDL >190 mg/dL

Age 40-75 years + diabetes + LDL 70-189 mg/dL

Age 40-75 + ASCVD 10 year risk of > 7.5%

ASCVD = ACS, history of MI, stable or unstable angina, coronary or other arterial

revascularization, stroke, TIA, or peripheral arterial disease of atherosclerotic origin.

ASCVD Risk Assessment

Use Pooled Cohort Risk Assessment Equations in non-Hispanic patients between age of 40 – 79 years

Risk factors considered

Sex

Age

Race

Total Cholesterol

HDL

Systolic BP

Treated for HBP

Diabetes

Smoker

Cholesterol Targets

High-Intensity (LDL-C

reduction > 50%)

Moderate-Intensity (LDL-C

reduction 30 – 50%)

• Age < 75 years + clinical

ASCVD

• Age 40 – 75years +

diabetes + ASCVD risk >

7.5%

• LDL-C > 190 mg/dL

• ASCVD > 7.5%

• Age > 75 years + clinical

ASCVD

• Age 40 – 75 years +

diabetes and ASCVD risk

< 7.5%

Intensity of Statin Therapy

High-intensity Moderate-intensity Low-intensity

Daily dose lowers LDL-C on

average, by ~ > 50%


average, by 30 - 50%


average, by < 30%

Atorvastatin 40 – 80mg

Rosuvastatin 20 - 40mg

Atorvastatin 10 – 20mg

Rosuvastatin 5 - 10mg

Simvastatin 20 – 40mg

Pravastatin 40 – 80mg

Lovastatin 40mg

Fluvastatin 40mg BID

Pitavastatin 2 – 4mg

Simvastatin 10mg

Pravastatin 10 – 20mg

Lovastatin 20mg

Fluvastatin 20 – 40mg

Pitavastatin 1mg

Selection of statin and dose should be based on patient characteristics, level

of ASCVD risk, patient preference, and potential for adverse drug reactions

and drug interactions

Comparison of Statins

Variable Rosuva- Atorva- Simva

-

Prava- Lova- Fluva- Pitava-

Half-life

(hrs)

13-20 7-14 2 1.8 5 1.2 12

Protein

Binding (%)

88 >90 95 50 >95 >90 99

Active

Metab

Yes Yes Yes No Yes No No

Solubility Hydro- Lipo- Lipo- Hydro- Lipo- Lipo- Lipo-

CYP 450

isoenzyme

2C9

2C19

3A4 3A4 --- 3A4 2C9 ---

Adapted by Rosenson RS. The Am J of Med. 2004;116:408-416.

Statin Safety Concerns

Hepatotoxicity

Muscle adverse effects

Myalgias = muscle aches, soareness, stiffness,

tenderness, cramps

Myopathy = muscle weakness

Myositis = muscle inflammation; pain + CK elevation

Myonecrosis +/- myoglobinuria or AKI

Increased blood sugar?

Cognitive adverse effects?

Rosenson RS, et. al. J Clin Lipid. 2014;8:s58-71

Monitoring of Statin Therapy

Liver enzymes at baseline and as clinically

indicated thereafter

Routine monitoring of CK and hepatic transaminase

levels is not recommended

Nonstatin Therapy

Drug Class Effects (% change) Safety

Niacin LDL (15-30), HDL (15-35)

TG (20-50)

Flushing, ↑ BG, ↑ UA,

GI upset, hepatotoxicity

Fibric Acids LDL (5-20), HDL (10-35)

TG (20-50)

Dyspepsia, gallstones,

myopathy

Bile Acid

sequestrants

LDL (15 – 30%), HDL (3-

5%), no significant effect on

TG

GI distress, many DDI

Cholesterol

absorption inhibitor

LDL( 14-18), HDL (1-3)

TG (2)

Headache, GI distress

Omega-3-acid ethyl

esters

LDL, HDL,

TG (17 - 48)

GI distress

Summary

No longer use targets for cholesterol levels

Identify patients at risk

Know the 4 high risk groups

Use medications proven to reduce risk, ie statins

Encourage healthy lifestyle

Understand that questions and concerns remain

Patient Profile

32



Medication Profile

Date Rx No. Physician Drug/Strength Qty Sig Refills

5/30 112555 Davis Carvedilol 25mg 60 1 bid 2





4/27 111001 Davis Carvedilol 12.5mg 60 1 bid 2





Patient Case: Additional Information

Ethnicity: Caucasian

PMHx: DM x 20 years; CAD x 15 years (MI in 1999 and 2001), heart failure, and osteoarthritis

Social Hx: tobacco use

OTC: aspirin 81mg daily, ibuprofen PRN

BP: 144mmHg/85mmHg

Total cholesterol = 195 mg/dL

LDL = 120 mg/dL

HDL = 45 mg/dL

TG = 150 mg/dL

Patient Case

According to AHA 2013 Document, would this

patient benefit from statin therapy? If yes,

recommend an appropriate lipid lowering regimen

for this patient.

Yes. Patient falls into a statin benefit group

High-intensity statin: atorvastatin 40 – 80mg daily or

rosuvastatin 20 – 40mg daily

Provide patient education with regard to high

cholesterol and drug therapy for this patient

Heart Failure Guidelines Update

What’s new?

Emphasis placed on education and transitions of

care

Broadened indication for the use of aldosterone

antagonist

Routine use of ACEI + ARB + ALDO ANT is harmful

Treatment Goals

Identify and control risk factors for HF

Improve quality of life

Relieve/reduce signs and symptoms

Prevent/minimize hospitalizations

Slow progression of the disease process

Prolong survival

Definition of Heart Failure

Classification Ejection

Fraction

Description

Heart Failure with Reduced

Ejection Fraction (HFrEF)

≤40% Also referred to as systolic

HF

Heart Failure with Preserved

Ejection Fraction (HFpEF)

≥50% Also referred to as diastolic

HF.

a. HFpEF, Borderline 41% -

49%

b. HFpEF, Improved >40% A subset of patients with

HFpEF previously had HFrEF

with improvement or

recovery in EF.

Classification of Heart Failure

ACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without

structural heart disease or

symptoms of HF.

B Structural heart disease but

without signs or symptoms of

HF.

I No limitation of physical activity. Ordinary physical

activity does not cause symptoms of HF.

C Structural heart disease with

prior or current symptoms of HF.

I No limitation of physical activity. Ordinary physical

activity does not cause symptoms of HF.

II Slight limitation of physical activity. Comfortable at rest,

but ordinary physical activity results in symptoms of HF.

III Marked limitation of physical activity. Comfortable at

rest, but less than ordinary activity causes symptoms of

HF.

IV Unable to carry on any physical activity without

symptoms of HF, or symptoms of HF at rest.D Refractory HF requiring

specialized interventions.

Non-Pharmacologic Therapy40

Discontinue drugs that may aggravate HF

Physical activity

Stable patients only

20 – 45 minutes, 3 – 5 times per week

Smoking cessation (if applicable)

Vaccinations

Annual influenza

Pneumococcal

Restrict dietary sodium

Restrict fluid (< 2L/day)

Avoid salt substitutes (ex. Nu-salt, Also Salt)

Drugs that May Precipitate or Exacerbate

Heart Failure41

Antiarrhythmic agents: except amiodarone (Cordarone, Pacerone) and dofetilide (Tikosyn)

Calcium channel blockers: verapamil (Calan SR, Isoptin SR, Covera HS, Verelan), diltiazem (Cardizem)

Beta blockers

Nonsteroidal anti-inflammatory drugs

Rosiglitazone (Avandia)/Pioglitazone (Actos)

Glucocorticoids

Androgens and estrogens

Chemotherapeutic agents: doxorubicin, daumomycin, cyclophosphamide

Amphetamines

Treatment of Stage A HF42

Identify and modify risk factors

HTN

Dyslipidemia

DM

Smoking cessation

Limit alcohol consumption and illicit drug use

Consider ACEI or ARB for patients with multiple risk factors

Treatment of Stage B HF43

Therapy from stage A

ACEI and BB for:

Recent MI

Reduced EF

ARB (if intolerant to ACEI)

Treatment of Stage C HFrEF44

Therapy for stage A and B

Diuretics and salt restriction (if fluid retention)

ACEI

BB

ARB (if intolerant to ACEI)

Avoid drugs known to exacerbate HF

Consider aldosterone antagonist, digoxin, and/or

hydralazine/isosrbide dinitrate combination

Loop Diuretics

Furosemide

(Lasix)

Bumetanide

(Bumex)

Torsemide

(Demadex)

Usual daily dose 20 – 160 mg 0.5 – 4 mg 10 – 80 mg

Ceiling dose 160 mg 2 mg 40 mg

Bioavailability 10– 100% 80- 90% 80- 100%

Duration of effect 6 – 8 hrs 4 – 6 hrs 12 – 16 hrs

Indicated for control of fluid overload

Initiate at low dose

Target weight decrease of 0.5 to 1 kg/day (until symptoms resolve)

The appropriate chronic dose is that which maintains the patient at a stable dry weight without symptoms of dyspnea

45

Beta-Blockers46

Recommended for all stable patients with no or

minimal signs of fluid overload and reduced LVEF

Benefits:

Decrease mortality and slow disease progression

Decrease hospitalizations

Improvement in functional class

May lead to symptomatic worsening or

decompensation

Use in combination with diuretics and ACEI

Beta-Blockers

Drug Initial Dose Target Dose

Bisoprolol* 1.25mg daily 10mg daily

Carvedilol 3.125mg BID 25 - 50 mg BID

Carvedilol CR 10mg daily 80mg daily

Metoprolol succinate CR/XL 12.5-25mg daily 200 mg daily

47

Initiate low, double the dose every 2 weeks or as tolerated

Patient should be clinically stable and euvolemic at time of initiation

May take 2-3 months to see improvement in clinical response

* Not FDA approved

Aldosterone Antagonist48

Agents

Spironolactone (Aldactone): 12.5 – 25mg daily

Eplerenone (Inspra): 25 - 50mg daily

Recommended for patients with NYHA Class III – IV and LVEF <35% or NYHA Class II + LVEF < 35% + history of CV hospitalization or elevated natriuretic peptide

Adverse effects: hyperkalemia, gynecomastia

Avoid concomitant use of NSAIDs, COX-2 inhibitors, high doses of ACEI or ARBs, potassium supplements, strong CYP3A4 inhibitors (eplerenone)

DO NOT initiate if:

GFR < 30 ml/min or SCr > 2.0 mg/dL in women or SCr> 2.5 mg/dL in men

Potassium > 5 mEq/L

Triple therapy with ACEI + ARB + spironolactone is NOT routinely recommended

Isosorbide Dinitrate/Hydralazine49

Shown to decrease mortality, hospitalization for HF, and quality of life in patients with symptomatic HF and decreased EF

Should be considered: As an alternative to ACEI

In addition to standard therapy in African American patients with symptomatic HF

Dose: Hydralazine 25 – 75 mg QID + Isosorbide dinitrate 20 – 40mg QID

Bidil (isosorbide dinitrate 20mg/Hydralazine 37.5mg): 1-2 tablets TID

Adverse effects: Common: headache, dizziness, nausea, hypotension

Severe: leukopenia, hepatotoxicity, lupus

Digoxin50

Consider adding if:

Stage C or D + reduced EF + persistent symptoms of HF despite therapy with ACEI, BB, and diuretic

Chronic atrial fibrillation

Dosing considerations Decrease dose in elderly and patients with decreased renal

function

Target serum concentrations 0.5 – 1 ng/mL

Adverse effects: GI complaints

Visual disturbances

Cardiac arrhythmias

Treatment of Stage C HFpEF51

Control underlying etiology of HF

Use diuretics for pulmonary congestion and

peripheral edema

May use BB, ACEI, ARBs, or CCB to control symptoms

Role for digoxin is not well established

Aldosterone antagonists have not been studied in

these patients

Fluid and sodium restriction

Treatment of Stage D HF

Control fluid retention

Fluid restriction

Loop diuretic +/- thiazide

like diuretic

IV inotropic agents

Non-pharmacologic

measures

Consider end-of life care

Cardiac transplant

Left-ventricular assist devices

Intra-aortic balloon pump

52

Overview of Stages, Phenotypes and

Treatment of HF

STAGE AAt high risk for HF but

without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or

symptoms of HF

THERAPY

Goals

· Control symptoms

· Improve HRQOL

· Prevent hospitalization

· Prevent mortality

Strategies

· Identification of comorbidities

Treatment

· Diuresis to relieve symptoms

of congestion

· Follow guideline driven

indications for comorbidities,

e.g., HTN, AF, CAD, DM

· Revascularization or valvular

surgery as appropriate

STAGE CStructural heart disease

with prior or current

symptoms of HF

THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality

Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists

Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin

In selected patients· CRT· ICD· Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPY

Goals

· Prevent HF symptoms

· Prevent further cardiac

remodeling

Drugs

· ACEI or ARB as

appropriate

· Beta blockers as

appropriate

In selected patients

· ICD

· Revascularization or

valvular surgery as

appropriate

e.g., Patients with:

· Known structural heart disease and

· HF signs and symptoms

HFpEF HFrEF

THERAPY

Goals

· Heart healthy lifestyle

· Prevent vascular,

coronary disease

· Prevent LV structural

abnormalities

Drugs

· ACEI or ARB in

appropriate patients for

vascular disease or DM

· Statins as appropriate

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure


· Marked HF symptoms at

rest

· Recurrent hospitalizations

despite GDMT


· Previous MI

· LV remodeling including

LVH and low EF

· Asymptomatic valvular

disease


· HTN

· Atherosclerotic disease

· DM

· Obesity

· Metabolic syndrome

or

Patients

· Using cardiotoxins

· With family history of

cardiomyopathy

Development of

symptoms of HFStructural heart

disease

Patient Education

Symptom management

Daily weight

Sodium restriction

Medication adherence

Physical activity

Modification of risk factors

Follow-up appointments

Patient Case (Continued)

Three months later BE presents to your pharmacy

with the following prescriptions from Dr. Wonder:

Diovan 160mg, take 1 tablet PO daily, #30

Spironolactone 25mg, take 1 tablet PO daily, #30

55

Patient Profile

56



Medication Profile

Rx No. Physician Drug/Strength Qty Sig Refills

112555 Davis Atorvastatin 80mg 30 1 daily 3

112555 Davis Carvedilol 25mg 60 1 bid 2

111002 Davis Furosemide 40mg 30 1 daily 2

111003 Davis Fosinopril 40mg 30 1 daily 1

111004 Wonder Glipizide XL 10mg 30 1 daily 4

111005 George Tramadol 50mg 60 1 bid 1

111001 Davis Carvedilol 12.5mg 60 1 bid 2

111002 Davis Furosemide 40mg 60 1 daily 2

111003 Davis Fosinopril 40mg 30 1 daily 2

111004 Wonder Glipizide XL 10mg 30 1 daily 5

111005 George Tramadol 50mg 60 1 bid 2

Patient Case

What concerns, if any, do you have regarding the

new prescriptions for this patient?

Provide patient education with regard to heart

failure and drug therapy for this patient

58

Key Points: Heart Failure

Avoid factors known to exacerbate chronic HF

Most patients with heart failure should be treated with an

ACEI, BB, diuretic

In patients with reduced EF and symptomatic HF despite

standard therapy, consider: Isosorbide dinitrate/hydralazine (especially in African Americans)

Aldosterone antagonist

Digoxin

ARBs

For patients with preserved EF may use diuretics, BB, ACEI, ARBs, or

CCBs

Combine pharmacologic + non-pharmacologic therapy

58

Atrial Fibrillation Guidelines Update

What’s new?

Emphasis on shared decision making and

individualization of therapy

Increased emphasis on non-pharmacologic care

Encourage the use of CHA2DS2-VASc vs. CHADS2

score in stroke risk assessment

Recommendations for use of dabigatran,

rivaroxaban, and apixaban added

Diminished role for aspirin use

Treatment Goals

Relieve symptoms

Prevent thromboembolic complications

Control ventricular rate

Target resting HR < 80bpm

May target resting HR < 110bmp if patient remains

asymptomatic

Restore and/or maintain normal sinus rhythm (NSR)

61

Stroke Prevention in Atrial Fibrillation

Patients with AF are at risk of cardioembolic stroke

Risk of stroke increases with age and in presence of additional risk factors

Consider antithrombotic therapy regardless of whether or not sinus rhythm is maintained

Risk of thromboembolism AF > 48 hours = 15% rate of atrial thrombus

AF > 72 hours = 30 % rate of atrial thrombus

Thrombi present + cardioversion = 91% stroke rate

Need for long-term antithrombotic therapy depends on assessment of risk of stroke

62

CHA2DS2 - VASc Score

Cardiac failure

Hypertension

A2ge (>75 years)

Diabetes

S2:stroke

Vascular disease*

Age 65 - 74

Sex category: female

Lip GY, et. al. Chest 2010;137(2):263-272.

CHA2DS2VA

Sc Score

Stroke Rate

0 0

1 1.3%

2 2.2%

3 3.2%

4 4%

5 6.7%

6 9.8%

*Vascular disease = CAD, myocardial infarction, peripherl artery disease, complex aortic plaque

Stroke Prevention: Summary

Stroke Risk Category Recommended Therapy

Low

(CHA2DS2-VASc score= 0)

No therapy

Intermediate

(CHA2DS2-VASc score= 1)

Aspirin 81-325mg daily or

warfarin (target INR 2-3)

High

(CHA2DS2-VASc score > 2)

1st line: anticoagulant

2nd line: aspirin + clopidogrel

64

Stroke.ahajournals.org/content/early/2012/08/02SRT.0b01318266722

Comparison of Oral Anticoagulants

Warfarin

(Coumadin)

Dabigatran

(Pradaxa)

Rivaroxaban

(Xarelto)

Apixaban

(Eliquis)

MOA VKA DTI FXa inhibitor FXa inhibitor

Dose Variable 150mg BID 20mg QD WF 5mg BID

P-gp substrate No Yes Yes Yes

Hepatic

elimination

CYP2C9

(major),

CYP3A4,

CYP2C19,ot

hers

Glucuroni-

dation

CYP3A4 CYP3A4

Dosage adjust

in renal insuf?

No Yes Yes Yes

Half-life 20-60 hrs 12-17 hrs 5-9 hrs ~ 12 hrs

65

Comparison of Oral Anticoagulants

Warfarin Dabigatran

(Pradaxa)

Rivaroxaban

(Xarelto)

Apixaban

(Eliquis)

DDI CYP2C9 and

3A4

inhibitors;

antibiotics;

vitamin K

P-gp inducers

and inhibitors;

PPIs, H2

blockers

CYP3A4

and/or P-gp

inhibitors

CYP3A4

and/or P-gp

inhibitors

Adverse effects Bleeding,

alopecia,

skin necrosis,

purple toe

syndrome

Bleeding

Dyspepsia

Bleeding Bleeding

Monitoring INR --- --- ---

Antidote Vitamin K --- --- ---

66

Patient Education: Anticoagulants

Warfarin

Take warfarin at the same time each day

Avoid drugs or alcohol that can interact with warfarin

Keep a diet containing vitamin K consistent

Dabigatran Swallow capsules whole. DO NOT break, chew, or empty pellets from

the capsule Dispense in the original container. Once open, use within 4 months May cause indigestion, stomach upset

Do not take newer agent with grapefruit or grapefruit juice

Do not D/C abruptly

Notify a healthcare provider if any signs of bleeding, clotting, or stroke occur and of any upcoming surgery or procedure

Rate Control: Decision Algorithm68

Paroxysmal or permanent

A. Fib

No HF, LVEF > 40% LVEF < 40%

B-blocker, digoxin, amiodaroneB-Blocker, CCB

Assess HR control

HR > 110 bpm: increase dose of initial drug

or add second drug

Choosing an Anti-arrhythmic Agent to

Maintain Sinus Rhythm69

Maintenance of sinus rhythm

No Stuctural

heart disease

Dronedarone*

Flecainide

Propafenone

Sotalol

Dofetilide

Coronary artery

disease

Heart Failure

LVH

Amiodarone

Dofetilide

Dronedarone*

Sotalol

Amiodarone

NYHA Class III/IV

Amiodarone

Dofetilide

*paroxysmal or persistent AF only

Safety Considerations in Maintenance

of Sinus Rhythm

Drug Caution/Exclude Pharmacokinetics

Flecainide HF, CAD Metabolized by CYP2D6

Renally excreted

Propafenone HF, CAD, liver

disease, asthma

Metabolized by CYP2D6

Inhibits P-glycoprotein and

CYP2C9

Safety Considerations in Maintenance

of Sinus Rhythm

Drug Caution/Exclude Pharmacokinetics

Amiodarone Lung disease, may prolong QT Inhibits many CYP enzymes

and P-glycoprotein

Dofetilide Prolonged QT, renal disease,

hypokalemia, diuretic therapy

Metabolized by CYP3A4

DDI with inhibitors of

tubular secretion

Dronedarone Bradycardia, HF, liver disease,

may prolong QT

Metabolized by CYP3A4

Inhibits CYP3A4, CYP2D6,

P-glycoprotein

Sotalol Prolonged QT, renal disease,

hypokalemia, diuretic therapy,

HF

Patient Case

Three months later BE is diagnosed with atrial

fibrillation.

PMHx: DM x 20 years; CAD x 15 years (MI in 1999

and 2001), heart failure, and osteoarthritis

Medications: spironolactone, atorvastatin,

valsartan, carvedilol, tramadol, furosemide, and

glipizide

BP = 134/78 mmHg, HR = 78 bpm

Patient Case

What is DA’s CHA2DS2VASc Score?

Recommend an antithrombotic agent for this patient

to prevent thromboembolic complications.

Provide patient education with regard to

antithrombotic therapy for this patient

CHA2DS2 - VASc Score

Cardiac failure

Hypertension

A2ge (>75 years)

Diabetes

S2:stroke

Vascular disease*

Age 65 - 74

Sex category: female

Lip GY, et. al. Chest 2010;137(2):263-272.

CHA2DS2VA

Sc Score

Stroke Rate

0 0

1 1.3%

2 2.2%

3 3.2%

4 4%

5 6.7%

6 9.8%

*Vascular disease = CAD, myocardial infarction, peripherl artery disease, complex aortic plaque

Summary

Treatment options to control rate are BB, CCB,

digoxin, and amiodarone

All patients need to be evaluated for risk of stroke.

Most patients require therapy for stroke prevention

Rhythm control is indicated in select patients to help

control symptoms

Amiodarone and dofetilide are preferred for patients

with structural heart disease

75

Thank you!

Documents

Updates in the Management of Cardiovascular Diseases · ACEI Hyperkalemia, ↑SCr, cough, angioedema, hypotension ... What’s New in 2013 Guidelines? Focus on reduction of cardiovascular