1. Therapeutics Tutoring
Sarah Darby
August 30, 2017

2. Ischemic stroke Hemorrhagic stroke Hypertension

3. Local thrombus vs. embolism Hemorrhagic
Stroke
Ischemic
Majority of strokes
Local thrombus vs. embolism
Hemorrhagic
Intracerebral hemorrhage
Subarachnoid hemorrhage

4. Ischemic Stroke
BP: only treat when > 220/120 mmHg or aortic dissection, acute myocardial dysfunction, pulmonary edema, hypertensive encephalopathy
Why?
NIHSS (0 to 42)

5. Ischemic Stroke Acute treatment Reperfusion Alteplase (rt-PA)
Antiplatelet
Aspirin

6. Ischemic Stroke Acute Treatment Alteplase (rt-PA) aids in reperfusion.
Gold standard of therapy
MOA: binds to fibrin in a clot and promotes conversion of plasminogen to plasmin
Risk? Bleeding
Should be given within 4.5 hours
Increases likelihood of a favorable outcome
LONG LIST of exclusion criteria
Dose: 0.9mg/kg total over 60 minutes
10% given as a bolus over 1 minute
Maximum dose is 90mg

7. Ischemic Stroke 70 yo female, presents to ER 1h after sx onset
Is Alteplase (rt-PA) therapy appropriate in each of the following settings?
BP = 200/120
Platelets = 120,000/mm3
Received heparin infusion 24 hours prior
Stable on warfarin with INR of 2.0
No history of intracranial hemorrhage

8. Ischemic Stroke 70 yo female, presents to ER 4h after sx onset
Is Alteplase (rt-PA) therapy appropriate in each of the following situations?
Hx of T2DM and ischemic stroke
Warfarin tx with INR of 1.5
NIHSS = 28

9. Ischemic Stroke 70 yo female, 55.5kg, presents to ER 1h after sx onset
The healthcare team deems Alteplase appropriate. What is her dose?
50mg infusion over 60 min.
5mg bolus over 1 min., followed by 45mg over 60 min.
50mg bolus over 1 min., followed by 40mg over 60 min.
5mg bolus over 1 min., followed by 85mg over 60 min.

10. Ischemic Stroke
65 yo male, 105kg, presents to ER 1h after sx onset. His BP is 205/100. Which agent is not an acceptable choice to lower his BP?
Labetalol 10-20mg IVP
Diltiazem 25mg IVP
Clevidipine 2mg/h titrated
Nicardipine 5mg/h titrated

11. Ischemic Stroke 65 yo male, 105kg, presents to ER 1h after sx onset
The healthcare team deems Alteplase appropriate. What is his dose?
9.5mg bolus over 1 min., followed by 85mg over 60 min.
95mg infusion over 60 min.
9mg bolus over 1 min., followed by 81mg over 60 min.
95mg bolus over 1 min., followed by 5mg over 60 min.

12. Ischemic Stroke Acute Treatment when not t-PA eligible
Give antiplatelet as soon as possible
Choose Aspirin or Clopidogrel
Don’t pick dipyridamole (bad headaches)

13. Ischemic Stroke Anticoagulation
Unclear cause? Monitor heart rhythm for AF
Cardioembolic origin needs anticoagulation
Initiate within 14 days

14. Ischemic Stroke Secondary prevention Non-cardioembolic Antiplatelet
Aspirin, Clopidgorel, or Aggrenox
Cardioembolic
Anticoagulation
Warfarin, Dabigatran, Apixaban, Rivaroxaban, Edoxaban
Atherosclerosis
statins
All patients
BP reduction

15. Hemorrhagic Stroke Intracerebral hemorrhage Gradual increase in sx
Causes: think anticoagulation and HTN
BP:
SBP is mmHg
Decrease to <140 quickly
SBP is >220mmHg
Use CIVI and monitoring to get to <140
Management
Cont. Inf.: Clevidipine and Nicardipine
Boluses: Hydralazine and Labetalol

16. Hemorrhagic Stroke Reversing Bleeds
Kcentra and FEIBA are both 4 factor prothrombin complex concentrates
Difference: FEIBA has activated factor 7
Warfarin
Vit K
Kcentra
FEIBA
FFP
Dabigatran
Kcentra
FEIBA
Hemodialysis
Praxbind
Rivaroxaban
Kcentra
FEIBA
Apixaban
Kcentra
FEIBA

17. Hemorrhagic Stroke DVT Prophylaxis Intracerebral hemorrhage
LMWH started 1-4 days after bleeding stops in immobile patients
Subarachnoid hemorrhage
No treatment until aneurysm is protected via surgery
LMWH or UFH started 24 hours after surgery
When to restart anticoag?
No heart valves: wait at least 4 weeks
Aspirin monotherapy can be started back sooner
Controversy over mechanical valves

18. Hemorrhagic Stroke Subarachnoid hemorrhage “worst headache”
Sudden onset
Highest risk of re-bleeding in first 72 hours
BP:
Get below 160mmHg
Use same drugs as ICH, except lower target with ICH
Special: Nimodipine
Only indicated for reducing vasospasm associated ischemia after SAH

19. Hemorrhagic Stroke
72 yo female presents to ER with vomiting and severe headache
Pt currently taking warfarin 5mg daily for AF
Her current BP is 230/135mmHg.
What do you recommend for treatment of her blood pressure?
Labetalol continuous infusion
Clevidipine continuous infusion
Amlodipine bolus
No therapy; she’s fine with that BP!

20. Hemorrhagic Stroke
78 yo male presents to ER with vomiting and severe headache
Pt currently taking Rivaroxaban 20mg daily for AF
What reversal strategy do you recommend?
Hemodialysis to quickly pull of the Rivaroxaban
Kcentra
Vitamin K
LMWH
No treatment

21. Hemorrhagic Stroke
78 yo male presents to ER with vomiting and severe headache
Pt currently taking Rivaroxaban 20mg daily for AF (no mechanical valve)
When can we safely restart his anticoagulation?
Immediately
7 days
1 year
4 weeks

22. HTN

23. HTN Staging patients with hypertension Systolic Diastolic Normal
<120
<80
Pre-HTN
80-90
Stage 1
90-99
Stage 2
≥160
≥100

24. HTN
TH is a 56 yo male who comes into your pharmacy today for his first MTM session. His BP reading today is 156/90. What BP stage is this?
Normal
Pre-HTN
Stage 1
Stage 2
Can’t know

25. HTN
JT is a 49 yo male who comes into the clinic today for a follow up visit. You last saw him on August 1st, and his BP reading was 148/92. Today his BP is 155/98.
Normal
Pre-HTN
Stage 1
Stage 2
Can’t know

26. HTN
HK is a 62 yo female. At her last visit on August 1st her BP was 150/105. Today her BP is 155/110 .
Normal
Pre-HTN
Stage 1
Stage 2
Can’t know

27. HTN Which activity does not impact measuring blood pressure?
Recent caffeine intake
Talking during the reading
Going to the bathroom right before
Placing the cuff over a shirt sleeve

28. HTN
Determining BP goals
Age
Disease

29. HTN

30. HTN Let’s look at specific patient populations… Age>80 yo
Goal is <150/90
According to all guidelines
Gen. Pop ≥60 yo
JNC8 says goal is <150/90
ASH/ISH says goal is <140/90
Gen. Pop<60 yo
Goal is <140/90
Diabetes
CKD
According to JNC8, ASH/ISH, and KDIGO
KDIGO makes special recommendation for albumin excretion ≥30mg/24h

31. HTN In other words… Choose a goal of <140/90 EXCEPT
General patients ≥60 yo (JNC8)
Patients >80 yo (ASH/ISH)
CKD patients with albumin excretion ≥30mg/24h (KDIGO)

32. HTN What is the BP goal for an 85 yo female according to JNC8?
<150/90
<140/90
<130/80

33. HTN What is the BP goal for an 65 yo female according to JNC8?
<150/90
<140/90
<130/80

34. HTN What is the BP goal for an 85 yo female according to ASH/ISH?
<150/90
<140/90
<130/80

35. HTN What is the BP goal for an 65 yo female according to ASH/ISH?
<150/90
<140/90
<130/80

36. HTN
At what age do the JNC8 guidelines increase the goal BP from <140/90 to <150/90? 60 65 70 75 80

37. HTN
At what age do the ASH/ISH guidelines increase the goal BP from <140/90 to <150/90? 60 65 70 75 80

38. HTN
MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 15mg/24h.What is his BP goal according to the ADA guidelines?
<150/90
<140/90
<130/80

39. HTN
MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 40mg/24h. What is his BP goal according to the ADA guidelines?
<150/90
<140/90
<130/80

40. HTN
MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 36mg/24h. What is his BP goal according to the KDIGO guidelines?
<150/90
<140/90
<130/80

41. HTN
Determining agent of choice – JNC8

42. HTN Determining agent of choice – JNC8 TLC for EVERYONE!!!
Then pick out specific disease populations
Consider age for BP goal
Consider race
If SBP>20mmHg above goal, start with 2 drug therapy

43. HTN - JNC8 Non-black Thiazide ACEI or ARB CCB Diabetes No CKD present
Look at race
Black
Thiazide
CCB
CKD
No matter what race
ACEI or ARB +/- other agents

44. HTN
Determining agent of choice – ASH/ISH

45. HTN Determining agent of choice – ASH/ISH TLC for EVERYONE!!!
Then consider what stage of HTN
Consider race
Consider age

46. HTN - ASH/ISH Stage 1 Stage 2** Non-black ACEI or ARB
Age<60 – ACEI or ARB
Age≥60 – CCB or thiazide
Stage 2**
ACEI or ARB
AND
CCB or thiazide
**start with 2 drugs
Black
CCB or thiazide

47. HTN
JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to JNC-8, what is his BP goal?
<150/90
<140/90
<135/85
<130/80

48. HTN
JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to JNC8, what is your initial treatment recommendation?
Metoprolol
Clonidine
Lisinopril
Furosemide

49. HTN
JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to ASH/ISH, what is your initial treatment recommendation?
Amlodipine
Lisinopril
Metoprolol
Losartan

50. HTN
DK is a 58 yo AA female with stage 2 HTN. No significant PMH. According to ASH/ISH, what is your initial treatment recommendation?
Amlodipine
Chlorthalidone
Amlodipine + Chlorthalidone
Amlodipine + Lisinopril
Lisinopril + Losartan

51. HTN
DK is a 58 yo AA female with stage 2 HTN. No significant PMH. Therapy has been maximized on Amlodipine and Lisinopril, but his BP is still not at goal. What additional treatment do you recommend?
Losartan
Benazepril
HCTZ
Atenolol

52. HTN
BH is a 62 yo AA male with T2DM and CKD. According to JNC8, what is your initial treatment recommendation for his HTN?
Chlorthalidone
Benazepril
Felodipine
Atenolol

53. HTN
In which scenario is recommending a beta- blocker and ACEI not appropriate?
Coronary artery disease
HFrEF
Stroke
Post-ACS

54. HTN
In what patient would you recommend spironolactone as add-on therapy?
CKD
HFrEF
Stroke DM

55. HTN
According to the ISHIB guidelines, what is the target BP for an AA male with CVD and CrCL=40ml/min?
<150/90
<140/90
<130/80
<135/85

56. HTN
Which lifestyle modification has the biggest impact on blood pressure reduction?
Weight loss
Sodium reduction
Alcohol reduction
Exercise

57. HTN Crises
DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. How should this patient be treated?
HTN emergency – admit the patient for inpatient treatment
HTN urgency – admit the patient for inpatient treatment
HTN emergency – send patient home with oral antihypertensive
HTN urgency – send patient home with oral antihypertensive

58. HTN Crises
DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. How fast should his BP be lowered?
Reduce the BP as quickly as possible to <140/90
Reduce the MAP by 50% in the first hour, then to less <140/90 in the next 24 hours
Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 24 hours
Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 2-6 hours

59. HTN Crises
DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. Which agent do you prefer to lower the BP?
Nicardipine 20mg PO TID
Nicardipine 5mg/h IV
SL Nitroglycerin
Labetalol 40mg IV bolus q 10 min

60. HTN Crises
TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. How should this patient be treated?
HTN emergency – admit the patient for inpatient treatment
HTN urgency – admit the patient for inpatient treatment
HTN emergency – send patient home with oral antihypertensive
HTN urgency – send patient home with oral antihypertensive

61. HTN Crises
TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. How fast should her BP be lowered?
Reduce the BP as quickly as possible to <140/90
Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 2-6 hours
Reduce the BP to <160/110 over hours to days
Reduce the BP to <140/90 over hours to days

62. HTN Crises
TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. What do you recommend for treatment?
Lisinopril 20mg PO daily
Losartan 50mg PO daily
Nicardipine 5mg/h IV
Nicardipine 20mg PO TID

63. HTN Crises What is the DOC for BP reduction in eclampsia? Hydralazine
Enalaprilat
Nitroglycerin
Sodium nitroprusside

64. HTN Crises Which agent is not given via intermittent bolus?
Hydralazine
Enalaprilat
Labetalol
Clevidipine

65. HTN Crises Which agent does not increase intracranial pressure?
Hydralazine
Nicardipene
Nitroglycerin
Sodium nitroprusside

66. HTN Crises Which agent causes “coronary steal?” Nitroglycerin
Sodium nitroprusside
Nicardipine
Clevidipine

67. HTN Crises
Which agent is the DOC for hypertensive emergencies associated with renal disease?
Labetalol
Fenoldopam
Hydralazine
Esmolol

68. Therapeutics Tutoring Questions?
Sarah Darby
August 30, 2017