A day to day case based scenario that every DM resident faces in the ward

1. CONSULTATIONS IN
CARDIOLOGY
Dr. Vijay Yadav
DM Resident
MCVTC, IOM

2. • Bleeding with anti-thrombotics and anticoagulants (UGIB &
Hemorhagic stroke)
• ACS management in CKD
• Anticoagulation in pregnancy with mechanical prosthetic
valves
• Anticoagulation bridging in mechanical prosthetic valves
• Warfarin induced coagulopathy
• Hypertension management in pregnanacy
• When to stop anti-thrombotic therapies before surgery?

3. BLEEDING WITH BLOOD
THINNERS
• Bleeding is a frequent complication with both oral anticoagulation
and with antiplatelet therapy
• Rate of major bleeding is 5% within one year in both groups
• Despite the bleeding risk, DAPT remains the cornerstone of
treatment in patients with acute coronary syndrome (ACS) and those
undergoing percutaneous coronary intervention (PCI) with stenting.

4. MILD BLEEDING
• Needing medical attention
without hospital stay
• Continue DAPT
• Switching from
ticagrelor/prasugrel to the
weaker clopidogrel should be
considered
• Vitamin K antagonist should
be postponed until the INR is
below 2
• Omit one dose of NOAC’s
• In case of triple therapy (OAC
and DAPT), downgrading to
dual therapy (OAC and
clopidogrel) should be
considered

5. MODERATE
BLEEDING
• Significant blood loss
(≥2mmol/L
haemoglobin) or
requires hospitalisation
• Haemodynamically
stableHigh Thrombotic Risk
Mechanical heart valve
Cardiac assist device
CHA2DS2-VASc ≥4

7. GASTROINTESTINAL BLEEDING
WHEN USING
ANTIPLATELET THERAPY
• In patients on aspirin or DAPT for secondary
prevention with upper gastrointestinal bleeding,
continue aspirin or DAPT if endoscopy shows no
active bleeding.
• Consider a 3 day interruption of aspirin in patients with
active bleeding by endoscopy.
• In case of DAPT, continue the P2Y12 inhibitor and
interrupt aspirin for 3 days.
• Aspirin for secondary prevention should be continued
in patients with lower gastrointestinal bleeding.

8. • In patients on DAPT, the P2Y12 inhibitor should be
interrupted for 7 days and aspirin should be continued
unless the patient had ACS within 90 days or coronary
stent within 30 days.
• Consider in patients on DAPT to shorten the duration
and to switch to DAPT with aspirin and clopidogrel.
• Start with intravenous PPI in case of upper
gastrointestinal bleeding and continue with oral PPI
after discharge when antiplatelet therapy is reinitiated

9. GASTROINTESTINAL BLEEDING
WHEN USING OAC
• Stop OAC in patients with a moderate gastrointestinal
bleeding or worse.
• Restart OAC between 7–15 days after gastrointestinal
bleeding.
• Patients at very high thrombotic risk, e.g. mechanical
heart valve, cardiac assist device, CHA2DS2-VASc
score ≥4 may benefit from resumption in the first week
• Consider oral PPI when OAC is reinitiated
• Consider low-dose NOAC or Apixaban in patients with
NOAC-related gastrointestinal bleeding

10. INTRACRANIAL HAEMORRHAGE WHILE
USING
ANTIPLATELET THERAPY
WITHHOLD OAC IF INTRACRANIAL
HAEMORRHAGE OCCURRED
WHILE ADEQUATELY DOSED:
• Uncontrolled
hypertension,
• If the bleeding is
located cortically,
• If there are multiple
microbleeds (>10) or
• If DAPT is needed
REINITIATE OAC
• If intracranial
haemorrhage occurred on
VKA or in the setting of
overdose
• If the bleeding was
traumatic or has a
treatable cause
• If the bleeding is located in
the basal ganglia
• If the white matter lesions
are mild
• Removed subdural
haematoma or clipped/

11. • Switch to a NOAC after intracranial haemorrhage
• If it is decided to restart antithrombotic treatment, start
after one month
• Restart single antiplatelet therapy in patients with deep
intracranial haemorrhage and a high thrombotic risk
after one month
• In patients with lobar intracranial haemorrhage
restarting antiplatelet therapy is not advised
• Restart DAPT with aspirin plus clopidogrel, one month
after intracranial haemorrhage in ACS patients with
DES implantation shorter than 3 months ago and
continue DAPT until the minimal advised duration

12. ACS MANAGEMENT IN CKD
• Cardiovascular disease accounts for almost half the
deaths of patients with end-stage renal disease. Of
those, 20 percent can be attributed to coronary artery
disease
• Chronic kidney disease (CKD) is an independent risk
factor for the development of coronary artery disease,
and for more severe coronary heart disease.
• Increased mortality after an acute coronary syndrome,
after percutaneous coronary intervention (PCI) with or
without stenting and after coronary artery bypass.

13. CLINICAL FEATURES
• Angina – may be provoked by dialysis
• Exertional dyspnoea
• Intrdialytic or Interdialytic hypotension
• Arrhythmias
• Sudden cardiac death
• Silent myocardial ischemia
• Dialysis patients are more likely than non-dialysis
patients to have atypical symptoms, such as isolated
dyspnea, weakness, syncope, palpitations, or cardiac
arrest.

14. CARDIAC BIOMARKERS IN CKD
• Cardiac biomarkers are used in conjunction with
symptoms, ECG changes, and cardiac imaging to
diagnosis acute myocardial infarction in patients with
chronic kidney disease
• The principal cardiac biomarkers are cardiac troponin
T (cTnT) and cardiac troponin I (cTnI) because of their
superior specificity and sensitivity for myocardial injury
• Stably elevated troponin concentrations are commonly
observed in CKD patients in the absence of clinical
evidence of myocardial damage

15. • Stably increased cTnI is less prevalent in CKD
patients
• cTnI is more specific for myocardial injury in CKD
patients and thus is the preferred biomarker.
• A change in troponin concentration (ie, rise or fall over
three to six hours after presentation) should be used to
define AMI
• The degree of elevation of either cTnT or cTnI that is
required for the diagnosis of AMI among CKD patients
is not known but at least one troponin value should be
above the 99th percentile upper reference limit

16. • For CKD patients in whom all troponin levels are at or
above the 99th percentile, a greater than 20 percent
change in serially measured troponins is probably an
acceptable threshold change for a positive AMI
diagnosis
• Increased troponin levels in stable, asymptomatic CKD
patients predict worse long-term cardiovascular
outcomes and poor survival
• The criteria for a diagnosis of AMI is same for dialysis
patients as for non-dialysis CKD patients

17. • Baseline ECG at the initiation of maintenance dialysis
• Transthoracic echocardiogram (TTE) within one to
three months of initiation of maintenance dialysis
• Patients with a reduced ejection fraction of <40
percent require further evaluation including
noninvasive stress imaging and often coronary
angiography
• Among dialysis patients, dobutamine stress
echocardiography (DSE) is more sensitive than other
noninvasive tests

18. Anti-anginals
Nitroglycerin 0.4 mg S/L for relief of chest pain
Max 3 doses with 15 minutes
5-200 microgram/min IV
No specific dose adjustment
required
Given at the end of a
hemodialysis session
Ranolazine 500-1000 mg PO BD
Max: 2000 mg /day
No specific dose adjustment
required
Prolongs QTc
Metoprolol Acute MI
Metoprolol tartarate: 2-2.5 mg
IV every 2-5 minutes, upto 15 mg
over 10-15 min followed 50 mg
PO every 6 hours for 48 hrs, then
50-100mg PO BD
Angina
Metoprolol tartarate: 50 mg
PO BD upto 200 mg BD
Metoprolol succinate: 100 mg
PO OD upto 400 mg/day
No specific dose adjustment
required

19. Antiplatelet CKD dose
Aspirin No specific dosing adjustments
Clopidogrel No specific dosing adjustments
Prasugrel No specific dosing adjustments
Ticagrelor No specific dosing adjustments
Angiotensin-Converting Enzyme Inhibitors (ACEi)
Indications CKD dose
Hypertension Individualize for each dialysis
session in order to avoid intradialytic
hypotension.
Reduce dose by 50-75% in ESRD
Reduction in DKD progression
Reduction in CV events following MI
with LVSD
Heart failure

20. Angiotensin II Receptor Blockers (ARB’s)
Indications CKD dose
Hypertension First line treatment in majority of patients with
CKD
Levels of ARBs do not change significantly
during hemodialysis
Reduction in DKD progression
Reduction in CV events following MI with LVSD
Heart failure intolerant to ACEi
Calcium Channel Blockers (CCBs)
Indications CKD dose
In the absence of LV dysfunction or other
contraindications if beta blocker is contraindicated
No specific dosing modification required

21. Intravenous GPIIb/IIIa inhibitors
Abciximab 0.25mg/kg IVB over 1 min f/b
0.125 microgram/kg/min for
12 hours
No specific dose adjustment
required
Eptifibatide 180 microgram/kg IVB
repeated after 10 mins f/b 2
microgram/kg/min for 18 hrs
Decrease infusion to half if
CrCl < 50 ml/min
Tirofiban 25 microgram/kg IV over 3
minutes f/b 0.15
microgram/kg/min for 18
hours
Decrease infusion to half if
CrCl < 30 ml/min
Anticoagulants
UFH 70-100U/kg IVB (no GP)
50-70 U/kg IVB (with GP)
50U/kg IVB f/b 18U/kg/hr
Enoxaparin 1mg/kg S/C IV OD if CrCl
< 30 ml/min
Fondaparinux 2.5 mg IVB f/b 2.5 mg S/C
OD
C/I if CrCl < 30 ml/min

22. Statins Normal dose CKD dose
Atorvastatin 10-80 mg No specific dosing required
TNT & GREACE studies
favoured 10 mg in CKD
Rosuvastatin 5-40 mg As low as 2.5mg is efficacious
Simvastatin 20-40 mg 5mg in evening
SHARP study: Statin +
Ezetemibe beneficial
Fluvastatin 40mg No specific dosing required
Pravastatin 40-80mg 10mg in CKD
Pitavastatin 1-4 mg 1 mg in CKD

23. INVASIVE REVASCULARIZATION
• Both the mortality after CABG and the complication
rate after PCI are increased in patients with ESRD
compared with nondialysis patients
• Long-term risk of cardiac events and/or death in
dialysis patients is generally higher following PCI than
after CABG
• Favor CABG rather than PCI in the treatment of
coronary disease in dialysis patients
• Drug-eluting stents, compared with bare metal stents,
are associated with reduced restenosis rates and a
decreased requirement for repeat revascularization

24. • DAPT is given if no contraindication
• Dobutamine stress echocardiography is performed in
all dialysis patients who have undergone angioplasty
or stenting, most commonly at 12 to 16 weeks
postprocedure

25. ANTICOAGULATION IN A PREGNANT
WOMEN WITH MECHANICAL
PROSTHETIC VALVE
• Pre-pregnancy:
• Discuss anticoagulation regimen with the patient
• Continue warfarin until pregnancy is acheived
• 6th to 12th weeks of pregnancy
• Warfarin embroyopathy in 2 – 4%. (stippled epiphysis, nasal
hypoplasia) and Warfarin fetopathy (optic atrophy , CNS
abnormalities)
• Continue warfarin if the dose is < 5 mg
• Otherwise substitute with subcutaneous LMWH twice daily
• Adjust LMWH dose to achieve peak anti-Xa levels of 0.8 to 1.2
U/mL 4 hours post injection
• Check anti-Xa levels weekly

26. • 13th to 35th week of pregnancy:
• Resume warfarin
• 36th weeks onwards:
• Otherwise substitute with LMWH twice daily
• Adjust LMWH dose to achieve peak anti-Xa levels of 0.8 to 1.2
U/mL 4 hours post injection
• Check anti-Xa levels weekly

28. ANTICOAGULATION BRIDGING
IN MECHANICAL PROSTHETIC
VALVE
• Mitral valve replacement and Aortic valve replacement
with high risk factors (AF, prior thromboembolism, LV
dysfunction, Hypercoaguable state, older generation
mechanical valve)
• VKA with INR goal 3.0 (2.5-3.5) + Aspirin 75-100 mg OD
• If VKA therapy interrupted for any non-cardiac procedure,
bridging anticoagulation with UFH/LMWH is required.

29. • Aortic valve replacement without any high risk
features:
• VKA with INR goal 2.5 (2 -3) + Aspirin 75-100 mg OD
• No Bridging anticoagulation required if VKA stopped for non-
cardiac procedures.

31. FFP 10 – 15 ml/kg @
10-20 ml/kg/hr rapid

33. HYPERTENSION MANAGEMENT
IN PREGNANCY

34. WHEN TO STOP ANTITHROMBOTIC
THERAPY BEFORE SURGERY?
ELECTIVE SURGERY
Clopidogrel and Ticagrelor 5 days prior
Prasugrel 7 days prior
Abciximab 12 hours prior
Eptifibatide/Tirofiban 2-4 hours prior
Enoxaparin 12-24 hours prior
Fondaparinux 24 hours prior
Bivalirudin 3 hours

35. WHEN TO STOP ANTITHROMBOTIC
THERAPY BEFORE SURGERY?
EMERGENCY SURGERY
Clopidogrel/Ticagrelor Minimum of 24 hours
Aspirin can be continued
Hold aspirin 5 days
prior in:
1. neuro/spinal
surgery
2. Plastic surgery
3. Spinal surgery
4. Posterior chamber
eye surgery
5. Prostate surgery

36. THANK YOU