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COMPREHENSIVE CARDIOLOGY CLINICAL GUIDE

OPD | IPD | Emergency - Exact Prescriptions, Doses, Brand Names

Disclaimer: This guide is for qualified medical professionals. Drug doses must be individualized for renal/hepatic function, weight, age, and comorbidities. Always verify current institutional formularies.

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PART 1: OPD (OUTPATIENT) CASES

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1. ESSENTIAL HYPERTENSION (Uncomplicated)

• Amlodipine 5 mg + Telmisartan 40 mg OD (Telma-AM)
• Amlodipine 5 mg + Ramipril 5 mg OD (Cardace AM)
• Telmisartan 40 mg + HCTZ 12.5 mg OD (Telma-H)

• Add Spironolactone 25-50 mg OD (Aldactone) for resistant hypertension
• Or add beta-blocker: Metoprolol Succinate 25-50 mg OD (Metolar XR, Betaloc ZOK)

Rx:
1. Tab Amlodipine 5 mg  OD  x 30 days
2. Tab Aspirin 75 mg (if CVD risk ≥10%)  OD after food  x 30 days
3. Tab Atorvastatin 10-20 mg  OD at night  x 30 days
- Review in 4 weeks, target BP <130/80

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2. HYPERTENSION WITH DIABETES

Rx:
1. Tab Telmisartan 40 mg  OD morning  x 30 days
2. Tab Amlodipine 5 mg  OD  x 30 days
3. Tab Metformin 500 mg  BD after meals  (for glycemic control)
4. Tab Rosuvastatin 10-20 mg  OD at night  (Rosuvas, Crestor)
5. Tab Aspirin 75 mg  OD after breakfast  x 30 days
- Target BP: <130/80 mmHg

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3. HYPERTENSION WITH CKD

Rx:
1. Tab Ramipril 5 mg  OD  x 30 days (Cardace 5)
   - Monitor K+, creatinine at 2 weeks
2. Tab Amlodipine 5 mg  OD  x 30 days
3. Tab Furosemide 20-40 mg  OD morning  (Lasix) - if fluid overload
4. Restrict salt <2 g/day; restrict protein

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4. STABLE ANGINA (Chronic Coronary Syndrome)

Rx:
1. Tab Aspirin 75-150 mg  OD after food  x 90 days  (Ecosprin 75, Loprin)
2. Tab Atorvastatin 40-80 mg  OD at night  x 90 days  (Lipitor, Storvas)
3. Tab Metoprolol Succinate 25-50 mg  OD  x 90 days  (Metolar XR 25/50, Betaloc ZOK)
   - HR target: 55-60 bpm
4. Tab Isosorbide Mononitrate 10-20 mg  BD  x 30 days  (Ismo, Monotrate)
   - Give with nitrate-free interval of 8-10 hrs to avoid tolerance
5. Tab Ramipril 5 mg  OD  x 90 days  (if LVEF <40% or post-MI)
6. Sublingual Nitroglycerine 0.5 mg SL (Sorbitrate SL, GTN)
   - For acute angina episodes: 1 tab SL, repeat x2 at 5 min intervals

Optional add-ons:
7. Tab Ranolazine 500 mg  BD (increase to 1000 mg BD if needed)  (Ranexa)
8. Tab Ivabradine 5 mg  BD (if HR still >70 bpm on beta-blocker)  (Ivabrad, Coralan)
9. Nitrate patch: GTN 5 mg/24 hr patch on chest  (NitroDaily) - apply at 8 AM, remove at 8 PM

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5. DYSLIPIDEMIA / HYPERCHOLESTEROLEMIA

• LDL <70 mg/dL for high-risk (known ASCVD)
• LDL <55 mg/dL for very high-risk (recurrent events)

Rx (High-intensity statin for ASCVD):
1. Tab Rosuvastatin 20-40 mg  OD at night  (Rosuvas, Crestor)
   OR Tab Atorvastatin 40-80 mg  OD at night  (Lipitor, Storvas)

Rx (Moderate-intensity statin for primary prevention):
1. Tab Atorvastatin 10-20 mg  OD at night  (Storvas 10/20)
   OR Tab Rosuvastatin 5-10 mg  OD at night  (Rosuvas 5)
2. Tab Ezetimibe 10 mg  OD  (Ezetrol, Ezentia) - add if LDL not at goal
3. For very high-risk not at LDL goal on max statin+ezetimibe:
   - Evolocumab 140 mg SC every 2 weeks  (Repatha)
   - OR Alirocumab 75-150 mg SC every 2 weeks  (Praluent)
4. Tab Fenofibrate 145 mg  OD  (Tricor, Fenolib) - if TG >500 mg/dL
5. For isolated high TG: Cap Omega-3 fatty acids 1-4 g/day  (Omacor, Vascepa)

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6. OUTPATIENT HEART FAILURE WITH REDUCED EF (HFrEF)

Rx:
1. Tab Sacubitril/Valsartan 24/26 mg  BD  (Vymada, Entresto)
   - Titrate to 49/51 mg BD then 97/103 mg BD as tolerated
   - (If not affordable, use Enalapril 2.5-10 mg BD as substitute)
2. Tab Carvedilol 3.125 mg  BD  (Carvidon, Coreg)
   - Titrate every 2 weeks: 6.25 → 12.5 → 25 mg BD
   - OR Metoprolol Succinate 12.5-200 mg OD  (Metolar XR)
3. Tab Spironolactone 25-50 mg  OD  (Aldactone)
   - OR Eplerenone 25-50 mg OD  (Inspra) - fewer gynecomastia side effects
4. Tab Dapagliflozin 10 mg  OD  (Forxiga) - SGLT2 inhibitor
   - OR Empagliflozin 10 mg OD  (Jardiance)
5. Tab Furosemide 20-80 mg  OD/BD  (Lasix) - for symptom relief (diuresis)
   - Adjust dose to maintain euvolemia; daily weight monitoring
6. Tab Digoxin 0.125-0.25 mg  OD  (Lanoxin) - if AF or persistent symptoms
   - Monitor digoxin levels and K+; target level 0.5-0.9 ng/mL
7. Ivabradine 5 mg BD if HR >70 bpm on max beta-blocker  (Coralan)

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7. HEART FAILURE WITH PRESERVED EF (HFpEF)

Rx:
1. Tab Empagliflozin 10 mg  OD  (Jardiance) - mortality benefit proven
2. Tab Dapagliflozin 10 mg  OD  (Forxiga)
3. Tab Furosemide 20-40 mg  OD  (Lasix) - symptom relief
4. Control BP strictly: target <130/80
   - Amlodipine 5-10 mg + Ramipril 5-10 mg
5. Tab Spironolactone 25 mg  OD  (Aldactone) - modest benefit
6. Treat underlying cause: AF rate control, ischemia revascularization, HTN treatment

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8. ATRIAL FIBRILLATION (OPD - Chronic)

Rx (Rate control, target HR <80 bpm at rest):
1. Tab Metoprolol Succinate 25-200 mg  OD  (Metolar XR)
   OR Tab Bisoprolol 2.5-10 mg  OD  (Concor, Biselect)
   OR Tab Diltiazem CD 120-360 mg  OD  (Dilzem CD) - if beta-blocker contraindicated
2. Tab Digoxin 0.125-0.25 mg  OD  (Lanoxin) - if HF + AF

Anticoagulation (CHA₂DS₂-VASc ≥2 in males, ≥3 in females):
3. Tab Rivaroxaban 20 mg  OD with evening meal  (Xarelto, Rivarox)
   OR Tab Apixaban 5 mg  BD  (Eliquis) - preferred in elderly/CKD
   OR Tab Dabigatran 150 mg  BD  (Pradaxa) - avoid if GFR <30
   OR Tab Warfarin (INR target 2-3)  adjusted dose  (Warf, Coumadin)

Rhythm Control (if symptomatic, paroxysmal, young patient):
4. Tab Amiodarone 200 mg  BD for 2 weeks, then 200 mg OD  (Cordarone, Amiodar)
   - Baseline TFT, LFT, CXR; annual monitoring
5. OR Tab Flecainide 100-200 mg  BD  (Tambocor) - only if no structural heart disease
6. OR Tab Dronedarone 400 mg  BD with meals  (Multaq) - contraindicated in HF

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9. DIABETES WITH CARDIAC RISK (Primary Prevention)

Rx:
1. Tab Empagliflozin 10 mg OD  (Jardiance) - cardioprotective in DM
2. Tab Semaglutide 0.5-1 mg SC weekly  (Ozempic) - CV outcomes benefit
3. Tab Aspirin 75 mg OD  (only if ASCVD present)
4. Tab Rosuvastatin 10-20 mg OD  (Rosuvas) - if LDL >70 mg/dL
5. Tab Ramipril 5 mg OD  (Cardace) - if microalbuminuria

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PART 2: IPD (INPATIENT) CASES

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10. ACUTE CORONARY SYNDROME - NSTEMI/UA (Inpatient)

STAT Orders:
1. Inj Heparin UFH: Loading dose 60 U/kg IV bolus (max 4000 U), then 12 U/kg/hr IV infusion (max 1000 U/hr)  - adjust to aPTT 60-100 sec
   OR Inj Enoxaparin (LMWH) 1 mg/kg SC BD  (Clexane, Lovenox) - preferred in most
2. Tab Aspirin 150-300 mg STAT (loading), then 75-100 mg OD  (Ecosprin)
3. Tab Clopidogrel 300-600 mg STAT loading, then 75 mg OD  (Clopilet, Plavix)
   OR Tab Ticagrelor 180 mg STAT loading, then 90 mg BD  (Brilinta) - preferred
   OR Tab Prasugrel 60 mg STAT loading, then 10 mg OD  (Effient) - if PCI planned; avoid >75 yrs, prior TIA/stroke
4. Inj Nitroglycerin 10-200 mcg/min IV infusion (titrate for pain relief)  (NTG IV, Nitrocine)
5. Tab Metoprolol 25-50 mg BD oral if hemodynamically stable; HR >60, no block  (Metolar)
6. Inj Morphine 2-4 mg IV q5-15 min PRN for severe pain  (avoid if possible - may worsen outcomes)
7. O₂: Maintain SpO₂ >95%
8. Monitor: Continuous ECG, vitals q1h, repeat troponin at 3 and 6 hrs

Within 24-48 hours:
9. Coronary angiography + PCI (invasive strategy for high-risk)
   - High risk triggers: dynamic ECG changes, troponin positive, GRACE score >140, hemodynamic instability
10. Tab Atorvastatin 80 mg  OD  (high-intensity statin STAT) - Storvas 80
11. Tab Ramipril 2.5-5 mg  OD  (if LVEF <40%, HTN, DM)
12. Inj Pantoprazole 40 mg IV OD  (Pantop IV) - GI protection on DAPT

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11. STEMI - ST-ELEVATION MYOCARDIAL INFARCTION (Emergency/IPD)

STAT:
1. Tab Aspirin 300 mg chew + swallow immediately
2. Tab Ticagrelor 180 mg loading  OR  Tab Clopidogrel 600 mg loading
3. Inj Heparin UFH 70-100 U/kg IV bolus at time of PCI
4. Activate Cath Lab immediately
5. O₂ if SpO₂ <90%
6. IV access x2, continuous monitoring
7. Inj Morphine 4 mg IV if pain severe (controversial - use cautiously)

Post-PCI (IPD orders):
8. Tab Aspirin 75-100 mg OD  lifelong
9. Tab Ticagrelor 90 mg BD  x 12 months  (dual antiplatelet therapy)
10. Tab Atorvastatin 80 mg OD  (Storvas 80, Lipitor 40-80)
11. Tab Metoprolol 25-50 mg BD → Switch to Metoprolol Succinate 50-200 mg OD at discharge
12. Tab Ramipril 2.5-5 mg OD (start 24 hrs after PCI if stable, esp. if anterior MI)  (Cardace)
13. Tab Eplerenone 25-50 mg OD (if EF <40%, DM, or clinical HF post-MI)  (Inspra)

Inclusion: STEMI <12 hrs from symptom onset, no contraindications

1. Inj Tenecteplase (TNK-tPA): Weight-based single IV bolus:
   - <60 kg: 30 mg
   - 60-69 kg: 35 mg
   - 70-79 kg: 40 mg
   - 80-89 kg: 45 mg
   - ≥90 kg: 50 mg
   (Brand: TNKase, Metalyse)
   
2. Inj Enoxaparin:
   - <75 yrs: 30 mg IV bolus, then 1 mg/kg SC BD
   - ≥75 yrs: No IV bolus, 0.75 mg/kg SC BD (max 75 mg per dose)
   (Clexane, Lovenox)
   
3. Aspirin 300 mg STAT + 75 mg OD thereafter
4. Clopidogrel 300 mg STAT (if <75 yrs), then 75 mg OD
5. Streptokinase 1.5 million U IV over 60 min  (alternative to TNK) - if allergic, repeat not recommended

Contraindications to thrombolysis:
- Prior hemorrhagic stroke ever
- Ischemic stroke <3 months
- Active bleeding, recent surgery <2 weeks
- Uncontrolled severe HTN >180/110
- Head trauma <3 months

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12. ACUTE DECOMPENSATED HEART FAILURE (IPD)

Immediate:
1. Sit up 90°, O₂ to maintain SpO₂ ≥95% (CPAP/BiPAP if SpO₂ <90% despite O₂)
2. IV access, ECG, echo (urgent), BNP/NT-proBNP, troponin, CMP, CBC, CXR

Diuresis (cornerstone):
3. Inj Furosemide 40-80 mg IV STAT (double outpatient dose if on oral furosemide)
   - Then 20-40 mg IV q6-12h; target urine output 100-200 mL/hr
   - (Lasix IV)
   
4. Inj Morphine 2-4 mg IV  (venodilation, reduces preload + anxiety) - use cautiously
5. Inj Nitroglycerin 10-200 mcg/min IV infusion (if SBP >100 mmHg) - preload/afterload reduction
6. Restrict fluid to 1-1.5 L/day; fluid balance chart every 4 hrs

After stabilization:
7. Tab Furosemide 40-80 mg OD/BD oral  (Lasix)
8. Resume/initiate Sacubitril/Valsartan (if HFrEF)
9. Resume beta-blocker at reduced dose once euvolemic
10. Aldosterone antagonist: Spironolactone 25-50 mg OD  (Aldactone)
11. SGLT2 inhibitor: Dapagliflozin 10 mg OD (start in-hospital if de novo HF, CrCl >25)

Monitoring:
- Daily weight (target loss 0.5-1 kg/day)
- BMP + Mg q24-48 hrs
- BNP or NT-proBNP at discharge (goal-directed)

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13. HYPERTENSIVE EMERGENCY (IPD)

ICU-level monitoring required:

1. Inj Labetalol 20 mg IV over 2 min, repeat 40-80 mg q10 min (max 300 mg)  OR
   Labetalol IV infusion 0.5-2 mg/min  (Trandate, Normodyne)

2. Inj Sodium Nitroprusside 0.3-10 mcg/kg/min IV infusion  - most potent; requires arterial line
   (Nipride) - avoid in pregnancy, elevated ICP; monitor thiocyanate toxicity

3. Inj Nicardipine 5-15 mg/hr IV infusion  (Cardene IV) - preferred in neurologic emergencies

4. Inj Hydralazine 10-20 mg IV over 20 min  q4-6h  (Apresoline) - preferred in pregnancy/eclampsia

5. Inj Clevidipine 1-2 mg/hr IV infusion titrated up  (Cleviprex) - titratable CCB

6. Tab Clonidine 0.2 mg oral (Catapress) - for urgent HTN without target organ damage
   OR Tab Captopril 12.5-25 mg sublingual  (Capoten) - used in some settings

Hypertensive Urgency (BP >180/120, NO organ damage):
- Can use oral agents, reduce BP over 24-48 hrs
- Tab Amlodipine 5-10 mg STAT + usual meds
- Tab Clonidine 0.1-0.2 mg q1h x3 (max 0.6 mg)

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14. COMPLETE HEART BLOCK / BRADYARRHYTHMIA (IPD)

Emergency:
1. Atropine 0.5-1 mg IV q3-5 min (max 3 mg) - for symptomatic sinus bradycardia, 2nd degree Mobitz I
2. Transcutaneous pacing - if atropine fails or Mobitz II/CHB
3. Inj Dopamine 5-20 mcg/kg/min IV infusion  (if pacing not immediately available)
4. Inj Epinephrine 2-10 mcg/min IV infusion  (for severe hemodynamic compromise)
5. Arrange Transvenous pacing / Permanent pacemaker implantation

Stop offending drugs: beta-blockers, digoxin, CCB, amiodarone - hold all

Drug-induced bradycardia:
- Digoxin toxicity: Inj Digibind (Digoxin Fab) 38-228 mg IV depending on level/dose ingested

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15. ACUTE PULMONARY EDEMA (IPD)

1. Sit upright, high-flow O₂ (mask 10-15 L/min), consider NIV (CPAP/BiPAP)
2. Inj Furosemide 80-120 mg IV bolus STAT  (Lasix)
3. Inj Morphine 2-5 mg IV  (sedation, venodilation) - use cautiously
4. Inj Nitroglycerin 10-20 mcg/min IV increasing by 10 mcg q5 min  (if SBP >100)
5. If BP OK and fluid overloaded: continue IV furosemide infusion 5-40 mg/hr
6. If cardiogenic shock (SBP <90): 
   - Inj Dobutamine 2.5-20 mcg/kg/min IV infusion  (positive inotrope)
   - Inj Norepinephrine 0.1-0.5 mcg/kg/min  (if vasoplegic shock)
   - Intra-aortic balloon pump (IABP) or Impella if refractory

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PART 3: EMERGENCY CASES

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16. CARDIAC ARREST - ADVANCED CARDIAC LIFE SUPPORT (ACLS)

1. CPR: 30:2, 100-120 compressions/min, 5-6 cm depth
2. Defibrillation: 200 J biphasic (360 J monophasic) ASAP
3. Resume CPR 2 min, reassess
4. Inj Epinephrine 1 mg IV/IO q3-5 min  (every other cycle)
5. Inj Amiodarone 300 mg IV STAT (if VF/pVT persists after 2 shocks), then 150 mg in 10 min  (Cordarone)
   OR Inj Lidocaine 1-1.5 mg/kg IV  (if no amiodarone)
6. Continue CPR + shocks every 2 min
7. Treat reversible causes (4H4T): Hypoxia, Hypovolemia, Hypothermia, H⁺ acidosis; Tension PTX, Tamponade, Toxins, Thrombosis

Non-shockable rhythms (PEA/Asystole):
1. CPR 30:2 continuously
2. Inj Epinephrine 1 mg IV q3-5 min immediately
3. No defibrillation
4. Treat reversible causes aggressively
5. Inj Sodium Bicarbonate 1 mEq/kg IV (if prolonged arrest, hyperkalemia, TCA overdose)

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17. VENTRICULAR TACHYCARDIA (VT) - PULSED, STABLE

1. Inj Amiodarone 150 mg IV over 10 min (loading), then 1 mg/min x 6 hrs, then 0.5 mg/min  (Cordarone IV)
2. Inj Lidocaine 1-1.5 mg/kg IV bolus, then 1-4 mg/min infusion  (Xylocaine IV)
3. If hemodynamically unstable → synchronized DC cardioversion 100-200 J
4. Treat underlying cause: hypokalemia, hypomagnesemia
   - Inj MgSO₄ 2 g IV over 10-15 min  (for Torsades de Pointes)
   - KCl infusion to maintain K+ >4 mEq/L

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18. SUPRAVENTRICULAR TACHYCARDIA (SVT)

1. Vagal maneuvers: Valsalva, carotid sinus massage
2. Inj Adenosine 6 mg rapid IV push (follow with 20 mL NS flush); if no response → 12 mg x2  (Adenocor, Adenocard)
   - Monitor: brief asystole normal
3. If Adenosine fails or AF/flutter:
   - Inj Diltiazem 15-20 mg (0.25 mg/kg) IV over 2 min (Dilzem IV)
   - OR Inj Metoprolol 5 mg IV over 5 min, repeat x3  (Betaloc)
   - OR Inj Verapamil 2.5-5 mg IV over 2 min  (Calaptin IV)
   - (NEVER give verapamil with beta-blocker IV)
4. If pre-excited SVT (WPW): Inj Procainamide 15-17 mg/kg IV infusion at 25-50 mg/min
   - Avoid adenosine, CCB, digoxin in WPW

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19. ACUTE AORTIC DISSECTION (Emergency IPD)

Immediate:
1. ICU admission, 2 large-bore IVs, type and crossmatch, CT angiography chest/abdomen
2. Target SBP 100-120 mmHg, HR <60 bpm within 20 minutes

Pain Control:
1. Inj Morphine 4-8 mg IV  PRN (Morph, Morphine Sulphate)
2. Inj Fentanyl 25-50 mcg IV PRN (Fentanyl)

Rate + BP Control:
3. Inj Esmolol 250-500 mcg/kg/min IV loading, then 50-200 mcg/kg/min infusion  (Brevibloc) - FIRST line
4. Inj Labetalol 20 mg IV q10 min or 2 mg/min infusion  (Trandate)
5. Add Sodium Nitroprusside 0.3-5 mcg/kg/min ONLY after adequate heart rate control with beta-blocker (avoid reflex tachycardia)
6. AVOID: vasodilators alone without beta-blocker first

Long-term (Type B discharge):
- Tab Metoprolol Succinate 50-100 mg OD
- Tab Amlodipine 5-10 mg OD
- Target SBP 120-130 mmHg lifelong

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20. CARDIAC TAMPONADE (Emergency)

Emergency:
1. Inj Normal Saline 500 mL IV rapid bolus (temporizing - increases preload)
2. Avoid diuretics, vasodilators (reduce preload - dangerous)
3. Inj Atropine 0.5 mg IV if bradycardia
4. Pericardiocentesis (definitive): 
   - Echo-guided drainage, 18G spinal needle, subxiphoid approach
   - Drain slowly, send fluid for LDH, protein, glucose, culture, cytology, ADA
5. If surgical cause (hemopericardium, trauma, type A dissection) → emergency surgical drainage

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21. ACUTE PULMONARY EMBOLISM (PE)

1. O₂ high flow, IV access, continuous monitoring
2. Inj Heparin UFH: 80 U/kg IV bolus, then 18 U/kg/hr infusion  (adjust to aPTT 60-100)
3. Thrombolysis (massive PE or submassive with deterioration):
   - Inj Alteplase (r-tPA) 100 mg IV over 2 hrs  (Actilyse, Activase)
   - OR Tenecteplase weight-based bolus
4. After lysis: continue UFH, transition to oral anticoagulation
5. If thrombolysis contraindicated: surgical embolectomy or catheter-directed therapy

Submassive/Non-massive PE (hemodynamically stable):
6. Inj Enoxaparin 1 mg/kg SC BD  x 5-10 days  (Clexane)
   OR Fondaparinux 5-10 mg SC OD (weight-based)  (Arixtra)
7. Oral anticoagulation (preferred DOACs):
   - Tab Rivaroxaban 15 mg BD x 21 days, then 20 mg OD  (Xarelto)
   - OR Tab Apixaban 10 mg BD x 7 days, then 5 mg BD  (Eliquis)
   Duration: 3-6 months (provoked), 6-12+ months (unprovoked/recurrent)
8. Consider IVC filter ONLY if anticoagulation absolutely contraindicated

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22. INFECTIVE ENDOCARDITIS (IPD)

Native Valve Endocarditis (community-acquired, no IVDU):
1. Inj Ampicillin 2 g IV q4h  (Ampilin)  PLUS
2. Inj Nafcillin/Oxacillin 2 g IV q4h  PLUS
3. Inj Gentamicin 3 mg/kg/day IV divided q8h  (first 2 weeks only)

If Penicillin allergic or MRSA concern:
1. Inj Vancomycin 25-30 mg/kg/day IV divided q8h (target trough 10-20 mcg/mL)  PLUS
2. Inj Gentamicin as above

Streptococcal NVE (viridans strep):
1. Inj Ceftriaxone 2 g IV OD  x 4 weeks  OR
2. Inj Penicillin G 12-18 million U/day IV divided q4h x 4 weeks

IVDU / Prosthetic Valve Endocarditis:
1. Inj Vancomycin 15-20 mg/kg q8-12h IV x 6 weeks  PLUS
2. Inj Rifampicin 300 mg q8h oral  x 6 weeks  PLUS
3. Inj Gentamicin 3 mg/kg/day IV x 2 weeks only

Surgery criteria: Valve destruction causing HF, uncontrolled infection, large vegetation >10 mm with emboli

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23. CARDIOGENIC SHOCK (IPD/ICU)

1. Identify and treat cause: STEMI → emergent PCI, mechanical complication → surgery
2. O₂, intubation if needed, ICU
3. Inj Norepinephrine 0.1-2 mcg/kg/min IV infusion (vasopressor of choice)  (Levophed)
4. Inj Dobutamine 2.5-20 mcg/kg/min IV infusion (inotrope)  (Dobutrex)
   - Can combine: Norepi for MAP + Dobutamine for cardiac output
5. Inj Milrinone 0.375-0.75 mcg/kg/min IV infusion (inodilator, PDE inhibitor)  (Primacor)
   - Preferred if on beta-blocker (not affected)
6. Intra-aortic Balloon Pump (IABP) - augments diastolic pressure, reduces afterload
7. Impella device (Impella CP/5.0) - mechanical LV support, best hemodynamic support
8. ECMO (VA-ECMO) - for refractory cardiogenic shock as bridge to recovery/transplant
9. Avoid: aggressive fluids, nitrates/diuretics if preload-dependent

Monitoring: Arterial line, central venous catheter, urine output q1h, echo serial, lactate q4-6h

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24. ACUTE RHEUMATIC FEVER (IPD - Pediatric/Young Adults)

Anti-streptococcal:
1. Inj Benzathine Penicillin G 1.2 million U IM single dose  (Penidure LA)
   - Penicillin V oral 250 mg QID x 10 days (alternative)
   - Erythromycin 250 mg QID x 10 days (if pen allergic)

Anti-inflammatory:
2. Tab Aspirin 50-100 mg/kg/day divided q6h x 4-8 weeks  (for arthritis, carditis)
   - Max 4-6 g/day; reduce slowly, monitor salicylate levels
3. Prednisolone 1-2 mg/kg/day (max 80 mg) x 2-3 weeks then taper  (for severe carditis/CHF)  (Wysolone)

Secondary Prophylaxis (lifelong or duration-based):
4. Benzathine Penicillin G 1.2 million U IM q3-4 weeks  (Penidure LA)
   - Duration: 5 yrs or until age 21 (no carditis); 10 yrs/age 25 (mild carditis); lifelong (severe valvular)

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PART 4: STANDARD PROTOCOLS & DRUG REFERENCE

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DUAL ANTIPLATELET THERAPY (DAPT) GUIDE

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ANTICOAGULATION QUICK REFERENCE

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BETA-BLOCKER DOSING IN CARDIAC CONDITIONS

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COMMON IV INOTROPE/VASOPRESSOR REFERENCE (ICU)

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KEY CARDIAC DRUGS - BRAND NAMES AT A GLANCE

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SPECIAL POPULATIONS - KEY ADJUSTMENTS

• Safe: Methyldopa, Labetalol, Hydralazine, Nifedipine (for HTN)
• Avoid: ACE inhibitors (teratogenic), ARBs, DOACs, Warfarin (1st trimester)
• Anticoagulation: LMWH (Enoxaparin) throughout; switch to UFH near delivery

• Reduce Dabigatran to 110 mg BD; Rivaroxaban 15 mg OD for AF if CrCl 15-50
• Start beta-blockers/ACEI at half dose
• Check orthostatic BP; avoid alpha-blockers as monotherapy

• Prefer Apixaban over other DOACs (least renal excretion)
• Reduce Enoxaparin dose or switch to UFH
• Avoid Metformin (lactic acidosis), NSAIDs, contrast without pre-hydration

• Avoid non-selective beta-blockers (propranolol, carvedilol) - use selective BB (bisoprolol, metoprolol) cautiously only if cardioprotection benefit outweighs risk
• Prefer CCB for rate control in AF

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DISCHARGE PRESCRIPTION CHECKLIST (Post-MI)

1. Tab Aspirin 75 mg  OD  (lifelong)
2. Tab Ticagrelor 90 mg  BD  x 12 months (then aspirin alone)
   - OR Clopidogrel 75 mg OD x 12 months if Ticagrelor not tolerated
3. Tab Atorvastatin 80 mg  OD at night  (lifelong)
4. Tab Metoprolol Succinate 25-200 mg  OD  (minimum 3 years, often lifelong)
5. Tab Ramipril 2.5-10 mg  OD  (lifelong, especially if EF <40%)
6. Tab Eplerenone 25-50 mg  OD  (if EF <40% post-MI)
7. GTN SL 0.5 mg  PRN (keep at bedside, teach patient use)
8. Tab Pantoprazole 40 mg  OD  (GI protection on DAPT)
9. Cardiac rehabilitation referral
10. Diet counseling, smoking cessation, activity restriction

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References: Braunwald's Heart Disease 12th Ed (2022), Harrison's Principles of Internal Medicine 22E (2025), Katzung's Basic & Clinical Pharmacology 16th Ed, ACC/AHA Guidelines (2023-2024), ESC Guidelines 2023, Goldman-Cecil Medicine, Fuster & Hurst's The Heart 15th Ed.

Note on brand names: Indian brand names are listed primarily. Generic substitution is recommended wherever bioequivalence is established. Drug availability may vary by region and formulary.