2025 PACUPrep BCCCP Preparatory Course
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Pulmonary
ARDS4 Topics|1 Quiz -
Asthma Exacerbation4 Topics|1 Quiz
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COPD Exacerbation4 Topics|1 Quiz
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Cystic Fibrosis6 Topics|1 Quiz
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Foundational Principles of Cystic Fibrosis in Critical Care
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Empiric Antibiotic Management of Acute Cystic Fibrosis Pulmonary Exacerbations
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Airway Clearance and Adjunctive Pharmacotherapy in Hospitalized Cystic Fibrosis
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Critical Care Management of Cystic Fibrosis
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Nutritional Support and Pancreatic Enzyme Therapy in ICU Cystic Fibrosis
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Monitoring, Prevention, and Transition of Care in Critically Ill Cystic Fibrosis Patients
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Foundational Principles of Cystic Fibrosis in Critical Care
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Drug-Induced Pulmonary Diseases3 Topics|1 Quiz
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Mechanical Ventilation Pharmacotherapy5 Topics|1 Quiz
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Pharmacologic Management of Mechanically Ventilated Critically Ill Patients
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Pharmacologic Management of Mechanically Ventilated Patients
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Pharmacotherapy and Monitoring of Neuromuscular Blocking Agents in Mechanically Ventilated Patients
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Pharmacotherapy for Prevention and Management of Mechanical Ventilation-Associated Complications
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Pharmacotherapy in Mechanical Ventilation
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Pharmacologic Management of Mechanically Ventilated Critically Ill Patients
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Pleural Disorders5 Topics|1 Quiz
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Foundational Concepts in Pleural Disorders
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Diagnostic and Severity Assessment in Pleural Disorders
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Pharmacotherapy and Adjunctive Medical Management of Pleural Disorders
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Procedural and Post-Procedure Management in Pleural Drainage
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Management of Pleural Disorders in Special Populations and Complex Scenarios
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Foundational Concepts in Pleural Disorders
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Pulmonary Hypertension (Acute and Chronic severe pulmonary hypertension)5 Topics|1 Quiz
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Foundational Principles & Classification of Pulmonary Hypertension
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Hemodynamic and Imaging-Based Severity Assessment in Critical Pulmonary Hypertension
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Acute Pharmacologic Management of Decompensated Pulmonary Hypertension
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Individualized Chronic Management and Discharge Planning in Severe Pulmonary Hypertension
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Monitoring and Supportive Care Strategies for Special Pulmonary Hypertension Populations in the ICU
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Foundational Principles & Classification of Pulmonary Hypertension
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CardiologyAcute Coronary Syndromes6 Topics|1 Quiz
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Differentiation of Acute Coronary Syndromes: Biomarkers, Clinical Presentation, and ECG Criteria
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Risk Stratification and Timing of Invasive Strategy in Acute Coronary Syndromes
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Antiplatelet Therapy in ACS: Selection, Loading, and Duration
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Anticoagulation Strategies in Acute Coronary Syndromes
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Management of Acute ACS Complications & Secondary Prevention
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Reperfusion Strategies in Acute Coronary Syndromes
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Differentiation of Acute Coronary Syndromes: Biomarkers, Clinical Presentation, and ECG Criteria
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Atrial Fibrillation and Flutter6 Topics|1 Quiz
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Fundamental Principles of Atrial Tachyarrhythmias
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Diagnosis and Classification of Atrial Arrhythmias
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Management of Unstable Atrial Arrhythmias: Emergency Cardioversion and Procainamide Strategy
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Acute IV Pharmacotherapy for Stable Atrial Fibrillation and Flutter
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Thromboembolism Prevention and Anticoagulation Management in the ICU
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Pharmacologic Strategies for Acute Management of Supraventricular Tachycardia
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Fundamental Principles of Atrial Tachyarrhythmias
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Cardiogenic Shock4 Topics|1 Quiz
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Heart Failure7 Topics|1 Quiz
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Integration of Natriuretic Peptides and Pulmonary Artery Catheter Hemodynamics in ADHF
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Optimizing Loop Diuretic Therapy and Resistance Management in ADHF
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Vasoactive Agent Selection and Titration in Acute Decompensated Heart Failure
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Acute Decompensated Heart Failure: Advanced Pharmacotherapy and Supportive Management
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Phenotype-Specific Management of Acute Decompensated Heart Failure
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Acute Decompensated Heart Failure in the ICU: Management and Transition
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Recovery, De-Escalation, and Safe Transition of Care in Acute Decompensated Heart Failure
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Integration of Natriuretic Peptides and Pulmonary Artery Catheter Hemodynamics in ADHF
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Hypertensive Crises5 Topics|1 Quiz
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Foundational Principles of Hypertensive Crises
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Diagnostic and Classification Strategies in Hypertensive Crises
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IV Pharmacotherapy Planning in Hypertensive Emergencies
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Pharmacologic Management and Blood Pressure Targets in Hypertensive Crises
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Monitoring, Over-Reduction Prevention, and Care Transitions in Hypertensive Emergencies
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Foundational Principles of Hypertensive Crises
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Ventricular Arrhythmias and Sudden Cardiac Death Prevention5 Topics|1 Quiz
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Fundamentals of Monomorphic and Polymorphic Ventricular Tachycardia
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ECG Patterns and Stability Assessment in Ventricular Tachycardia
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Acute Management of Ventricular Tachycardias
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Acute Ventricular Tachycardia: Pharmacologic and Electrical Management and SCD Prevention
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Secondary Prevention of Ventricular Tachyarrhythmias and Sudden Cardiac Death
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Fundamentals of Monomorphic and Polymorphic Ventricular Tachycardia
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NEPHROLOGYAcute Kidney Injury (AKI)5 Topics|1 Quiz
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Acute Kidney Injury: Foundations, Management, and Recovery
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Acute Kidney Injury: Diagnosis, Classification, and Pharmacotherapy Optimization
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Pharmacotherapy Optimization and Dosing in Acute Kidney Injury
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Pharmacotherapy Optimization and Supportive Care in Acute Kidney Injury
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Optimizing Pharmacotherapy and Management in Acute Kidney Injury
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Acute Kidney Injury: Foundations, Management, and Recovery
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Contrast‐Induced Nephropathy5 Topics|1 Quiz
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Contrast-Induced Nephropathy: Pathophysiology, Prevention, and Management
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Contrast‐Induced Nephropathy: Pathophysiology, Prophylaxis, and Management
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Contrast-Induced Nephropathy: Prevention and Management
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Contrast‐Induced Nephropathy: Pharmacologic Prophylaxis and Supportive Care
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Pharmacologic Prophylaxis of Contrast-Induced Nephropathy
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Contrast-Induced Nephropathy: Pathophysiology, Prevention, and Management
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Drug‐Induced Kidney Diseases5 Topics|1 Quiz
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Rhabdomyolysis5 Topics|1 Quiz
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Syndrome of Inappropriate Antidiuretic Hormone (SIADH)5 Topics|1 Quiz
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Pathophysiology, Etiologies, and Clinical Manifestations of SIADH
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Syndrome of Inappropriate Antidiuretic Hormone (SIADH) in Critical Care: Diagnosis, Management, and Transitions
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Therapeutic Management of SIADH
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Monitoring and Management of Hyponatremia Correction in SIADH
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Pharmacotherapy and Management of SIADH
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Pathophysiology, Etiologies, and Clinical Manifestations of SIADH
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Renal Replacement Therapies (RRT)5 Topics|1 Quiz
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NeurologyStatus Epilepticus5 Topics|1 Quiz
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Acute Ischemic Stroke5 Topics|1 Quiz
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Subarachnoid Hemorrhage5 Topics|1 Quiz
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Spontaneous Intracerebral Hemorrhage5 Topics|1 Quiz
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Neuromonitoring Techniques5 Topics|1 Quiz
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Neuromonitoring and Ventriculostomy Management in Neurocritical Care
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Neuromonitoring and Ventriculostomy Management
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Neuromonitoring Data Interpretation and Clinical Application
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Neuromonitoring and Ventriculostomy Management in Neurocritical Care
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Ventriculostomy Management and Complication Prevention
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Neuromonitoring and Ventriculostomy Management in Neurocritical Care
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GastroenterologyAcute Upper Gastrointestinal Bleeding5 Topics|1 Quiz
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Foundational Concepts in Acute Upper Gastrointestinal Bleeding
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Diagnostic Evaluation and Risk Stratification in Acute Upper Gastrointestinal Bleeding
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Management of Acute Upper Gastrointestinal Bleeding
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Management of Acute Upper Gastrointestinal Bleeding
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Management of Acute Upper Gastrointestinal Bleeding
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Foundational Concepts in Acute Upper Gastrointestinal Bleeding
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Acute Lower Gastrointestinal Bleeding5 Topics|1 Quiz
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Foundational Concepts in Acute Lower Gastrointestinal Bleeding
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Foundational Concepts in Acute Lower Gastrointestinal Bleeding
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Foundational Principles and Management Framework for Acute Lower Gastrointestinal Bleeding
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Acute Lower Gastrointestinal Bleeding Management in Critical Care
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Management of Acute Lower Gastrointestinal Bleeding in Critically Ill Patients
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Foundational Concepts in Acute Lower Gastrointestinal Bleeding
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Acute Pancreatitis5 Topics|1 Quiz
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Enterocutaneous and Enteroatmospheric Fistulas5 Topics|1 Quiz
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Enterocutaneous and Enteroatmospheric Fistulas
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Enterocutaneous and Enteroatmospheric Fistulas: Foundations and Management
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Pharmacotherapy and Supportive Management of Enterocutaneous and Enteroatmospheric Fistulas
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Management Strategies for Enterocutaneous and Enteroatmospheric Fistulas in Critical Care
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Management of Enterocutaneous and Enteroatmospheric Fistulas
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Enterocutaneous and Enteroatmospheric Fistulas
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Ileus and Acute Intestinal Pseudo-obstruction5 Topics|1 Quiz
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Foundational Concepts in Ileus and Acute Intestinal Pseudo-Obstruction
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Ileus and Acute Intestinal Pseudo-obstruction in Critically Ill Patients
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Pharmacologic and Supportive Management of Ileus and Acute Intestinal Pseudo-Obstruction
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Ileus and Acute Intestinal Pseudo-obstruction
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Management of Ileus and Acute Intestinal Pseudo-obstruction in the Critically Ill
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Foundational Concepts in Ileus and Acute Intestinal Pseudo-Obstruction
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Abdominal Compartment Syndrome5 Topics|1 Quiz
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HepatologyAcute Liver Failure5 Topics|1 Quiz
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Foundational Principles and Pathophysiology of Acute Liver Failure
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Diagnostic Criteria and Severity Stratification in Acute Liver Failure
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Evidence-Based Pharmacotherapy Planning in Acute Liver Failure
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Supportive Care Strategies for Managing Complications in Acute Liver Failure
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Recovery, De-escalation, and Transition of Care in Acute Liver Failure
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Foundational Principles and Pathophysiology of Acute Liver Failure
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Portal Hypertension & Variceal Hemorrhage5 Topics|1 Quiz
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Foundations of Portal Hypertension: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Evaluation and Risk Stratification in Variceal Hemorrhage
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Pharmacotherapy Strategies for Prophylaxis and Acute Management of Variceal Hemorrhage
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Supportive Care & Complication Monitoring in Acute Variceal Hemorrhage
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Recovery, De-escalation, and Transition of Care After Variceal Hemorrhage
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Foundations of Portal Hypertension: Epidemiology, Pathophysiology, and Risk Factors
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Hepatic Encephalopathy5 Topics|1 Quiz
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Foundational Principles and Pathophysiology of Hepatic Encephalopathy
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Diagnosis and Classification of Hepatic Encephalopathy
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Escalating Pharmacotherapy Strategies in Critically Ill Hepatic Encephalopathy
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Supportive Care and Monitoring in Hepatic Encephalopathy
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Recovery, De‐escalation, and Transition of Care in Hepatic Encephalopathy
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Foundational Principles and Pathophysiology of Hepatic Encephalopathy
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Ascites & Spontaneous Bacterial Peritonitis5 Topics|1 Quiz
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Foundational Principles of Ascites & SBP: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic & Classification Strategies for Ascites & SBP
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Advanced Pharmacotherapy of Ascites & SBP in the Critically Ill
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Supportive Care and Monitoring in Ascites & SBP
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Recovery, De-Escalation, and Safe Transitions in Ascites & SBP
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Foundational Principles of Ascites & SBP: Epidemiology, Pathophysiology, and Risk Factors
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Hepatorenal Syndrome5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic and Classification Strategies for Hepatorenal Syndrome
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Pharmacotherapy Planning: Vasoconstrictor and Albumin Strategies
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Supportive ICU Management and Complication Mitigation
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Therapeutic De-escalation, Enteral Conversion, and Transition Planning
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Drug-Induced Liver Injury5 Topics|1 Quiz
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Foundational Principles of Drug-Induced Liver Injury
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Diagnostics and Classification of Drug-Induced Liver Injury
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Pharmacotherapy Strategies for Drug-Induced Liver Injury
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Supportive Care and Complication Management in Drug-Induced Liver Injury
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Patient Recovery, Rehabilitation, and Transition of Care Post-DILI
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Foundational Principles of Drug-Induced Liver Injury
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DermatologyStevens-Johnson Syndrome and Toxic Epidermal Necrolysis5 Topics|1 Quiz
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Erythema multiforme5 Topics|1 Quiz
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Drug Reaction (or Rash) with Eosinophilia and Systemic Symptoms (DRESS)5 Topics|1 Quiz
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ImmunologyTransplant Immunology & Acute Rejection5 Topics|1 Quiz
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Foundational Principles and Risk Factors in Transplant Immunology & Acute Rejection
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Diagnostic Criteria and Classification Systems for Acute Transplant Rejection
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Pharmacotherapy Strategies for Prevention and Treatment of Acute Transplant Rejection
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Supportive Care and Complication Management in Acute Transplant Rejection
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Recovery Optimization and Transition of Care Post-Acute Rejection
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Foundational Principles and Risk Factors in Transplant Immunology & Acute Rejection
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Solid Organ & Hematopoietic Transplant Pharmacotherapy5 Topics|1 Quiz
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Foundations of Transplant Pharmacotherapy: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostics and Classification Systems in Transplant Pharmacotherapy
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Designing Escalating Immunosuppressive Therapy in Critically Ill Transplant Patients
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Supportive Care and ICU-Level Complication Management in Transplant Recipients
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Weaning, Enteral Conversion, PICS Mitigation, and Discharge Planning in Transplant Patients
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Foundations of Transplant Pharmacotherapy: Epidemiology, Pathophysiology, and Risk Factors
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Graft-Versus-Host Disease (GVHD)5 Topics|1 Quiz
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Hypersensitivity Reactions & Desensitization5 Topics|1 Quiz
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Foundational Principles of Hypersensitivity Reactions and Desensitization
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Diagnostic Strategies and Classification of Hypersensitivity Reactions
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Pharmacotherapy Planning for Acute Hypersensitivity Reactions
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Supportive Care and Complication Management in Hypersensitivity Reactions
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Recovery, De-escalation, and Transition of Care Strategies
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Foundational Principles of Hypersensitivity Reactions and Desensitization
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Biologic Immunotherapies & Cytokine Release Syndrome5 Topics|1 Quiz
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Fundamentals of Biologic Immunotherapies & CRS: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Evaluation and Classification of CRS
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Pharmacotherapy Planning and Dose Optimization in CRS
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Supportive Care and Monitoring of CRS-Associated Complications
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Recovery, Mitigation of Long-Term Sequelae, and Transition of Care Post-CRS
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Fundamentals of Biologic Immunotherapies & CRS: Epidemiology, Pathophysiology, and Risk Factors
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EndocrinologyRelative Adrenal Insufficiency and Stress-Dose Steroid Therapy5 Topics|1 Quiz
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Hyperglycemic Crisis (DKA & HHS)5 Topics|1 Quiz
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Foundational Principles and Epidemiology of Hyperglycemic Crises
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Diagnostic Evaluation and Severity Stratification of DKA and HHS
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Escalating Pharmacotherapy in Hyperglycemic Crises
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Supportive Care and Complication Management in Hyperglycemic Crises
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Weaning, Transition, and Safe Handoff Post-Hyperglycemic Crisis
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Foundational Principles and Epidemiology of Hyperglycemic Crises
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Glycemic Control in the ICU5 Topics|1 Quiz
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Foundational Principles and Risk Factors of Dysglycemia in Critical Illness
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Diagnostic Assessment and Classification of Dysglycemia in the ICU
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Pharmacotherapy Strategies for Dysglycemia in the ICU
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Supportive Care and Management of Dysglycemia-Related Complications
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Weaning, Transition, and Discharge Planning after ICU Glycemic Management
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Foundational Principles and Risk Factors of Dysglycemia in Critical Illness
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Thyroid Emergencies: Thyroid Storm & Myxedema Coma5 Topics|1 Quiz
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Foundations of Thyroid Emergencies: Epidemiology, Pathophysiology, and Risk Factors
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Diagnosis and Severity Stratification of Thyroid Emergencies
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Advanced Pharmacotherapy in Thyroid Emergencies
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Supportive Care and Complication Monitoring in Thyroid Emergencies
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Recovery, Transition of Care, and Long-Term Management
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Foundations of Thyroid Emergencies: Epidemiology, Pathophysiology, and Risk Factors
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HematologyAcute Venous Thromboembolism5 Topics|1 Quiz
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Foundational Principles of Acute Venous Thromboembolism
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Diagnosis and Risk Stratification of Acute Venous Thromboembolism
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Pharmacotherapy Strategies for Acute VTE in Critically Ill Patients
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Supportive Care and Complication Management in Acute VTE
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Recovery, De-escalation, and Transition of Care in VTE
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Foundational Principles of Acute Venous Thromboembolism
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Drug-Induced Thrombocytopenia5 Topics|1 Quiz
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Foundational Principles, Pathophysiology, and Risk Factors of Drug-Induced Thrombocytopenia
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Diagnostic and Classification Frameworks for Drug-Induced Thrombocytopenia
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Evidence-Based Pharmacotherapy Strategies for Drug-Induced Thrombocytopenia
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Supportive Care and Complication Management in Drug-Induced Thrombocytopenia
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Recovery Facilitation and Safe Transition of Care in Drug-Induced Thrombocytopenia
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Foundational Principles, Pathophysiology, and Risk Factors of Drug-Induced Thrombocytopenia
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Anemia of Critical Illness5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Evaluation and Classification of Anemia in Critical Illness
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Pharmacotherapeutic Strategies in Anemia of Critical Illness
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Supportive Care and Management of Complications in Anemia of Critical Illness
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Recovery, De-escalation, and Transition of Care
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Drug-Induced Hematologic Disorders5 Topics|1 Quiz
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Foundational Concepts: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Assessment and Classification of Drug-Induced Hematologic Disorders
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Escalating Pharmacotherapy Strategies for Drug-Induced Hematologic Disorders
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Supportive Care and Monitoring in Drug-Induced Hematologic Disorders
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Recovery, De-Escalation, and Transitions of Care
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Foundational Concepts: Epidemiology, Pathophysiology, and Risk Factors
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Sickle Cell Crisis in the ICU5 Topics|1 Quiz
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Foundational Principles and Risk Stratification in Sickle Cell Crisis
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Diagnostic and Classification Criteria for Sickle Cell Crisis
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Pharmacotherapy Strategies in ICU Management of Sickle Cell Crisis
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Supportive Care and Complication Prevention in Sickle Cell Crisis
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Recovery, De-escalation, and Transition of Care for Sickle Cell Crisis Patients
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Foundational Principles and Risk Stratification in Sickle Cell Crisis
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Methemoglobinemia & Dyshemoglobinemias5 Topics|1 Quiz
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Foundational Principles and Pathophysiology of Methemoglobinemia & Dyshemoglobinemias
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Diagnostic Criteria and Severity Classification in Methemoglobinemia & Dyshemoglobinemias
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Pharmacotherapy Strategies for Methemoglobinemia & Dyshemoglobinemias
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Supportive Care, Monitoring, and Complication Management in Methemoglobinemia & Dyshemoglobinemias
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Recovery, De-escalation, and Transition of Care in Methemoglobinemia & Dyshemoglobinemias
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Foundational Principles and Pathophysiology of Methemoglobinemia & Dyshemoglobinemias
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ToxicologyToxidrome Recognition and Initial Management5 Topics|1 Quiz
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Management of Acute Overdoses – Non-Cardiovascular Agents5 Topics|1 Quiz
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Foundational Concepts and Risk Factors in Non-Cardiovascular Acute Overdoses
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Diagnostic Assessment and Severity Classification for Non-Cardiovascular Overdoses
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Pharmacotherapeutic Management and Enhanced Elimination Strategies
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Supportive Care, Monitoring, and Complication Management
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De-escalation, Recovery, and Safe Transition of Care
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Foundational Concepts and Risk Factors in Non-Cardiovascular Acute Overdoses
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Management of Acute Overdoses – Cardiovascular Agents5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic and Classification Strategies in Acute Overdoses
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Pharmacotherapy: Escalating Evidence-Based Treatment
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Supportive Care, Complication Prevention, and Multidisciplinary Decision-Making
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De-escalation, Transition of Care, and Long-Term Recovery
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Toxic Alcohols and Small-Molecule Poisons5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostics and Classification Criteria for Toxic Alcohol Poisoning
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Escalating Pharmacotherapy Planning for Toxic Alcohol Poisoning
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Supportive ICU Care and Complication Prevention
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Therapy De-escalation, Post-ICU Recovery, and Transition of Care
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Antidotes and Gastrointestinal Decontamination5 Topics|1 Quiz
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Foundations of Toxic Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Assessment and Risk Stratification in Poisoned Patients
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Escalating Antidotal Pharmacotherapy and Adjunctive Therapies
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Supportive Care, Complication Prevention, and Multidisciplinary Decision-Making
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Weaning and Transition of Care: From Antidote Infusions to ICU Recovery and Discharge Planning
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Foundations of Toxic Epidemiology, Pathophysiology, and Risk Factors
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Extracorporeal Removal Techniques5 Topics|1 Quiz
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Foundational Principles of Extracorporeal Removal Techniques
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Diagnostic and Classification Criteria for Extracorporeal Intervention
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Evidence‐Based Planning and Modality Selection
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Supportive Care and Complication Prevention During Extracorporeal Therapy
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Weaning, Pharmacotherapy Transition, and Post‐Extracorporeal Recovery
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Foundational Principles of Extracorporeal Removal Techniques
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Withdrawal Syndromes in the ICU5 Topics|1 Quiz
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Foundational Principles of ICU Withdrawal Syndromes
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Diagnostics and Classification of ICU Withdrawal Syndromes
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Evidence-Based Pharmacotherapy for ICU Withdrawal Syndromes
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Supportive Care and Complication Management in ICU Withdrawal Syndromes
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Weaning, Conversion, and Transition of Care in ICU Withdrawal Syndromes
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Foundational Principles of ICU Withdrawal Syndromes
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Infectious DiseasesSepsis and Septic Shock5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of Sepsis and Septic Shock
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Diagnostic Criteria and Severity Stratification in Sepsis and Septic Shock
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Escalating Pharmacotherapy in Sepsis and Septic Shock
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Supportive Care and Complication Prevention in Sepsis and Septic Shock
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Recovery, Rehabilitation, and Transition of Care Post-Sepsis
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of Sepsis and Septic Shock
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Pneumonia (CAP, HAP, VAP)5 Topics|1 Quiz
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Foundational Principles of Pneumonia: Epidemiology, Pathophysiology & Risk Factors
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Diagnostics & Classification: Clinical, Laboratory & Scoring Tools
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Escalating Pharmacotherapy for Critically Ill Pneumonia Patients
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Supportive Care & Complication Monitoring in Pneumonia
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De-escalation, Recovery & Safe Transition of Care
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Foundational Principles of Pneumonia: Epidemiology, Pathophysiology & Risk Factors
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Endocarditis5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic and Classification Criteria in Endocarditis
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Evidence-Based Pharmacotherapy Strategies for Endocarditis
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Supportive Care and Management of Complications in Endocarditis
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Transition of Care, De-Escalation, and Recovery Planning
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors
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CNS Infections5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of CNS Infections
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Diagnostic Evaluation and Severity Stratification in CNS Infections
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Escalating Pharmacotherapy Strategies for Critically Ill Patients with CNS Infections
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Adjunctive Supportive Care and Complication Management in CNS Infections
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Recovery, Rehabilitation, and Transition of Care in CNS Infections
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of CNS Infections
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Complicated Intra-abdominal Infections5 Topics|1 Quiz
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Antibiotic Stewardship & PK/PD5 Topics|1 Quiz
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Foundational Principles of Antibiotic Stewardship & PK/PD in Critical Care
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Diagnostic Criteria and Risk Stratification for Antimicrobial Stewardship in Critical Care
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Evidence-Based Pharmacotherapy Planning and PK/PD Optimization in Critically Ill Patients
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Supportive Care and Management of Antimicrobial-Related Complications in the ICU
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De-escalation Strategies and Transition of Care Post-Antimicrobial Therapy
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Foundational Principles of Antibiotic Stewardship & PK/PD in Critical Care
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Clostridioides difficile Infection5 Topics|1 Quiz
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Febrile Neutropenia & Immunocompromised Hosts5 Topics|1 Quiz
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Epidemiology, Pathophysiology, and Risk Factors of Febrile Neutropenia
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Diagnostic Evaluation and Risk Stratification in Febrile Neutropenia
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Empiric Antimicrobial Pharmacotherapy and Dosing in Febrile Neutropenia
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Supportive Care and Critical Care Management in Febrile Neutropenia
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Recovery, De-Escalation, and Transition of Care in Febrile Neutropenia
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Epidemiology, Pathophysiology, and Risk Factors of Febrile Neutropenia
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Skin & Soft-Tissue Infections / Acute Osteomyelitis5 Topics|1 Quiz
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Urinary Tract and Catheter-related Infections5 Topics|1 Quiz
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Foundational Principles of Urinary Tract and Catheter-related Infections
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Diagnostic Criteria and Severity Stratification for Urinary Tract and Catheter-related Infections
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Designing Evidence-Based Pharmacotherapy for Urinary Tract and Catheter-related Infections in Critically Ill Patients
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Supportive Care and Management of Complications Associated with Urinary Tract and Catheter-related Infections
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Antimicrobial De-escalation, IV-to-Oral Conversion, and Safe Transition of Care
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Foundational Principles of Urinary Tract and Catheter-related Infections
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Pandemic & Emerging Viral Infections5 Topics|1 Quiz
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Foundational Principles and Risk Factors in Pandemic & Emerging Viral Infections
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Diagnostics and Severity Classification in Pandemic & Emerging Viral Infections
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Escalating Pharmacotherapy for Pandemic & Emerging Viral Infections
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Supportive Care and Monitoring in Pandemic & Emerging Viral Infections
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Recovery, De-escalation, and Transition of Care in Pandemic & Emerging Viral Infections
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Foundational Principles and Risk Factors in Pandemic & Emerging Viral Infections
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Supportive Care (Pain, Agitation, Delirium, Immobility, Sleep)Pain Assessment and Analgesic Management5 Topics|1 Quiz
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Foundational Principles of Pain Assessment and Analgesic Management
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Diagnostic and Classification Strategies for Pain Assessment in Critically Ill Patients
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Evidence-Based Escalating Pharmacotherapy for ICU Pain Management
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Supportive Care Measures and Monitoring for Pain-Related Complications
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Analgesic De-escalation, Weaning, and Transition of Care
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Foundational Principles of Pain Assessment and Analgesic Management
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Sedation and Agitation Management5 Topics|1 Quiz
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Foundations of Sedation and Agitation: Epidemiology, Pathophysiology, and Risk Assessment
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Diagnostic Assessment and Classification of Sedation and Agitation in the ICU
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Evidence-based Pharmacotherapy for Sedation and Agitation in Critical Illness
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Supportive Care and Monitoring of Complications in Sedation and Agitation Management
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Weaning, Transition, and Post-ICU Care in Sedation Management
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Foundations of Sedation and Agitation: Epidemiology, Pathophysiology, and Risk Assessment
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Delirium Prevention and Treatment5 Topics|1 Quiz
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Sleep Disturbance Management5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of ICU Sleep Disturbances
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Assessment and Classification of ICU Sleep Disturbances
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Pharmacologic Management: Designing an Evidence-Based Escalation Plan
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Supportive Care, Environmental Strategies, and Monitoring
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Recovery, De-Escalation, and Transition of Care
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of ICU Sleep Disturbances
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Immobility and Early Mobilization5 Topics|1 Quiz
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Foundational Principles and Risk Factors for Immobility and ICU‐Acquired Weakness
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Diagnostic and Classification Criteria for Immobility‐Related Complications
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Evidence‐Based Pharmacotherapy Planning to Optimize Early Mobilization
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Supportive Care Measures and Management of Complications
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Recovery Pathways and Safe Transition of Care
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Foundational Principles and Risk Factors for Immobility and ICU‐Acquired Weakness
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Oncologic Emergencies5 Topics|1 Quiz
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Pathophysiology and Clinical Presentations of ICU‐Relevant Oncologic Emergencies
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Diagnostic Assessment and Risk Stratification in Oncologic Emergencies
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Evidence‐Based Pharmacologic Management of Oncologic Emergencies
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ICU‐Level Supportive Care and Complication Prevention in Oncologic Emergencies
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Transition‐of‐Care and De‐escalation Strategies Post‐Oncologic Emergencies
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Pathophysiology and Clinical Presentations of ICU‐Relevant Oncologic Emergencies
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End-of-Life Care & Palliative CareGoals of Care & Advance Care Planning5 Topics|1 Quiz
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Foundational Principles and Frameworks of Goals of Care & Advance Care Planning
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Patient Stratification and Prioritization for Advance Care Planning
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Pharmacotherapy Alignment with Patient-Defined Goals in Critical Care
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Supportive Symptom Management and Monitoring in Comfort-Focused Care
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Structured Communication and Interprofessional Collaboration for Goals of Care Transitions
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Foundational Principles and Frameworks of Goals of Care & Advance Care Planning
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Pain Management & Opioid Therapy5 Topics|1 Quiz
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Dyspnea & Respiratory Symptom Management5 Topics|1 Quiz
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Sedation & Palliative Sedation5 Topics|1 Quiz
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of Sedation
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Diagnostic Assessment: Sedation Depth and Refractory Symptom Classification
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Pharmacotherapy Planning: Escalation Strategies for Sedation and Palliative Sedation
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Supportive Care and Monitoring during Deep Sedation
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Weaning Protocols and Continuity of Care Post-Sedation
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Foundational Principles: Epidemiology, Pathophysiology, and Risk Factors of Sedation
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Delirium Agitation & Anxiety5 Topics|1 Quiz
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Foundational Principles of ICU Delirium, Agitation & Anxiety
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Diagnostic Assessment and Classification in ICU Delirium, Agitation & Anxiety
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Pharmacotherapy Strategies for ICU Delirium, Agitation & Anxiety
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Supportive Care and Monitoring in ICU Delirium, Agitation & Anxiety
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Recovery, De-Escalation, and Transition of Care in ICU Delirium, Agitation & Anxiety
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Foundational Principles of ICU Delirium, Agitation & Anxiety
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Nausea, Vomiting & Gastrointestinal Symptoms5 Topics|1 Quiz
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Foundational Principles of Nausea, Vomiting & Gastrointestinal Symptoms
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Diagnostic and Classification Criteria for Nausea, Vomiting & Gastrointestinal Symptoms
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Evidence-Based Pharmacotherapy Strategies for Nausea, Vomiting & Gastrointestinal Symptoms
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Supportive Care and Monitoring of Nausea, Vomiting & Gastrointestinal Symptoms
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Facilitating Recovery, Weaning, and Safe Transition of Care
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Foundational Principles of Nausea, Vomiting & Gastrointestinal Symptoms
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Management of Secretions (Death Rattle)5 Topics|1 Quiz
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Foundational Principles and Pathophysiology of Death Rattle
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Diagnostic Evaluation and Classification of Death Rattle
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Pharmacotherapeutic Strategies for Management of Secretions
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Supportive Care and Complication Monitoring in Death Rattle Management
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Therapy De-escalation, Route Conversion, and Transitional Care Planning
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Foundational Principles and Pathophysiology of Death Rattle
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Fluids, Electrolytes, and Nutrition ManagementIntravenous Fluid Therapy and Resuscitation5 Topics|1 Quiz
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Foundational Principles and Pathophysiology of Intravenous Fluid Therapy
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Diagnostic Assessment and Classification of Volume Status
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Evidence-Based Pharmacotherapy in Fluid Resuscitation
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Supportive Care and Complication Management in Fluid Resuscitation
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De-escalation, Transition, and Long-term Recovery Post-Resuscitation
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Foundational Principles and Pathophysiology of Intravenous Fluid Therapy
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Acid–Base Disorders5 Topics|1 Quiz
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Foundational Principles: Pathophysiology, Epidemiology, and Risk Factors
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Diagnostic Assessment and Classification of Acid–Base Disorders
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Pharmacotherapy Strategies for Metabolic and Respiratory Disturbances
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Supportive Care, Ventilation, and Complication Management
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Recovery, De‐Escalation, and Safe Transition of Care
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Foundational Principles: Pathophysiology, Epidemiology, and Risk Factors
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Sodium Homeostasis and Dysnatremias5 Topics|1 Quiz
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Foundational Principles of Sodium Homeostasis and Dysnatremias
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Diagnostic and Classification Framework for Dysnatremias
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Evidence-Based Pharmacotherapy Planning for Sodium Disorders in Critical Care
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Supportive Monitoring and Complication Management during Dysnatremia Correction
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Transition of Care and Recovery Planning after Dysnatremia Management
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Foundational Principles of Sodium Homeostasis and Dysnatremias
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Potassium Disorders5 Topics|1 Quiz
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Foundational Principles of Potassium Disorders: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Criteria and Severity Classification in Potassium Disorders
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Evidence-Based Pharmacotherapy for Hypokalemia and Hyperkalemia in Critically Ill Patients
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Supportive Care Measures and Monitoring in the Management of Potassium Disorders
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De-escalation Strategies and Transition of Care in Potassium Disorders
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Foundational Principles of Potassium Disorders: Epidemiology, Pathophysiology, and Risk Factors
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Calcium and Magnesium Abnormalities5 Topics|1 Quiz
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Foundational Principles of Calcium and Magnesium Abnormalities in Critical Illness
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Diagnostic Evaluation and Severity Stratification of Calcium and Magnesium Disorders
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Advanced Pharmacologic Strategies for Calcium and Magnesium Repletion and Removal
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Supportive Care and Monitoring Strategies in Calcium and Magnesium Disorders
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Recovery, Transition of Care, and Long-Term Management of Calcium and Magnesium Abnormalities
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Foundational Principles of Calcium and Magnesium Abnormalities in Critical Illness
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Phosphate and Trace Electrolyte Management5 Topics|1 Quiz
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Foundational Concepts and Epidemiology of Phosphate and Trace Electrolyte Disturbances
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Diagnostics and Classification of Phosphate and Trace Electrolyte Disturbances
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Pharmacotherapy Strategies for Hypo- and Hyperphosphatemia
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Supportive Care and Monitoring in Electrolyte Disturbances
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Recovery, Weaning, and Transition of Care in Electrolyte Management
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Foundational Concepts and Epidemiology of Phosphate and Trace Electrolyte Disturbances
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Enteral Nutrition Support5 Topics|1 Quiz
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Foundational Principles of Enteral Nutrition Support
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Assessment and Classification Criteria for Enteral Nutrition Support
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Designing an Evidence-Based Escalation Plan for Enteral Nutrition Therapy
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Supportive Care and Complication Management in Enteral Nutrition Support
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Weaning, Medication Conversion, and Transition of Care in Enteral Nutrition Support
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Foundational Principles of Enteral Nutrition Support
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Parenteral Nutrition Support5 Topics|1 Quiz
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Foundations of Parenteral Nutrition Support: Epidemiology, Pathophysiology, and Risk Factors
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Diagnostic Evaluation and Risk Stratification in Parenteral Nutrition Support
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Pharmacotherapeutic Planning and Formulation Selection in Parenteral Nutrition Support
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Supportive Care, Complication Prevention, and Goals of Care in Parenteral Nutrition Support
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Weaning, Transition of Nutrition Support, and Post-ICU Continuity in Parenteral Nutrition Support
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Foundations of Parenteral Nutrition Support: Epidemiology, Pathophysiology, and Risk Factors
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Refeeding Syndrome and Specialized Nutrition5 Topics|1 Quiz
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Foundational Principles: Pathophysiology, Epidemiology, and Risk Factors of Refeeding Syndrome
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Diagnosis and Risk Stratification of Refeeding Syndrome
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Pharmacotherapy and Specialized Nutrition Strategies in Refeeding Syndrome
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Supportive Care Measures and ICU Complication Prevention in Refeeding Syndrome
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Recovery, Weaning, and Transition of Care in Refeeding Syndrome
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Foundational Principles: Pathophysiology, Epidemiology, and Risk Factors of Refeeding Syndrome
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Trauma and BurnsInitial Resuscitation and Fluid Management in Trauma5 Topics|1 Quiz
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Foundational Principles, Pathophysiology, and Epidemiology of Trauma-Induced Hypovolemia
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Diagnostics and Classification of Hemorrhagic Shock in Trauma Patients
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Evidence-Based Fluid Selection and Transfusion Strategies in Trauma Resuscitation
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Supportive Care and Management of Complications Post-Resuscitation
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Recovery, De-escalation, and Transition of Care after Initial Resuscitation
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Foundational Principles, Pathophysiology, and Epidemiology of Trauma-Induced Hypovolemia
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Hemorrhagic Shock, Massive Transfusion, and Trauma‐Induced Coagulopathy5 Topics|1 Quiz
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Foundational Principles and Epidemiology of Hemorrhagic Shock and Trauma‐Induced Coagulopathy
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Diagnostics and Classification in Hemorrhagic Shock and Trauma‐Induced Coagulopathy
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Designing an Evidence‐Based, Escalating Pharmacotherapy and Transfusion Plan
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Supportive Care, Monitoring, and Complication Management
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Recovery, De‐Escalation, and Transition of Care after Massive Transfusion
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Foundational Principles and Epidemiology of Hemorrhagic Shock and Trauma‐Induced Coagulopathy
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Burns Pharmacotherapy5 Topics|1 Quiz
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Foundational Principles of Burn Shock Pathophysiology and Hypermetabolism
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Diagnostic Assessment and Classification in Acute Burn Care
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Evidence-Based Pharmacotherapy Strategies for Burn Fluid Resuscitation
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Supportive Care and Monitoring to Prevent and Manage Resuscitation Complications
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Transition to Recovery: Fluid Tapering, Nutritional Transition, and Discharge Planning
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Foundational Principles of Burn Shock Pathophysiology and Hypermetabolism
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Burn Wound Care5 Topics|1 Quiz
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Foundational Principles of Burn Wound Pathophysiology and Risk Factors
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Diagnostic Evaluation and Risk Stratification in Burn Injury and Sepsis
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Pharmacotherapy for Burn Wound Infection Prevention and Sepsis Management
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Supportive Care and Monitoring of Complications in Burn Patients
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Recovery, De-Escalation, and Transition of Care in Burn Patients
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Foundational Principles of Burn Wound Pathophysiology and Risk Factors
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Open Fracture Antibiotics5 Topics|1 Quiz
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Foundational Principles of Infection Risk in Open Fractures
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Diagnostics and Classification of Open Fractures
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Evidence-Based Antibiotic Selection and Dosing for Open Fractures
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Supportive Care and Prevention of Complications in Open Fracture Management
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De-escalation, IV to Oral Conversion, and Transition of Care in Open Fracture Patients
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Foundational Principles of Infection Risk in Open Fractures
Participants 432
Antiplatelet Therapy in ACS: Selection, Loading, and Duration
Selection, Loading, and Duration of DAPT in ACS
Learning Objective
Optimize dual antiplatelet therapy (DAPT) strategies in acute coronary syndromes (ACS) by selecting appropriate agents, timing, and duration based on patient risk profiles and clinical context.
1. Aspirin Pharmacotherapy
Aspirin plays a crucial role in the management of acute coronary syndromes (ACS) by irreversibly inhibiting platelet cyclooxygenase-1 (COX-1). This action blocks the production of thromboxane A₂ (TXA₂), a potent mediator of platelet aggregation and vasoconstriction. Effective aspirin therapy reduces mortality and the risk of reinfarction in patients with ACS. The choice of formulation and dosing regimen is critical to balance the rapidity of onset with the potential for bleeding complications.
Mechanism & PK/PD
- Aspirin achieves its antiplatelet effect through irreversible acetylation of serine residue on platelet COX-1.
- This inhibition lasts for the entire lifespan of the affected platelets, typically 7–10 days.
- Suppression of TXA₂ synthesis effectively prevents platelet aggregation and reduces vasoconstriction at the site of coronary plaque rupture.
Formulations & Onset of Action
- Chewable/Non–Enteric-Coated Aspirin: This formulation is preferred for loading doses in ACS. It allows for rapid absorption, with peak plasma concentrations achieved within 20–30 minutes. Chewing the tablet facilitates buccal absorption and hastens onset.
- Enteric-Coated Aspirin: This formulation is designed to protect the gastric mucosa but delays absorption by 1–3 hours. It is not recommended for acute loading in ACS due to its slower onset of antiplatelet effect.
Dosing Recommendations
- Loading Dose: A dose of 162–325 mg of chewable, non-enteric-coated aspirin should be administered as soon as ACS is diagnosed or suspected.
- Maintenance Dose: For secondary prevention, a daily dose of 75–100 mg (commonly 81 mg in North America) of aspirin is recommended.
Monitoring & Contraindications
- Routine laboratory monitoring of aspirin’s antiplatelet effect is generally not required.
- Clinicians should monitor for signs and symptoms of gastrointestinal (GI) bleeding, such as melena, hematemesis, or unexplained anemia.
- Contraindications:
- Active pathological bleeding (e.g., intracranial hemorrhage, active peptic ulcer).
- Known hypersensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in patients with asthma and nasal polyps (aspirin-exacerbated respiratory disease).
- Severe active peptic ulcer disease.
- GI Prophylaxis: Consider a proton pump inhibitor (PPI) for patients at high risk of GI bleeding. Risk factors include a history of GI bleeding, concurrent use of anticoagulants or corticosteroids, advanced age, and H. pylori infection.
Key Pearls for Aspirin Therapy
- Always use chewable, non-enteric-coated aspirin for the initial loading dose in ACS to ensure rapid and effective platelet inhibition.
- A daily maintenance dose of 81 mg (or 75-100 mg) generally provides an optimal balance between antiplatelet efficacy and bleeding risk for long-term secondary prevention. Higher maintenance doses have not shown additional benefit and may increase bleeding.
2. P2Y₁₂ Inhibitor Pharmacotherapy
Oral P2Y₁₂ receptor inhibitors are a cornerstone of DAPT, complementing aspirin by blocking adenosine diphosphate (ADP)-mediated platelet activation and aggregation. The selection of a specific P2Y₁₂ inhibitor depends on several factors, including the type of ACS (STEMI vs. NSTEMI), planned treatment strategy (invasive vs. conservative), patient-specific pharmacokinetic and pharmacogenomic considerations, and individual ischemic and bleeding risk profiles.
A. Mechanism & PK/PD Overview
- Clopidogrel: A thienopyridine prodrug requiring a two-step metabolic activation process primarily by the cytochrome P450 (CYP) enzyme CYP2C19. Its onset of action is relatively slow (2–6 hours after a loading dose). Antiplatelet effect can be variable due to genetic polymorphisms affecting CYP2C19 activity. It causes irreversible blockade of the P2Y₁₂ receptor.
- Prasugrel: Another thienopyridine prodrug, but it undergoes a more efficient one-step activation, largely independent of CYP2C19. This results in a faster onset (approximately 30 minutes) and more potent, consistent, and irreversible P2Y₁₂ receptor inhibition compared to clopidogrel.
- Ticagrelor: A direct-acting, non-thienopyridine cyclopentyltriazolopyrimidine (CPTP). It binds reversibly to the P2Y₁₂ receptor and does not require metabolic activation for its effect. Onset of action is rapid (approximately 30 minutes).
B. General Indications for P2Y₁₂ Inhibitors in ACS
- All patients with ACS undergoing percutaneous coronary intervention (PCI) should receive DAPT, consisting of aspirin and a P2Y₁₂ inhibitor.
- For patients with high-risk NSTEMI managed medically (i.e., without early revascularization), DAPT is generally recommended, with the choice and timing of P2Y₁₂ inhibitor initiation guided by clinical judgment and subsequent decisions regarding invasive strategy.
C. Agent Selection & Clinical Decision Points
- Utilize validated risk scores such as the DAPT score (for ischemic risk) and PRECISE-DAPT score (for bleeding risk) to help guide the choice and duration of P2Y₁₂ inhibitor therapy.
- STEMI: In patients presenting with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI, potent P2Y₁₂ inhibitors (prasugrel or ticagrelor) are generally preferred over clopidogrel due to their faster onset and greater platelet inhibition, leading to improved ischemic outcomes.
- NSTEMI: In patients with non-ST-segment elevation ACS (NSTEMI), the strategy for P2Y₁₂ inhibitor loading is more nuanced. If an early invasive strategy is planned, it is often recommended to defer loading with potent P2Y₁₂ inhibitors until after coronary angiography defines the anatomy. This approach minimizes bleeding risk in patients who may not undergo PCI or may require coronary artery bypass grafting (CABG). Clopidogrel may be considered for initial loading if bleeding risk is high or if potent agents are contraindicated.
D. Agent Profiles
Agent | Loading Dose | Maintenance Dose | Potential Advantages | Potential Disadvantages/Cautions |
---|---|---|---|---|
Clopidogrel | 600 mg PO (300 mg if presentation <6 h or fibrinolysis given) | 75 mg QD | Lower bleeding risk compared to potent agents; cost-effective; standard of care in conjunction with fibrinolytic therapy. | Slower onset of action; significant inter-individual variability in response due to CYP2C19 genetic polymorphisms; less potent platelet inhibition. |
Prasugrel | 60 mg PO | 10 mg QD (reduce to 5 mg QD if age ≥75 years OR body weight <60 kg) | Rapid onset; potent and consistent platelet inhibition; demonstrated reduction in MI and stent thrombosis compared to clopidogrel in PCI patients. | Increased risk of major and fatal bleeding compared to clopidogrel; contraindicated in patients with a history of stroke or transient ischemic attack (TIA). Use with caution in elderly (≥75 years) and low body weight (<60 kg) patients. |
Ticagrelor | 180 mg PO | 90 mg BID | Rapid onset; consistent platelet inhibition without need for metabolic activation (no known major genetic variability in response); demonstrated reduction in vascular death and overall mortality compared to clopidogrel in ACS. | Dyspnea is a common side effect (10–15%); can cause asymptomatic bradyarrhythmias; potential for interactions with strong CYP3A4 inhibitors or inducers; higher cost than clopidogrel. Twice daily dosing may affect adherence. |
E. Monitoring & Interactions
- Proton Pump Inhibitors (PPIs): If a PPI is indicated for gastroprotection in patients receiving clopidogrel, pantoprazole or rabeprazole are often preferred due to a potentially lower risk of inhibiting CYP2C19, although the clinical significance of this interaction remains debated. This is less of a concern with prasugrel or ticagrelor.
- Ticagrelor Interactions: Avoid co-administration of ticagrelor with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin, ritonavir) which can increase ticagrelor levels and bleeding risk, or strong CYP3A4 inducers (e.g., rifampin, phenytoin, carbamazepine) which can decrease ticagrelor efficacy. Monitor for dyspnea and bradycardia.
- Platelet Function Testing/Genotyping: Routine platelet function testing or CYP2C19 genotyping is not generally recommended for all patients. However, it may be considered in select high-risk patients (e.g., those with recurrent ischemic events despite DAPT, or prior to elective PCI) to guide P2Y₁₂ inhibitor selection or adjustment, particularly if clopidogrel is being considered or used.
Key Pearls for P2Y₁₂ Inhibitor Therapy
- For prasugrel, dose reduction (5 mg daily maintenance) is crucial in elderly patients (≥75 years) or those with low body weight (<60 kg) to mitigate bleeding risk, unless a compelling ischemic benefit outweighs this risk. Prasugrel is contraindicated in patients with a history of stroke/TIA.
- Emerging strategies, such as ticagrelor monotherapy after a short course of DAPT (e.g., 1-3 months of aspirin), aim to leverage the rapid offset of ticagrelor’s reversible binding and potentially reduce long-term bleeding complications without compromising ischemic protection in select patients.
3. Loading Strategies and Timing of P2Y₁₂ Inhibitors
The timing of P2Y₁₂ inhibitor loading dose administration—whether “upstream” (e.g., in the prehospital setting or emergency department before angiography) or “in-lab” (at the time of PCI after coronary anatomy is defined)—can significantly influence both ischemic and bleeding outcomes. The optimal strategy often varies depending on the ACS subtype (STEMI vs. NSTEMI).
Upstream Loading (Pre-PCI Administration)
- Goal: To achieve therapeutic levels of platelet inhibition at the time of coronary vessel instrumentation during PCI, potentially reducing periprocedural ischemic complications.
- STEMI: The ATLANTIC trial investigated prehospital administration of ticagrelor in STEMI patients. While prehospital ticagrelor was found to be safe and resulted in a reduction in early stent thrombosis, it did not significantly improve pre-PCI coronary reperfusion rates. Current guidelines generally support upstream loading with a potent P2Y₁₂ inhibitor (ticagrelor or prasugrel) for STEMI patients undergoing primary PCI.
- NSTEMI: The ACCOAST trial evaluated pretreatment with prasugrel in NSTEMI patients scheduled for an invasive strategy. Prasugrel pretreatment was associated with a significant increase in bleeding complications without a corresponding reduction in ischemic events. Consequently, routine upstream loading with potent P2Y₁₂ inhibitors is generally not recommended for NSTEMI patients before coronary angiography.
In-Lab Loading (At the Time of PCI)
- This strategy involves administering the P2Y₁₂ inhibitor loading dose after diagnostic angiography has defined the coronary anatomy and the decision to proceed with PCI has been made.
- It is particularly relevant in NSTEMI patients where coronary anatomy is uncertain, as it minimizes bleeding risk in patients who may ultimately be managed medically, require CABG, or have non-obstructive coronary disease.
STEMI vs. NSTEMI Loading Considerations
- STEMI: Urgent upstream loading with ticagrelor or prasugrel is generally recommended to achieve rapid and robust platelet inhibition prior to or at the time of primary PCI.
- NSTEMI: It is generally advisable to defer P2Y₁₂ inhibitor loading until coronary anatomy is defined by angiography, especially for potent agents like prasugrel or ticagrelor. If a P2Y₁₂ inhibitor is given upstream in NSTEMI, clopidogrel may be a safer option, particularly if bleeding risk is high or if there’s a possibility of CABG.
Key Pearls for Loading Strategies
- Do not routinely pretreat NSTE-ACS patients with potent P2Y₁₂ inhibitors (prasugrel or ticagrelor) before diagnostic angiography, as this practice has been associated with increased bleeding without clear ischemic benefit.
- In STEMI patients receiving upstream P2Y₁₂ inhibitor loading, be mindful of potential drug-drug interactions, such as morphine-induced delay in the absorption and onset of action of oral P2Y₁₂ inhibitors. Consider strategies to mitigate this if clinically significant.
4. Maintenance Therapy and Duration of DAPT
Following an ACS event and initial loading, the duration of DAPT is a critical consideration. While a standard 12-month course has been the traditional approach, contemporary practice emphasizes individualizing therapy duration. This involves shortening DAPT for patients at high bleeding risk, potentially prolonging it for those at high ischemic risk, and considering transitions to P2Y₁₂ inhibitor monotherapy or de-escalation strategies based on evolving patient factors and risk assessments.
Standard 12-Month DAPT
- A 12-month duration of DAPT (aspirin plus a P2Y₁₂ inhibitor, typically a potent agent like ticagrelor or prasugrel post-PCI) has been the standard of care, supported by landmark clinical trials such as CURE (clopidogrel), TRITON-TIMI 38 (prasugrel), and PLATO (ticagrelor).
- This duration is generally recommended for most ACS patients unless there is a high risk of bleeding or other contraindications.
Shortened DAPT Duration (e.g., 3–6 Months)
- For patients identified as having a high bleeding risk (e.g., PRECISE-DAPT score ≥25, advanced age ≥75 years, history of major bleeding, need for chronic oral anticoagulation), a shorter duration of DAPT (e.g., 1, 3, or 6 months) followed by P2Y₁₂ inhibitor or aspirin monotherapy is increasingly recommended.
- Trials like STOPDAPT-2 and SMART-DATE have suggested that shorter DAPT durations in selected PCI populations do not significantly increase ischemic events but do lead to a reduction in bleeding complications.
Prolonged DAPT Duration (>12 Months)
- In patients with a high ischemic risk (e.g., DAPT score ≥2, history of recurrent MI, complex PCI, multivessel disease, diabetes) and a low bleeding risk, extending DAPT beyond 12 months may be considered.
- The DAPT Study and PEGASUS-TIMI 54 trial demonstrated that prolonged DAPT can reduce the risk of myocardial infarction and stent thrombosis but at the cost of an increased risk of bleeding. The decision requires careful balancing of absolute risk reductions in ischemic events against the incremental bleeding risk.
P2Y₁₂ Inhibitor Monotherapy (Aspirin Discontinuation)
- An emerging strategy involves discontinuing aspirin after an initial period of DAPT (e.g., 1–3 months post-PCI) and continuing with P2Y₁₂ inhibitor monotherapy (typically ticagrelor or clopidogrel).
- The TWILIGHT trial, for instance, showed that in high-risk PCI patients who completed 3 months of DAPT, ticagrelor monotherapy for an additional 12 months significantly reduced clinically relevant bleeding by 44% compared to ticagrelor plus aspirin, without an increase in ischemic events.
De-Escalation Protocols
- De-escalation involves switching from a more potent P2Y₁₂ inhibitor (ticagrelor or prasugrel) to clopidogrel after an initial period of intensive antiplatelet therapy (e.g., 1 month post-ACS).
- This strategy may be guided by factors such as bleeding events, intolerable side effects from potent agents, patient preference, cost considerations, or results from platelet function testing/genotyping in selected cases. The goal is to maintain adequate ischemic protection while minimizing long-term bleeding risk.
Key Pearls for DAPT Duration and Maintenance
- Utilize validated bleeding risk scores like PRECISE-DAPT to identify candidates who may benefit from a shortened duration of DAPT (e.g., ≤6 months) to minimize bleeding complications.
- Employ ischemic risk scores like the DAPT score to help weigh the potential benefits and risks of extending DAPT beyond 1 year in patients with high ischemic risk and low bleeding risk.
References
- Rao SV, Newby LK, Hochman JS, et al. 2025 ACC/AHA guideline for the management of patients with acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151:e771–e862.
- Wiviott SD, Braunwald E, McCabe CH, et al; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–2015.
- Wallentin L, Becker RC, Budaj A, et al; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–1057.
- Montalescot G, van ‘t Hof AW, Lapostolle F, et al; ATLANTIC Investigators. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med. 2014;371(11):1016–1027.
- Montalescot G, Bolognese L, Dudek D, et al; ACCOAST Investigators. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med. 2013;369(11):999–1010.
- Costa F, van Klaveren D, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and dual antiplatelet therapy (PRECISE-DAPT) score. Lancet. 2017;389(10073):1025–1034.
- Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA. 2016;315(16):1735–1749.
- Mehran R, Baber U, Sharma SK, et al; TWILIGHT Investigators. Ticagrelor with or without aspirin in high-risk patients after PCI. N Engl J Med. 2019;381(21):2032–2042.
- Bellemain-Appaix A, O’Connor SA, Silvain J, et al. Association of clopidogrel pretreatment with mortality, cardiovascular events, and major bleeding in patients with non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. JAMA. 2012;308(23):2507–2516.
- Steg PG, James S, Harrington RA, et al; PLATO Study Group. Ticagrelor versus clopidogrel in patients with ST-elevation acute coronary syndromes intended for reperfusion with primary percutaneous coronary intervention: A Platelet Inhibition and Patient Outcomes (PLATO) trial subgroup analysis. Circulation. 2010;122(21):2131–2141.