1 Coronary Artery Disease Flashcards
Chronic Coronary Disease
- ___ angina / ___ ischemic heart disease
- post ___ or revascularization
- angina with coronary artery ___ / microvascular angina
- stable/stable
- ACS
- spasm
Acute Coronary Syndromes
- ___ angina
- non ___ segment elevation MI
- ___ segment elevation MI
- unstable
- ST
- ST
Clinical Syndromes of Chronic Coronary Disease
- Stable angina pectoris: ___ disease
- Post-ACS; post-revascularization
- variant or Prinzmetal angina: ___ disease
- cardiac syndrome X: ___ disease
- silent myocardial ___
- macrovascular
- vasospastic
- microvascular
- ischemia
Myocardial Ischemia - Oxygen Supply/Demand Imbalance
1) fixed ___ , vaso ___ , thrombus
2) decreased coronary ___
3) ischemia
4) angina
1) stenosis, spasm
2) bloodflow
Myocardial Ischemia - Oxygen Supply/Demand Imbalance
1) increased ___ , contractility, afterload, preload
2) increased oxygen ___
3) ischemia
4) angina
1) HR
2) consumption
Factors Impacting Myocardial O2 Supply/Demand Ratio
- Contractility - decrease will ___ O2 consumption
- HR - decrease will ___ O2 consumption and ___ coronary perfusion
- Preload-LVEDV - ___ by venodilation, decrease leads to ___ in O2 consumption, decrease leads to ___ in myocardial perfusion
- Afterload - ___ by dilation of arteries, decrease leads to ___ in O2 consumption
Contractility - decrease
HR - decrease, increase
Preload-LVEDV - decreaased,
decrease, increase
Afterload - decreased, decrease
Epicardial Vessels
1, 2, 3: ___
11: ___
12, 13, 14: ___
18,19: ___
RCA = right coronary artery
LM = left main
LAD = left anterior
LCX = left circumflex
LAD = “widow maker”
Pathophysiology of Stable Angina
Myocardial ischemia
- imbalance between myocardial oxygen ___ and ___
- usually secondary to increased myocardial work ( ___ induced) in the setting of a fixed decrease in myocardial oxygen ___
- produces disturbances in myocardial function without causing myocardial ___
- supply, demand
- effort, supply
- necrosis
Stable Angina Pectoris
___ discomfort in the chest/other areas
caused by myocarridal ___ and assocaited with a disturbance in function without ___
___ characterisitics of anginal episodes
- substernal
- ischemia, necrosis
- unchanging
Clinical Presentation: PQRST
- Precipitating factors: ___
- Palliative measures: ___ and/or ___
- Quality and quantity of pain: squeezing, heaviness, tightening
- Region and radiation: ___
- Severity of the pain: subjective > 5/10
- Timing and temporal pattern: lasts < ___ min, usually relieved in 5-10 min
- exertion
- rest, SL NTG
- substernal
- 20 min
Classic Clinical Characteristics
ECG findings
- ___ segment depression (during ___)
- ___ segment elevation in variant ___
- ST, ischemia
- ST, angina
Diagnostic Procedures for CHD - Exercise Tolerance Testing
- treadmill or bicycle exercise testing
- endpoints: duration, workload achieved, ECG changes, BP and HR responses, Sxs
- double product: ___ x ___ is used as an index of MVO2
- assessment of drug therapy - ___ and ___ may complicate interpretation by decreaseing HR
- HR x SBP
- beta blockers, CCBs
Diagnostic Procedures for CHD
Cardiac Imaging
- pharmacologic stress testing ( ___ )
- nuclear imaging
- electron beam computerized tomography (EBCT)
- calcium score (contraversial)
Echocardiography
Cardiac catheterization and coronary angiography
- definitive assessment of coronary anatomy
- invasive
- most ___ medical procedure in the US
- Dobutamine
- common
Question 1
A
Treatment of CCD
desired outcome 1
- risk factor modification
- prevent ___ and ___
desired outcome 2
- management of ___ episodes
- alleviate acute Sxs and prevent recurrent Sxs of ___
- ACS, death
- anginal
- ischemia
Treatment Algorithm - Risk Factor Modification
1) LSM
2) ___ vaccine
3) management of comorbidities - HTN: BP goal of less than or equal to ___ mmHg, DM: A1c less than or equal to ___ % , moderate to ___ intensity statins
4) antiplatelet therapy - ASA ___ mg daily OR ___ 75 mg daily if allergy
5) ___ - if HTN, DM, LVEF < 40%, or CKD OR ARB if intolerant
- flu
- 130/80, 7, high
- 81, clopidogrel
- ACEi
Treatment Algorithm - Management of Angina
1) ___ - for acute attacks
2) Vasospastic angina? yes: BP < 130/80, add ___ , BP > 130/80, add ___, no: HR > 60 bpm: add ___ or ___
3) Angina symptoms controlled? yes: continue therapy and monitor, no…
4) BP < 130/80? yes: add ___ or ___ , no: add ___
5) continued angina? consider ___ or ___ surgery
- SL NTG
- LA nitrate, CCB
- beta-blocker, Non-DHP CCB
- ranolazine, LA nitrate
- DHP CCB
- PCI, CABG
Other Risk Factor Modifications
- influenza vaccination
- alcohol consumption
- exposure to air pollution
- management of psychological factors
Pharmacotherapy
Stable Angina/Ischemic Heart Disease, Post-ACS, or revascularization (5)
1) anti-platelet therapy
2) statin therapy
3) ACEi/ARB
4) colchicine?
5) beta-blockers
ASA: Platelet COX-1 inhibition
acetylation and ___ inactiation of COX-1
antiplatelet activity: blocking ___ synthesis
- interferes with platelet ___
- prolongs ___ time
- blocks arterial ___ formation
high doses of ASA also inhibit COX-2
irreversible
TXA2
- aggregation
- bleeding
- thrombi
COX-1 vs COX-2
COX-1 produces ___, which promotes ___ , increases platelet ___ , and vaso ___ occurs
- ASA prevents platelet ___
COX-2 produces ___ which has protective ___ effect, inhibits platelet ___, and vaso ____ occurs
- coxibs have higher ___ risk
high doses of ASA also inhibit COX-2
TXA2, clotting, aggregation, vasoconstriction
- aggregation
PGI2, anti-coagulative, aggregation, vasodilation
- thrombotic
Anti-platelet Therapy - ASA (solube or EC)
- Loading Dose: ___ - ___ mg
- Dose: ___ - ___ mg daily
- MOA: (low dose) - ___ inhibitis COX-1, blocking production of ___
- ASA is detrimental at higher doses bc it also inhbits COX-2, which blocks ___
- 162-325
- 75-162
- irreverisbly, TXA2
- PGI2
Anti-platelet Therapy - P2Y12i
clopidogrel ( ___ )
Loading Dose: ___ - ___ mg
Dose: ___ mg
MOA: ___ inhibit adenosine diphosphate induced platelet aggregation with no direct effect on ___
Plavix
300-600
75
selectively, TXA2
Anti-platelet Therapy - P2Y12i
prasugrel ( ___ )
Loading Dose: ___ mg
Dose: ___ mg
MOA: ___ inhibit adenosine diphosphate induced platelet aggregation with no direct effect on ___
- indicated following ___
Effient
60
10
selectively, TXA2
ACS
Anti-platelet Therapy - P2Y12i
ticagrelor ( ___ )
Loading Dose: ___ mg
Dose: ___ mg BID
MOA: ___ inhibit adenosine diphosphate induced platelet aggregation with no direct effect on ___
- indicated following ___ or prior ___
Brilinta
180
90
selectively, TXA2
ACS, MI
Anti-platelet Therapy - P2Y12i
cangrelor ( ___ )
___ only
MOA: ___ inhibit adenosine diphosphate induced platelet aggregation with no direct effect on ___
- indicated following ___
Kengreal
IV
selectively, TXA2
ACS
AE: ASA
- GI: ___
- Hematologic: ___ and ___ bleeding
- Hypersensitivity
- major bleeding 2-3% in year 1
bleeding
intracranial, extracranial
If pt calls you thinking that they have a heart attack, instruct them to take ___ with their NTG. If they have the ec kind, tell them to ___ because it won’t dissolve until 4 hours later
- ASA
- chew
