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Year 3 - Clinical > 18 - Stable Coronary Artery Disease > Flashcards

18 - Stable Coronary Artery Disease Flashcards

1
Q

Describe the coronary circulation

A
  • Right coronary artery supplies AV node; branches into right marginal branch
  • SA node has its own branch, so rarely affected
  • Left main artery branches into circumflex artery & left anterior descending artery
  • Circumflex artery branches called obtuse marginal branches (ex: OM1, OM2, etc)
  • Left anterior descending artery branches called diagonal branches (ex: D1, D2, etc.)
    • Second most important artery; is this is blocked you likely die
  • Posterior descending artery
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2
Q

Describe coronary artery disease. Symptoms and what it may result in.

A
  • AKA coronary heart disease (CHD); once severe enough to cause ischemic heart disease
  • Manifestation of atherosclerotic CV disease w/in coronary arteries
  • Generally, only symptomatic w/ greater than 70% stenosis
  • May result in chronic stable angina (aka stable ischemic heart disease) & most instances of acute coronary syndrome
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3
Q

Describe the pathophys of coronary artery disease

A
  • Stable atherosclerotic plaques in coronary arteries cause fixed limit on blood supply causing MI due to imbalance between oxygen supply & demand
  • Myocardial O2 supply determined by coronary blood flow, O2 content of blood, and O2 extraction by myocardium
  • Myocardial O2 demand determined by heart rate & contractility/myocardial wall tension (heart rate can be modified, but not really contractility)
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4
Q

Conditions affecting myocardial O2 supply

A
  • Coronary artery disease/spasm/dissection
  • Anemia
  • Hypoxemia (pneumonia, asthma, COPD, obstructive sleep apnea
  • Alkalemia
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5
Q

Conditions affecting myocardial O2 demand

A
  • Tachycardia
  • Left ventricular hypertrophy
  • Hypertension
  • Aortic stenosis
  • Cardiomyopathy
  • Hyper/hypothermia
  • Hyperthyroidism
  • Cocaine/amphetamine use
  • Anxiety/excitement
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6
Q

What is angina?

A

Chest pain or discomfort due to myocardial ischemia

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7
Q

Common characteristics of angina

A
  • Chest pain or discomfort; sensation of pressure; discomfort unchanged w/ respiration or position
  • May be radiation to arm, shoulder, neck/jaw, abdomen, or back
  • Dyspnea
  • Sweating
  • Nausea +/- vomiting
  • Dizziness, light-headedness, weakness
  • Mnemonic – DDSS (dizzy, dyspneic, sweaty, sick)
  • Significant variability & sx may be indistinguishable from ACS
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8
Q

What is the timing of angina?

A
  • Onset & offset usually gradual

- Duration normally 1-15 minutes (stable generally lasts minutes, not seconds)

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9
Q

Precipitating factors of angina

A
  • Exercise
  • Hot/cold environment
  • Activity after large meal
  • Emotions (anger, anxiety, excitement)
  • Coitus
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10
Q

Cause of chronic stable angina

A

Stable restriction in blood flow resulting in (reproducible) supply-demand mismatch

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11
Q

Cause and duration of unstable angina

A
  • Unstable plaque resulting in abrupt & unpredictable change in coronary blood flow
  • Duration > 20 minutes
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12
Q

When does unstable angina occur and what can relieve the sx?

A
  • May occur at rest

- Not relieved by rest; may or may not respond to nitroglycerin

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13
Q

Class 1 angina

A

Occurs w/ strenuous, rapid, or prolonged exertion

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14
Q

Class 2 angina

A
  • Occurs on walking or climbing stairs rapidly, on walking uphill, on walking or stair climbing after meals, in cold/wind, under emotional stress, or only during the few hours after wakening
  • Angina on walking more than 2 blocks or climbing more than 1 flight of stairs
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15
Q

Class 3 angina

A

Occurs after walking 1-2 blocks or climbing 1 flight of stairs

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16
Q

Class 4 angina

A

Sx may be present at rest or w/ very little movement

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17
Q

Describe chest pain that is classified as typical angina

A

Meets 3 of the following characteristics:

  • Substernal chest discomfort
  • Provoked by exertion or emotional stress
  • Relieved by rest and/or nitroglycerin
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18
Q

Describe chest pain that is classified as atypical angina

A

Meets 2 of the following characteristics:

  • Substernal chest discomfort
  • Provoked by exertion or emotional stress
  • Relieved by rest and/or nitroglycerin
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19
Q

Describe chest pain that is classified as non-anginal chest pain

A

Meets 1 or none of the following characteristics:

  • Substernal chest discomfort
  • Provoked by exertion or emotional stress
  • Relieved by rest and/or nitroglycerin
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20
Q

What are some non-invasive diagnostic tests for angina?

A
  • Stress tests

- Increase myocardial O2 consumption and observe for ischemic ECG changes

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21
Q

Types of stress tests for angina

A
  • Graded exercise stress test

- Pharm stress tests (adenosine, dipyridamole, or dobutamine)

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22
Q

What percent of people w/ angina will demonstrate ECG changes after their myocardial O2 consumption is increased?

A

~50%

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23
Q

What is an invasive test used for angina? Describe it

A

Coronary angiography

  • Gold standard for diagnosing coronary artery disease
  • Access via radial artery (previously femoral)
  • Catheter advanced to coronary circulation, radio-opaque dye injected & flow observed under fluoroscope
  • Indicated for px deemed to be high-risk
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24
Q

Goals of therapy for angina

A
  • Relieve acute angina sx
  • Prevent recurrent angina sx
  • Maintain/improve activity level & QOL
  • Reduce risk of CV complications
  • Improve survival
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25
What do beta blockers do?
Reduce myocardial O2 demand (decrease HR, decrease myocardial contractility, & decrease intramyocardial wall tension via decreasing BP)
26
Beta-blockers are first line for ___ angina
Chronic stable angina
27
What can beta-blockers be combined w/ for angina tx?
Nitrates and DHP CCBs
28
Which beta-blockers should be used in asthma, PAD, diabetes, and sexual dysfunction?
Cardio-selective agents
29
What can happen to angina sx w/ abrupt withdrawal of beta-blockers or CCBs? What can be done to avoid this?
- May induce ischemia, leading to increased severity and # of pain episodes - May precipitate arrhythmia - Taper gradually, ex: over 2 weeks
30
Adverse effects of beta-blockers
- Hypotension, dizziness - Bradycardia (only worried if symptomatic) - Fatigue - Bronchospasm - Cold extremities - Erectile dysfunction (rare)
31
Beta 1 (cardio) selective agents
- Atenolol - Bisoprolol (most beta 1 selective) - Metoprolol
32
Non-selective beta-blockers
- Nadolol | - Propranolol
33
Non-selective alpha and beta blockers
- Carvedilol | - Labetalol
34
Cardio-selective and nitric oxide-mediated vasodilating beta blockers
Nebivolol (most beta 1 selective, but not beneficial so never used)
35
What do non-DHP CCBs do?
- Reduce cardiac O2 demand by decreasing HR, myocardial contractility, and myocardial wall tension (via decreasing BP) - Increase myocardial O2 supply by vasodilating coronary arteries and preventing vasospasms
36
What do DHP CCBs do?
- Reduce cardiac O2 demand by decreasing myocardial wall tension (via decreasing BP) - Increase myocardial O2 supply by vasodilating coronary arteries and preventing vasospasms
37
Are CCBs more or less effective than beta blockers at preventing angina?
Same efficacy
38
Which drugs are DHP CCBs?
- Amlodipine - Felodipine - Nifedipine
39
Do DHP or non-DHP CCBs have more arterial vasodilation?
DHP
40
Do DHP or non-DHP CCBs have effect on myocardial contractility?
Non-DHP; have significant inotropic effects
41
Do DHP or non-DHP CCBs have effect on SA or AV nodal condution?
Non-DHP; significantly reduce conduction (verapamil > diltiazem)
42
Which drugs are non-DHP CCBs?
- Diltiazem | - Verapamil
43
Adverse effects of CCBs
- Hypotension, dizziness - Flushing - Headache - Peripheral edema - Non-DHP specific - > bradycardia, constipation, heart failure exacerbation (avoid in heart failure reduced ejection fraction)
44
How do nitrates work?
- Reduce myocardial O2 demand (decrease myocardial wall tension by decreased preload w/ venodilation & decreasing BP w/ arterial dilation) - Increase myocardial O2 supply (increase coronary blood flow)
45
What effect do nitrates have on long-term survival?
No effect
46
How long do the effects of long-acting nitrates last?
Approx. half a day
47
Long-acting nitrates are ___ line for controlling angina sx
3rd line (after BB and CCBs)
48
Long-acting nitrates are generally used in combination w/ ____
BB or CCB
49
Adverse effects of nitrates
- Headache - Flushing - Hypotension - Rash (w/ patch)
50
What should nitrates never be combined w/ and why?
- Phosphodiesterase-5-inhibitors - Massive drop in BP - No nitrate w/in 24 h of sildenafil/vardenafil, w/in 48 h of tadalafil
51
Examples of rapid acting nitrates
- Nitroglycerin spray | - Nitroglycerin tablet
52
Examples of long acting nitrates
- Isosorbide dinitrate - Isosorbide-5-mononitrate - Nitroglycerin patch
53
Rapid-acting nitroglycerin pt education
- If you experience chest pain or discomfort, stop what you’re doing & sit or lie down - Place 1 tablet or give 1 spray under the tongue & leave it there - If pain/discomfort not relieved after 5 mins, repeat dose - If pain/discomfort continues after 2 doses (10 mins), use a third dose & immediately call 911 - Carry a supply of nitroglycerin w/ you at all times - May experience headache or dizziness
54
Ranolazine
- Available through special access program only - MOA unknown; doesn’t affect HR or BP - Adjunctive tx to BB, CCB, and/or long-acting nitrates - Indicated for px w/ chronic stable angina unresponsive or intolerant to standard anti-anginal therapy - Doesn’t improve outcomes
55
Lifestyle modification for secondary prevention of angina
- Smoking cessation - Physical activity & weight management - - 30-60 mins moderate intensity aerobic activity at least 5 (preferably 7) days/week - - Resistance training at least 2 days/week - Dietary optimization (controlled caloric intake)
56
Antiplatelets for secondary prevention of angina
- Single antiplatelet therapy (ASA 81-325 mg daily or clopidogrel 75 mg daily) - Long-term DAPT in absence of acute coronary syndrome or other indication NOT appropriate
57
Statins for secondary prevention of angina
- Reduced risk of atherosclerosis-associated acute events & death - Moderate-to-high dose statin indicated in all px w/ clinical atherosclerosis - In practice, ignore targets & use maximally tolerated dose - - Preferred = atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily
58
Omega-3 fatty acids for secondary prevention of angina
- Low doses don’t appear to have benefit (ASCEND trial in moderate CV risk diabetic px) - REDUCE-IT trial - - High-risk population - - 4 g/day EPA reduced incidence of major adverse CV event by ~25% over 4.9 years - - Px also on statin
59
ACE inhibitors for secondary prevention of angina
- Not proven to improve symptomatic ischemia - Ramipril & perindopril proven to reduce risk of CV death, non-fatal MI, & non-fatal stroke (Ramipril) or cardiac arrest (perindopril) - Indicated if concomitant HTN, prior MI, LV dysfunction, diabetes, chronic kidney disease
60
ARBs for secondary prevention of angina
- Mechanism similar to ACE inhibitors - ONTARGET trial – telmisartan 80 mg daily vs. Ramipril 10 mg daily => telmisartan non-inferior to Ramipril - Recommended for px at high-risk of CV events who are intolerant to ACE inhibitors

Year 3 - Clinical (30 decks)

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