Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Conditions affecting myocardial O2 supply

A
  • Coronary artery disease/spasm/dissection
  • Anemia
  • Hypoxemia (pneumonia, asthma, COPD, obstructive sleep apnea
  • Alkalemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Conditions affecting myocardial O2 demand

A
  • Tachycardia
  • Left ventricular hypertrophy
  • Hypertension
  • Aortic stenosis
  • Cardiomyopathy
  • Hyper/hypothermia
  • Hyperthyroidism
  • Cocaine/amphetamine use
  • Anxiety/excitement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is angina?

A

Chest pain or discomfort due to myocardial ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the timing of angina?

A
  • Onset & offset usually gradual

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Precipitating factors of angina

A
  • Exercise
  • Hot/cold environment
  • Activity after large meal
  • Emotions (anger, anxiety, excitement)
  • Coitus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Cause of chronic stable angina

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Cause and duration of unstable angina

A
  • Unstable plaque resulting in abrupt & unpredictable change in coronary blood flow
  • Duration > 20 minutes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Class 1 angina

A

Occurs w/ strenuous, rapid, or prolonged exertion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Class 3 angina

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Class 4 angina

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are some non-invasive diagnostic tests for angina?

A
  • Stress tests

- Increase myocardial O2 consumption and observe for ischemic ECG changes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Types of stress tests for angina

A
  • Graded exercise stress test

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

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

A

~50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What do beta blockers do?

A

Reduce myocardial O2 demand (decrease HR, decrease myocardial contractility, & decrease intramyocardial wall tension via decreasing BP)

26
Q

Beta-blockers are first line for ___ angina

A

Chronic stable angina

27
Q

What can beta-blockers be combined w/ for angina tx?

A

Nitrates and DHP CCBs

28
Q

Which beta-blockers should be used in asthma, PAD, diabetes, and sexual dysfunction?

A

Cardio-selective agents

29
Q

What can happen to angina sx w/ abrupt withdrawal of beta-blockers or CCBs? What can be done to avoid this?

A
  • May induce ischemia, leading to increased severity and # of pain episodes
  • May precipitate arrhythmia
  • Taper gradually, ex: over 2 weeks
30
Q

Adverse effects of beta-blockers

A
  • Hypotension, dizziness
  • Bradycardia (only worried if symptomatic)
  • Fatigue
  • Bronchospasm
  • Cold extremities
  • Erectile dysfunction (rare)
31
Q

Beta 1 (cardio) selective agents

A
  • Atenolol
  • Bisoprolol (most beta 1 selective)
  • Metoprolol
32
Q

Non-selective beta-blockers

A
  • Nadolol

- Propranolol

33
Q

Non-selective alpha and beta blockers

A
  • Carvedilol

- Labetalol

34
Q

Cardio-selective and nitric oxide-mediated vasodilating beta blockers

A

Nebivolol (most beta 1 selective, but not beneficial so never used)

35
Q

What do non-DHP CCBs do?

A
  • 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
Q

What do DHP CCBs do?

A
  • Reduce cardiac O2 demand by decreasing myocardial wall tension (via decreasing BP)
  • Increase myocardial O2 supply by vasodilating coronary arteries and preventing vasospasms
37
Q

Are CCBs more or less effective than beta blockers at preventing angina?

A

Same efficacy

38
Q

Which drugs are DHP CCBs?

A
  • Amlodipine
  • Felodipine
  • Nifedipine
39
Q

Do DHP or non-DHP CCBs have more arterial vasodilation?

A

DHP

40
Q

Do DHP or non-DHP CCBs have effect on myocardial contractility?

A

Non-DHP; have significant inotropic effects

41
Q

Do DHP or non-DHP CCBs have effect on SA or AV nodal condution?

A

Non-DHP; significantly reduce conduction (verapamil > diltiazem)

42
Q

Which drugs are non-DHP CCBs?

A
  • Diltiazem

- Verapamil

43
Q

Adverse effects of CCBs

A
  • Hypotension, dizziness
  • Flushing
  • Headache
  • Peripheral edema
  • Non-DHP specific
  • > bradycardia, constipation, heart failure exacerbation (avoid in heart failure reduced ejection fraction)
44
Q

How do nitrates work?

A
  • 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
Q

What effect do nitrates have on long-term survival?

A

No effect

46
Q

How long do the effects of long-acting nitrates last?

A

Approx. half a day

47
Q

Long-acting nitrates are ___ line for controlling angina sx

A

3rd line (after BB and CCBs)

48
Q

Long-acting nitrates are generally used in combination w/ ____

A

BB or CCB

49
Q

Adverse effects of nitrates

A
  • Headache
  • Flushing
  • Hypotension
  • Rash (w/ patch)
50
Q

What should nitrates never be combined w/ and why?

A
  • Phosphodiesterase-5-inhibitors
  • Massive drop in BP
  • No nitrate w/in 24 h of sildenafil/vardenafil, w/in 48 h of tadalafil
51
Q

Examples of rapid acting nitrates

A
  • Nitroglycerin spray

- Nitroglycerin tablet

52
Q

Examples of long acting nitrates

A
  • Isosorbide dinitrate
  • Isosorbide-5-mononitrate
  • Nitroglycerin patch
53
Q

Rapid-acting nitroglycerin pt education

A
  • 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
Q

Ranolazine

A
  • 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
Q

Lifestyle modification for secondary prevention of angina

A
  • 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
Q

Antiplatelets for secondary prevention of angina

A
  • 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
Q

Statins for secondary prevention of angina

A
  • 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
Q

Omega-3 fatty acids for secondary prevention of angina

A
  • 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
Q

ACE inhibitors for secondary prevention of angina

A
  • 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
Q

ARBs for secondary prevention of angina

A
  • 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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions