2 CAD Flashcards

1
Q

P2Y12 Inhbitors

  • clopidogrel
  • prasugrel
  • ticagrelor

___ and ___ are both prodrugs

A

clopidogrel, prasugrel

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2
Q

P2Y12i

clopidogrel
- class: ___
- ___ dependent conversion to active
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs (300 mg), ___ - ___ hrs (600 mg)
- Time required for effect dissipation: ___ days

A
  • thienopyridine
  • CYP
  • (+)
  • 4-5, 2-3
  • 5
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3
Q

P2Y12i

prasugrel
- class: ___
- “less” ___ dependent conversion to active
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs
- Time required for effect dissipation: ___ days

A
  • thienopyridine
  • CYP
  • ++
  • 2-4
  • 7
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4
Q

P2Y12i

ticagrelor
- class: ___
- ___ acting
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs
- Time required for effect dissipation: ___ days

A
  • cyclopentyl-triazolepyrimidine
  • direct
  • ++
  • 2-4
  • 5
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5
Q

AE P2Y12 Inhibitors

clopidogrel
- bleeding, diarrhea, rash
- ~1% increase in major bleeding when added to ___

prasugrel
- bleeding, diarrhea, rash
- 0.6% increase in major bleeding, 0.5% increase in life threatening bleeding (vs ___ )

ticagrelor
- bleeding, ___ , heart block, dyspnea

A
  • ASA
  • clopidogrel
  • bradycardia
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6
Q
A

E

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7
Q

1) CCD: no history of stent implantation

AKA: ___ prevention - stable angina/stable ischemic heart disease, post-ACS or revascularization

SAPT (single-antiplatelet therapy) - all pts with a history of CCD should receive ___ ___ mg for life
- if CI or significant intolerance, do ___ mg

DAPT (dual antiplatelet therapy)
- certain high risk patients may receive both ___ and ___

A

secondary
ASA 81
clopidogrel 75
ASA, P2Y12i

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8
Q

T or F: all patients with CAD should receive ASA 81 mg for life

A

True

unless they are allergic for obv reasons

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9
Q

Intracoronary Artery Stents

Bare metal stents: uncommonly used

Drug eluting stents
1st generation: ___ and ___
2nd generation: ___ and ___
3rd generation (biosorbable polymer): ___ , ___ , and ___

A
  • sirolimus, paclitaxel
  • everolimus, zotarolimus
  • biolimus, sirolimus, everolimus
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10
Q

2) CCD: Elective PCI + Drug Eluting Stent

Before procedure: ___ and ___ loading dose

After procedure:
- Low bleeding risk: DAPT: min ___ months, SAPT: ___
- High bleeding risk: DAPT: ___ - ___ months, SAPT: ___ for 12 months, SAPT: ___ indefinitely

New recommendations do not distinguish between choice of P2Y12i
- clopidogrel ___ mg daily, prasugrel ___ mg daily, ticagrelor ___ mg BID

A

ASA, P2Y12i
- 6, indefinitely
- 1-3, P2Y12, ASA

loading doses:
ASA - 325 mg
clopidogrel - 300-600 mg

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11
Q

3) SIHD: CABG

DAPT: ___ ___ mg/day + ___ ___ mg/day
SAPT: __ indefinitely
- ___ may be reasonable for 12 months

controversy regarding need for DAPT

A

ASA 81, clopidogrel 75
ASA
- clopidogrel

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12
Q
A

A

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13
Q

T or F: if a patient is on ticagrelor, ASA dose MUST BE > 100

A

F; less than 100

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14
Q

RAS (ACEi; ARBs)

___ plaque, improved ___ function, inhibition of ___ cell growth, decreased ___ migration.
- do not improve symptomatic ___
- decrease ___ events in high risk patients; should be considered in all patients with CCD (especially in patients with LVEF < ___ %, HTN, DM, or CKD)

A

stabilize, ET, VSM, macrophage
- ischemia
- CV, 40%

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15
Q

Colchicine

LoDoCo = low dose colchicine 0.5 mg
reduces ___, likely via reduction in ___ and ___
- indicated for reducing the risks of MI, stroke, coronary revascularization, and CV death
- reserved for patients with elevated ___ > 2
- ___ and ___ substrate: caution with strong inhibitors
- CI in severe ___ and ___ disease

A

inflammation, IL-1B, IL-18
hsCRP
CYP3A, P-gp
renal, hepatic

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16
Q

PCOL to Prevent/Reduce Ischemia/Angina

___ myocardial oxygen supply
- dilation of coronary arteries (reduce ___ ), collateral blood flow, prolong diastole

___ myocardial oxygen demand
- ___ , contractility, intramyocardial wall tension (afterload and preload)

A

increase, vasospasm
decrease
HR

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17
Q

Nitrates

___ HR
___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ LV Volume

A

increase
N/A
decrease
super decrease

18
Q

beta-blockers

___ HR
___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ LV Volume

A
  • super decrease
  • decrease
  • decrease
  • increase
19
Q

nifedipine (DHP)

___ HR
___ or ___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume

A
  • increase
  • N/A or decrease
  • super decrease
  • N/A or decrease
20
Q

verapamil

___ HR
___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume

A
  • super decrease
  • decrease
  • decrease
  • N/A or decrease
21
Q

diltiazem

___ HR
___ or ___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume

A
  • decrease
  • N/A or decrease
  • decrease
  • N/A or decrease
22
Q

ranolazine

___ HR
___ myocardial contractility

LV Wall Tension
- ___ systolic pressue
- ___ LV Volume

A

N/A
N/A
N/A
N/A

23
Q

PCOL to relieve ACUTE ischemia and angina - Organic Nitrates

MOA: activation of ___

Activity:
- marked veno ___ (decreased ___ )
- less ___ diation, coronary and peripheral
- inhibition of platelet ___ (minor)

A

guanylate cyclase
- venodilation, preload
- arteriole
- aggregation

24
Q

Nitrates - Clinical effects

Increased myocardial O2 Supply
- ET dependent ___
- dilates epicardial ___ and coronary collateral vessels

Decreased myocardial O2 demand
- venous ___ causes reduced ___ and decreased LV volume

A
  • vasodilation
  • arteries
  • vasodilation, preload
25
Q

Instructions for Nitroglycerin

1) sit down - going to give potent ___ , last thing we want is passing out
2) let tab dissolve under __ , pain should go away very ___
3) if pain doesnt go away within ___ min, call 911 and take another tablet
4) while waiting on ambulance for another ___ min, take another

A
  • vasodilator
  • tongue, quickly
  • 5 min
  • 5 min
26
Q

Patient Education Points - tabs

  • keep in original ___ glass container
  • place under ___
  • do not store in bathroom/ ___ conditions
  • ___ plug removal
  • no ___ cap
A
  • dark
  • tongue
  • humid
  • cotton
  • safety
27
Q

Patient Education Points - spray

  • spray under ___
  • do not ___
  • do not ___
A
  • tongue
  • inhale
  • shake
28
Q

Patient Education Points - tabs and spray

  • keep at all times
  • need for Rx refills: ___ months for tabs, ___ years for spray
  • ___ use instructions
  • 911 procedure
A
  • 6, 3
  • preventative
29
Q
A

A, B, E

30
Q

AE: nitroglycerin

headache, hypotension, dizziness, lightheadedness, facial dlushing, reflex tachycardia
- no ___ or ___ use: APAP instead
- extreme caution with ___

A
  • NSAIDs, ASA
  • PDEi

no ASA dosed for pain

31
Q
A

D

32
Q

Drug interactions/CI - PDEi

vasodilatory effects of nitrates may be substantially enhanced ( ___ mmHg drop in SBP) fatal events have occured

Duration of time to avoids PDEi within nitrates
- Avanafil: ___ hours
- Sildenafil and Vardenafil: ___ hours
- Tadalafil: ___ hours

A
  • 25 mmHg
  • 12
  • 24
  • 48
33
Q

Clinical Recommendations for Nitrates

SL NTG tabs ( ___ - ___ mg) or SL spray delivers ( ___ mg/spray) should be utilized in all patients
- useful for angina prevention when taken just ___ to initiation of exertion

A

0.15-0.6
0.4
prior

34
Q

PCOL to prevent recurrent ischemia and angina symptoms (3)

chronic use

A

1) beta-blockers
2) CCB
3) nitrates

35
Q

beta-blockers: primary effects

MOA: ___ , reversible inhibitors of beta-adrenergic stimulation by ___

Desired effects of oxygen demand
- reduced ___ (mainly during sympathetic stimulation)
- reduced myocardial ___
- reduced arterial ___ ( ___ load)

Undesired effect on myocardial oxygen demand
- ___ HR → increased diastolic ___ time→ ____ LVEDV → ___ preload

Associated with reduced ventricular ___ and ___

A

competitive, catecholamines
- HR
- contractility
- BP, afterload
- reduced, filling, increased, increased
arrhythmias, remodeling

36
Q

beta-blockers

B1 selective (2)

A

atenolol and metoprolol

37
Q

beta-blockers

non-selective (2)

A

propranolol, carvedilol

38
Q

beta-blockers

ISA (2)

partial agonist

A

pindolol, acebutolol

don’t like these bc it will increase HR and cause angina

39
Q

beta-blockers

lipid soluble (2)
eliminated ___

A

propranolol, carvedilol
hepatically

40
Q

beta-blockers

water soluble (2)
eliminated ___

A

atenolol, bisoprolol
renally

41
Q

beta-blockers: AE

cardiac: sinus ___ , sinus ___ , ___ block, reduced ___
- others: ___ constriction, fatigue, depression, nightmares, ___ dysfunction, ___ intolerance, masking of ___
- ___ syndrome

A

bradycardia, arrest, AV, LVEF
- bronchoconstriction, sexual, exercise, hypoglycemia
- withdrawal

42
Q

beta-blockers: dosage and monitoring parameters

initiate at lowest dose and titrate to symptom reduction

Goal HR
- rest: ___ - ___ BPM
- exercise: < ___ BPM, ___ % of HR that typically causes angina

Painful episodes:
- ___ use

A
  • 50-60
  • 100, 75
  • NTG