2 CAD Flashcards
P2Y12 Inhbitors
- clopidogrel
- prasugrel
- ticagrelor
___ and ___ are both prodrugs
clopidogrel, prasugrel
P2Y12i
clopidogrel
- class: ___
- ___ dependent conversion to active
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs (300 mg), ___ - ___ hrs (600 mg)
- Time required for effect dissipation: ___ days
- thienopyridine
- CYP
- (+)
- 4-5, 2-3
- 5
P2Y12i
prasugrel
- class: ___
- “less” ___ dependent conversion to active
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs
- Time required for effect dissipation: ___ days
- thienopyridine
- CYP
- ++
- 2-4
- 7
P2Y12i
ticagrelor
- class: ___
- ___ acting
- Potency: ___
- Time to peak inhibition: ___ - ___ hrs
- Time required for effect dissipation: ___ days
- cyclopentyl-triazolepyrimidine
- direct
- ++
- 2-4
- 5
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
- ASA
- clopidogrel
- bradycardia
E
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 ___
secondary
ASA 81
clopidogrel 75
ASA, P2Y12i
T or F: all patients with CAD should receive ASA 81 mg for life
True
unless they are allergic for obv reasons
Intracoronary Artery Stents
Bare metal stents: uncommonly used
Drug eluting stents
1st generation: ___ and ___
2nd generation: ___ and ___
3rd generation (biosorbable polymer): ___ , ___ , and ___
- sirolimus, paclitaxel
- everolimus, zotarolimus
- biolimus, sirolimus, everolimus
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
ASA, P2Y12i
- 6, indefinitely
- 1-3, P2Y12, ASA
loading doses:
ASA - 325 mg
clopidogrel - 300-600 mg
3) SIHD: CABG
DAPT: ___ ___ mg/day + ___ ___ mg/day
SAPT: __ indefinitely
- ___ may be reasonable for 12 months
controversy regarding need for DAPT
ASA 81, clopidogrel 75
ASA
- clopidogrel
A
T or F: if a patient is on ticagrelor, ASA dose MUST BE > 100
F; less than 100
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)
stabilize, ET, VSM, macrophage
- ischemia
- CV, 40%
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
inflammation, IL-1B, IL-18
hsCRP
CYP3A, P-gp
renal, hepatic
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)
increase, vasospasm
decrease
HR
Nitrates
___ HR
___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ LV Volume
increase
N/A
decrease
super decrease
beta-blockers
___ HR
___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ LV Volume
- super decrease
- decrease
- decrease
- increase
nifedipine (DHP)
___ HR
___ or ___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume
- increase
- N/A or decrease
- super decrease
- N/A or decrease
verapamil
___ HR
___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume
- super decrease
- decrease
- decrease
- N/A or decrease
diltiazem
___ HR
___ or ___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ or ___ LV Volume
- decrease
- N/A or decrease
- decrease
- N/A or decrease
ranolazine
___ HR
___ myocardial contractility
LV Wall Tension
- ___ systolic pressue
- ___ LV Volume
N/A
N/A
N/A
N/A
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)
guanylate cyclase
- venodilation, preload
- arteriole
- aggregation
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
- vasodilation
- arteries
- vasodilation, preload
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
- vasodilator
- tongue, quickly
- 5 min
- 5 min
Patient Education Points - tabs
- keep in original ___ glass container
- place under ___
- do not store in bathroom/ ___ conditions
- ___ plug removal
- no ___ cap
- dark
- tongue
- humid
- cotton
- safety
Patient Education Points - spray
- spray under ___
- do not ___
- do not ___
- tongue
- inhale
- shake
Patient Education Points - tabs and spray
- keep at all times
- need for Rx refills: ___ months for tabs, ___ years for spray
- ___ use instructions
- 911 procedure
- 6, 3
- preventative
A, B, E
AE: nitroglycerin
headache, hypotension, dizziness, lightheadedness, facial dlushing, reflex tachycardia
- no ___ or ___ use: APAP instead
- extreme caution with ___
- NSAIDs, ASA
- PDEi
no ASA dosed for pain
D
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
- 25 mmHg
- 12
- 24
- 48
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
0.15-0.6
0.4
prior
PCOL to prevent recurrent ischemia and angina symptoms (3)
chronic use
1) beta-blockers
2) CCB
3) nitrates
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 ___
competitive, catecholamines
- HR
- contractility
- BP, afterload
- reduced, filling, increased, increased
arrhythmias, remodeling
beta-blockers
B1 selective (2)
atenolol and metoprolol
beta-blockers
non-selective (2)
propranolol, carvedilol
beta-blockers
ISA (2)
partial agonist
pindolol, acebutolol
don’t like these bc it will increase HR and cause angina
beta-blockers
lipid soluble (2)
eliminated ___
propranolol, carvedilol
hepatically
beta-blockers
water soluble (2)
eliminated ___
atenolol, bisoprolol
renally
beta-blockers: AE
cardiac: sinus ___ , sinus ___ , ___ block, reduced ___
- others: ___ constriction, fatigue, depression, nightmares, ___ dysfunction, ___ intolerance, masking of ___
- ___ syndrome
bradycardia, arrest, AV, LVEF
- bronchoconstriction, sexual, exercise, hypoglycemia
- withdrawal
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
- 50-60
- 100, 75
- NTG
