2.5.1 Treatment of Cardiovascular Disorders

Question 1

Other than statins, what is a promising therapy to reduce LDL levels?

Answer 1

PCSK9 Inhibitors

Question 2

What are the two epidemics of the US addressed in this lecture?

Answer 2

Obesity and HF

Question 3

Are statins created equal?

Answer 3

No, statins have different levels of efficacy.

Question 4

Which aldosterone blockade has an estrogenic effect that can lead to gynecomastia?

Answer 4

Spironolactone

Question 5

Two examples of PCSK9 inhibitors. Why aren’t these as commonly used?

Answer 5

Alirocumab and evolocumab

Still awaiting results of outcome trials

Question 6

What is the one well studied method to reduce relative risk for coronary heart disease?

Answer 6

Lipid lowering therapy

Question 7

What are some of the causes of HF?

Answer 7

CAD

HTN

Valve dysfunction

Idopathic

Infection (Chagas disease)

Toxins (alcohol or cytotoxic drugs)

Valvular disease

Prolonged dysrhythmias

Question 8

What are the primary effects of PCSK9 inhibitors?

Answer 8

LDL lowering

Question 9

What is angina pectoris? What triggers it? Location? When is it considered stable?

Answer 9

Discomfort (not pain) in chest and related areas

Typically retrosternal in location brought on by exertion or emotional stress

Can orginate/radiate to jaw, neck, throat, shoulders, back, or arms

“Stable” when no change in frequency, duration, precipitating, or relieving factors in past 60 days

Question 10

What is ischemia?

Answer 10

Supply/demand mismatch, most often due to severe CAD

Question 11

What is used to treat bradydysrhythmias (SA node dysfunction, AV node dysfunction, complete AV block)?

Answer 11

Pacemakers

Question 12

List the statins in order of relative potency (low to high).

Answer 12

Lovastatin, Pravastatin, Simvastatin, Fluvastatin, Atorvastatin, Rosuvastatin

Question 13

What are the primary effects of statins?

Answer 13

LDL lowering, modest HDL raising and triglyceride lowering

Question 14

In what patient population does CABG have an especially better mortality reduction in than PCI?

Answer 14

Diabetes mellitus

Question 15

What are medical therapies are known to reduce mortality in HF?

Answer 15

Beta blockers (carvedilol, metoprolol succinate, and bisoprolol)

ACE Inhibitors/ ARBs (Lisinopril)

Neprilysin inhibitor/ ARB (sacubitril/valsartan)

Vasodilators (Hydralazine/isosorbide dinitrate combo)

Diuretics - Aldosterone antagonists (spironolactone, eplerenone)

Loop diuretic - furosemide

Sinus node inhibitor (ivabradine)

Question 16

What is the normal function of PCSK9?

Answer 16

PCSK9 binds LDLRs and facilitates their degradation, which ultimately results in lower LDLRs and increased blood cholesterol

Question 17

What is commonly used to in CABG of the LAD?

Answer 17

Left internal mammary artery

Question 19

What do statins inhibit?

Answer 19

HMG-CoA Reductase

Question 20

In patients with STEMI w/o contraindications (asthma, COPD, bradycardia, advanced heart block), what should be administered?

Hint: Common side effect = fatigue

Answer 20

Beta blocker

Question 21

When are nitrates indicated? Effect on CAD mortality? Common side effect?

Answer 21

Patients with refractory symptoms despite beta blockers (or intolerant to beta blockers)

Effect on CAD mortality: no mortality benefit

Common side effect: headache

Question 22

What treatments are used for symptom management in HF?

THESE DO NOT REDUCE MORTALITY.

Answer 22

Vasodilators

Loop diuretics (furosemide)

Nitrates

Digoxin

Inotropes/infusion therapy (refractory HF)

Question 23

What is the lifetime risk of developing symptomatic CAD after age 40 in men and women?

Answer 23

Men: 49%

Women: 32%

Question 24

What are some other terms for coronary artery disease (CAD)?

Answer 24

Ischemic heart disease (IHD)

Atherosclerotic heart disease (ASHD)

Arteriosclerosis

Atherosclerotic cardiovascular disease (ASCVD)

Question 25

What anticoagulant can be used as ancillary therapy to fibrinolytic therapy?

Answer 25

Heparin (UFH) Can be used in both STEMI and NSTEMI

Question 26

ACE Inhibitors are especially good for what type of post-MI patients? What is the most common side effect? A severe side effect?

Answer 26

MI-patients with LV systolic dysfunction (EF \< or = 40%) Most common side effect is cough, angioedema is uncommon but serious

Question 27

What does PCI stand for?

Answer 27

Percutaneous coronary intervention (PCI)

Question 28

What is the most common side effect of statins?

Answer 28

Muscles pains (myalgias). It can cause patients to stop taking the medications Statins have been indicated to possibly raise blood sugar resulting in memory impairment

Question 29

What did the Framingham Heart Study establish as a relationship between BMI and HF risk?

Answer 29

For every unit increase in BMI, risk of HF increased by 5% in males and 7% in females

Question 30

What are some possible medical therapies for CAD?

Answer 30

Aspirin (ASA) Thienopyridines (clopidogrel, prasugrel) P2Y12 inhibitor (ticagrelor) Beta blockers ACEI/Angiotensin Receptor Blockers (ARB) Nitrates (NTG, isosorbide) Aldosterone antagonists Lipid lowering agents Fibrinolytics (for STEMI)

Question 31

What is important about the stages, phenotypes, and treatment of HF?

Answer 31

HF is a progressive disease. Everyone starts in stage A. This is where we can best try to prevent progression into the other stages of HF. By the time patients get to stage D, there aren't many proven beneficial therapies. Treatment may shift over to palliative comfort care.

Question 32

Why must platelet counts be monitored daily for a patient on heparin?

Answer 32

HIT, heparin-induced thrombocytopenia

Question 33

How does the half-life of LMW heparins (enoxaparin, dalteparin, tinzaparin) compare to heparin?

Answer 33

Longer half-life, less commonly used

Question 34

What is the failure rate of fibrinolytics in the treatment of STEMIs?

Answer 34

~20-40%

Question 35

When are implantable cardioverter defibrillators (ICDs) preferred over pacemakers?

Answer 35

Patients with persistently low EF (\< or = 35%) despite optimal HF medical therapy

Question 36

What is CABG?

Answer 36

Coronary artery bypass grafting

Question 37

What is used to treat angina?

Answer 37

Nitroglycerin (NTG)

Question 38

What are the 4 "statin benefit groups"?

Answer 38

Known ASCVD LDL \> or = 190 Diabetics Adults w/ 10-yr ASCVD risk of \>/= 7.5%

Question 39

What is the most common antiplatelet therapy given for CAD (post-MI and maintenance therapy indefinitely)?

Answer 39

Aspirin (ASA)

Question 40

What are the two types of left ventricular dysfunction in HF?

Answer 40

Systolic: impaired contractility Diastolic: impaired filling, relaxation, or compliance

Question 41

Fibrinolytics are indicated in what type of MI? Examples?

Answer 41

STEMI only Atleplase, reteplase, tenecteplase, streptokinase

Question 42

When a patient is allergic to ASA, what are some alternatives?

Answer 42

Clopidogrel, Prasugrel, Ticagrelor

Question 43

What symptom is associated with acute ischemic syndromes/acute coronary syndromes? What are the two possible types of MI

Answer 43

Unstable angina Non-ST segment elevation MI (NSTEMI) or ST segment elevation MI (STEMI)

Question 44

CAD is commonly asymptomatic. When it is symptomatic, what are the main symptoms?

Answer 44

Chronic stable angina or unstable angina

Question 45

What are the primary effects of niacin? What side effect causes patients to discontinue taking it?

Answer 45

LDL lowering, good HDL and trig effects Flushing

Question 46

What are two conditions (other than DM) that indicate CABG over PCI?

Answer 46

3 vessel disease and L ventricular dysfunction

Question 47

What are fibrates and what are they used for?

Answer 47

These have an effect on raising HDL, triglyceride loweing and modest LDL lowering

Question 48

What are common side effects of fibrates?

Answer 48

myopathy - especially in individuals with decreased creatinine clearance

Question 49

What are bile acid resins?

Answer 49

These have modest LDL lowering ability

Question 50

What are the current guidelines for prevention of CHD?

Answer 50

Focus on primary prevention. Less focus on achievement of a specific goal and use of non statin. Put them on a drug that will lower their risk

Question 51

When would you use fibrinolytics?

Answer 51

Use in acute ST elevation MI - these convert plasminogen to plasmin to break up a clot

Question 52

When would you not want to use an aldosterone blockade?

Answer 52

Because of its potassium raising effects, avoid using in patient with advanced renal disease or elevated serum potassium

Question 53

Hydralazine/isosorbide combo can have what side effect at high doses?

Answer 53

Lupus-like symptoms

Question 54

What are your survival promoting drugs therapies in heart failure patients?

Answer 54

Beta blockers ACE inhibitors or ARBs Aldosterone antagonists Hydralazine/isosorbide dinitrate combo

Question 55

When would a patient need biventricular pacing (CRT)?

Answer 55

This is beneficial to patients with symptomatic HF and bundle branch block. This is intended to restor synchronous right and left ventricular conduction. ## Footnote **Low ejection fraction, significant HF symptoms despite optimal medical therapy, delayed intraventricular conduction**

Question 56

When would you prescribe ICDs?

Answer 56

**Low ejection fraction patients, or have hypertrophic cardiomyopathy** Use for resuscitated sudden cardiac arrest not associated with acute MI