29. Stable Ischemic Heart Disease Flashcards
___ angina is a/w predictable chest pain, often brought on by exertion or emotional stress and relieved within minutes by rest or with nitroglycerin
Stable
____ agina is a type of acute coronary syndrome (ACS); a medical emergency where chest pain increases (frequency, intensity, or duration) and is not relieved with nitroglycerin or rest
Unstable
___ angina is when chest pain is caused by vasospasm of the coronary arteries. Can occur at rest and be caused by illicit drug use (cocaine)
Prinzmetal’s
Myocardial oxygen (demand/supply) increases when heart is working harder d/t increased HR, contractility, or left ventricular wall tensions (increased preload and/or afterload)
Demand
In SIDH, myocardial oxygen (demand/supply) is often decreased d/t atherosclerosis. Aka coronary artery disease (CAD)
supply
Risk factors of SIHD
HTN, smoking, HLD, DM, obesity, physical inactivity
___ test is performed to assess likelihood of CAD and SIHD diagnosis
Cardiac stress test
Cardiac stress test increases myocardial oxygen demand with either ___ or IV meds like (list 4 examples) and then monitored for s/sx.
exercise (treadmill) or adenosine, dipyridamole, dobutamine, or regadenoson (Lexiscan)
Non-pharm treatment
Heart healthy diet
BMI 18.5-24.9
Waist circumference <35 inches in females, <40 inches in males
150 min exercise/week
Smoking cessation
Limit alcohol intake
Typical SIHD drug regimen
Antiplatelet and antianginal drug
Antianginal treatment (increases/decreases) myocardial oxygen demand or (increases/decreases) myocardial oxygen supply
Decreases, increases
List antianginal treatment options and place in therapy
Beta-blockers (first line)
CCBs (both DHP and non-DHP) or long-acting nitrates (use when beta-blockers CI or additional symptomatic relief needed)
Ranolazine (substitution or in additional to beta-blockers)
Short-acting nitroglycerin (SL tab, powder, or translingual spray, for immediate relief in all patients)
T/F: SIHD is one of the atherosclerotic cardiovascular diseases (ASCVD)
True
SIHD treatment approach ABCDE acronym
A - antiplatelet and antianginal drugs
B - BP and beta-blockers
C - cholesterol (statins) and cigarettes (cessation)
D - diet and diabetes
E - exercise and education
Aspirin MOA
irreversibly inhibits COX-1 and COX-2 – decreases prostaglandin (PG) and thromboxane A1 (TXA2) production
TXA is a potent (vasoconstrictor/vasodilator) and inducer of platelet aggregation
vasoconstrictor
T/F: Clopidogrel is a prodrug
True
Clopidogrel MOA
Irreversible inhibition of P2Y12 ADP-mediated platelet activation and aggregation
Aspirin Contraindications
NSAID or salicylate allergy; children and teenagers with viral infection d/t Reye’s syndrome (s/sx: somnolence, N/V, confusion)
Rhinitis, nasal polyps or asthma (d/t risk of urticaria, angioedema, or bronchospasm)
Aspirin Warnings
Bleeding (including GI bleed/ulceration), increased risk with heavy alcohol use or when used with other drugs with bleeding risk (e.g. NSAIDs, anticoagulants, other antiplatelets)
Tinnitus (salicylate overdose)
Aspirin ADEs
Dyspepsia, heartburn, bleeding, nausea
T/F: aspirin is used indefinitely in SIHD
True, unless contraindicated
Decreases incidence of MI, CV events, and death
Aspirin is used with ____ to reduce the risk of major CV events (e.g. MI, stroke)
low-dose rivaroxaban
T/F: Non-enteric coated, chewable aspirin is preferred in ACS. If only EC aspirin is available, it should be chewed (325mg).
True
T/F: Durlaza (aspirin ER) and Yosprala (aspirin+omeprazole) can be used when rapid onset is needed (e.g. ACS, pre-PCI)
False - should NOT be used for rapid onset
How to decrease nausea ADE for aspirin
Use EC or buffered product or take with food
___ may be used to protect the gut with chronic aspirin use
PPIs (e.g. Yosprala is indicated for those at risk of developing aspirin-associated gastric ulcers)
Note: Consider risks from chronic PPI use (decreased bone density and increased infection risk)
Clopidogrel boxed warning
Clopidogrel is prodrug - depends on CYP2C19
Poor metabolizers of CYP2C19 exhibit higher CV events than normal CYP2C19 function
Can use tests to check genotype to determine therapeutic strategy
Clopidogrel contraindications
Active serious bleedings (e.g. GI bleed, intracranial hemorrhage)
Clopidogrel Warnings
Bleeding risk (stop 5 days prior to elective surgery)
Do NOT use with omeprazole or esomeprazole (CYP2C19 inhibitors)
Premature discontinuation increases risk of thrombosis
Thrombotic thrombocytopenic purpura (TTP)
T/F: Omeprazole or esomeprazole should be used with clopidogrel to decrease risk of GI ulcers
False - do NOT use omeprazole or esomeprazole with clopidogrel (drug interaction)
Clopidogrel place in therapy for SIDH
If contraindication to aspirin
Can be used in combo with aspirin (dual antiplatelet therapy)
3 scenarios where double antiplatelet therapy (DAPT) should be used
1) bare metal stent, 2) drug-eluting stent, 3) post-CABG
Duration of DAPT therapy in patients with bare metal stent
at least 1 month
Duration of DAPT therapy in patients with drug-eluting stent
at least 6 months
Duration of DAPT therapy in patients post-CABG
12 months
Aspirin is dosed at ___ daily in DAPT regiments and continued indefinitely after course of DAPT is completed
81mg
SIHD Mechanism of Clinical Benefit: Beta-blockers
Reduce myocardial oxygen demand
decrease HR, contractility, LV wall tension
SIHD Mechanism of Clinical Benefit: CCB
Reduce myocardial oxygen demand: Non-DHPs decrease HR, contractility // DHPs decrease SVR (afterload)
Increase myocardial oxygen supply: all CCBs increase blood flow through coronary arteries
SIHD Mechanism of Clinical Benefit: Nitrates
Reduce myocardial oxygen demand: decrease preload (free radical nitric oxide produces vasodilation of veins more than arteries)
Increases myocardial oxygen supply: increases blood flow through collateral (non-atherosclerotic) arteries
SIHD Mechanism of Clinical Benefit: Ranolazine
Selectively inhibits the late phase Na current and decreases intracellular Ca; can decrease oxygen demand by decreasing ventricular tension and oxygen consumption
(beta-blockers/CCBs/nitrates) is preferred for Prinzmetal’s (variant) angina
CCBs
T/F: beta-blockers provide symptom improvement but no mortality reduction
False - beta-blockers provide both mortality reduction and symptom improvement
Beta-blockers (with/without) ISA are preferred
Without (e.g. metoprolol, carvedilol)
T/F: beta-blockers should not be used with other antianginal treatment options (DHP CCBs, long-acting nitrates and/or ranolazine)
False - beta-blockers can be used as monotherapy or in combo with DHP CCBs, long-acting nitrates, and/or ranolazine
T/F: beta-blockers are more effective than nitrates and CCBs for silent ischemia and Prinzmetal’s angina
False - beta-blockers are more effective than nitrates and CCBs for silent ischemia but should be avoided in Prinzmetal’s angina
T/F: Short-acting CCBs are preferred over long-acting
False - Slow-release or long-acting DHPs or non-DHPs are effect; avoid short-acting DHPs (e.g. nifedipine IR)
T/F: non-DHP CCBs are preferred when used in combo with beta-blockers
False - DHP CCBs are preferred when used in combo with beta-blockers (d/t risk of excessive bradycardia when non-DHPs are used with beta-blockers)
Short-acting nitrates are used in all patients for fast relief of angina. When are long-acting nitrates used?
When beta-blockers are contraindicated or as add-on therapy if symptoms persists
Nitrate-free interval is required to prevent tolerance
Ranolazine Contraindications
Liver cirrhosis, do not use with strong CYP3A4 inhibitors or inducers
Ranolazine warnings
can cause QT prolongation
Acute renal failure observed when CrCl <30
Ranolazine side effects
dizziness, HA, constipation, nausea
Ranolazine monitoring
ECG, K, renal function
T/F: Ranolazine affects HR but not BP
False - little to no clinical effects on HR or BP
T/F: Ranolazine is used for acute treatment of chest pain
False
Typical dose for short-acting nitroglycerin
0.4mg
Nitrates contraindications
Hypersensitivity to organic nitrates
Do NOT use with PDE-5 inhibitors or riociguat
Short-acting nitrates: increased intracranial pressure, severe anemia, circulatory failure and shock
Nitrates warnings
Hypotension, HA, tachyphylaxis (decrease effectiveness/tolerance with long-acting products)
Can aggravate angina caused by hypertrophic cardiomyopathy
Nitrates side effects
HA, flushing, syncope, dizziness
T/F: nitrate tolerance develops with both short-acting and long-acting products
False - does not develop with SL/TL products
Nitroglycerin SL tabs storage
Original amber glass bottle and keep tightly capped after each use (to maintain potency)
Long-acting nitrates require ____ hour nitrate-free interval to decrease tolerance (longer for some products)
10-12 hours
Long-acting nitrate patch instructions for use
Wear on for 12-14 hours, off to 10-12 hours, rotate sites, dispose of safely and away from children and pets
Long-acting nitrate ointment instructions for use
Dosed BID, 6 hours apart with a 10-12 hour nitrate-free interval
Isosorbide mononitrate instructions for use
IR dosed BID, 7 hours apart (e.g. 8 AM and 3 PM)
ER dosed once daily in AM
Isosorbide dinitrate instructions for use
IR dosed BID or TID
If TID, take 8 AM, 12 PM, and 4PM for 14 hour nitrate-free interval (or similar)
Isosorbide (mono/dinitrate) in combo with hydralazine is preferred combination for HFrEF
Dinitrate
Do NOT use long-acting nitrates in combo with ___ inhibitors and ____
PDE-5 inhibitors and riociguat
Use caution with other anti-HTN meds and alcohol - can cause sig decrease in BP
Ranolazine is a major substrate of CYP___ and a minor substrate of CYP___ and P-gp
CYP3A4, CYP2D6
Ranolazine is a weak inhibitor of CYP ___,___, and ___
3A4, 2D6, and P-gp
Do NOT use ranolazine with strong CYP___ inhibitors or inducers
3A4
Limit ranolazine dose to 500mg BID if taking moderate CYP3A4 inhibitors (e.g. ___, ___)
diltiazem, verapamil
Limit simvastatin to ___mg per day if using with ranolazine
20mg per day
Aspirin counseling points
Can cause bleeding/bruising, dyspepsia, allergy, tinnitus or loss of hearing with overdose
Clopidogrel counseling points
Can cause bleeding/bruising, thrombotic thrombocytopenic purpura (TTP)
All nitroglycerin products counseling points
Can cause orthostasis, flushing and HA (flushing/HA often a sign the medication is working, usually goes away with time)
Nitrate-free interval required with long-acting products
Drug interactions with PDE-5 inhibitors
Short-acting nitrate counseling points
Take 1 dose at first sign of chest pain
Call 911 immediately if chest pain persists after first dose
continue to take 2 additional doses at 5 min intervals while waiting for ambulance to arrive
Do NOT take more than 3 doses within 15 mins
Short-acting nitrates: do NOT take more than ___ doses within ___ mins
3 doses within 15 mins
T/F: slight burning or tingling sensation when using nitroglycerin SL tabs is a sign that the medication is working
False - it is NOT a sign of how well the medication is working
Nitroglycerin TL Spray instructions for use
Prime before first use and if not used within 6 weeks
Do NOT shake
Press button firmly to release spray onto or under tongue and close mouth
Do not inhale spray and try not to swallow too quickly afterward
Do not spit or rinse mouth for 5-10 min after dose
For nitroglycerin patches, ___ is the preferred application site, though any area can be selected except extremities below the ___ or ___
Chest, though any area can be selected except extremities below the knees or elbows
Nitroglycerin ointment instructions for use
Measure dose with dose-measuring applicator provided (squeeze onto applicator before spreading ointment on the skin with the applicator)
Do NOT rub into skin, tape applicator into place
Can stain clothing, cover applicator completely
