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NAPLEX 2024 > 29. Stable Ischemic Heart Disease > Flashcards

29. Stable Ischemic Heart Disease Flashcards

1
Q

___ angina is a/w predictable chest pain, often brought on by exertion or emotional stress and relieved within minutes by rest or with nitroglycerin

A

Stable

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2
Q

____ 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

A

Unstable

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3
Q

___ 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)

A

Prinzmetal’s

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4
Q

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)

A

Demand

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5
Q

In SIDH, myocardial oxygen (demand/supply) is often decreased d/t atherosclerosis. Aka coronary artery disease (CAD)

A

supply

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6
Q

Risk factors of SIHD

A

HTN, smoking, HLD, DM, obesity, physical inactivity

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7
Q

___ test is performed to assess likelihood of CAD and SIHD diagnosis

A

Cardiac stress test

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8
Q

Cardiac stress test increases myocardial oxygen demand with either ___ or IV meds like (list 4 examples) and then monitored for s/sx.

A

exercise (treadmill) or adenosine, dipyridamole, dobutamine, or regadenoson (Lexiscan)

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9
Q

Non-pharm treatment

A

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

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10
Q

Typical SIHD drug regimen

A

Antiplatelet and antianginal drug

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11
Q

Antianginal treatment (increases/decreases) myocardial oxygen demand or (increases/decreases) myocardial oxygen supply

A

Decreases, increases

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12
Q

List antianginal treatment options and place in therapy

A

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)

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13
Q

T/F: SIHD is one of the atherosclerotic cardiovascular diseases (ASCVD)

A

True

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14
Q

SIHD treatment approach ABCDE acronym

A

A - antiplatelet and antianginal drugs
B - BP and beta-blockers
C - cholesterol (statins) and cigarettes (cessation)
D - diet and diabetes
E - exercise and education

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15
Q

Aspirin MOA

A

irreversibly inhibits COX-1 and COX-2 – decreases prostaglandin (PG) and thromboxane A1 (TXA2) production

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16
Q

TXA is a potent (vasoconstrictor/vasodilator) and inducer of platelet aggregation

A

vasoconstrictor

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17
Q

T/F: Clopidogrel is a prodrug

A

True

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18
Q

Clopidogrel MOA

A

Irreversible inhibition of P2Y12 ADP-mediated platelet activation and aggregation

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19
Q

Aspirin Contraindications

A

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)

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20
Q

Aspirin Warnings

A

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)

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21
Q

Aspirin ADEs

A

Dyspepsia, heartburn, bleeding, nausea

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22
Q

T/F: aspirin is used indefinitely in SIHD

A

True, unless contraindicated
Decreases incidence of MI, CV events, and death

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23
Q

Aspirin is used with ____ to reduce the risk of major CV events (e.g. MI, stroke)

A

low-dose rivaroxaban

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24
Q

T/F: Non-enteric coated, chewable aspirin is preferred in ACS. If only EC aspirin is available, it should be chewed (325mg).

A

True

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25
Q

T/F: Durlaza (aspirin ER) and Yosprala (aspirin+omeprazole) can be used when rapid onset is needed (e.g. ACS, pre-PCI)

A

False - should NOT be used for rapid onset

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26
Q

How to decrease nausea ADE for aspirin

A

Use EC or buffered product or take with food

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27
Q

___ may be used to protect the gut with chronic aspirin use

A

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)

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28
Q

Clopidogrel boxed warning

A

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

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29
Q

Clopidogrel contraindications

A

Active serious bleedings (e.g. GI bleed, intracranial hemorrhage)

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30
Q

Clopidogrel Warnings

A

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)

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31
Q

T/F: Omeprazole or esomeprazole should be used with clopidogrel to decrease risk of GI ulcers

A

False - do NOT use omeprazole or esomeprazole with clopidogrel (drug interaction)

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32
Q

Clopidogrel place in therapy for SIDH

A

If contraindication to aspirin
Can be used in combo with aspirin (dual antiplatelet therapy)

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33
Q

3 scenarios where double antiplatelet therapy (DAPT) should be used

A

1) bare metal stent, 2) drug-eluting stent, 3) post-CABG

34
Q

Duration of DAPT therapy in patients with bare metal stent

A

at least 1 month

35
Q

Duration of DAPT therapy in patients with drug-eluting stent

A

at least 6 months

36
Q

Duration of DAPT therapy in patients post-CABG

A

12 months

37
Q

Aspirin is dosed at ___ daily in DAPT regiments and continued indefinitely after course of DAPT is completed

A

81mg

38
Q

SIHD Mechanism of Clinical Benefit: Beta-blockers

A

Reduce myocardial oxygen demand
decrease HR, contractility, LV wall tension

39
Q

SIHD Mechanism of Clinical Benefit: CCB

A

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

40
Q

SIHD Mechanism of Clinical Benefit: Nitrates

A

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

41
Q

SIHD Mechanism of Clinical Benefit: Ranolazine

A

Selectively inhibits the late phase Na current and decreases intracellular Ca; can decrease oxygen demand by decreasing ventricular tension and oxygen consumption

42
Q

(beta-blockers/CCBs/nitrates) is preferred for Prinzmetal’s (variant) angina

A

CCBs

43
Q

T/F: beta-blockers provide symptom improvement but no mortality reduction

A

False - beta-blockers provide both mortality reduction and symptom improvement

44
Q

Beta-blockers (with/without) ISA are preferred

A

Without (e.g. metoprolol, carvedilol)

45
Q

T/F: beta-blockers should not be used with other antianginal treatment options (DHP CCBs, long-acting nitrates and/or ranolazine)

A

False - beta-blockers can be used as monotherapy or in combo with DHP CCBs, long-acting nitrates, and/or ranolazine

46
Q

T/F: beta-blockers are more effective than nitrates and CCBs for silent ischemia and Prinzmetal’s angina

A

False - beta-blockers are more effective than nitrates and CCBs for silent ischemia but should be avoided in Prinzmetal’s angina

47
Q

T/F: Short-acting CCBs are preferred over long-acting

A

False - Slow-release or long-acting DHPs or non-DHPs are effect; avoid short-acting DHPs (e.g. nifedipine IR)

48
Q

T/F: non-DHP CCBs are preferred when used in combo with beta-blockers

A

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)

49
Q

Short-acting nitrates are used in all patients for fast relief of angina. When are long-acting nitrates used?

A

When beta-blockers are contraindicated or as add-on therapy if symptoms persists
Nitrate-free interval is required to prevent tolerance

50
Q

Ranolazine Contraindications

A

Liver cirrhosis, do not use with strong CYP3A4 inhibitors or inducers

51
Q

Ranolazine warnings

A

can cause QT prolongation
Acute renal failure observed when CrCl <30

52
Q

Ranolazine side effects

A

dizziness, HA, constipation, nausea

53
Q

Ranolazine monitoring

A

ECG, K, renal function

54
Q

T/F: Ranolazine affects HR but not BP

A

False - little to no clinical effects on HR or BP

55
Q

T/F: Ranolazine is used for acute treatment of chest pain

A

False

56
Q

Typical dose for short-acting nitroglycerin

A

0.4mg

57
Q

Nitrates contraindications

A

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

58
Q

Nitrates warnings

A

Hypotension, HA, tachyphylaxis (decrease effectiveness/tolerance with long-acting products)
Can aggravate angina caused by hypertrophic cardiomyopathy

59
Q

Nitrates side effects

A

HA, flushing, syncope, dizziness

60
Q

T/F: nitrate tolerance develops with both short-acting and long-acting products

A

False - does not develop with SL/TL products

61
Q

Nitroglycerin SL tabs storage

A

Original amber glass bottle and keep tightly capped after each use (to maintain potency)

62
Q

Long-acting nitrates require ____ hour nitrate-free interval to decrease tolerance (longer for some products)

A

10-12 hours

63
Q

Long-acting nitrate patch instructions for use

A

Wear on for 12-14 hours, off to 10-12 hours, rotate sites, dispose of safely and away from children and pets

64
Q

Long-acting nitrate ointment instructions for use

A

Dosed BID, 6 hours apart with a 10-12 hour nitrate-free interval

65
Q

Isosorbide mononitrate instructions for use

A

IR dosed BID, 7 hours apart (e.g. 8 AM and 3 PM)
ER dosed once daily in AM

66
Q

Isosorbide dinitrate instructions for use

A

IR dosed BID or TID
If TID, take 8 AM, 12 PM, and 4PM for 14 hour nitrate-free interval (or similar)

67
Q

Isosorbide (mono/dinitrate) in combo with hydralazine is preferred combination for HFrEF

A

Dinitrate

68
Q

Do NOT use long-acting nitrates in combo with ___ inhibitors and ____

A

PDE-5 inhibitors and riociguat
Use caution with other anti-HTN meds and alcohol - can cause sig decrease in BP

69
Q

Ranolazine is a major substrate of CYP___ and a minor substrate of CYP___ and P-gp

A

CYP3A4, CYP2D6

70
Q

Ranolazine is a weak inhibitor of CYP ___,___, and ___

A

3A4, 2D6, and P-gp

71
Q

Do NOT use ranolazine with strong CYP___ inhibitors or inducers

A

3A4

72
Q

Limit ranolazine dose to 500mg BID if taking moderate CYP3A4 inhibitors (e.g. ___, ___)

A

diltiazem, verapamil

73
Q

Limit simvastatin to ___mg per day if using with ranolazine

A

20mg per day

74
Q

Aspirin counseling points

A

Can cause bleeding/bruising, dyspepsia, allergy, tinnitus or loss of hearing with overdose

75
Q

Clopidogrel counseling points

A

Can cause bleeding/bruising, thrombotic thrombocytopenic purpura (TTP)

76
Q

All nitroglycerin products counseling points

A

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

77
Q

Short-acting nitrate counseling points

A

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

78
Q

Short-acting nitrates: do NOT take more than ___ doses within ___ mins

A

3 doses within 15 mins

79
Q

T/F: slight burning or tingling sensation when using nitroglycerin SL tabs is a sign that the medication is working

A

False - it is NOT a sign of how well the medication is working

80
Q

Nitroglycerin TL Spray instructions for use

A

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

81
Q

For nitroglycerin patches, ___ is the preferred application site, though any area can be selected except extremities below the ___ or ___

A

Chest, though any area can be selected except extremities below the knees or elbows

82
Q

Nitroglycerin ointment instructions for use

A

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

NAPLEX 2024 (74 decks)

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