3 CAD Flashcards
Ca Channel Blockers (CCB): MOA
Cardiac
- decreased ___ of trigger Ca in myocytes, decreased ___ in nodal cells; ___ in myocytes
Vascular
- vaso ___
- influx, chronotropy, inotropy
- vasodilation
DHPs
HR: reflex ___
Contractility: ___ / ___ (nifedipine)
AV Nodal Conduction: ___
Vasodilation
- peripheral: ___
- coronary: ___
more potent vasodilators
Verapamil
HR: ___
Contractility: ___
AV Nodal Conduction: ___
Vasodilation
- peripheral: ___
- coronary: ___
- decrease
- super decrease
- super decrease
- (++)
- (+)
Diltiazem
HR: ___
Contractility: ___
AV Nodal Conduction: ___
Vasodilation
- peripheral: ___
- coronary: ___
decrease
decrease
decrease
(+)
(++)
which CCBs are short acting (2)
nifedipine (Procardia, Adalat)
nicardipine (Cardene)
these are not used, but the XL/ER versions are
CCB AE
DHP - primarily work in ___ space
- hypotension, flushing, headache, and dizziness
- peripheral edema likely related to arteriolar ___
- reduced myocardial ____
- reflex adrenergic activation
vasculature
- vasodilation
- contractility
CCB AE
Non-DHPs - potent reducers of ___, contraindicated in ___
- reduced myocardial contractility ( V ___ D)
- AV/SA nodal conduction disturbances: ___ and ___ block (V ___ D)
- hypotension, flushing, headache, and dizziness
- constipation (V ___ D)
ionotropy, HF
- >
- bradycardia, AV, >
- >
CCB Monitoring
initiate at lowest dose and titrate to symptom reduction
Painful episodes
- ___ use
Monitoring paramerters
- DHP: assess ___ and ___
- Non-DHP: ___ and HR ___ - ___ and < ___ at exercise
- NTG
- BP, edema
- constipation, 50-60, 100
Nitrate Tolerance
- ___ response in the presence of continuous/frequently administered nitrates
- occurs in ___ - ___ days depending on the patient, will require higher doses as time goes on
Examples:
- __ hour application of transdermal NTG
- ___ infusions of IV NTG
- ISDN administered ___ times daiy
Prevention of nitrate tolerance
- nitrate free period of at least ___ - ___ hours
- decreased
- 1-3
- 24
- continuous
- four
- 10-12
Pharmacology of Nitrate Tolerance
- ___ inactivation in mitochondria
- ISMN and ISDN also elicit tolerance but via a slower, less understood process
ALDH2
Nitrates: Dosing
NTG: patch
dosing interval: ___ daily
once
example: on for 12-14 hours, off 10-12 hours
- on 7 am off, off 7-9 pm
Nitrates: Dosing
ISDN tabs
dosing interval: ___ - ___ times/day
2-3
example: 8 am, 12 pm, 4 pm
10 mg TID
Nitrates: Dosing
ISMN tabs
dosing interval: ___ times/day, ___ hours apart
2, 7
example: 8 am and 3 pm
20 mg BID
Nitrates: Dosing
ISMN SR tabs
dosing interval: ___ daily
once
examples: 8am
30 mg once daily
Patient counseling: Nitrate Patches
- discuss nitrate ___ interval
Patches
- apply patch between ___ and ___
- choose a different area each day
- you can shower while wearing
- free
- elbows, knees
Patient counseling: NTG Ointment
- do not ___ ointment
- do not ___ area
- used in hospital setting, a bit easier to titrate vs patch
rub/massage
cover
Vasodilator induced Tachycardia
we dont want tachycardia to occur because an increase in ___ will lead to higher O2 ___ which leads to more ___
CO
demand
angina
Cellular Events During Ischemia
1) ischemia
2) drop in ___ and ___ supply, decrease in ___ function
3) influx of ___
4) influx of ___
5) increased ___ activation
6) increased ___ and ___ wall tension, increased ___ and ___ consumption
7) ___ microcirculation
cycles and leads to more angina
- O2, ATP, LV
- Na
- Ca
- myofilament
- LVEDP/LV, O2, ATP
- decreased
Ranolazine (Ranexa)
MOA: inhibition of late inward ___ current in ischemic ___ which prevents ___ influx
- does not affect ___ , ___ , ___ or ___ like traditional anti-ischemic agents
Na, myocytes, Ca
- HR, BP, inotropy, perfusion
Ranolazine
Brand: ___ 500 mg ER tablets
- titration from 500 mg ___ to ___ mg BID over 1-2 weeks
- combo therapy: add to ___ , ___ , or ___ when inadequate response
- monotherapy only when ___ / ___ too low for first line agents
Ranexa, BID, 1000 mg
beta-blockers, CCB, nitrates
BP/HR
Ranolazine
metabolized via CYP ___ and CYP ___ , substrate for ___
- should not be used with strong ___ inhibitors ( ___ , ___ , ___ ) or inducers ( ___ , ___ , ___ )
- limit dose ( ___ mg BID) with moderate inhibitors ( ___ , ___ , ___ , and ___ )
ranolazine inhibits ___ and ___
- 3A4, 2D6, Pgp
- 3A, (ketoconazole, itraconazole, protease inhibitors)
- carbamazepine, rifampin, St. John’s Wort
- 500 mg, diltiazem, verapamil, erythromycin, fluconazole
CYP3A, Pgp
Ranolazine: AE
constipation, nausea, dizziness, headache
- dose related increase in ___ interval; should not be used with other drugs that prolong ___ interval
QT, QT
B
Selecting a Treatment option
if possible ___ are first line, but initial drug should be based upon pateint characteristics
- CCB and nitrates can also be used
beta blockers
Sowinski wouldnt use beta blockers in patients with severe asthma
Place in therapy: Beta Blockers
should be selected as ___ therapy in patients without CIs
- compelling indications: stable ___ , history of ___
- useful in AFib, high resting ___ , migraine
- avoid in ___ / Prinzmetal’s angina, conduction disturbances
- CIs: bradycardia (HR < ___ ); high degree ___ block or sick ___ syndrome (with no pacemaker)
- initial
- HR, MI
- HR
- vasospastic
- 50
- AV, sinus
Place in Therapy: CCBs
___ CCBs preferred, instead of B-blockers if …
- CI to BB
- undesirable side effects to BB
- potentially useful in chronic lung diseases, HTN, DM, and peripheral vascular disease
CI
- Non-DHPs: HFrEF, bradycardia (HR < ___ ); high degree ___ block or sick ___ syndrome (with no pacemaker)
- DHPs: HFrEF (except ___ and ___ )
non-DHP
50, AV, sinus
amlodipine, felodinpine
Place in Therapy: Nitrates
monotherapy not preferred due to tolerance and required nitrate free period
- combo with ___ / ___ (to blunt nitrate induces increase in HR)
- short acting ___ nitrates to relieve discomfort or prevent ischemia before exertion
- cautions: ___ , severe aortic stenosis, ___ use
Beta-blockers, non-DHP
PRN
HOCM, PDI
Clinical Conditions that Favor use
Beta Blockers
- prior ___ / ___ (non-ISA)
- HF/LVD
- sinus ___ , SV ___ , AFib
- ventricular ___
- migraines
- ___ thyroidism
- ACS/MI
- tachycardia, tachycardia
- arrhythmias
- hyperthyroidism
Clinical Conditions that Favor use
DHP CCB
- HTN
- ___ / AV block
- diabetes
- PVD/Raynaud’s
- severe ___ / ___
- ___ angina
- bradycardia
- asthma/COPD
- Prinzmetal’s
Clinical Conditions that Favor use
Verapamil/Diltiazem
- HTN
- sinus ___, SV ___, A Fib
- diabetes
- PVD/Raynaud’s
- severe ___ / ___
- ___ angina
- tachycardia, tachycardia
- asthma/COPD
- Prinzmetal’s
Clinical Conditions that Limit use
Beta-Blockers
- ___ / AV Block
- sick ___ syndrome
- HF ___
- severe ___
- severe asthma/COPD
- bradycardia
- sinus
- decompensation
- depression
Clinical Conditions that Limit use
CCBs
- ___ / AV block
- sick ___ syndrome ( ___ )
- HF
- severe ___
- severe aortic ___
- bradycardia
- sinus, non-DHP
- HOCM
- stenosis
Clinical Conditions that Limit use
Nitrates
- ED treated with ___
- severe ___
- severe aortic ___
PDE5
HOCM
stenosis
combo therapy
- beta-blockers and ___ should be avoided
- triple therapy: ___ , ___ , and ___
- can add ranolazine with other agents if they arent effective
- non-DHP CCBs
- beta-blockers, nitrates, DHP CCB
C
algorithm
Aspirin appropriate, need ACEi, atorvastatin at appropriate high dose. Increase metoprolol to 50 mg. Can use colchicine if high C protein. Only use dual antiplatelet therapy 1 year post MI
- Anginal symptoms: sublingual nitroglycerin, metoprolol 25 mg BID
- Risk reduction: 81 mg aspirin, ACEi, high intensity statin
- metoprolol might make him cranky bc of not being able to exert himself as much during pickleball
C
- Metoprolol: not going to mess around bc heart rate is at goal
- Reduce aspirin to 81 mg (lower risk of bleeding and GI upset)
- Need additional BP control: DHP CCB would be most logical AND add low dose lisinopril
- Low dose amlodipine and low dose lisinopril
Not Approved in the US: Ivabradine
HCN channel inhibitor - reduces diastolic depolarization
- slows ___
- prolongs ___ and improves ventricular ___
- reduces myocardial oxygen ___
- no hemodynamic or conduction abnormalities
FDA approved for ___ , but not SIHD
- brand: ___ , ___
- HR
- diastole, filling
- consumption
HF
Procoralan, Corlanor
Therapies with no benefit/potentially harmful fo CCB
- postmenopausal ___
- antioxidants (scam, just do ___ )
- homocysteine/Folic acid, Vit B6 or B12
- herbal supplemets
- ___ / ___ inhibitors
- ___ glitazone
- ___ therapy
- HRT
- one-a-day
- NSAIDs/COX-2
- Rosiglitazone
- chelation
ASA with NSAIDs
NSAIDs compete with ASA at ___ site that diminishes the effect of ASA
COX-1
Use of NSAIDs in CV Disease
- shared dicision making
- consider GI, renal, and AE
- prioritize non-PCOL
- use ___ dose for ___ time
- select ___ or ___ as first alternatives with gastroprotection ( ___ )
- ___ doses up to 200 mg per day have similar CV risk , but poorer analgesic effects.
- avoid ___
- lowest, shortest
- ibuprofen, naproxen, PPI
- celecoxib
- diclofenac
Systemic NSAID is Chosen
- take ASA at least ___ hours prior to NSAID
- adjunctive ___ may minimize NSAID needs
- within 1 week, review benefits of NSAID use
- prioritize non-PCOL
- 2
- APAP
Vasospasm
- ___ angina
- ischemia/angina usually occurs at ___ , not precipitated by physical exertion or emotional stress
- associated with ECG ___ segment elevation
- not necessarily associated with ___
- Prinzmetal’s
- rest
- ST
- atherosclerosis
Management of Vasospastic Angina
acute: ___
chronic: ___ , ___ , or combo therapy
- NO ___
SL NTG
CCB, nitrates
- beta-blocker
A,E
