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PHRM 845 > 3 CAD > Flashcards

3 CAD Flashcards

1
Q

Ca Channel Blockers (CCB): MOA

Cardiac
- decreased ___ of trigger Ca in myocytes, decreased ___ in nodal cells; ___ in myocytes

Vascular
- vaso ___

A
  • influx, chronotropy, inotropy
  • vasodilation
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2
Q

DHPs

HR: reflex ___
Contractility: ___ / ___ (nifedipine)
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

A

more potent vasodilators

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3
Q

Verapamil

HR: ___
Contractility: ___
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

A
  • decrease
  • super decrease
  • super decrease
  • (++)
  • (+)
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4
Q

Diltiazem

HR: ___
Contractility: ___
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

A

decrease
decrease
decrease
(+)
(++)

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5
Q

which CCBs are short acting (2)

A

nifedipine (Procardia, Adalat)
nicardipine (Cardene)

these are not used, but the XL/ER versions are

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6
Q

CCB AE

DHP - primarily work in ___ space
- hypotension, flushing, headache, and dizziness
- peripheral edema likely related to arteriolar ___
- reduced myocardial ____
- reflex adrenergic activation

A

vasculature
- vasodilation
- contractility

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7
Q

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)

A

ionotropy, HF
- >
- bradycardia, AV, >
- >

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8
Q

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

A
  • NTG
  • BP, edema
  • constipation, 50-60, 100
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9
Q

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

A
  • decreased
  • 1-3
  • 24
  • continuous
  • four
  • 10-12
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10
Q

Pharmacology of Nitrate Tolerance

  • ___ inactivation in mitochondria
  • ISMN and ISDN also elicit tolerance but via a slower, less understood process
A

ALDH2

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11
Q

Nitrates: Dosing

NTG: patch
dosing interval: ___ daily

A

once

example: on for 12-14 hours, off 10-12 hours
- on 7 am off, off 7-9 pm

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12
Q

Nitrates: Dosing

ISDN tabs
dosing interval: ___ - ___ times/day

A

2-3

example: 8 am, 12 pm, 4 pm
10 mg TID

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13
Q

Nitrates: Dosing

ISMN tabs
dosing interval: ___ times/day, ___ hours apart

A

2, 7
example: 8 am and 3 pm
20 mg BID

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14
Q

Nitrates: Dosing

ISMN SR tabs
dosing interval: ___ daily

A

once
examples: 8am
30 mg once daily

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15
Q

Patient counseling: Nitrate Patches

  • discuss nitrate ___ interval

Patches
- apply patch between ___ and ___
- choose a different area each day
- you can shower while wearing

A
  • free
  • elbows, knees
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16
Q

Patient counseling: NTG Ointment

  • do not ___ ointment
  • do not ___ area
  • used in hospital setting, a bit easier to titrate vs patch
A

rub/massage
cover

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17
Q

Vasodilator induced Tachycardia

we dont want tachycardia to occur because an increase in ___ will lead to higher O2 ___ which leads to more ___

A

CO
demand
angina

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18
Q

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

A
  • O2, ATP, LV
  • Na
  • Ca
  • myofilament
  • LVEDP/LV, O2, ATP
  • decreased
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19
Q

Ranolazine (Ranexa)

MOA: inhibition of late inward ___ current in ischemic ___ which prevents ___ influx
- does not affect ___ , ___ , ___ or ___ like traditional anti-ischemic agents

A

Na, myocytes, Ca
- HR, BP, inotropy, perfusion

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20
Q

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

A

Ranexa, BID, 1000 mg
beta-blockers, CCB, nitrates
BP/HR

21
Q

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 ___

A
  • 3A4, 2D6, Pgp
  • 3A, (ketoconazole, itraconazole, protease inhibitors)
  • carbamazepine, rifampin, St. John’s Wort
  • 500 mg, diltiazem, verapamil, erythromycin, fluconazole

CYP3A, Pgp

22
Q

Ranolazine: AE

constipation, nausea, dizziness, headache
- dose related increase in ___ interval; should not be used with other drugs that prolong ___ interval

A

QT, QT

23
Q
A

B

24
Q

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

A

beta blockers

Sowinski wouldnt use beta blockers in patients with severe asthma

25
Q

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)

A
  • initial
  • HR, MI
  • HR
  • vasospastic
  • 50
  • AV, sinus
26
Q

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 ___ )

A

non-DHP
50, AV, sinus
amlodipine, felodinpine

27
Q

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

A

Beta-blockers, non-DHP
PRN
HOCM, PDI

28
Q

Clinical Conditions that Favor use

Beta Blockers
- prior ___ / ___ (non-ISA)
- HF/LVD
- sinus ___ , SV ___ , AFib
- ventricular ___
- migraines
- ___ thyroidism

A
  • ACS/MI
  • tachycardia, tachycardia
  • arrhythmias
  • hyperthyroidism
29
Q

Clinical Conditions that Favor use

DHP CCB
- HTN
- ___ / AV block
- diabetes
- PVD/Raynaud’s
- severe ___ / ___
- ___ angina

A
  • bradycardia
  • asthma/COPD
  • Prinzmetal’s
30
Q

Clinical Conditions that Favor use

Verapamil/Diltiazem
- HTN
- sinus ___, SV ___, A Fib
- diabetes
- PVD/Raynaud’s
- severe ___ / ___
- ___ angina

A
  • tachycardia, tachycardia
  • asthma/COPD
  • Prinzmetal’s
31
Q

Clinical Conditions that Limit use

Beta-Blockers
- ___ / AV Block
- sick ___ syndrome
- HF ___
- severe ___
- severe asthma/COPD

A
  • bradycardia
  • sinus
  • decompensation
  • depression
32
Q

Clinical Conditions that Limit use

CCBs
- ___ / AV block
- sick ___ syndrome ( ___ )
- HF
- severe ___
- severe aortic ___

A
  • bradycardia
  • sinus, non-DHP
  • HOCM
  • stenosis
33
Q

Clinical Conditions that Limit use

Nitrates
- ED treated with ___
- severe ___
- severe aortic ___

A

PDE5
HOCM
stenosis

34
Q

combo therapy

  • beta-blockers and ___ should be avoided
  • triple therapy: ___ , ___ , and ___
  • can add ranolazine with other agents if they arent effective
A
  • non-DHP CCBs
  • beta-blockers, nitrates, DHP CCB
35
Q
A

C

36
Q
A
37
Q

algorithm

A
38
Q
A

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

39
Q
A
  • 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
40
Q
A

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

41
Q

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: ___ , ___

A
  • HR
  • diastole, filling
  • consumption

HF
Procoralan, Corlanor

42
Q

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
A
  • HRT
  • one-a-day
  • NSAIDs/COX-2
  • Rosiglitazone
  • chelation
43
Q

ASA with NSAIDs

NSAIDs compete with ASA at ___ site that diminishes the effect of ASA

A

COX-1

44
Q

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 ___
A
  • lowest, shortest
  • ibuprofen, naproxen, PPI
  • celecoxib
  • diclofenac
45
Q

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
A
  • 2
  • APAP
46
Q

Vasospasm

  • ___ angina
  • ischemia/angina usually occurs at ___ , not precipitated by physical exertion or emotional stress
  • associated with ECG ___ segment elevation
  • not necessarily associated with ___
A
  • Prinzmetal’s
  • rest
  • ST
  • atherosclerosis
47
Q

Management of Vasospastic Angina

acute: ___
chronic: ___ , ___ , or combo therapy
- NO ___

A

SL NTG
CCB, nitrates
- beta-blocker

48
Q
A

A,E

PHRM 845 (62 decks)

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