3 - Ischemic Heart Disease Flashcards
1
Q
Ischemic heart disease can also be called ??
A
CHD - coronary heart disease
CAD - coronary artery disease
2
Q
Ischemic heart disease may present as?
A
- Ischemia without clinical symptoms
- Chronic stable angina pectoris
- Acute coronary syndrome (ACS)
3
Q
Modifiable risk factors for heart disease
A
- tobacco use/smoking
- dyslipidemia
- diabetes
- hypertension
- chronic kidney disease
- physical inactivity
- poor diet
- obesity
- depression
- drugs (cocaine, steroids, progestins, NSAIDs)
4
Q
Non-modifiable risk factors for heart disease
A
- age > 40 (men)
- age > 50 or postmenopausal (women)
- being male
- family history of premature CV disease
- ethnicity
5
Q
Define ischemia
A
mismatch between coronary oxygen supply and demand
6
Q
What factors affect oxygen demand
A
- heart rate
- contractility
- intramyocardial wall tension
7
Q
What factors affect oxygen delivery
A
- coronary blood flow
- oxygen extraction
- oxygen availability
8
Q
ACS = ______ ischemia
A
supply
9
Q
Ischemic heart disease = ______ ischemia
A
demand
10
Q
What are some chronic stable angina symptoms?
A
- chest pain/discomfort “tightness”
- shortness of breath
- sweating
- nausea
- fatigue, light-headedness, weakness, onset is gradual
- duration between 0.5 - 30 min
- usually left sided radiation to arm, shoulder of jaw
11
Q
Chronic stable angina:
Precipitating factors?
A
- exercise
- cold environment
- walking after a large meal
- emotions (anger, anxiety)
- coitus
12
Q
Chronic stable angina:
Responsive to ?
A
nitroglycerin
-relief of pain within 45 seconds to 5 min
13
Q
Describe a stress test used to diagnose stable angina
A
Stress test
- aimed at measuring the heart’s reaction to increased oxygen demand
- exercise or pharmacologic agents (ex. adenosine, dobutamine) to induce stress
- ECG and BP taken before, during and after stress introduced
14
Q
What is am MIBI stress test?
A
- use of radioisotope with stress test
- imaging taken to record pattern of radioactivity distribution to various parts of myocardium; difference in uptake in certain areas indicate potential ischemic sites
15
Q
When is an echocardiography used?
A
- indicated when heart failure suspected
- measure left ventricular systolic function
16
Q
What is an angiogram?
A
- procedure in which a contrast material that can are seen using x-ray equipment is injected into the coronary arteries in order to visualize blood flow through the heart
- provides real-time visualization of coronary blood flow
- indicated for patients with high risk features during stress test, or if severe angina or diabetic
17
Q
When recommending antacids what must you always tell patients?
A
If the discomfort in the chest is not received with antacids GO SEE A DOCTOR
18
Q
What is the PQRST acronym ?
A
- provoking/palliative factors
- quality of pain
- region/location
- severity
- timing and duration
19
Q
What are the goals of therapy for stable angina?
A
- relieve acute angina symptoms
- prevent recurrent angina symptoms
- maintain/improve activity level and quality of life
- reduce risk of cardiovascular complications (acute coronary syndrome)
- minimize risk of death
20
Q
What do we use to relieve acute angina symptoms?
A
nitrates
21
Q
What agents do we use to prevent recurrent angina symptoms and maintain/improve activity level and quality of life?
A
- B blockers
- calcium channel blockers
- nitrates
22
Q
What agents do we use to reduce risk of CV complications?
A
- antiplatelets
- statins
- ACEi
- risk factor modification
23
Q
Beta blockers reduce ??
A
cardiac oxygen demand
24
Q
How do beta blockers work?
A
Reduce cardiac oxygen demand:
- decrease HR
- decrease contractility
- decrease intramyocardial wall tension (via decreased BP)
25
How do beta blockers benefit stable angina patients?
- reduce occurrence of angina symptoms
| - improve survival in patients with LV dysfunction (HF) or history of MI
26
What is first line therapy for treatment of chronic stable angina?
beta blockers
27
Why are beta blockers not the best in diabetic patients?
- B blockers may inhibit insulin release
| - B blockers mask some symptoms of hypoglycaemia
28
What can B blockers worsen the symptoms of?
reactive airway disease or peripheral arterial disease
29
T or F: do you need to taper B blockers?
yes - taper over 10-14 days
*abrupt withdrawal may increase severity and number of pain episodes
30
B blockers: which one is more effective?
all equally effective
31
What B blockers do you avoid in severe angina?
ones with ISA (some alpha effects)
32
What B blockers do you choose in asthmatics?
cardioselective agents
33
Metoprolol loses selectivity at what dose?
> 200 mg/day
34
What 3 BB's have evidence for decreased mortality post-MI?
- timolol
- propranolol
- metoprolol
35
List the Cardioselective beta blockers
- atenolol
- bisoprolol
- metoprolol
36
List the Non-selective B blockers
- nadolol
- propranolol
- timolol
37
List the mixed alpha and B blockers
-carvedilol
38
List the cardioselective and vasodilatory B blockers
-nebivolol
39
Abrupt discontinuation of B blockers may induce _____
ischemia
40
Who are cardioselective beta blockers recommended for?
- asthma
- COPD
- PAD
- DM
- dyslipidemias
- sexual dysfunction
41
What type of patients have additional benefits from nonselective beta blockers?
patients with essential tremor, migraine, headache, portal hypertension, thyrotoxicosis
42
Usual dose of Atenolol
25-100 mg daily
43
Usual dose of Bisoprolol
2.5 - 10 mg daily
44
Usual dose of Metoprolol tartrate
50 - 200 mg BID
45
Usual dose of Metoprolol succinate ER
50 - 200 mg daily
46
Usual dose of Nadolol
40-120 mg daily
47
Usual dose of Propranolol
40 - 160 mg BID
48
Usual dose of Propranolol LA (Inderal LA, Inderal XL)
80 - 320 mg daily
49
Usual dose of Timolol
10 - 40 mg daily
50
What is an additional side note of carvedilol?
It is a mixed alpha and beta blocker:
| -Additional alpha blockade produces vasodilation and more orthostatic hypotension
51
How is nebivolol better than carvediolol?
It is cardioselective and vasodilatory:
| -Additional vasodilation does not result in more orthostatic hypotension
52
Usual dose of Carvedilol
25 - 50 mg BID
53
Usual dose of Nebivolol
5 - 20 mg daily
54
How do calcium channel blockers reduce cardiac oxygen demand?
Reduce cardiac oxygen demand:
- reduce conduction velocity through SA and AV nodes
- decrease BP through arterial dilation
- decrease wall tension and decrease myocardial contractility
55
How do calcium channel blockers improve coronary blood flow?
Improve coronary blood flow:
- vasodilate coronary arteries
- decrease coronary vascular resistance
- prevent vasospasm
56
How effective are CCBs compared to BBs at preventing angina?
just as effective
57
Do CCBs improve survival after MI?
No
58
List Dihydropyridines
Amlodipine
Nifedipine
Felodipine
59
List Non-DHPs
Verapamil
| Diltiazem
60
____ act peripherally and cause vasodilation
DHPs (amlodipine, nifedipine, felodipine)
61
______ act centrally and decrease contractility in the coronary arteries
non-DHPs (verapamil, diltiazem)
62
Are DHPs or non-DHPs used in combo with B blockers?
only DHPs (amlodipine, nifedipine, felodipine)
63
What are side effects of calcium channel blockers?
- hypotension
- flushing
- headache
- dizziness
- peripheral edema
* all due to vasodilation
64
What are some additional side effects that non-DHPs have?
- bradycardia
| - worsening heart failure
65
What additional SE does verapamil have?
constipation
66
Diltiazem IR dose
60 mg po TID
67
Diltiazem CD/ER/XC dose
120 - 360 mg daily
68
Verapamil IR dose
80 mg TID
69
Verapamil SR dose
120 - 180 mg daily
70
Amlodipine dose
5 - 10 mg daily
71
Nifedipine XL dose
30 - 60 mg daily
72
When should you avoid using diltiazem?
in HF or 2nd or 3rd degree heart block
73
What do nitrates do?
Reduce myocardial oxygen demand:
-Venodilation and arterial-arteriolar dilation
Dilate coronary arteries:
-Increase coronary blood flow
74
What are nitrates used to treat?
1) Acute anginal attacks
- SL, buccal or spray products rapidly absorbed
- Relieves pain in 3-15 minutes
2) Prevent effort or stress-induced attacks
- Use 5 mins prior to activity (lasts approx 30 mins)
3) Long-acting formulations
- 3rd line (after BB or CCB) for controlling symptoms
- used in combo with BB or CCB
75
What are the long-acting formulations of nitrates?
- isosorbide dinitrate
| - transdermal nitroglycerin
76
Are nitrates used as monotherapy?
No - have not been shown to reduce mortality in patients with CAD
77
SE of nitrates?
- headache
- flushing
- hypotension
78
Nitrates:
| ____ can develop with chronic therapy (7-10 days)
Tolerance
79
How do you manage nitrate tolerance?
use a nitrate free period (8-12 hours) to avoid tolerance
80
What do nitrates interact with?
- sildenafil
- tadalafil
- vardenafil
81
Dose of nitroglycerin SL pumpspray
0.4 mg q5min prn
82
Comments for nitroglycerin, sublingual pumpspray?
If discomfort persists 5 minutes after 1 dose, call ambulance and continue to use spray q5min for total 3 doses/ambulance arrival
83
Dose of Nitroglycerin transdermal patches
Start with 0.2mghr patch applied and removed daily.
Max 0.8 mg/hr patch daily
84
Comments for nitroglycerin transdermal patches?
Ensure 10-12 hour nitrate free period
85
Dose of isosorbide dinitrate SL?
5mg q5min prn
86
Dose of isosorbide dinitrate IR?
10 - 30 mg po TID
87
Comments for isosorbide dinitrate?
Ensure 10 - 12 hour nitrate free period for IR formulation
88
Dose of Isosorbide mononitrate ER?
Start with 30 - 60 mg daily
| Max 240 mg daily
89
Comments for isosorbide mononitrate?
daily nitrate free period difficult to implement
90
What are some points you would tell your pt about nitroglycerin SL spray? (3)
- do not shake container. store away from light
- prior to initial use, prime the pump by spraying 5 times
- preferably be seated when administering the spray
* more on slide 30
91
What are some points you would tell your pt about nitroglycerin SL tablet? (3)
- keep in original dark glass container. do not store in bathroom
- preferably be seated when administering the tablet
- typically only good for 6 months after opened
* more on slide 30
92
Do nitrates improve outcomes?
No - they only relieve symptoms
93
What types of agents are used for secondary prevention of CAD?
- antiplatelet agents (ASA, clopidogrel)
- statins
- ACEi or ARBs
-revascularization (coronary stent or CABG)
94
Rationale of antiplatelets?
prevent thrombus formation
95
What dose of ASA is recommended and shown to have a 30% decrease in MI and sudden death?
75-325 mg
96
Is clopidogrel or ASA more effective?
ASA
| *CAPRIE trial showed marginal benefit of clopidogrel over ASA
97
What dose of clopidogrel is recommended?
75 mg daily
98
When is clopidogrel recommended over ASA?
if pt cannot tolerate ASA
99
Combining ASA and clopidogrel: Effective?
no benefit compared to ASA alone
100
How do statins help patients with stable angina?
decrease CV death and nonfatal MI in patients with established CHD
101
What are the 2 statins that are recommended? (with doses)
simvastatin 40 mg daily
| atorvastatin 80 mg daily
102
MOA of ACEi
* ACEi cause vasodilation
- decrease sympathetic adrenergic transmission
- decrease after load (BP lowering)
- increase coronary blood flow
103
Which ACEi showed no difference compared to placebo in reducing CV death, MI, cardiac arrest?
trandalopril
104
Which 2 ACEi showed a reduced risk of CV death, MI and cardiac arrest?
ramipril, perindopril
105
Benefit of ACEi beyond BP control in ____ risk CHD patients is questionable
low
106
When are ACEi indicated?
for BP control in additional to beta blockers, prior MI, LV dysfunction (HF), diabetes, chronic kidney disease
107
When are ARBs recommended?
in high risk of CV events patients who are intolerant to ACEi
- could have dry cough
- ACEi can affect kidneys and increase Scr
108
PTCA
percutaneous coronary angioplasty
109
CABG
coronary artery bypass surgery
110
PTCA and CABG are types of ________
revascularization
111
When you are on a statin, monitor for ???
MUSCLE PAIN BITCHES
