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Clinical 2 (Sam) > 3 - Ischemic Heart Disease > Flashcards

3 - Ischemic Heart Disease Flashcards

1
Q

Ischemic heart disease can also be called ??

A

CHD - coronary heart disease

CAD - coronary artery disease

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2
Q

Ischemic heart disease may present as?

A
  • Ischemia without clinical symptoms
  • Chronic stable angina pectoris
  • Acute coronary syndrome (ACS)
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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)
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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
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5
Q

Define ischemia

A

mismatch between coronary oxygen supply and demand

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6
Q

What factors affect oxygen demand

A
  • heart rate
  • contractility
  • intramyocardial wall tension
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7
Q

What factors affect oxygen delivery

A
  • coronary blood flow
  • oxygen extraction
  • oxygen availability
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8
Q

ACS = ______ ischemia

A

supply

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9
Q

Ischemic heart disease = ______ ischemia

A

demand

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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
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11
Q

Chronic stable angina:

Precipitating factors?

A
  • exercise
  • cold environment
  • walking after a large meal
  • emotions (anger, anxiety)
  • coitus
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12
Q

Chronic stable angina:

Responsive to ?

A

nitroglycerin

-relief of pain within 45 seconds to 5 min

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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
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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
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15
Q

When is an echocardiography used?

A
  • indicated when heart failure suspected

- measure left ventricular systolic function

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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
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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

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18
Q

What is the PQRST acronym ?

A
  • provoking/palliative factors
  • quality of pain
  • region/location
  • severity
  • timing and duration
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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
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20
Q

What do we use to relieve acute angina symptoms?

A

nitrates

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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
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22
Q

What agents do we use to reduce risk of CV complications?

A
  • antiplatelets
  • statins
  • ACEi
  • risk factor modification
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23
Q

Beta blockers reduce ??

A

cardiac oxygen demand

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24
Q

How do beta blockers work?

A

Reduce cardiac oxygen demand:

  • decrease HR
  • decrease contractility
  • decrease intramyocardial wall tension (via decreased BP)
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25
Q

How do beta blockers benefit stable angina patients?

A
  • reduce occurrence of angina symptoms

- improve survival in patients with LV dysfunction (HF) or history of MI

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26
Q

What is first line therapy for treatment of chronic stable angina?

A

beta blockers

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27
Q

Why are beta blockers not the best in diabetic patients?

A
  • B blockers may inhibit insulin release

- B blockers mask some symptoms of hypoglycaemia

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28
Q

What can B blockers worsen the symptoms of?

A

reactive airway disease or peripheral arterial disease

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29
Q

T or F: do you need to taper B blockers?

A

yes - taper over 10-14 days

*abrupt withdrawal may increase severity and number of pain episodes

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30
Q

B blockers: which one is more effective?

A

all equally effective

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31
Q

What B blockers do you avoid in severe angina?

A

ones with ISA (some alpha effects)

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32
Q

What B blockers do you choose in asthmatics?

A

cardioselective agents

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33
Q

Metoprolol loses selectivity at what dose?

A

> 200 mg/day

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34
Q

What 3 BB’s have evidence for decreased mortality post-MI?

A
  • timolol
  • propranolol
  • metoprolol
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35
Q

List the Cardioselective beta blockers

A
  • atenolol
  • bisoprolol
  • metoprolol
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36
Q

List the Non-selective B blockers

A
  • nadolol
  • propranolol
  • timolol
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37
Q

List the mixed alpha and B blockers

A

-carvedilol

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38
Q

List the cardioselective and vasodilatory B blockers

A

-nebivolol

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39
Q

Abrupt discontinuation of B blockers may induce _____

A

ischemia

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40
Q

Who are cardioselective beta blockers recommended for?

A
  • asthma
  • COPD
  • PAD
  • DM
  • dyslipidemias
  • sexual dysfunction
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41
Q

What type of patients have additional benefits from nonselective beta blockers?

A

patients with essential tremor, migraine, headache, portal hypertension, thyrotoxicosis

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42
Q

Usual dose of Atenolol

A

25-100 mg daily

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43
Q

Usual dose of Bisoprolol

A

2.5 - 10 mg daily

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44
Q

Usual dose of Metoprolol tartrate

A

50 - 200 mg BID

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45
Q

Usual dose of Metoprolol succinate ER

A

50 - 200 mg daily

46
Q

Usual dose of Nadolol

A

40-120 mg daily

47
Q

Usual dose of Propranolol

A

40 - 160 mg BID

48
Q

Usual dose of Propranolol LA (Inderal LA, Inderal XL)

A

80 - 320 mg daily

49
Q

Usual dose of Timolol

A

10 - 40 mg daily

50
Q

What is an additional side note of carvedilol?

A

It is a mixed alpha and beta blocker:

-Additional alpha blockade produces vasodilation and more orthostatic hypotension

51
Q

How is nebivolol better than carvediolol?

A

It is cardioselective and vasodilatory:

-Additional vasodilation does not result in more orthostatic hypotension

52
Q

Usual dose of Carvedilol

A

25 - 50 mg BID

53
Q

Usual dose of Nebivolol

A

5 - 20 mg daily

54
Q

How do calcium channel blockers reduce cardiac oxygen demand?

A

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
Q

How do calcium channel blockers improve coronary blood flow?

A

Improve coronary blood flow:

  • vasodilate coronary arteries
  • decrease coronary vascular resistance
  • prevent vasospasm
56
Q

How effective are CCBs compared to BBs at preventing angina?

A

just as effective

57
Q

Do CCBs improve survival after MI?

A

No

58
Q

List Dihydropyridines

A

Amlodipine
Nifedipine
Felodipine

59
Q

List Non-DHPs

A

Verapamil

Diltiazem

60
Q

____ act peripherally and cause vasodilation

A

DHPs (amlodipine, nifedipine, felodipine)

61
Q

______ act centrally and decrease contractility in the coronary arteries

A

non-DHPs (verapamil, diltiazem)

62
Q

Are DHPs or non-DHPs used in combo with B blockers?

A

only DHPs (amlodipine, nifedipine, felodipine)

63
Q

What are side effects of calcium channel blockers?

A
  • hypotension
  • flushing
  • headache
  • dizziness
  • peripheral edema
  • all due to vasodilation
64
Q

What are some additional side effects that non-DHPs have?

A
  • bradycardia

- worsening heart failure

65
Q

What additional SE does verapamil have?

A

constipation

66
Q

Diltiazem IR dose

A

60 mg po TID

67
Q

Diltiazem CD/ER/XC dose

A

120 - 360 mg daily

68
Q

Verapamil IR dose

A

80 mg TID

69
Q

Verapamil SR dose

A

120 - 180 mg daily

70
Q

Amlodipine dose

A

5 - 10 mg daily

71
Q

Nifedipine XL dose

A

30 - 60 mg daily

72
Q

When should you avoid using diltiazem?

A

in HF or 2nd or 3rd degree heart block

73
Q

What do nitrates do?

A

Reduce myocardial oxygen demand:
-Venodilation and arterial-arteriolar dilation

Dilate coronary arteries:
-Increase coronary blood flow

74
Q

What are nitrates used to treat?

A

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
Q

What are the long-acting formulations of nitrates?

A
  • isosorbide dinitrate

- transdermal nitroglycerin

76
Q

Are nitrates used as monotherapy?

A

No - have not been shown to reduce mortality in patients with CAD

77
Q

SE of nitrates?

A
  • headache
  • flushing
  • hypotension
78
Q

Nitrates:

____ can develop with chronic therapy (7-10 days)

A

Tolerance

79
Q

How do you manage nitrate tolerance?

A

use a nitrate free period (8-12 hours) to avoid tolerance

80
Q

What do nitrates interact with?

A
  • sildenafil
  • tadalafil
  • vardenafil
81
Q

Dose of nitroglycerin SL pumpspray

A

0.4 mg q5min prn

82
Q

Comments for nitroglycerin, sublingual pumpspray?

A

If discomfort persists 5 minutes after 1 dose, call ambulance and continue to use spray q5min for total 3 doses/ambulance arrival

83
Q

Dose of Nitroglycerin transdermal patches

A

Start with 0.2mghr patch applied and removed daily.

Max 0.8 mg/hr patch daily

84
Q

Comments for nitroglycerin transdermal patches?

A

Ensure 10-12 hour nitrate free period

85
Q

Dose of isosorbide dinitrate SL?

A

5mg q5min prn

86
Q

Dose of isosorbide dinitrate IR?

A

10 - 30 mg po TID

87
Q

Comments for isosorbide dinitrate?

A

Ensure 10 - 12 hour nitrate free period for IR formulation

88
Q

Dose of Isosorbide mononitrate ER?

A

Start with 30 - 60 mg daily

Max 240 mg daily

89
Q

Comments for isosorbide mononitrate?

A

daily nitrate free period difficult to implement

90
Q

What are some points you would tell your pt about nitroglycerin SL spray? (3)

A
  • 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
Q

What are some points you would tell your pt about nitroglycerin SL tablet? (3)

A
  • 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
Q

Do nitrates improve outcomes?

A

No - they only relieve symptoms

93
Q

What types of agents are used for secondary prevention of CAD?

A
  • antiplatelet agents (ASA, clopidogrel)
  • statins
  • ACEi or ARBs

-revascularization (coronary stent or CABG)

94
Q

Rationale of antiplatelets?

A

prevent thrombus formation

95
Q

What dose of ASA is recommended and shown to have a 30% decrease in MI and sudden death?

A

75-325 mg

96
Q

Is clopidogrel or ASA more effective?

A

ASA

*CAPRIE trial showed marginal benefit of clopidogrel over ASA

97
Q

What dose of clopidogrel is recommended?

A

75 mg daily

98
Q

When is clopidogrel recommended over ASA?

A

if pt cannot tolerate ASA

99
Q

Combining ASA and clopidogrel: Effective?

A

no benefit compared to ASA alone

100
Q

How do statins help patients with stable angina?

A

decrease CV death and nonfatal MI in patients with established CHD

101
Q

What are the 2 statins that are recommended? (with doses)

A

simvastatin 40 mg daily

atorvastatin 80 mg daily

102
Q

MOA of ACEi

A
  • ACEi cause vasodilation
  • decrease sympathetic adrenergic transmission
  • decrease after load (BP lowering)
  • increase coronary blood flow
103
Q

Which ACEi showed no difference compared to placebo in reducing CV death, MI, cardiac arrest?

A

trandalopril

104
Q

Which 2 ACEi showed a reduced risk of CV death, MI and cardiac arrest?

A

ramipril, perindopril

105
Q

Benefit of ACEi beyond BP control in ____ risk CHD patients is questionable

A

low

106
Q

When are ACEi indicated?

A

for BP control in additional to beta blockers, prior MI, LV dysfunction (HF), diabetes, chronic kidney disease

107
Q

When are ARBs recommended?

A

in high risk of CV events patients who are intolerant to ACEi

  • could have dry cough
  • ACEi can affect kidneys and increase Scr
108
Q

PTCA

A

percutaneous coronary angioplasty

109
Q

CABG

A

coronary artery bypass surgery

110
Q

PTCA and CABG are types of ________

A

revascularization

111
Q

When you are on a statin, monitor for ???

A

MUSCLE PAIN BITCHES

Clinical 2 (Sam) (18 decks)

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