Angina

Question 1

Angina

Answer 1

Decreased blood flow through the vessel = tissue ischemia

Question 2

Stable Angina

Answer 2

Classic or chronic:

Exertional ( most common)

Question 3

Prinzmetal’s angina

Answer 3

Variant/vasospastic ( studded influx of calcium intracellular) 3%
Occurs at various times, including rest

Tx CCB
EKG may show ST elevation

Question 4

Unstable Angina

Answer 4

Pre-infarction, rest or crescendo, coronary syndromes

Question 5

Micro vascular Angina

Answer 5

Metabolic syndrome

Question 6

Angina signs/symptoms

Answer 6

Characteristic chest discomfort lasting several minutes
Exertional is usually precipitated by physical activity; subside with rest
Nitroglycerin shortens or prevents attacks

Question 7

Angina physical exam findings

Answer 7

May see signs of peripheral Arterial disease
Levine’s sign = “clenched fist sign”
Transient S4 not uncommon during angina

Question 8

Angina Lab/Diagnostic

Answer 8

EKG may be normal, with down sloping ST segment, or T wave peak or inversion during attack
Exercise EKG
Lipid Panel
Coronary angiography is the definitive diagnostic procedure but not indicated solely for diagnosis

Question 9

Cholesterol Levels

Answer 9

Total: Desirable: <200
VLDLs Triglycerides: Normal = < 150
LDL: optimal: <100
HDL: low <4 High >60

Goals for DM or CAD
LDL <70
HDL >40
TG <150

Question 10

Angina Management

Answer 10

Reduction of risk factors when possible
Managed diet: Decrease saturated fats, then decrease unsaturated fats, and then consider plant sterols
Low dose enteric-coated aspirin 81 mg daily
Common pharmacotherapy for angina:
Nitrates
Beta blockers
Calcium channel blockers
Optimizing lipid panel values
Estimate 10 year arthro-sclerotic cardiovascular disease risk
Identify individuals who may benefit from statin therapy

Question 11

10 year atherosclerotic cardiovascular disease risk (ASCVD)

Answer 11

Defined as the first occurrence of non-fatal and fatal M I and non-fatal and fatal stroke
To identify candidates for statin therapy; estimated risk of a SCVD is based on:
Age
Sex
Race
Total cholesterol
HDL
Systolic blood pressure
Diabetes status
Smoking

Question 12

Individuals who may benefit from statin therapy

Answer 12

Individuals with clinical evidence of ASCVD
Individuals with elevated LDL greater than or equal to 190
Diabetics 40–75 years of age with LDL between 70–1 89 but without clinical evidence of ASCVD
Individuals without ASCVD or diabetes with LDL between 70–1 89 but with an estimated 10 year risk ASCVD of 7.5% or higher

Question 13

High Intensity Statin Therapy

Answer 13

Daily dose lowers LDL on average , by > 50%

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

Question 14

Moderate Intensity Statin Therapy

Answer 14

Daily dose lowers LDL on average, by approximately 30 to <50%
Atorvastatin 10-20mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg
Pravastatin 40-80mg
Lovastatin 40mg
Fluvastatin 80mg
Pitavastatin 2-4

Question 15

Low Intensity Statin Therapy

Answer 15

Daily dose lowers LDL on average, by <30%

Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg
Pitavastatin 1mg

Question 16

Common agents other than statins

Answer 16

Bile acid sequestrants: mostly decrease LDL; may increase TG
Cholestyramine (questran)
Colesevelem (Welchol)
Colestipol (Colestid)

Fibrates: decrease TG, slightly decrease LDL and possible increase HDL
Gemfibrozil (Lopid)
Fenofibrate (Tricor)
Fenofibric Acid (Trilipix)

Cholesterol absorption inhibitors: Used in combo with a statin to decrease LDL
Ezetimibe (zeta)

Niacin: decrease LDL and TG and increase HDL
“Flushing”