Angina Flashcards
risk factors for angina pectoris
diabetes mellitus (worst, considered CAD equivalent)
smoking
hyperlipidemia
HTN
male sex
> 45 in men
> 55 in women
FHx of CAD
obesity
elevated homocysteine
increased C-reactive protein
lack of estrogen
Coronary artery disease equivalents
diabetes mellitus
carotid artery disease
abdominal aortic aneurysm
peripheral arterial disease
10-year risk of MI at least 20%
causes of increased myocardial oxygen demand
increased heart rate
increased systolic blood pressure (after load)
increased myocardial contractility
increased myocardial wall tension or stress
classic sx of angina pectoris
midsternal pain that may radiate to jaw, shoulders, arm, wrists, back of neck or some combination.
associated sx of Angina pectoris
dyspnea
nausea
diaphoresis
numbness
fatigue
stable angina is exacerbated by? and received by?
exacerbated by exertion
relieved by rest/nitroglycerin
how often can you repeat sublingual nitroglycerin for Angina pectoris
every 5 minutes up to 3 times
what should you suspect if angina doesn’t resolve with nitroglycerin
unstable angina or MI
prinzmetal angina
vasospasm at rest
preservation of exercise capacity
unstable angina
NSTEMI
suspect when pain is less responsive to NTG, lasts longer, and occurs at rest or with less exertion than previous episodes of angina
a type of ACS associated w critical coronary artery stenosis without myocardial cell death
how long can unstable angina pain last
up to 30 min
pain at rest indicates 90% occlusion
how long does pain usually last with stable angina
usually lasts less than 3 minutes
chronic angina is caused by
fixed stenosis (coronary plaque)
what sign might you see in angina and what is it
levine sign
holding clenched fist over chest; may have clenched teeth
initial test of choice for angina
ECG
ECG findings for angina
horizontal/down-sloping ST depression
nonspecific T wave changes (T wave inversion)
Poor R wave progression
in what percent of people w angina is an EKG normal
25-50%
what is the most important noninvasive testing for angina
stress testing
what is used to provoke ischemia in a stress echo
dobutamine or dopamine
when is a stress EKG used
only if baseline EKG is normal
positive findings for stress EKG
ST depressions
T wave inversions
Poor R wave progression
reproduction of sx or signs
limitations of stress EKG
does not locate the area of ischemia
what does myocardial perfusion imaging use for imaging in angina
thallium or technetium
indications of myocardial perfusion imaging in angina
can be used if baseline EKG is abnormal
gives info regrading the location and extent of ischemia
can be performed either w exercise or a pharmacologic agent if the patient cannot exercise (use Adenosine or Dipyridamole - vasodilators)
contraindications to vasodilators
bronchospastic disease
hypotension
AV blocks
what should be stopped before doing myocardial perfusion imaging for angina and for how long should they be stopped
theophylline (48 hours) and caffeine (12 hours)
indications ofr stress echocardiogram in angina
can be used if baseline EKG is abnormal
gives info regarding the location and extent of ischemia
can be performed w exercise or pharmacologic if pt cannot exercise w positive inotropes (dopamine or dobutamine)
contraindications to positive inotropes
severe LV outflow obstruction (aortic stenosis)
ventricular arrhythmias
recent MI (1-3 days)
severe systemic HTN
should patients without a history of coronary artery disease withhold antianginal meds prior to stress testing?
yes
withhold 48 hours prior to stress testing
includes nitrates, beta blockers, calcium channel blockers
should patients with a known history of coronary artery diseases withhold abtianginal meds prior to stress testing
no
definitive diagnosis and gold standard for angina
coronary angiography “Cath”
outlines the coronary artery anatomy
defines location and extent of coronary artery disease
indications for coronary angiography “Cath”
confirm/exclude CAD in patients w sx consistent w CAD
confirm/exclude CAD in pts w negative noninvasive testing for CAD
patients who may possibly need revascularization (PTCA or CABG)
typical outpatient regimen for angina
daily aspirin + beta blockers (both decrease mortality), sublingual short-acting nitroglycerin as needed for immediate sx relief, daily statin
what is the first line long-term therapy to reduce anginal episodes and improve exercise tolerance
beta blockres
benefits of beta blockers for angina
reduce mortality ‘prevent ischemic occurrences
improve sx by reducing myocardial oxygen demand via decrease in heart rate and myocardial contractility
how do beta blockers increase myocardial blood supply (MOA)
increase coronary artery filling time (coronary arteries fill during diastole), improving coronary circulation
how do beta blockers decrease myocardial oxygen demand (MOA)
reduce myocardial oxygen requirements during stress and exercise (negative chronotropes and inotropes that decrease heart rate and contractility) as well as decrease blood pressure
contraindications for beta blockers in angina and why
vasospastic or variant (prinzmetal) angina
beta blockers may increase the tendency to induce coronary vasospasm from unopposed alpha-receptor activity (vasoconstriction)
what is first line therapy for immediate relief of acute anginal sx
short-acting nitroglycerin
sublingual MC
is there any mortality benefit from nitroglycerin
no
how does nitroglycerin increase myocardial blood supply (MOA)
increases coronary artery blood flow and collateral circulation as well as reduces coronary artery vasospasm
how does nitroglycerin decrease myocardial oxygen demand (MOA)
ventilation (decreases preload) and vasodilation of arteries (decreases after load)
can short-acting nitro be used prophylactically
yes - can be given 5 minutes before an activity likely to cause ischemia
ADE short-acting nitroglycerin
vasodilation - HA, flushing of the skin, hypotension, peripheral edema
tolerance - tachyphylaxis after 24 h (allow for nitrate-free period for 8 hours)
deteriorates w exposure to light, moisture, and air
contraindications to short-acting nitro
systolic BP < 90
right ventricular infarction
use of phosphodiesterase-5 inhibitors (Sildenafil) - when co-administered can cause significant hypotension
benefits of aspirin for angina
reduces in the risk of subsequent myocardial infarction, stroke, and vascular death among a wide range of patients who have survived an occlusive cardiovascular disease event
considerations for aspirin
increased risk of major bleeding
in patients who are unable to take aspirin or those w a history of GI bleed, what is an alternative? (for angina)
Clopidogrel
MC ADE of aspirin
GI upset due to COX1 inhibition - chronic use can cause gastric ulceration
what organ can aspirin damage and what can this cause
renal injury - acute failure or interstitial nephritis
people with an aspirin hypersensitivity that take aspirin may experience
asthma from increased synthesis of leukotrienes
what can occur at higher doses of aspirin
tinnitus
vertigo
hyperventilation
respiratory alkalosis
at HIGHER doses -
metabolic acidosis
dehydration
hyperthermia
collapse
coma
death
long-acting non-dihydropyridines
Diltiazem
Verapamil
long-acting dihydropyridines
Amlodipine
Felodipine
Nifedipine
Nicardipine
indications for calcium channel blockers in angina
alternatives of beta blockers are contraindicated or cause adverse effected
when should patches be taken off for long-acting nitroglycerin
taken off after 12-14 hours of use for a 10-12 hour patch-free interval daily
indications of long-acting nitroglycerin
alternative if beta blockers are contraindicated or cause adverse effects
ADE long-acting nitroglycerin
tachyphylaxis
vasodilation - headache, flushing, hypotension, light-headedness, peripheral edema
contraindications for long-acting nitroglycerin
phosphodiesterase inhibitors should not be taken within 24 hours of nitrate use
MOA Ranolazine
late sodium channel blockers - reduces oxygen requirements of cardiac muscle (reduced tension in the heart wall) by reducing intracellular calcium overload and the subsequent increase in diastolic tension via its inhibition of late inward sodium channel in myocardial disease states (ischemia and hypertrophy)
does not exert a significant effect on the normal myocardium at usual dosages
indications for Ranolazine
effective at reducing anginal sx and improving exercise capacity when added to conventional medical therapy, esp in patients refractory to conventional therapy
Ranolazine has no effect on
heart rate and BP
can you use Ranolazine with erectile dysfunction meds
yes
can Ranolazine be used for tx of acute anginal episodes
no
Contraindications of Ranolazine
can cause QT prolongation - contraindicated in patients w existing QT prolongation
significant kidney and liver disease
unstable angina is characterized by
ischemic sx suggestive of acute coronary syndrome
negative cardiac biomarkers (troponin and CK-MB - creatine kinase myocardial band)
with or without EKG changes indicative of ischemia (ST segment depression or new T wave inversion)
pathophysiology of unstable angina
MC due to plaque rupture of a previous nonsecure lesion w subsequent thrombus formation, leading to critical coronary artery stenosis that is not fully occlusive (so no myocardial cell death!!!)
when is angina considered unstable
presents in any of the following:
rest angina generally lasting longer > 20-30 min
new onset angina esp if it significantly limits physical activity
change in angina pattern - increasing angina that is more frequent, lasts longer, or occurs w less exertion that previous angina
what can you use to diagnose unstable angina
EKG
cardiac enzymes
what will EKG show for unstable angina
with or without EKG changes indicative or ischemia - ST segment depression, new deep T wave inversions or flattening, poor R wave progression, pseudo normalization of the T waves, hyperacute T waves
cardiac enzymes for unstable angina
negative CK and troponin reflecting ischemia without cell death
tx UA
relief of ischemia pain - antiplatelet (aspirin, oxygen (if hypoxic), beta blocker)
initiation of anti thrombotic - anti platelet (Aspirin + P2Y12 receptor blocker) and anticoagulant therapy (unfractionated heparin, enoxaparin, fondaparinux, Bivalirudin)
examples of P2Y12 receptor antagonists
Ticagrelor
Prasugrel
Clopidogrel
what should you consider adding to pts w unstable angina who are not treated w an invasive approach
GP IIb/IIIa inhibitor
examples of GP IIb/IIIa inhibitor
Eptifibatide
Tirofiban
vasospastic/prinzmetal angina
spontaneous episodes of angina accompanied by transient EKG ischemic ST changes due to epicardial coronary artery vasospasm leading to transient myocardial ischemia
triggers of vasospastic angina
cold weather
alpha agonists
hyperventilation
marijuana
alcohol
exercise is a potential trigger but it doesn’t usually trigger episodes
cocaine use, esp w concurrent cig smoking history
Sumatriptan
examples of alpha agonists
pseudoephedrine
oxymetazoline
cocaine
amphetamines
risk factors for vasospastic angina
females
smoking
other vasospastic disorders (Raynaud, migraine)
magnesium deficiency
clinical manifestations vasospastic angina
usually younger (< 50 years)
fewer classic cardiovascular risk factors (except for smoking)
chest pain mainly at rest (esp midnight to early morning), usually not triggered by exertion nor relieved w rest
how long do episodes last for vasospastic angina
5-15 min - but may be persistent
what can be used to diagnose vasospastic angina
EKG
angiography
what will EKG show for vasospastic angina
transient ST elevations in the pattern of the affected artery that resolve w sx resolution (ST elevations may resolve w CCB or nitro)
EKG is usually normal btw anginal episodes in vasospastic angina
what will angiography show for vasospastic angina
rules out coronary artery disease and may show evidence of coronary vasospasm during angiography (>90% constriction) - especially w the use of Ergonovine, hyperventilation, or Acetylcholine
Usually no evidence of high-grade coronary stenosis
initial therapy vasospastic angina
cessation of smoking
CCB and sublingual nitroglycerin as needed for sx of angina
what is the mainstay of therapy for vasospastic angina
CCB - Diltiazem, Amlodipine, Nifedipine
what is preferred w the onset of each episodes of vasospastic angina - long acting or short acting nitro
short acting nitro - can be used to decrease duration of sx and ischemia
what meds are avoided in vasospastic angina
beta blockers - may lead to unopposed alpha-mediated vasoconstriction and vasospasm especially non-selective beta blockers
tx for chronic coronary artery disease
nitrates as needed
aspirin or clopidogrel
beta blockers or CCB
definitive tx for coronary artery disease
revascularization using percutaneous transluminal coronary angioplasty (PTCA)
or
coronary artery bypass graft (CABG)
indications for revascularization using percutaneous transluminal coronary angioplasty
patients with CAD and resultant angina involving one or two vessels but not involving the left main coronary artery and in those with normal ventricular function
in patients with diabetes with single-vessel disease
indications for coronary artery bypass graft
patients with left main coronary artery involvement with > 50% stenosis, >70% stenosis three vessel disease, or decreased left ventricular ejection fraction < 40%
patients with diabetes and multi vessel disease
all patients with CAD should take
daily aspirin
patients w CAD who just had a stent placement should take
dual antiplatelet therapy - Aspirin + P2Y12 inhibitor (Clopidogrel or Ticagrelor)
