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EOR Family med > Angina > Flashcards

Angina Flashcards

1
Q

risk factors for angina pectoris

A

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

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2
Q

Coronary artery disease equivalents

A

diabetes mellitus
carotid artery disease
abdominal aortic aneurysm
peripheral arterial disease
10-year risk of MI at least 20%

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3
Q

causes of increased myocardial oxygen demand

A

increased heart rate
increased systolic blood pressure (after load)
increased myocardial contractility
increased myocardial wall tension or stress

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4
Q

classic sx of angina pectoris

A

midsternal pain that may radiate to jaw, shoulders, arm, wrists, back of neck or some combination.

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5
Q

associated sx of Angina pectoris

A

dyspnea
nausea
diaphoresis
numbness
fatigue

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6
Q

stable angina is exacerbated by? and received by?

A

exacerbated by exertion
relieved by rest/nitroglycerin

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7
Q

how often can you repeat sublingual nitroglycerin for Angina pectoris

A

every 5 minutes up to 3 times

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8
Q

what should you suspect if angina doesn’t resolve with nitroglycerin

A

unstable angina or MI

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9
Q

prinzmetal angina

A

vasospasm at rest
preservation of exercise capacity

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10
Q

unstable angina

A

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

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11
Q

how long can unstable angina pain last

A

up to 30 min
pain at rest indicates 90% occlusion

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12
Q

how long does pain usually last with stable angina

A

usually lasts less than 3 minutes

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13
Q

chronic angina is caused by

A

fixed stenosis (coronary plaque)

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14
Q

what sign might you see in angina and what is it

A

levine sign
holding clenched fist over chest; may have clenched teeth

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15
Q

initial test of choice for angina

A

ECG

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16
Q

ECG findings for angina

A

horizontal/down-sloping ST depression
nonspecific T wave changes (T wave inversion)
Poor R wave progression

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17
Q

in what percent of people w angina is an EKG normal

A

25-50%

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18
Q

what is the most important noninvasive testing for angina

A

stress testing

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19
Q

what is used to provoke ischemia in a stress echo

A

dobutamine or dopamine

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20
Q

when is a stress EKG used

A

only if baseline EKG is normal

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21
Q

positive findings for stress EKG

A

ST depressions
T wave inversions
Poor R wave progression
reproduction of sx or signs

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22
Q

limitations of stress EKG

A

does not locate the area of ischemia

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23
Q

what does myocardial perfusion imaging use for imaging in angina

A

thallium or technetium

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24
Q

indications of myocardial perfusion imaging in angina

A

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)

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25
Q

contraindications to vasodilators

A

bronchospastic disease
hypotension
AV blocks

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26
Q

what should be stopped before doing myocardial perfusion imaging for angina and for how long should they be stopped

A

theophylline (48 hours) and caffeine (12 hours)

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27
Q

indications ofr stress echocardiogram in angina

A

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)

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28
Q

contraindications to positive inotropes

A

severe LV outflow obstruction (aortic stenosis)
ventricular arrhythmias
recent MI (1-3 days)
severe systemic HTN

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29
Q

should patients without a history of coronary artery disease withhold antianginal meds prior to stress testing?

A

yes
withhold 48 hours prior to stress testing
includes nitrates, beta blockers, calcium channel blockers

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30
Q

should patients with a known history of coronary artery diseases withhold abtianginal meds prior to stress testing

A

no

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31
Q

definitive diagnosis and gold standard for angina

A

coronary angiography “Cath”
outlines the coronary artery anatomy
defines location and extent of coronary artery disease

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32
Q

indications for coronary angiography “Cath”

A

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)

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33
Q

typical outpatient regimen for angina

A

daily aspirin + beta blockers (both decrease mortality), sublingual short-acting nitroglycerin as needed for immediate sx relief, daily statin

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34
Q

what is the first line long-term therapy to reduce anginal episodes and improve exercise tolerance

A

beta blockres

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35
Q

benefits of beta blockers for angina

A

reduce mortality ‘prevent ischemic occurrences
improve sx by reducing myocardial oxygen demand via decrease in heart rate and myocardial contractility

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36
Q

how do beta blockers increase myocardial blood supply (MOA)

A

increase coronary artery filling time (coronary arteries fill during diastole), improving coronary circulation

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37
Q

how do beta blockers decrease myocardial oxygen demand (MOA)

A

reduce myocardial oxygen requirements during stress and exercise (negative chronotropes and inotropes that decrease heart rate and contractility) as well as decrease blood pressure

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38
Q

contraindications for beta blockers in angina and why

A

vasospastic or variant (prinzmetal) angina

beta blockers may increase the tendency to induce coronary vasospasm from unopposed alpha-receptor activity (vasoconstriction)

39
Q

what is first line therapy for immediate relief of acute anginal sx

A

short-acting nitroglycerin
sublingual MC

40
Q

is there any mortality benefit from nitroglycerin

A

no

41
Q

how does nitroglycerin increase myocardial blood supply (MOA)

A

increases coronary artery blood flow and collateral circulation as well as reduces coronary artery vasospasm

42
Q

how does nitroglycerin decrease myocardial oxygen demand (MOA)

A

ventilation (decreases preload) and vasodilation of arteries (decreases after load)

43
Q

can short-acting nitro be used prophylactically

A

yes - can be given 5 minutes before an activity likely to cause ischemia

44
Q

ADE short-acting nitroglycerin

A

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

45
Q

contraindications to short-acting nitro

A

systolic BP < 90
right ventricular infarction
use of phosphodiesterase-5 inhibitors (Sildenafil) - when co-administered can cause significant hypotension

46
Q

benefits of aspirin for angina

A

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

47
Q

considerations for aspirin

A

increased risk of major bleeding

48
Q

in patients who are unable to take aspirin or those w a history of GI bleed, what is an alternative? (for angina)

A

Clopidogrel

49
Q

MC ADE of aspirin

A

GI upset due to COX1 inhibition - chronic use can cause gastric ulceration

50
Q

what organ can aspirin damage and what can this cause

A

renal injury - acute failure or interstitial nephritis

51
Q

people with an aspirin hypersensitivity that take aspirin may experience

A

asthma from increased synthesis of leukotrienes

52
Q

what can occur at higher doses of aspirin

A

tinnitus
vertigo
hyperventilation
respiratory alkalosis

at HIGHER doses -
metabolic acidosis
dehydration
hyperthermia
collapse
coma
death

53
Q

long-acting non-dihydropyridines

A

Diltiazem
Verapamil

54
Q

long-acting dihydropyridines

A

Amlodipine
Felodipine
Nifedipine
Nicardipine

55
Q

indications for calcium channel blockers in angina

A

alternatives of beta blockers are contraindicated or cause adverse effected

56
Q

when should patches be taken off for long-acting nitroglycerin

A

taken off after 12-14 hours of use for a 10-12 hour patch-free interval daily

57
Q

indications of long-acting nitroglycerin

A

alternative if beta blockers are contraindicated or cause adverse effects

58
Q

ADE long-acting nitroglycerin

A

tachyphylaxis
vasodilation - headache, flushing, hypotension, light-headedness, peripheral edema

59
Q

contraindications for long-acting nitroglycerin

A

phosphodiesterase inhibitors should not be taken within 24 hours of nitrate use

60
Q

MOA Ranolazine

A

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

61
Q

indications for Ranolazine

A

effective at reducing anginal sx and improving exercise capacity when added to conventional medical therapy, esp in patients refractory to conventional therapy

62
Q

Ranolazine has no effect on

A

heart rate and BP

63
Q

can you use Ranolazine with erectile dysfunction meds

A

yes

64
Q

can Ranolazine be used for tx of acute anginal episodes

A

no

65
Q

Contraindications of Ranolazine

A

can cause QT prolongation - contraindicated in patients w existing QT prolongation
significant kidney and liver disease

66
Q

unstable angina is characterized by

A

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)

67
Q

pathophysiology of unstable angina

A

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!!!)

68
Q

when is angina considered unstable

A

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

69
Q

what can you use to diagnose unstable angina

A

EKG
cardiac enzymes

70
Q

what will EKG show for unstable angina

A

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

71
Q

cardiac enzymes for unstable angina

A

negative CK and troponin reflecting ischemia without cell death

72
Q

tx UA

A

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)

73
Q

examples of P2Y12 receptor antagonists

A

Ticagrelor
Prasugrel
Clopidogrel

74
Q

what should you consider adding to pts w unstable angina who are not treated w an invasive approach

A

GP IIb/IIIa inhibitor

75
Q

examples of GP IIb/IIIa inhibitor

A

Eptifibatide
Tirofiban

76
Q

vasospastic/prinzmetal angina

A

spontaneous episodes of angina accompanied by transient EKG ischemic ST changes due to epicardial coronary artery vasospasm leading to transient myocardial ischemia

77
Q

triggers of vasospastic angina

A

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

78
Q

examples of alpha agonists

A

pseudoephedrine
oxymetazoline
cocaine
amphetamines

79
Q

risk factors for vasospastic angina

A

females
smoking
other vasospastic disorders (Raynaud, migraine)
magnesium deficiency

80
Q

clinical manifestations vasospastic angina

A

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

81
Q

how long do episodes last for vasospastic angina

A

5-15 min - but may be persistent

82
Q

what can be used to diagnose vasospastic angina

A

EKG
angiography

83
Q

what will EKG show for vasospastic angina

A

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

84
Q

what will angiography show for vasospastic angina

A

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

85
Q

initial therapy vasospastic angina

A

cessation of smoking
CCB and sublingual nitroglycerin as needed for sx of angina

86
Q

what is the mainstay of therapy for vasospastic angina

A

CCB - Diltiazem, Amlodipine, Nifedipine

87
Q

what is preferred w the onset of each episodes of vasospastic angina - long acting or short acting nitro

A

short acting nitro - can be used to decrease duration of sx and ischemia

88
Q

what meds are avoided in vasospastic angina

A

beta blockers - may lead to unopposed alpha-mediated vasoconstriction and vasospasm especially non-selective beta blockers

89
Q

tx for chronic coronary artery disease

A

nitrates as needed
aspirin or clopidogrel
beta blockers or CCB

90
Q

definitive tx for coronary artery disease

A

revascularization using percutaneous transluminal coronary angioplasty (PTCA)
or
coronary artery bypass graft (CABG)

91
Q

indications for revascularization using percutaneous transluminal coronary angioplasty

A

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

92
Q

indications for coronary artery bypass graft

A

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

93
Q

all patients with CAD should take

A

daily aspirin

94
Q

patients w CAD who just had a stent placement should take

A

dual antiplatelet therapy - Aspirin + P2Y12 inhibitor (Clopidogrel or Ticagrelor)

EOR Family med (25 decks)

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