Angina Flashcards
Discuss apporpriate non-pharmacologic measures for a patient with angina.
-smoking cessation -increase physical activity and weight control -plasma glucose control -immunizations
List the goals for pharmacologic therapy in chronic stable angina.
-Prevent progression to USA, MI or death (through anti-platelet therapy and cholesterol control) -provide effective relief of anginal symptoms (using beta blockers, calcium channel blockers, and nitrates) -Modify risk factors for CAD (blood pressure control, smoking)
What should you monitor when using a beta blocker for chronic stable angina relief?
heart rate-don’t start one on pt with t increase the dose with HR at goal.
What should you monitor when using a calcium channel blocker for chronic stable angina relief?
blood pressure-can cause orthostatic hypotension HR-can cause reflex tachycardia watch for pitting edema
what are the hard indications for use of a beta blocker for treatment of chronic stable angina?
-6 months post MI (ideally 3 years) -Ejection Fraction is <40%
When should you initiate therapy with calcium channel blockers for chronic stable angina?
*Use non-DHP to replace beta blocker or if a beta blocker isn’t desirable. -don’t start if the HR is /= 2+ pitting edema or if patient has othostatic hypotension.
When should you initiate therapy with a long acting nitrate for chronic stable angina?
-add to a beta blocker or non-DHP to improve symtom control -useful over DHP in patients with cautions for use -Use with DHP if a pt can’t tolerate beta blocker or non-DHP
When should you initiate therapy with a short acting nitrate for chronic stable angina?
use to terminate acute attacks or to prophylaxis INFREQUENT stress or effort attacks
How would you initiate therapy with nitrates for chronic stable angina based on patient-specific information?
To alleviate pain, consider a beta blocker first, then add or substitute a CCB as needed, and then add or substitute a long-acting nitrate as needed.
Nitrates (short-acting and long-acting)
LA nitrates can be used for long term prophylaxis, are generally added to BB or non-dyhidropyridines to control anginal pain, are useful over DHP in patients with cautions for use, and can be combined with dyhidropyridines if patient can’t tolerate beta blockers or non-dyhidropyridines.
SA nitrates are used to terminate acute anginal attacks, prevent effort- or stress-induced attacks, and to prophylax infrequent stress or effort attacks.
How would you initiate therapy with beta-blockers for chronic stable angina based on patient-specific information?
To alleviate pain, consider a beta blocker first, then add or substitute a CCB as needed, and then add or substitute a long-acting nitrate as needed.
Beta Blocker
Avoid use of beta blockers with intrinsic sympathomimetic agents, which will negate the “exercise-induced” benefits of beta blockers.
Try beta blockers first for patients with hard indications and no contraindications (use beta blockers for 6 months, preferably 3 years, post MI; use beta blockers for systolic HF [EF
For patients with cautions for use and NO hard indications, try something else first. Do NOT start a beta blocker if HR < 55.
Do NOT increase the dose with HR at a goal level of 55-60
Cautions: type I DM, asthma, decompensated HF, moderate to severe PAD.
Contraindications: bradycardia (HR<50), 2nd degree heart block
How would you initiate therapy with calcium channel blockers for chronic stable angina based on patient-specific information?
To alleviate pain, consider a beta blocker first, then add or substitute a CCB as needed, and then add or substitute a long-acting nitrate as needed.
Calcium Channel Blocker
For dihydropyridines, add to beta blocker if HR <= goal or combine with LA nitrates in patients who can’t take beta blockers or non-DHP.
Use non-dihydropyridines if HR > goal and a beta blocker is not recommended for use (no hard indications with cautions) or contraindicated.
Non-DHP contraindications include left ventricular dysfunction (EF<40%), bradycardia (HR<50 bpm), and AV block (2nd or 3rd).
Use non-DHP to replace a beta blocker or if a beta blocker is undesirable but do NOT use if HR<55 or increase the dose if HR is at goal. Use DHP in addition to a beta blocker when HR is at goal but do NOT start with >= 2+ pitting edema or with orthostatic hypotension.
