Angina

Question 1

Therapy for chronic stable angina?

most common form of angina, caused by a reduciton of coronary perfusion

Answer 1

Rest, nitro; may add b-blockers/CCB depending on comorbidities

Question 2

Chronic stable angina tx plan…

Answer 2

A - Aspirin, Anti-Anginal therapy
B - Beta Blocker / Blood pressure
C - Cigarette smoking cession / Cholestrol control
D - Diet / Diabetes
E - Education / Exercise

Question 3

Beneift in angina: reduce myocardial oxgen demand by decreasing catecholamine-induced incraeses in HR, BP, contractility

Answer 3

Beta blockers

BUT AVOID THOSE W/ ISA

Question 4

Preferred drug for variant/Prinzmetal angina (relieves vasospasms)

Answer 4

CCBs

Question 5

Least selective of non-DHP CCBs

Useful for migraine/cluster headaches

Answer 5

Verapamil

Question 6

Less pronounced negative inotropic effects compared to verapmil

Useful for supraventricular tachyarrhytmia

Answer 6

diltiazem

Question 7

Additive for HTN and symptomatic control

But causes gingival enlargement

Answer 7

Nifedipine

Question 8

Causes constipation

Needs to be monitored for bradycardia

Answer 8

Verapamil

Question 9

Nitrate usage in angina?

Answer 9

Maintenance w/ CCB/Beta-blocker

PRN

Prophylaxis before exercise

But tolerance develops quicky (need a nitrate free period)

Question 10

Nitrates adverse effects

Answer 10

HA

increased ICP

methemoglobinemia

Reflex tachycardia

Question 11

Nitrate contraindicated?

Answer 11

sildenafil/tadalafil (PDE5 inhibitor)

Question 12

Patient education stipulations for Nitrates…

Answer 12

Don’t use nitrates older than 6 mos (reduced efficacy)

Sit down and take tab/spray. Relief shoudl occur w/in 5 mins.

If after 3 doses, no relief, seek medical assistance

Question 13

Acute decompensated HF (primarily warm/wet)

ideal choice in HTN emergency for patients w/ IHD, MI

Preferred agent for preload reduction in pts w/ pulmonary congestion

Answer 13

Nitroglcyerin

Question 14

Stipulation w/ nitro transdermal patch?

Answer 14

Dosing at 12-14 hours during day, patch off 10-12 hours at night

Question 15

What’s Bidil?

Answer 15

Isosorbide Dinitrate/HYdralazine - for heart failture

Question 16

Isosorbide MONOnitrate

Answer 16

Nitrate used for chronic stable angina w beta blockers

Note that this is NOT FDA approved for HF (vs. Isosorbide DInitrate)

Question 17

Third line for stable angina when other mgmt isn’t effective

Answer 17

Ranolazine (Na channel blocker)

CAN PROLONG QT interval at certain doses! Limit to 500mgx2/day

Question 18

Form of ACS, between stable angina and MI

Answer 18

Unstable angina

Question 19

All patietns w/ an NSTEMI, unless absolute contraindicated, get antiplatelet therapy… which includes

Answer 19

aspirin + P2Y12 receptor inhibitor +/- glycoprotein 2b/3a inhibitor

Question 20

What’s early revascularization/reperfusion therapy?

Answer 20

Determined by TIMI risk score, PCI/stent implantation can performed.

Note that fibrinolytics have no role in NSTEMI (vs usage in STEMI)!

Question 21

TIMI risk score numbers?

Answer 21

Low: 0-2
Moderate: 3-4
High: 5-7

Question 22

In a STEMI (ACS) with symptoms less than 12 hrs, what are your first line options?

Answer 22

Morphone, O2, Nitro, ASPIRIN

MONA

Use of Nitro doesn’t preclude other mortailty reducing therapies (beta blocker, ACEI)

Question 23

Early mgmt of ACS… Beta blocker considerations?

Answer 23

AVOID BETAS W/ ISA

Question 24

What are the beta blockers with ISA?

to avoid in early mgmt of ACS and post MI

Answer 24

Acebutolol

Pindolol

Penbutolol

Question 25

Stipulations for ACEI in early mgmt of ACS?

Answer 25

Indicated orally (NO IV) in anterior MI, LVEF < 40,

Consider in all pts post-ACS (unless pregnant, HOTN, bilateral renal arterty stenosis)

Question 26

Aldosterone antagonist stipulation for early mgmt of ACS?

Answer 26

After giving ACEI/ARB and beta blocker w/ LVEF < 40 AND either symptomatic HF or diabetic

Contraindicated in hyperkalemia, CrCl<30