CAD, Angina, MI Flashcards
Review for Kaplan Pharm
Patho of CAD: What is the most common cause of CAD?
Development of atherosclerosis in arteries supplying the myocardium is the most common cause?
Patho of CAD: What does development of atherosclerosis in arteries supplying the myocardium lead to?
O2 reduction to cardiac muscle
Patho of CAD: What would lead to angina?
Ischemia –> accumulation of lactic acid & metabolic wastes –> angina
Patho of CAD: What part of the heart is most susceptible?
LV most susceptible
Patho of CAD: What is it a prognosis for?
Prognosis for MI
Patho of CAD: What are other causes of MI?
Vasospasm
Cardiomyopathy
Thrombi
Patho of CAD: What are contributing factors to CAD?
DM
Stress
HTN
Smoking
Patho of CAD: What is stable angina initiated by?
Initiated w/ ↑ O2 demand w/ activity
Patho of CAD: How is stable angina reduced?
Reduced at rest
Patho of CAD: How does CAD progress?
Plaque ulceration –> inflammation –> platelets aggregation & thrombi
Platelets –> thromboxane A2 (vasoconstrictor) –> artery spasm
Patho of CAD: What is CAD a repeated cycle of?
Repeated cycle of aggregation of spasms
Patho of CAD: How does unstable angina occur? When does it occur?
Unpredictable
Occurs at rest
Patho of CAD: What are complications of CAD?
MI
HF
Dysrhythmias
Presentation & Management of CAD:
What are clinical manifestations?
Radiating angina ~ jaw, neck, arm, back
Indigestion-like sensation
N/V
Cool, clammy extremities
Diaphoresis
Fatigue
Presentation & Management of CAD:
How is diagnosis of CAD made?
Identifying contributing factors
PMH & PE
Exercise stress test
Echocardiogram
EKG ~ depression of ST-segment if chronic
Presentation & Management of CAD:
Diagnosis of CAD: What are identifying factors?
Lipid profile
Angiography
Nuclear imaging
Presentation & Management of CAD:
What is treatment of CAD?
PX of MI ~ modifiable risk factors
Angioplasty, bypass & laser procedures
Medications
Presentation & Management of CAD:
What are medications for CAD?
Antiplatelet agents,
anticoagulants,
thrombolytics
Lipid-lowering medications
Nitrates, BBlockers, CCBs ~ vasodilation increase O2
Angina: What is it?
Sudden pain beneath the sternum
Angina: How is the pain?
Often radiating to the left shoulder, left arm, jaw
Angina: What is the cause?
Insufficient O2 supply to the heart
Angina: What occurs?
Most ~ atherosclerosis of coronary arteries
Angina: O2 demand effects what?
HR
Myocardial contractility
Intramyocardial wall tension ~ preload & afterload
Angina: What do drugs target?
O2 demand
Angina:
Under normal conditions, what does an increase in O2 demand lead to?
increase in O2 demand –> dilation of coronary arterioles–> decrease in PR and increase in blood flow
Angina:
Under normal conditions, how is O2 supply during exertion?
Increased during exertion
Angina:
Under normal conditions, when does perfusion occur?
Perfusion occurs during diastole (relaxation)
Angina:
What are goals of treatment having to do with MI and death?
Meds for dysplipidemia and antiplatelets
Angina:
What are goals of treatment having to do with myocardial ischemia and anginal pain?
Meds for angina
Angina:
What are anti-anginal agents?
Organic nitrates-NTG
BBlockers- metroprolol
CCBs- verapamil
Ranolazine
Chronic Stable (Exertional) Angina aka?
Angina of effort
Chronic Stable (Exertional) Angina: What are triggers?
Physical activity
Emotional excitement
Large meals
Exposure to cold
Chronic Stable (Exertional) Angina: What is an underlying cause?
CAD
Chronic Stable (Exertional) Angina: What happens to arterial walls in an angina?
deposition of fatty plaque in arterial wall
Leading to partial occlusion–> angina
Chronic Stable (Exertional) Angina: What happens to arterial walls in a MI?
Deposition of fatty plaque in arterial wall
Complete occlusion –> MI
Chronic Stable (Exertional) Angina: How is O2 demand at rest?
At rest, O2 demand and supply in balance
Leads to dilation of distal vessel
Chronic Stable (Exertional) Angina: What is treatment of risk factors for stable angina?
Meds for dyslipidemia and htn
Meds for DM
Smoking cessation
Chronic Stable (Exertional) Angina: What is the treatment to reduce risk of MI?
Antiplatelet agents
Chronic Stable (Exertional) Angina: How does angina treatment work?
Increases cardiac O2 supply
Decreases cardiac O2 demand
Chronic Stable (Exertional) Angina:
Approach to angina treatment:
Decrease cardiac O2 demand does what?
Meds to decrease HR, contractility, afterload, preload
Only provide symptomatic relief
Won’t alter underlying patho
Nitrates, BBlockers, CCBs
Chronic Stable (Exertional) Angina:
Approach to angina treatment:
What drugs decrease cardiac O2 demand?
Nitrates, BBlockers, CCBs
Chronic Stable (Exertional) Angina:
Ranolazine
What does it help with? What does it NOT do?
No effect on HR, PR, BP
Helps myocardium generate energy more efficiently
Nondrug TX for stable angina?
Avoid triggers
Smoking cessation
Establish regular pattern of aerobic exercise
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: Nitrates- what do they do?
Dilation of veins decreases preload
SL for breakthrough
Long-acting for last line maintenance
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: Beta Blockers- What do they do?
Decrease in HR and contractility
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: Beta Blockers- What is it a first line add on to?
1st line add-on to sublingual NTG for maintenance
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: Beta Blockers- What does it prevent?
PX reflex tachycardia
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: Beta Blockers- What are cases where you would always add a BBlocker?
Always add if (+) prior MI
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: CCBs
All agents: dilation of arterioles decreases afterload
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: CCBs- What are examples? What do they do?
Verapamil & diltiazem only: decrease HR & contractility
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: CCBs- Why would they be added?
Added if BBlocker failed or CI
Chronic Stable Angina:
Antianginal meds to decrease O2 demand: CCBs- What should be avoided? Why?
Avoid nondihydropyridines if concurrent Bblocker
Chronic Stable Angina:
Antianginal meds to decrease O2 demand:
What is done if there is failure of Long acting nitrate + BBlocker +CCB?
Coronary artery bypass graft CABG
Percutaneous coronary intervention PCI
Variant (Vasospastic) Angina aka?
AKA Prinzmetal’s angina
Variant (Vasospastic) Angina Patho?
CAD –> coronary artery spasm
Decrease blood flow to myocardium ~ insufficient O2 ~ angina
Variant (Vasospastic) Angina: What does it frequently occur with?
Frequently occurring in conjunction w/ stable angina
Variant (Vasospastic) Angina: What is the approach to treatment?
increase cardiac O2 supply (pain not due to demand)
Variant (Vasospastic) Angina: Antianginal meds to increase O2 supply- What meds are not effective?
BBlockers & ranolazine NOT effective for this form
Variant (Vasospastic) Angina: What do meds do?
Agents that promote vasodilation ~ relax spasm
Variant (Vasospastic) Angina: Antianginal meds to increase O2 supply
What are they?
Nitrates & CCBs
Variant (Vasospastic) Angina: Antianginal meds to increase O2 supply- What meds are first line, second, last?
Antianginal meds to increase O2 supply
1st line: LA nitrate or CCB
2nd line: combo of above
Last line: CABG
Unstable Angina- Symptoms?
Angina at rest
New-onset exertional angina
Intensification of existing angina
Unstable Angina- risk of death?
Risk of death > stable angina
Unstable Angina- what is it considered?
Medical emergency
Unstable Angina- Approach to TX
Reduce pain & PX progression to MI
Maintain O2 supply
decrease O2 demand
Anti-ischemic therapy w/ antiplatelet & anticoagulant agents
Unstable Angina-includes what?
Nitroglycerin
BBlocker
Supplemental O2 if (+) cyanosis or respiratory distress
IV morphine sulfate
Unstable Angina-Anti-ischemic therapy
Nitroglycerin- how is it given?
SL dose q5min x 3
Unstable Angina-Anti-ischemic therapy
Nitroglycerin- Persistent ischemia or HTN hows it given?
IV
Unstable Angina-Anti-ischemic therapy
BBlocker
When is IV given over PO?
Ongoing chest pain initial IV > PO
Unstable Angina- Anti-ischemic therapy
When is supplemental O2 given?
Supplemental O2 if (+) cyanosis or respiratory distress
Unstable Angina- Anti-ischemic therapy
IV morphine sulfate : for what?
Pain unrelieved by NTG
Pulmonary congestion or severe agitation
Unstable Angina- Anti-ischemic therapy
When would Ace inhibitor be given?
ACE-I if (+) LVD or CHF
Unstable Angina
Antiplatelet therapy
ASA indefinitely
Clopidogrel, prasugrel, or ticagrelor x 2m
Unstable Angina
Antiplatelet therapy
When would Abciximab be given?
Abciximab if angioplasty planned
Unstable Angina
Antiplatelet therapy
When would Eptifibatide or tirofiban be given?
Eptifibatide or tirofiban if high-risk w/ continuing ischemia (angioplasty not planned
Unstable Angina
Anticoagulant therapy: What meds?
Enoxaparin SQ
Direct thrombin inhibitors ~ bivalirudin
Factor Xa inhibitors ~ fondaparinux
IV UF heparin
Drug Classes Used for Angina
Organic Nitrates
Beta Blockers
Calcium Channel Blockers
Ranolazine
Organic Nitrates- example?
Nitroglycerin
Organic Nitrates- What is Mode of action of stable angina?
Direct action on VSM
Vasodilation
decrease in venous return causes decrease in preload ~ decrease in O2 demand
Organic Nitrates- stable angina
How are effects?
Veins > arterioles
Relief due to effects on peripheral blood vessels, NOT coronary blood flow
Organic Nitrates-
MOA for variant:
Relaxation of coronary artery spasm
Increase in O2 supply
Organic Nitrates cont.
ADE
HA
Orthostatic Hypotension
Reflex Tachycardia
Tolerance
Organic Nitrates cont.
ADE: HA