CAD, MI (ACS) Flashcards
drugs for IHD (ischemic heart disease)
IHD- ischemic heart ds
- 2 types
Angina Pectoris and MI (ACS)
Angina Pectoris
- types
Typical v. Variant/Atypical
typical:
- stable: attack occurs w exertion, relieve w rest, occur under same circumstances
- unstable: attack inc in freq and severity
variant/atypical:
- prinzmetal/vasospastic: due to acute coronary vasospasm, occurs during rest or sleep
angina characteristics
- where, radiation, how is it induced
substernal or left precordial pain
- radiate to L shoulder
- induced by exercise or cold temps
goals for tx angina
inc our O2 supply (BB, CCB, vasodilators)
dec myocardial O2 demand
(BB and CCB to dec HR, CO, and contractility)
tx typical vs. atypical angina
typical- stable angina first line is BB
atypical- prinzmetal first line is CCB (DO NOT GIVE BB, it cannot counteract vasospasm)
adjunct tx
stabilize atherosclerotic plaques to prevent ACS
manage modifiable RFs
- HTN, HLD, DM, smoking cessation
non pharm tx
PCI and CABG
ANGINA
beta blockers
- names and categories
B1 selective: metoprolol, atenolol, nebivolol (M.A.N)
non selective: propanolol, nadolol
a1/B blockers: carvedilol, labetalol
ANGINA
Beta Blockers
- MOA
- indications
- CI
-olol
- first line for typical angina if no CI
MOA- dec HR, BP, CO, and myocardial O2 demand
Indications- HTN, CHF, typical angina, Mi, certain arrythmias, migraine
NOT FOR PRINZMETALS ANGINA or ACUTE angina attack
CI- sinus bradycardia, SBP <100, heart block, cardiogenic shock
- selective agents CI in COPD, asthma, DM
ANGINA
Beta Blockers
- ADRs
- DDIs
- monitoring parameters
ADRs- hypotension, bradycardia, bronchospasm, hypercholesteremia
DDIs- verapamil (dec CO and contractility too much)
monitor- BP, HR
ANGINA
CCBs
- names and categories
Non-DHPs (Central acting)
- verapamil, diltiazem
DHPs (peripheral acting)
- amlodipine, nifedipine, felopdipine
ANGINA
CCBs
- MOA
- indications
- CI
MOA- smooth muscle relaxation, suppress cardiac activity, inc O2 supply/dec myocardial O2 demand
indications- HTN, angina (prinzmetals), arrhythmias (central acting)
CI- SBP <100, Hr <60, EF <40% (neg inotrope bad for HFrEF)
ANGINA
CCBs
- ADRs
- DDI
- monitoring
ADRs- constipation, bradycardia, flushing, reflex tachy, periph edema
- CHF, heart block, hypotension w CENTRAL acting
DDI- dixgoxin, amiodarone, azoles (w verap and diltiaz)
monitor- BP, HR, EKG
ANGINA
CCB in angina management
when to use:
- DHP initial tx?
- other use for DHP
- combo with?
- non DHP for?
- use DHP as initial tx when BB are CI
- DHP as add on therapy to BB
- combo w nitrates
- non DHP for atypical/prinzmetal
ANGINA
organic nitrites and nitrates
- names and routes
amyl nitrates (INH), nitroglycerin (IV, PO, SL, buccal, topical, transdermal), isosorbide (PO, SL), Ranolazine
ANGINA
nitrites and nitrates
- MOA
- higher doses ?
- indications
- CI
MOA- release NO to dec preload, ventricular diastolic vol, ventricular pressure and myocardial wall tension & O2 demand
- higher doses: can dec LV afterload
indications- angina (that persists w monotherapy), MI, CHF
CI- aortic valve stenosis, concurrent use w sildenafil/tadalafil (for PAH and ED), close angle glaucoma, severe hypotension and anemia
ANGINA
nitrites/nitrates
- ADRs
- DDI
- monitoring
ADRs- tolerance develops, syncope, orthostat hypotension
- overdose—> reflex tachy and arrhythmias
DDIs- PDE 5 inhibitors (sildenafil), isosorbide is CYP3A4 substrate
monitor- BP, HR
ANGINA
nitrites/nitrates
- role in angina managment
SL formulation to relieve acute SS of Myocardial Ischemia
- SUBLINGUAL NITRO IS IMMEDIATE EFFECTIVE
SL/PO to prevent effort induced angina
- prophylaxis
long acting for maintenance tx
ANGINA
nitrites/nitrates
- Amyl Nitrate
- onset, DOA, use
- rapid onset, brief DOA
- used for cyanide poisoning
angina
nitrites/nitrates
- nitroglycerin
- SL, buccal ointment, patch, PO, IV uses
- SL and buccal- deteriorates in sunlight, replace bottle 3-6 month after opening
- ointment- nitrobid 2%
- patch- several doses
- PO- administer QD or BID to minimize tolerance
- IV- contains propylene glycol, need special tubing
ANGINA
nitrites/nitrates
- Isosorbide
- dinitrate v. mononitrate
dinitrate- PO or SL, give TID (8am, 1, 6)
mononitrate- Po only, longer acting
- ismo BID 7 hrs apart
- imdur QD
ANGINA
Ranolazine
- MOA
- CI
- Precautions
MOA- sodium current inhibitor
Indications- chronic stable angina in combo w CCB, BB, or nitrates
CI- pre existing QT prolongation, uncorrected hypokalemia, hepatic failure , potent CYP3A4 inhibitors
precaution- can prolong QT, induce torsades de pointe!!!!!!!!!!!!
ranolazine will PROLONG QT
ANGINA
ranolazine
- ADRs
- DDIs
ADRs- dizzy, HA, constipation, PROLONGS QT INTERVAL
(less HR/BP effect than other classes)
DDIs- CYP450 substrate
ANGINA
adjunct tx for angina
- categories
antiplatelet drugs, ACEi, and optimizing RFs
ANGINA
adjunct tx- Antiplatelet
- use in what pts?
Aspirin
- prevents platelet aggregation and thrombosis
- used to prevent ACS in UNSTABLE ANGINA PTS
other agents:
- clopidogrel, prasugrel, ticagrelor
optimize modifiable RFs
ANGINA management overview
- asthma
- DM
- HF
- HTn
- prior MI
- bradycardia/heart block
- asthma: non DHP/central CCB or cardioselective BB
- DM: non DHP CCB, nitrates/cardioselective BB alternative
- HF: BB and nitrates, nonDHP CCB least preferred
- HTN: BB and Non DHP CCB
- prior MI: BB
- bradycardia/heart block: DHP CCB
ACUTE STEMI
Acute STEMI pharm tx
-names
CAMONABAS
- CCB
- ACEi
- morphine/analgesics
- Oxygen
- NTG IV
- Aspirin
- BB
- Anticoag (UFH, LMWH)
- Statins
additional
- (P2y-12 inhibitors) antiplatelet agents/thrombolytics - clopidogrel, prasugrel
- fibrinolytics
- PCI
ACUTE STEMI
CCBs
- which CCB
- indicated for what kind of pts
- do NOT affect morbidity and mortality
- give to pts intolerant to BB
- diltiazem (pts w non Q wave Mi w out LV dysfunction)
ACUTE STEMI
ACEi
- indicated for what pts
recc for all post MI pts with LV dysfunction or CHF
ACUTE STEMI
Morphine/analgesics
IV morphine for pain relief if NTG did not alr relieve pain
ACUTE STEMI
NTG
- when should it be administered
- purpose
IV NTG recc for first 24-48 hrs of acute MI
- do NOT give if SBP <90 or HR <40
- alleviates ischemic myocardial pain
ACUTE STEMI
Aspirin
- when to administer
- what pts
- freq
- antiplatelet
- use for all MI pt unless CI
- start ASAP, continue indefinitely
ACUTE STEMI
BB
- when to administer
- freq continued
- start IV dose ASAP, continue post Mi with PO unless CI
- reduces morbid/mortality
Anticoag/UFH or LMWH
duration of tx depends on type of reperfusion
UFH, LMWH (10a inhib)
ACUTE STEMI
Statins
start pt on statins post MI for long term reduction CV events, morbidity, and mortality
ACUTE STEMI
P2Y-12 inhibitiors/antiplatelet agents
dose and duration?
- clopidogrel, prasugrel, ticagrelor
- dose and duration depends on revasc therapy (PCTA/PCI - DES vs. BMS)
- continued as DAPT for maintenance (dual antiplatelet therapy)
DES- 12 month DAPT
BMS- 1 month min to 12 month DAPT
ACUTE STEMI
reperfusion- fibrinolytics
- what do they do
- MOA
- types
- CI (absolute v. relative)
- acheive RAPID thrombolysis
- plasminogen activators dissolve existing clots
- types: streptokinase, alteplase, reteplase
absolute CI—> previous hemorrhagic stroke, other CVA within 1 yr, incranial neoplasm, suspected aortic dissection
relative CI—> uncontrolled HTN, recent trauma or internal bleeding,m pregnancy, PUD, hx chronic severe HTN
ACUTE STEMI
Reperfusion PCI vs. Fibrinolytics
- if hospital has PIC capability, treat w primary PCI within 90 mins of medical contact
- if no PCI and cannot be transfered to hopsital w PCI within 90 mins, tx with fibrinolytics within 30 mins in hospital unless CI
ACUTE STEMI
PCI
- stent placement
- some pts require CABG
ACUTE STEMI
if pt requires CABG, what must you stop
must stop antiplatelets for 5-7 days if possible
major diff in tx stemi vs nstemi?
NSTEMI– fibrinolytics are NOT USED
