CAD Sowinski Flashcards
significant coronary artery disease is defined as > ___-___% atherosclerotic reduction in a major coronary vessel
70-75%
what does PPQRST stand for?
precipitating factors
palliative measures
quality and quantity of the pain
region and radiation
severity of the pain
timing and temporal pattern
ECG findings for typical angina
ST-segment depression (during event)
Each of the following statements regarding chronic coronary disease is correct EXCEPT?
A. Stable angina is associated with pain that is increasing in severity and not relieved by NTG
B. Women and patients with diabetes may experience atypical symptoms
C. Angina is discomfort associated with ischemia
D. Prinzmetal’s or variant angina is associated with coronary vasospasm
E. Chronic coronary disease is usually associated with atherosclerosis
A. Stable angina is associated with pain that is increasing in severity and not relieved by NTG
LDL reduction goal for CV risk factor reduction
50% or more reduction (LDL goal < 90)
BP goal for CV risk factor reduction
< 130/80
A1C goal for CV risk factor reduction
< 7%
BMI goal range for CV risk factor reduction
18.5-24.9
CV risk factors: how many alcohol beverages per day is acceptable for male vs female patients?
males: 2 per day
females: 1 per day
how does aspirin prevent platelet aggregation?
by blocking thromboxane (TXA2) synthesis
(TXA2 promotes clotting)
loading dose for aspirin (range)
162-325 mg
loading dose range for clopidogrel
300-600 mg
loading dose for prasugrel
60 mg
loading dose for ticagrelor
180 mg
why is low dose aspirin beneficial vs higher doses?
-at low dose, it irreversibly inhibits COX-1, blocking TXA2 formation
-at higher doses it inhibits COX-2, blocking formation of prostacyclin (PGI2), which is the opposite effect of above
what is the maintenance dose for these P2Y12 inhibitors?
clopidogrel, prasugrel, ticagrelor, cangrelor
clopidogrel 75 mg daily
prasugrel 10 mg daily
ticagrelor 90 mg BID
cangrelor IV only
MOA of P2Y12 inhibitors
selectively inhibt ADP induced platelet aggregation with no effect on TXA2
main adverse effects of aspirin
GI bleeding, hematologic bleeding
which of the following P2Y12 inhibitors are prodrugs? SELECT ALL THAT APPLY
a. clopidogrel
b. prasugrel
c. ticagrelor
a, b
plavix MOA
A. Blocks activation of factors Xa and IIa
B. Decreases prostaglandin production
C. Blocks synthesis of COX-1 and -2 and decreases thromboxane A2 production
D. Selectively blocks synthesis of COX-2 and increases platelet activation
E. Inhibits P2Y12 ADP-mediated platelet activation and aggregation
E. Inhibits P2Y12 ADP-mediated platelet activation and aggregation
(C is high dose aspirin, D is celecoxib)
Pt with no history of a stent: what drug should they take if they have a CI or intolerance to aspirin?
clopidogrel
what is dual antiplatelet therapy?
aspirin + P2Y12 inhibitor
sirolimus, paclitaxel, everolimus, zotarolimus, and biolimus are used in drug eluting stents. What kinds of drugs are these?
anti-proliferative (anti-rejection)
Pt with elective PCI + drug eluting stent: what two drugs do they receive before procedure?
aspirin and P2Y12 inhibitor loading dose
dual antiplatelet therapy for pt with CABG
aspirin 81 mg + clopidogrel 75 mg daily
how long should a pt be on clopidogrel following a CABG?
12 months
A 56-year-old patient had coronary artery bypass graft (CABG) surgery performed for refractory symptoms of angina despite maximally tolerated medical therapy and multiple PCIs. Which of the following medications should be initiated following CABG surgery and continued indefinitely? SELECT ALL THAT APPLY
A. Aspirin
B. Carvedilol
C. Enalapril
D. Nitroglycerin sublingual
E. Clopidogrel
A. Aspirin
D. Nitroglycerin sublingual
if a pt is on aspirin and ticagrelor, the dose of aspirin must be < ___ mg due to risk of stroke
< 100 mg
how does colchicine work for CV disease?
reduces inflammation (atherosclerosis is an inflammatory disease)
how do nitrates dec myocardial O2 demand?
venous vasodilation causes reduced preload and dec LV volume
how do nitrates inc myocardial O2 supply?
via endothelium-dependent vasodilation; dilation of epicardial arteries and coronary collateral vessels
main advantage of NTG spray vs tablet
NTG spray has shelf life of 3 years, tablets are about 6 months
true or false: NTG spray should be shaken before use, and sprayed under the tongue and inhaled
false
(Don’t shake, spray under tongue but don’t inhale)
How should a pt be counseled on their nitromist PRN for chest pain? SELECT ALL THAT APPLY
A. Do not shake
B. Call 911 if the CP is not relieved after first dose
C. Inhale the medication with a quick, deep breath
D. Use twice daily at 7 AM and 3 PM to provide a nitrate free period
E. May cause a headache, flushing or drop in BP
A. Do not shake
B. Call 911 if the CP is not relieved after first dose
E. May cause a headache, flushing or drop in BP
true or false: reflex tachycardia is an adverse effect of nitrates
true
what drug class should nitrates be avoided with due to huge drop in BP?
PDE5 inhibitors such as sildenafil/tadalafil
how long after taking tadalafil should a patient wait before taking a nitrate?
48 hours
how long after taking sildenafil and vardenafil should a patient wait before taking a nitrate?
24 hours
beta-blockers MOA
competitive, reversible inhibitors of beta-adrenergic stimulation by catecholamines
what 3 desired effects do beta blockers have on myocardial oxygen demand?
-reduce heart rate (mainly during sympathetic stimulation)
-reduce myocardial contractility
-reduce arterial BP (afterload)
what is the undesired effect of beta blockers on myocardial oxygen demand?
increased preload (force that stretches cardiac muscle prior to contraction)
which two beta blockers have intrinsic sympathomimetic activity (ISA)?
acebutolol and pindolol
which 2 CCBs should not be used due to profound BP drop leading to reflex tachycardia?
short acting DHPs (Nifedipine, nicardipine)
nitrate tolerance is due to which enzyme?
ALDH2 (aldehyde dehydrogenase 2)
true or false: it is appropriate to take ISMN tabs at 8 AM, 12 PM, and then at 4 PM
false (this is appropriate for ISDN not ISMN)
how many hours apart should ISMN be taken?
7 hours apart (2 times/day: 8 AM and 3 PM)
which of the following increases heart rate? SELECT ALL THAT APPLY
a. nitrates
b. beta-blockers
c. nifedipine (DHP)
d. verapamil
e. diltiazem
f. ranolazine
a. nitrates
c. nifedipine (DHP)
ranolazine MOA
inhibition of late inward Na+ current in ischemic myocytes, which dec intracellular Na+, which leads to dec Ca2+ influx
describe ranolazine’s effect on HR, BP, and myocardial contractility
has no effect on any of these
USA indication for ranolazine
tx of chronic angina
(in Europe it is indicated as add-on therapy)
The clinic pharmacist is performing a medication reconciliation and is reviewing the patient’s medications to ensure they are being taken properly. Which one of the following medications should be taken twice daily, with doses separated by 7 hours (e.g. at 8 AM and 3 PM)?
A. Isordil
B. Monoket
C. Nifedipine XL
D. Norvasc
E. NTG Patches
B. Monoket
(a is TID; c, d, and e are all once daily)
three first line agents for stable angina
beta blocker, CCB, nitrates
true or false: pts with stable HF and a history of an MI should never take beta blockers
false (these are compelling indications)
CI’s for non-DHP CCBs (3)
-HFrEF
-HR < 50
-high degree AV block or sick sinus syndrome
A 65 YO with CCD receives the following meds: Accupril 20 mg daily; Metformin 1000 mg daily; Trulicity 0.75 mg SC weekly; HCTZ 25 mg daily; Coreg 12.5 mg BID; NitroMist PRN for CP.
- PE/Vitals: BP 138/87 mmHg; HR 87; RR 18
- Which one of the following should be added to his regimen to better control his angina?
A. Diltiazem
B. Atenolol
C. Amlodipine
D. Clonidine
E. Aspirin
C. Amlodipine
A 68-year-old male presents with complaints of angina when walking up flights of stairs. The pain is relieved with rest and only occasionally requires a dose of SL NTG for relief. He has a history of MI, HTN, and dyslipidemia. He quit smoking 3 years ago after his MI. His meds include aspirin 81 mg daily, metoprolol 25 mg XL once daily, and atorvastatin 80 mg daily.
Vital signs: BP is 158/92 mmHg, HR 82 bpm. Which of the following is most appropriate to treat this patient’s angina?
A. Lisinopril 5 mg daily
B. Ranolazine 1,000 mg twice daily
C. Increase metoprolol XL to 50 mg once daily
D. SL NTG 1 tablet as needed for angina
C. Increase metoprolol XL to 50 mg once daily
(a not for angina; b is wrong starting dose; d he is already on this)
JJ is a 58-year-old male with a past medical history of hypertension, dyslipidemia, and chronic coronary artery disease. He presents to clinic with complaints of chest pain occurring with exertion several times per week. The chest pain is promptly relieved with one SL NTG tablet or upon resting. His current medications include aspirin 325 mg daily, metoprolol 100 mg BID, and rosuvastatin 20 mg PO hs. His vital signs are: HR 60 bpm and BP 145/95 mmHg. What one of the following is most appropriate therapy to improve the treatment of his CCD?
A. add clopidogrel 75 mg QD
B. add ISDN 10 mg every 12 hours
C. add amlodipine 5 mg PO QD
D. add verapamil SR 180 mg every 12 hours
C. add amlodipine 5 mg PO QD
what drug class is ivabradine (Corlanor)?
HCN channel inhibitor (reduces diastolic depolarization)
true or false: diclofenac and aspirin are ok to take together
false
if taking both aspirin and a systemic NSAID, how many hours prior should you take the aspiring before the NSAID?
2 hours before
does Prinzmetal’s angina occur upon exertion or at rest?
at rest
first line drugs for management of vasospastic angina
CCBs
Which of the following medications is preferred for treatment of Prinzmetal’s angina
A. ISDN
B. Plavix
C. Toprol XL
D. Ranolazine
E. Norvasc
E. Norvasc
