cardio treatment pt 3

Question 1

stable/unstable angina

· Sublingual _____ is medication of choice for acute management
· Buccal spray is also available (0.4mg) in metered dose delivery system
· Prevention of further attacks. Identify and treat aggravating factors: hypertension, LV failure, arrhythmia (usually tachycardias). Strenuous activity, cold temperatures, emotional stress
· Long acting _____

· _____:
o Only antianginal agents that have been shown to prolong life in patients with CAD (post MI)
o Should be considered first line therapy in most patients with chronic angina; recommended as such in stable ischemic heart disease guidelines
o Those with intrinsic sympathomimetic activity (pindolol) are less desirable and may exacerbate angina
o Major contraindications are severe bronchospastic disease, brady arrhythmias and decompensated heart failure

· Alternative and combination therapies
o May be worthwhile to try alternate agent before progressing to combinations
o Stable ischemic heart disease guidelines recommend starting with _____ as initial therapy followed by _____, long acting nitrates or ranolazine
o Platelet inhibiting agents
§ Unless contraindicated, _____ should be prescribed
§ _____ daily reduces vascular events in patients with stable vascular disease (as an alternate to ASA) and in combo with ASA, acute coronary syndromes

revascularization
types of procedures:
§	PCI:  percutaneous coronary intervention including \_\_\_\_\_ 
§	Includes \_\_\_\_\_ and stenting 
·	Coronary artery bypass grafting
·	CABG
·	Mechanical extracorporeal conterpulsation
·	Neuromodulation

Answer 1

Nitroglycerin
nitrates
Beta blockers
beta blocker
CCB
ASA
Clopidogrel
stenting
balloon angioplasty

Question 2

coronary vasospasm
prinzmetal

• Undergo coronary _____ to determine whether fixed stenotic lesions are present
  o If they are present – aggressive medical therapy or _____ is indicated
  o If they are not and spasm is suspected:
  § Avoidance of precipitants such as cigarette smoking and cocaine is top priority
  § Episodes generally respond well to _____ prn
  § Nitrates and _____ (long-acting nifedipine, diltiazem and amlodipine) are effective prophylactic treatments
  § Beta Blockers are avoided because they cause unoopposed alpha-1 mediated vasoconstriction and may exacerbate coronary spasm
  • May have a role in spasm associated with fixed stenosis

Answer 2

arteriography
revascularization
NITRATES
CCBs

Question 3

NSTEMI
M\_\_\_\_
O\_\_\_\_
N\_\_\_\_
A\_\_\_\_

+ _____, and _____

Answer 3

morphine IV
supplemental oxygen
Nitrates
ASA
heparin and BB

Question 4

STEMI

M____
O____
N____
A____

and then… primary _____ within 90 mins of first medical contact is the goal and is superior to fibrinolytic therapy

_____ therapy within 30 mins of hospital presentation is the goal and reduces mortality if given within 12 hours of onset of symptoms

ongoing management:

1. _____/_____
2. _____
3. _____ + _____
4. _____

Answer 4

morphine IV
supplemental oxygen
Nitrates
ASA
PCI
fibrinolytic
ACEI/ARB
BB
ASA+clopidogrel
statin

Question 5

post infarct ischemia

o Vigorous medical therapy should be instituted:
§ _____
§ _____
§ _____ 81-325 mg
§ ANTICOAGULATION THERAPY (unfractionated HEPARIN, ENOXAPARIN, or FONDAPARINUX)
§ _____
o Most patients with post-infarct angina and those refractory to medical therapy should undergo early catheterization and revascularization by PCI or CABG

Answer 5

BB
nitrates
ASA
CLOPIDEGREL

Question 6

dyslipidemia

 RAISE HDL’S
- Quit _____
- Exercise and weight management
- Modest ETOH (1-2oz daily)
- Medication not demonstrated to provide additional benefit (aka not shown to lower morbidity and mortality)
o Niacin in addition to statins shows no effect in raising HDL

 DIET
- 5-10% ↓ in LDLs (some can see up to 25% ↓)
- Reassess diet therapy effect 4 wks after starting
- Recommended diet = MEDITERRANEAN DIET
o ↑ soluble fiber: oat bran, apples, psyllium  5-10% reduction
o Plant stanols and sterols (fake butters)  10% reduction
o Garlic, soy protein, vitamin C, and pecans  modest reduction
o Antioxidant rich diet

• _____ ***used in “everyone else” besides preg unless they can’t tolerate
  o Inhibit the rate-limiting enzyme in the formation of cholesterol & ↓ production of LDL in liver promoting ↑ uptake of circulating LDL
  o Modest increase in HDL and decrease triglyceride level
  o Reduce MI and total mortality in CAD pt
  o High intensity - ↓ by 50%; moderate intensity - ↓ by 30-50%
  o Side effects:
  § Muscle aches
  § GI problems
  § 10% ↑ risk of DM
  § Liver failure
  § Myositis and rhabdomyolysis
  · Muscle disease more common if in combo with fibrates, niacin, erythromycin, antifungals (nefazadone and cyclosporin)
• _____ (nicotinic acid): full therapeutic dose = 3-4.5 g/day
  o ↓ VLDL production with secondary ↓ in LDL (15-25%) and ↑ in HDL (25-35%)
  o ↓ triglycerides by half and lowers lipoprotein (a) and increases homocysteine levels
  o Intolerance is common – only 50-60% of pt can take full dose
  § Associated with prostaglandin mediated flushing (hot flashes) or pruritis; can be reduced with ASA or NSAIDS or initiating therapy slowly with low doses doubled until 1.5 g tolerated
  § Extended release is better tolerated
  § Can exacerbate gout and PUD
• BILE ACID SEQUESTERANTS (_____): dose = 12 – 36 g (something you eat to help absorb cholesterol) **use resins in _____
  o Cholestyramine, colesevelam, colestipol
  o Reduces coronary events by 20%
  o Bind bile acids in the intestine; ↓ enterohepatic circulation; liver ↑ bile acid production using hepatic cholesterol; ↓ plasma LDL; 15-25% ↓ in LDL
  o Not used with high triglycerides since can ↑ triglyceride levels
  o Cause GI symptoms (constipation and gas) – concurrent use of psyllium may ameliorate
  o Can bind water soluble vitamins and other drug
  **not as strong as STATINS – can be used in combo with statins b/c these don’t go through the liver combos usually not necessary - ↑ risk for complications
• _____ DERIVATIVES: GEMFIBROZIL (600 mg qd-bid) and FENOFIBRATE
  o Potent ↓ in triglycerides (40%), ↑ HDL (15-20%), ↓ LDL (10-15%)
  o Reduces cardiovascular events
  o Side effects: cholelithiasis (gall-stones), hepatitis, myositis (higher incidence in pts also taking statins)

Answer 6

smoking
STATINS
NIACIN
resin
pregnancy
FIBRIC ACID

Question 7

vasovagal syncope

· Reassure patients it is _____
· Avoid potential triggers
· Avoid injury due to falling when sxs occur: if patient feels like they are going to “pass out” they should lay _____ with legs elevated
· Physical counterpressure _____

Answer 7

benign
supine
maneuvers

Question 8

orthostatic (postural) hypotension

·	Discontinue exacerbating meds
·	Modification of daily activities
·	\_\_\_\_\_ and abdominal binders
·	Counterpressure \_\_\_\_\_
·	Increase \_\_\_\_\_ and water intake 
·	In refractory cases can use meds: \_\_\_\_\_ (a adrenergic agonist), droxidopa (NE precursor)

Answer 8

Compression stockings
maneuvers
salt
midodrine