Cardiovascular Medicine: Chronic Stable Angina Flashcards
3 typical components for anginal CP
- substernal CP or discomfort
- worse on exertion or emotional stress
- relieved by rest and/or nitroglycerin
what is the definition of atypical CP?
2 of 3 components of typical CP
what is the definition of nonanginal CP?
1 or none of the components of typical CP
non-coronary artery causes of angina
- AS
- HCM
when should you order a stress test?
intermediate (10-90%) risk pts
indications for selecting the correct stress test:
- exercise ECG WITHOUT imaging
- pts who can exercise
- normal or nonspecific baseline ECG changes
- complete RBBB
indications for selecting the correct stress test:
- exercise ECG WITH myocardial perfusion imaging
- pre-excitation (WPW)
- > 1 mm STD
- previous CABG or PCI
- LBBB (excercise echo)
- intermediate risk result following exercise ECG
indications for selecting the correct stress test:
- exercise echocardiography
- pre-excitation (WPW)
- > 1 mm STD
- previous CABG or PCI
- LBBB (excercise echo)
- intermediate risk result following exercise ECG
indications for selecting the correct stress test:
- pharmacologic stress myocardial perfusion imaging
- unable to exercise
- electrically paced ventricular rhythm
- LBBB
indications for selecting the correct stress test:
- dobutamine echocardiography
- unable to exercise
- electrically paced ventricular rhythm
- LBBB
when should you order coronary angiography?
- high pretest probability pts, or:
- LV dysfunction
- class 3 or 4 angina despite tx
- highly positive stress or imaging test
- high pretest probability of left main or 3-vessel CAD
- uncertain dx after noninvasive testing
- h/o surviving sudden cardiac arrest
- suspected coronary spasm
LIFESTYLE MODIFICATION for all pts w/ chronic stable angina
- smoking cessation
- regular exercise
- heart healthy diet
goal BP in pts w/ chronic stable angina
< 140/90
goal HbA1c in pts w/ chronic stable angina
< 7
what are the 3 major classes of antianginal medications for pts w/ chronic stable angina?
- BBs
- nitrates
- CCBs
what is first-line therapy for pts w/ chronic stable angina?
cardioselective BBs
what is the goal resting HR for pts w/ chronic stable angina?
about 60 bpm
absolute CI’s to BBs
- severe bradycardia
- advanced AVB
- decompensated HF
- severe reactive airways disease
which med is as effective as BBs and CCBs in reducing angina?
nitrates
how to prevent nitrate tachyphylaxis when treating pts w/ chronic stable angina?
nitrate-free period of 8 to 12 hours per day
which meds are CI to use in combination w/ nitrates?
- PDEIs (sildenafil, vardenafil, tadalafil)
if absolute CI to BB, which med class should be initiated as first-line therapy?
CCBs
if angina even w/ BBs and nitrates, what should be added?
CCBs (long-acting preferred)
which med should be considered if angina persists despite being on BBs, nitrates, and CCBs?
ranolazine
reduces r/o stroke, MI, and vascular death in pts w/ CAD
aspirin
reduce r/o cardiovascular and all-cause mortality for most pts
ACEIs
reduce cardiovascular events, including MI and death
high-intensity statins
in which pts should revascularization therapy w/ PCI or CABG be considered?
persistent sxs despite maximal medical therapy
revascularization does not confer additional protection from cardiovascular events except for which pts?
- left-main CAD
- triple-vessel disease w/ LV dysfunction
DON’T BE TRICKED
- in the absence of high-risk features for early mortality or unresponsiveness to medical therapy, which therapies should not be selected in pts w/ chronic stable angina?
PCI or CABG
DON’T BE TRICKED
- which treatments should not be selected as tx for pts w/ chronic stable angina?
- HRT (in women)
- antioxidant vitamins (vitamin E)
- tx of elevated homocysteine levels w/ folate or B12
