Chapter 29: Ischemic Heart Disease

Question 1

Stable Angina

Answer 1

a. k.a stable ischemic heart disease (SIHD)
- Predictable chest pain, often brought on by exertion or emotional stress and relieved by rest or nitroglycerin
- Myocardial O2 supply is often decreased due to plaque build up (atherosclerosis) this is know as CAD

Question 2

Unstable Angina

Answer 2

• Type of acute coronary syndrome
• This is a medical emergency where the chest pain increases in frequency, intensity, or duration, and is not relieved with nitroglycerin or rest

Question 3

Prinzmetal’s variant

Answer 3

Is caused by vasospasm of the coronary arteries. This type of angina can occur at rest and can be caused by illicit drug use, particularly cocaine

Question 4

Pathophysiology

Answer 4

• Chest pain occurs when there is an imbalance between myocardial o2 demand (workload) and supply (blood flow)
• Myocardial oxygen demand increases when the heart is workiing harder due to an increased heart rate, contractility or left ventricular wall tension

Question 5

Risk Factors for SIHD

Answer 5

• hypertension
• smoking
• dyslipidemia
• diabetes
• obesity
• physical inactivity

Question 6

IV meds for cardiac stress test

Answer 6

• adenosine
• dipyridamole
• dobutamine
• regadenoson (lexiscan)

Question 7

Non-drug TX

Answer 7

• heart healthy diet
• BMI 18.5-24.9
• waist circumference <35 inches in females
• waist circumference <40 inches in males
• moderate intensity aerobic activity 30-60min 5-7 days/week
• smokers should quit
• alcohol should be limited to 1 drink/day for women and 1-2 drinks/day for men

Question 8

Tx approach for SIHD (ABCDE)

Answer 8

A- antiplatelet and antianginal drugs
B- beta blockers and blood pressure
C- cholesterol and cigarettes
D- diet and diabetes
E- exercise and education

Question 9

Aspirin MOA

Answer 9

Irreversibly inhibits COX-1 and 2 enzymes which results in decreased prostaglandin and thromboxane A2 production.

Question 10

Clopidogrel MOA

Answer 10

Is a prodrug that irreversibly inhibits p2y12 adp-mediated platelet activation and aggregation

Question 11

Dual Anti-platelet therapy

Answer 11

DAPT with aspirin and clopidogrel is for people of have a bare metal stent (DAPT for at least 1 month), drug-eluting stent (DAPT for at least 6 months), or post-CABP (DAPT for 12 months)

Question 12

Beta-Blockers

Answer 12

• 1st line therapy
• carvedilol and metoprolol preferred
• titrate to resting HR 55-60
• avoid abrupt withdrawal

Question 13

Calcium Channel Blockers

Answer 13

• Preferred for prinzmetal’s variant angina
• Avoid short acting DHPs (nifedipine ir)
• Slow release or long acting DHP and Non-DHP are effective
• DHPs with BBs

Question 14

Nitrates MOA

Answer 14

Reduce myocardial oxygen demand: decrease preload (free radical nitric oxide produces vasodilation of veins more than arterioles)

Question 15

Ranolazine

Answer 15

• Can cause QT prolongation
• Not for acute treatment of chest pain
• Has little to no clinical effects on HR or BP

Question 16

Nitroglycerin Short-Acting Formulations

Answer 16

• Nitrostat 0.4mg sl tab
• Nitromist, Nitrolingual 0.4mg tl spray (do not shake, spray onto or under tongue, do not inhale)
• Gonitro 0.4mg sl powder packet

nitrate tolerance does not develop with these products

Question 17

Nitroglycerin Long-Acting Formulations

Answer 17

-Nitro-bid 2% ointment (dose BID with 10-12hr nitrate free interval)
-Isosorbide mononitrate IR/ER tab (dose 7hrs apart)
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