Chapter 29: Ischemic Heart Disease

Question 1

Another name for stable angina

Answer 1

Stable ischemic heart disease (SIHD)

Question 2

SIHD is associated with

Answer 2

predictable chest pain, often brought on by exertion or emotional stress

Question 3

Which type of angina is relieved by rest or nitroglycerin

Answer 3

Stable angina or SIHD

Question 4

Unstable angina is a type of

Answer 4

acute coronary syndrome (ACS)

Question 5

What is Prinzmetal’s angina

Answer 5

When chest pain is caused by vasospasm of the coronary arteries. Can occur at rest & often caused by illicit drug use, particularly cocaine

Question 6

Chest pain occurs when there is an imbalance between _____ and _____

Answer 6

myocardial oxygen demand (workload)

supply (blood flow)

Question 7

In stable ischemic heart disease (SIHD), myocardial O2 supply is often ↓ d/t _____ within the inner walls of the coronary arteries

Answer 7

plaque build-up (atherosclerosis)

Question 8

What is performed to assess the likelihood of CAD and diagnose SIHD

Answer 8

Cardiac stress test

Question 9

How is a cardiac stress test performed

Answer 9

Exercise on treadmill or stationary bike or IV meds

Question 10

Which IV meds can be used in a cardiac stress test

Answer 10

dipyriadmole, adenosine (Adenoscan), regadenoson (Lexiscan) or dobutamine

Question 11

What is the recommended antiplatelet drug for AIHD

Answer 11

Aspirin (clopidogrel can be used when there is an allergy or other CI to aspirin)

Question 12

Antianginal treatment ____ myocardial oxygen demand or ____ myocardial oxygen supply

Answer 12

decreases

increases

Question 13

Which drug class is first line for angina

Answer 13

Beta-blockers

Question 14

What should be used as second line for angina or when additional symptomatic relief is needed

Answer 14

CCBs or long-acting nitrates

Question 15

Which medication is recommended for immediate relief of angina in all pts

Answer 15

Nitroglycerin, as a SL tab, powder or translingual spray

Question 16

Patients with SIHD should be treated with a ___-intensity statin

Answer 16

high

Question 17

What is the treatment approach for stable ischemic heart disease

Answer 17

A- antiplatelet and antianginal drugs (BB, CCBs, and nitrates)
B- BP and BB
C - Cholesterol (statins) and cigarettes (cessation)
D- Diet and diabetes
E - exercise & education

Question 18

Aspirin MOA

Answer 18

irreversibly inhibits COX-1 and COX-2 enzymes which results in decreased prostaglandin and thromboxane A2 production (TXA2)

Question 19

Clopidogrel MOA

Answer 19

irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

Question 20

ASA dosing

Answer 20

75-162 mg daily

Question 21

Clopidogrel dosing

Answer 21

75 mg daily

Question 22

Aspirin CI

Answer 22

NSAID or salicylic acid allergy: children and teenagers with vital infection d/t risk of Reye’s syndrome

Question 23

Aspirin warnings

Answer 23

Bleeding, tinnitus (salicylate OD)

Question 24

Aspirin SE

Answer 24

dyspepsia, heartburn, bleeding

Question 25

How long is aspirin used for in SIHD

Answer 25

indefinitely

Question 26

Which formulation of ASA is preferred in ACS

Answer 26

non-enteric coated, chewable ASA

Question 27

What should a patient do in ACS if only EC aspirin is available

Answer 27

chew it (325 mg tab)

Question 28

Which two formulations of ASA should not be used when rapid onset is needed

Answer 28

``` ER capsule (Durlaza) DR tablet (Yosprala) ```

Question 29

What can be used to protect the gut with chronic NSAID use

Answer 29

PPIs (consider risks - decreased bone density and increased infection risk)

Question 30

Which CYP enzyme converts clopidogrel to its active metabolite

Answer 30

2C19

Question 31

Clopidogrel CI

Answer 31

active serious bleeding

Question 32

Clopidogrel should be stopped 5 days prior to:

Answer 32

elective surgery

Question 33

Clopidogrel should not be used with which 2 drugs

Answer 33

omeprazole and esomeprazole

Question 34

Clopidogrel can cause

Answer 34

thombotic thrombocytopenic purpura (TTP)

Question 35

When is clopidogrel used in SIHD

Answer 35

when there is a CI to aspirin

Question 36

Dual antiplatelet therapy (DAPT) with ASA and clopidogrel is reserved for which patients (& what is the duration)

Answer 36

- bare metal stent placement (DAPT for at least 1 month) - Drug-eluting stent (DAPT for at least 6 months) - post-CABG (DAPT for 12 months)

Question 37

Aspirin is dosed at ___ mg daily in Dual antiplatelet therapy (DAPT) regimens and is continued indefinitely at 75-162 mg daily after this course of DAPT therapy

Answer 37

81 mg

Question 38

Mechanism of clinical benefit of BB in SIHD

Answer 38

decreases HR, decreases contractility, and decreases LV wall tension

Question 39

Which drug class is preferred for Prinzmetal's angina

Answer 39

CCBs

Question 40

Mechanism of clinical benefit of CCBs in SIHD (non-DHP and DHP)

Answer 40

non-DHPs: decrease HR and contractility | DHPs: decrease SVR (afterload)

Question 41

Mechanism of clinical benefit of nitrates in SIHD

Answer 41

Decrease preload (free radical NO produces vasodilation of veins more than arteries)

Question 42

BB should be titrated ti resting HR of

Answer 42

55-60 BPM

Question 43

Which types of BB are preferred in SIHD

Answer 43

BB without ISA (metoprolol, atenolol)

Question 44

BB should be avoided in

Answer 44

Prinzmetal's angina

Question 45

Which CCBs should be avoided in SIHD

Answer 45

short-acting DHPs (like nifedipine IR)

Question 46

When are DHP CCBs preferred in SIHD

Answer 46

when they are used in combination with BB (d/t risk of excessive bradycardia when non-DHPs are used with BB)

Question 47

When are long-acting nitrates used in SIHD

Answer 47

when BB are CI or as add-on therapy for treatment of symptoms

Question 48

Ranolazine CI

Answer 48

strong 3A4 inhibitors and inducers

Question 49

Ranolazine warning

Answer 49

QT prolongation

Question 50

Nitroglycerin formulas all come in which dose

Answer 50

0.4 mg

Question 51

Which meds are long-acting nitrates

Answer 51

Nitroglycerin ointment 2% (Nitro-BID) | Isosorbide mononitrate IR/ER tablet

Question 52

Nitrate CI

Answer 52

Do not use with PDE5 inhibitors

Question 53

Nitrate warnings

Answer 53

Hypotension, HA, tachyphylaxis (↓ effectiveness/tolerance with LA products)

Question 54

Nitrate SE

Answer 54

HA, flushing, syncope

Question 55

How long after opening nitroglycerin SL tab vial should the bottle be discarded

Answer 55

6 months

Question 56

Long-acting nitrates require a __-__ hour nitrate-free interval to decrease tolerance

Answer 56

10-12

Question 57

Nitroglycerin patch should be worn on for __-__ hours & rotate sites

Answer 57

12-14

Question 58

Nitroglycerin ointment is dosed how many times per day and how many hours apart

Answer 58

BID, 6 hours apart

Question 59

Isosorbide mononitrate IR is dosed BID, __ hours apart

Answer 59

7

Question 60

Isosorbide dinitrate in combination with ___ is the preferred formulation for systolic HF

Answer 60

hydralazine

Question 61

When using NTG SL tabs, powder or spray, when should 911 be called

Answer 61

if chest pain persists after the first dose

Question 62

Take ___ additional dose(s) at __ minute intervals of NTG while waiting for an ambulance to arrive

Answer 62

2 | 5

Question 63

Do NOT take more than __ doses of NTG within 15 min

Answer 63

3

Question 64

What is not a sign that NTG is working well

Answer 64

Slight burning or tingling sensation

Question 65

Counseling for NTG TL spray

Answer 65

Do not shake Spray onto or under the tongue Do not inhale the spray

Question 66

What is the preferred application site for NTG patches

Answer 66

Chest

Question 67

Counseling for NTG ointment

Answer 67

Measure the dose of ointment with the dose measuring applicator Can stain clothing