CHF/CAD Flashcards
Name 6 example chronic coronary syndrome
1 .Stable angina (chest pain on exertion relieved by rest) and or dyspnoea - suspected CAD
- New onset HF or LV dysfunction and suspected CAD
- asymptomatic and symptomatic pts with stabilised symptoms <1 year after ACS or pts with recent revascularisation
- Asymptomatic and symptomatic >1 year after initial diagnosis or revascularisation
- Angina or suspected vasospastic or micro vascular disease
- Asymptomatic subjects in whom CAD is detected at screening
Name 2 examples Acute coronary syndromes
Unstable angina
STEMI
Cardiac emergency!
Pathophysiology stable angina?
Atheroma in 1/more coronary arteries, angina experienced when plaque >50% vessel
Name 3 treatment options chronic stable angina
1 nitrates
2 beta blockers or CCBS
3 aspirin or clopidogrel (anti platelet)
Name 4 treatments Acute unstable angina or nstemi
1 nitrates IV
2 beta blockers
3 aspirin AND clopidogrel
4 heparin (anticoag)
Name 6 treatment component of Acute MI stemi
1 nitrates
2 beta blockers: carvedilol, bisoprolol, metoprolol
3 aspirin plus clopidogrel second and lifelong
4 heparin eg clexane third
5 alteplase/streptokinase (thrombolytic) first
6 +/- ACE-I as soon as hemodynamicalle stable.
What is given for Acute immediate pain relief of stable angina?
AKA Acute prophylaxis
Short acting nitrate: nitroglycerin
Sublingual or spray
What is prescribed for definitive long term prophylaxis of stable angina?
First line: Beta blockers OR non-dihydropyridine CCB eg verapamil, diltiazem
If first line C/I, poorly tolerated, insufficient: long acting nitrate formulations eg, isosorbide mononitrate ISM
Name 3 examples long acting nitrate formula
1 erythrityl tetranitrate
2 pentaerythritol tetranitrate
3 isosorbide mononitrate ISM
Name 3 examples short acting nitrates
1 nitroglycerin
2 isosorbide dinitrate
3 glyceryl trinitrate
Moa nitrates? (4)
Metabolised by smooth muscle cells to produce No!
This activates guanylyl cyclase
Increased cGMP (second messenger)!
Dephosphorylation myosin light chain and sequestration Ca in sr
Thereby relaxing smooth muscle !
Relatively selective for venous smooth muscle. Venodilation reduce cardiacpreload!
Therefore decreased venous return, ventricular filling, ventricular chamber diameter, ventricular wall tension, cardiac work
Decreased oxygen demand!
Decreased LVEDP: increased coronary blood flow!
Mild reduction centennial tone; decreased of terload and so oxygen demand
Name adverse effects nitrates ( 3 )
- Hypotension and reflex tachycardia, angina
- headache and flushing (vasodilation)
- tolerance
Name a drug interaction with nitrates
Interact with pde-5 inhibitors, potentially fatal eg sildenafil (erectile dysfunction)!
Life threatening hypotension.
Which CCB preferred for stable angina?
Non-dihydropyridines: diltiazem or verapamil
Name 4 functions/actions aspirin
- Analgesic
- antipyretic
- anti-inflammatory
- anti-platelet
Aspirin moa?
- Block synthesis thromboxane a2 from arachidonic acid in platelets by acetylating and so inhibiting enzyme cyclooxygenase (cox) 1! (Selective and irreversible)
- thromboxane a2 stimulate PLC and so increase calcium levels and cause platelet aggregation
• block synthesis prostacyclin from endothelium which inhibit platelet aggregation
Aspirin AE? (2)
• Git ulceration and haemorrhage (inhibit PGE2 biosynthesis in stomach causing less mucous secretion, more acid, vasoconstriction submucosal microvessels, decreased git motility aka constipation )!
. Bleeding tendency (inhibit platelet TXA2)
Clopidogrel moa?
Adenosine diphosphate inhibitor (irreversible inhibit platelet adenosine p2y12 r)
Name 3 ways unstable angina can present
- rest angina > 20 min
- new onset angina, recent (2 months) onset of moderate to severe angina
- crescendo angina , ie previous angina which progressively increases in severity and intensity, and at lower threshold, over short period time
How diagnose acute mi? (6)
Increased cardiac biomarker, troponin, with at least 1 of following;
• symptoms ischaemia (chest pain)
• New significant st-t wave changes or left bundle branch block on 12 lead ECG
• pathological q waves
• imaging: new loss viable myocardium or regional wall motion abnormality
• intracoronary thrombus detected on angiography or autopsy
Name 4 injectable anticoagulants for acute phase unstable angina/ nstemi
- Fondaparinux: selective factor 10a inhibitors
- unfractioned heparin UFH!
- lmwh eg enoxaparin!
- bivalirudin: bind directly to thrombin so inhibit thrombin Induced conversion of fibrinogen to fibrin; used during PCI
Unfractioned heparin UFH moa?
Activate antithrombin 3!, which limit blood clotting by inactivate thrombin and factor 10a
(Monitor appt after admin)
Lmwh moa?
Similar to UFH but
Only increase action of antithrombin 3 on factor 10a!, not its action on thrombin
Longer acting and more predictable
Name 2 examples lmwh
- Enoxaparin
* dalteparin
When is oral anticoagulation following acute phase of unstable angina or nstemi indicated?
If concomitant conditions eg afib, mechanical heart valves, venous thromboembolism,
Name 2 types oral anticoagulation following acute phase of unstable angina or nstemi
- Vitamin K antagonist: warfarin
* non vitamin K antagonists noac: rivaroxaban, apixaban
Warfarin moa?
- Block reduction vitamin K epoxide, necessary for action as cofactor in synthesis of clotting factors: 2,7,9,10
- delayed onset of action
Antidote warfarin? (2)
• vitamin K
. FFP
Antidote heparin?
Protamine sulphate
Important pharmacokinetic detail of UFH?
Zero order kinetics
Fibrinolytic therapy indication for stemi?
Within 12 hours of symptom onset if primary PCI (percutaneous coronary intervention) can’t be performed within 120 minutes from stemi diagnosis and no contraindications
Name 4 fibrinolytic drugs
• Alteplase: tissue-type plasminogen activators
. Streptokinase: activate plasminogen to plasmin
• anistrepelase:liberate streptokinase- prodrug
• urokinase: unlicensed for mi.
Which physiological agent breaks down fibrin clots?
Plasmin
Name 5 contraindications streptokinase
(Fibrinolytic) • active gi bleed/ pud • trauma • recent surgery • Head injury/stroke, cerebrovascular disease • pregnancy
Chronic prophylaxis vasospastic angina?
Ccb:diltiazem
Name 2 indications aspirin and clopidogrel
- Secondary prevention cv events caused by IHD
* acute coronary syndrome dapt,
Indication fibrinolytic?
Eg streptokinase, alteplase.
Embolic stroke, stemi, nstemi
Name 3 adverse effects fibrinolytic
Eg streptokinase
• hypotension
• antigenic
• risk cerebral haemorrhage
