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Pharm 835 > Chronic Coronary Artery Disease (CAD) > Flashcards

Chronic Coronary Artery Disease (CAD) Flashcards

1
Q

Antiplatelet drugs

A
  • Reduce vascular events in patients with CAD

- Prevent thrombotic complications following coronary artery stent placement

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2
Q

Predictors of late stent thrombosis

A
  • stenting of small vessels
  • overlapping stents
  • long stents
  • diabetes
  • low ejection fraction
  • advanced age
  • renal failure
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3
Q

After bare-metal stent (BMS) placement…

A

-Aspirin
AND
-P2Y12 inhibitor is superior to Aspirin alone

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4
Q

Which is better BMS or DES

A

-Stent endothelialization is better in BMS (Vision) than DES

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5
Q

Longer duration of dual antiplatelet therapy (DAPT) post stent are associated with…

A
  • Fewer CV events

- But an increased risk of bleeding

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6
Q

Aspirin

A
  • EC better tolerated than IR
  • Use 81mg daily dose
  • Monitor for bleeding and GI upset
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7
Q

P2Y12 inhibitors

A
  • Clopidogrel (Plavix)
  • Prasugrel (Effient)
  • Ticagrelor (Brilinta)
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8
Q

Clopidogrel (Plavix)

A
  • Once daily
  • Pharmacogenomic variability
  • Lowest bleed risk
  • Interacts with PPIs
  • Cheap
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9
Q

Prasugrel (Effient)

A
  • No stent, no Prasugrel
  • CI; prior transient ischemic attack (TIA) or stroke
  • Expensive
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10
Q

Ticagrelor (Brilinta)

A
  • Twice daily
  • CI: severe hepatic impairment, intracranial hemorrhage
  • Expensive
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11
Q

Dipyridamole

A
  • MoA largely unknown
  • NOT recommended as antiplatelet agent in patients with CAD
  • Has not been shown to be effective in these patients
  • May have a role in secondary stroke prevention when used with Aspirin
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12
Q

Vorapaxar (Zontivity)

A
  • PAR1 antagonist
  • Irreversibly inhibits thrombin induced platelet aggregation
  • Pros: reduces MI and stroke
  • Risk: increased bleeding risk
  • CI: history of Stroke/ TIA, or active bleeding
  • $300/month
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13
Q

Clopidogrel- PPI interaction

A
  • Clopidogrel is a prodrug metabolized by CYP2C19
  • Esomeprazole and Omeprazole are are metabolized by same CYP
  • Taking PPI with Clopidogrel will decrease the antiplatelet effects of Clopidogrel
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14
Q

CYP2C19*1

A

-Fully functional metabolism of clopidorgrel

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15
Q

CYP2C19*2 and 3

A
  • No functional metabolism of clopidogrel

- Diminished antiplatelet effects in these patients

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16
Q

When to not give Prasugrel

A

-If patient has a history of stroke or TIA

17
Q

Nitrates

A
  • No evidence of efficacy at reducing cardiac events

- Primarily used for relief of chest discomfort

18
Q

Beta blockers

A
  • Reduce reinfarction and mortality when used chronically post STEMI
  • Also benefits in the unstable angina/NSTEMI population
19
Q

Dosing pearls for Beta Blockers

A
  • Maintain resting heart rate between 50 and 60
  • HR less than 50 do NOT give
  • Use cardio selective beta blockers for patients with lung disease
20
Q

Do not give beta blockers to…

A
  • Patients with signs of heart failure
  • HR < 50
  • Hypotension
  • Severe COPD or asthma
21
Q

LVEF < 40% which Beta blocker do you give?

A
  • Carvedilol
  • Metoprolol succinate
  • Bisoprolol
22
Q

ACEI

A
  • decreases progression of heart failure
  • patients with low LVEF have greatest benefit
  • Use Ramipril or perindopril
23
Q

ARBs

A
  • Valsartan and Telmisartan are most . effective in preventing major CV events
  • ACEIs have more data but ARBs should work too
24
Q

Aldosterone antagonists

A
  • Epleronone or spironolactone

- Has been shown to reduce morbidity and mortality in patients with MI complicated by LV dysfunction and hear t failure

25
Q

When to give ACEIs to CAD patients

A
  • LVEF < 40%
  • Diabetes
  • Hypertension
  • CKD
26
Q

Statin therapy in CAD

A
  • Decreases cardiovascular mortality
  • Good for both primary and secondary MI prevention
  • Pleiotropic effects
27
Q

What intensity statin?

A

a) ages < 75 = high intensity statin (Atorvastatin 40-80mg or Rosuvastatin 20-40mg)
b) ages > 75 = moderate intensity (atorvastatin 10-20mg or Rosuvastatin 5-10mg)

28
Q

Calcium Channel Blockers

A
  • No benefit on death or nonfatal MI
  • Mostly used for symptom relief (chest pain)
  • NonDHP is preferred for prevention of ischemic symptoms (Verapamil or Diltazem)
29
Q

Class III rec for CCBs

A
  • Do NOT give
    a) short acting DHP
    b) Non DHP in the presence of; heart failure, or HR < 50bpm
30
Q

Warfarin

A
  • Reduces risk of reinfarction in patients who are unable to take aspirin
  • Reduces rates of thrombosis and embolism in high risk patients
31
Q

When to give Warfarin

A
  • Atrial fibrillation
  • Mechanical heart valve
  • Venous Thromboembolism
  • Hypercoaguable disorder
32
Q

Analgesics

A
  • Selective COX2 inhibitors and other nonselective NSAIDs have been associated with increased CV risk
  • Start with Tylenol
  • If that does not work, then move down the pyramid in the hand out
33
Q

Analgesic recommendation flow chart

A
  • Tylenol
  • Naproxen
  • Aspirin
  • small dose narcotics
  • Tramadol
34
Q

Ranolazine (Ranexa)

A
  • Inhibits intracellular sodium current
  • No effect on HR or BP
  • Clinical benefits are restricted to relief of angina
  • Expensive
  • Prolongs QT interval
  • Contraindication with use of other CYP3A inhibitors (Diltiazem)
35
Q

Prinzmetal’s Variant Angina

A
  • Unstable angina
  • Spontaneously resolves or with the use of NTG
  • Due to prolonged vasospasm
  • ST segment elevation
  • Chest discomfort even at rest
  • Use acetlycholine and methacholine to provoke vasospasm
  • Smoking and illicit drug use are contributing factors
36
Q

Cocaine and methamphetamine induced MI

A
  • Increased HR and BP
  • Platelet aggregation
  • Arrhythmias
  • Coronary vasospasm
37
Q

How to treat Vasospastic MI

A

a) Due to intoxication
- Benzodiazepines with or with out NTG to manage HTN and tachycardia
- Do NOT give a beta blocker
b) Not due to intoxication
- give CCB or long acting nitrate for symptom relief
- If symptoms presist combine therapy
- treat with a statin to improve endothelium dependent vasodilation

Pharm 835 (4 decks)

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