Chronic Stable Angina

Question 1

What are the 3 main goals of angina therapy?

Answer 1

1. prevent progression to unstable angina, MI or death
2. provide relief of anginal sxs
3. modify risk factors for CAD

Question 2

What therapies are used to prevent progression of chronic stable angina?

Answer 2

• anti-platelet therapy

- cholesterol control

Question 3

What medications are used to provide relief of anginal sxs in chronic stable angina?

Answer 3

• BB
• CCB
• nitrates

Question 4

How can a pt modify his or her risk factors for CAD?

Answer 4

• exercise and weight control
• BP control
• no smoking

Question 5

What drug (and dose) should all patients (unless CI) be taking for their chronic stable angina?

Answer 5

-aspirin 75-162 mg per day

Question 6

What is the goal of anginal pain treatment with BB? (think vital signs)

Answer 6

-target resting HR of 55-60 bpm

Question 7

What are the cautions for BB use for relief of angina?

Answer 7

• type I DM (BB increase glucose levels)
• asthma (BB cause constriction in lungs)
• decompensated HF
• mod-severe peripheral vascular dz

Question 8

What are the CIs for BB use for relief of angina?

Answer 8

• bradycardia (HR <50)

- 2nd degree heart block

Question 9

Which pts might be good candidates for trying a BB first for anginal relief?

Answer 9

-pts with hard indications and NO CI: 6 months post MI or systolic HF (EF <40%)

Question 10

What should you not do if your pt is on a BB or you are considering a BB?

Answer 10

• do not start BB with HR<55

- do not increase dose with HR at goal

Question 11

When should CCB dihydropyridines be used for angina relief?

Answer 11

• add to BB if HR < goal

- combine with long-acting nitrates in pts who can’t take BB or non-DHP

Question 12

When should CCB non-dihydropyridines be used for angina relief?

Answer 12

-HR> goal and a BB would be CI or no hard indication w/ cautions

Question 13

CCB Adverse Effects

Answer 13

• orthostatic HoTN
• reflex tachycardia
• peripheral edema

Question 14

CCB CIs

Answer 14

• left ventricular dysfunction
• bradycardia (<50 bpm)
• 2nd or 3rd degree AV block

Question 15

When should you NOT start a DHP?

Answer 15

• don’t start with >2+ pitting edema

- don’t start with orthostatic HoTN

Question 16

MOA of Nitrates

Answer 16

• dilates peripheral veins at large doses
• dilates coronary arteries at all doses
• nitrates will not affect BP!

Question 17

When might long acting nitrates be used?

Answer 17

• long term prophylaxis
• generally added on to other therapies (eg BB or non-DHP to improve sxs control)
• combine with DHP if pt can’t tolerate BB or non-DHP

Question 18

When might short acting nitrates be used?

Answer 18

• terminate acute anginal attack

- prevention of effort or stress-induced attacks

Question 19

How should an angina patient respond to chest pain?

Answer 19

• stop activity, sit down, take one NTG
• if pain not improved or worse in 5 mins, take NTG and call 911
• can repeat q5 minutes for total of 3 doses

Question 20

What is LA Nitrate Tolerance?

Answer 20

-decreases response or increased amount needed for same effect

Question 21

What is a daily nitrate free interval? When should patients dose? What is the purpose?

Answer 21

• 8-12 hour period of no nitrate meds
• dose at 8 am and 2 pm
• decreases nitrate tolerance

Question 22

Role of ACE-I in Chronic Stable Angina

Answer 22

• not shown to be effective in reducing angina

- use to reduce morbidity and mortality in pts with HF, DM, CKD, HTN