Chronic Stable Angina (CSA) Flashcards
Describe chest pain in angina
Squeezing, grip-like, heavy or suffocating and typically doesn’t vary with position or respiration
What’s stable angina also known as?
Stable ischemic heart dx (SIHD)
What’s stable angina or SIHD associated with?
Predictable chest pain often brought on by exertion or emotional stress and relieved within minutes by rest (or nitroglycerin)
What causes stable angina?
Plaque build up on the inner walls of coronary arteries (atherosclerosis) causing narrowing in the arteries and reduced blood flow to heart
What’s Prinzmetal’s (variant or vasospastic angina) angina?
Angina that’s present in pts with NORMAL coronary arteries, where angina sx are as a result of vasospasm in the arteries
List types of angina
Stable angina
Prinzmetal’s angina
Silent ischemia
Unstable angina
What’s stable angina?
Decreased myocardial O2 supply to due to reduced blood flow from narrowed arteries by atherosclerotic plaque
Sx have been occurring for weeks but without worsening
What’s Prinzmetal’s angina?
Decreased myocardial O2 supply due to vasospasm of the artery
What’s silent ischemia?
Transient myocardial ischemia without sx of angina
What’s unstable angina?
Severe, crushing chest pain unrelieved by rest; acute medical care is needed
What’s the non-pharmacologic tx of CSA?
Heart healthy lifestyle
saturated fats < 7% of total calories and
Trans fat < 1% of total calories
Fresh fruits and vegetables
Low fat dairy pdts
Stop smoking
Maintain BMI of 18.5-24.9 kg/m2
Waist circumference
Females < 35 inches
Males < 40 inches
Encourage physical exercise
30-60 minutes of moderate-intensity aerobic activity, at least 5 days a wk, preferably 7 days a wk
What’s a Heart healthy lifestyle in CSA?
saturated fats < 7% of total calories
Trans fat < 1% of total calories
Fresh fruits and vegetables
Low fat dairy pdts
How much saturated fat should be consumed in heart healthy lifestyle in CSA?
< 7% of total calories
How much trans fat should be consumed in heart healthy lifestyle in CSA?
< 1% of total calories
What’s the recommended BMI in CSA?
18.5 - 24.9 kg/m2
What’s the recommended waist circumference in CSA?
Males < 40 inches
Females < 35 inches
Whats the tx goals of CSA?
Reduce the risk of an acute coronary syndrome (unstable angina/ myocardial infarction) and provide symptomatic relief from angina pain
What’s combo is most often used to meet the tx goals of CSA?
Antiplatelet (usually Aspirin; Plavix is allergy or CI to aspirin) + Antianginal
What’s the first line therapy for tx of CSA?
Beta blockers
CCB or long-acting nitrates are used when bb is CI or when additional relief is needed
What’s recommended for immediate relief of angina?
Sulpblingual nitroglycerin or nitroglycerin spray
What med should ALL pts with CSA be on regardless?
Moderate or high dose statin (regardless of LDL values)
What annual vaccine is recommended in CSA?
Annual flu shot
What’s the acronym that summarizes the non-pharmacologic and pharmacologic therapies in chronic therapy?
A - Antiplatelet and Antianginal drugs
B - Blood pressure and beta-blockers
C - Cholesterol (statins) and cigarettes
D - Diet and diabetes
E - Exercise and education
List Antiplatelet agents
Aspirin (Bayer, Ascriptin, Bufferin)
Clopidogrel (Plavix)
SE of aspirin (Bayer, Ascriptin, Bufferin)?
Dyspepsia
Heartburn
GI upset
GI bleed/ ulceration
Bleeding
Renal impairment
Hypersensitivity
What’s the black box warning of Clopidogrel (Plavix)?
Effectiveness depends on the activation to an active metabolite mainly by CYP2C19.
Poor metabolizes exhibit higher cardiovascular events than pts with normal CYP2C19 fxn
Which allele corresponds to fully functional metabolism of Clopidogrel (Plavix)?
CYP2C19*1 allele
Which allele corresponds to nonfunctional metabolism of Clopidogrel (Plavix)?
CYP2C19*2 and *3 allele
SE of Clopidogrel (Plavix)?
Bleeding
Bruising
Rash
TTP (thrombotic thrombocytopenia purpura)
When’s Clopidogrel (Plavix) used in CSA?
In pts with CI to aspirin
List drugs that should be avoided in aspirin use, bcuz they increase bleeding risk
Anticoagulants
Other Antiplatelet
Ginkgo
Dextran
NSAIDs
SSRIs
SNRIs
Thrombolytics etc
Effect of aspirin (and NSAIDs) on lithium and methotrexate levels?
They increase lithium and methotrexate levels
Avoid concurrent usr
List Ototoxicity agents that should not be used with aspirin
Vancomycin
Loop diuretics
Others
List meds that shouldn’t be used with Clopidogrel (Plavix)
Cimetidine
Fluconazole
Ketoconazole
Voriconazole
Fluoxetine
Fluvoxamine
Omeprazole
Esomeprazole
List Antianginal agents in CSA?
Beta blockers
CCB
Nitrates
Ranolazine
In what type of angina is beta blockers avoided?
Prinzmetal’s angina
What’s the preferred agent for Prinzmetal’s (variant) angina?
CCB
What type of CCB is CI in CSA?
Short-acting CCBs e.g. Nifedipine IR
When should u call 911 in CSA?
If chest pain doesn’t go away after first dose of SL tabs or spray
Uses of long-acting nitrates in CSA?
Not used alone for chronic therapy (used in combo with bb or CCB)
Req nitrate-free interval
What’s the warning associated with Ranolazine (Ranexa) use?
Can cause QT prolongation
SEs of Ranolazine?
Dizziness
Constipation
Headache
Nausea
Effect of Ranolazine on HR or BP?
Ranolazine has little to no clinical effects on HR or BP
What meds should be avoided with nitrate?
PDE-5 inhibitors
What’s the dose of simvastatin that can be safely used with Ranolazine?
Limit simvastatin to 20mg/day if used with Ranolazine
List Nitroglycerin formulations
Nitroglycerin SL tabs (Nitrostat) 0.3, 0.4, 0.6 mg
Nitroglycerin sublingual spray 0.4mg/spray (Nitromist, Nitrolingual Pump Spray)
Isosorbidr mononitrate IR/ET tabs/caps (Monoket)
What’s the brand name and dose of Nitroglycerin SL tabs?
Nitrostat
0.3, 0.4, 0.6mg
What’s the brand name and dose of Nitroglycerin SL spray?
Nitromist, Nitrolingual Pump Spray
0.4mg /spray
What’s the brand name of Isosorbide mononitrate IR/ER tabs/caps?
Monoket
SEs of nitroglycerin formulations
Headache
Dizziness
Lightheadedness
Flushing
Hypotension
Tachyphylaxis
Syncope
How does pts dose the nitrate-free interval?
10-12 hour nitrate-free period to reduce tolerance
In what container should the nitroglycerin IV be prepared?
Glass bottles or polyolefin bags (non-PVC)
Can nitroglycerin SL tab be used prophylactically?
Yes, nitroglycerin SL tab can be taken prophylactically 5-10 minutes before activities that bring on chest pain)
How should nitroglycerin tabs be stored? Effect
Room temperature
If stored and handled properly, the tabs should be stable until manufacturer provided expiration date
NTG stored in original amber glass bottle?
Yes
NTG SL tabs should be kept in original amber glass bottle which is kept tightly capped
How do u use NTG pump spray?
Spray 5 times into air to prime
If not used within 6 wks, prime the pump with 1 spray before use
Don’t shake
Press button firmly with forefinger to release spray onto or under the tongue
Close mouth after spray
Don’t eat or drink or rinse the mouth for 5-10 mins after dose
Use 1 spray Q5mins, but no more than 3 sprays in 15 mins
What meds should be avoided in NTG use?
PDE-5 inhibitor
Sildenafil (Viagra, Revatio)
Tadalafil (Cialis, Adcirca)
Vardenafil (Levitra, Staxyn)
Avanafil (Stendra)
How do u use Isosorbide Mononitrate?
Take 1st dose when us wake up
Take 2nd dose 5 hrs later
How should Isosorbide Mononitrate be used?
Take at the same times each day
Don’t change dosing times unless directed by healthcare provider
Which of the SE of Isosorbide Mononitrate becomes tolerable as time goes on?
Headache
Uses of Ranolazine?
Used to decrease the number of times u may get chest pain
What’s angina?
Chest pain, pressure or discomfort
