Coronary Artery Disease Flashcards
1
Q
Is CVD more common in men or women?
A
Men
2
Q
What’s the number one killer in men and women??
A
Atherosclerotic CAD!
3
Q
Does alcohol increase the risk of CVD?
A
No
4
Q
What are risk factors of CAD?
A
Tobacco, HTN, dyslipidemia, physical inactivity, stress, obesity, DM
5
Q
What is cardiac syndrome X?
A
Narrowing of small coronary arteries that traverse the heart
6
Q
What is variant angina?
A
Spasm of coronary artery that causes angina (as opposed to plaque)
7
Q
Is variant angina more common in men or women?
A
Women
8
Q
What is Prinzmetal’s angina?
A
Variant angina
9
Q
What is silent myocardial ischemia?
A
Ischemia present with no S/S (can occur with stable angina, cardiac syndrome X, or variant angina)
10
Q
What is myocardial ischemia?
A
Reduction in blood flow to heart that leads to dysfunction; imbalance between oxygen supply and demand
11
Q
Does myocardial ischemia cause myocardial necrosis?
A
no
12
Q
What is angina?
A
Chest discomfort
13
Q
What causes angina
A
Ischemia (angina is a symptom)
14
Q
What usually causes SIHD?
A
Single to multivessel atherosclerotic CAD
15
Q
Angina pectoris is usually associated with what?
A
Coronary artery disease in a major coronary vessel
16
Q
What percentage of atherosclerotic reduction usually causes ischemia/angina?
A
> 70-75%
17
Q
What are epicardial vessels?
A
Larger vessels found on top of the myocardium
18
Q
ASCVD usually occurs in _____ vessels
A
epicardial
19
Q
How is coronary blood flow affected by SIHD?
A
The blood vessels are narrowed by the plaque formation, which causes constant dilation of smaller vessels to keep normal blood flow to heart
20
Q
What happens when a patient with SIHD exercises?
A
The smaller blood vessels are already fully dilated because of the plaque, so they cannot dilate anymore to keep up with increased demand during exercise. This causes ischemia!
21
Q
What 3 things influence oxygen demand in the heart?
A
HR, contractility, and BP
22
Q
What is the mechanism of action of drugs for SIHD?
A
Decrease oxygen demand
23
Q
What is stable angina pectoris?
A
Discomfort in chest caused by myocardial ischemia
24
Q
What are the requirements for angina to be classified as stable?
A
Characteristics of episode have been constant over the past 2 months
25
What are the unique symptoms that women experience from a heart attack?
```
Discomfort in back, shoulders, arms, stomach, jaw, neck, or throat
Inability to sleep
SOB
Lightheadedness/dizziness
N/V
Cold Sweat
```
26
What are common precipitating factors to angina?
- Exertion (exercise, sex, etc)
- Exposure to cold
- Large meals
- Stress/anger/anxiety
27
What are clinical characteristics of angina?
Substernal
Lasts 5-20 minutes
NTG/Rest bring relief
28
What ECG findings are present during ischemia?
ST-segment depression
29
What is used to diagnose IHD?
Electrocardiogram
Exercise Tolerance testing
Risk factors
Cardiac Imaging (stress testing, nuclear imaging, electron beam computerized tomography)
Echocardiography
Cardiac catheterization/coronary angiography
30
What are the abnormalities in ECGs that indicate stable angina?
ST segment depression
31
What is the abnormality in ECG that indicates variant angina?
ST segment elevation
32
What medications can complicate interpretation of an exercise tolerance test?
Beta blockers and non-DHP CCBs
33
What endpoints are looked at during an exercise tolerance test?
Duration, workload, ECG changes, BP and HR responses, Sxs
34
What is used to assess coronary anatomy?
Cardiac catheterization/coronary angiography
35
What does an electron beam computerized tomography measure?
Calcium present in coronary lesion
36
What are the 2 goals of treatment for SIHD?
1. Prevent death/ACS
| 2. Alleviate Sxs and prevent Sxs of ischemia
37
What treatments are used to prevent ACS/death from SIHD?
1. Aspirin (or other antiplatelet)
2. ACEI or ARB
3. Risk reduction therapies for HTN, dyslipidemia, DM
38
What treatments are used to manage angina?
1. SL NTG
2. Beta-blocker
3. Long-acting nitrate, DHP CCB, or ranolazine
39
When do you select a DHP CCB over long-acting nitrate or ranolazine?
When BP >140/90
40
What treatment is used to manage vasospastic angina?
CCB (if uncontrolled HTN) or nitrate
| NOT beta blocker
41
Which medication can be used to treat angina and reduce risk of ACS?
Beta blockers
42
What are the guidelines for managing stable angina?
```
ABCDE
A - aspirin, antiplatelets, anti-anginals
B - Beta blocker and blood pressure
C - Cholesterol and cigarettes
D - diet and diabetes
E - education and exercise
```
43
What is the target blood pressure for a patient with stable angina?
<130/80
44
What is the ideal diet for a patient with stable angina?
Low cholesterol and low fat
45
What is the goal BMI and waist circumference?
18.5-24.9
W: <35
M: <40
46
P2Y12 inhibitors inhibit _____ induced ____ without affecting TXA2
adenosine diphosphate induced platelet aggregation
47
ASA inhibits ___ atlow doses, which normally increases ____ and causes vaso____
COX-1; increases platelet aggregation; vasoconstriction
48
ASA inhibits ____ at higher doses, which normally inhibits ____ and causes vaso____
Prostacyclin PGI2; inhibits platelet aggregation; vasodilation
49
What are adverse effects of ASA?
GI bleeding
hematologic bleeding
Hypersensitivity
50
Which P2Y12 inhibitor is activated by CYP2C19?
clopidogrel (and a little prasugrel)
51
What are adverse effects of clopidogrel?
bleeding, diarrhea, rash
52
What are adverse effects of prasugrel?
bleeding, diarrhea, rash
53
What are adverse effects of ticagrelor?
bleeding, bradycardia, heart block, dyspnea
54
Does prasugrel or clopidogrel have greater bleeding risk?
Prasugrel
55
Who is recommended to have anti-platelet primary prevention therapy?
Age 50-69 with >10% ASCVD 10-year risk
56
What is secondary prevention for SIHD (no stent)?
Just aspirin (for life)
57
What is secondary prevention for SIHD w/elective PCI & stent?
ASA (for life) + clopidogrel (for 1 year traditionally)
58
What is the minimum time for DAPT w/DES?
6 months (12 traditional; maybe 3 months if high bleeding risk)
59
What is the minimum time for DAPT w/BMS?
1 month
60
What drugs are used in DES?
Everolimus and zotarolimus
61
What is the loading dose for clopidogrel?
300-600 mg
62
What is the secondary prevention for CABG?
ASA 81 mg/day + clopidogrel 75 mg/day for 12 months
63
What happens if someone is on DAPT and needs non-cardiac surgery?
Postpone the surgery for as long as possible
64
What is the risk scoring system for DAPT? (What score is considered too high risk for prolonged DAPT?)
<2: Unfavorable risk profile
| >=2: Favorable risk profile
65
How do ACE Inhibitors help with SIHD?
- Stabilize ____
- Improved __ function
- Inhibit ___ cell growth
- Decrease ____ migration
- ____ properties
```
Stabilize plaque
Improved ET function
Inhibit VSM cell growth
Decrease macrophage migration
Anti-ox properties
```
66
Which drugs increase heart rate?
Nitrates and nifedipine
67
Which drugs decrease HR?
Beta-blockers, verapamil, diltiazem
68
Which drugs decrease myocardial contractility?
Verapamil, beta-blocker (sometimes diltiazem and nifedipine)
69
Which anti-anginals decrease systolic pressure?
All of them (esp DHPs)
70
Which anti-anginals increase LV volume?
Just Beta blockers
71
What dosage forms do acute nitrates come in?
Sublingual tablets
Translingual spray
Buccal tablets
Chewable tablets
72
Is the NTG nasals pray or SL tab more effective?
They have equal efficacy
73
What are the instructions for NTG?
- Take one tablet
| - If pain is not is not better or worsens in 5 minutes, take another tablet and call 911
74
What are some counseling tips for NTG?
- Sit down before taking
- Store in original container w/out safety cap
- Keep it with you
- Keep it dry
75
What are adverse effects of NTG?
- HA
- Hypotension, dizziness, flushing
- Reflex tachycardia
76
What drugs should you NOT use Nitrates with??
PDEI
77
What are MPs for nitrates?
- Bp
- HR
- journal listing use
78
What are the cardioselective Beta-blockers?
Atenolol, metoprolol
79
What are the non-selective Beta-blockers?
Propranolol, carvedilol, labetalol, pindolol
80
What beta-blocker has ISA?
Pindolol! Do not use!
81
What are cardiac adverse effects of beta-blockers?
Bradycardia, AV block, reduced LVEF, sinus arrest
82
What are non-cardiac adverse effects of beta-blockers?
bronchoconstriction, fatigue, depression, nightmares, sexual dysfunction, insulin-induced hypoglycemia, peripheral vascular complication; withdrawal
83
What is the goal HR for beta-blockers?
Rest: 50-60 bpm
Exercise: <100 or 75% of HR that causes angina
84
DHP or non-DHPs?
| Reflex tachycardia
DHPs
85
DHPs or non-DHPs?
| Decrease AV Nodal conduction
non-DHPs
86
DHPs or non-DHPs?
| Reduce myocardial contractility?
More non-DHPs (but both)
87
DHPs or non-DHPs?
| Peripheral vasodilation?
Peripheral
88
DHPs or non-DHPs
| Coronary vasodilation?
Diltiazem and DHPs
89
Which CCBs work in the heart?
Verapamil and diltiazem
90
Which CCBs work in veins?
DHPs
91
Never use what type of DHPs in SIHD patients?
Short-acting! Causes reflexive tachycardia!!
92
What are the short-acting DHPs?
Nifedipine and nicardipine
93
What are the adverse effects of DHPs?
Hypotension, flushing, HA, dizziness
Peripheral edema
Reduced myocardial contractility
Reflex adrenergic activation
94
What are the adverse effects of non-DHPs?
Reduced myocardial contractility (V)
AV/SA nodal conduction disturbances (bradycardia and AV block) (V)
Hypotension, flushing, HA, dizziness
Constipation (V)
95
What are monitoring parameters for DHPs?
Same as nitrates (HR, BP)
96
What are monitoring parameters for Non-DHPs?
Same as Beta-blockers (HR goal)
97
To prevent nitrate tolerance have nitrate-free period of ___ hours
10-12 hours (but dosage free for longer b/c of PK, half-life stuff)
98
Counseling points for nitrate patches?
```
-Nitrate free interval
New area every day
Apply between elbows and knees
Do not cut
Wash hands before/after
Can shower while you wear
```
99
What is a dosing regimen for ISDN tabs?
2-3 times a day (4 hours a part)
100
What is a dosing regimen for ISMN tabs?
2 times a day (7 hours a part)
101
What is a dosing regimen for ISMN SR tabs?
Once daily (morning)
102
When is ranolazine used? Why (It does not affect ___)
When BP/HR too low with other anti-anginals
| It doesn't affect the rate pressure product
103
What are AEs of ranolazine?
Constipation, nausea, dizziness, prolonged QT interval, headache
104
What are drug interactions of ranolazine?
CYP3A4, Cyp2D6, P-gp
105
Patients can only take ivabradine if what two qualifications are met
Normal sinus rhythm
| HR > 70 bpm
106
When is ivabradine used?
If beta-blockers aren't tolerated or don't work
107
When should beta-blockers be avoided (2 circumstances)?
Variant angina
| Conduction disturbances
108
For monotherpay treatment of angina, what order should classes be used in?
1. Beta blocker
2. Non-DHP CCB
3. Nitrate (not great b/c of nitrate-free period)
109
What Beta-blockers are good with HF?
Carvedilol
Metoprolol
Bisoprolol
110
What Beta-blockers are good after MI?
Non-ISA (not pindolol)
111
Which anti-anginal should be avoided in variant angina?
Beta-blockers!
112
What's the risk of NSAIDs/Cox-2 inhibitors with SIHD?
Increased thrombosis risk (esp NSAIDs!!)
113
What is the risk of using NSAID with ASA?
NSAID may reduce ASA efficacy--take ASA 2 hours before NSAID
