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Pharmacotherapy III > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

Is CVD more common in men or women?

A

Men

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2
Q

What’s the number one killer in men and women??

A

Atherosclerotic CAD!

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3
Q

Does alcohol increase the risk of CVD?

A

No

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4
Q

What are risk factors of CAD?

A

Tobacco, HTN, dyslipidemia, physical inactivity, stress, obesity, DM

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5
Q

What is cardiac syndrome X?

A

Narrowing of small coronary arteries that traverse the heart

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6
Q

What is variant angina?

A

Spasm of coronary artery that causes angina (as opposed to plaque)

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7
Q

Is variant angina more common in men or women?

A

Women

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8
Q

What is Prinzmetal’s angina?

A

Variant angina

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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)

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10
Q

What is myocardial ischemia?

A

Reduction in blood flow to heart that leads to dysfunction; imbalance between oxygen supply and demand

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11
Q

Does myocardial ischemia cause myocardial necrosis?

A

no

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12
Q

What is angina?

A

Chest discomfort

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13
Q

What causes angina

A

Ischemia (angina is a symptom)

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14
Q

What usually causes SIHD?

A

Single to multivessel atherosclerotic CAD

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15
Q

Angina pectoris is usually associated with what?

A

Coronary artery disease in a major coronary vessel

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16
Q

What percentage of atherosclerotic reduction usually causes ischemia/angina?

A

> 70-75%

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17
Q

What are epicardial vessels?

A

Larger vessels found on top of the myocardium

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18
Q

ASCVD usually occurs in _____ vessels

A

epicardial

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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

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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!

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21
Q

What 3 things influence oxygen demand in the heart?

A

HR, contractility, and BP

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22
Q

What is the mechanism of action of drugs for SIHD?

A

Decrease oxygen demand

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23
Q

What is stable angina pectoris?

A

Discomfort in chest caused by myocardial ischemia

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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

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25
Q

What are the unique symptoms that women experience from a heart attack?

A 
Discomfort in back, shoulders, arms, stomach, jaw, neck, or throat
Inability to sleep
SOB
Lightheadedness/dizziness
N/V
Cold Sweat
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26
Q

What are common precipitating factors to angina?

A
  • Exertion (exercise, sex, etc)
  • Exposure to cold
  • Large meals
  • Stress/anger/anxiety
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27
Q

What are clinical characteristics of angina?

A

Substernal
Lasts 5-20 minutes
NTG/Rest bring relief

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28
Q

What ECG findings are present during ischemia?

A

ST-segment depression

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29
Q

What is used to diagnose IHD?

A

Electrocardiogram
Exercise Tolerance testing
Risk factors
Cardiac Imaging (stress testing, nuclear imaging, electron beam computerized tomography)
Echocardiography
Cardiac catheterization/coronary angiography

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30
Q

What are the abnormalities in ECGs that indicate stable angina?

A

ST segment depression

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31
Q

What is the abnormality in ECG that indicates variant angina?

A

ST segment elevation

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32
Q

What medications can complicate interpretation of an exercise tolerance test?

A

Beta blockers and non-DHP CCBs

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33
Q

What endpoints are looked at during an exercise tolerance test?

A

Duration, workload, ECG changes, BP and HR responses, Sxs

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34
Q

What is used to assess coronary anatomy?

A

Cardiac catheterization/coronary angiography

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35
Q

What does an electron beam computerized tomography measure?

A

Calcium present in coronary lesion

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36
Q

What are the 2 goals of treatment for SIHD?

A
  1. Prevent death/ACS

2. Alleviate Sxs and prevent Sxs of ischemia

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37
Q

What treatments are used to prevent ACS/death from SIHD?

A
  1. Aspirin (or other antiplatelet)
  2. ACEI or ARB
  3. Risk reduction therapies for HTN, dyslipidemia, DM
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38
Q

What treatments are used to manage angina?

A
  1. SL NTG
  2. Beta-blocker
  3. Long-acting nitrate, DHP CCB, or ranolazine
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39
Q

When do you select a DHP CCB over long-acting nitrate or ranolazine?

A

When BP >140/90

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40
Q

What treatment is used to manage vasospastic angina?

A

CCB (if uncontrolled HTN) or nitrate

NOT beta blocker

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41
Q

Which medication can be used to treat angina and reduce risk of ACS?

A

Beta blockers

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42
Q

What are the guidelines for managing stable angina?

A 
ABCDE
A - aspirin, antiplatelets, anti-anginals
B - Beta blocker and blood pressure
C - Cholesterol and cigarettes
D - diet and diabetes
E - education and exercise
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43
Q

What is the target blood pressure for a patient with stable angina?

A

<130/80

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44
Q

What is the ideal diet for a patient with stable angina?

A

Low cholesterol and low fat

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45
Q

What is the goal BMI and waist circumference?

A

18.5-24.9
W: <35
M: <40

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46
Q

P2Y12 inhibitors inhibit _____ induced ____ without affecting TXA2

A

adenosine diphosphate induced platelet aggregation

47
Q

ASA inhibits ___ atlow doses, which normally increases ____ and causes vaso____

A

COX-1; increases platelet aggregation; vasoconstriction

48
Q

ASA inhibits ____ at higher doses, which normally inhibits ____ and causes vaso____

A

Prostacyclin PGI2; inhibits platelet aggregation; vasodilation

49
Q

What are adverse effects of ASA?

A

GI bleeding
hematologic bleeding
Hypersensitivity

50
Q

Which P2Y12 inhibitor is activated by CYP2C19?

A

clopidogrel (and a little prasugrel)

51
Q

What are adverse effects of clopidogrel?

A

bleeding, diarrhea, rash

52
Q

What are adverse effects of prasugrel?

A

bleeding, diarrhea, rash

53
Q

What are adverse effects of ticagrelor?

A

bleeding, bradycardia, heart block, dyspnea

54
Q

Does prasugrel or clopidogrel have greater bleeding risk?

A

Prasugrel

55
Q

Who is recommended to have anti-platelet primary prevention therapy?

A

Age 50-69 with >10% ASCVD 10-year risk

56
Q

What is secondary prevention for SIHD (no stent)?

A

Just aspirin (for life)

57
Q

What is secondary prevention for SIHD w/elective PCI & stent?

A

ASA (for life) + clopidogrel (for 1 year traditionally)

58
Q

What is the minimum time for DAPT w/DES?

A

6 months (12 traditional; maybe 3 months if high bleeding risk)

59
Q

What is the minimum time for DAPT w/BMS?

A

1 month

60
Q

What drugs are used in DES?

A

Everolimus and zotarolimus

61
Q

What is the loading dose for clopidogrel?

A

300-600 mg

62
Q

What is the secondary prevention for CABG?

A

ASA 81 mg/day + clopidogrel 75 mg/day for 12 months

63
Q

What happens if someone is on DAPT and needs non-cardiac surgery?

A

Postpone the surgery for as long as possible

64
Q

What is the risk scoring system for DAPT? (What score is considered too high risk for prolonged DAPT?)

A

<2: Unfavorable risk profile

>=2: Favorable risk profile

65
Q

How do ACE Inhibitors help with SIHD?

  • Stabilize ____
  • Improved __ function
  • Inhibit ___ cell growth
  • Decrease ____ migration
  • ____ properties
A 
Stabilize plaque
Improved ET function
Inhibit VSM cell growth
Decrease macrophage migration
Anti-ox properties
66
Q

Which drugs increase heart rate?

A

Nitrates and nifedipine

67
Q

Which drugs decrease HR?

A

Beta-blockers, verapamil, diltiazem

68
Q

Which drugs decrease myocardial contractility?

A

Verapamil, beta-blocker (sometimes diltiazem and nifedipine)

69
Q

Which anti-anginals decrease systolic pressure?

A

All of them (esp DHPs)

70
Q

Which anti-anginals increase LV volume?

A

Just Beta blockers

71
Q

What dosage forms do acute nitrates come in?

A

Sublingual tablets
Translingual spray
Buccal tablets
Chewable tablets

72
Q

Is the NTG nasals pray or SL tab more effective?

A

They have equal efficacy

73
Q

What are the instructions for NTG?

A
  • Take one tablet

- If pain is not is not better or worsens in 5 minutes, take another tablet and call 911

74
Q

What are some counseling tips for NTG?

A
  • Sit down before taking
  • Store in original container w/out safety cap
  • Keep it with you
  • Keep it dry
75
Q

What are adverse effects of NTG?

A
  • HA
  • Hypotension, dizziness, flushing
  • Reflex tachycardia
76
Q

What drugs should you NOT use Nitrates with??

A

PDEI

77
Q

What are MPs for nitrates?

A
  • Bp
  • HR
  • journal listing use
78
Q

What are the cardioselective Beta-blockers?

A

Atenolol, metoprolol

79
Q

What are the non-selective Beta-blockers?

A

Propranolol, carvedilol, labetalol, pindolol

80
Q

What beta-blocker has ISA?

A

Pindolol! Do not use!

81
Q

What are cardiac adverse effects of beta-blockers?

A

Bradycardia, AV block, reduced LVEF, sinus arrest

82
Q

What are non-cardiac adverse effects of beta-blockers?

A

bronchoconstriction, fatigue, depression, nightmares, sexual dysfunction, insulin-induced hypoglycemia, peripheral vascular complication; withdrawal

83
Q

What is the goal HR for beta-blockers?

A

Rest: 50-60 bpm
Exercise: <100 or 75% of HR that causes angina

84
Q

DHP or non-DHPs?

Reflex tachycardia

A

DHPs

85
Q

DHPs or non-DHPs?

Decrease AV Nodal conduction

A

non-DHPs

86
Q

DHPs or non-DHPs?

Reduce myocardial contractility?

A

More non-DHPs (but both)

87
Q

DHPs or non-DHPs?

Peripheral vasodilation?

A

Peripheral

88
Q

DHPs or non-DHPs

Coronary vasodilation?

A

Diltiazem and DHPs

89
Q

Which CCBs work in the heart?

A

Verapamil and diltiazem

90
Q

Which CCBs work in veins?

A

DHPs

91
Q

Never use what type of DHPs in SIHD patients?

A

Short-acting! Causes reflexive tachycardia!!

92
Q

What are the short-acting DHPs?

A

Nifedipine and nicardipine

93
Q

What are the adverse effects of DHPs?

A

Hypotension, flushing, HA, dizziness
Peripheral edema
Reduced myocardial contractility
Reflex adrenergic activation

94
Q

What are the adverse effects of non-DHPs?

A

Reduced myocardial contractility (V)
AV/SA nodal conduction disturbances (bradycardia and AV block) (V)
Hypotension, flushing, HA, dizziness
Constipation (V)

95
Q

What are monitoring parameters for DHPs?

A

Same as nitrates (HR, BP)

96
Q

What are monitoring parameters for Non-DHPs?

A

Same as Beta-blockers (HR goal)

97
Q

To prevent nitrate tolerance have nitrate-free period of ___ hours

A

10-12 hours (but dosage free for longer b/c of PK, half-life stuff)

98
Q

Counseling points for nitrate patches?

A 
-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
Q

What is a dosing regimen for ISDN tabs?

A

2-3 times a day (4 hours a part)

100
Q

What is a dosing regimen for ISMN tabs?

A

2 times a day (7 hours a part)

101
Q

What is a dosing regimen for ISMN SR tabs?

A

Once daily (morning)

102
Q

When is ranolazine used? Why (It does not affect ___)

A

When BP/HR too low with other anti-anginals

It doesn’t affect the rate pressure product

103
Q

What are AEs of ranolazine?

A

Constipation, nausea, dizziness, prolonged QT interval, headache

104
Q

What are drug interactions of ranolazine?

A

CYP3A4, Cyp2D6, P-gp

105
Q

Patients can only take ivabradine if what two qualifications are met

A

Normal sinus rhythm

HR > 70 bpm

106
Q

When is ivabradine used?

A

If beta-blockers aren’t tolerated or don’t work

107
Q

When should beta-blockers be avoided (2 circumstances)?

A

Variant angina

Conduction disturbances

108
Q

For monotherpay treatment of angina, what order should classes be used in?

A
  1. Beta blocker
  2. Non-DHP CCB
  3. Nitrate (not great b/c of nitrate-free period)
109
Q

What Beta-blockers are good with HF?

A

Carvedilol
Metoprolol
Bisoprolol

110
Q

What Beta-blockers are good after MI?

A

Non-ISA (not pindolol)

111
Q

Which anti-anginal should be avoided in variant angina?

A

Beta-blockers!

112
Q

What’s the risk of NSAIDs/Cox-2 inhibitors with SIHD?

A

Increased thrombosis risk (esp NSAIDs!!)

113
Q

What is the risk of using NSAID with ASA?

A

NSAID may reduce ASA efficacy–take ASA 2 hours before NSAID

Pharmacotherapy III (12 decks)

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