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Cardio Exam 2 > Coronary Disease and Angina > Flashcards

Coronary Disease and Angina Flashcards

1
Q

CAD VS. CHD

A

CAD IS ATHEROSCLEROSIS IN THE CORONARY ARTERIES. (THE DISEASE)

CHD IS THE MANIFESTATION OF THE DISEASE/CAD.
* THE RESULT OF INADEQUATE SUPPLY OF BLOOD TO THE MYOCARDIUM (ISCHEMIA)

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2
Q

= MOST COMMON HEART DISEASE

A

CAD

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3
Q

Modifiable risk factors for CAD

A

Comorbidities: DM, HTN, Hyperlipidemia, Obesity, SLE, RA, NAFLD, IBD, HIV, CKD,
hypothyroid disease, testosterone replacement therapy, Vitamin D deficiency
Lifestyle: inactivity, unhealthy diets
Smoking (current & former; prolonged exposure to 2 nd hand smoke)
Socio-economic status/Social determinants of health

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4
Q

Nonmodifiable risk factors for CAD

A

Family History (in particular, premature events in primary relatives, <55 male relative,
<65 female relative)*
Age, Sex (M>F), Ethnicity (Black, Hispanic, Latino, Southeast Asian)

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5
Q

THE UNDERLYING ETIOLOGY OF CAD IS _____

A

ATHEROSCLEROSIS

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6
Q

4 step process of Atheroclerosis

A

STEP 1: DISRUPTION OF A CORONARY ARTERY’S ENDOTHELIUM DUE TO: HTN,
SMOKING, DM, LDL
STEP 2: PLATELETS ADHERE TO THE INJURED AREA OF EPITHELIUM –> CHRONIC
INFLAMMATION BEGINS
STEP 3: PLAQUE FORMATION - MACROPHAGES EAT THE LDL (FOAM CELLS), LYMPHOCYTES, INCREASED RELEASE OF CYTOKINES, & GROWTH FACTORS, –> REMODELING OF THE ARTERIAL WALL, CALCIFICATIONS
STEP 4: PLAQUE RUPTURE –> Acute coronary syndrome

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7
Q

ISCHEMIA/INFARCTION:
ETIOLOGY/PATHOPHYSIOLOGY

A
  • IN ESSENCE, ATHEROSCLEROTIC PLAQUE BUILDS
    UP WITHIN THE ENDOTHELIAL LINING OF THE
    CORONARY ARTERIES.
  • ACUTE RUPTURE OF AN UNSTABLE PLAQUE,
    REGARDLESS OF THE SIZE OF THE PLAQUE
  • INEXORABLE INCREASE IN SIZE OF THE
    PLAQUE SUCH THAT IT MAY ACUTELY
    DECREASE BLOOD FLOW FOR A GIVEN
    DEMAND ON THE HEART
  • COMBINATION OF THE TWO
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8
Q

OTHER UNCOMMON CAUSES of Ischemia/Infarction:

A

a) CORONARY SPASM (PRINTZMETAL ANGINA) - temporary tighttening
b) SMALL VESSEL DISEASE
c) SPONTANEOUS CORONARY ARTERY
DISSECTION (SCAD)
d) MUSCLE BRIDGE - lays over the coronaries, squeezing them
e) EMBOLISM

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9
Q

ANGINA PECTORIS

A

PATHOLOGICAL PROCESS: ISCHEMIA – NO CELL DEATH/NECROSIS
ASSOCIATED DIAGNOSES: STABLE ANGINA, UNSTABLE ANGINA

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10
Q

Coronary causes of Demand ischemia

A

ACS, VASOSPASM, CORONARY EMBOLISM, CORONARY ARTERITIS

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11
Q

Non- coronary causes of Demand ischemia

A

ANEMIA, HYPOTENSION, HYPERTENSION,
TACHYCARDIA, HYPERTROPHIC CM, SEVERE AORTIC STENOSIS, PULMONARY
EMBOLISM, MYOCARDITIS, SEVERE HF, SEPSIS, CARDIOTOXIC DRUGS

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12
Q

THE MOST COMMON FORM OF ANGINA

A

Stable angina

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13
Q

PREDICTABLE PATTERN that governs stable angina

A
  • RESULTING FROM CORONARY INSUFFICIENCY DUE TO PARTIAL VESSEL OCCLUSION CAUSED BY ATHEROSCLEROSIS.
  • ATTACKS USUALLY OCCUR DURING EXERCISE (CLIMBING STAIRS, MOWING LAWN, ETC.) WHEN OXYGEN DEMAND EXCEEDS OXYGEN SUPPLY.
  • SYMPTOMS TYPICALLY LAST 2-15 MINUTES, AND ARE RELIEVED BY REST AND/OR NITROGLYCERIN
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14
Q

Variant Angina

A
  • CORONARY INSUFFICIENCY DUE TO
    VASOSPASM (WHICH MAY BE CAUSED BY
    ENDOTHELIAL DYSFUNCTION OR DAMAGE &
    SMOOTH MUSCLE HYPER-REACTIVITY).
  • ATTACKS OFTEN OCCUR DURING REST (ESP.
    AT NIGHT) WHEN VAGAL TONE IS HIGHER.
  • ON EKG YOU MAY SEE TRANSIENT ST
    SEGMENT CHANGES
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15
Q

UNSTABLE ANGINA

A

NO PREDICTABLE PATTERN
* CAUSED BY PLATELET AGGREGATION AT
FRACTURED ATHEROSCLEROTIC PLAQUES.
* OFTEN OCCURS AT REST AND REPRESENTS A
CHANGE IN THE USUAL PATTERN OF STABLE
ANGINA.
* SYMPTOMS ARE MORE INTENSE & OF
LONGER DURATION (E.G. >20 MINUTES)
THAN FOR “TYPICAL” EXERTIONAL ANGINA

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16
Q

Why is unstable angina included as part of ACS?

A
  • OFTEN DEGENERATES INTO MYOCARDIAL
    INFARCTION (AND IS THEREFORE CONSIDERED A MEDICAL EMERGENCY)
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17
Q

NSTEMI classic symptoms

A

CHEST DISCOMFORT OR PRESSURE,
RADIATING TO LEFT JAW OR LEFT ARM, OR BOTH.
DIAPHORETIC (ONGOING SWEATY APPEARANCE ABSENT
ANY CURRENT EXERTION).
“SENSE OF IMPENDING DOOM!”

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18
Q

ANGINAL EQUIVALENTS of NSTEMI

A

EXERTIONAL DYSPNEA OR
SHORTNESS OF BREATH WITH LESS EXERTION THAN THEY
USUALLY CAN COMPLETE.
OVERWHELMING FATIGUE WITH USUAL ACTIVITY THAT
IMPROVES WITH MINUTES OF RESTING.
CHEST DISCOMFORT OVER THE RIGHT OR BILATERAL CHEST.

Should still consider MI on the differential

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19
Q

NSTEMI workup

A

CHECK: EKG, TROPONIN
Unstable Angina: NO ST ELEVATION ON EKG +
NEGATIVE TROP
NSTEMI: NO ST ELEVATION ON EKG +
POSITIVE TROP

20
Q

“SENSE OF IMPENDING DOOM!” is seen often with _____

A

NSTEMI

21
Q

NITRATES

A

■ ISOSORBIDE DINITRATE (ISORDIL)
■ ISOSORBIDE MONONITRATE (IMDUR, ISMO)
■ NITROGLYCERIN

22
Q

SODIUM CHANNEL BLOCKER

A

RANOLAZINE (RANEXA)

23
Q

NITRATES: INDICATIONS

A

ACUTE ANGINA – SHORT ACTING FORMS
CHRONIC ANGINA (PROPHYLAXIS) - LONG ACTING FORMS (ISOSORBIDE
DINITRATE)
HTN - LONG ACTING FORMS (SODIUM NITROPRUSSIDE – USUALLY A DRIP GIVEN
FOR HYPERTENSIVE EMERGENCY)
CHF - LONG ACTING FORMS (USUALLY ISOSORBIDE DINITRATE + HYDRALAZINE)

24
Q

What do nitrates do to the heart

A

Rebalances supply and demand by relaxing (dilating) the heart vessels, reducing stress on the heart by improving blood flow to the heart muscle

25
Q

NITRATES: MINOR SIDE EFFECTS

A

● HEADACHE
● LIGHTHEADEDNESS
● DIZZINESS
● WEAKNESS
● FLUSHING
● HYPOTENSION, ORTHOSTATIC

26
Q

NITRATES: MAJOR SIDE EFFECTS

A

● HYPOTENSION, SEVERE
● PARADOXICAL BRADYCARDIA
● SYNCOPE
● ANAPHYLACTOID RXN
● EXFOLIATIVE DERMATITIS
● METHEMOGLOBINEMIA
● NITRATE TOLERANCE (EXCESSIVE OR CONTINUOUS USE)

27
Q

SHORT-ACTING DOSES of Nitroglycerin

A
  • SUBLINGUAL TABLET – 0.3 TO 0.6 MG, UP TO 1.5 MG AS NEEDED A DAY
  • TRANSDERMAL PATCH – 0.2 – 0.8 MG/H, ONE PATCH A DAY (REMOVE AT NIGHT
    FOR 12H)
  • OINTMENT – 7.5 – 40 MG A DAY
  • CAPSULE – 5 – 6.5 MG, 3 TO 4 TIMES A DAY
  • SPRAY – 0.4 TO 0.8 MG, 1 TO 3 TIMES A DAY; MAX 3 ACTUATIONS IN 15 MINUTES
  • IV – RANGE FROM 10 TO 120 MICROGRAMS/MIN
28
Q

USUAL DIRECTIONS for taking nirtoglycerin

A

1) TAKE 1ST NTG AND ASSESS WHETHER SYMPTOMS RESOLVE IMMEDIATELY TO WITHIN 5 MINUTES. IF YES, GOOD. DO NOTHING ELSE.
2) IF NO. TAKE 2ND NTG AND ASSESS WHETHER SYMPTOMS RESOLVE IMMEDIATELY TO WITHIN 5 MINUTES. IF YES, GOOD. CALL PROVIDER TO LET THEM KNOW YOUR ANGINA
REQUIRED 2 NTG.
3) IF NO. TAKE A 3RD NTG AND CALL EMS.

29
Q

LONG-ACTING DOSES Nitrates

A

ISOSORBIDE DINITRATE
* TABLET – 10 TO 40 MG 3 TIMES A DAY
* SUBLINGUAL TABLET – 2.5 TO 10 MG
* SPRAY – 1.25 MG PER DOSE
ISOSORBIDE MONONITRATE
* TABLET – 20 MG TWICE DAILY, 7 HOURS APART
* TABLET (SUSTAINED RELEASE) – 30 TO 120 DAILY; MAX DAILY DOSE 240 MG
DAILY

30
Q

SOSORBIDE DINITRATE (ISDN) - ISORDIL features

A
  • MUST UNDERGO SIGNIFICANT “FIRST PASS” THROUGH LIVER TO BE
    ACTIVATED
  • SHORT HALF LIFE OF 1 HOUR (THUS 2 HOUR TRUE EFFECTIVENESS)
  • HAS FDA APPROVAL FOR CHF TREATMENT (OFTEN USED IN COMBINATION
    WITH HYDRALAZINE)
  • 3-4 TIMES A DAY
31
Q

ISOSORBIDE MONONITRATE (ISMN) - IMDUR, ISMO Features

A
  • BIOAVAILABLE FORM OF ISDN
  • LONGER HALF-LIFE OF 4-6 HOURS
  • NO FDA APPROVAL FOR CHF
  • 2 TIMES A DAY
32
Q

SODIUM CHANNEL BLOCKER MOA

A

EXACT MECHANISM OF ACTION IS UNKNOWN
* INHIBITS LATE SODIUM CURRENT à REDUCTION OF CALCIUM
OVERLOAD IN MYOCYTES

33
Q

Indication for SODIUM CHANNEL BLOCKER:
RANOLAZINE (RANEXA)

A

CHRONIC ANGINA (PROPHYLAXIS)
* USEFUL IN SMALL VESSEL DISEASE
* OR IF TOLERANT TO NITRATES

34
Q

SODIUM CHANNEL BLOCKER Contraindications

A

CIRRHOSIS OR HYPERSENSITIVITY
REACTIONS
Caution:
* AGE >75
* CRCL <60
* LONG QT SYNDROME/FHX OR QT PROLONGATION
* TORSADES DES POINTS
* ELECTROLYTE ABNORMALITIES
* RECENT MI
* CHF
* BRADYCARDIA
* VENTRICULAR ARRHYTHMIAS

35
Q

MAJOR ADVERSE REACTIONS of Sodium channel blocker

A
  • QT PROLONGATION
  • SYNCOPE
  • BRADYCARDIA
  • HYPOTENSION
  • ANGIOEDEMA
  • RENAL FAILURE
  • PULMONARY FIBROSIS
  • THROMBOCYTOPENIA, LEUKOPENIA, PANCYTOPENIA
36
Q

COMMON REACTIONS of RANOLAZINE (Renexa)

A
  • DIZZINESS
  • HEADACHE
  • CONSTIPATION, NAUSEA, VOMITING, DYSPEPSIA,
    ABDOMINAL PAIN
  • ASTHENIA
  • PALPITATIONS
  • VERTIGO, TINNITUS, BLURRED VISION
  • PERIPHERAL EDEMA
  • ANOREXIA
  • CONFUSION
  • DYSPNEA
37
Q

DUAL ANTI-PLATELET THERAPY

A

+ BRILINTA (TICAGRELOR 90 MG BID) OR
+ EFFIENT (PRASUGREL 10 MG DAILY) OR
+ PLAVIX (CLOPIDOGREL 75 MG DAILY) FOR 12 MONTHS

38
Q

Why would we need to do dual anti-platelet therapy as secondary prevention?

A
  • TO AVOID THROMBOSIS OF STENT
  • PATIENT HAS DEMONSTRATED PLAQUE RUPTURE Before
  • MAY DISCONTINUE SECOND AGENT AFTER 12-18 MONTHS POST EVENT –>
    MONOTHERAPY (likley on this forever)
39
Q

BETA-BLOCKER THERAPY IN NSTE-ACS OR STEMI SHOULD BE INITIATED When?

A

IN THE FIRST 24 HOURS
- METOPROLOL SUCCINATE, CARVEDILOL, OR BISOPROLOL

40
Q

AVOID Beta-Blocker therapy if:

A
  • SIGNS OF Heart failure
  • EVIDENCE OF LOW-OUTPUT STATE,
  • INCREASED RISK FOR CARDIOGENIC SHOCK, OR
  • OTHER CONTRAINDICATIONS TO BETA BLOCKADE (E.G., PR INTERVAL >0.24 SECOND,
    SECOND- OR THIRD-DEGREE HEART BLOCK WITHOUT A CARDIAC PACEMAKER, ACTIVE
    ASTHMA, OR REACTIVE AIRWAY DISEASE)
41
Q

RENIN-ANGIOTENSIN-ALDOSTERONE INHIBITION MEDICATIONS
IN NSTE-ACS OR STEMI SHOULD BE INITIATED ____

A

IN THE FIRST 24 HOURS

42
Q

CHOLESTEROL LOWERING THERAPY IN NSTE-ACS OR STEMI SHOULD BE INITIATED _____

A

IN HOSPITAL AS HIGH INTENSITY DOSE

43
Q

ANTI-ANGINAL THERAPY IN NSTE-ACS OR STEMI CAN BE USED FOR ____

A

THOSE PATIENT WHO
HAVE A MEDICALLY CONSERVATIVE APPROACH (IE, NO STENT OR BYPASS) OR WHO CONTINUE
TO EXPERIENCE ANGINA DESPITE REVASCULARIZATION

44
Q

CHOLESTEROL LOWERING THERAPY IN NSTE-ACS OR STEMI

A

TORVASTATIN 40 OR 80 MG PO DAILY
ROSUVASTATIN 20 OR 40 MG PO DAILY

45
Q

BETA-BLOCKER THERAPY IN NSTE-ACS OR STEMI

A

METOPROLOL SUCCINATE, CARVEDILOL, OR BISOPROLOL

46
Q

ANTI-ANGINAL THERAPY (NITRATES) IN NSTE-ACS OR STEMI

A
  • RANOLAZINE 500 MG BID OR
  • ISOSORBIDE MONONITRATE 60 MG QD OR BID OR
  • ISOSORBIDE DINITRATE 5 MG TO 40 MG BID OR TID
  • AND RESCUE SUBLINGUAL NITROGLYCERIN 0.4 MG TABLETS PRN UP TO 3 Q5 MIN

Cardio Exam 2 (12 decks)

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