CV 16 Flashcards
Obstructive CAD
greater than 50% diameter stenosis and fractional flow reserve less than 0.8 during coronary angiography
INOCA
ischemia with no obstructive coronary arteries. Syndrome of pts with either symptoms and/or signs or ischemia but found to have no obstructive coronary artery disease (CAD)
Vasospastic Angina
reproduction of angina symptoms, ischemic ECG changes with greater than 90% constriction in major epicardial artery
Microvascular Angina
No obstructive CAD plus objective evidence of coronary microvascular dysfunction (as defined by abnormal response to intracoronary acetylcholine and/or systemic adenosine)
CAD
build up of fat and cholesterol which causes plaques in the coronary arteries, resulting in blocks of blood flow to the heart
what is angina/ischemia
chest pain or discomfort caused by CAD, when the heart muscle doesnt get adequate blood supply
Class 1 recommendation
Benefit > risk , is recommended, strong
Class 2a recommendation
benefit > risk, moderate, suggested
Class 2b
Weak, benefit greater than or equal to risk, can be considered.
class 3 moderate
no benefit, benefit = risk. not recommended
class 3 strong
risk > benefit, potentially harmful
risk factors for MACE
age, male sex, poor social support, poverty, access
Risk factors for MACE Medical history
elevated BMI, previous MI, HF, AF, DM, dyslipidemia, CKD, smoking, depression, poor adherance to therapy
4 goals of treatment for CCD
decrease cardiac death, nonfatal ischemic events, disease progression, symptoms and functional limitations
In patients with CCD, no NHP and supplements help
NO!
what type of diets should be recommended to CCD patients
vegetables, fruits, whole grains, lean protein.
Anti-anginal therapy for symptom relief
nitrates (SL and long acting products)
Beta Blockers
Calcium Channel Blockers
2nd line: Novel anti-anginals (ranolazine, ivabradine only if HFrEF
Therapy to prevent MI/Death
Anti-platelets (ASA +/- Clopidogrel/ticagrelor)
anti thrombotic agents (riveroxaban)
beta blockers (only if recent MI or HFrEF)
RAAS blockers (ACEI or ARB)
Immunization
Colchicine
what do you do if someone has vasospastic angina
dont treat with beta blockers, first with CCB then nitrates if still symptomatic
which drugs to avoid in vasospastic angina
drugs that cause vasospasm
- non selective beta blockers
- triptans for migraines
- 5-fluorouracil
NYHA classifications Class 1
Mild, no symptoms, can perform ordinary activities without any limitations
NYHA Class II
mild - light limitation of ordinary activity, no symptoms at rest, ordinary activity results in symptoms
NYHA class III
moderate - Marked limitation of physical activity, no symptoms at rest, less than ordinary activity results in symptoms.
NYHA Class 4
severe - unable to do any physical activity without discomfort
symptoms at rest
CCS Classification, more specific for Class 2 ad CLass 3
Class 2 - symptoms with walking greater than 2 level blocks and climbing greater than 1 flight of stairs at normal pace in normal conditions
Class 3 - symptoms with walking less than/=to 2 blocks or climbing less than/=to 1 flight of stairs at normal pace in normal conditons
main goal of anti-anginal therapy
prevent episodes of angina and relieve symptoms
main goal of secondary prevention treatment
prevent CV events and death
what class of agents is most effective in preventing angina
none, but more SE with beta blockers
3 Steps for medical therapy for angina patients with CCD
BB, CCB, LAN, then if symptoms continue, add a second antianginal from a differnet class, then add ranolazine for patients who remain symptomatic.
what is recommended for short term immediate relief of angina
sublingual nitroglycerin or nitroglycerin spray.
is ivabradine recommended?
only in patients with HFrEF, can be harmful in those with normal LV function.
three main CI of beta-blockers
heart rate less than 60bpm
systolic arterial pressure <100mmHg
asthma
mod or severe LV failure
which is the most cardioselective agent
bisoprolol
Beta 1 side effects
hypotension, bradycardia, cardiac failiure
beta 2 effects
bronchospasm, vasoconstriction, cold extremities, hyperglycemia, hypoglycemia
two non dihydropridine agents CCB + side effects
verapamil, diltiazem
decreased AV node conduction
Decreased intropy and chronotropy
3 dihydropyridine CCB + SE
amlodipine, felodipine, nifedipine XL
peripehral vasodilation
main side effects and CI with CCB
constipation
dont use SL or Short acting Nifedipine due to reflex tachycardia
Avoid use of non DHP CCB with other AV nodal blocking agents like beta blockers
Avoid use of non-DHP CCB in HFrEF
nitrate tolerance
continuous use of nitrates >24 hours decreases hemodynamic effects and antianginal effects, recommend 10-12 hours of nitrate free interval and dont use as MONOTHERAPY
Nitrate CI
severe hypotension
interaction with phosphodiesterase inhibitors - sildenafil, vardenafil, tadalfil.
Ivabradine key points
direct and selective inhibitor of the IF current in the sinoatrial node. limits its use to patients iwth sinus rhythm(exludes pts in AF or atrial flutter)
If HR is fast, which CCB is preferred
non-DHP CCB
If no indication for OAC, what is recommended
ASA 81mg, if they have had ACS, DAPT
what is recommended as an alternative to aspirin
clopidogrel 75mg daily
when can ASA + Clop be used in combo
post MI or PCI
BB recommendations
if you are more than a year out from your MI, you should not be on a BB.
no benefit of a BB in pts who haveavnt had an MI and dont have HFrEF
ACE evidence
in pts with hypertension and DM, ACE, ARBS should be used!
In pts without, can be considered.
Low DAPT score
less than 2
high dapt score
greater than or equal to 2
adding a second antithrombotic drug to aspirin for long-term secondary prevention should be considered in pts with
high risk of ischaemic events and without high risk of bleeding.
for patients starting warfarin, what should be considered
stop ASA if no recent ACS or extensive symptoms.
