Exam 1 Flashcards
1
Q
What are the three types of angina?
A
-prinzmetal’s variant angina
-chronic stable angina
-unstable angina
2
Q
What causes prinzmetal’s variant angina?
A
vasospasm
3
Q
What causes chronic stable angina?
A
fixed stenosis
4
Q
What causes unstable angina?
A
thrombus
5
Q
Do most coronary artery disease drugs act on myocardial oxygen supply or demand?
A
oxygen demand
6
Q
How does increased heart rate, contractility, afterload, and preload affect oxygen consumption?
A
increase oxygen consumption
7
Q
Is ischemia a physiological outcome or clinical symptom?
A
physiological outcome
8
Q
Is angina a physiological outcome or clinical symptom?
A
clinical symptom
9
Q
What characterizes stable versus unstable angina?
A
consistent symptoms of anginal episodes over last few months
10
Q
What is the clinical presentation acronym for stable angina?
A
PQRST
11
Q
What does PQRST stand for?
A
P: Precipitating factors and palliative measures
Q: Quality and quantity of pain
R: Region and radiation
S: Severity of pain
T: Timing and temporal pattern
12
Q
What are typical stable angina symptoms?
A
-substernal chest pain
-short duration (usually 0.5 - 20 minutes)
-pain relief with nitroglycerin and/or rest
13
Q
What ECG findings denote stable angina?
A
ST-segment depression during anginal episode
14
Q
What is the treatment goal for dyslipidemia?
A
≥50% reduction in LDL
15
Q
What are the preferred treatments for dyslipidemia?
A
-lifestyle modifications
-low saturated fat (<7%)
-low cholesterol (<200 mg/dL)
-moderate- to high-intensity statin
16
Q
What is the treatment goal for hypertension?
A
BP: <130/80 mm Hg
17
Q
What are the preferred treatments for hypertension?
A
-lifestyle modifications
-pharmacological treatment (beta blockers, ACEis, ARBs, etc.) as necessary
18
Q
What is the treatment goal for diabetes mellitus?
A
HbA1c: <7%
19
Q
What are the preferred treatments for diabetes mellitus?
A
-individualized based on each patient
-SGLT2-inhibitor or GLP-1 RA for patients with T2DM and high ASCVD risk
20
Q
What is the treatment goal for smoking?
A
complete smoking cessation/exposure
21
Q
What are the preferred treatments for smoking?
A
-systematic strategy
-pharmacotherapy
22
Q
What are the treatment goals for weight management?
A
-BMI: 18.5-24.9
-waist circumference: 35 (women) or 40 (men)
-weight loss: 5-10% initially
23
Q
What are the preferred treatments for weight management?
A
-diet/lifestyle counseling
-printed educational materials and encourage weight loss
24
Q
What are the treatment goals for physical activity?
A
-30-60 minutes of moderate intensity activity 5-7 days per week
-cardiac rehabilitation/supervision
25
What are the preferred treatments for physical activity?
-brisk walking
-swimming
-cycling
-increased daily activities
26
What are risk factor modifications for stable angina?
-influenza vaccination
-alcohol consumption
-exposure to air pollution
-management of psychological factors
27
What medications decrease cardiovascular risk?
-aspirin
-P2Y12 inhibitors
-ACE inhibitors
28
What medications manage anginal symptoms?
-nitrates
-beta blockers
-calcium channel blockers
-ranolazine
29
What is the loading dose for aspirin?
162-325 mg
30
What is the maintenance dose for aspirin?
75-162 mg QD
31
What is the loading dose for clopidogrel?
300-600 mg
32
What is the maintenance dose for clopidogrel?
75 mg QD
33
What is the loading dose for prasugrel?
60 mg
34
What is the maintenance dose for prasugrel?
10 mg QD
35
What is the loading dose for ticagrelor?
180 mg
36
What is the maintenance dose for ticagrelor?
90 mg BID
37
What are the prodrug P2Y12 inhibitors?
clopidogrel and prasugrel
38
What is the dose of aspirin with concurrent use of ticagrelor?
≤81 mg
39
What conditions are colchicine contraindicated in?
severe renal and hepatic disease
40
What are the effects of nitrates on myocardial oxygen demand?
-increase heart rate
-decrease systolic pressure
-decrease left ventricular volume (significantly)
41
What are the effects of beta blockers on myocardial oxygen demand?
-decrease heart rate (significantly)
-decrease myocardial contractility
-decrease systolic pressure
-increase left ventricular volume
42
What are the effects of nifedipine on myocardial oxygen demand?
-increases heart rate
-no effect/decreases myocardial contractility
-decreases systolic pressure (significantly)
-no effect/decreases left ventricular volume
43
What are the effects of verapamil on myocardial oxygen demand?
-decreases heart rate (significantly)
-decreases myocardial contractility
-decreases systolic pressure
-no effect/decreases left ventricular volume
44
What are the effects of diltiazem on myocardial oxygen demand?
-decreases heart rate
-no effect/decreases myocardial contractility
-decreases systolic pressure
-no effect/decreases left ventricular volume
45
What are the effects of ranolazine on myocardial oxygen demand?
no effects
46
What is the dosing for nitroglycerin sublingual tablets?
0.3-0.6 mg SL PRN for angina; repeat dose 1-3 times Q5 minutes
47
What is the dosing for nitroglycerin spray?
0.4 mg SL PRN for angina; repeat dose 1-3 times Q5 minutes
48
What is the dosing for nitroglycerin powder packets?
0.4 mg SL PRN for angina; repeat dose 1-3 times Q5 minutes
49
What are counseling points for nitroglycerin sublingual tablets?
-keep in original dark glass container
-do not administer with safety cap
-place under tongue; do not swallow tablet
-remove cotton plug before dispensing
-do not store in bathroom or humid locations
-keep on hand at all times
-need refill every 6 months
-educate patient on proper administration and procedure
50
What are counseling points for nitroglycerin sublingual spray?
-spray under tongue; do not inhale
-do not shake bottle
-keep on hand at all times
-need refill every 3 years
-educate patient on proper administration and procedure
51
nitrate adverse effects
-headache
-hypotension
-dizziness
-lightheadedness
-facial flushing
-reflex tachycardia
52
What is the time period between avanafil and nitrates?
12 hours
53
What is the time period between sildenafil/vardenafil and nitrates?
24 hours
54
What is the time period between tadalafil and nitrates?
48 hours
55
What is the brand name for atenolol?
Tenormin
56
What is the maintenance dose for atenolol?
50-100 mg QD
57
What is the brand name for metoprolol tartrate?
Lopressor
58
What is the maintenance dose for metoprolol tartrate?
50-100 mg BID
59
What is the brand name for metoprolol succinate?
Toprol XL
60
What is the maintenance dose for metoprolol succinate?
100-200 mg QD
61
What is the brand name for propranolol LA?
Inderal LA
62
What is the maintenance dose for propranolol LA?
80-160 mg QD
63
Which beta blockers are B1 selective?
-atenolol
-metoprolol
64
Which beta blockers are non-selective?
-carvedilol
-propranolol
65
What are the adverse effects of beta blockers?
-sinus bradycardia
-sinus arrest
-AV block
-reduced left ventricular ejection fraction
-bronchoconstriction
-fatigue
-depression
-nightmares
-sexual dysfunction
-exercise intolerance
-intensification of insulin-induced hypoglycemia and peripheral vascular complication
66
What is the goal resting heart rate for patients on beta blockers?
50-60 bpm
67
What is the goal exercise heart rate for patients on beta blockers?
<100 bpm OR 75% of heart rate that typically causes angina
68
Are DHP CCBs more vascular or myocardial selective?
vascular selective
69
What is the brand name for amlodipine?
Norvasc
70
What is the maintenance dose for amlodipine?
5-10 mg QD
71
What is the brand name for felodipine-ER?
Plendil
72
What is the maintenance dose for felodipine-ER?
5-10 mg QD
73
What is the brand name for nifedipine-CC?
Adalat-CC
74
What is the maintenance dose for nifedipine-CC?
30-60 mg QD
75
What is the brand name for nifedipine-XL?
Procardia-XL
76
What is the maintenance dose for nifedipine-XL?
30-60 mg QD
77
What are the brand names for verapamil?
-Calan
-Isoptin
78
What is the maintenance dose for verapamil?
60-90 mg TID-QID
79
What are the brand names for verapamil-SR?
-Calan-SR
-Isoptin-SR
-Covera-HS
-Verelan
80
What is the maintenance dose for verapamil-SR?
240 mg QD
81
What is the brand name for diltiazem?
Cardizem
82
What is the maintenance dose for diltiazem?
80-120 mg TID
83
What is the brand name for diltiazem-SR?
Cardizem SR
84
What is the maintenance dose for diltiazem-SR?
60-120 mg BID
85
What is the brand name for diltiazem-CD?
Cardizem CD
86
What is the maintenance dose for diltiazem-CD?
180-360 mg QD
87
What is the brand name for diltiazem-XR?
Dilacor-XR
88
What is the maintenance dose for diltiazem-XR?
180-540 mg QD
89
What are the brand names for diltiazem-ER?
-Tiamate
-Tiazac
90
What is the maintenance dose for diltiazem-ER?
180-360 mg QD
91
What are the adverse effects for DHP CCBs?
-hypotension
-flushing
-headache
-dizziness
-peripheral edema
-reduced myocardial contractility
-reflex adrenergic activation
92
What are the adverse effects for non-DHP CCBs?
-reduced myocardial contractility
-bradycardia
-AV block
-hypotension
-flushing
-headache
-dizziness
-constipation
93
What are the monitoring parameters for DHP CCBs?
-signs/symptoms of edema
-blood pressure
94
What is the monitoring parameter for non-DHP CCBs?
heart rate
95
How long is the nitrate free period?
10-12 hours
96
What is the dosing interval for nitroglycerin patch?
QD
97
What is the dosing interval for isosorbide dinitrate tablets?
BID-TID
98
What is the dosing interval for isosorbide mononitrate tablets?
BID (7 hours apart)
99
What is the dosing interval for isosorbide mononitrate SR tablets?
QD
100
What is the dosing for ranolazine?
500-1000 mg PO BID (titrate over 1-2 weeks)
101
What drug class is considered first-line treatment for chronic stable angina?
beta blockers
102
What are contraindications for beta blockers in the treatment of chronic stable angina?
-prinzmetal's/vasospastic angina
-conduction disturbances
-bradycardia
-high degree AV block or sick sinus syndrome (with no pacemaker)
103
Are non-DHP or DHP CCBs preferred for the treatment of chronic stable angina?
non-DHP CCBs
104
What are contraindications for non-DHP CCBs in the treatment of chronic stable angina?
-HFrEF
-bradycardia
-high degree AV block or sick sinus syndrome (with no pacemaker)
105
What is the contraindication for DHP CCBs in the treatment of chronic stable angina?
HFrEF
106
Is monotherapy or combined therapy of nitrates preferred?
combined therapy
107
When should nitrates be used with caution?
-hypertrophic obstructive cardiomyopathy
-severe aortic stenosis
-phosphodiesterase inhibitor use
108
What combination therapy in the treatment of chronic stable angina should be avoided?
non-DHP CCBs and beta blockers
109
What is the stepwise therapy for pain management for patients with chronic stable angina?
-nonpharmacological treatment
-acetaminophen
-ibuprofen or naproxen
110
What NSAIDs should be avoided with concurrent use of aspirin?
celecoxib and diclofenac
111
How far apart should aspirin and NSAIDs be taken?
take aspirin at least 2 hours prior to NSAIDs
112
What causes a spontaneous myocardial infarction?
atherosclerotic plaque rupture
113
What causes a myocardial infarction secondary to ischemic imbalance?
oxygen supply/demand mismatch to heart
114
What is the most common type of ACS?
NSTEMI
115
What are risk factors for ACS?
-older age
-male
-family history of CAD
-peripheral artery disease
-diabetes
-renal insufficiency
-smoking
-history of MI
116
What are precipitating factors for ACS?
-recent exercise
-extreme weather (hot or cold)
-large meal
-emotions
-sexual activity
-walking against the wind
-smoking
117
What populations are atypical symptoms more common in?
-elderly
-females
-diabetics
-impaired renal function
-dementia
118
What are atypical symptoms of ACS?
-epigastric pain
-indigestion
-stabbing or pleuritic pain
-increasing dyspnea in the absence of chest pain
119
How soon upon arrival at the emergency department should a patient receive an ECG?
within 10 minutes
120
What type of ACS shows Q wave changes on an ECG?
STEMI
121
How soon upon arrival at the emergency department should a patient's troponin be measured?
ASAP
122
What type of troponin is preferred?
high sensitivity troponin
123
What unit of measurement is troponin measured in?
ng/L
124
What level of troponin indicates a myocardial injury?
>14 ng/L
125
How often should troponin be measured?
3 levels every 3-6 hours for the first 12 hours
126
What characterizes unstable angina?
-unexpected chest pain that may occur at rest, while sleeping, or with little physical exertion
-more severe than stable angina
-lasts longer than stable angina (may be >30 minutes)
127
Is angina usually relieved by SL NTG in MI?
No
128
What characterizes NSTEMI in an ECG?
ST depression or T wave inversion
129
If the initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS, how often should serial ECGs be performed?
every 15-30 minutes for the first hour
130
What does MONA stand for?
-morphine
-oxygen
-nitroglycerin
-aspirin
131
What is the initial dose of morphine for the treatment of ACS?
4-8 mg IV, then 2-8 mg IV Q5-15 minutes (if angina continues)
132
What are side effects of morphine?
-sedation
-respiratory depression
-nausea/vomiting
133
What is the treatment goal for oxygen?
oxygen saturation >90%
134
When should IV nitroglycerin be used for ACS?
persistent ischemia, HF, or HTN
135
What is the dosing for IV nitroglycerin?
10 mcg/min, then titrate by 5 mcg/min Q5 minutes
136
What is the maximum dose for IV nitroglycerin?
200 mcg/min
137
When can be enteric-coated aspirin be used for ACS?
if the patient chews the aspirin
138
What fibrinolytics are weight-based dosing?
tenecteplase and alteplase
139
Is there a preference for any of the fibrinolytics?
No
140
What are the reperfusion therapy options for a patient presenting with STEMI?
-percutaneous coronary intervention (PCI)
-fibrinolytic
141
What is the door-to-needle time for reperfusion therapy for a patient with a STEMI?
within 30 minutes of hospital arrival
142
What is the door-to-balloon time for reperfusion therapy for a patient with a STEMI?
within 90 minutes of hospital arrival
143
When is a fibrinolytic preferred over a PCI for a patient with a STEMI?
if a PCI-capable hospital is ≥120 minutes away
144
What are the reperfusion therapy options for a patient presenting with UA/NSTEMI?
-early invasive strategy
-ischemia guided strategy
145
When is cangrelor used for patients with ACS?
if patient did not receive loading dose of P2Y12 inhibitor before PCI
146
What are the loading doses for clopidogrel when a fibrinolytic is used concurrently?
-no loading dose (age >75)
-300 mg (age ≤75)
147
What P2Y12 inhibitors are recommended for ischemia guided strategy?
-ticagrelor
-clopidogrel
148
What is the contraindication for prasugrel?
history of TIA/stroke
149
When should prasugrel be avoided?
-age ≥75
-<60 kg
-high bleeding risk
150
When should you switch a patient from clopidogrel?
inadequate response (genetics or CV event)
151
When should you switch a patient to clopidogrel?
-bleeding
-cost
-dyspnea (ticagrelor)
-adherence (ticagrelor)
-stroke/TIA (prasugrel)
152
What P2Y12 inhibitors are preferred for early invasive strategy?
-ticagrelor
-prasugrel
153
What P2Y12 inhibitor is preferred with concurrent use of fibrinolytics?
clopidogrel
154
What are minor signs and symptoms of bleeding?
-bruising
-light nosebleeds
-bleeding gums when flossing
155
What are major signs and symptoms of bleeding?
-blood in urine/stool
-coughing up blood
-cut that keeps bleeding after pressure for ≥10 minutes
156
Does aspirin need to be held before a CABG?
No
157
How long should ticagrelor be held before an elective CABG?
3 days
158
How long should clopidogrel be held before an elective CABG?
5 days
159
How long should prasugrel be held before an elective CABG?
7 days
160
How long should P2Y12 inhibitors be held before an urgent CABG?
24 hours if possible
161
When are GP IIb/IIIa inhibitors administered for patients with NSTEMI?
high risk features, such as positive troponin
162
When are GP IIb/IIIa inhibitors administered for patients with STEMI?
large thrombus burden
163
Can fondaparinux be used alone for patients undergoing a PCI?
No
164
What is the contraindication for fondaparinux?
CrCl <30 mL/min
165
When can unfractionated heparin be used in patients with ACS?
-ischemia guided strategy
-early invasive strategy
-fibrinolytic
-PCI
166
When should unfractionated heparin be administered until for patients with UA/NSTEMI?
-48 hours (ischemia guided strategy)
-until PCI (early invasive strategy)
167
When should unfractionated heparin be administered until for patients with STEMI?
-48 hours (fibrinolytic)
-until PCI (PCI)
168
When can bivalirudin be used in patients with ACS?
-early invasive strategy
-PCI
169
When can enoxaparin be used in patients with ACS?
-ischemia guided strategy
-early invasive strategy
-fibrinolytic
170
When should enoxaparin be administered until for patients with UA/NSTEMI?
-duration of hospital stay up to 8 days (ischemia guided strategy)
-until PCI (early invasive strategy)
171
When should enoxaparin be administered until for patients with STEMI?
duration of hospital stay up to 8 days (fibrinolytic)
172
When can fondaparinux be used in patients with ACS?
-ischemia guided strategy
-fibrinolytic
173
When should fondaparinux be administered until for patients with ACS?
duration of hospital stay up to 8 days
174
How soon after an ACS should a beta blocker be initiated?
within first 24 hours
175
What is the starting dose of metoprolol tartrate?
25-50 mg Q6-12 hours
176
What is the starting dose of carvedilol?
6.25 mg BID
177
What is the target dose of carvedilol?
25 mg BID
178
What is the starting dose of propranolol?
40 mg BID-TID
179
What is the target dose of propranolol?
80 mg QID
180
What is the starting dose of atenolol?
25-50 mg QD
181
Which beta blockers should be used in patients with HFrEF?
-metoprolol succinate
-carvedilol
-bisoprolol
182
When should an IV beta blocker be administered in patients with ACS?
hypertensive or ongoing ischemia
183
What is the dosing for IV metoprolol tartrate?
5 mg IV Q5 minutes up to 3 doses
184
What type of beta blocker should be administered to a patient with active cocaine use?
non-selective beta blocker
185
When should beta blockers be avoided in patients with ACS?
heart failure, but continue home dose of beta blockers
186
What are the hold parameters for beta blockers?
-HR <50 bpm
-SBP <90 mm Hg and/or DBP <60 mm Hg
187
What are the high-intensity statins?
-atorvastatin 40-80 mg QD
-rosuvastatin 20-40 mg QD
188
How soon after an ACS should an ACE inhibitor be initiated?
after 24 hours
189
What is the starting dose of captopril?
6.25-12.5 mg TID
190
What is the target dose of captopril?
25-50 mg TID
191
What is the starting dose of lisinopril?
2.5-5 mg QD
192
What is the target dose of lisinopril?
≥10 mg QD
193
What is the starting dose of ramipril?
2.5 mg BID
194
What is the target dose of ramipril?
5 mg BID
195
What is the starting dose of trandolapril?
0.5 mg QD
196
What is the target dose of trandolapril?
4 mg QD
197
What is the starting dose of valsartan?
20 mg BID
198
What is the target dose of valsartan?
160 mg BID
199
What are the contraindications for ARBs?
-hypotension/shock
-bilateral renal artery stenosis or history of worsening of renal function with ACE inhibitor/ARB exposure
-acute renal failure
-drug allergy/angioedema
200
What are monitoring parameters for ACE inhibitors?
-serum creatinine
-potassium
-blood pressure
-angioedema
201
By what percentage increase of serum creatinine should an ACE inhibitor be discontinued?
>30%
