Exam 1: CAD (Sowinski) Flashcards
Printzmetal’s Variant Angina
vasospasm that causes the coronary artery to close, decreasing the supply of blood to muscle
Chronic Stable Angina
fixed stenosis, demand ischemia
Unstable Angina
caused by a formation of a thrombus, supply ischemia
Factors affecting O2 supply
vascular resistance, coronary blood flow, and O2 carrying capacity
Factors affecting O2 Demand
heart rate, contractility, wall tension (LV volume and systolic pressure)
Contractility’s effect on supply/demand ratio
decrease contractility will decrease O2 consumption
Heart rate’s effect on supply/demand ratio
decreased HR will decrease O2 consumption
Decreased HR will increase coronary perfusion
Preload’s (LVEDV) effect on supply/demand ratio
decreased by venodilation
decrease leads to decrease in O2 consumption
decrease leads to increase in myocardial perfusion
Afterload’s effect on supply/demand ratio
decreased by dilation of arteries
decrease leads to decrease in O2 consumption
Diagnosis of significant coronary artery disease with angina pectoris
70-75% occlusion due to atherosclerotic plaque
Myocardial Ischemia
imbalance between myocardial oxygen supply and demand, secondary to increased work (effort induced)
Does myocardial ischemia cause necrosis?
NO. It causes disturbances in function without causing myocardial necrosis
Angina
resulting symptoms from ischemia, also known as chest discomfort
Stable Angina Pectoris Definition
discomfort in the chest and/or adjacent areas caused by myocardial ischemia and associated with a disturbance in myocardial function without myocardial necrosis
Clinical Presentation: P and P
Precipitating Factors: exertion
Palliative Measures: rest/and or SLNTG
Clinical Presentation: Q
Quality and Quantity of the Pain: squeezing, heaviness, tightening
Clinical Presentation: R
Region and Radiation: substernal
Clinical Presentation: S
Severity of the Pain: subjective >5
Clinical Presentation: T
Timing and temporal pattern: lasts <20 minutes, usually relieved in 5-10 minutes
ECG Findings: Chronic Angina
ST segment depression during event
Treatment of Chronic Coroanry Disease Goals
1: risk factor modification/prevent ACS and death
2: management of angina, prevent recurrent symptoms of ischemia
Medications to Reduce Risk and Prevent ACS/Death
- Anti-platelet therapy
- Statin
- RAS Inhibitors
- Colchicine
Does aspirin reversibly or irreversibly inactivate platelet COX-1?
irreversibly
Aspirin’s anti-platelet activity
blocking TXA2s synthesis
High Dose Aspirin Risks
high dose aspirin can block COX2, blocking prostaglandin which increases platelet aggregation
Aspirin Loading Dose
162-325 mg
Aspirin Maintenance Dose
75-162 mg (81 mg preferred)
Clopidogrel (Plavix) Loading Dose
300-600 mg
Clopidogrel (Plavix) Maintenance Dose
75 mg daily
Prasugrel (Effient) Loading Dose
60 mg
Prasugrel (Effient) Maintenance Dose
10 mg daily
Ticagrelor (Brilinta) Loading Dose
180 mg
Ticagrelor (Brilinta) Maintenance Dose
90 mg BID
Mechanism of Action: P2Y12 Inhibitors
selectively inhibit adenosine diphosphate induced platelet aggregation with no direct effect on TXA2
Aspirin Adverse Effects
- GI Bleeding
- Intra/extracranial Bleeding
- hypersensitivity
Adverse Effects: Clopidogrel
bleeding, rash, diarrhea, 1% increase risk in bleeding with aspirin
Adverse Effects: Prasugrel
bleeding, rash, diarrhea, 0.6% increase in major bleeding risk, 0.5% increase risk of life-threatening bleeding
Adverse Effects: Ticagrelor
bleeding, bradycardia, heart block, dyspnea (SOB)
No History of Stent Implantation Anti-platelet therapy
SAPT: all patients should receive 75-100 mg/day (81 mg preferred)
contraindication: use plavix 75 mg daily
Elective PCI and Stent Anti-platelet therapy
Before Procedure: ASA and P2Y12 Loading Dose
Low Risk:
- DAPT 6 months
- SAPT indefinitely
High Risk:
- DAPT: 1-3 months
- SAPT: P2Y12 inhibitor until 12 months
- SAPT: indefinitely
CABG Anti-platelet Therapy
DAPT: ASA 81 mg + Plavix 75 mg/day (12 months)
SAPT: ASA indefinitely
ASA and Ticagrelor
ASA dose must be ≤ 100 mg with ticagrelor
ACE/ARBs in CCD
reduce progression of the disease but do not treat/prevent angina symptoms
When to consider ACEi/ARBs in patients with CCD
Should be considered in all patients with CCD, especially in patients with LVEF< 40%, HTN, DM, or CKD
ARBs in those who are intolerant to ACEis
Colchicine in patients with CCD
reduces inflammation, likely via reduction in IL-1B and IL-18
can be used in patients who are high risk with elevated hs c-reactive protein
Increasing myocardial oxygen supply to prevent recurrent ischemia
dilate coronary arteries (reducing vasospasm), collateral blood flow, prolong diastole
Decrease myocardial oxygen demand to prevent ischemia
heart rate, mycoardial contractility, wall tension (SBP = afterload and LVEDV = preload)
Nitrates: HR
increase
Nitrates: Contractility
no effect
Nitrates: Systolic pressure (afterload)
decrease
Nitrates: LV Volume (preload)
significantly decrease
Beta Blockers: HR
significantly decrease
Beta Blockers: contractility
decrease
Beta Blockers: Systolic pressure (afterload)
decrease
Beta Blockers: LV Volume (preload)
increase
Nifedipine (DHP): HR
increase
Nifedipine (DHP): Contractility
no effect/decreases
Nifedipine (DHP): systolic pressure (afterload)
significantly decreases
Nifedipine (DHP): LV Volume (preload)
no effect/decreases
Verapamil: HR
significantly decreases
Verapamil: Contractility
decreases
Verapamil: Systolic Pressure (afterload)
decrease
Verapamil: LV volume (preload)
no effect/decreases
Diltiazem: HR
decreases
Diltiazem: contractility
no effect/decreases
Diltiazem: Systolic Pressure (afterload)
decreases
Diltiazem: LV volume (preload)
no effect/decreases
Ranolazine
no effect on HR, contractility, systolic pressure, LV volume
Mechanism of Action: Organic Nitrates
nitric oxide donors/releasers via activation of guanylate cyclase
Activity of Nitrates
- marked venodilation (decreased preload and LV volume)
- less arteriole dilation, coronary and peripheral
- inhibition of platelet aggregation (minor)
Do nitrates effect the natural history of CCD
NO
Nitroglycerin Tabs Dosing
0.3-0.6 mg PRN, repeat dose 1-3 times q5 min
Nitroglycerin Spray Dosing
0.4 mg/spray prn repeat dose 1-3 times q5min
Instructions for Nitroglycerin
- sit down
- dissolve one tablet under the tongue
- if needed after 5 min, take another tablet and call 922
- repeat for a 3rd dose if necessary
Adverse Effects: Nitrates
- headache
- hypotension, dizziness, lightheadedness
- facial flushing
- reflex tachycardia
- extreme caution with PDEi
Time frame between PDEis and Nitrates
Avanafil: 12 hours
Sildenafil/Varendafil: 24 hours
Tadalafil: 48 hours
Clinical Recommendation for Nitrates
should be utilized in all patients to prevent angina and to relieve episodes
Mechanism of Action: Beta Blockers
competitive, reversible inhibitors of beta-adrenergic stimulation by catecholamines
Desired Effects on Myocardial Oxygen Demand: Beta Blockers
- reduce HR
- reduce myocardial contractility
- reduce arterial BP (afterload)
BBs Undesired Effect on Myocardial Oxygen Demand
reduces HR –> increase diastolic filling time –> incfrease LVEDV –> increase preload
Atenolol Brand Name
Tenormin
Atenolol Dosing
50-100 mg QD
Bisoprolol Brand Name
Zebeta
Bisoprolol Dosing
5-10 mg QD
Carvedilol Brand Name
Coreg
Carvediol Dosing
25-50 mg BID
Labetalol Brand Name
Normodyne/Trandate
Labetalol Dosing
200-400 mg BID
Metoprolol Brand Name
Lopressor
Metoprolol Dosing
50-100 mg BID
Metoprolol Succinate Brand Name
Toprol XL
Metoprolol Succinate Dosing
100-200 mg QD
Propranolol Brand Name
Inderal
Propranolol Dosing
LA: 80-160 mg QD
B1 Selective BBs
atenolol, metoprolol
non selective BBs
propranolol, carvedilol
ISA BBs
pindolol, acebutolol
Lipid Soluble BBs
propranolol, carvedilol
Water Soluble BBs
atenolol, bisoprolol
Beta Blockers Adverse Effects
- bradycardia
- sinus arrest
- AV block
- reduced LVEF
- bronchoconstriction
- fatigue
- depression
- sexual dysfunction
- exercise intolerance
- mask symptoms of hypoglycemia
Dosage of Beta Blockers
initiate at lowest dose and titrate to symptom reduction
Monitoring Parameters: Beta Blockers
HR: 50-60 bpm
Exercise: < 100 bpm (75% of HR that typically causes angina
Mechanism of Action: Calcium Channel Blocker
Cardiac: decrease influx of trigger calcium in myocytes , decreased chronotropy in nodal cells and inotropy in myocytes
Vascular: vasodilation
Nifedipine CC Brand Name
Adalat CC or Procardia XL
Nifedipine Dosing
30-60 mg QD
Amlodipine Brand Name
Norvasc
Amlodipine Dosing
5-10 mg QD
Brand Name: Felodipine ER
Plendil
Dosing Felodipine ER
5-10 mg qd
Brand Name: Verapamil
Calan, Isoptin
Dosing Verapamil
60-90 mg TID/QID
SR 240 mg
Diltiazem Brand Name
Cardizem, Dilacor XR, Tiamate,Tiazac
Diltiazem Dosing
80-120 mg TID
SR: 60-120 mg BID
CD/XR/ER: 180-360 mg
Adverse Effects: DHPs
- hypotension
- flushing
- headache
- dizziness
- peripheral edema
- reflex tachycardia
Adverse Effects : non DHPs
- reduced contractility (V>D)
- Bradycardia and AV Block (V>D)
- hypotension
- dizziness
- flushing
- headache
- constipation (V>D)
Dosing CCBs
initiate at lowest dose and titrate to symptom reduction
Monitoring Parameters: DHPs
- edema
- BP
Monitoring Parameters: NonDHPs
- constipation
- HR
Nitrate Free Period
10-12 hours
Mechanism of Nitrate Tolerance
- takes hours to regenerate ALDH2 enzyme, continuous nitrate use does not allow ALDH2 to regenerate, creating decreased effectiveness/tolerance
NTG patch dosing
once daily
on for 12-14 hours, off for 10-12 hours
ISDN tabs dosing
2-3 times/day
10 mg TID (8,12, 4)
ISMN tabs
2 times/day 7 hours apart
20 mg BID
ISMN SR tabs
once daily
30 mg once daily
Monitoring Continuous Nitrates
adverse effects
BP reduction
reflex tachycardia
Ranolazine Mechanism of Action
inhibition of late inward NA+ current in ischemic myocytes
this decreases intracellular sodium, which decreases influx of calcium
Dosing: Ranolazine
Ranexa 500 mg BID titrated to 1000 mg BID
Drug Interactions: Ranolazine
Should not be used with strong 3A inhibitors (KTZ,ITZ, PIs)
Limit Dose (500 bid) with moderate inhbitors (Dilt, Ver, ERY, FLZ)
Adverse Effects: Ranolazine
- constipation
- nausea
- dizziness
- headache
- QT prolongation
1st line Therapy: Prevention of Ischemic Events
Beta blockers should be selected as initial therapy in patients without contraindications, especially in stable HF and history of MI
Contraindications of BB
bradycardia (<50 bpm)
AV block/sick sinus syndrome with no pacemaker
Place in Therapy: CCBs
non DHP preferred if BBs contraindicated, in patients with chronic lung diseases, HTN, DM, and peripheral vascular disease (reynauds)
Contraindications: NonDHPS
- HFrEF
- bradycardia
- high degree of AV block or sick sinus syndrome (no pacemaker)
Contraindications: DHPs
HFrEF, except amlodipine and felodipine
Place in therapy: Nitrates
- combination with BB/nonDHP to blunt reflex tacycardia
- short acting PRN nitrates to relieve discomfort or prevent ischemia before exertion
Pain and CV Disease
consider non pharm first, and instigate before using pain medications
prefer tylenol over NSAIDs, prefer ibuprofen/naproxen > celebrex up to 200 mg
use lowest dose for shortest time
avoid diclofenac
use PPIs for gastroprotection
ASA and NSAID
take ASA 2 hours prior to NSAID
