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phrm 845 > Exam 1: CAD (Sowinski) > Flashcards

Exam 1: CAD (Sowinski) Flashcards

1
Q

Printzmetal’s Variant Angina

A

vasospasm that causes the coronary artery to close, decreasing the supply of blood to muscle

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2
Q

Chronic Stable Angina

A

fixed stenosis, demand ischemia

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3
Q

Unstable Angina

A

caused by a formation of a thrombus, supply ischemia

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4
Q

Factors affecting O2 supply

A

vascular resistance, coronary blood flow, and O2 carrying capacity

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5
Q

Factors affecting O2 Demand

A

heart rate, contractility, wall tension (LV volume and systolic pressure)

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6
Q

Contractility’s effect on supply/demand ratio

A

decrease contractility will decrease O2 consumption

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7
Q

Heart rate’s effect on supply/demand ratio

A

decreased HR will decrease O2 consumption

Decreased HR will increase coronary perfusion

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8
Q

Preload’s (LVEDV) effect on supply/demand ratio

A

decreased by venodilation

decrease leads to decrease in O2 consumption

decrease leads to increase in myocardial perfusion

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9
Q

Afterload’s effect on supply/demand ratio

A

decreased by dilation of arteries

decrease leads to decrease in O2 consumption

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10
Q

Diagnosis of significant coronary artery disease with angina pectoris

A

70-75% occlusion due to atherosclerotic plaque

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11
Q

Myocardial Ischemia

A

imbalance between myocardial oxygen supply and demand, secondary to increased work (effort induced)

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12
Q

Does myocardial ischemia cause necrosis?

A

NO. It causes disturbances in function without causing myocardial necrosis

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13
Q

Angina

A

resulting symptoms from ischemia, also known as chest discomfort

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14
Q

Stable Angina Pectoris Definition

A

discomfort in the chest and/or adjacent areas caused by myocardial ischemia and associated with a disturbance in myocardial function without myocardial necrosis

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15
Q

Clinical Presentation: P and P

A

Precipitating Factors: exertion

Palliative Measures: rest/and or SLNTG

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16
Q

Clinical Presentation: Q

A

Quality and Quantity of the Pain: squeezing, heaviness, tightening

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17
Q

Clinical Presentation: R

A

Region and Radiation: substernal

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18
Q

Clinical Presentation: S

A

Severity of the Pain: subjective >5

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19
Q

Clinical Presentation: T

A

Timing and temporal pattern: lasts <20 minutes, usually relieved in 5-10 minutes

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20
Q

ECG Findings: Chronic Angina

A

ST segment depression during event

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21
Q

Treatment of Chronic Coroanry Disease Goals

A

1: risk factor modification/prevent ACS and death

2: management of angina, prevent recurrent symptoms of ischemia

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22
Q

Medications to Reduce Risk and Prevent ACS/Death

A
  • Anti-platelet therapy
  • Statin
  • RAS Inhibitors
  • Colchicine
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23
Q

Does aspirin reversibly or irreversibly inactivate platelet COX-1?

A

irreversibly

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24
Q

Aspirin’s anti-platelet activity

A

blocking TXA2s synthesis

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25
Q

High Dose Aspirin Risks

A

high dose aspirin can block COX2, blocking prostaglandin which increases platelet aggregation

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26
Q

Aspirin Loading Dose

A

162-325 mg

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27
Q

Aspirin Maintenance Dose

A

75-162 mg (81 mg preferred)

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28
Q

Clopidogrel (Plavix) Loading Dose

A

300-600 mg

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29
Q

Clopidogrel (Plavix) Maintenance Dose

A

75 mg daily

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30
Q

Prasugrel (Effient) Loading Dose

A

60 mg

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31
Q

Prasugrel (Effient) Maintenance Dose

A

10 mg daily

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32
Q

Ticagrelor (Brilinta) Loading Dose

A

180 mg

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33
Q

Ticagrelor (Brilinta) Maintenance Dose

A

90 mg BID

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34
Q

Mechanism of Action: P2Y12 Inhibitors

A

selectively inhibit adenosine diphosphate induced platelet aggregation with no direct effect on TXA2

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35
Q

Aspirin Adverse Effects

A
  • GI Bleeding
  • Intra/extracranial Bleeding
  • hypersensitivity
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36
Q

Adverse Effects: Clopidogrel

A

bleeding, rash, diarrhea, 1% increase risk in bleeding with aspirin

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37
Q

Adverse Effects: Prasugrel

A

bleeding, rash, diarrhea, 0.6% increase in major bleeding risk, 0.5% increase risk of life-threatening bleeding

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38
Q

Adverse Effects: Ticagrelor

A

bleeding, bradycardia, heart block, dyspnea (SOB)

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39
Q

No History of Stent Implantation Anti-platelet therapy

A

SAPT: all patients should receive 75-100 mg/day (81 mg preferred)

contraindication: use plavix 75 mg daily

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40
Q

Elective PCI and Stent Anti-platelet therapy

A

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

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41
Q

CABG Anti-platelet Therapy

A

DAPT: ASA 81 mg + Plavix 75 mg/day (12 months)

SAPT: ASA indefinitely

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42
Q

ASA and Ticagrelor

A

ASA dose must be ≤ 100 mg with ticagrelor

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43
Q

ACE/ARBs in CCD

A

reduce progression of the disease but do not treat/prevent angina symptoms

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44
Q

When to consider ACEi/ARBs in patients with CCD

A

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

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45
Q

Colchicine in patients with CCD

A

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

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46
Q

Increasing myocardial oxygen supply to prevent recurrent ischemia

A

dilate coronary arteries (reducing vasospasm), collateral blood flow, prolong diastole

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47
Q

Decrease myocardial oxygen demand to prevent ischemia

A

heart rate, mycoardial contractility, wall tension (SBP = afterload and LVEDV = preload)

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48
Q

Nitrates: HR

A

increase

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49
Q

Nitrates: Contractility

A

no effect

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50
Q

Nitrates: Systolic pressure (afterload)

A

decrease

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51
Q

Nitrates: LV Volume (preload)

A

significantly decrease

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52
Q

Beta Blockers: HR

A

significantly decrease

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53
Q

Beta Blockers: contractility

A

decrease

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54
Q

Beta Blockers: Systolic pressure (afterload)

A

decrease

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55
Q

Beta Blockers: LV Volume (preload)

A

increase

56
Q

Nifedipine (DHP): HR

A

increase

57
Q

Nifedipine (DHP): Contractility

A

no effect/decreases

58
Q

Nifedipine (DHP): systolic pressure (afterload)

A

significantly decreases

59
Q

Nifedipine (DHP): LV Volume (preload)

A

no effect/decreases

60
Q

Verapamil: HR

A

significantly decreases

61
Q

Verapamil: Contractility

A

decreases

62
Q

Verapamil: Systolic Pressure (afterload)

A

decrease

63
Q

Verapamil: LV volume (preload)

A

no effect/decreases

64
Q

Diltiazem: HR

A

decreases

65
Q

Diltiazem: contractility

A

no effect/decreases

66
Q

Diltiazem: Systolic Pressure (afterload)

A

decreases

67
Q

Diltiazem: LV volume (preload)

A

no effect/decreases

68
Q

Ranolazine

A

no effect on HR, contractility, systolic pressure, LV volume

69
Q

Mechanism of Action: Organic Nitrates

A

nitric oxide donors/releasers via activation of guanylate cyclase

70
Q

Activity of Nitrates

A
  • marked venodilation (decreased preload and LV volume)
  • less arteriole dilation, coronary and peripheral
  • inhibition of platelet aggregation (minor)
71
Q

Do nitrates effect the natural history of CCD

A

NO

72
Q

Nitroglycerin Tabs Dosing

A

0.3-0.6 mg PRN, repeat dose 1-3 times q5 min

73
Q

Nitroglycerin Spray Dosing

A

0.4 mg/spray prn repeat dose 1-3 times q5min

74
Q

Instructions for Nitroglycerin

A
  1. sit down
  2. dissolve one tablet under the tongue
  3. if needed after 5 min, take another tablet and call 922
  4. repeat for a 3rd dose if necessary
75
Q

Adverse Effects: Nitrates

A
  • headache
  • hypotension, dizziness, lightheadedness
  • facial flushing
  • reflex tachycardia
  • extreme caution with PDEi
76
Q

Time frame between PDEis and Nitrates

A

Avanafil: 12 hours

Sildenafil/Varendafil: 24 hours

Tadalafil: 48 hours

77
Q

Clinical Recommendation for Nitrates

A

should be utilized in all patients to prevent angina and to relieve episodes

78
Q

Mechanism of Action: Beta Blockers

A

competitive, reversible inhibitors of beta-adrenergic stimulation by catecholamines

79
Q

Desired Effects on Myocardial Oxygen Demand: Beta Blockers

A
  • reduce HR
  • reduce myocardial contractility
  • reduce arterial BP (afterload)
80
Q

BBs Undesired Effect on Myocardial Oxygen Demand

A

reduces HR –> increase diastolic filling time –> incfrease LVEDV –> increase preload

81
Q

Atenolol Brand Name

A

Tenormin

82
Q

Atenolol Dosing

A

50-100 mg QD

83
Q

Bisoprolol Brand Name

A

Zebeta

84
Q

Bisoprolol Dosing

A

5-10 mg QD

85
Q

Carvedilol Brand Name

A

Coreg

86
Q

Carvediol Dosing

A

25-50 mg BID

87
Q

Labetalol Brand Name

A

Normodyne/Trandate

88
Q

Labetalol Dosing

A

200-400 mg BID

89
Q

Metoprolol Brand Name

A

Lopressor

90
Q

Metoprolol Dosing

A

50-100 mg BID

91
Q

Metoprolol Succinate Brand Name

A

Toprol XL

92
Q

Metoprolol Succinate Dosing

A

100-200 mg QD

93
Q

Propranolol Brand Name

A

Inderal

94
Q

Propranolol Dosing

A

LA: 80-160 mg QD

95
Q

B1 Selective BBs

A

atenolol, metoprolol

96
Q

non selective BBs

A

propranolol, carvedilol

97
Q

ISA BBs

A

pindolol, acebutolol

98
Q

Lipid Soluble BBs

A

propranolol, carvedilol

99
Q

Water Soluble BBs

A

atenolol, bisoprolol

100
Q

Beta Blockers Adverse Effects

A
  • bradycardia
  • sinus arrest
  • AV block
  • reduced LVEF
  • bronchoconstriction
  • fatigue
  • depression
  • sexual dysfunction
  • exercise intolerance
  • mask symptoms of hypoglycemia
101
Q

Dosage of Beta Blockers

A

initiate at lowest dose and titrate to symptom reduction

102
Q

Monitoring Parameters: Beta Blockers

A

HR: 50-60 bpm
Exercise: < 100 bpm (75% of HR that typically causes angina

103
Q

Mechanism of Action: Calcium Channel Blocker

A

Cardiac: decrease influx of trigger calcium in myocytes , decreased chronotropy in nodal cells and inotropy in myocytes

Vascular: vasodilation

104
Q

Nifedipine CC Brand Name

A

Adalat CC or Procardia XL

105
Q

Nifedipine Dosing

A

30-60 mg QD

106
Q

Amlodipine Brand Name

A

Norvasc

107
Q

Amlodipine Dosing

A

5-10 mg QD

108
Q

Brand Name: Felodipine ER

A

Plendil

109
Q

Dosing Felodipine ER

A

5-10 mg qd

110
Q

Brand Name: Verapamil

A

Calan, Isoptin

111
Q

Dosing Verapamil

A

60-90 mg TID/QID
SR 240 mg

112
Q

Diltiazem Brand Name

A

Cardizem, Dilacor XR, Tiamate,Tiazac

113
Q

Diltiazem Dosing

A

80-120 mg TID
SR: 60-120 mg BID
CD/XR/ER: 180-360 mg

114
Q

Adverse Effects: DHPs

A
  • hypotension
  • flushing
  • headache
  • dizziness
  • peripheral edema
  • reflex tachycardia
115
Q

Adverse Effects : non DHPs

A
  • reduced contractility (V>D)
  • Bradycardia and AV Block (V>D)
  • hypotension
  • dizziness
  • flushing
  • headache
  • constipation (V>D)
116
Q

Dosing CCBs

A

initiate at lowest dose and titrate to symptom reduction

117
Q

Monitoring Parameters: DHPs

A
  • edema
  • BP
118
Q

Monitoring Parameters: NonDHPs

A
  • constipation
  • HR
119
Q

Nitrate Free Period

A

10-12 hours

120
Q

Mechanism of Nitrate Tolerance

A
  • takes hours to regenerate ALDH2 enzyme, continuous nitrate use does not allow ALDH2 to regenerate, creating decreased effectiveness/tolerance
121
Q

NTG patch dosing

A

once daily

on for 12-14 hours, off for 10-12 hours

122
Q

ISDN tabs dosing

A

2-3 times/day

10 mg TID (8,12, 4)

123
Q

ISMN tabs

A

2 times/day 7 hours apart

20 mg BID

124
Q

ISMN SR tabs

A

once daily

30 mg once daily

125
Q

Monitoring Continuous Nitrates

A

adverse effects
BP reduction
reflex tachycardia

126
Q

Ranolazine Mechanism of Action

A

inhibition of late inward NA+ current in ischemic myocytes

this decreases intracellular sodium, which decreases influx of calcium

127
Q

Dosing: Ranolazine

A

Ranexa 500 mg BID titrated to 1000 mg BID

128
Q

Drug Interactions: Ranolazine

A

Should not be used with strong 3A inhibitors (KTZ,ITZ, PIs)

Limit Dose (500 bid) with moderate inhbitors (Dilt, Ver, ERY, FLZ)

129
Q

Adverse Effects: Ranolazine

A
  • constipation
  • nausea
  • dizziness
  • headache
  • QT prolongation
130
Q

1st line Therapy: Prevention of Ischemic Events

A

Beta blockers should be selected as initial therapy in patients without contraindications, especially in stable HF and history of MI

131
Q

Contraindications of BB

A

bradycardia (<50 bpm)
AV block/sick sinus syndrome with no pacemaker

132
Q

Place in Therapy: CCBs

A

non DHP preferred if BBs contraindicated, in patients with chronic lung diseases, HTN, DM, and peripheral vascular disease (reynauds)

133
Q

Contraindications: NonDHPS

A
  • HFrEF
  • bradycardia
  • high degree of AV block or sick sinus syndrome (no pacemaker)
134
Q

Contraindications: DHPs

A

HFrEF, except amlodipine and felodipine

135
Q

Place in therapy: Nitrates

A
  • combination with BB/nonDHP to blunt reflex tacycardia
  • short acting PRN nitrates to relieve discomfort or prevent ischemia before exertion
136
Q

Pain and CV Disease

A

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

137
Q

ASA and NSAID

A

take ASA 2 hours prior to NSAID

phrm 845 (14 decks)

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