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
2
Q
Chronic Stable Angina
A
fixed stenosis, demand ischemia
3
Q
Unstable Angina
A
caused by a formation of a thrombus, supply ischemia
4
Q
Factors affecting O2 supply
A
vascular resistance, coronary blood flow, and O2 carrying capacity
5
Q
Factors affecting O2 Demand
A
heart rate, contractility, wall tension (LV volume and systolic pressure)
6
Q
Contractility’s effect on supply/demand ratio
A
decrease contractility will decrease O2 consumption
7
Q
Heart rate’s effect on supply/demand ratio
A
decreased HR will decrease O2 consumption
Decreased HR will increase coronary perfusion
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
9
Q
Afterload’s effect on supply/demand ratio
A
decreased by dilation of arteries
decrease leads to decrease in O2 consumption
10
Q
Diagnosis of significant coronary artery disease with angina pectoris
A
70-75% occlusion due to atherosclerotic plaque
11
Q
Myocardial Ischemia
A
imbalance between myocardial oxygen supply and demand, secondary to increased work (effort induced)
12
Q
Does myocardial ischemia cause necrosis?
A
NO. It causes disturbances in function without causing myocardial necrosis
13
Q
Angina
A
resulting symptoms from ischemia, also known as chest discomfort
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
15
Q
Clinical Presentation: P and P
A
Precipitating Factors: exertion
Palliative Measures: rest/and or SLNTG
16
Q
Clinical Presentation: Q
A
Quality and Quantity of the Pain: squeezing, heaviness, tightening
17
Q
Clinical Presentation: R
A
Region and Radiation: substernal
18
Q
Clinical Presentation: S
A
Severity of the Pain: subjective >5
19
Q
Clinical Presentation: T
A
Timing and temporal pattern: lasts <20 minutes, usually relieved in 5-10 minutes
20
Q
ECG Findings: Chronic Angina
A
ST segment depression during event
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
22
Q
Medications to Reduce Risk and Prevent ACS/Death
A
- Anti-platelet therapy
- Statin
- RAS Inhibitors
- Colchicine
23
Q
Does aspirin reversibly or irreversibly inactivate platelet COX-1?
A
irreversibly
24
Q
Aspirin’s anti-platelet activity
A
blocking TXA2s synthesis
25
High Dose Aspirin Risks
high dose aspirin can block COX2, blocking prostaglandin which increases platelet aggregation
26
Aspirin Loading Dose
162-325 mg
27
Aspirin Maintenance Dose
75-162 mg (81 mg preferred)
28
Clopidogrel (Plavix) Loading Dose
300-600 mg
29
Clopidogrel (Plavix) Maintenance Dose
75 mg daily
30
Prasugrel (Effient) Loading Dose
60 mg
31
Prasugrel (Effient) Maintenance Dose
10 mg daily
32
Ticagrelor (Brilinta) Loading Dose
180 mg
33
Ticagrelor (Brilinta) Maintenance Dose
90 mg BID
34
Mechanism of Action: P2Y12 Inhibitors
selectively inhibit adenosine diphosphate induced platelet aggregation with no direct effect on TXA2
35
Aspirin Adverse Effects
- GI Bleeding
- Intra/extracranial Bleeding
- hypersensitivity
36
Adverse Effects: Clopidogrel
bleeding, rash, diarrhea, 1% increase risk in bleeding with aspirin
37
Adverse Effects: Prasugrel
bleeding, rash, diarrhea, 0.6% increase in major bleeding risk, 0.5% increase risk of life-threatening bleeding
38
Adverse Effects: Ticagrelor
bleeding, bradycardia, heart block, dyspnea (SOB)
39
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
40
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
41
CABG Anti-platelet Therapy
DAPT: ASA 81 mg + Plavix 75 mg/day (12 months)
SAPT: ASA indefinitely
42
ASA and Ticagrelor
ASA dose must be ≤ 100 mg with ticagrelor
43
ACE/ARBs in CCD
reduce progression of the disease but do not treat/prevent angina symptoms
44
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
45
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
46
Increasing myocardial oxygen supply to prevent recurrent ischemia
dilate coronary arteries (reducing vasospasm), collateral blood flow, prolong diastole
47
Decrease myocardial oxygen demand to prevent ischemia
heart rate, mycoardial contractility, wall tension (SBP = afterload and LVEDV = preload)
48
Nitrates: HR
increase
49
Nitrates: Contractility
no effect
50
Nitrates: Systolic pressure (afterload)
decrease
51
Nitrates: LV Volume (preload)
significantly decrease
52
Beta Blockers: HR
significantly decrease
53
Beta Blockers: contractility
decrease
54
Beta Blockers: Systolic pressure (afterload)
decrease
55
Beta Blockers: LV Volume (preload)
increase
56
Nifedipine (DHP): HR
increase
57
Nifedipine (DHP): Contractility
no effect/decreases
58
Nifedipine (DHP): systolic pressure (afterload)
significantly decreases
59
Nifedipine (DHP): LV Volume (preload)
no effect/decreases
60
Verapamil: HR
significantly decreases
61
Verapamil: Contractility
decreases
62
Verapamil: Systolic Pressure (afterload)
decrease
63
Verapamil: LV volume (preload)
no effect/decreases
64
Diltiazem: HR
decreases
65
Diltiazem: contractility
no effect/decreases
66
Diltiazem: Systolic Pressure (afterload)
decreases
67
Diltiazem: LV volume (preload)
no effect/decreases
68
Ranolazine
no effect on HR, contractility, systolic pressure, LV volume
69
Mechanism of Action: Organic Nitrates
nitric oxide donors/releasers via activation of guanylate cyclase
70
Activity of Nitrates
- marked venodilation (decreased preload and LV volume)
- less arteriole dilation, coronary and peripheral
- inhibition of platelet aggregation (minor)
71
Do nitrates effect the natural history of CCD
NO
72
Nitroglycerin Tabs Dosing
0.3-0.6 mg PRN, repeat dose 1-3 times q5 min
73
Nitroglycerin Spray Dosing
0.4 mg/spray prn repeat dose 1-3 times q5min
74
Instructions for Nitroglycerin
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
Adverse Effects: Nitrates
- headache
- hypotension, dizziness, lightheadedness
- facial flushing
- reflex tachycardia
- extreme caution with PDEi
76
Time frame between PDEis and Nitrates
Avanafil: 12 hours
Sildenafil/Varendafil: 24 hours
Tadalafil: 48 hours
77
Clinical Recommendation for Nitrates
should be utilized in all patients to prevent angina and to relieve episodes
78
Mechanism of Action: Beta Blockers
competitive, reversible inhibitors of beta-adrenergic stimulation by catecholamines
79
Desired Effects on Myocardial Oxygen Demand: Beta Blockers
- reduce HR
- reduce myocardial contractility
- reduce arterial BP (afterload)
80
BBs Undesired Effect on Myocardial Oxygen Demand
reduces HR --> increase diastolic filling time --> incfrease LVEDV --> increase preload
81
Atenolol Brand Name
Tenormin
82
Atenolol Dosing
50-100 mg QD
83
Bisoprolol Brand Name
Zebeta
84
Bisoprolol Dosing
5-10 mg QD
85
Carvedilol Brand Name
Coreg
86
Carvediol Dosing
25-50 mg BID
87
Labetalol Brand Name
Normodyne/Trandate
88
Labetalol Dosing
200-400 mg BID
89
Metoprolol Brand Name
Lopressor
90
Metoprolol Dosing
50-100 mg BID
91
Metoprolol Succinate Brand Name
Toprol XL
92
Metoprolol Succinate Dosing
100-200 mg QD
93
Propranolol Brand Name
Inderal
94
Propranolol Dosing
LA: 80-160 mg QD
95
B1 Selective BBs
atenolol, metoprolol
96
non selective BBs
propranolol, carvedilol
97
ISA BBs
pindolol, acebutolol
98
Lipid Soluble BBs
propranolol, carvedilol
99
Water Soluble BBs
atenolol, bisoprolol
100
Beta Blockers Adverse Effects
- bradycardia
- sinus arrest
- AV block
- reduced LVEF
- bronchoconstriction
- fatigue
- depression
- sexual dysfunction
- exercise intolerance
- mask symptoms of hypoglycemia
101
Dosage of Beta Blockers
initiate at lowest dose and titrate to symptom reduction
102
Monitoring Parameters: Beta Blockers
HR: 50-60 bpm
Exercise: < 100 bpm (75% of HR that typically causes angina
103
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
104
Nifedipine CC Brand Name
Adalat CC or Procardia XL
105
Nifedipine Dosing
30-60 mg QD
106
Amlodipine Brand Name
Norvasc
107
Amlodipine Dosing
5-10 mg QD
108
Brand Name: Felodipine ER
Plendil
109
Dosing Felodipine ER
5-10 mg qd
110
Brand Name: Verapamil
Calan, Isoptin
111
Dosing Verapamil
60-90 mg TID/QID
SR 240 mg
112
Diltiazem Brand Name
Cardizem, Dilacor XR, Tiamate,Tiazac
113
Diltiazem Dosing
80-120 mg TID
SR: 60-120 mg BID
CD/XR/ER: 180-360 mg
114
Adverse Effects: DHPs
- hypotension
- flushing
- headache
- dizziness
- peripheral edema
- reflex tachycardia
115
Adverse Effects : non DHPs
- reduced contractility (V>D)
- Bradycardia and AV Block (V>D)
- hypotension
- dizziness
- flushing
- headache
- constipation (V>D)
116
Dosing CCBs
initiate at lowest dose and titrate to symptom reduction
117
Monitoring Parameters: DHPs
- edema
- BP
118
Monitoring Parameters: NonDHPs
- constipation
- HR
119
Nitrate Free Period
10-12 hours
120
Mechanism of Nitrate Tolerance
- takes hours to regenerate ALDH2 enzyme, continuous nitrate use does not allow ALDH2 to regenerate, creating decreased effectiveness/tolerance
121
NTG patch dosing
once daily
on for 12-14 hours, off for 10-12 hours
122
ISDN tabs dosing
2-3 times/day
10 mg TID (8,12, 4)
123
ISMN tabs
2 times/day 7 hours apart
20 mg BID
124
ISMN SR tabs
once daily
30 mg once daily
125
Monitoring Continuous Nitrates
adverse effects
BP reduction
reflex tachycardia
126
Ranolazine Mechanism of Action
inhibition of late inward NA+ current in ischemic myocytes
this decreases intracellular sodium, which decreases influx of calcium
127
Dosing: Ranolazine
Ranexa 500 mg BID titrated to 1000 mg BID
128
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)
129
Adverse Effects: Ranolazine
- constipation
- nausea
- dizziness
- headache
- QT prolongation
130
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
131
Contraindications of BB
bradycardia (<50 bpm)
AV block/sick sinus syndrome with no pacemaker
132
Place in Therapy: CCBs
non DHP preferred if BBs contraindicated, in patients with chronic lung diseases, HTN, DM, and peripheral vascular disease (reynauds)
133
Contraindications: NonDHPS
- HFrEF
- bradycardia
- high degree of AV block or sick sinus syndrome (no pacemaker)
134
Contraindications: DHPs
HFrEF, except amlodipine and felodipine
135
Place in therapy: Nitrates
- combination with BB/nonDHP to blunt reflex tacycardia
- short acting PRN nitrates to relieve discomfort or prevent ischemia before exertion
136
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
137
ASA and NSAID
take ASA 2 hours prior to NSAID
