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Therapeutics 3 - Spring 2018 > Exam 1 - Sowinski (Ischemia) > Flashcards

Exam 1 - Sowinski (Ischemia) Flashcards

1
Q

Typical Clinical Presentation for SIHD (stable angina) (acronym)

A 
PQRST
Precipitating factors
Pallative Measures
Quality of Pain
Region/Radiation
Severity of Pain
Timing/Temporal Pattern
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2
Q

what typically precipitates stable angina pectoris

A

exertion - walking gardening, ADOL

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3
Q

what typically relieves SIHD

A

rest and or SL NTG

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4
Q

what type of pain is it for SIHD

A

squeezing, heaviness, tightening

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5
Q

where is the pain for SIHD

A

substernal

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6
Q

ECG findings with typical Angina

A

ST-Segment DEPRESSION

ONLY DURING THE EVENT THO

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7
Q

Guidelines for Angina (acronym)

A 
ABCDE
A - aspirin/antiplatelets/antianginals/
B - beta blockers, blood pressure
C - Cholesterol and Cigarettes
D - Diet and Diabetes
E - Exercise and Education
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8
Q

If someone has vasospastic angina — what do you for managing their anginal episodes?

A

NO BETA BLOCKERS!!

If BP > 140/90 – give CCB
if BP < 140/90 — give Nitrate

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9
Q

what drugs are P2Y12 inhibitors

A

Ticlodipine, clopidogrel, prasugrel, ticagrelor, canegrelor

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10
Q

Aspirin at too high of doses is an issue because?

A

it will start blocking COX-2 and puts patient at actually a HIGHER thrombotic risk (we end up blocking some vasodilation)

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11
Q

which P2Y12 inhibitor needs CYP450 to activate it?

A

Clopidogrel

Prasugrel to a lesser extent

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12
Q

ADEs for Clopidogrel

A

Bleeding, Diarrhea, Rash

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13
Q

ADEs for Prasugrel

A

Bleeding, Diarrhea, Rash

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14
Q

ADEs for Ticagrelor

A

Bleeding, Bradycardia, DYSPNEA!, Heartblock

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15
Q

PRIMARY PREVENTION - Anti-Platelet Therapy:

who gets it?

A

if 50 - 59 with > 10% CVD risk
and…
if 60 - 69 with > 10% CVD risk
aka 50 - 59 w/ CVD risk >10%

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16
Q

what are the 3 categories of secondary prevention of anti-platelet therapy in CAD

A 
SIHD  w/ no stent
or
SIHD with elective PCI + stent
or
SIHD and CABG
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17
Q

Secondary Prevention w/ antiplatelets for SIHD with NO STENT: what do they do?

A

Aspirin 81 mg QD FOR LIFE
or
Clopidogrel 75 mg/day IF absolute contraindication/significant intolerance

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18
Q

2 types of stents

A

Drug eluting or Bare metal stent

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19
Q

What are the two common (aka 2ng gens used today) drug eluting stents (DES)

A

Everolimus and Zotarolimus

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20
Q

For SIHD pts getting an elective PCI: how do they utilize antiplatelets

A

They will do DAPT (dual antiplatelet therapy)
ASA 325 prior to PCI - then 81 mg QD for life
AND
Clopidogrel (300 - 600 mg before PCI) THEN 75 mg/day for either min. 6 mos (DrugElutingStent) or min. 1 month (BareMetalStent) – if major bleeding/high risk stop at 3 mos
*traditional to do clopidogrel for 12 mos

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21
Q

For SIHD pts: if Pt gets a CABG what do they do for secondary prevention with antiplatelts

A

they do ASA 81 mg/day for life and clopidogrel 75 mg/day ~ 12 mos
(IF they had a PCI/stent before - they RESTART the 12 mos timeline after the CABG)

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22
Q

why do DES need longer time on clopidogrel rather than the BMS

A

DES take longer to heal… (but in long run better than a BMS)

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23
Q

if pt on DAPT (because of Stent/CABG) what do you do if they need non-cardiac surgery?

A

cant really stop DAPT…. defer the surgery as long as possible (6 mos to a year!!) only done if it is a life threatening surgery

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24
Q

if pt on DAPT (because of Stent/CABG) why do a PPI

A

if high risk - use a PPI

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25
Q

if pt on DAPT (because of Stent/CABG) what do you do if pt requires anticoagulation?

A

use clopidogrel because it is less risky for pts that may have A.Fib, DVT, or PE prevention needs

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26
Q

if pt on DAPT (because of Stent/CABG) when would you use Ticagrelor/Prasugrel?

A

if pt cant do clopidogrel for some reason

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27
Q

if pt on DAPT (because of Stent/CABG) - what is risk scoring used for?

A

risk scoring helps you see how long they should be on DAPT -
if overall score is > 2 - then ok/benfit vs risk is ok for prolonged therapy
if overall score is < 2 —- unfavorable benefit vs risk for prolonger therapy

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28
Q 
ACEI are good for preventing ACS and death because....
they stabilize \_\_\_\_\_\_\_\_
improve \_\_\_\_\_\_ function
inhibit \_\_\_\_\_\_\_ cell growth
decrease \_\_\_\_\_\_\_\_ migration
and possible \_\_\_\_\_\_ properties
A 
stabilize PLAQUE
improve ET function
inhibit VSM cell growth
decrease MACROPHAGE migration
Anti-Ox properties
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29
Q

T or F: ACEI will improve symptomatic ischemia

A

FALSE! only for risk factor managing

30
Q

T or F: ACEI should be used in all pts with IHD/CAD

A

TRUE (especially in HTN, DM, CKD, and LVEF < 40% patients!!)

31
Q

what ACEI is best for preventing ACS and death

A

any of them!!!

32
Q

Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:

which one will actually INCREASE LV Volume

A

beta blockers

33
Q 
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:
which one(s) will actually increase HR
A

nitrates; DHPs

34
Q 
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:
which one(s) will decrease HR really well
A

B-blockers and verapamil (diltiazem is decent-ish)

35
Q

Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:

which one decreases systolic pressure the most?

A

DHPs

36
Q

Storage facts for Nitroglycerin tabs

A

cannot keep them in weekly pill remainder crap; keep in original container
has to be in easy open container

37
Q

Nitro tabs: directions

A

take one tab - wait 5 mins - still angina? call 911 and take another; another 5 mins and STILL angina take another one

MAX 3 tabs/day

38
Q

counseling points for nitro tabs

A 
SIT TF DOWN when taking it; vasodilation/may faint
headache from it 
can increase HR (reflex tachycardia)
keep on ya person all the time
keep in dry location (not da bathroom)
39
Q

what should patients take for their headache post nitroglycerin tabs

A

APAP

40
Q

if pt has pretty large spike in HR after nitro tabs - what do ya do

A

lower da dose

41
Q

PDE Inhibitors and Nitrates?

A

Hypotension from hell can happen
aka
do NOT take nitrate if had ingested a PDEI in past 24/48 hours

42
Q

3 drugs used to PREVENT recurrent ischemia/angina symptoms

A

beta-blockers; CCBs; Nitrates

43
Q

Beta-Blockers:

Reduce (venous or arterial BP) and thus decrease _____load

A

ARTERIAL; AFTER LOAD

44
Q

which beta blocker(s) are more lipid soluble

A

propranolol; metoprolol (aka liver excreted)

45
Q

which beta blocker(s) are more water soluble

A

Atenolol (aka renally cleared)

46
Q

what are the 2 common cardioselective beta blockers

A

atenolol and metoprolol

47
Q

atenolol and metoprolol are cardioselective — but after about what dose do they become less cardioselective

A

atenolol - 50 mg

metoprolol - 100 mg

48
Q

For Clopidogrel:
Discontinue it ___ days prior to elective CABG
or discontinue it ______ prior to urgent CABG

A

5 days

24 hours

49
Q

Which P2Y12 Inhibitor has extreme caution in patients that are 75 years or older

A

Prasugrel

50
Q

Which P2Y12 inhibitor has extreme caution for patients that are under 60 kg

A

Prasugrel

51
Q

Which P2Y12 inhibitor should not be used in patients w/ Hx of TIA/Stroke

A

Prasugrel

52
Q

For Prasugrel:

D/C it _____ days prior to CABG

A

7 days

53
Q

Prasugrel Regiman for Primary PCI (Loading and Maintenance)

A 
Loading: 60 mg (one dose before PCI)
Maint: 10 mg (if > 60 kg)
5 mg (if < 60 kg)
54
Q

Which P2Y12 inhibitor shouldn’t be used with an ASA above 100 mg

A

Ticagrelor

55
Q

What are the Contraindications for ALL 3 P2Y12 Inhibitors

A

Hx of Hemorrhagic stroke
Pts receiving oral anticoags
Pts w/ mod-severe liver disease

56
Q

For Ticagrelor:

D/C ____ days prior to CABG

A

5 days

57
Q

Ticagrelor Regiman for Primary PCI (Loading and Maintenance)

A

180 mg once before PCI, then 90 mg BID

58
Q

Clopidogrel Regiman for Primary PCI (Loading and Maintenance)

A

600 mg before PCI, then 75 mg/day

59
Q

which P2Y12 inhibitor do we avoid for STEMI treatments - and WHY

A

Clopidogrel; CYP2C19 genetic variations b/w patients can make toxicities harder to predict

60
Q

when are GP IIb/IIIa inhibitors used for STEMI

A

ONLY for STEMI when primary PCI is performed and given when P2Y12 inhibitors are not given

61
Q

what are the contraindications for GPIIb/IIIa inhibitors

A
  • THROMBOCYTOPENIA!
  • Hx of hemorraghic stroke
  • Active internal bleeding, major surgery/ stroke < 30 days
  • Intracranial Neoplasm, AV malformation
  • Acute Pericarditis
  • uncontrolled HTN (SBP > 180 and/or DBP > 110)
62
Q

what anticoags can be used in STEMI PCI Tx

A
  • bivalirudin
  • Heparin
  • Enoxaparin
63
Q

two main ways to treat a STEMI

A

PCI OR Fibrinolytics

64
Q

what fibrinolytics can be used for STEMI Tx

A

t-PA; Reteplase; Tenecteplase; SK

65
Q

what DAPT therapy is used for STEMI Tx POST Fibrinolytic administration

A

ASA + Clopidogrel

Ticagrelor and Prasugrel NOT studied yet

66
Q

Absolute Contraindications for Fibrinolytics

A
  • Any prior intracranial hemorrhage
  • Malignany Neoplasm/Cerebral Vascular Legion
  • Ischemic stroke w/in 3 minths
  • Significant closed head or facial trauma w/in 3 months
  • Severe HTN
  • Suspected aortic dissection

(For SK ONLY: prior exposure w/in past 6 mos, or prior allergic rxn)

67
Q

How to Choose b/w fibrinolytics for treating STEMI

A

no superior agent been defined - ALL WILL REDUCE MORTALITY!
- Reteplase dosing is NON-wt based
- Tenecteplase is single bolus
(is controversial in pts > 75 yo)

68
Q

how long to be on clopidogrel post fibrinolytic administration for STEMI

A

14 days to 1 year…..

use 4ever if pt has ASA allergy

69
Q

What drugs can be used for anti-coag therapy for fibrinolytic tx for STEMI

A

heparin, LMWH, fondaparinux

70
Q

how long should pts be on anti-coag therapy for fibrinolytic tx for STEMI

A

48 hrs up to 8 days or end of hospitalization

71
Q

Post- STEMI Discharge Meds: Beta Blockers:

recommended to start in first ______ hours unless CI

A

24

72
Q

Post- STEMI Discharge Meds: Beta Blockers:

Use for _____ years especially when (_______)

A

3 years; when EF > 40%

Therapeutics 3 - Spring 2018 (20 decks)

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