Exam 1 - Sowinski (Ischemia) Flashcards
Typical Clinical Presentation for SIHD (stable angina) (acronym)
PQRST Precipitating factors Pallative Measures Quality of Pain Region/Radiation Severity of Pain Timing/Temporal Pattern
what typically precipitates stable angina pectoris
exertion - walking gardening, ADOL
what typically relieves SIHD
rest and or SL NTG
what type of pain is it for SIHD
squeezing, heaviness, tightening
where is the pain for SIHD
substernal
ECG findings with typical Angina
ST-Segment DEPRESSION
ONLY DURING THE EVENT THO
Guidelines for Angina (acronym)
ABCDE A - aspirin/antiplatelets/antianginals/ B - beta blockers, blood pressure C - Cholesterol and Cigarettes D - Diet and Diabetes E - Exercise and Education
If someone has vasospastic angina — what do you for managing their anginal episodes?
NO BETA BLOCKERS!!
If BP > 140/90 – give CCB
if BP < 140/90 — give Nitrate
what drugs are P2Y12 inhibitors
Ticlodipine, clopidogrel, prasugrel, ticagrelor, canegrelor
Aspirin at too high of doses is an issue because?
it will start blocking COX-2 and puts patient at actually a HIGHER thrombotic risk (we end up blocking some vasodilation)
which P2Y12 inhibitor needs CYP450 to activate it?
Clopidogrel
Prasugrel to a lesser extent
ADEs for Clopidogrel
Bleeding, Diarrhea, Rash
ADEs for Prasugrel
Bleeding, Diarrhea, Rash
ADEs for Ticagrelor
Bleeding, Bradycardia, DYSPNEA!, Heartblock
PRIMARY PREVENTION - Anti-Platelet Therapy:
who gets it?
if 50 - 59 with > 10% CVD risk
and…
if 60 - 69 with > 10% CVD risk
aka 50 - 59 w/ CVD risk >10%
what are the 3 categories of secondary prevention of anti-platelet therapy in CAD
SIHD w/ no stent or SIHD with elective PCI + stent or SIHD and CABG
Secondary Prevention w/ antiplatelets for SIHD with NO STENT: what do they do?
Aspirin 81 mg QD FOR LIFE
or
Clopidogrel 75 mg/day IF absolute contraindication/significant intolerance
2 types of stents
Drug eluting or Bare metal stent
What are the two common (aka 2ng gens used today) drug eluting stents (DES)
Everolimus and Zotarolimus
For SIHD pts getting an elective PCI: how do they utilize antiplatelets
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
For SIHD pts: if Pt gets a CABG what do they do for secondary prevention with antiplatelts
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)
why do DES need longer time on clopidogrel rather than the BMS
DES take longer to heal… (but in long run better than a BMS)
if pt on DAPT (because of Stent/CABG) what do you do if they need non-cardiac surgery?
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
if pt on DAPT (because of Stent/CABG) why do a PPI
if high risk - use a PPI
if pt on DAPT (because of Stent/CABG) what do you do if pt requires anticoagulation?
use clopidogrel because it is less risky for pts that may have A.Fib, DVT, or PE prevention needs
if pt on DAPT (because of Stent/CABG) when would you use Ticagrelor/Prasugrel?
if pt cant do clopidogrel for some reason
if pt on DAPT (because of Stent/CABG) - what is risk scoring used for?
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
ACEI are good for preventing ACS and death because.... they stabilize \_\_\_\_\_\_\_\_ improve \_\_\_\_\_\_ function inhibit \_\_\_\_\_\_\_ cell growth decrease \_\_\_\_\_\_\_\_ migration and possible \_\_\_\_\_\_ properties
stabilize PLAQUE improve ET function inhibit VSM cell growth decrease MACROPHAGE migration Anti-Ox properties
T or F: ACEI will improve symptomatic ischemia
FALSE! only for risk factor managing
T or F: ACEI should be used in all pts with IHD/CAD
TRUE (especially in HTN, DM, CKD, and LVEF < 40% patients!!)
what ACEI is best for preventing ACS and death
any of them!!!
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:
which one will actually INCREASE LV Volume
beta blockers
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem: which one(s) will actually increase HR
nitrates; DHPs
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem: which one(s) will decrease HR really well
B-blockers and verapamil (diltiazem is decent-ish)
Nitrates, B-blockers, DHPs, Verapamil, or Diltiazem:
which one decreases systolic pressure the most?
DHPs
Storage facts for Nitroglycerin tabs
cannot keep them in weekly pill remainder crap; keep in original container
has to be in easy open container
Nitro tabs: directions
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
counseling points for nitro tabs
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)
what should patients take for their headache post nitroglycerin tabs
APAP
if pt has pretty large spike in HR after nitro tabs - what do ya do
lower da dose
PDE Inhibitors and Nitrates?
Hypotension from hell can happen
aka
do NOT take nitrate if had ingested a PDEI in past 24/48 hours
3 drugs used to PREVENT recurrent ischemia/angina symptoms
beta-blockers; CCBs; Nitrates
Beta-Blockers:
Reduce (venous or arterial BP) and thus decrease _____load
ARTERIAL; AFTER LOAD
which beta blocker(s) are more lipid soluble
propranolol; metoprolol (aka liver excreted)
which beta blocker(s) are more water soluble
Atenolol (aka renally cleared)
what are the 2 common cardioselective beta blockers
atenolol and metoprolol
atenolol and metoprolol are cardioselective — but after about what dose do they become less cardioselective
atenolol - 50 mg
metoprolol - 100 mg
For Clopidogrel:
Discontinue it ___ days prior to elective CABG
or discontinue it ______ prior to urgent CABG
5 days
24 hours
Which P2Y12 Inhibitor has extreme caution in patients that are 75 years or older
Prasugrel
Which P2Y12 inhibitor has extreme caution for patients that are under 60 kg
Prasugrel
Which P2Y12 inhibitor should not be used in patients w/ Hx of TIA/Stroke
Prasugrel
For Prasugrel:
D/C it _____ days prior to CABG
7 days
Prasugrel Regiman for Primary PCI (Loading and Maintenance)
Loading: 60 mg (one dose before PCI) Maint: 10 mg (if > 60 kg) 5 mg (if < 60 kg)
Which P2Y12 inhibitor shouldn’t be used with an ASA above 100 mg
Ticagrelor
What are the Contraindications for ALL 3 P2Y12 Inhibitors
Hx of Hemorrhagic stroke
Pts receiving oral anticoags
Pts w/ mod-severe liver disease
For Ticagrelor:
D/C ____ days prior to CABG
5 days
Ticagrelor Regiman for Primary PCI (Loading and Maintenance)
180 mg once before PCI, then 90 mg BID
Clopidogrel Regiman for Primary PCI (Loading and Maintenance)
600 mg before PCI, then 75 mg/day
which P2Y12 inhibitor do we avoid for STEMI treatments - and WHY
Clopidogrel; CYP2C19 genetic variations b/w patients can make toxicities harder to predict
when are GP IIb/IIIa inhibitors used for STEMI
ONLY for STEMI when primary PCI is performed and given when P2Y12 inhibitors are not given
what are the contraindications for GPIIb/IIIa inhibitors
- 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)
what anticoags can be used in STEMI PCI Tx
- bivalirudin
- Heparin
- Enoxaparin
two main ways to treat a STEMI
PCI OR Fibrinolytics
what fibrinolytics can be used for STEMI Tx
t-PA; Reteplase; Tenecteplase; SK
what DAPT therapy is used for STEMI Tx POST Fibrinolytic administration
ASA + Clopidogrel
Ticagrelor and Prasugrel NOT studied yet
Absolute Contraindications for Fibrinolytics
- 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)
How to Choose b/w fibrinolytics for treating STEMI
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)
how long to be on clopidogrel post fibrinolytic administration for STEMI
14 days to 1 year…..
use 4ever if pt has ASA allergy
What drugs can be used for anti-coag therapy for fibrinolytic tx for STEMI
heparin, LMWH, fondaparinux
how long should pts be on anti-coag therapy for fibrinolytic tx for STEMI
48 hrs up to 8 days or end of hospitalization
Post- STEMI Discharge Meds: Beta Blockers:
recommended to start in first ______ hours unless CI
24
Post- STEMI Discharge Meds: Beta Blockers:
Use for _____ years especially when (_______)
3 years; when EF > 40%
