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PHM 604 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

ischemia

A

deficient supply of blood to body part that is due to obstruction of inflow of arterial blood

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2
Q

chronic stable angina

A

pattern of predictable transient chest discomfort during exertion/emotional stress

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3
Q

unstable angina

A

sudden increase in tempo and duration of ischemic episodes

ischemic symptoms at rest

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4
Q

determinants of myocardial oxygen supply

A

oxygen content - hemoglobin concentration, o2 saturation
coronary blood flow - Q = P/R
coronary perfusion during diastole
coronary vascular resistance greatest during systole

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5
Q

determinants of myocardial oxygen demand

A

heart rate
contractility
ventricular wall stress

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6
Q

clinical presentation of stable ischemic heart disease

A

Precipitating factor - exertion
Palliative measure - rest/NTG
Quality of pain - squeezing, aching, crushing, burning, heavy, tightness
Region - substernal, above diaphragm
Severity - subjective but mostly over 5 out of 10
Temporal pattern- lasts less than 20 min and relieved in 5 - 10 min

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7
Q

typical anginal characteristics

A

substernal chest discomfort
provoked by exertion/emotional stress
relief by rest/NTG

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8
Q

atypical anginal characteristics

A

SOB, anxiety, weakness, heartburn, indigestion

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9
Q

people prone to atypical angina characteristics

A

women, older adults, DM patients

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10
Q

modifiable risk factors for angina

A 
tobacco usage
hyperlipidemia
hypertension
obesity
physical activity
stress
diabetes
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11
Q

Diagnostic Testing

A

12 lead ECG - 1st line
exercise stress testing
pharmacologic stress imaging
cardiac catheterization- coronary angiography- contrast dye injected into catheter in femoral/radial arteries

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12
Q

Biomarkers

A

BNP - cardiac hormone synth in LV in response to increase ventricular volume/pressure.
NT-proBNP
Cardiac troponin - release when there is myocyte death

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13
Q

Medical Management of Angina Symptoms

A

SL nitroglycerin/spray - immediate relief of angina
BB- initial tx
CCB/Nitrates - when BB contraindicated or unacceptable AE
CCB/Nitrate combo w/BB when tx w/BB unsuccessful
Ranolazine

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14
Q

Cardio-selective BB

A

Bisoprolol (Ziac)
Atenolol (Tenormin)
Metoprolol (Lopressor/Toprol XL)

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15
Q

cardio selective and vasodilatory

A

Nebivolol (Bystolic)

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16
Q

Non selective BB

A

Propranolol (Inderal)

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17
Q

Mixed Alpha and Beta Blocker

A

Carvedilol (Coreg)

Labetolol (Trandate)

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18
Q

atenolol

A 
tenormin
50 - 200mg
QD
not as effective for HTN and SIDH
adjust for renal
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19
Q

bisoprolol

A

ziac
5 - 20 mg
QD

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20
Q

metoprolol tartrate

A

lopressor
50 -100mg
BID

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21
Q

metoprolol succinate

A

toprol xl
50 - 200mg
QD

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22
Q

propranolol

A

inderal
80 - 120mg
QD
lipophilic can cross BBB

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23
Q

nebivolol

A

bystolic
5 - 40mg
QD

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24
Q

carvedilol

A

coreg
25 - 50mg
BID
take with food

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25
Q

labetalol

A

normodyne
200 - 600mg
BID

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26
Q

BB may mask ___________

A

insulin induced hypoglycemia

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27
Q

BB contraindications

A

severe bradycardia
2nd/3rd degree AV block
Sick Sinus Syndrome w/o permanent pacemaker
severe liver impairment

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28
Q

DDI with BB

A

decrease effectiveness of sulfonylureas

non-DHPs may increase effect and toxicity of BB

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29
Q

Monitoring w/BB

A

2 - 4 weeks after start/change in dose
heart rate
blood pressure

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30
Q

Target HR from BB

A

55 - 60 bpm

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31
Q

avoid _______ of BB- it can worsen angina MI

A

abrupt discontinuation

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32
Q

HTN and SIDH

A

Avoid BB w/ISA

Atenolol - not used since it is less effective than placebo

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33
Q

CCB - 2 types

A

DHP- felodipine, amlodipine, nifedipine

Non-DHP- verapamil, diltiazem

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34
Q

CCB DDIs

A

CYP3A4- cyclosporine, carbamazepine, lithium, amiodarine, digoxin

avoid non-DHP w/ BB (AE on AV nodal conduction, HR, cardiac contractility)

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35
Q

DHP AE

A

peripheral edema, dizziness, HA, gingival hyperplasia

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36
Q

non DHP AE

A

worsening of systolic dysfunction, conduction defects, peripheral edema, HA, nausea

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37
Q

Non- DHP contraindications

A

hypotension SBP < 90 mmHg

severe LV defects

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38
Q

when are CCBs used?

A

if BB use is unacceptable
if treating vasospastic angina
in combo w/BB

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39
Q

amlodipine

A

norvasc
5 - 10mg
QD

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40
Q

diltiazem

A

dilt-XR
120 - 320mg
IR form - QID
ER form - QD

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41
Q

verapamil

A

calan
80 - 160mg
TID

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42
Q

nitrates

A

NTG (IV, SL, Ointment, Patch)

isosorbide dinitrate/mononitrate

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43
Q

nitrate AEs

A

headache, lightheadedness, flushing, syncope, dizziness

44
Q

nitrate contraindication

A

concurrent use w/PDE-5 inhibitors

45
Q

nitrate DDIs

A

no PDEIs w/in 24 h of long acting nitrates

no nitrates for 24 h after use of sildenafil or 48 h after tadalafil

46
Q

NTG tablets should be refilled every _____

NTG spray should be refilled every _____

A

6 mo

3 years

47
Q

dose nitrate BID formulations ____ hours apart

A

7

48
Q

why is it better for nitrate to be add on tx w/BB Or CCB

A

avoid lack of coverage during nitrate free period

49
Q

Ranolazine

A

Ranexa
500 mg BID
max 1000mg BID
late Na channel blocker

50
Q

ranolazine contraindication

A

liver cirrhosis

concurrent use of strong CYP3A4 inhibitor/inducers

51
Q

monitor ______ for ranolazine

A

renal fxn in pt CrCl < 60 ml/min

52
Q

ranolazine causes dose related _______ which can lead to ____________

A

QT prolongation

Vtach

53
Q

if taking simvastatin with ranolazine lower statin to ____

A

20 mg/day

54
Q

use ranolazine in patients

A

who achieved HR/BP goals and still have exertional angina sx
reached max dose of agents and still have angina sx
can’t achieve hemodynamic goals due to AEs

55
Q

if taking w/non DHP- should only be ____

A

low dose

56
Q

Relief of angina symptoms Rx treatment steps

A

1st line BB
CCB/longacting nitrates - when BB contraindicated/intolerant
BB + CCB - when 1st line BB unsuccessful
SL/Spray NTG recommended

57
Q

aspirin 75 - `162 mg/daily recommended for _____

A

indefinitely in absence of contraindication

alternative: clopidogrel when aspirin contraindicated

58
Q

revascularization options

A

CABG : coronary artery bypass grafting

PCI: percutaneous coronary intervention w or w/o stents

59
Q

type 1 MI

A

plaque rupture, fissure, erosion of unstable atherosclerosis

60
Q

non-STE ACS

A

ST wave depression, T wave inversion, nonspec ECG change and negative biomarkers

61
Q

non-STE MI

A

ST wave depression, T wave inversion, nonspec ECG change and positive biomarkers

62
Q

STE MI

A

ST elevation

positive biomarkers

63
Q

steps to deal w/ACS

A

chest pain?
12 lead ECG w/in 10 min of arrival
serial ECG in 15 - 30 min intervals during 1st h patient remains symptomatic
cardiac biomarkers: serial cardiac troponin at presentation and 3 - 6 h after sx

64
Q

Anti-ischemic therapies

A 
Morphine 
Oxygen
Nitroglycerin
Aspirin
Beta blocker
65
Q

morphine dosage for anti-ischemic tx

A

1 - 5 mg IV every 5 - 30 min if sx aren’t relieved despite max tolerated anti-ischemic meds

66
Q

oxygen supplementation for anti-ischemic tx if Sa O2 ____

A

< 90%

or respiratory distress

67
Q

Nitroglycerin for anti-ischemic tx
SL
IV

A

sl/spray - 0.3 - 0.4mg q 5 min up to 3 doses in 15 min

IV - in 1st 48 hours for persistent chest pain, HTN, heartfailure

68
Q

Aspirin- anti ischemic tx

A

chew/swallow non enteric coated 162 - 325 mg tab

69
Q

beta blocker - anti ischemic tx

A

initiate w/in 24 hours if no contraindications

avoid BB w/ ISA property

70
Q

All ACS patients should be on ________ and ________ therapy

A

anticoagulation

antiplatelet

71
Q

preferred strategy for STEMI

A

PCI

* should be done w/in 90 min of 1st medical contact

72
Q

fibrinolytics

A

preferred only if > 120 min delay from 1st medical contact to primary PCI
should be done in less than 30 min from contact

alteplase, reteplase, tenecteplase

73
Q

anti thrombotic therapy for STEMI and Primary PCI

A

DAPT (aspirin w/ Clopidogrel/Ticagrelor/Prasugrel)

Anticoagulant therapy w/ either UFH or IV bivalirudin (stop UFH 30 min before admin bivalirudin)

74
Q

Clopidogrel

A

Plavix
LD: 300mg (6 h full effect) 600 mg (2 h full effect)
Maintenance: 75 mg QD

75
Q

prasugrel

A

Effient
LD: 60 mg
Maintenance: 10mg QD

76
Q

ticagrelor

A

Brilinta
LD: 180mg
Maintenance: 90mg BID

77
Q

aspirin

A

162- 325mg

initial dose non-enteric

78
Q

NSAIDS other than aspirin and COX-2 selective inhibitors are _____ in STEMI

A

contraindicated

79
Q

anticoagulant management

A

UFH for all
Bivalirudin for PCI (d/c at end)
fondaparinux - not sole agent for PCI
enoxaparin - adj fibrinolytic

80
Q

beta blockers for _______ or _____ if needed for HTN or _____

A

3 years
indefinitely
heartfailure

81
Q

late/post hospital care

A 
beta block
aspirin indefinitely
nitroglycerin prn
antiplatelet w/P2y12 inhibitor
no NSAIDs
acei/arb indefinitely if ef <40%, HTN, CKD,DM
aldosterone antag indefinitely if  ef <40% 
statins ASAP
82
Q

a patient presents with ACS and undergoes _____ and is treated with _______ and _____ and goes home with ____ for _______

A

medical management
anticoagulant and antiplatelet
DAPT
12 mo

83
Q

early invasive recommended for

A

pt w/elevated risk for death/MI
refractory angina
sx of cardiogenic shock/arrhythmias

left heart catheterization, coronary angiography, PCI, CABG

84
Q

medical management aka _______

A

ischemia guided strategy

antiplatelet + anticoagulant

then continue P2y12 inhibitor w/aspirin - 12 mo

85
Q

UFH

A

dosing weight based

no renal adjustment - ok for patients w/renal impairment

86
Q

enoxaparin

A

dosing: 1mg/kg SC q12h

if CrCl < 30 ml/min - 1mg/kg SC q24h

87
Q

bivalirudin

A

if Cr/Cl < 30 ml/min need dose adjustment

monitor SCR-

88
Q

fondaparinux

A

not to be used as sole agent for PCI - risk of catheter thrombosis
contraindicated for CrCl < 30 ml/min

89
Q

antiplatelet management

A

Aspirin - all
Clopidogrel - all (but not preferred in those at high risk of bleeding for NSTEACS early invasive)
Prasugrel - PCI and NSTEACS early invasive
Ticragrelor - PCI and NSTEACS ischemia guided and early invasive

90
Q

GP 2b/3a antagonists

A

abciximab
tirofiban
eptifibatide

91
Q

abciximab

A

no dose adj for renal impairment

not for ACS w/o PCI

92
Q

tirofiban

A

reduce infusion by 50% for pt CrCl < 60

93
Q

Eptifibatide

A

reduce by 50% for pt CrCl < 50

avoid in pt on hemodialysis

94
Q

clopidogrel: d/c at least ____ before CABG surgery if bleeding risk > benefit

A

5 days

95
Q

prasugrel: d/c at least _____ before CABG surger if bleeding risk > benefit

A

7 days

96
Q

cangrelor

A

PCI adjunct in pt not treating with PO p2y12 or GP inhibitors

97
Q

Cangrelor + P2Y12 inhibitors

A

ticagrelor- anytime during infusion or immediately after

clopidogrel/prasugrel immediately after d/c cangrelor NOT during

98
Q

CABG management

A
  1. nonenteric coated aspirin
    if elective - d/c clopidogrel/ticagrelor at least 5 days before
    prasugrel d/c at least 7 days before
    if urgent - clopidogrel/ticagrelor at least 24 hours
    eptifibatide/tirofiban d/c 2 - 4 h before
    abciximab at least 12 h
99
Q

duration of DAPT

A

all at least 12 mo

except for fibrinolytic STEMI- at least 14 days but up to 12 mo

100
Q

triple therapy =

A

DAPT + anticoagulant
more for pt w/a fib
but increases risk of bleeding

101
Q

vorpaxar

A

par-1 antagonist
2.08mg in combo w/aspirin or clopidogrel
not to be used w/ severe liver impairment
strong CYP3A4 DDI

102
Q

acute limb ischemia

A

acute < 2 weeks

103
Q

critical limb ischemia

A

chronic 2+ weeks, ischemic rest pain, nonhealing wound/ulcers, gangrene

104
Q

PAD nonpharm therapy

A

smoking cessation
exercise
percutaneous transluminal angioplasty
aortofemoral bypass or femoral popliteal bypass

105
Q

PAD pharm therapy

A

A1c goal < 7%
aspirin or clopidogrel (no DAPT)
anticoagulation - not recommended per guidelines

106
Q

intermittent claudication

A 
cilostazol
PDE3 inhibitor - relax VSM
100mg BID
AE: HA, peripheral edema
contraindicated: heart failure
DDI: antiplatelet agents, CYP3A4

take drug at least 30 min before or 2 h after meal

(pentoxifylline - no benefit)

PHM 604 (1 decks)

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