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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
labetalol
normodyne 200 - 600mg BID
26
BB may mask ___________
insulin induced hypoglycemia
27
BB contraindications
severe bradycardia 2nd/3rd degree AV block Sick Sinus Syndrome w/o permanent pacemaker severe liver impairment
28
DDI with BB
decrease effectiveness of sulfonylureas | non-DHPs may increase effect and toxicity of BB
29
Monitoring w/BB
2 - 4 weeks after start/change in dose heart rate blood pressure
30
Target HR from BB
55 - 60 bpm
31
avoid _______ of BB- it can worsen angina MI
abrupt discontinuation
32
HTN and SIDH
Avoid BB w/ISA | Atenolol - not used since it is less effective than placebo
33
CCB - 2 types
DHP- felodipine, amlodipine, nifedipine | Non-DHP- verapamil, diltiazem
34
CCB DDIs
CYP3A4- cyclosporine, carbamazepine, lithium, amiodarine, digoxin avoid non-DHP w/ BB (AE on AV nodal conduction, HR, cardiac contractility)
35
DHP AE
peripheral edema, dizziness, HA, gingival hyperplasia
36
non DHP AE
worsening of systolic dysfunction, conduction defects, peripheral edema, HA, nausea
37
Non- DHP contraindications
hypotension SBP < 90 mmHg | severe LV defects
38
when are CCBs used?
if BB use is unacceptable if treating vasospastic angina in combo w/BB
39
amlodipine
norvasc 5 - 10mg QD
40
diltiazem
dilt-XR 120 - 320mg IR form - QID ER form - QD
41
verapamil
calan 80 - 160mg TID
42
nitrates
NTG (IV, SL, Ointment, Patch) | isosorbide dinitrate/mononitrate
43
nitrate AEs
headache, lightheadedness, flushing, syncope, dizziness
44
nitrate contraindication
concurrent use w/PDE-5 inhibitors
45
nitrate DDIs
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
NTG tablets should be refilled every _____ | NTG spray should be refilled every _____
6 mo | 3 years
47
dose nitrate BID formulations ____ hours apart
7
48
why is it better for nitrate to be add on tx w/BB Or CCB
avoid lack of coverage during nitrate free period
49
Ranolazine
Ranexa 500 mg BID max 1000mg BID late Na channel blocker
50
ranolazine contraindication
liver cirrhosis | concurrent use of strong CYP3A4 inhibitor/inducers
51
monitor ______ for ranolazine
renal fxn in pt CrCl < 60 ml/min
52
ranolazine causes dose related _______ which can lead to ____________
QT prolongation | Vtach
53
if taking simvastatin with ranolazine lower statin to ____
20 mg/day
54
use ranolazine in patients
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
if taking w/non DHP- should only be ____
low dose
56
Relief of angina symptoms Rx treatment steps
1st line BB CCB/longacting nitrates - when BB contraindicated/intolerant BB + CCB - when 1st line BB unsuccessful SL/Spray NTG recommended
57
aspirin 75 - `162 mg/daily recommended for _____
indefinitely in absence of contraindication alternative: clopidogrel when aspirin contraindicated
58
revascularization options
CABG : coronary artery bypass grafting | PCI: percutaneous coronary intervention w or w/o stents
59
type 1 MI
plaque rupture, fissure, erosion of unstable atherosclerosis
60
non-STE ACS
ST wave depression, T wave inversion, nonspec ECG change and negative biomarkers
61
non-STE MI
ST wave depression, T wave inversion, nonspec ECG change and positive biomarkers
62
STE MI
ST elevation | positive biomarkers
63
steps to deal w/ACS
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
Anti-ischemic therapies
``` Morphine Oxygen Nitroglycerin Aspirin Beta blocker ```
65
morphine dosage for anti-ischemic tx
1 - 5 mg IV every 5 - 30 min if sx aren't relieved despite max tolerated anti-ischemic meds
66
oxygen supplementation for anti-ischemic tx if Sa O2 ____
< 90% | or respiratory distress
67
Nitroglycerin for anti-ischemic tx SL IV
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
Aspirin- anti ischemic tx
chew/swallow non enteric coated 162 - 325 mg tab
69
beta blocker - anti ischemic tx
initiate w/in 24 hours if no contraindications avoid BB w/ ISA property
70
All ACS patients should be on ________ and ________ therapy
anticoagulation | antiplatelet
71
preferred strategy for STEMI
PCI | * should be done w/in 90 min of 1st medical contact
72
fibrinolytics
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
anti thrombotic therapy for STEMI and Primary PCI
DAPT (aspirin w/ Clopidogrel/Ticagrelor/Prasugrel) Anticoagulant therapy w/ either UFH or IV bivalirudin (stop UFH 30 min before admin bivalirudin)
74
Clopidogrel
Plavix LD: 300mg (6 h full effect) 600 mg (2 h full effect) Maintenance: 75 mg QD
75
prasugrel
Effient LD: 60 mg Maintenance: 10mg QD
76
ticagrelor
Brilinta LD: 180mg Maintenance: 90mg BID
77
aspirin
162- 325mg | initial dose non-enteric
78
NSAIDS other than aspirin and COX-2 selective inhibitors are _____ in STEMI
contraindicated
79
anticoagulant management
UFH for all Bivalirudin for PCI (d/c at end) fondaparinux - not sole agent for PCI enoxaparin - adj fibrinolytic
80
beta blockers for _______ or _____ if needed for HTN or _____
3 years indefinitely heartfailure
81
late/post hospital care
``` 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
a patient presents with ACS and undergoes _____ and is treated with _______ and _____ and goes home with ____ for _______
medical management anticoagulant and antiplatelet DAPT 12 mo
83
early invasive recommended for
pt w/elevated risk for death/MI refractory angina sx of cardiogenic shock/arrhythmias left heart catheterization, coronary angiography, PCI, CABG
84
medical management aka _______
ischemia guided strategy antiplatelet + anticoagulant then continue P2y12 inhibitor w/aspirin - 12 mo
85
UFH
dosing weight based | no renal adjustment - ok for patients w/renal impairment
86
enoxaparin
dosing: 1mg/kg SC q12h | if CrCl < 30 ml/min - 1mg/kg SC q24h
87
bivalirudin
if Cr/Cl < 30 ml/min need dose adjustment | monitor SCR-
88
fondaparinux
not to be used as sole agent for PCI - risk of catheter thrombosis contraindicated for CrCl < 30 ml/min
89
antiplatelet management
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
GP 2b/3a antagonists
abciximab tirofiban eptifibatide
91
abciximab
no dose adj for renal impairment | not for ACS w/o PCI
92
tirofiban
reduce infusion by 50% for pt CrCl < 60
93
Eptifibatide
reduce by 50% for pt CrCl < 50 | avoid in pt on hemodialysis
94
clopidogrel: d/c at least ____ before CABG surgery if bleeding risk > benefit
5 days
95
prasugrel: d/c at least _____ before CABG surger if bleeding risk > benefit
7 days
96
cangrelor
PCI adjunct in pt not treating with PO p2y12 or GP inhibitors
97
Cangrelor + P2Y12 inhibitors
ticagrelor- anytime during infusion or immediately after | clopidogrel/prasugrel immediately after d/c cangrelor NOT during
98
CABG management
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
duration of DAPT
all at least 12 mo | except for fibrinolytic STEMI- at least 14 days but up to 12 mo
100
triple therapy =
DAPT + anticoagulant more for pt w/a fib but increases risk of bleeding
101
vorpaxar
par-1 antagonist 2.08mg in combo w/aspirin or clopidogrel not to be used w/ severe liver impairment strong CYP3A4 DDI
102
acute limb ischemia
acute < 2 weeks
103
critical limb ischemia
chronic 2+ weeks, ischemic rest pain, nonhealing wound/ulcers, gangrene
104
PAD nonpharm therapy
smoking cessation exercise percutaneous transluminal angioplasty aortofemoral bypass or femoral popliteal bypass
105
PAD pharm therapy
A1c goal < 7% aspirin or clopidogrel (no DAPT) anticoagulation - not recommended per guidelines
106
intermittent claudication
``` 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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