IHD: 1

Question 1

Etiology

Answer 1

-Atherosclerosis
-HLD

Question 2

Angina Classification

Answer 2

1. Ordinary PA does not cause angine (walking/stairs), exercise/exertion does
2. Angina with walking uphill, stairs, stress, cold
3. Walking 1-2 blocks or climbing 1 flight of stairs
4. Can’t do any PA without discomfort

Question 3

Cardiac Biomarkers

Answer 3

-Negative in stable ischemic heart disease
-Negative unstable angina
-Positive in NSTE-MI or STE-MI

Question 4

Normal Cr Kinase

Answer 4

0-175

Question 5

Normal CKMB

Answer 5

M < 4.9
F < 2.9

Question 6

Normal Cardiac Index

Answer 6

< 2.5%

Question 7

Normal Troponin T

Answer 7

< 22

Question 8

Diagnostic Overview

Answer 8

ST elevation + Positive BM
= STEMI

ST depression or T-wave
-Positive BM = NSTEMI
-Negative BM = Unstable Angina

Non-specific ECG + Negative BM = SIHD/CCD

Question 9

Aspirin (ASA)

Answer 9

81 mg PO QD
-If allergic = use Clopidogrel 75 mg PO QD

AE:
-GI: NV, dyspepsia, bleeding
-Frank melena
-Hematemesis

~CI:
-GI bleed, PUD

Question 10

ACEI/ARBs

Answer 10

Recommended in patients with SIHD who have HTN, diabetes, LVEF ≤ 40%, or CKD

Question 11

Nitrates

Answer 11

Induce coronary vasodilation

Can have nitrate tolerance (use nitrate free intervals of 10-14 hrs to restore response)

AE:
-HA, flushing
-Halitosis (SL NTG)
-Rash (patch)
-Syncope, hypotension, tachy/brady

Question 12

Nitroglycerin: Dose

Answer 12

SL 0.4-0.6 (x3dose if needed)

Max 1.5 mg

Onset 1-3 min

Protect from light/moisture, advise to sit down against wall, keep in original dark container, avoid swallowing

Question 13

Nitrate/NTG: CI (when not to use)

Answer 13

1. Hypertrophic obstructive
   cardiomyopathy (HOCM)
2. Acute R ventricular MI
3. Use with PDE5is

In case, look for origin! If it says R…

Question 14

Beta Blockers: For Who

Answer 14

– where physical exercise figures prominently into their anginal attacks
– with coexisting hypertension
– with a history of supraventricular tachyarrhythmias (SVT)
– with post-MI angina
– with anxiety-induced angina
– with LVEF ≤ 40% with or without previous MI
(SHAME L)

Question 15

Beta Blockers: Duration of Therapy

Answer 15

-Chronic in SIHD with angina
-One year if normal LV function after MI/ACS

Question 16

Metoprolol

Answer 16

25-450 mg in 1-3 divided doses

5 mg IV for early ACS only

Succinate if LVEF < 40

Question 17

Carvedilol

Answer 17

IR 3.125-25 BID

ER 10-80 QD

Question 18

Atenolol

Answer 18

50-200 QD

Caution in renal

Question 19

CCBs: For Who

Answer 19

1. CI to BB
2. Conduction system disease (DHPs)
3. Peripheral vascular disease or ventricular dysfunction (use amlodipine)
4. Concurrent HTN

Question 20

Ranolazine (Ranexa): CIs

Answer 20

Avoid in:
-Long QTS
-Hypokalemia
-Ventricular tachycardia
-QT longing meds
-Hepatic insufficiency
-CYP3A4s

After Amlodipine, BB, Nitrates are maximized, can add on

Question 21

Ranolazine: Dose/AE

Answer 21

HA, dizzy, nausea, constipation

500 mg BID

Max 1000 BID

Question 22

Drug Tx for Angina

Answer 22

1. ASA or Clop
2. BBs
3. NTG
4. CCBs (alt/add)
5. Statins
6. ACEIs
7. Ranolazine
8. Rivaroxaban

Question 23

TX Algorithm

Answer 23

1. SL NTG for Acute Attacks
2. Vasospastic angina?
   *YES
   -High BP: CCB
   -Low BP: Nitrate ER
   *NO
   -HR > 60: BB, non DHP CCB
3. If sx uncontrolled
   -Low BP?
   *YES = add Ranolazine or Nitrate ER
   *NO = DHP CCB

Question 24

CABG over PCI in:

Answer 24

– left main coronary stenosis
– 3-vessel disease (especially in patients w/ LVEF < 50%)
– diabetics*

Question 25

Meds Post-CABG

Answer 25

1. Aspirin indef
2. DAPT 3-6mo then aspirin indef (off-pump cabg)
3. If ACS + on DAPT + go CABG = P2Y12 tx for 12 mo of DAPT