IHD/ACS I Flashcards
Risk Factors for First-Time Myocardial Infarction
-ApoB to apoA-1 ratio
-Current smoking
-Psychosocial
-Diabetes
-Hypertension
-Abdominal Obesity
Cardiac Biomarkers
- Negative in stable ischemic heart disease
- Negative unstable angina
- Positive in NSTE-MI or STE-MI
Desired Outcomes in Ischemic Heart Disease
– Reduce premature CVD
– Prevent complications of IHD
– Maintain or restore activity, functional capacity, and QOL
– Completely or nearly completely eliminate ischemic symptoms
– Minimize costs of health care by avoiding unnecessary testing and treatment, preventing hospitalizations, and avoiding complications of testing
Aspirin (ASA)
Dose: 81 mg PO daily
-allergy: subs w/ clopidogrel 75mg PO daily
-325mg can impair endothelial secretion of prostacyclin (a natural vasodilator)
AE: GI, dyspepsia, NV, GI bleeding, frank melena, hematemesis
Relative CI: GI bleeding, PUD
ACE Inhibitors / ARBs
Recommended in patients with SIHD who have HTN, diabetes, LVEF ≤ 40%, or CKD
Nitrates
HF, angina, ACS
AE: HFHR
-Headaches
-Facial flushing
-Halitosis
-Rash
*serious: syncope, hypotension, tachycardia, bradycardia, methemoglobinemia, heparin resistance
CI: PARAH
-Angina from HOCM
-Acute R ventricular MI
-With PDE5i (afils), OK if taken > 48 hrs ago
Patient Education: Sublingual Nitroglycerin
-Keep in the original dark glass container
-Do not store in the bathroom
-Keep SL NTG close by at all times; may need multiple vials in different places
-Should be sitting down with back against wall and rest while taking the tablet
-Keep the tablet under tongue until dissolved; avoid swallowing the tablet
-If you don’t get a tingling sensation under your tongue, your tablets might have gone bad
-Contact 911 if first SL NTG does not relieve angina; continue with doses 2 and 3 (if necessary) while on the phone with 911
-Do not drive yourself to the ED
Beta Blockers
Ideal candidates: SHALAP
– 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
*metoprolol, carvedilol, atenolol, esmolol
CCBs
For:
-CAD
-Coronary spasm
-Angina
Ideal candidates: CCHVV
1. CI or intolerances to BB
2. coexisting conduction system disease (only
dihydropyridines)
3. peripheral vascular disease or severe
ventricular dysfunction (use amlodipine)
4. concurrent hypertension
Ranolazine (RanexaTM)
Used for chronic effort angina or presumed microvascular disease, when other agents are maxed = 500 mg BID, max 1000 BID
AVOID IN: KL is QT
– Long QT syndrome
– Uncorrected hypokalemia
– Known hx of ventricular tachycardia
– Other QT prolonging medications
– Hepatic failure
AE: CHND
– nausea
– constipation
– dizziness
– headache
SUMMARY: Recommended Drug Therapy for Angina
- Aspirin (or clopidogrel)
- BB (prior MI, angina, high HR)
- Nitroglycerin
1-3: EVERYONE
- CCBs or long-acting nitrates (CI to BB then in combo with BB)
- Statins, ACEi
- Ranolazine
- Rivaroxaban 2.5 mg BID
Summary Table of TX
PCI Revascularization
useful for patients w/ single & multivessel disease AND symptomatic as well as asymptomatic patients
Drug Eluting Stents (DES)
= prevents restenosis and minimizes neointimal hyperplasia as well as the need for urgent target lesion revascularization
CABG
CABG is preferred over PCI in:
– left main coronary stenosis
– 3-vessel disease (especially in patients w/ LVEF < 50%)
– diabetics ?
Antiplatelet therapy improves early & late patency rates
– Aspirin indefinitely
– Off-pump CABG: DAPT for 3-6 months, then aspirin indefinitely
– ACS with DAPT and CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT after ACS
