IHD - CAD √ Flashcards
What work up should you do for someone with chest pain?
Hemoglobin
Fasting glucose
Fasting lipoprotein
Chest X-ray
Cardiac bio markers
Resting ECG
What defines Class I-IV mean for angina
Class I - strenuous physical activities or prolonged = angina
Class II - Able to walk 2 blocks or 1 flight without angina and only occurs under stress = Angina
Class III - Walking 2 block or 1 flight causes = Angina
Class IV - can be caused at rest or any activity = Angina
Can you rely on ECG for Ischemia
No bc 50% do not have a normal ECG
words the describe the severity of Ischemia
How do you confirm CAD
Cardio angiogram
Risk factors for SIHD or CCD
Smoking one for the highest to lower 33%
Blood pressure
Lipid
Diabetes
Physical activity 30-60 for 5 days
Weight management - 18.5 and 24.9 BMI (5-10% if need weight loss)
Influenza
Alcohol consumption - 1 drink per day
What are the drugs that we can use for MVO2 increase
Nitrate
Beta blocker
Nifedipine
Verapamil
Dilizaem
Aspirin
Aspirin Side Effects
GI bleeding (can be a contraindication if had previously)
Gi upset with EC aspirin
What medication can i use if im allergic to Aspirin
Clopidogrel 75 mg
In practice, when are the 4 types of pt to use ACEi
IHD who have:
HTN
diabetes
LVEF ≤40%
CKD
What can become an issue with chronic use of nitrates
Nitrate tolerance
Benefits on Sublingual nitrate
Fast acting
Isosobride dinitrae dosing
5-20 mg TID (onset 20-40 mins)
Do I dose Isosobride Dinitrae TID q8hrs
no bc of the tolerance and last dose should be given at 7 pm
Ismo, Monoket dosing
Ismo, monoket - 20 mg BID (onset 30-60mins)
Imdur dosing
30 - 120 mg QD
Isosobride mononitrate
What is a pro of Imdur?
after 6 weeks it is effect for 12 hours
What is a pro of Isosobride Mononitrae
Can be used in hepatic failure patients and it isn’t eliminated through the liver
Sublingal dosing for Nitrate
0.4 mg q 5min Prn
Dosing for Nitrate ointment
2% 1/2 - 2 inchs TID - QID
Dosing for Nitrate IV
5-300mcg/min
Dosing for Nitrate Patch
0.2-0.8 mg/h for 12-16 then off for 8-12
Can you build up a nitrate tolerance and how long should you go off nitrates?
Yes you can so you must give a nitrate free interval
10-14hr
4 Consulting points for nitroglycerin
3mins 75% of people resolved next 2 15% of people resolved if it is CAD angina
NEED TO HAVE THEM SIT BEFORE ADMINISTRAITON
Keep away from light
Seek medical if 1 does doesn’t work
What is the benefit of oral nitroglycerin agents
Prophylaxis against angina
What are the AD for Nitrates and what are the 4 bolded side effects
Common
HEADACHE
FACIAL FLUSHING
Halitosis
Rash -more with the patch
Serious
SYNCOPE and HYPOTENSION
TACHYCARDIA
Unexplained bradycardia
Methomoglobinemia ( rare)
Heparin resistances
What are the 3 contraindications for nitrates
HOCM (hypertrophic obstructive cardiomyopathy)
Acute right ventricular MI - bc blood flow very sensitive (preload)
Concurrent use of PDE-5i
Pt education points for sub nitroglycerin (test question)
What are the 6 ideal patients for I would use beta-blockers in?
ANGINA DUE TO PHYSICAL ACTIVITIES
HTN
SVT
Post MI
Anxiety induce angina
LVEF ≤ 40% w/ or w/o MI
What are the treatment goals with beta-blockers and at what level of doses do we initiate
resting HR 50-60 bpm
Start on the lowest dose
If patient is have adverse effect with BB how do we take them off?
tapering off over 2-3 weeks
What determines the duration of use for Beta-blockers
1 year if LV is normal after MI/ACS
but indefinitely if reduced LV
or can be chronic in IHD with stable Angina
Starting dose for Metropolol Tartate IR
Metoprolol - 25-450 mg PO 2-3x a day
Starting dose for Metropolol Succinate
25mg-450 po daily
When do we use Metropolol Succinate over Tartate
when pt LVEF ≤ 40%
Dosing for early ACS treatment with Metropolol
5 mg IV q 5 minutes x 3 for early ACS only
Carvedilol IR starting dose
IR*: 3.125 – 25 mg PO twice daily
Coreg CR starting dose
CR: 10 – 80 mg PO daily
what are 2 Benefits to using Carvedilol
Alpha and Beta blocking
taking with food can reduce Hypotension side effect
What dose of Carvedilol do we give in a patient that is over 85 kg
50 mg po BID
Atenolol starting dose
50-200 mg PO daily
Out of the 3 beta blockers for IDH which one is renaly eliminated
Atenolol the rest are hepatically eliminated
What are the 4 ideal patients for CCB
Intolerance/contraindications to BB
Pt with Conduction(electrical) heart disease (DHP only)
Pt with vascular disease or severe ventricular dysfunction
Pt with HTN
Which CCB can I use with Pt with conduction Heart disease?
Non-DHP (Verapamil and Diltiazem)
What CCB can we give to a patient that has a IHD but has a vascular problem or severe ventricular dysfunction
Amlodipine
What CCB can I use to treat someone that has a IHD but also has a Conduction system disease
DHP
amlodipine
Nicardipine
Nifedipine
Felodipine
What 2 patients in IHD is Ranazoline indicated for
Chronic effort Angina and
presumed microvascular disease
For Ranexa when can I add it in my therapy regiment?
Only in combo when pt BP is >130/80 and Nitrates, Amlodipine or BB are maxed out
What are the DDI that are contraindicated in Ranazoline
Hepatic failure
Strong CYP3A4 inhibitors (ketoconazole, clarithromycin, nelfinavir)
CYP3A4 inducers (Carbamazepine, Phenytoin, Phenobarbital, St johns worts, Glucocorticoids)
Ranolazine effects which 5 drugs/effects
inhibitor
Simvastatin
Digoxin
CYP2D6 (antidepressants and codine)
prolongs QTC
metformin
Ranexa side effects
nausea
constipation
dizziness
headache
Ranolazine dosing
500 BID
Max 1000 BID in 1 -2 weeks
What is does the regiment look like for all SIHD/CCD pts
- Aspirin or clopidogrel
- BB
- Spray or sublingual nitro
EVERYONE WILL HAVE 1-3 - CCB or long nitrates if BB contra or if not reaching relive of symptoms
- LDL and ACE for lipid and HTN
- Ranolazie if still not effective treatment
- Rivaroxaban 2.5 BID maybe
Therapy slide for SIHD/CCD must know if anything (PIC)
If the patient has Vasospastic Angina what medications do I add after giving them sublingual nitrates
IF BP < 130/80: add nitrate ER
IF BP ≥ 130/80: add CCB
(basically, I need a prophylactic medication)
Once the patient is on a sublingual nitrate what medications can I give to control their heart rate
HR >60
BB is the first line unless contra then use non-DHP CCB or Nitrate ER
When would I add Rivaroxaban?
In combo with ASA or clopidogrel in patients that are low to moderate bleeding risk but
high risk individuals for IHD
What are the 3 types of PCI and which one do we do the most?
W/O stent - inflate the ballon and push the plaque back
W/ stent - inflate the ballon and put a metal cage left behind to hold open artery
W/ anti-proliferative drug - same as above just with drug to prevent restenosis
What are the complications with PCI
You can get restenosis - smooth muscles grows over the metal cage
This is why we use the drug stents
When is CABG preferred over PCI
Left main coronary stenosis
3-vessel disease - 3 main lines are blocked
Diabetic
What must be giving post CABG
Post-CABG statin therapy
post CABG antiplatelet therapy
SIHD treatment guideline
SIHD treatment guideline
