IHD - CAD

Question 1

When does chest pain occur

Answer 1

When demand of O2 exceed the amount of O2 supply

Question 2

What work up should you do for someone with chest pain?

Answer 2

Hemoglobin
Fasting glucose
Fasting lipoprotein
Resting ECG
Chest X-ray
Cardiac bio markers

Question 3

What does Class I-IV mean for angina

Answer 3

Class I - strenuous physical activities angina
Class II - walking or climbing rapidly angina or after eating
Class III - walking or climbing normally angina
Class IV - all physical activity cause Angina

Question 4

Can you rely on ECG for Ischemia

Answer 4

No bc 50% do not have a normal ECG

Question 5

Creatine kinase (CK or CPK) normal values

Answer 5

0-175 units/L

Question 6

CK-MB normal values

Answer 6

Males <4.9 ng/mL
Females <2.9 ng/mL

Question 7

Cardiac index normal values

Answer 7

<2.5%

Question 8

Troponin T gen 5 normal values

Answer 8

< 22 ng/mL

Question 9

How do you confirm CAD

Answer 9

Cardio angiogram

Question 10

Risk factors for SIHD or CCD

Answer 10

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

Question 11

What are the drugs that we can use for MVO2 increase

Answer 11

Nitrate
Beta blocker
Nifedipine
Verapamil
Dilizaem
Aspirin

Question 12

baby aspirin dosing and alternatives

Answer 12

81mg
If allergic - clopidogrel 75mg

Question 13

Name 2 ACEi/ARBS for SIHD and CCD benefits

Answer 13

Stabile coronary plaque
Provide restoration or improvement in endothelial function
Inhibit vascular smooth muscle growth
Decrease macrophage migration
Maybe prevent oxidative stress

Question 14

Nitroglycerin dosing for sublingual, patches and IV

Answer 14

Sublingual - 0.4-0.6 mg up to 1.5 (onset 1-3 mins)
Patches - 0.2 - 0.8 for 12-16hr then off 8-12h (30-60mins)
IV - 5 - 300 mcg/min (1-2mins)

Question 15

Isosobride dinitrae

Answer 15

5-20 mg TID (onset 20-40 mins)

Question 16

Isosobride mononitrate 2 oral formulations

Answer 16

Ismo, monoket - 20 mg BID (onset 30-60mins)
Imdur 30-120 mg QD ( 30 - 60mins) USED AT UCSD

Question 17

Can you build up a nitrate tolerance and how long should you go off nitrates?

Answer 17

Yes you can so you must give a nitrate free interval
10-14hr

Question 18

Consulting points for nitroglycerin

Answer 18

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

Question 19

What is the benefit and cons of oral nitroglycerin agents

Answer 19

Prophylaxis against angina
But long onset and higher doses

Question 20

AD for Nitrates

Answer 20

Common
Headache
Facial flushing
Halitosis
Rash -more with the patch

Serious
Hypotension
Tachycardia
Unexplained bradycardia
Methomoglobinemia ( rare)
Heparin resistances

Question 21

Contraindications for nitrates

Answer 21

HOCM (hypertrophic obstructive cardiomyopathy
Acute right ventricular MI - bc blood flow very sensitive (preload)
Concurrent use of PDE-5

Question 22

Pt education points for sub nitroglycerin (test question)

Answer 22

Question 23

Ideal candidates of SIHD/CCD with beta blockers

Answer 23

Physical actives majority of angina
HTN
SVT
Post MI
Anxiety induce angina
LVEF ≤ 40% w/ or w/o MI

Question 24

Goals of BB for SIHD/CCD

Answer 24

Lower RR to 50-60
Avoid BB with ISA (timilol)
Can be chronic treatment with SIHD with angina

Question 25

What BB can be used for SIHD/CCB

Answer 25

Metoprolol - succinct for LVEF
Carbedilol - take with food
Atenolol - renal dysfunction
Esmolol - most used for acute MI

Question 26

ideal candidates for CCB

Answer 26

Intolerance to BB
Pt with condition system disease (only DDP 4)
Pt with vascular disease or severe ventricular dysfunction - use amlodipine
Pt with HTN

Question 27

What is ranolazine used for and what is the brand name

Answer 27

Ranexa
Chronic angina and presumed microvascular disease
Preserve microvascular system

Question 28

Ranolazine cons

Answer 28

Ranexa
Prolongs QTC
Uncirrected Hypokalemia
Ventricular tachycardia
CAN NOT BE USED ALONE NEED TO BE COMBO

Question 29

What conditions should we avoid with ranolazine

Answer 29

Renal needs to be adjusted
Hepatic failure can not use med X
CYP3A4 inhibitors and inducers X

Affects
Simvastatin - 20mg max
Digoxin -1.5x
CYP2D6 - blocks
QT - prolongates even more
Metformin - increase conc

Question 30

Ranolazine dosing

Answer 30

500 BID
Max 1000 BID in 1 -2 weeks

Question 31

What is does the regiment look like for all SIHD/CCD pts

Answer 31

1. Aspirin or clopidogrel
2. BB
3. Spray or sublingual nitro
   EVERYONE WILL HAVE 1-3
4. CCB or long nitrates if BB contra or if not reaching relive of symptoms
5. LDL and ACE for lipid and HTN
6. Ranolazie if still not effective treatment
7. Rivaroxaban 2.5 BID

Question 32

Therapy slide for SIHD/CCD must know if anything (PIC)

Answer 32

Question 33

What are the 3 types of PCI and which one do we do the most?

Answer 33

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

Question 34

What are the complications with PCI

Answer 34

You can get restenosis - smooth muscles grows over the metal cage
This is why we use the drug stents

Question 35

When is CABG preferred over PCI

Answer 35

Left main coronary stenosis
3-vessel disease - 3 main lines are blocked
Diabetic

Question 36

What is CABG?

Answer 36

Revascularize over the blockage