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Pharmacotherapy 4271 > IHD Part II (SIHD) > Flashcards

IHD Part II (SIHD) Flashcards

1
Q

what are the common characteristics of stable ischemic heart disease (SIHD)

A

similar to acute
- chest pain or discomfort: described as squeezing, heavy, crushing, burning (discomfort is unchanged with respiration or position
- pain may radiate to arm, shoulder, neck/jaw, abdomen or back
- dizziness, lightheaded, weakness
- dyspnea
- sweating
- N/V

sxs may be indistinguishable from ACS!!!!

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2
Q

what are some precipitating factors of SIHD

A
  • exercise
  • cold environment
  • activity after a large meal
  • emotions (excitement, anxiety, anger)
  • sexual activity
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3
Q

true or false: chest pain in SIHD is usually responsive to nitroglycerin or rest

A

true

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4
Q

does this describe SIHD or ACS?
usually caused by an unstable plaque rupture (with clot formation) resulting in abrupt and unpredictable change in coronary blood flow

A

ACS

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5
Q

does this describe SIHD or ACS?
caused by fixed/stable plaque with progressive restriction in blood flow resulting in supply/demand mismatch

A

SIHD

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6
Q

does this describe SIHD or ACS?
shorter durations (1-15min)

A

SIHD

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7
Q

does this describe SIHD or ACS?\
longer durations (>20 mins)

A

ACS

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8
Q

does this describe SIHD or ACS?
may occur at rest

A

ACS

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9
Q

does this describe SIHD or ACS?
triggered by specific preicipitating factors (exercise/emotion)

A

SIHD

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10
Q

does this describe SIHD or ACS?
is not relieved by rest +/- response to nitroglycerin

A

ACS

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11
Q

does this describe SIHD or ACS?
symptoms are unpredictable, may worsen with time

A

ACS

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12
Q

does this describe SIHD or ACS?
symptoms are stable/reproducible (“if I do this, I will get chest pain”)

A

SIHD

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13
Q

true or false: ACS is a medical emergency

A

true

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14
Q

this is one of the three principle presentations of chest pain of ACS
A) rest angina
B) new-onset angina or
C) increasing angina

anigna occurring at rest and usually prolonged > 20 mins, occurring within 1 week of presentation

A

rest angina

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15
Q

this is one of the three principle presentations of chest pain of ACS
A) rest angina
B) new-onset angina or
C) increasing angina

previously diagnosed angina that is distinctly more frequent, longer in duration, or lower in threshold (i.e. increased by at least more than 1 CCS class within 2 months of initial presentation to more than CCS Class III severity)

A

increasing angina

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16
Q

this is one of the three principle presentations of chest pain of ACS
A) rest angina
B) new-onset angina or
C) increasing angina

angina of at least CCS Class III severity with onset within 2 months of initial presentation

A

new-onset angina

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17
Q

this is a type of angina; it is severe pain due to vasospasm in coronary arteries. minimal or no atherosclerotic disease. angina at rest that may occur in cycles. usually in younger patients +/- CV risk factors

A

vasospastic angina
(what I think I had that one time)

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18
Q

this is a classification of chest pain; meets three of the following:
1. substernal chest discomfort of characteristic quality an duration
2. provoked by exertion or emotional stress
3. relieved by rest and/or NTG

A

typical angina

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19
Q

this is a classification of chest pain; meets two of three of the following:
1. substernal chest discomfort of characteristic quality an duration
2. provoked by exertion or emotional stress
3. relieved by rest and/or NTG

A

probable angina

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20
Q

this is a classification of chest pain; meets one or none of the following:
1. substernal chest discomfort of characteristic quality an duration
2. provoked by exertion or emotional stress
3. relieved by rest and/or NTG

A

non-cardiac chest pain

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21
Q

this is a class of Canadian cardiovascular society (CCS) angina; ordinary physical activity (walking, climbing stairs) does not cause angina. angina occurs with strenuous, rapid or prolonged exertion

A

class I

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22
Q

this is a class of Canadian cardiovascular society (CCS) angina;
slight limitation of ordinary activity. angina occurs with walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold/wind or under emotional stress. angina occurs when walking 2 or more blocks on level ground and climbing more than one flight of stairs at normal pace and under normal conditions

A

class II

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23
Q

this is a class of Canadian cardiovascular society (CCS) angina;
marked limitations of ordinary physical activity. angina occurs on walking 1 or 2 blocks on the levels an d climbing one flight of stairs in normal conditions and at a normal pace

A

class III

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24
Q

this is a class of Canadian cardiovascular society (CCS) angina;
inability to carry on any physical activity without discomfort. anginal symptoms may be present at rest

A

class IV

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25
Q

what are some lab tests that a clinician may order in terms of SIHD

A
  • hgb (if anemic, puts more stress on heart to pump more oxygenated blood)
  • scr and electrolhytes
  • FBG and A1C
  • lipid panel
  • thyroid function tests
  • liver function tests
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26
Q

what are some potential features associated with a higher risk of MACE

A
  • age
  • male
  • poor social support
  • poverty or lack of health access
  • obesity
  • previous MI, PCI or CABG
  • HF
  • Afib
  • DM
  • dyslipidemia
  • CKD
  • current or former smoker
  • depression
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27
Q

what are some goals of therapy for SIHD

A
  1. prevent ACS and death
    - modify CV risk factors
    - slow the progression of atherosclerosis
    - stabilize existing plaques
  2. alleviate acute sx’s of myocardial ischemia & prevent recurrent sx’s
  3. avoid or minis a/e of tx
28
Q

the MOA of this class of medication includes
- reduces contractility and CO
- reduces HR
- reduces central release of adrenegeric substances
- inhibits peripheral NE release
- inhibits renin release from kidneys

A

beta-blockers

29
Q

true of false: beta-blockers is the DOC for classic angina

A

true

30
Q

true or false: beta-blockers can be used to treat vasospastic angina

A

false

31
Q

what are some contraindications of beta blockers

A
  • 2nd/3rd degree heart block
  • severe peripheral arterial disease
  • uncompensated HF
  • hypotension
  • relative asthma/COPD
32
Q

these two beta blockers have intrinsic sympathomimetic activity (ISA) therefore they do not decrease HR and should not be used in tx of angina

A

acebutalol and pindolol

33
Q

what are the 4 cardioselective beta blockers

A

think “BAAM”
B-bisoprolol
A-atenolol
A-acebutolol
M-metoprolol

34
Q

what are some a/e of beta blockers

A
  • bradycardia (slow HR)
  • AV conduction abnormalities
  • acute HF
  • mask symptoms and inhibits recovery of hypoglycaemia
  • headache
  • dizziness & fatigue
  • hyperlipidemia
  • bronchospasm
  • sexual dysfunction
35
Q

this MOA of this class of mediation is vasodilators that can cause reflex tachycardia

A

DHP calcium channel blockers (e.g. amlodipine, nifedipine and felodipine)

36
Q

what are some a/e of DHP CCBs

A
  • dizziness
  • flushing
  • peripheral edema
  • h/a
  • gingival hyperplasia
  • GI upset
  • mood changes
    GRAPEFRUIT INTERACTION
37
Q

the MOA of this class of medication is blocks AV node, reducing HR and contractility; may have some vasodilation

A

non-DHP calcium channel blockers (e.g. verapamil and diltiazem)

38
Q

what are some a/e of non-DHP CCBs

A
  • bradycardia
  • AV block
  • peripheral edema
  • hypotension
  • constipation
  • anorexia
  • nausea
  • induce HF
39
Q

true or false: CCBs can be used to treat vasospastic angina

A

yes - 1st line

40
Q

if a patient has SIHD along with sinus bradycardia, AV conduction abnormalities or sick sinus sydnrome, what type of CCB should be used

A

DHP CCB

41
Q

if a patient has SIHD along with LV dysfunction & unable to tolerate beta blocker therapy, what CCB should be used

A

amlodipine preferred

42
Q

what are some contraindications of CCBs

A
  • SBP < 90
  • recent ACS or pulmonary edema

non-DHPs: HF, 2nd or 3rd degree heart block

43
Q

which type of calcium channel blockers can be combined with beta blockers?

A

DHP CCBs

44
Q

the MOA of this class of medications is decreased myocardial O2 demand through relaxation of smooth muscle, venous pooling (decreased preload), arteriolar vasodilation (decreased afterload), relieve coronary vasospasm & redistribute coronary blood flow

A

nitrates

45
Q

what type of nitrate would be used for an acute attack

A

sublingual NTG (e.g. 0.4mg SL spray, 0.3mg SL tab, 0.6mg SL tab) or IV nitro

46
Q

what type of nitrate is used for prophylaxis

A

long acting NTG (e.g. patch, isosorbide mononitrate)

short acting NTG may be used if pt knows a certain activity will precipitate chest pain

47
Q

how is short acting NTG dosed

A

e.g. spray: use 1 or 2 sprays SL q 5 mins and repeat 2 more times. if after three times no relief, seek medical attention

48
Q

how is long acting NTG dosed

A

need to have a nitrate free period of 10/12 hours to prevent nitrate tolerance

49
Q

what are some a/e of nitrates

A
  • hypotension
  • dizziness/flushing
  • h/a
  • nausea
  • heartburn
  • reflex tachycardia
50
Q

what class of drug should be avoided when using nitrates

A

PDE-5 inhibitors (e.g. sildenafil, vardenafil, tadalafil) due to severe hypotension risk!!

51
Q

all patients with IHD should receive this type of therapy, and should be continued lifelong unless the patient has a bleeding risk or active bleeding. this tx decreases platelet adhesion/aggregation

A

antiplatelet therapy

52
Q

this medication is used for tx in SIHD to prevent ACS and death. this specific type of antiplatelet therapy is the DOC unless contraindicated. it is an irreversible inhibitor of COX thus inhibits platelet aggregation. decreases MI and death. a dose of 81mg is used for prevention

A

ASA

53
Q

what are some drug interactions with aspirin

A

other highly protein bound drugs (warfarin, phenytoin)

54
Q

what are some a/e of aspirin

A

GI - N/V, heartburn, ulceration, epigastric pain
Bleeding - impaired clotting for 7-20 days after d/c

rare: leukopenia, thrombocytopenia, rash, hypersensitivity, bronchospasm, anaphylaxis

55
Q

this medication is used for tx in SIHD to prevent ACS and death. specific type of antiplatelet therapy is a platelet ADP-receptor antagonist that inhibits platelet aggregation. it is used as long term anti platelet therapy for patient who are intolerant to ASA. dose is usually 75 mg po daily

A

Thienopyridines (clopidopgrel)

56
Q

what are some a/e of clopidogrel

A
  • GI: N/V, abdominal pain, dyspepsia
  • bleeding
  • headache, dizziness
  • rash (rare)
57
Q

this medication is used for tx in SIHD to prevent ACS and death. this type of medication is beneficial in patients with SIHD along with HTN, DM, LVEF < 40% or CKD to reduce CV events. it is reasonable to consider this med in all patients with SIHD to reduce CV events

MOA: blocks conversion of angiotensin I to angiotensin II, therefore reducing angiotensin II mediated vasoconstriction and aldosterone secretion. Blocks degeneration of bradykinin and stimulates synthesis of other vasodilation substances.

A

ACE inhibitors - the “pril’s”

58
Q

what are some contraindications of ACEi?

A
  • pregnancy
  • bilateral renal artery stenosis
  • hx of angiedema with ACEi
59
Q

what should be monitored if starting a patient on ACEi

A
  • BP
  • SCr, urea and K+ should be checked 1-2 weeks after starting on ACEi
60
Q

what are some a/e of ACEi

A
  • hyperkalemia (Monitor)
  • acute renal failure (higher risk if depleted Na+ levels, dehydrated or on high hose of diuretic)
  • DRY COUGH
  • angioedema

rare: neutropenia and agranulocytosis

61
Q

this medication can be used for patients who are intolerant to ACEi

A

ARBS

62
Q

this medication is used for tx in SIHD to prevent ACS and death. this class of medication is used to improve prognosis in patients with SIHD AND LVEF < 40% with or without HF

A

beta blockers

63
Q

what other medications should patients with SIHD receive? (not heart rate/BP related)

A

statins!!

64
Q

this is used for tx in SIHD to prevent ACS and death. this type of intervention refers to percutaneous coronary interventions (PC) or coronary artery bypsdd grafting (CABG), which is beneficial to increase blood flow to the narrow, affected areas.

it is typically reserved for patients with unacceptable angina (e.g. high risk features, persistent sx’s), patients to have a survival benefit from receiving this therapy

A

revascularization therapy

65
Q

during follow up visits, what should the pharmacist assess in patients with SIHD?

A
  • optimal control of risk factors
  • changes in sx’s of angina
  • frequency of use of SL NTG
  • adherence to meds
  • smoking cessation
  • weight

Pharmacotherapy 4271 (29 decks)

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