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IPFC 4 Midterm 1 > IHD therapeutics > Flashcards

IHD therapeutics Flashcards

1
Q

What is Chronic Coronary disease mean?

A

includes patients with/without angina, a history of revascularization and previous ACS
- NO MI or MI more than 12-30 months ago
- this lecture only focus on primary prevention (no previous ACS)

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2
Q

Is framingham risk score valid in patients with CCD?

A

No
- Stable angina was excluded

CCD is already at high risk

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3
Q

Does risk level in matter in terms of therapeutics for patients with CCD? What changes?

A

Therapeutics the same for all
- healthy interventions and mortality will change

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4
Q

The risk stratification for vessels, LV ejection fraction, stress induced, ECG findings show risk of how many years?
Soft/hard outcomes?

A

Annually
Hard outcomes only

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5
Q

Goal of therapy with angina

A

Reduce symptoms of angina
- cannot reduce the incidence of UA/MI or saves lives

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6
Q

Which interventions are for preventative therapies (lifesaving) (4)

A
  • Antiplatelet therapy
  • ACEi/ARB
  • Statin
  • Healthy behaviours
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7
Q

Which interventions are for antiaginal therapies?

A

Beta blockers
CCBs
Nitrates

PCI and CABG

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8
Q

Should ASA be given to patients with CCD?

A

Yes

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9
Q

When do we give clopidogrel

A

When ASA is not tolerable

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10
Q

What does the SAPAT trial tell us?
Group?
Intervention?

A

Patients with exertional chest pain
- no previous MI
- All on Sotalol (BB)

ASA reduce risk of MI & death by 34%

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11
Q

What did the ADAPTABLE trial tell us?

A

There is no additional benefit of higher dose ASA
- maybe more risk of GI haemorrhage

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12
Q

CAPRIE
Group?
Intervention?
Outcome?
over/under estimation?

A

Group
- Stroke, MI, symptomatic ASCV PAD

Intervention
- Clopidogrel 75mg vs ASA 325

RRR = 8.7%
- clopidogrel is technically more efficacious

Underestimation of results
- 0.33% of ASA vs 0.47% of intracranial haemorrhage
- if using ASA 81 the difference would be more

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13
Q

What did the CHARISMA trial tell us?
Group?
Intervention?
Outcome?

A

Group
- Primary group OR
- angina without event OR
- event was 12-30 months ago

Intervention
- Placebo + low dose ASA
- Clopidogrel + low dose ASA

Outcome:
- RR 0.93%
- no difference in primary prevention for dual anti platelet

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14
Q

COMPASS trial
Group
Intervention outcome

A

Group
- With or without diabetes
- Mix of primary and secondary prevention (previous MI)
- Most on ACE, BB, Statin

Comparison
- ASA + placebo vs ASA + rivaroxaban 2.5mg

Outcome:
- Can add low dose rivaroxaban if they are at high risk of stroke, & low-mod risk of bleed

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15
Q

What is the level A recommendation for ACE? for who?

A

For patients in CCD with
- HTN
- Diabetes
- LVEF less than 40%
- CKD

Can be considered if just have CCD (although not common to have that alone)

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16
Q

What are the benefits of ACE inhibitors? Benefits in low risk?

A
  • hard outcomes
  • revascularization
  • mortality in high risk

Low risk patients have no sig benefit but reasonable to still give

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17
Q

RAAS natural effects

A
  • inc BP
  • inc Na/H2O retention
  • inc wall tension
  • Endothelial dysfunction
  • inc clot formation
  • myocardial fibrosis
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18
Q

Should you start with ACE or ARB? Are there differences?

A

No differences in the risk of stroke, IHD, and HF for each 5 mmHg reduction in BP

When assessed at zero BP reduction, the risk reduction for ACE was greater for IHD than ARBs

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19
Q

What is the level A recommendation for statin? For who?

A

All patients with CCD should be on a high-intensity statin

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20
Q

What should you add if patient on max-tolerated Statin + Ezetimibe with uncontrolled LDL or HDL:

A

PCSK9-inhibitor (-umab ending)
- Evolocumab

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21
Q

What are benefits of statins in IHD?

A
  • reduce morbidity and mortality in IHD
  • Help in plaque stabilization, even with patients in normal “LDL”
  • improve endothelial function + anti-inflammatory effects
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22
Q

What is the target in adults with CCD who have hypertension?

A

Under 130/80

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23
Q

In adults with CCD, what are first line therapy to lower BP in those with elevated BP (120-129/<80 mmHg)

A

Nonpharms

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24
Q

Which non-pharm has the most reduction in BP?

A

Healthy diet
- DASH diet

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25
What is first line for patients with CCD and hypertension (130+/80+)
ACE/ARB BB
26
What are initial therapies for IHD?
BB and NTG
27
Do beta-blockers help reduce risk of mortality or events?
No - only for symptom management
28
When is ranolazine recommended?
Last line after BB and CCB do not work
29
When do BB have survival benefits in IHD?
If they have IHD and evidence of previous ACS or HF (EF <40%)
30
T/F BB do not increase exercise tolerance in patients with SIHD
False
31
T/F BB cannot be used for Vasospastic angina
False
32
Which BB can you use for vasoconstriction (severe PAD) or prinzmetal's angina? ALTHOUGH
- can use BB with A1 blocking ability (labetalol) or direct vasodilators (Nebivolol)
33
T/F BB with alpha blocking are first line for vasospastic (prinzmetal's angina)
False
34
Which BB do you give for patients with resting bradycardia
BB with ISA - Acebutolol - Pindolol
35
Which BB do you give for patients with COPD/Asthma
B-1 selective - Metoprolol - Atenolol - Bisoprolol
36
What BB to give patients if they have PAD?
Give with alpha-1 blocking ability - labetalol
37
What are ABSOLUTE contraindications for BB? (4)
- Severe bradycardia - Pre-existing high-degree AV block - Sick sinus syndrome (without a pacemaker) (becomes a natural pacemaker) - Refractory heart failure
38
What are RELATIVE contraindications for BB? (3)
Bronchospastic disease (COPD, Asthma) - use B-1 selective Active PAD - use BB with Alpha blocking effect T1DM: - B-blockers can increase BG (mask HYPOglycemia)
39
What are the non-selective BB? (3)
Propranolol Nadolol Timolol
40
Which BB are B-1 selective (5)
Metoprolol Atenolol Esmolol Bisoprolol Nebivolol
40
Which BB is nonselective with ISA?
Pindolol
41
Which BB is B-1 selective with ISA?
Acebutolol
42
Which BB has alpha-1 blocking ability and nonselective beta blocking
Labetolol
43
How to withdraw BB?
Tapered over 1-3 weeks (to avoid reflex tachy) - give SL nitro or a NDHP-CCB during withdrawal
44
MOA of CCB?
Decrease calcium influx through voltage-dependant L-type calcium channels
45
Which CCBs are safer DHP or NDHP
DHP is safer NDHP Dec HR so caution with - sick sinus syndrome, bradycardia, AV conduction disturbance Dec Contractility so caution with - HF and <40% LVEF
46
When are CCBs first line?
For prinzmetal's angina with nitrates
47
Can you combine BB and NDHP? Why?
AVOID/with caution (NDHP-CCBs reduce HR, no need for additional effect from B-blocker)
48
What to use if BB is contraindicated?
NDHP is preferred - has their own anti-chronotropic effects
49
ADRs of CCB
- hypotension - sinus bradychardia - AV block reflex tachycardia peripheral edema headache constipation (esp. verapamil) flushing/dizziness CYP3A4 interaction
50
Which is better BB vs CCBs? Can either affect mortality?
neither is better for symptoms (or outcomes) both equally effective - but B-blockers have more favourable side effects No just for symptomatic prophylaxis
51
What are the main effects of NTG at low doses?
Venous dilation - dec preload --> dec O2 demand
52
What are the main effects of NTG at higher doses?
Coronary artery vasodilation - inc O supply Dec afterload as well
53
MOA of nitrate vasodilation with Nitric Oxide (4)
- inc cGMP - inc Activation of cGK-1 (cGMP dependant kinase) - dec intracellular calcium - relaxation of muscle cells
54
What are the benefits of NTG? (3)
- improve exercise tolerance - Inc time to ST-segment depression - Inc time to onset of angina
55
When are nitrate contraindicated?
Hypertrophic obstructive cardiomyopathy - inc wall thickness = dec blood = dec preload = dec afterload - NTG will worsen this
56
When are long acting NTG used?
Can be used as initial therapy OR when BBs and NDHPs are CI OR when additional therapy to control angina is necessary
57
When does nitrate tolerance occur?
Occurs in SR forms only (SR tablet/patch) - The SL route has no tolerance Can still use SL NTG spray during the OFF period
58
What are the proposed MOA of nitrate tolerance
depletion of sulfhydryl groups, compensatory NE release (neurohormonal hypothesis) - Most likely hypothesis: compensatory free radical release (Free radical hypothesis)
59
T/F Long-acting nitrates do not result in tolerance to SL products?
True
60
How to prevent NTG tolerance?
Have NTG-free intervals during the 24 hours (usually 10-14 hours)
61
What effect does withdrawal of transdermal NTG have?
Caused a sig decrease in treadmill walking time
62
Directions for NTG?
Remain seated (to avoid syncope) - 1 dose q5min - if no improvement after 1 dose call 911 (can continue to use NTG while waiting for 911)
63
How do you know when NTG tablets have lost potency?
No burning sensation beneath the tongue
64
ADRs of NTG
Vasodilation effects - headache - flushing - hypotension Methemoglobinemia (rare) Can use prophylactic analgesia
65
How long should you space nitrates with PDE5?
24 hours if viagara/sildenefil 48 hours if cialis/tadalafil
66
What if PDE5 was used first, then having anginal pain?
DON'T use nitrate -> go to hospital if it is severe - Nitrate won't save your life -> but, taking nitrate + PDE5 can kill you
67
Ranolazine MOA
- inhibits inward Na sodium current - dec intracellular calcium --> dec wall tension (afterload) --> O2 demand
68
T/F Ranolazine has effect on HR and BP
False
69
ADRs of Ranolazine
GI effects Dizziness Syncope inc QT interval
70
Why did observational studies show that HRT in women reduced major CVD and fatal CVD?
Healthier patients were selected to receive HRT so they did better due to baseline health, not HRT - RCT showed no benefit for HRT vs placebo - only reduced hip fracture
71
Theory of anti-oxidants?
Will reduce atherogenesis
72
Vit E effect on CVD in trials?
At high doses 400+ IU increased mortality
73
B-carotene effect
Increased mortality
74
Folic acid, Vit B6/B12 theory
Reduce homocysteine levels so theoretically should reduce ischemic events
75
What do trials say for folic acid?
No additional benefit for CVD But folic acid MAY have a role in stroke prevention (one RCT showed significant RRR in first stroke for folic acid + enalapril vs placebo + enalapril) - trial used ACE
76
Does coronary artery bypass graft (CABG) improve mortality in patients who could not be medically controlled?
No - only improve QOL
77
What patients recieve mortality benefits with CABG? (3)
High-risk coronary anaotmy - 50% stenosis of the left main artery - 70% stenosis of all 3 coronary arteries - Particularly with LVEF <35%
78
In STICH trial , in what group did patients see a mortality/hospitalization benefit with CABG?
Patients with previous MI
79
Which method of Percutaneous Coronary Intervention (PCI) is better, Bare metal stent or drug eluting stent?
Drug eluting stent (need to be on dual antiplatelet for life) - in BMS, endothelium will grow over stent
80
What is the bottom line for surgical interventions with chronic stable angina
All surgical intervention do NOT reduce mortality/MI - They only reduce need for revascularization (need to open the vessel again) ACS does not apply

IPFC 4 Midterm 1 (7 decks)

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