Ischemic Disease Dr. Stewart Flashcards
Dr. Stewart EXAM VI
Definiton of Ischemia and Infarction
Ischemia: lack of oxygen delivery at the tissue/organ level
Angina pectoris: chest pain resulting from ischemia (due to ischemia!!!)
Infarction: an area of tissue necrosis (irreversible) secondary to ischemia
Definition of atypical chest pain and noncardiac chest pain and Reperfusion
-atypical chest pain: cardiac chest pain without the typical signs
-noncardiac chest pain: chest pain from non-anginal source (musculoskeletal)
-Reperfusion: opening a blocked artery via procedures (balloon angioplasty with or w/o stents)
Which blood vessel provide blood flow to the heart?
Coronary artery -> branching out to left and right coronary artery
When is an ischemic disease considered stable
-Plaque occlusion -> can become unstable when it ruptures -> total (STEMI) or partial (NSTEMI) occlusion with thrombus
-symptomatic (unstable) vs asymptomatic (stable)
-cardiac vs non-cardiac
if unstable it needs to be evaluated, it can worsen quickly -> ER
What is the difference between STEMI and NSTEMI?
STEMI: total occlusion after plaque rupture
NSTEMI: partial occlusion after plaque rupture
What are typical signs of ischemic disease?
Chest pain
-sub-sternal chest discomfort (may radiate to shoulder and neck)
-crushing/pressure
-intense
-relieved by nitrates (vasodilation) or other meds
-other signs: N/V, pain only in the neck or shoulder
Which patients may present with N/V as a sign of ischemic disease?
-female, older age, diabetes
What is Printzmental’s angina?
-also called variant or vasospasm angina
-due to coronary arteries vasospasm (constriction), not arteriosclerosis
-chest pain occurs anytime the artery contracts or has a spasm, and is not due to physical activity
-> treatment is going to be different (fix the spasm)
at this point, we are not worried about arteriosclerosis (statins) or plaque rupture (antiplatelets)
Which Labs should be drawn in ischemic events?
-Troponin (released from myocardial tissue in the event of ischemia), doesn’t mean the tissue has died (infarction), renal elimination -> it goes down after a while, takes longer to decrease in renal impaired patients
-CK-MB
What are non-invasive tests in ischemic events?
-ECG
-Coronary CT angiography (look for calcification, and plaques in the coronary arteries)
-Stress testing (intentionally increase the HR while observing the heart with ECK or nuclear imaging (contrast) to see how much of the heart is getting perfused -> HR can be increased by running or pharmacologically)
What are invasive tests in ischemic events?
-cardiac catheterization (put a catheter through an artery -> contrast -> X-ray to see the artery
-can also be therapeutic
What is a PCI?
Percutaneous coronary intervention = balloon angioplasty with stent deployment (push the plaque against the wall, put a stent there)
What are the types of stents?
-Drug-eluting stents (DES) with an immunosuppressive drug like tacrolimus to help the tissue heal back - most often used
-bare metal stent (not often used anymore)
What does CABG and MACE mean?
-Coronary artery bypass grafting (bypass surgery) -> harvest a vein and place it to the occluded artery and bypass the blood flow to the heart (open heart surgery can mean valve replacement or structural repair to the heart)
MACE: major adverse coronary event (heart attack, stroke, stent put in, in the catheterization lab)
Stable angina
-mild and predictable symptons
-stable relative to Acute coronary syndrome
-MVO2 mismatch (the heart needs more oxygen than it gets due to the occlusion)
-treatment is outpatient, but may end up getting a PCI or CABG (reperfusion therapy)
How would a patient with stable angina might present?
-chest pain with physical activity or exercise, happens occasionally when physically active
->doesn’t need to go to the ER but should be referred, also medical treatment
What are pharmacologic treatment options for ischemic diseases?
-BB
-CCB (DHP & non-DHP)
-Nitrates (isorsobide dinitrate or mononitrate (Imdur)
-Ranolazine (Ranexa) - antianginal
interventional treatment: PCI
What are the risk factor modifications for ischemic disease?
-Lifestyle: diet, exercise, weight, smoking
-influenza vaccine
-HTN (<130/80), A1c < 7%, statins if needed
-HFrEF: if LV <40% -> Entresto or ACEi/ARB
-anyone with ischemic disease or atherosclerosis: antiplatelet (Aspirin 81/Clopidogrel 75 daily)
Angina management strategy
-Chest pain: SL nitroglycerin
-if vasospastic angina and BP <130/80 -> LA nitrate (imdur)
when >130/80 –> CCB to lower BP
if not vasospastic, assess the HR
if >60 bpm (tachycardia): BB or non-DHP-CCB
if <60 bpm: don’t give BB or non-DHP-CCB (contraindication in low HR)
if that doesn’t help -> assess BP
if <130/80: LA nitrate or Ranolazine
if >13/80: DHP-CCB
Which drug should be used in vasospastic angina?
-assess BP
-if <130/80: LA nitrate (Imdur)
-if >130/80: CCB (DHP (preferred) or non-DHP)
Can CCB and nitrates be given together, since both lower BP?
Yes as long as the HR is not too low (<60 bpm)
Which drugs to use in a non-vasospastic angina?
BB or Non-DHP-CCB
as long as the HR is high enough (not < 60 bpm, bradycardia)
-a BB is indicated in HF, when the LVEF is <50% or post-MI -> if there is no indication use BB or Non-DHP-CCB
Which BBs are used in heart failure?
-Metoprolol succinate
-Carvedilol
-Atenolol (not preferred)
-Nebivolol (in elderly)
Which dose should be used with BB in ischemic disease?
-start low and titrate up -> if the patient has symptoms -> go back down
-the goal is symptom control
What is the first-line drug for Printzmental’s angina?
CCB
Non-DHP-CCB: target HR
DHP-CCB: target BB
can be used together -> improving ischemic disease targeting 2 different MOAs
Long-acting, Immediate and short-acting nitrates
short-acting
-Spray
-SL tablets
-Paste
long-acting
-Patch (24hr)
-Isosorbide dinitrate (BID, TID)
-Isosorbide mononitrate (1x daily)
-need a nitrate free interval
Antiplatetes for stable Ischemic heart disease (SIHD)
-Aspirin 81 mg (75 - 100 mg) unless contraindicated
when would Aspirin be contraindicated??? -> Aspirin allergy
-if Aspirin is contraindicated use Clopidogrel 75 mg
-DAPT (Asp + Clopidogrel) is not useful in reducing MACE
Other therapies in stable ischemia
-Lipid management: high or moderate intensity
-ACEi/ARB: compelling indications
post-MI/stroke or PAD
HTN (goal: <130/80)
DM
HFrEF
CKD
How to manage diabetes with cardiovascular disease
if the patient has diabetes and CVD
-SGLT2 or GLP-1-RA
FYI:
to reduce MACE, CV death, progression of CKD
If a patient presents with ischemia, do we need to calculate ASCVD risk?
No, it is to assess the risk for the primary event
it has happened already
-> put on a high-intensity statin!, treat symptoms
-Approach:
mitigate risk: lifestyle, vaccination, managing HTN, diabetes, statins, giving antiplatelets, managing HF with Entresto
treat chest pain: nitrate, BB, CCB
Which drug should be given for an acute attack (chest pain)?
Sublingual (SL) Nitroglycerin
-0.4 mg SL q5 min PRN up to 3 doses,
if it doesn’t improve -> call EMS
Which drug should be used in vasospastic angina?
-assess BP
-if <130/80: LA nitrate (Imdur)
-if >130/80: CCB (DHP (preferred) or non-DHP)
