Ischemic Disease Dr. Stewart

Question 1

Definiton of Ischemia and Infarction

Answer 1

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

Question 2

Definition of atypical chest pain and noncardiac chest pain and Reperfusion

Answer 2

-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)

Question 3

Which blood vessel provide blood flow to the heart?

Answer 3

Coronary artery -> branching out to left and right coronary artery

Question 4

When is an ischemic disease considered stable

Answer 4

-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

Question 5

What is the difference between STEMI and NSTEMI?

Answer 5

STEMI: total occlusion after plaque rupture

NSTEMI: partial occlusion after plaque rupture

Question 6

What are typical signs of ischemic disease?

Answer 6

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

Question 7

Which patients may present with N/V as a sign of ischemic disease?

Answer 7

-female, older age, diabetes

Question 8

What is Printzmental’s angina?

Answer 8

-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)

Question 9

Which Labs should be drawn in ischemic events?

Answer 9

-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

Question 10

What are non-invasive tests in ischemic events?

Answer 10

-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)

Question 11

What are invasive tests in ischemic events?

Answer 11

-cardiac catheterization (put a catheter through an artery -> contrast -> X-ray to see the artery
-can also be therapeutic

Question 12

What is a PCI?

Answer 12

Percutaneous coronary intervention = balloon angioplasty with stent deployment (push the plaque against the wall, put a stent there)

Question 13

What are the types of stents?

Answer 13

-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)

Question 14

What does CABG and MACE mean?

Answer 14

-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)

Question 15

Stable angina

Answer 15

-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)

Question 16

How would a patient with stable angina might present?

Answer 16

-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

Question 17

What are pharmacologic treatment options for ischemic diseases?

Answer 17

-BB
-CCB (DHP & non-DHP)
-Nitrates (isorsobide dinitrate or mononitrate (Imdur)
-Ranolazine (Ranexa) - antianginal

interventional treatment: PCI

Question 18

What are the risk factor modifications for ischemic disease?

Answer 18

-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)

Question 19

Angina management strategy

Answer 19

-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

Question 20

Which drug should be used in vasospastic angina?

Answer 20

-assess BP
-if <130/80: LA nitrate (Imdur)
-if >130/80: CCB (DHP (preferred) or non-DHP)

Question 21

Can CCB and nitrates be given together, since both lower BP?

Answer 21

Yes as long as the HR is not too low (<60 bpm)

Question 22

Which drugs to use in a non-vasospastic angina?

Answer 22

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

Question 23

Which BBs are used in heart failure?

Answer 23

-Metoprolol succinate
-Carvedilol
-Atenolol (not preferred)
-Nebivolol (in elderly)

Question 24

Which dose should be used with BB in ischemic disease?

Answer 24

-start low and titrate up -> if the patient has symptoms -> go back down

-the goal is symptom control

Question 25

What is the first-line drug for Printzmental’s angina?

Answer 25

CCB

Non-DHP-CCB: target HR
DHP-CCB: target BB

can be used together -> improving ischemic disease targeting 2 different MOAs

Question 26

Long-acting, Immediate and short-acting nitrates

Answer 26

short-acting
-Spray
-SL tablets
-Paste

long-acting
-Patch (24hr)
-Isosorbide dinitrate (BID, TID)
-Isosorbide mononitrate (1x daily)

-need a nitrate free interval

Question 27

Antiplatetes for stable Ischemic heart disease (SIHD)

Answer 27

-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

Question 28

Other therapies in stable ischemia

Answer 28

-Lipid management: high or moderate intensity

-ACEi/ARB: compelling indications
post-MI/stroke or PAD
HTN (goal: <130/80)
DM
HFrEF
CKD

Question 29

How to manage diabetes with cardiovascular disease

Answer 29

if the patient has diabetes and CVD
-SGLT2 or GLP-1-RA

FYI:
to reduce MACE, CV death, progression of CKD

Question 30

If a patient presents with ischemia, do we need to calculate ASCVD risk?

Answer 30

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

Question 31

Which drug should be given for an acute attack (chest pain)?

Answer 31

Sublingual (SL) Nitroglycerin
-0.4 mg SL q5 min PRN up to 3 doses,
if it doesn’t improve -> call EMS

Question 32

Which drug should be used in vasospastic angina?

Answer 32

-assess BP
-if <130/80: LA nitrate (Imdur)
-if >130/80: CCB (DHP (preferred) or non-DHP)