Ischemic Heart Disease

Question 1

Angina is…

Answer 1

chest pain, pressure, tightness, or discomfort

Question 2

Stable angina, or stable ischemic heart disease (SIDH), is associated with…

Answer 2

predictable chest pain, often brought on my exertion or emotional distress and is relieved within minutes by rest or with nitroglycerin (NG)

Question 3

Unstable angina (UA) is a type of acute coronary syndrome (ACS); this is a medical emergency where…

Answer 3

the chest pain increases and is not relieved with NG or rest

Question 4

Prinzmetal’s angina is….

Answer 4

when chest pain is caused by vasospasm of the coronary arteries; it can occur at rest and is often caused by illicit drug use

Question 5

Chest pain occurs when…

Answer 5

there is an imbalance between O2 demand and supply in the heart

Question 6

In SIHD, myocardial oxygen supply is often decreased due to…

Answer 6

plaque build up (atherosclerosis) within the inner walls of the coronary arteries (also known as coronary artery disease (CAD))

Question 7

A cardiac stress test is performed to…

Answer 7

assess the likelihood of CAD and diagnose SIHD

Question 8

A cardiac stress test is done by…

Answer 8

exercise or giving IV medications (e.g. dipyridamole, adenosine, regadenoson, or dobutamine)

Question 9

As myocardial O2 demand increases, the patient is monitored for…

Answer 9

the development of symptoms, changes in HR and BP, transient rhythm disturbances or ST segment abnormalities on an ECG

Question 10

Multiple risk factors for heart disease, vascular disease and stroke are typically present in SIHD, including:

Answer 10

HTN, smoking dyslipidemia, diabetes, obesity and physical inactivity

Question 11

Treatment approach for SIHD:

Answer 11

A- antiplatelet and antianginal drugs (BBs +/- CCBs, + aspirin (clopidogrel if C/I) +/- ranolazine and nitrates PRN)
B- Blood pressure and BBs
C- Cholesterol (statins) and cigarettes (cessation)
D- Diet and diabetes
E- Exercise and education

Question 12

If a stress test is positive, they may be sent to get…

Answer 12

an elective cardiac catherization/angiography

Question 13

aspirin (preferred antiplatelet): use indefinitely in SIDH, unless C/I

Answer 13

C/Is: NSAID or salicylate allergy; children and teenagers due to risk of Reye’s syndrome, nasal polyps or asthma
S/Es: dyspepsia, heartburn, bleeding, nausea (take with food to decrease)

Question 14

Non-enteric coated, chewable aspirin is…

Answer 14

preferred in ACS; if only enteric coated (EC) aspirin is available, it should be chewed (325 mg)

Question 15

aspirin ER capsule (Durlaza), DR tablet + omeprazole (Yosprala)

Answer 15

Do not use when rapid onset is needed (e.g. ACS, pre-PCI)

Question 16

clopidogrel (Plavix)

Answer 16

BBW: prodrug converted by CYP450 2C19; Test to check genotype.
C/Is: active serious bleeding
Warnings: Bleeding risk, stop 5 days before elective surgery, do not use with omeprazole or esomeprazole, premature discontinuation, thrombotic thrombocytopenic purpura (TTP)

Question 17

Do not use dual antiplatelet therapy (DAPT) unless patient had placement of…

Answer 17

• a bare metal stent (DAPT for at least 1 month)
• a drug-eluting stent (DAPT for at least 6 months)
• post-CABG (DAPT for 12 months)

Question 18

Beta-blockers without ISA (ex. atenolol, metoprolol, bisoprolol) are first-line for SIDH. Decrease HR, contractility, and left ventricular wall tension

Answer 18

Start low, titrate HR 55-60 BPM, do not stop abruptly; avoid in Prinzmetal’s angina

Question 19

Ca channel blockers (preferred drugs for Prinzmetal’s angina). Reduce heart O2 demand: non-DHPs decrease HR and contractility; DHPs decrease afterload. Increase myocardial oxygen supply: all CCBs increase blood flow through coronary arteries

Answer 19

• Can be used in SIHD when beta-blockers are C/I or as add-on therapy to BBs for continued symptoms
• Slow-release or long-acting DHPs and non-DHPs are effective; avoid short-acting DHPs (e.g nifedipine IR)
• DHPs are preferred when CCBs are used in combo with BBs (due to risk of excessive bradycardia)

Question 20

Nitrates (use for fast relief and for chronic symptoms)

Answer 20

SL tablets, SL powder or TL spray (recommended for all patients for fast relief of angina). Long-acting nitrates (use when BBs are CI or as add-on therapy for tx of symptoms; a nitrate-free interval is required to prevent tolerance)

Question 21

Ranolazine (Ranexa). Not for acute tx of chest pain. Can use in place of BB or as add-on tx. Has little to no clinical effect on HR or BP.

Answer 21

Unique MOA: Selectively inhibits the late Na current and decreases intracellular Ca; can decrease myocardial O2 demand by decreasing ventricular tension and O2 consumption
CI: liver cirrhosis, do not use with strong CYP3A4 inhibitors and inducers. Limit simvastatin to 20mg/day if used together. Limit dose to 500 mg BID if taking moderate CYP3A4 inhibitors (e.g. diltiazem, verapamil)
Warnings: QT prolongation; acute renal failure observed in CrCl< 30 mL/min

Question 22

Nitrates C/I & Warnings

Answer 22

Hypersensitivity to organic nitrates, do not use with PDE-5 inhibitors or riociguat
Short-acting nitrates: increase intracranial pressure, severe anemia, circulatory failure and shock (SL powder only)
Warnings: hypotension, headache, tachyphylaxis (effectiveness/tolerance with long-acting products)
Side effects: headache, flushing, syncope, dizziness

Question 23

Short-acting nitrates (use PRN for immediate relief of acute chest pain). Can give 3 doses at 5 minute intervals. If symptoms do not improve 5 min after 1st dose, call 911.

Answer 23

-nitroglycerin SL tablet (Nitrostat); 0.3, 0.4, 0.6 mg
- nitroglycerin translingual spray (NitroMist, Nitrolingual Pumpspray); 0.4 mg/spray (do not shake)
- nitroglycerin SL powder (GoNitro) 0.4mg/packet
Counseling: keep NG SL tablets in the original amber glass bottle; discard 6 months after opening. Tolerance does not develop with SL/TL products

Question 24

Long-acting nitrates (required a 10-12 hour nitrate-free interval to decrease tolerance)

Answer 24

• nitroglycerin ointment 2% (Nitro-BID)
• nitroglycerin transdermal patch (Minitran, Nitro-Dur)
• nitroglycerin ER capsule (Nitro-Time)
• isosorbide mononitrate IR/ER tablet (Monoket, Imdur)
• isosorbide dinitrate IR/ER (Dilatrate-SR, Isordil Titradose)

Question 25

The preferred formulation for systolic HF is…

Answer 25

isosorbide dinitrate in combo with hydralazine

Question 26

NG transdermal patch counseling

Answer 26

Wear on for 12-14 hours, off for 10-12 hours; preferred site is the chest; rotate sites; dispose of safely, away from children and pets

Question 27

NG ointment 2% dosing (dosed in inches)

Answer 27

Dose BID, 6 hours apart with a 10-12 hour nitrate-free interval

Question 28

Isosorbide mononitrate IR (10 mg, 20 mg); ER (30, 60, 120 mg)

Answer 28

IR: dose BID, 7 hours apart

Question 29

Isosorbide dinitrate

Answer 29

IR dosed BID (same as mononitrate) or TID; 14-hour-nitrate-free interval
ER (40 mg): Take in the morning or BID for an 18-hour nitrate-free interval

Question 30

If only short-acting nitrates are used, they should not be used if…

Answer 30

a PDE-5 inhibitor was taken recently (avanafil in the past 12 hours, sildenafil or vardenafil in the past 24 hours, or tadalafil in the past 48 hours)

Question 31

-nitroglycerin SL tablet (Nitrostat) counseling

Answer 31

Place one tablet under the tongue or in the area between the inside of the cheek and the gum