Ischemic Heart Disease

Question 1

O (acute treatment)

Answer 1

Oxygen- provide if O2 sat <90%

Question 2

S (acute/chronic treatment)

Answer 2

Statin- start or continue a high intensity statin
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg

Question 3

N (acute/chronic treatment)

Answer 3

Acute - Nitroglycerin- SL NTG every 5 minutes for 3 times and if chest pain is still ongoing then we can consider IV NTG
Chronic - send home with Rx for sublingual nitroglycerin

Question 4

A (acute/chronic treatment)

Answer 4

Aspirin- loading dose of 162-325 mg should be given in a chewable non-enteric coated tablet

Question 5

A (acute ONLY treatment)

Answer 5

Anticoagulant- IV unfractionated heparin for 48 hours or until PCI can be performed or SQ Enoxaparin for the duration of hospitalization or until PCI is performed

Question 6

P (acute/chronic treatment)

Answer 6

P2Y12 inhibitor LOAD (acute)- Ticagrelor (180 mg), Prasugrel (60 mg), Clopidogrel (300-600 mg) are given as loading doses in acute treatment
P2Y12 inhibitor MAINTENANCE (chronic) - ticagrelor 90 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily

Question 7

B (chronic treatment)

Answer 7

Beta Blockers (Longterm Treatment)

Patient on Beta Blocker at least 3 years/
Indefinitely

All beta blockers are okay, except for Heart Failure With reduced Ejection Fraction with Heart Failure use: Metoprolol Succinate, Carvedilol, Bisoprolol

Question 8

A (chronic treatment)

Answer 8

ACE/ARB (Longterm Treatment)

Patient is on indefinitely

If possible, all patients (mortality benefit with normal EF (Hope Trial))
Given to patients with LVEF <40%
People that have HTN, DM, stable CKD

Question 9

M (chronic treatment)

Answer 9

Mineralocorticoid Receptor Antagonist (Longterm Treatment)

Should be on indefinitely

Drugs: Spironolactone or Eplerenone
Patients with EF <40% (on ACE and Beta Blocker)
Contraindications: Serum Creatine: >2.5 mg/dl men and women >2.0 mg/dL
-Potassium: >5mEq/L

Question 10

Medications with Cardiovascular and Diabetes benefit

Answer 10

Metformin
GLP1 Antagonists (Dulaglutide + Liraglutide)
SGLT2 Inhibitors (Empagliflozin + Canagliflozin)

Question 11

All patients with SIHD should receive what medications

Answer 11

Moderate-high dose statin
Aspirin

Question 12

SIHD: First line for anginal symptoms

Answer 12

SL Nitroglycerin

Question 13

SIHD: What line is beta-blocker therapy?

Answer 13

2nd line agent for Angina Chest Pain Treatment

One or more anginal episodes per day (Chronic Prophylaxis)

Decreases HR and contractility, which results in a decrease in O2 demand
(GOAL: HR: 50-60bpm; exercise HR: 100bpm

Antiarrhythmic and slow progression of plaque

Question 14

Beta-blockers adverse effects

Answer 14

bradycardia, heart block, worsening HF, bronchospasm, cold extremities, fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence

Question 15

Beta-blocker pearls

Answer 15

1. Must be tapered upon discontinuation
2. mortality benefit in HFrEF: bisoprolol, metoprolol succinate, carvediol
3. Do not initiate while a heart failure exacerbation
4. Reduce dose if pt experiencing exacerbation (try not to discontinue)

Question 16

SIHD: What line is CCB therapy?

Answer 16

3rd line

Both DHP and non-DHP work
Non-DHP: decreased HR and contractility → decreased O2 demand
DHP: decreased afterload → decrease O2 demand

As effective as beta-blockers in preventing anginal symptoms.
Use/try beta blockers first if not contraindicated

Question 17

SIHD: Avoid Non-DHP CCB in these scenarios

Answer 17

Concomitant beta-blocker
Severe LV dysfunction

Question 18

SIHD: What line is Ranolazine therapy

Answer 18

4th/last line OR in patients who need an anti-anginal that has no impact on HR/BP

Question 19

Ranolazine MOA

Answer 19

MOA: inhibits persistent/late inward Na+ current in the ventricles; also has anti-ischemic activity related to reduced accumulation of intracellular calcium.

Question 20

Ranolazine adverse effect

Answer 20

QT prolongation

Question 21

Ranolazine metabolism

Answer 21

CYP3A4, 2D6, pGp