Ischemic Heart Disease Flashcards
What is stable angina?
Chronic angina precipitated by activity or upset, relieved at rest
etiology of ischemic heart disease
Etiology
atherosclerotic plaque builds up in the coronary arteries.
These vessels vasodilate to continue to bring blood to the myocardium.When oxygen demand increases above the baseline, the vessels cant vasodilator any further.
The demand for oxygen becomes greater than the supply. This results in ischemia and chest pain.
Risk factors for IHD
modifiable and non modifiable
Non Modifiable:
- Male >45 years
- Female > 55 years old
- Family history of premature CAD event
- Male < 55
- Female < 65 years old
Modifiable
- smoking
- hypertension
- dyslipidemia
- diabetes
- obesity
- physical inactivity
Characteristics of Stable Angina
Quality:
Location:
Duration:
Precipitating factors:
relieving factors:
Characteristics of Stable Angina
Quality: Pressure or heavy weight on chest, crushing, burning, tightness
Location: Substernal, may radiate (neck, jaw, shoulders, chest, left arm, abdomen), but not common
Duration: 0.5-20 minutes
Precipitating factors: Exercise, cold weather, postprandial (after meal)
relieving factors: rest, sublingual nitroglycerin
Types of Angina
Typical:
Atypical
Non cardiac chest pain
Types of Angina
Typical:
a. occurs with characteristic quality, location duration
b. provoked by exertion or emotional stress
c. relieved by nitroglycerin or at at rest
Atypical
Meets only 2of 3 criteria above.
women, older adults and pts. with diabetes can present with other symptoms (atypical) like anxiety, SOB, weakness, fatigue, indigestion
Non cardiac chest pain
: meets one or none of criteria above
Modifiable treatment of Stable Ischemic Heart Disease (SIHD)
Treatment of SIHD (Modifiable risk factors)
- Treatment of Concomitant Diseases
a. Physical inactivity/ obesity: encourage physical activity and weightloss
b. Cigarrete smoking: smoking cessation
c. Hypertension: ACC/AHA 2018 update
d. Diabetes: glycemic control
I. Some diabetes medications also have cardiac benefit. If pt. has diabetes and IHD, these medication shave dual benefit.
a. Metformin
b. SGLT-2 inhibitors (empagliflozin, canagliflozins)
c. GLP-1 antagonists (dulagluitide, liraglutide)
What diabetes medications have dual diabetic and cardiac benefits
Metformin
SGLT-2 inhibitors
GLP-1 antagonists
Pharmacologic treatment of Stable Angina. (Prevention of development to unstable ischemic heard disease)
Pharmacologic treatment of Stable Angina. (Prevention of development to unstable ischemic heard disease)
- in addition to lifestyle changes, a moderate or high intensity statin should be prescribed
- treatment with Aspirin 75-192 mg daily should be continued indefinitely as long as there are no contraindications for it
- treatment with clopidogrel is reasonable when aspirin is contraindicated in its with SIHD.
- treatment with aspirin 75-162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high risk patients with SIHD
Pharmacologic treatment of stable angina
- sub lingual nitroglycerin
- beta blocker
add or substitute - CCB (DHPs proffered but still can use non DHP’s)or long acting nitrate
- Ranolazine
Treatment of stable angina
Sublingual Nitroglycerin PRN
Class: nitrate
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls:
Sublingual Nitroglycerin PRN
Class: nitrate
Indication: treatment of infrequent angina attacks or use prior to known activities that cause angina
Mechanism of Action: forms free radical nitric oxide, which activates cyclic GMP (cGMP), which causes smooth muscle relaxation. .
Effects of mechanism of Action: produces vasodilator effect on peripheral arteries and veins but more so on veins. overall reduces demand of oxygen to relieve angina.
Adverse Effects: Headache
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls:
- SIT DOWN WHEN YOU TAKE IT
- Dissolve under tongue
- take up to 3 doses 5 minutes apart
- call 911 if pain is not relieved
Treatment of stable angina
beta blockers
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: —
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:–
Pearls:
1.TREATMENT goal:
Beta Blockers
examples: in general, end in -OLOL.
Class: Beta blockers
Indication: chronic prophylaxis for patients with > or equal to 1 anginas episode per day.
Mechanism of Action: inhibiting Beta 1 +/- Beta 2 receptors.
Effects of mechanism of Action: decreased heart rate and myocardial contractility. decreases O2 demand.
Adverse Effects: Bradycardia, heart block, worsening heart failure, bronchospasm fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence.
Absolute Contraindications: severe bradycardia
Pregnancy: —
Warning/ Precautions: Use with cautioning patients with bronchospastic diseases (COPD, asthma). use with caution in patients with diabetes
Drug-Drug Interactions (DDIs): Use with caution with other drugs that cause bradycardia
Monitoring Parameters:–
Pearls:
- TREATMENT goal: 50-60 BPM and max exercise HR 100 BPM
- additional protective benefits such as antiarrhythmic and may slow progression of plaque.
- MUST BE TAPERED upon D/C. can cause rebound hypertension
- can mask symptoms of hypoglycemia in patients with diabetes.( i.e palpitations, shakiness, anxiety)
- enhance hypoglycemic effects of insulin and sulfonylureas
Treatment of stable angina
Dihydropyridines (DHP) Calcium channel blockers
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls:
Dihydropyridines (DHP) Calcium channel blockers
examples:end in -DIPINE: Amlodipine (Norvasc), Nifedipine (Procardia) etc.
Class: Calcium Channel Blockers
Indication: chronic stable angina
Mechanism of Action: inhibits calcium ions form entering vascular smooth muscle and myocardial leading to peripheral arterial and coronary artery dilation
Effects of mechanism of Action: decrease after load and decrease O2 demand
Adverse Effects: pedal edema (D/C if this happens), headache, dizziness, flushing, potential for reflex tachycardia (short acting agents only).
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls: can take up to one week to see full blood pressure lowering effects
- as effective as beta blockers in preventing anginas symptoms
- preffered over non DHPs for chronic angina treatment.
Treatment of stable angina
NON Dihydropyridines (DHP)
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
NON Dihydropyridines (DHP)
examples: Diltiazem ER, Verapamil (Canalan)
Class: Calcium Channel Blockers
Indication:Management of chronic stable angina
Mechanism of Action: inhibits calcium ions form entering vascular smooth muscle and myocardial
Effects of mechanism of Action: peripheral arterial and coronary artery vasodilation, ALSO has negative Inotropy (decreased contractility) and negative chronotropy (decreased heart rate), which decreases O2 demand
Adverse Effects: Diltiazem: edema, headache, constipation, conduction disturbances, bradycardia, heart failure.
Verapamil : edema,constipation, gingival hyperplasia, headache, conduction disturbances, bradycardia, dizziness, heart failure exacerbations.
Absolute Contraindications:- avoid use in patients with HFrEF.
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): avoid routine use with beta blockers, CP3A4 major substrate and moderate inhibitor->dose aadjustments required for simvastatin an lovastatin, as well as be careful with interactions with other drugs involved with CYP3A4
Monitoring Parameters: –
Pearls: can take up to one week to see full blood pressure lowering effects
Treatment of stable angina
Long acting nitrates
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications: –
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:–
Pearls:
Long acting nitrates
examples: PO isosorbide dinitrate, isosorbide mononitrate (Transdermal patch)
Class: Beta blockers
Indication: for prevention of recurrent angina, in combo with other anti-anginas therapies
Mechanism of Action:form free radical nitric oxide. this activates cyclic GMP
(cGMP) leading to smooth muscle relaxation.
Effects of mechanism of Action:peripheral dilation of veins and arteries, more so veins.overall decreases O2 demand.
Adverse Effects: headache, hypotension,
Absolute Contraindications: –
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:–
Pearls: avoid tachyphylaxis by having 10-14 hour nitrate free period
Ranolazine
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
Ranolazine
Class: anti anginal
Indication: Management of chronic stable angina. may be used with beta blockers, nitrates, or CCBs, or can be substituted for these routine abtianginal therapies if they are not tolerated due to side effects
Mechanism of Action: inhibits persistent/ late inward Na+ current in the ventricles, thereby reducing calcium influx.
Effects of mechanism of Action: decrease intracellular calcium reduces ventricular tension and myocardial oxygen consumption, causes anti ischemic activity.
Adverse Effects: QT prolongation
Absolute Contraindications:– avoid use in patients with HFrEF.
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): CYP3A4 drug reactions
Monitoring Parameters: –
Pearls: metabolized by cup 3A4, high risk for drug interactions
- does not effect BP or HR
What is
Unstable angina:
What is it?
Unstable angina: increased frequency or duration of angina episodes produced at lower level of exertions or at rest
what is it
NSTEMI
What is it?
NSTEMI: myocardial necrosis resulting from prolonged interruption of the blood supply, generally results from an acute thrombus(partial occlusion), increased cardiac markers,
but no ECG changes.
general acute treatment of unable angina or NSTEMI
medical management (ischemic guided therapy) and early invasive
pharmacologic acute treatment of unstable angina and NSTEMI
OSNAAP oxygen s. statin n nitroglycerin aspirin anticoagulant p2y12 inhibitors
OSNAAP
oxygen
only give if if o2 less than 90%
OSNAAP
statin
high intensity statin
OSNAAP
nitroglycerin
give SLx3 q 5 min, if not relieved, consider iv nitroglycerin
OSNAAP aspirin
162-365 loading dose non enteric coated must be cheewed
OSNAAP
antcoagulant
iv unfractioned heparin for 48 hrs or until PCI is performed and completed
or enoxaprin for duration of hospitalization or until PCI ISP performed and completed
what can be given if patient has had history of heparin induced thrombocytopenia
Bivalirudin and fondaparunix
OSNAAP
p2y12
ticagrelor ld 180 mgx1
clopidogrel LD 600 mg x1
prasugrel LD 60 mg x1 (only use if PCI is performed)
UA and NSTEMI nitroglycerin drug card
Nitroglycerin
Class:
Indication: PO:
IV:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
Administer x3 NTG SL every 5 min for continuing ischemic pain and then assess for need for IV NTG
Nitroglycerin
Class: nitrates
Indication: PO: administration of acute treatment of unstable angina or NSTEMI.
IV: persistent ischemia ACS pain, HF, Hypertension
Mechanism of Action: forms free radical nitric oxide, which activates cyclic GMP (cGMP), which causes smooth muscle relaxation. .
Effects of mechanism of Action: produces vasodilator effect on peripheral arteries and veins but more so on veins. overall reduces demand of oxygen to relieve angina.
Adverse Effects: Headache
Absolute Contraindications:recent use with phosphodiesterase inhibitor . Sildenafil/ Avanafil: 24 hr, Tadalafil: 48 hr
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): can cause profound hypotension with recent use of PDE inhibitors like sildenafil, Avanafil, and Tadalafil
Monitoring Parameters: –
Pearls:
SL NTG every 5 min x3 for continuing ischemic pain and then assess need for IV NTG.
UA and NSTEMI p2y12 drug card
P2Y12 INHIBITORS
Class: P2Y12 INHIBITORS
Indication:
Examples:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Ticagrelor:
Pregnancy: –
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
P2Y12 INHIBITORS
Class: P2Y12 INHIBITORS
Indication: unstable angina: NSTEMI , Bare metal stent (for 1month) and drug eluting stent placement (for 3 months)
Examples: Ticagrelor, Clopidogrel, Prasugrel
Mechanism of Action: reversibly and non competitively binds the adenosine diphosphate (ADP) P2Y12 receptor on the platelet surface which prevents ADP mediated activation of the GPIIb/IIIa receptor complex thereby reducing platelet aggregation
Effects of mechanism of Action: reduces platelet aggregation
Adverse Effects: bleeding
Tecagrelor: dose related dyspnea or brady arrhythmias
Absolute Contraindications: Prasugrel:; hx of stroke/TIA
Ticagrelor: history of cerebral bleed and severe liver disease
Pregnancy: –
Warning/ Precautions: Clopidogrel:D/C 5 days before surgery
Prasugrel : D/C 7 days before surgery
Ticagrelor: d/c 5 days before surgery
Drug-Drug Interactions (DDIs):
Clopidogrel: use with PPI’s (especially omeprazole may decrease efficacy
Ticagrelor:avoid use with strong CYP3A4 inducers.
Max aspirin daily dose of 100 mg
Monitoring Parameters: –
Pearls: in UA and NSTEMI, Ticagrelorl proffered over clopidogrel and prasugrel
2. only use Prasogrel only if PCI performed (stent placement)
UA and NSTEMI
gbIIb/IIIa inhibitors drug card
GIIB/IIIA INHIBITORS
Class: GIIB/IIA INHIBITORS
Indication:
Examples:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
GIIB/IIIA INHIBITORS
Class: GIIB/IIA INHIBITORS
Indication: NST- Elevation acute coronary syndromes. Not routinely used, but used in some catheterization procedures in patients with significant clot burden, determined by interventionaliist
OR
administer at the time of PCI to patients with NSTE-ACS who were not pre treated with p2y12 inhibitor (need to place a stent now but oral P2Y12 inhibitor will take too long to work)
Examples: Tirofiban (Aggrastat), Eptifibatide (Integrilin), Abciximab (reopro)
Mechanism of Action: reversible antagonist of the GPIIb/IIIa receptor complex, the major platelet surface receptor involved in final common pathway of platelet aggregation thereby reducing platelet aggregation.
Effects of mechanism of Action: reduces platelet aggregation
Adverse Effects: bleeding, acute thrombocytopenia (plt count <50,000)[occurs in about 1%of patients )
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: Monitor for thrombocytopenia
long term treatment of UA and NSTEMI
SNAP BAM statin nitroglycerin aspirin p2y12 beta blocker ACEi/ARB mineral corticoid receptor antagonist
SNAP BAM
Statin
continue on high intensity statin
indefinitely
SNAP BAM
nitroglycerin
send them home with a prescription for SL nitroglycerin
indefinitely
SNAP bam
aspirin
MD 81 mg
indefinitely
SNAP BAM
mineralcorticosteroid receptor antagonist
spironolactone or eplerenone.
do not use if Scr>2.0 in females and >2.5 in males to avoid hyperkalemia
indefinitely
SNAP BAM
p2y12
Tacagrelor: MD 90 mg BID
prasugrel: MD 10mg daily
clopidogrel: MD: 75 mg daily
for 12 months
if bare metal stent was put in: 1 month
if drug eluting stent was put in: for 3 months
SNAP BAM
Beta blocker
any beta blocker for up to 3 years or infinitely
SNAP BAM
ace/arb
continue indefinitely
which drugs have mortality benefit treatment in ACS long term treatment
statins aspirin p2y12 inhibitors beta blockers ace arbs mineralcorticosteroid receptor antagonists
when should thrombolytic be used?
when time to PCI is greater than 90 min
what’s different about the general treatment between NSTEMI and STEMI
nstemi can go through either medical management route or early invasive route.
semi goes straight to early invasive route
what is the difference between p2y12 inhibitor use in NSTEMI and STEMI
in NSTEMI, ticagrelor is preferred over clopidogrel, but in STEMI, ticagrelor AND prasugrel is preferred over clopidogrel
if thrombolytics were administered, what p2y12 go you give acutely? what is LD and MD
clopidogrel only. LD. 300 mg
same MD when giving home medications (75 mg daily)
when is pasugrel used in stemi
only after visualization of coronary arteries just incase heart surgery needs to be performed
characteristics of stemi
chronic angina with elevated cardiac markers and st elevation
what is a stemi
myocardial necrosis resulting from prolonged interruption of the blood supply generally results from an acute thrombus, with elevated cardiac markers and ST elevation
peripheral artery disease
atherosclerosis in the arteries of lower extremeties
how is PAD diagnosed
ankle brachial indea
normal 1-1.4
some PAD:0.8-0.9
moderate PAD: 05-0.9
severe: <0.5
acute treatment of PAD
immediate treatment of systemic heparin in any scenario
- local administration of thrombolytics
- ballon stenting or thrombectomy
- surgical thrombus removal
Thrombolytics
Class: Thrombolytic
Indication:
Examples:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls.
Thrombolytics
Class: Thrombolytic
Indication:ST-Elevation myocardial Infarction (STEMI). PCI is preffered therapy, however thrombolysis therapy is an option in centers with out PCI capability and time to PCI is > 90 minutes. This should be done, followed by a transfer to a PCI capable center.
Examples: Alteplase (tPA), Reteplase, Tenecteplase
Mechanism of Action: binds to fibrin in a rhombus (clot) and converts entrapped plasminogen into plasmin. Plasmin degrades clots
Effects of mechanism of Action: initiates local fibrinolysis
Adverse Effects: bleeding
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
Pearls. 1. significantly increases bleeding risk, especially in combo with aspirin, a P2Y12 inhibitor, and an anticoagulant.
2. if lytic is administered, ONLY use clopidogrel 300 mg as p2y12 agent because clopidogrel has lower anti platelet potency and theoretically lowers bleeding risk
overall PAD treatment
- everyone. statin, anti platelet, BP control (ACE/ARB preffered)
- if have symptoms: cilostozol for intermittent claudication
- revascularize (consider aspirin+clopidogrel)
Cilostazol
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Pearls:
1.
Cilostazol
Class: Phosphodiesterase III enzyme inhibitor, anti platelet agent
Indication: Intermittent claudication. reduction of symptoms of intermittent claudication, as indicated by an increased walking distance.
Mechanism of Action: Cilostazol and its metabolites are inhibitors of phosphodiesterase III. as a result, cyclic GMP is increased.
Effects of mechanism of Action: leading to reversible inhibition of platelet aggregation, vasodilation, and inhibition of vascular smooth muscle cell proliferation
Adverse Effects: Headache, GI upset/diarrhea.
Absolute Contraindications: black box warning;>contraindicated in patients with heart failure
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): substrate of cyp1a2, CYP 2C19, CYP2D6, CYP3A4
Monitoring Parameters:–
Pearls:
1. ieffect on walking distance may take 2-4 weeks, may require up to 12 weeks
