Ischemic Heart Disease

Question 1

What is angina?

Answer 1

Chest pain, pressure, tightness caused by ischemia of the heart muscle or spasm of coronary arteries.

Question 2

What is stable angina?

Answer 2

AKA as Stable Ischemic Heart Disease (SIHD)

predictable chest pain brought on by exertion and relieved within minutes by rest or nitroglycerin.

Question 3

What is unstable angina?

Answer 3

Is a type of acute coronary syndrome (ACS) where chest pain is unrelieved by rest or nitroglycerin.

Question 4

What is Prinzmetal’s angina?

Answer 4

Chest pain caused by vasospasm of coronary arteries and occurs at rest and caused by cocaine use.

Question 5

Chest pain occurs when there is an imbalance of what?

Answer 5

Imbalance between myocardial oxygen demand (workload) and supply (blood flow).

Question 6

What is performed to diagnose CAD and SIHD?

Answer 6

Cardiac stress test - increase myocardial oxygen demand with exercise (walking on treadmill) or IV medications.

Question 7

Name the IV medications used in a cardiac stress test?

Answer 7

1. Adenosine
2. Dipyridamole
3. Dobutamine
4. Regadenoson (Lexiscan)

Question 8

Treatment Approach for SIDH

Answer 8

A - Antiplatelet and antianginal drugs
B - Blood pressure and beta-blockers
C - Cholesterol (statins) & cigarettes (cessation)
D - Diet and diabetes
E - Exercise & education

Question 9

What is the recommended antiplatelet in SIHD?

Answer 9

DOC: Aspirin

Alt: Clopidogrel (if allergy to salicylates or contraindicated)

Question 10

Name the antianginal agents.

Answer 10

First-line: Beta-blockers

Alt (if B-blockers CI): CCBs (DHP/Non-DHP), or long-acting nitrates

Substitution or add-on tx to B-blockers: Ranolazine

Question 11

What agents are recommended in patients for immediate relief?

Answer 11

Short-acting nitroglycerin sublingual (SL)

Question 12

Aspirin

MOA, Warnings & Contraindications

Answer 12

MOA: Irreversibly inhibits COX-1 and 2, which decreases prostaglandin and thromboxane A2

Warnings: Bleeding, tinnitus (salicylate OD)

Contraindications: salicylate allergy, children <18 due to Reye’s Syndrome

Question 13

Clopidogrel

MOA, Boxed Warnings, & Warnings

Answer 13

MOA: Prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

Boxed Warnings: Prodrug, converts to active metabolite by CYP450 2C19 (poor metabolizers)

Warnings: Bleeding risk; stop 5 days prior to elective surgery, no not use omeprazole or esomeprazole, TTP

Question 14

Dual Antiplatelet Therapy (DAPT) agents

Length of duration for specific indications

Answer 14

——Aspirin + Clopidogrel——

1. Bare metal stent (at least 1 month)
2. Drug-eluting stent (at least 6 months)
3. Post-CABG (12 months)

Question 15

DAPT DDIs

Answer 15

Anticoagulants, NSAIDs, SSRIs, SNRIs and some herbals —–> Increase bleeding risk

Question 16

What drug class is preferred in Prinzmetal’s angina?

Answer 16

Calcium Channel Blockers (CCBs)

Question 17

Nitroglycerin Formulations Used in SIHD

Nitrostat - Generic & Dose

Answer 17

Nitroglycerin SL tablet 0.4 mg

Question 18

Nitroglycerin Formulations Used in SIHD

Nitro-Bid - Generic & Strength

Answer 18

Nitroglycerin ointment 2%

Question 19

Nitroglycerin Formulations Used in SIHD

Nitroglycerin TL spray - Brand & Dose

Answer 19

NitroMist & Nitrolingual 0.4 mg

Question 20

Nitroglycerin Used in SIHD

Safety/Side Effects/Monitoring

Answer 20

CI: do NOT use with PDE-5 inhibitors

Warnings: Hypotension & tachyphylaxis

SE: HA, flushing, syncope

Question 21

Nitroglycerin Used in SIHD

Short-acting vs Long-acting Counseling Points

Answer 21

Short-acting nitrates: PRN for immediate relief of chest pain (call 911 if chest pain persist after 1st dose); keep in original amber glass bottle

Long-acting nitrates: Require a 10-12 hour nitrate-free interval to decrease tolerance
-Patch: wear on 12-14, off 10-12 hours (rotate sites)
-Ointment: dosed BID, 6 hours apart with 10-12 hour
nitrate-free

Question 22

Long-acting nitrates

How is isosorbide mononitrate IR dosed?

Answer 22

Dosed BID, 7 hours apart

Question 23

BiDil is the preferred formulation in HFrEF. What is generic?

Answer 23

Isosorbide dinitrate + Hydralazine

Question 24

What is the preferred application site for a nitroglycerin patch?

Answer 24

Chest

Question 25

Nitroglycerin SL tablet Counseling Points

Answer 25

1. Place tab under tongue and let it dissolve.
2. Slight burning and tingling sensation is not a sign of how well medication is working.
3. Keet SL tab in original amber glass bottle.
4. Call 911 if chest pain persists after 1st dose. Continue to take 2 additional doses at 5 min intervals. Do not exceed 3 doses within 15 min.

Question 26

Nitroglycerin TL Spray Counseling Points

Answer 26

1. Do not shake.
2. Spray onto or under the tongue.
3. Do NOT inhale the spray.