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NAPLEX Review > Ischemic Heart Disease > Flashcards

Ischemic Heart Disease Flashcards

1
Q

What is angina?

A

Angina is chest pain, pressure, tightness or discomfort, usually caused by ischemia of the heart muscle or spasm of the coronary arteries

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2
Q

What is a description of chest pain with angina?

A

The chest pain is described as “squeezing,” “grip-like,” “heavy” or “suffocating,” and typically does not vary with position or respiration

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3
Q

What is stable angina?

A

Stable angina, also known as stable ischemic heart disease (SIHD), is associated with predictable chest pain, often brought on by exertion or emotional stress and relieved within minutes by rest or with nitroglycerin

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4
Q

What is unstable angina?

A

Unstable angina is a type of acute coronary syndrome (ACS); this is a medical emergency where the chest pain increases (in frequency, intensity or duration) and is not relieved with nitroglycerin or rest

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5
Q

Which population may classic symptoms of SIHD not present?

A

In women, elderly patients or those with diabetes

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6
Q

What is Prinzmetal’s angina?

A

When chest pain is caused by vasospasm of coronary arteries

*This type of angina can occur at rest and can be caused by illicit drug use, particularly cocaine

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7
Q

What happens when chest pain occurs?

A

Chest pain occurs when there is an imbalance between myocardial oxygen demand (workload) and supply (blood flow)

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8
Q

What is the pathophysiology of SIHD?

A

In SIHD, myocardial oxygen supply is often decreased due to plaque build up (atherosclerosis) within the inner walls of the coronary arteries, which is known as coronary artery disease; it causes narrowing of the arteries and reduced blood flow to the heart. Myocardial oxygen demand increases when the heart is working harder due to an increased heart rate, contractility or left ventricular wall tension

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9
Q

What are the risk factors for SIHD?

A

Hypertension, smoking, dyslipidemia, diabetes, obesity and physical inactivity

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10
Q

What is performed to assess the likelihood of CAD and diagnose SIHD?

A

A cardiac stress test

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11
Q

What is the cardiac stress test?

A

The cardiac stress test increased myocardial oxygen demand with either exercise or intravenous medications. As myocardial oxygen demand increases, the patient is monitored for the development of symptoms, changes in heart rate and blood pressure, transient rhythm disturbances or ST segment abnormalities on an ECG

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12
Q

When the diagnosis of SIHD is certain, what can be performed to assess the extent of atherosclerosis and need for revascularization?

A

Coronary angiography

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13
Q

What should be evaluated with SIHD?

A
  • History and physical
  • CBC, CK-MG, troponins (I or T), aPTT, PT/INR, lipid panel, glucose
  • ECG (at rest and during chest pain)
  • Cardiac stress test/stress imaging
  • Cardiac catherization/angiography
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14
Q

What should be the goal diet and BMI of a patient with SIHD?

A

Patients should be encouraged to follow a heart healthy diet, adequate intake of fresh fruits and vegetables, low-fat dairy, maintain a BMI of 18.5-24.9 kg/m2, and maintain a waist circumference < 35 inches in females and < 40 inches in males

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15
Q

How much exercise should patients with SIHD engage in?

A

Patients should engage in 30-60 minutes of moderate-intensity aerobic activity 5-7 days per week, supplemented by an increase in daily lifestyle activities. Medically supervised programs, such as cardiac rehabilitation, are encouraged for at-risk patients at first diagnosis

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16
Q

What are some other non-drug treatments that should be recommended for patients with SIHD?

A

Patients who smoke should quit, and secondhand smoke should be avoided. Alcohol intake should be limited to 1 drink/day for women and 1-2 drinks/day for men

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17
Q

What are the treatment goals for SIHD?

A

The treatment goals for SIHD are to improve function (by eliminating chest pain), prevent future cardiovascular events and reduce the risk of cardiovascular death

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18
Q

What drug treatments are used together for SIHD?

A

An antiplatelet and an antifungal drug regimen are used together

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19
Q

What does an antiplatelet treatment to?

A

Antiplatelet treatment prevents platelets from sticking together and forming a clot that can block an artery and reduce blood flow to the heart

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20
Q

What is the recommended antiplatelet?

A

Aspirin is the recommended antiplatelet; clopidogrel (Plavix) is used when there is an allergy of other contraindication to aspirin

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21
Q

In what scenario is the combination of aspirin and clopidogrel beneficial in SIHD?

A

The combination of aspirin and clopidogrel is only beneficial in SIHD when there is a history of stent placement or recent CABG

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22
Q

What is the combination of low-dose rivaroxaban (Xarelto) in combination with aspirin indicated for?

A

To reduce the risk of cardiovascular events in patients with CAD or peripheral artery disease (PAD)

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23
Q

What does antianginal treatment do?

A

Antianginal treatment decreases myocardial oxygen demand or increases myocardial oxygen supply

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24
Q

What are some antianginal treatment options?

A

Beta-blockers are first-line; calcium channel blockers (DHP and non-DHP) or long-acting nitrates should be used when beta-blockers are contraindicated or when additional symptomatic relief is needed. Ranolazine can be used as a substitute for, or in addition to, beta-blockers

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25
Q

What medications are recommended for immediate relief of angina in all patients?

A

Short-acting nitroglycerin, as a sublingual (SL) tablet, powder or translingual (TL) spray, is recommended for immediate relief of angina in all patients

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26
Q

What are some other treatment recommendations for patients with SIHD?

A

SIHD is one of the ASCVD. Patients should be treated with a high-intensity statin. Hypertension, heart failure and diabetes should be aggressively managed with guideline-recommended treatments, including the use of an ACE inhibitor or ARB to manage hypertension in patients with SIHD and diabetes. An annual influenza vaccine is recommended; pneumococcal vaccines should be administered per ACIP recommendations

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27
Q

What is the general treatment approach for SIHD?

A
  • Antiplatelet and antianginal drugs
  • Blood pressure and beta-blockers
  • Cholesterol (statins) and cigarettes (cessation)
  • Diet and diabetes
  • Exercise and education
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28
Q

What is the MOA of aspirin?

A

Aspirin irreversibly inhibits cyclooxygenase-1 and -2 (COX-1 and 2) enzymes, which results in decreased prostaglandin (PG) and thromboxane A2 (TXA2) production. TXA2 is a potent vasoconstrictor and inducer of platelet aggregation

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29
Q

What is the MOA of Clopidogrel?

A

Clopidogrel is a prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

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30
Q

What are some contraindications of aspirin?

A

NSAID or salicylate allergy; children and teenagers with viral infection due to the risk of Reye’s syndrome (symptoms include somnolence, N/V, confusion); rhinitis, nasal polyps or asthma (due to the risk of urticaria, angioedema or bronchospasm)

31
Q

What are some warnings of aspirin?

A

Bleeding (including GI bleed/ulceration, increased risk with heavy alcohol use or use with other drugs with bleeding risk, tinnitus (salicylate overdose)

32
Q

What are some side effects of aspirin?

A

Dyspepsia, heartburn, bleeding, nausea

33
Q

What are some monitoring parameters of aspirin?

A

Symptoms of bleeding, bruising

34
Q

What are some notes about Aspirin?

A
  • Used indefinitely in SIHD (unless contraindicated); decreased incidence of MI, CV events and death
  • Used with low-dose rivaroxaban to reduce the risk of major cardiovasulcar events
  • Non-enteric coated, chewable aspirin is preferred in ACS; if only enteric-coated (EC) aspirin is available, it should be chewed (325 mg)
  • Durlaza and Yosprala should not be used when rapid onset is needed
  • To decrease nausea, use EC or buffered product or take with food
  • PPIs may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (decrease bone density, increase infection risk)
  • Yosprala is indicated for those at risk of developing aspirin-associated gastric ulcers
35
Q

What is a boxed warning associated with Clopidogrel?

A

Clopidogrel is a prodrug. Effectiveness depends on the conversion to an active metabolite, mainly by CYP450 2C19. Poor metabolizers of CYP2C19 exhibit higher cardiovascular events than patients with normal CYP2C19 function. Tests to check CYP2C19 genotype can be used as an aid in determining a therapeutic strategy. Consider alternative treatments in patients identified as CYP2C19 poor metabolizers

36
Q

What are contraindications of Clopidogrel?

A

Active serious bleeding

37
Q

What are some warnings associated with Clopidogrel (Plavix)?

A

Bleeding risk, stop 5 days prior to elective surgery, do not use with omeprazole or esomeprazole, premature discontinuation (increased risk of thrombosis), thrombotic thrombocytopenic purpura (TTP)

38
Q

What are some side effects of Clopidogrel?

A

Generally well tolerated, unless bleeding occurs

39
Q

What are some monitoring parameters of Clopidogrel?

A

Symptoms of bleeding, Hgb/Hct as necessary

40
Q

What are some noes associated Clopidogrel?

A

Used in SIHD when there is a contraindication to aspirin; can be used in combination with aspirin

41
Q

What is dual antiplatelet therapy reserved for?

A

Dual antiplatelet therapy with aspirin and clopidogrel is reserved for those who have had placement of bare metal stent (DAPT for at least one month), a drug-eluting stent (DAPT for at least 6 months) or post-CABG (DAPT for 12 months)

42
Q

What are some significant antiplatelet drug interactions?

A
  • Most drug interactions are due to additive effects with other drugs that can increase bleeding risk
  • Aspirin: use caution in combination with other ototoxic drugs
  • Clopidogrel: avoid in combination with CYP2C19 inhibitors omeprazole and esomeprazole (other PPIs interact less) and use caution with other CYP2C19 inhibitors
43
Q

What medications are given for antianginal treatment?

A

Beta-blockers (1st line in SIHD), calcium channel blockers (preferred for Prinzmetal’s angina), nitrates, ranolazine

44
Q

What is the mechanism of clinical benefit of beta blockers?

A

Reduce myocardial oxygen demand: decreases HR, decreases contractility and decreases left ventricular wall tension

45
Q

What are some clinical notes about beta-blockers?

A
  • Start low, go slow; titrate to resting HR of 55-60 BPM; avoid abrupt withdrawal
  • Beta blockers without ISA are preferred (e.g. metoprolol, carvedilol); can be used as monotherapy or in combination with DHP CCBs, long-acting nitrates and/or ranolazine
  • Provide mortality reduction and symptom improvement
  • More effective than nitrates and CCBs in silent ischemia; avoid in Prinzmetal’s angina
46
Q

What is the mechanism of clinical benefit for calcium channel blockers?

A
  • Reduce myocardial oxygen demand: non-DHPs decrease HR and contractility; DHPs decrease SVR (afterload)
  • Increase myocardial oxygen supply; all CCBs increase blood flow through coronary arteries
47
Q

What are some clinical notes of calcium channel blockers?

A
  • Generally used when beta-blockers are contraindicated or as add-on therapy to beta-blockers if continued symptoms
  • Slow-release or long-acting DHPs and non-DHPs are effective; avoid short-acting DHPs
  • DHPs are preferred when CCBs are used in combination with beta-blockers (due to the risk of excessive bradycardia when non-DHPs are used with beta-blockers)
48
Q

What is the mechanism of clinical benefit of nitrates?

A
  • Reduce myocardial oxygen demand: decreased preload (free radical nitric oxide produces vasodilation of veins more than arteries)
  • Increases myocardial oxygen supply: increases blood flow through collateral (non-atherosclerotic) arteries
49
Q

What are some clinical notes about the nitrate SL tablets, SL powder or TL spray?

A

Recommended for all patients for fast relief of angina

50
Q

What are some clinical notes about long-acting nitrates?

A

Long-acting nitrates are used when beta0blockers are contraindicated or as add-on therapy, if continued symptoms; a nitrate-free interval is required to prevent tolerance

51
Q

What is the mechanism of clinical benefit of Ranolazine?

A

Selective inhibits the late phase Na current and decreases intracellular Ca; can decrease myocardial oxygen demand by decreasing ventricular tension and oxygen consumption

52
Q

What are some contraindications of Ranolazine?

A

Liver cirrhosis, do not use with strong CYP3A4 inhibitors or inducers

53
Q

What are some warnings associated with Ranolazine?

A
  • Can cause QT prolongation

- Acute renal failure observed when CrCl < 30 mL/min

54
Q

What are some side effects of Ranolazine?

A

Dizziness, headache, constipation, nausea

55
Q

What are some monitoring parameters of Ranolazine?

A

ECG, K, renal function

56
Q

What are some clinical notes of Ranolazine?

A
  • Not for acute treatment of chest pain
  • Can use in place of beta-blockers or as add-on treatment
  • Has little to no clinical effects on HR or BP
57
Q

What are some examples of short-acting nitrates?

A

Nitroglycerin SL tablet (Nitrostat), Nitroglycerin TL spray (NitroMist, Nitrolingual), Nitroglycerin SL powder (GoNitro)

58
Q

What are some examples of long-acting nitrates?

A

Nitroglycerin ointment 2% (Nitro-Bid), Nitroglycerin transdermal patch (Minitran, Nitro-Dur), Nitroglycerin ER (Nitro-Time), Isosorbide mononitrate IR/ER tablet (Monoket, Imdur), Isosorbide dinitrate IR/ER (Dilatrate-SR, Isordil Titradose)

59
Q

What are some contraindications of nitroglycerin?

A
  • Hypersensitivity to organic nitrates, do not use with PDE-5 inhibitors or riociguat
  • Short-acting nitrates: increased intracranial pressure, severe anemia, circulatory failure and shock (SL powder only)
60
Q

What are some warnings associated with Nitroglycerin?

A

Hypotension, headache, tachyphylaxis (decreased effectiveness/tolerance with long-acting products), can aggravate angina caused by hypertrophic cardiomyopathy

61
Q

What are some side effects associated with nitroglycerin?

A

Headache, flushing, syncope, dizziness

62
Q

What are some monitoring parameters of nitroglycerin?

A

BP, HR, chest pain

63
Q

What are some notes about short-acting nitrates?

A
  • Used PRN for immediate relief of chest pain
  • Store nitroglycerin SL tablets in the original amber glass bottle and keep tightly capped after each use (to maintain potency)
  • Nitrate tolerance does not develop with SL/TL products
64
Q

What are some notes about long-acting nitrates?

A
  • Require a 10-12 hour nitrate-free interval to decreased tolerance (longer for some products)
  • Patch: wear on for 12-14 hours; off for 10-12 hours; rotate sites; dispose of safely, away from children and pets
  • Ointment: dosed BID, 6 hours apart with a 10-12 hour nitrate free
  • Isosorbide mononitrate: IR dosed BID, 7 hours apart
  • Isosorbide dinitrate: IR dosed BID or TID, take at 8 AM, 12 PM and 4 PM for a 14 hour nitrate-free interval
  • Take ER daily in the morning or BID with an 18 hour nitrate-free interval
  • Isosorbide dinitrate in combination with hydralazine is the preferred formulation for HFrEF
65
Q

What are some significant nitrate drug interactions?

A
  • Do not use long-acting nitrates in combination with PDE-5 inhibitors and riociguat; use caution with other antihypertensive medications and alcohol, as these combinations can cause a significant decrease in BP
  • If only short-acting nitrates are used, they should not be used if 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)
66
Q

What are some significant Ranolazine drug interactions?

A

Ranolazine is a major substrate of CYP3A4 and a minor substrate of CYP2D6 and P-gp. It is a weak inhibitor of CYP3A4, 2D6 and P-gp. Do not use with strong CYP3A4 inhibitors or inducers. Limit the dose to 500 mg BID if taking moderate CYP3A4 inhibitors. Limit simvastatin to 20 mg/day if used together

67
Q

What are some key counseling points of aspirin?

A

Can cause bleeding/bruising, dyspepsia, allergy, tinnitus or loss of hearing with overdose

68
Q

What are some key counseling points of Clopidogrel?

A

Can cause bleeding/bruising, thrombotic thrombocytopenic purpura (TTP)

69
Q

What are some key counseling points of all Nitroglycerin products?

A
  • Can cause orthostasis, flushing and headache (often a sign the medication is working and usually goes away with time)
  • Nitrate-free interval required with long-acting products
  • Drug interactions with phosphodiesterase-5 inhibitors
70
Q

What are some key counseling points of short-acting nitrates?

A
  • Take one dose at first sign of chest pain
  • Call 911 immediately if chest pain persists after the first dose. Continue to take two additional doses at five minute intervals while waiting for the ambulance to arrive. Do not take more than three doses within 15 minutes
71
Q

What are some key counseling points of Nitroglycerin SL tablets?

A
  • Place the tablet under the tongue or between the inside of the cheek and the gums/teeth, and let it dissolve. Do not chew, crush or swallow
  • Slight burning or tingling sensation is not a sign of how well the medication is working
  • Keep tightly capped in the original amber glass bottle and store at room temperature. Shake out one tablet only; do not let the other tablets get wet
72
Q

What are some key counseling points of Nitroglycerin TL spray?

A
  • Prime before first use and if not used within six weeks
  • Do not shake. Press the button firmly to release the spray onto or under the tongue. Close your mouth after the spray. Do not inhale the spray and try not to swallow too quickly afterward. Do not spit or rinse the mouth for 5-10 minutes after the dose
73
Q

What is a key counseling point of the nitroglycerin patch?

A

The chest is the preferred application site, though any area can be selected except the extremities below the knees of elbows

74
Q

What are some key counseling points of nitroglycerin ointment?

A
  • Measure the dose of ointment with the dose-measuring applicator provided. Place the applicator on a flat surface, squeeze the ointment onto the applicator and place the applicator on the chest or other desired area of the skin
  • Spread the ointment, using the dose measuring applicator, lightly onto the skin. Do not rub into the skin. Tape the applicator into place
  • Can stain clothing. Cover the applicator completely

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