Ischemic Heart Disease Flashcards
what mostly causes ischemic heart dz
by atherosclerotic narrowing of coronary arteries
what is the cardinal symptom of ischemic heart dz
chest pain (angina)
4 major factors that determine mycardial work
Heart rate
SBP
myocardial wall tension/ stress
myocardial contractility
why is it hard for the heart to increase O2 extraction with increased demand
heart extracts near maximal amount of O2 at rest
Angina characterized by paroxysmal chest “squeezing” or pressure, often accompanied by sensation of smothering and fear of impending death
Angina pectoris
Exacerbated by physical activity and relieved by rest or sublingual nitroglycerin
Chronic stable angina
Increasing pattern of pain in previously stable patient
Less responsive to medications, lasts longer, and occurs at rest or with less exertion
unstable angina
Occurs in patient with or without coronary heart disease and is due to a spasm of the coronary artery that decreases myocardial blood flow
More likely to experience pain at rest and in early morning hours
Pain not usually brought on by exertion or emotional stress or relieved by rest
Occurs most often in smokers, young patients, with illicit drug use (esp. cocaine) and with alcohol withdrawal
Vasospatic (Prinzmetal’s angina)
precipitating factors to angina
exercise use of arms above head cold environment walking against the wind walking after large meal emotional factors coitus
If nitroglycerin relieves chest pain what is it more likely
ischemic heart dz
risk factors for ischemic heart dz
HTN hypercholesterolemia smoking family hx of premature CHD DM CKD
what test should be done with those that have suspected stable ischemic heart dz?
stress testing
3 classes of drugs used for management of angina
nitrates
calcium channel blockers
beta blockers
what do all the drugs that help with angina do
decrease myocardial O2 demand
nitrates increase mycoardial O2 delivery by reversing coronary spasm
what drugs Relaxation of capacitance vessels (veins and venules) Decrease venous return- decrease heart size- decrease preload
nitrates
CCB
what drugs Blockade or attenuation of sympathatic influence on heart- decrease contractility- decrease HR- decrease Oxygen demand
BB
what drugs Coronary dilation- important for relieving vasospastic angina- increase oxygen supply
Nitrates
MOA of nitrates
Denitrated in smooth muscle cells NO activation of guanylate cyclasecGMP increased Ca++ uptake by SR
relax smooth muscle and decrease platelet aggregation
What is the method of administration for nitrates and why
Sublingual or transdermal due to significant first pass effect in liver
ADRs of nitrates
HA
orthostatic HPOTN
facial flushing tachycardia
What happens with tolerance to nitrates (occurs rapidly)
tachyphylaxis
how much time should patients have off for transdermal patches per day of nitrates
8 hours to avoid tachyphylaxis
what can not be used with nitroglycerin
Sildenafil (Viagra)
everyone with ischemic heart dz should have what available to them?
nitroglycerin sublingual tablets (or buccal spray, topical)
what are some long acting nitrates given orally qday or BID that is used in chronic stable angina
isosorbide dinitrate
isosorbide mononitrate
when are beta blockers contraindicated
Variant angina
who are CCB c/i in?
unstable angina
Mechanism of clinical effects of CCB
Decrease myocardial contractile force – decreases oxygen demand
Decrease arteriolar tone and PVR – decreases ventricular wall stress
Increase myocardial O2 supply
Relieve and prevent vasospasm
ADRs with CCB
HPOTN
gingival hyperplasia
constipation (verapamil)
2 CCB that can lead to myocardial dperssion
verapamil
diltiazem
what CCB may worsen CHF due to negative inotropic effects
verapamil
what is a late CCB that is used in place of BB or in addition to a BB, newer therapy
Ranolazine
if a patient has a cenet MI and angina what should you Rx
long acting nitrate, BB
is a pt has angina and astham/ COPD what drugs Rx
long acting nitrate, Ca++ blockers
Drugs for patients w/ DM and angina
long acting nitrate
Ca++ blockers
Tx for angina in addition to angina what should be Rx
baby aspirin
BB (with prior MI)
ACEI (with CAD, DM or LV systolic dysfunction)
LDL lowering therapy (w/ CAD and LDL >100)
SL nitroglycerin
CCB or long actin gnitrates when BB c/I of in combo if BB not successful
