Ischemic heart disease Flashcards
modifiable risk factors
smoking dyslipidemia diabetes hypertension chronic kidney disease physical inactivity poor diet obesity depression drugs
nonmodifiable risk factors
men over 40 women over 50 or postmenopausal male sex family history of premature CV disease ethnicity
difference between stable and unstable angina
in stable there is a fixed atherosclerotic plaque that has a thick fibrous cap
in unstable the plaque is disrupted
define ischemia
mismatch between coronary oxygen supply and demand
what can increase myocardial oxygen demand
heart rate
contractility
intramyocardial wall tension
3 examples of causes of increased oxygen demand
tachycardia
hypertension
hyperthyroidism
what can affect myocardial oxygen delivery
coronary blood flow
oxygen extraction
oxygen availability
examples of decrease oxygen delivery
coronary artery disease, anemia, COPD
clinical symptoms of chronic stable angina
chest pain - pressure, squeezing, crushing, tightness shortness of breath sweating nausea weakness gradual onset
where and how long do the symptoms last
.5-30min
left sided radiation to arm, shoulder, jaw
precipitating factors for chronic stbale angina
exercise cold walking after a large meal emotions coitus
chronic stable angina response to nitro
relief of pain within 45s to 5 min
describe ccs class 1 angina
ordinary physical activity doesnt cause angina
angina with strenuous exertion
describe ccs class 2 angina
slight limitation of ordinary activity
angina from walking more than 2 blockd or climbing more than 1 flight of stairs
ccs class 3 angina
marked limitations of ordinary physical activity
angina walking 1-2 blocks and climbing 1 set of stairs
ccs class 4 angina
inability to carry any physical activity without discomfort anginal symptoms at rest
what is the diagnosis of stable angina based on
symptoms
risk factors
diagnostic tests
what is the stress test
measures the hearts reaction to increased oxygen demand
exercise or pharmacologic agents to induce stress
ECG and BP taken before during an after stress induced
what is the mibi stress test
use of radioisotope with stress test
imaging taken to record pattern of radioactivity distribution to various parts of myocardium
difference in uptake in certain areas indicate potential ischemic sites
what is echocardiography and when is it indicated
measures left ventricular systolic function
indicated when heart failure suspected
what is an angiogram
contrast material that can be seen using xray equipment is injected into the coronary arteries to visualize blood flow through the heart
catheter through the femoral up to the heart
provides real time visualization of coronary blood flow
who is angiogram indicated for
patients with high risk features during stress test or if severe angina, diabetic
how do you describe pain (PQRST)
provoking factors quality of pain region severity timing
goals of therapy
relieve acute symptosm prevent recurrent symptoms maintain activity level and quality of life reduce CV complications minimize risk of death
how do beta blockers reduce cardiac oxygen demand
decrease heart rate, contractility, and intramyocardial wall tension
what is first line for treatment of chronic stable angina
beta blocker
abrupt withdrawal of BB may increase severity and number of pain episodes so what should you do
taper over 10-14 days
what might beta blockers worsen the symptoms of
reactive airway disease
peripheral artery disease
what can happen after chronic use of beta blockers
changes the beta receptors, if dont taper off could have rebound ischemia
why should you caution beta blockers in diabetes
may worsen hyperglycemia by inhibiting insulin release on pancreatic beta cells
masks symptoms of hypoglycemia**
which beta blockers should you avoid in severe angina
agents with intrinsic sympathic activities
what dose does metoprolol lose its selectivity
200mg/day
which beta blockers have evidence for decreasing mortality post mi
timolol
propranolol
metoprolol
cardio selective beta blockers
atenolol
bisoprolol
metoprolol
non selective beta blockers
nadolol
propranolol
timolol
mixed alpha and beta blocker
carvediol
note: more orthostatic hypotension
cardioselective and vasodilatory beta blocker
nebivolol
atenolol dose
25-100mg daily
bisoprolol dose
2.5-10mg daily
metoprolol dose
50-200 mg daily
nadalol dose
40-120mg daily
propranolol dose
40-160mg daily
propranolol LA dose
80-320mg daily
timolol dose
10-40mg daily
carvedilol dose
25-50mg daily
nebivolol dose
5-20mg daily
how do ccb decrease cardiac oxygen demand
decrease conduction veolcity through sa and av nodes
decrease bp through atrial dilation
decrease wall tension and myocardial contractility
how do ccb improve coronary blood flow
vasodilates coronary arteries
decrease coronary vascular resistance
precents vasospasm
ccb is as effective as beta blockers in preventing angina but why isnt it first line
hasnt been shown to improve survival after mi
difference between dihydropyridine and non dihydropyridines
dhp - do not decrease av node conduction or contractility, more peripheral vasodilation
non dhp: act more centrally decreasing contractility
example of dihydropyridine
amlodipine
nifedipine
example of non dihydropyridine
verapamil and diltiazem
what ccb can you use in combo with beta blockers
dihydropyridines only
nondhp would double the effects on the heart
side effects of ccb
hypotension flushing headache dizziness peripheral edema
non dhp side effects
bradycardia
worsening heart failure
verapamil - constipation
diltiazem dosing
IR: 60mg tid
ER: 120-360 daily
verapamil dosing
IR: 80 mg tid
SR: 120-180 daily
amlodipine dosing
5-10mg daily
nifedipine dosing why only use XL
30-60 daily avoid IR due t increased risk of mi/stroke
how do nitrate reduce myocardial oxygen demand
venodilation and arterial-arteriolar dilation
dilate coronary arteries - increase coronary blood flow
how and what nitreates are used for acute anginal attacks
sublingual, buccal, spray rapidly absorbed
relieves pain in 3-15 min
how are nitrates used to prevent effort or stress induced attacks
use 5 min prior to activity lasts for 30 min
long acting nitrates are used for what
3rd line for controlling angina symptoms
combo with beta blocker or ccb
2 long acting formulations
isosorbide dinitrate
transdermal nitroglycerin
why arent nitrates first line
havent been shown to reduce mortalitiy in patients with CAD
relieves symptoms but does not improve outcomes
side effects of nitrates
headache - take tylenol normally subsides
flushing
hypotension
tolerance can develop i taking nitrates for 7-10 days how do you manage this
nitrate free period 8-12 hr
recommend taking in the morning then wont need it at night so that can be nitrate free period
interaction with nitrates
phosphodiesterase inhibitors - sildenafil
dosing not nitro sublingual/spray
.4mg q5min prn
nitro transdermal dosing
.2mg/h patch removed daily start
max .8mg/h patch daily
isosorbide dinitrate dosing
SL: 5mg q5min prn
IR: 10-30mg tid
isosorbide mononitrate dosing
ER: start 30-60 mg daily
max 240g daily
***** COUNSELLING FOR NITRO PUMP SPRAY
do not shake, store away from light
prime by spraying 5 times
be seated
release spray onto or under tongue, close mouth, do not inhale the spray
do not expectorate or rinse the mouth for 10-15 min
contact 911 if does not relieve angina
prime again if unused for 6 weeks
use prophylactically as needed
make sure not expired and refill when needed
** counselling for nitro sublingual tablet
keep in original dark container, do not store in bathroom be seated put under tongue do not swallow contact 911 if does not relieve angina use prophalactically as needed good for 6 months after opened
what are secondary prevention agents
antiplatelet - asa, clopidogrel
statins
acei
revascularization - ptca, cabg
what is the use for antiplatelets in ischemic heart disease
prevent thromus formation
dose for asa
75- 325 mg daily
dos of clopidogrel and when do you use it
75mg daily
when cant tolerate asa
should you use asa and clopidogrel together
no benefit compared to asa alone and increase bleeding events - no
what do statins do in ischemia heart disease
decrease cv death and nonfatal mi in patients with established chd
what is the recommended target with statins
<2mmol/L or 50% reduction from baseline - wrong
what doses of simvastatin and atorvastatin are recommended
sim - 40 daily
ator - 80 daily
how do acei help in ischemic heart disease
decrease sympathetic adrenergic transmission
decrease afterload by lowering bp
increase coronary blood flow
which acei should reduction of cv death, nonfatal mi, and nonfatal stroke and at what dose
ramipril 10mg daily
perindopril 8mg
benefit of acei beyond bp control in low risk chd patients is questionable so when is it indicated for ischemia
bp control in addition to bb prior mi lv dysfunction diabetes chronic kidney carrier
what arb is used at what dose
telmisartan 80
when are arbs recommended for patients at high risk of cv events
intolerant to acei
when is revascularization indicated
in symptomatic high risk patients unlikely to benefit from medical treatment alone
no improvement after maximization on medications
whats triple vessel disease
plague in many of the main coronary arteries, often many other risk factors
see risk factor modications
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