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Clinical 2.0 > Ischemic heart disease > Flashcards

Ischemic heart disease Flashcards

1
Q

modifiable risk factors

A 
smoking 
dyslipidemia
diabetes
hypertension 
chronic kidney disease
physical inactivity 
poor diet
obesity 
depression 
drugs
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2
Q

nonmodifiable risk factors

A 
men over 40 
women over 50 or postmenopausal 
male sex
family history of premature CV disease
ethnicity
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3
Q

difference between stable and unstable angina

A

in stable there is a fixed atherosclerotic plaque that has a thick fibrous cap
in unstable the plaque is disrupted

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4
Q

define ischemia

A

mismatch between coronary oxygen supply and demand

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5
Q

what can increase myocardial oxygen demand

A

heart rate
contractility
intramyocardial wall tension

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6
Q

3 examples of causes of increased oxygen demand

A

tachycardia
hypertension
hyperthyroidism

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7
Q

what can affect myocardial oxygen delivery

A

coronary blood flow
oxygen extraction
oxygen availability

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8
Q

examples of decrease oxygen delivery

A

coronary artery disease, anemia, COPD

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9
Q

clinical symptoms of chronic stable angina

A 
chest pain - pressure, squeezing, crushing, tightness
shortness of breath 
sweating 
nausea
weakness
gradual onset
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10
Q

where and how long do the symptoms last

A

.5-30min

left sided radiation to arm, shoulder, jaw

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11
Q

precipitating factors for chronic stbale angina

A 
exercise
cold
walking after a large meal 
emotions
coitus
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12
Q

chronic stable angina response to nitro

A

relief of pain within 45s to 5 min

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13
Q

describe ccs class 1 angina

A

ordinary physical activity doesnt cause angina

angina with strenuous exertion

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14
Q

describe ccs class 2 angina

A

slight limitation of ordinary activity

angina from walking more than 2 blockd or climbing more than 1 flight of stairs

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15
Q

ccs class 3 angina

A

marked limitations of ordinary physical activity

angina walking 1-2 blocks and climbing 1 set of stairs

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16
Q

ccs class 4 angina

A

inability to carry any physical activity without discomfort anginal symptoms at rest

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17
Q

what is the diagnosis of stable angina based on

A

symptoms
risk factors
diagnostic tests

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18
Q

what is the stress test

A

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

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19
Q

what is the mibi stress test

A

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

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20
Q

what is echocardiography and when is it indicated

A

measures left ventricular systolic function

indicated when heart failure suspected

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21
Q

what is an angiogram

A

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

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22
Q

who is angiogram indicated for

A

patients with high risk features during stress test or if severe angina, diabetic

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23
Q

how do you describe pain (PQRST)

A 
provoking factors 
quality of pain 
region 
severity 
timing
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24
Q

goals of therapy

A 
relieve acute symptosm 
prevent recurrent symptoms 
maintain activity level and quality of life 
reduce CV complications 
minimize risk of death
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25
Q

how do beta blockers reduce cardiac oxygen demand

A

decrease heart rate, contractility, and intramyocardial wall tension

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26
Q

what is first line for treatment of chronic stable angina

A

beta blocker

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27
Q

abrupt withdrawal of BB may increase severity and number of pain episodes so what should you do

A

taper over 10-14 days

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28
Q

what might beta blockers worsen the symptoms of

A

reactive airway disease

peripheral artery disease

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29
Q

what can happen after chronic use of beta blockers

A

changes the beta receptors, if dont taper off could have rebound ischemia

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30
Q

why should you caution beta blockers in diabetes

A

may worsen hyperglycemia by inhibiting insulin release on pancreatic beta cells
masks symptoms of hypoglycemia**

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31
Q

which beta blockers should you avoid in severe angina

A

agents with intrinsic sympathic activities

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32
Q

what dose does metoprolol lose its selectivity

A

200mg/day

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33
Q

which beta blockers have evidence for decreasing mortality post mi

A

timolol
propranolol
metoprolol

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34
Q

cardio selective beta blockers

A

atenolol
bisoprolol
metoprolol

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35
Q

non selective beta blockers

A

nadolol
propranolol
timolol

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36
Q

mixed alpha and beta blocker

A

carvediol

note: more orthostatic hypotension

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37
Q

cardioselective and vasodilatory beta blocker

A

nebivolol

38
Q

atenolol dose

A

25-100mg daily

39
Q

bisoprolol dose

A

2.5-10mg daily

40
Q

metoprolol dose

A

50-200 mg daily

41
Q

nadalol dose

A

40-120mg daily

42
Q

propranolol dose

A

40-160mg daily

43
Q

propranolol LA dose

A

80-320mg daily

44
Q

timolol dose

A

10-40mg daily

45
Q

carvedilol dose

A

25-50mg daily

46
Q

nebivolol dose

A

5-20mg daily

47
Q

how do ccb decrease cardiac oxygen demand

A

decrease conduction veolcity through sa and av nodes
decrease bp through atrial dilation
decrease wall tension and myocardial contractility

48
Q

how do ccb improve coronary blood flow

A

vasodilates coronary arteries
decrease coronary vascular resistance
precents vasospasm

49
Q

ccb is as effective as beta blockers in preventing angina but why isnt it first line

A

hasnt been shown to improve survival after mi

50
Q

difference between dihydropyridine and non dihydropyridines

A

dhp - do not decrease av node conduction or contractility, more peripheral vasodilation
non dhp: act more centrally decreasing contractility

51
Q

example of dihydropyridine

A

amlodipine

nifedipine

52
Q

example of non dihydropyridine

A

verapamil and diltiazem

53
Q

what ccb can you use in combo with beta blockers

A

dihydropyridines only

nondhp would double the effects on the heart

54
Q

side effects of ccb

A 
hypotension 
flushing 
headache
dizziness
peripheral edema
55
Q

non dhp side effects

A

bradycardia
worsening heart failure
verapamil - constipation

56
Q

diltiazem dosing

A

IR: 60mg tid
ER: 120-360 daily

57
Q

verapamil dosing

A

IR: 80 mg tid
SR: 120-180 daily

58
Q

amlodipine dosing

A

5-10mg daily

59
Q

nifedipine dosing why only use XL

A

30-60 daily avoid IR due t increased risk of mi/stroke

60
Q

how do nitrate reduce myocardial oxygen demand

A

venodilation and arterial-arteriolar dilation

dilate coronary arteries - increase coronary blood flow

61
Q

how and what nitreates are used for acute anginal attacks

A

sublingual, buccal, spray rapidly absorbed

relieves pain in 3-15 min

62
Q

how are nitrates used to prevent effort or stress induced attacks

A

use 5 min prior to activity lasts for 30 min

63
Q

long acting nitrates are used for what

A

3rd line for controlling angina symptoms

combo with beta blocker or ccb

64
Q

2 long acting formulations

A

isosorbide dinitrate

transdermal nitroglycerin

65
Q

why arent nitrates first line

A

havent been shown to reduce mortalitiy in patients with CAD

relieves symptoms but does not improve outcomes

66
Q

side effects of nitrates

A

headache - take tylenol normally subsides
flushing
hypotension

67
Q

tolerance can develop i taking nitrates for 7-10 days how do you manage this

A

nitrate free period 8-12 hr

recommend taking in the morning then wont need it at night so that can be nitrate free period

68
Q

interaction with nitrates

A

phosphodiesterase inhibitors - sildenafil

69
Q

dosing not nitro sublingual/spray

A

.4mg q5min prn

70
Q

nitro transdermal dosing

A

.2mg/h patch removed daily start

max .8mg/h patch daily

71
Q

isosorbide dinitrate dosing

A

SL: 5mg q5min prn
IR: 10-30mg tid

72
Q

isosorbide mononitrate dosing

A

ER: start 30-60 mg daily

max 240g daily

73
Q

***** COUNSELLING FOR NITRO PUMP SPRAY

A

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

74
Q

** counselling for nitro sublingual tablet

A 
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
75
Q

what are secondary prevention agents

A

antiplatelet - asa, clopidogrel
statins
acei
revascularization - ptca, cabg

76
Q

what is the use for antiplatelets in ischemic heart disease

A

prevent thromus formation

77
Q

dose for asa

A

75- 325 mg daily

78
Q

dos of clopidogrel and when do you use it

A

75mg daily

when cant tolerate asa

79
Q

should you use asa and clopidogrel together

A

no benefit compared to asa alone and increase bleeding events - no

80
Q

what do statins do in ischemia heart disease

A

decrease cv death and nonfatal mi in patients with established chd

81
Q

what is the recommended target with statins

A

<2mmol/L or 50% reduction from baseline - wrong

82
Q

what doses of simvastatin and atorvastatin are recommended

A

sim - 40 daily

ator - 80 daily

83
Q

how do acei help in ischemic heart disease

A

decrease sympathetic adrenergic transmission
decrease afterload by lowering bp
increase coronary blood flow

84
Q

which acei should reduction of cv death, nonfatal mi, and nonfatal stroke and at what dose

A

ramipril 10mg daily

perindopril 8mg

85
Q

benefit of acei beyond bp control in low risk chd patients is questionable so when is it indicated for ischemia

A 
bp control in addition to bb 
prior mi 
lv dysfunction 
diabetes 
chronic kidney carrier
86
Q

what arb is used at what dose

A

telmisartan 80

87
Q

when are arbs recommended for patients at high risk of cv events

A

intolerant to acei

88
Q

when is revascularization indicated

A

in symptomatic high risk patients unlikely to benefit from medical treatment alone
no improvement after maximization on medications

89
Q

whats triple vessel disease

A

plague in many of the main coronary arteries, often many other risk factors

90
Q

see risk factor modications

A

ok

Clinical 2.0 (24 decks)

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