Ischemic Heart Disease, Angina, and Myocardial InfarctionCIS Flashcards
You initiate treatment with an oral agent that should reduce the frequency of chronic angina episodes by decreasing myocardial O2demand without causing systemic vasodilation. Which drug best fits this description?
metoprolol
Drugs for Angina Prophylaxis
Cardioselective beta blockers
Calcium channel blockers
Long-acting nitrates
- Choice of drug depends on presence of contraindications and individual response of patient
- Combinations may be more effective than monotherapy
Cardioselectivebeta blockers
–E.g., atenolol, metoprolol
–Nonselective agents also frequently used
Calcium channel blockers
–Long-acting dihydropyridine, e.g. amlodipine or felodipine
–Non-dihydropyridine, e.g. verapamil or diltiazem
Long-acting nitrates
–Oral: isosorbidedinitrateor nitroglycerin (NTG)
–Sublingual (tablet or spray): NTG as needed
55 y/o female presents to the emergency room with two episodes of retrosternal chest pain, each lasting 20 minutes and over the last 4 hours. She has never had anything like this before. Her EKG shows T-wave flattening and her initial CPK and troponin levels are negative. She has no history of hypertension or diabetes. There is no heart disease in her family. Her LDL cholesterol is 98. While in the emergency room she has a third episode of chest pain that is associated with ST depression and relieved with nitroglycerin. Her EKG findings return to her baseline with T-wave flattening. Her blood pressure is 130/70 her heart rate is 70. What is your management approach?
Admission to the hospital and treatment with anti-anginal agents and stress test evaluation
carvedilol and labetalol are beta blockers that cause
vasodiatlion by blocking alpha blockesr
The patient’s anti-anginal medications are adjusted as discussed and she is placed on an exercise treadmill with a standard Bruce protocol and reaches her maximum heart rate and has no ST changes. Your clinical approach should be to:
Discharge her from the hospital with a follow up in two weeks.
78 y/o woman presents to the hospital on a Saturday in rural Colorado. She has 45 minutes of retrosternal chest pain associated with nausea and diaphoresis. The pain is relieved after two sublingual nitroglycerin tablets. She has a history of NIDDM, HTN and hypercholesterolemia. The local hospital does not have a cath lab. The closest referral hospital is three hours away. Her EKG and cardiac enzymes are unremarkable. Her serum creatinine is 1.8. Her blood pressure is 138/88 pulse is 64 and her HBA1C is 8.5. Her cholesterol is 250 with an LDL of 170.
•Current medications are
–Metformin 500mg twice daily (for diabetes)
–Lovastatin 20mg daily (for elevated cholesterol)
–Celecoxib 200mg twice daily (for arthritis)
–Lisinopril 10 mg daily (for HTN)
•Your approach should be to:
•How would you classify (diagnose) this patient based upon how she first presented to the hospital?
Which of the patient’s current medications should be stopped immediately?
As a part of your risk stratification you choose which of the following work up options?
Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management
unstable angina
Celecoxib
Perform a stress test
Unstable angina definition
–New onset
–At rest
–Crescendo
In addition to the sublingual NTG already administered and O2, which of the following is recommended as initial therapy for this patient’s acute unstable angina?
Aspirin
Drugs for Acute Angina
•Oxygen, especially if O2saturation
•Aspirin for antiplatelet effects
–Clopidogrelis an alternative if aspirin is contraindicated
•Nitroglycerin to produce systemic vasodilation
–Reduces myocardial O2demand by reducing preload
–Increases O2delivery by dilating coronaries
•Morphine
–If chest pain is unresponsive to nitroglycerin
–Also relieves anxiety
–Associated with increased mortality in unstable angina/NSTEMI
also can dialate a little bit so it helps with that
NSAID Cyclooxygenase (COX) Selectivity
Non-selective
- Inhibit both COX-1 (aka platelet COX) and COX-2
- Diclofenac, ibuprofen, indomethocin, naproxen, sulindac, many others
- Aspirin is an irreversibleCOX inhibitor
- Acetaminophen is a weak inhibitor of COX-1 and COX-2, but is not an NSAID because it has no significant anti-inflammatory effects
NSAID Cyclooxygenase (COX) Selectivity
COX-2 Selective
- Celecoxib and meloxicam
- Several other “coxibs” withdrawn from the market
- No effect on platelets or bleeding time
- Significantly less GI ulcers
NSAID Cyclooxygenase (COX) Selectivity, why do you stop both with a heart problem
increase cv risk with both thats why you stop it immediately
NSAIDs and Cardiovascular Risk
- BothCOX-2 selective andnon-selective NSAIDs are associated with increased risk of adverse cardiovascular events
- Risk increases at higher doses
- New studies continue to evaluate whether the risk is higher or lower with any particular NSAID
NSAIDs and Cardiovascular Risk
exception
aspirin is cardioprotectiveat low doses (75-325 mg daily) where antiplatelet effects predominate
Perform an image augmented stress test with
lbbb
The patient is treated with aspirin, nitrates and on a standard Bruce protocol exercise stress test has ST segment depressions in leads V1-4 that resolve by stopping the stress test. She did not reach her maximum heart rate. What should be your next approach?
coronary angiogram
- 70 y/o male with long standing history of diabetes and hypertension presents to the emergency room with chest pain, worsening shortness of breath and diaphoresis. This has become progressively worse over the last month.
- On physical exam he is cyanotic, blood pressure is 160/94, pulse is 80 and respirations 20. He has crackles is his lungs at the bases bilaterally, +3 edema, and an S3.
- His HBA1C is 9.0, his LDL cholesterol is 170, and serum creatinine is 1.1.
- He is currently on metoprolol succinate 100mg qd, and nitroglycerin patch 0.4mg/hrchanged daily.
- His EKG is shown after he walks 200 feet in the ER hallway. st depression in 2356,
You are concerned about the nitroglycerin patch being “changed daily.” Which statement best summarizes your concern? Continuous treatment may lead to
Which of the following drugs are indicated to treat his worsening heart failure and uncontrolled hypertension?
After optimizing his CHF and blood pressure. Which diagnostic or therapeutic modality is most indicated?
In addition to coronary risk evaluation and treatment, your choices to reduce mortality should include:
nitrate tolerance
IV NTG and furosemide
coronary angiography
lisinopril and insulin
Drugs Shown to Prevent MI and Death
- Beta-blockers: timolol, metoprolol, and propranolol
- Anti-platelet drugs: aspirin, ADP receptor blockers (e.g., clopidogrel)
- HMG-CoA reductase inhibitors (the –statins)
- ACE inhibitors (the –prils) and ARBs (the –sartans)
77 y/o female with a history of diabetes and hypertension presents with sudden onset of diaphoresis and shortness of breath. In the emergency room blood pressure is 180/100 and pulse is 110. Her EKG shows a LBBB and her troponin is negative. She has JVD and pulmonary edema on examination. After giving her furosemide to give her some immediate symptom relief, your best recommendation is:
A cardiac catheterization to evaluate for ischemia
56 y/o male presents with a 17 hour history of persistent retrosternal chest pressure. He has an inferior wall MI on the EKG. His blood pressure is 80/50, heart rate is 120. What should you do to improve the patient’s blood pressure?
Intravenous normal saline bolus
e increases
afterload
48 y/o male presents to the emergency room with three hours retrosternal chest pain, shortness of breath and diaphoresis. His EKG indicates an anterior wall MI. He has elevated CPK-MB and troponin levels. He is three hours away from the nearest cardiac catheterization Lab. You should:
Which of the following would be a contraindication for the use of fibrinolytic (aka thrombolytic) therapy for this patient?
Initiate thrombolytic therapy
History of closed head trauma 2 months ago
higher inr
increases bleeding changes
don’t do thrombolytic after how many hours
12 or 3? I think he said 12
absolute contraindication of thrombolytic therapy
intracranial hemorrhage
ischemic stroke 3 months ago unless stroke is within 3 hours
cerebral vascular malformation or metastatic intracranial malignancy
bleeding diathesis or active bleeding
head or facial trauma within 3 months
relative contraindication of thrombolytic therapy
htn
ischemic stroke more than 3 months ago
dementia
intracranial disease that is not a absolute contraindication
greater than 10 minutes of resuscitation
internal bleeding or active peptic ulcer
concompressible vascular punctures
pregnancy
warfarin current
prior exposure within 5 days for these meds or allergy to the meds
A patient presenting to the ED with acute onset chest pain is given nitroglycerin (NTG). Which of the following statements concerning this treatment is correct?
NTG decreases myocardial O2consumption and increases O2delivery to the heart.
65 y/o male presents to the Emergency room with an acute ST segment elevation MI and ultimately undergoes coronary artery bypass grafting. He is discharged on an HMG-CoA reductase inhibitor, aspirin, and a beta blocker. What other intervention may help his overall mortality?
An ACE-inhibitor
A 45 y/o male asks his physician for a prescription for sildenafil (Viagra) to improve his sexual performance. Because of risks from a serious drug interaction, this drug should not be prescribed if he is also taking a/an:
organic nitrate
viagra
phosphodiesterase 5, degrades cgmp
42 y/o female comes into the emergency room with retrosternal chest pressure associated with diaphoresis and shortness of breath. It is brought on by jogging and in the ER relieved with two nitroglycerin. Her EKG is unremarkable. She does not smoke, have hypertension, her cholesterol is normal and she has no cardiac family history. You should stratify her by performing which test
Exercise stress test without augmentation, after medical therapy maximized
A 53 y/o female presents to the ED with severe chest pain. EKG changes indicate myocardial ischemia. Unknown to the ED team is the fact that the ischemia is due to coronary vasospasm, not coronary occlusion with thrombi. Given this etiology, which drug may make the vasospasm, and resulting ischemia, worse?
Atenolol
doesnt correctly treat the vasospasm
use nitrate or ccb to treat vasospasm
