Ischemic Heart Disease Therapies Flashcards
SL NTG indication
if anginal attacks are infrequent or use prior to activities that cause angina
storage of SL NTG
original container, replace tablets every 6 months and spray every 3 years
how to take SL NTG
sit down and dissolve under tongue, may repeat up to three doses every 5 minutes and call 911 if pain is not relieved
beta blocker indications
chronic prophylaxis for patients with 1 or more anginal episodes per day
how do beta blockers work for angina
decreases HR and contractility therefore decreasing oxygen demand
beta blockers treatment goal
resting HR between 50-60 BPM and max exercise HR of 100 bpm
additional protective effects of beta blockers
antiarrhythmic and may slow the progression of plaques
mechanism non-DHP calcium channel blockers for angina
decrease HR and contractility, decreasing the oxygen demand
mechanism of DHPs for angina
decrease afterload, decrease oxygen demand
when to avoid non-DHPs
concomitant beta blocker and severe LV dysfunction (HFrEF)
when to use a CCB over a beta blocker
beta blockers are first line because of their additional anti-arrhythmic benefits
long acting nitrate indications
a third line agent for anginal chest pain (equal to CCBs) that can be used as a substitute or in addition to a beta blocker
nitrate intolerance
nitrate intolerance is when there’s a lack of efficacy after consistent exposure, must provide a 10-14 hour nitrate free period (usually during sleep)
isosorbide dinitrate is usually dosed TID every 6 hours so that there isn’t any drug at night, isosorbide mononitrate is dosed in the morning and wears off at night
the idea is to give the patient the nitrate free period while they are asleep and unable to feel any chest pain
ranolazine MOA
inhibits persistent/late inward Na current in the ventricles which will decrease contractility
ranolazine effect on HR and BP
ranolazine has no effect on HR or BP
AEs of ranolazine
QT porlongation
metabolism of ranolazine
CYP3A4, 2D6, and pGp
if a patient has diabetes and IHD, list the three agents that can be used to get dual benefit
- metformin
- GLP 1 antagonists (dulaglutide, liraglutide)
- SGLT2 inhibitors (empagliflozin, canaglifozin)
pneumonic for medical treatment of acute ACS (NSTEMI and UA)
O - oxygen S - statin N - NTG A - aspirin A - anticoagulant P - P2Y12 inhibitor
indication for oxygen in ACS
only if the patient has an arterial oxygen saturation less than 90%, if the patient is in respiratory distress, or has other high risk features of hypoxemia
dosing for a statin during ACS
initiate or continue a high intensity statin in all patients, earlier the administration the better!
atorvastatin 40/90
rosuvastatin 20/40
statins have significant pleiotropic effects and can help to stabilize an thrombus in the coronary artery
dosing for NTG in treatment of ACS
SL NTG every 5 minutes for 3 doses, then assess need for IV NTG. Administer IV NTG for persistent ischemic, HF, or HTN
nitrate contraindications
recent use of phosphodiesterase inhibitor (sildenafil/avanafil = 24 hours, tadalafil = 48 hours): reason for the contraindication is that these PDE5 inhibitors work on the same pathway as NTG and can cause profound HTN so severe the patient loses a pulse
dosing for aspirin in treatment of ACS
should be CHEWED
should not be enteric coated
162-325mg loading dose immediately for quick administration and action
dosing for anticoagulants for the treatment of ACS
IV unfractionated heparin for 48 hours or until PCI is performed
OR
subcutaneous enoxaparin for duration of hospitalization or until PCI is performed
loading doses of P2Y12 inhibitors for the treatment of ACS
ticagrelor (Brilinta) 180mg x 1
clopidogrel 600mg x 1
maintenance doses of P2Y12 inhibitors
patient should be on P2Y12 inhibitor for 12 months after UA or NSTEMI:
ticagrelor: 90mg BID
clopidogrel 75mg daily
why is ticagrelor preferred over clopidogrel
preferred because it has increased amount of platelet inhibition and better cardiac outcomes
what’s the P2Y12 inhibitor for PCI
prasugrel, ONLY used if the patient has a PCI/catheterization!
loading dose of prasugrel
60mg x1
maintenance dose of prasugrel
10mg daily
mechanism of GIIB/GIIIA inhibitors
potent antiplatelet agents that block the binding site for fibrinogen, increase patient’s bleeding risk
pneumonic for LONG TERM treatment of ACS
SNAP BAM
what are the drugs in BAM for long term treatment of ACS?
B- beta blocker for at least three years or indefinitely
A- ACEi/ARB indefinitely
M- mineralocorticoid receptor antagonist indefinitely
indication for beta blockers
long term treatment in all patients after ACS, any beta blocker is okay unless the patient has HF (should use metoprolol succinate, carvediol, or bisoprolol)
indication for ACEi/ARBs
long term treatment of ACS for patients who have LVEF less than 40% and those with HTN, diabetes, or stable CKD. May use ARB instead of ACE in patients who are intolerant.
HOPE trial shows mortality benefit in patients with a normal EF, if the patient can tolerate, the patient should receive! If the patient can’t tolerate BB and ACEi/ARB, use only BB.
indication for mineralocorticoid receptor antagonist
long term treatment of ACS, spironolactone or eplerenone, patients with an EF <40% who are also on an ACEi and beta blocker
when are mineralocorticoid receptor antagonists contraindicated?
SCr >2.5 mg/dl in men, >2mg/dL in women
Potassium >5 meq/L
treatment plan for a patient with a STEMI?
MUST have early invasive treatment: immediate cardiac catheterization or fibrinolytic administration in addition to OSNAAP (simultaneously)
mechanism of fibrinolytic therapy
work to degrade fibrin clots and restore blood flow, considered revascularization, and will significantly increased bleeding risk. Works by activating plasminogen to plasmin that will degrade fibrin clots
what is the only P2Y12 agent that can be administered with a fibrinolytic?
only use clopidogrel as a P2Y12 agent because clopidogrel has lower antiplatelet potency and theoretically lowers bleeding risk
when to use a fibrinolytic
fibrinolytics are less effective than PCI and so a PCI is preferred but in the situation where a time to PCI is greater than 90 minutes, a fibrinolytic should be used (better than nothing)
fibrinolytic specificity for plasmin
alteplase (tPA) is the least specific and will bind to both free plasmin and fibrin bound plasmin
reteplase is slightly more specific for plasmin bound to firbin
tenecteplase is the most specific for plasmin bound to fibrin
what drugs in SNAP BAM will improve mortality?
everything except NTG! Statin aspirin P2Y12 inhibitor beta blocker ACEi/ARB MAR = all improve mortality
