ISHD Flashcards
What is the pathophysiology of Stable Angina?
- Ischemia: the imbalance between oxygen supply and demand
- Angina: the symptoms from the imbalance
What is Stable Angina?
Discomfort in the substernal part of the chest that can radiate down the left arm
- NO miocardial nercrosis
- NO change over the last 2 months
Explain how the PQRST relates toward the clincial presentations?
P: Precipitative factor & Palliative measures [what causes it and what helps it]
Q: Quality & Quantity of pain [tightness, pressure, etc…]
R: Region & Radiation [Where? - substernal]
S: Severity of pain [scale of 1 to 10]
T: Timing [How long does it last? - <20mins?]
What are some of the clinical presentations that are associated with Stable Angina?
- Pain that occurs behind the sternum that then radiates up to the jaw and/or down the left arm
- SOB, Massive pressure, tightness, crushing…
- Caused by weather [HOT or COLD], physical activity, large meals, emotional stress, sexual activity…
How does the ECG appear with a patient with Stable Angina?
Typically the ECG will appear normal but DURING AN EVENT the ECG will have ST DEPRESSION
What are some of the diagnostic procedures used to determine IHD [Ischemic Heart Disease]?
- Can use a ECG, will show whether the patient has ST Elevation [more CAS - Variant] or ST Depression [during an event or NSTEMI]
- Exercise testing: will help with looking at the ECG to see and abnormalities
- Heart Cath to see what is really happening within the arteries
For the treatment of SIHD, what are some way that we prevent ACS and Death?
- Lifestyle and rick factors modifications
- Vaccines
- Comorbidities: check BP and DM
- Antiplatelets: Aspirin 81mg or Clopidegrel 75mg
- ACEi: when they have HTN, LVEF <40% or CKD
For the treatment of SIHD, what are some of the ways that we help manage anginal episodes?
- NTG: Acute attacks
- Vasospastic?: high BP - Nitrate; low BP - CCB
- HR > 60bpm: Beta-Blocker then NON DHP
- Controlled?: monitor
-Not controlled & BP still high: Ranolazine or LA
Nitrate OR DHP CCB - Still angina: PCI or CABG
What is the role of atherosclerotic plaque, platelets and coagulation systems in CAD?
- Atherosclerotic plaques are a build up of fat due to monocytes becoming macrophages within the cell, eating up all the cholesterol.
- They then rupture, activating the clotting cascade making a thrombus - narrowing & blocking the arteries
What are some of the variables that influence myocardial oxygen supply and demand?
- Increase heart rate, contractility, preload, afterload [increase demand while decrease supply]
- Any sort of blockage in the arteries [decrease supply]
List the pharmacological ways to prevent ACS and Death?
Antiplatelet, Statins, ACEi/ARBs, Beta-Blockers
What is the drugs used in Antiplatelet therapies?
Aspirin & P2Y12 Inhibitors
What is the mechanism of Aspirin?
- At low doses, it inhibits COX-1 = blocking the formation of TXA2 [platelet aggregant and vasoconstrictor]
- At high doses, it inhibits COX-2 = blocking PGI2 [allowing platelets to aggregate]
What are the P2Y12’s and what is there mechanism?
- Clopidigrel, Ticagrelor, Cangrelor
- They inhibit adenosine diphosphate induced platelet aggregation
What are some of the adverse affects for Aspirin?
- Main one is INCREASED BLEEDING
- also have patients chew and swallow any aspirin during chest pain
What are some of the adverse affects for the P2Y12 Inhibitors?
Mainly all cause bleeding [a little bit higher than Aspirin], Diarrhea, Rash, Bradycardia [Most Ticagrelor]
What are the three clinical scenarios for Chronic CAD?
No Stent, PCI + Stent, CABG
Describe what NO STENT is in terms of a clinical scenario?
- Basically they do not put a stent in just yet, they just use ASPIRIN as a secondary prevention [could also use Clopidigrel if aspirin allergy]
Describe what PCI + STENT is in terms of a clinical scenario?
- They do a HEART CATH [PCI] on the patient seeing if they are in need of a STENT or NOT [Before; they give the patient 325mg of Aspirin and 300-600mg of Clopidigrel]
What are the two different types of STENTS?
- BMS [Bare Metal Stent]: Just what is sounds like, a metal stent that helps open the arteries [no meds released; clopidigrel for only 1 MONTH]
- DES [Drug Eluting Stent]: Stent that releases Anti-anginals so cells cant grow in that section [Clopidigrel for 6 MONTHS]
What do ACEi/ARBs do for ACS prevention?
- Reduce the cholesterol build up, which helps with reducing the plaques [doesn’t help with ischemia but helps with the cardiovascular events]
- Use ARBs when there is a dry cough
What are some way that we are able to decrease myocardial demand?
- Beta Blockers and NON DHP: decrease HR and Contractility
- Nitrates: Preload
- DHP: Afterload
What are some ways that we are able to increase myocardial supply?
- Dilation of the arteries and increase blood flow: Nitrates
What medicaitons do we use for the acute treatment of angina?
Nitroglycerin
What are the effects that NTG has on myocardial oxygen?
- Increase supply: Dilation of the arteries
- Decrease Demand: Because of the decrease in preload; the heart isn’t stretching as much
How to properly take NTG?
- Can take up to 3 tabs; taking one every 5 minutes – call 911 if the first tab doesn’t work
What are some side effects for NTG?
- Headache [most common], Hypotension, dizziness, lightheadedness…
- DO NOT take with NSAIDs
- DO NOT take with PDE5i [Cause massive dilation]
What are some of the drugs used in the PREVENTION of ischemia and angina sypmtoms?
Beta-Blockers, CCBs, Nitrates
What effects do the Beta-Blockers have on the myocardial?
- It will block Norepi and Epi from binding to the Beta Receptors [will decrease the HR, Contractility, Afterload - ALL will decrease DEMAND]
Describe the cardioselectivity of the Beta-Blockers?
B1: Metoprolol, Atenolol, Bisoprolol, Nebivolol
[Heart]
B2: Propranolol, Nadolol Sotaolol, Pindolol
[Lungs]
Mixed: Carvedilol, Labetolol
[B1, B2, a]
What might happen if given a higher does of a B1 selective beta-blocker?
It could cause some B2 blockage
What are some of the side effects of teh Beta-Blockers?
- Bradycardia [Decreased HR], Sinus Arrest [NO HR], AV blockage
What are the monitoring parameters that we should pay attention toward when giving a Beta-Blockers?
- Goal HR: 50 - 60BPM at rest; <100BPM during exercise
- Amount of NTG tabs used
What is the mechanism of action for the Calcium Channel Blockers?
- Block the passage of external Ca2+ from entering into the cell; this I’ll not all the binding of Ca2+ to Calmodulin - decreasing the producing of MLCK, which will DECREASE contraction
What are the two classes of CCBs?
DHP: “-pines” [will have more of an effect on ARTERIES]
NON DHP: “Verapamil & Diltiazem [will have more of an effect on the HEART - mainly the SA and AV node]
What are the side effects for the CCBs?
- DHP: Hypotension, Dizziness, Lightheadness [Similar to Nitrates], Edema
- NON DHP: Decrease contractility, Bradycardia, AV Block, Constipation [V>D]
How should we monitor someone on a CCB?
- Amount of NTG usage
- Goal HR: 50 - 60BPM at rest; <100BPM during exercise
How do Nitrates help with Prevention of anginial symptoms?
- They will dilate the veins causing an increase in blood flow [increasing the supply while reducing the demand]
- Will decrease preload
What causes Nitrate Tolerance?
- It occurs with high does or frequent usage of nitrate = decreasing the response of them
How to prevent Nitrate Tolerance?
- Need to have a Nitrate FREE period of at least 10 - 12 hours
What should you monitor for when taking Nitrates?
- Amount of NTG tabs taken
- SE: headache, hypotension
What is the mechanism of Ranolazine?
- Inhinbition of late inward Na+ current in ishcemic myocytes, Decreases Na+ causing decrease Ca2+ influx
When should Ranolazine be used?
- Combo with Beta-Blockers, CCBs or Nitrates when they aren’t working well
- Monotherapy: When BP and HR are too low for the first line agents [DOES NOT effect BP, HR, Inotropy or Perfusion]
What are the adverse side effects of Ranolazine?
- Constipation, Nausea, Dizziness, Headache
- QT interval Increase
What are the selection of drug therapy for chronic stable angina?
Beta-Blockers, Nitrates, CCBs
When should Beta-Blockers be used in therapy?
- 1st line therapy without contraindications [Bradycardia, AV block, sinus syndrome]
