Lecture 2 Flashcards
psy12 inhibitors
clopidogrel, prasgurel, ticagrelor
why do we use multiple antiplatelet agents together
They have different MOA in aggregation cascade
Which p2y12 inhibitors are prodrugs? What enzyme activates them?
clopidogrel and prasgurel
they are dependent on cytochrome P450 to be activated
P2y12 adverse effects
Bleeding, diarrhea, rash for all
clopidogrel- 1% increase in major bleeding when added to ASA
prasgurel- 0.6% increase in major bleeding, 0.5% increase in life threatening bleeding
ticagrelor- bleeding, bradycardia, heartblock, dyspnea
clopidogrel generic name
plavix
CCD menaing
chronic coronary disease
CABG? PCI?
coronary artery bypass graft, percutaneous coronary intervention
CCD with no history of stent also known as
stable angina/stable ischemic heart disease, post ACS or revascularization
WHich patients are gonna be on life long 81 mg ASA
patients with hx of CCD (stable angina, stable ischemic heart disease, post MI or have had a stent)
if contraindication to lifelong ASA, what to give patient?
clopidogrel 75 mg/day
DAPT meaning and use
Certain high risk patients may receive DAPT, dual antiplatelet therapy.
ASA+PSY12 inhibitor
types of stents
Bare metal stents (uncommonly used)
drug eluting stents
treating CCD in patients with elective PCI +drug eluting stents
Before procedure they get a single high dose of aspirin (325)
also a P2Y12 loading dose
after procedure if low risk of bleeding
DAPT for 6 months minimum
SAPT indefinitely
after procedure high risk of bleeding
DAPT- 1-3 months may be reasonable
SAPT- P2Y12 inhibitors until 12 months
SAPT- indefinitely
drugs to be used in patient undergoing CABG
DAPT for 12 months
SAPT- indefinitely
important thing to remember if patient is on aspirin and ticagrelor
Dose of aspirin must be below 100 mg
are ACEs and ARBs beneficial in patients with CCD
yes
when to use ACE or ARBS in CCD patients
Will almost always be used in CCD patients, especially in pts with decreased heart function, HTN, DM and CKD
How does colchicine work
decreases inflammation via decrease in IL-1B and IL-18
statin use in CCD patients
almost always high intensity
(rosuvastatin 20-40 mg rosuvastatin
40-80 mg atprvastatin)
show the myocardial schemia pxygen supply/demand chart leading to angina
fixed stenosis vasospasm thrombus–> decreased coronary blood flow–> ischemia (leads to angina
also
Increased HR contraction afterload and pre load—> increased O2 consumption—-> ischemia (Angina)
what do most drugs do to lower ischemia and angina
reduce myocardial O2 demand, reduce HR, reduce contractility, reduce afterload and pre load
How do nitrates reduce angina and ischemia
increase HR
no effect on myocardial conrractility
decrease systolic pressure
GREATLY reduce LV volume
how do B blockers reduce angina and ischemia
Greatly reduce HR
reduce myocardial conrractility
reduce systolic pressure
increase LV volume
how does nifedipine reduce angina and ischemia
Increase HR
little effect on myocardial contractility
GREATLY reduce systolic pressure
little effect on LV volume
how does verapamil reduce angina and ischemia
GREATLY reduce HR
reduce myocardial contractility
reduce systolic pressure
little effect on LV volume
How does diltiazem reduce angina and ischemia
reduce HR
little effect on myocardial contractility and LV volume
reduce sysotlic pressure
3 types of organic nitrates
ISMN
ISDN
NTG
MOA of nitrates
nitric acid donors/releasers activate guanylyl cyclase
activity of orgnic nitrates
marked vasodilation (decreased pre load)
less arteriole dilation (coronary and peripheral)
inhibition of platelet aggregation
where is NO produced
Endothelial cells
clinical effects of nitrates
increased myocardial O2 supply
decreased O2 demand
instructions for NTG once patient experiences chest pain
has patient been previously prescribed NTG? if yes, take 1 NTG dose
if no, is chest discomfort/ pain unimproved or worsening 5 minutes after start?
If no, notify physician, If yes call 911 immeditely
call 911 if chest pain has not been relieed after 1st dose
patient education points for tablet NTG
keep in original container (no plastic container)
no sfaety cap
place under togue, do not swallow
cotton plug out
no storage in bathroom/humid environments
need for rx refills 6 months
Patient education for spray NTG
spray under tongue, do not inhale
DO not shake
3 year refills
adverse effects of NTG
headaches, hypotension, dizziness, lightheadedness, facial flushing, reflex tachycardia
What type of painkillers to use for NTG
tylenol, not NSAIDS
LEgally, what do we have to make sure is not being taken with NTG
PDE 5 inhibitors (sildenafil, tadalafil)
could lead to hypotension leading to death
Duration of time to avoid PDE 5 Inhibitors with nitrates
avanafil- 12 hrs
sildenafil and vardenafil- 24 hrs
Tadalafil- 48 hrs
pcol therapy to prevent recurring angina/ischemia
B blocker
CCB
Nitrates
how do B blockers work
B blockers block catecholamines from being able to cause chronotropy/inotropy
desired effects of B blockers on myocardial O2 demand
decreased HR
decreased contractility
decreased BP
undesired effects of B blockers on myocardial O2 demand
reducing HR leads to increased diastolic filling time, leading to increased pre load
B1 selective drugs
Atenolol
Metoprolol
B non selective drugs
Propanolol
carvedilol
ISA B drugs
Pindolol
acebutolol
lipid soluble B blokcers
Propanolol
carvedilol
Water soluble B blockers
atenolol
bisoprolol
B blocker adverse effects
Cardiac- sinus bradycardia, sinus arrest, AV block, reduced LVEF
others- bronchoconstriction, fatigue, depression
Goal HR on B blockers
Initiate at lowest dose
goal HR- 50-60
exercise- less than 100
