Lecture 2 - Ischemic Heart Disease Flashcards
Ischemic Heart Disease occurs due to…
increase in myocardial O2 demand
or
Decrease in O2 supply to heart
Angina Pectoris is…..
characterized by pain or discomfort, primarily in the chest, but may also be described in the jaw/shoulder/back or arm
commonly due to IHD
Prinzmetals “Variant” Angina
Occurs at rest
Due to coronary Vasospasm
Reversed w/ Nitroglyc and CCB
Silent Myocardial Ischemia
More common in femlaes
Type 1 = less common
Type 2 = more common
Type 1 Silent Myocardial Ischemia
Due to defective anginal warning system
Type 2 Silent Myocardial Ischemia
Angina poor indicator of ischemia
indicated higher risk patient
Stable or Exertional Angina
Exertional pain lasting < 20 min, relieved by rest
Unstable Angina, STEMI, or NSTEMI
Pain occurring at rest lasting > 20 min
Alterable IHD Risk Factors
Smoking Dyslipidemia DM Hypertension Physical inactivity BMI >30 Low fruit/veggie consumption Alcohol overconsumption
Unalterable IHD Risk Factors
Gender = men + postmenopausal women Age = Men >45, Women > 55 FH = father <55, mother <65 Environment = climate, air pollution, drinking water
Subjective symptoms associated with angina
SOB SOB on exertion palpitations Chest pain Lightheadedness
Objective symptoms associated with angina
BP, HR,
decreased Oxygen saturation on ABG
ECG changes
ST seg elevation or depression
Measure of MVO2 (non-invasive)
Double product
HR X SBP
Determinants of Oxygen Supply (MVO2)
Arterial PO2
Diastolic Filling time
Coronary Blood flow
Determinants of Oxygen Demand (MVO2)
Heart Rate
Myocardial Contractility
Ventricular wall tension
IHD is the result of….
increase in Oxygen demand and decrease in Oxygen supply
Treating Angina
- Get symptoms
- Do workup
- Control risk factors
- Try 1’/2’ prevention
- Try antianginal therapy
Class I suggested wording
Is recommended/ is indicated
Class IIa suggested wording
Should be considered
Class IIb suggested wording
May be considered
Class III suggested wording
Is not recommended
Management of Angina (for acute attacks) use…
SL nitroglycerin for acute attacks
If Vasospastic angina, BP <130/80 then….
add LA nitrate
If Vasospastic angina, BP >130/80 then….
add CCB
If not Vasospastic angina, heart rate >60 BPM then….
- Beta-blocker
2. Non-DHP CCB
If angina symptoms not controlled on Beta-blocker & Non-DHP CCB then….
BP < 130/80 = Add Ranolazine/ LA nitrate
BP >130/80 = Add DHP CCB
Last line therapy for Angina?
Consider PCI or CABG surgery
Treatment outline for Angina
- Risk factor modifications
- Select appropriate anti platelet
- Assess comorbidities
- Select antianginal therapy
Nitrates effect on MVO2
HR: dec
Myocardial Contractility: 0
Systolic Pressure: dec
LV Volume: dec
Beta-blockers effect on MVO2
HR: dec
Myocardial Contractility: dec
Systolic Pressure: dec
LV Volume: inc
Nifedipine effect on MVO2
HR: inc
Myocardial Contractility: 0 or dec
Systolic Pressure: 0 or dec
LV Volume: 0 or dec
Verapamil effect on MVO2
HR: dec
Myocardial Contractility: dec
Systolic Pressure: dec
LV Volume: 0 or dec
Diltiazem effect on MVO2
HR: dec
Myocardial Contractility: 0 or dec
Systolic Pressure: dec
LV Volume: 0 or dec
How to reduce Myocardial Ischemia/Angina
Pharmacotherapy w/ Anti-Ischemics
Improve coronary blood flow mechanically (surgery)
Nitrates effects….
Inc coronary blood flow (Oxygen supply)
Dec Ventricular wall tension (oxygen demand)
Drug interacts w/ nitrates
PDE5 inhibitors contraindicated
Sildenafil/Vardenafil = 24hrs Tadalafil = 48 hrs
What to monitor with nitrates
ADR: Hypotension, headache, flushing
Monitor: BP, HR, PRN usage, anginal symptoms
Nitrate Mechanism of Action
Converted to Nitric Oxide
Predominantly venous vasodilation
Isosorbide would be ___ line therapy, after….
3rd, after Beta-Blocker and CCB
Can use as combo w/ either, but not as mono therapy
Nitrate-free interval for Nitrates
should be at-least 10-14 hrs
tolerance form use can develop
Usually dosed around 7am, and not after 5pm
Protocol for using Nitrate tab
Take 1 dose, if pain unimproved or worsening after 5 minutes then call 911. can take 2nd dose at that point
Make sure to store in original container
Using nitrate for prophylaxis….
take immediately before planned exercise or exertion
Nitrate storage considerations
Keep in original container Don't dump into prescription bottle Don't dispense w/ safety cap Don't store in Bathroom Remove cotton plug from bottle
Nitrate admin considerations
Keep with you at all times Pt should be sitting when taking Describe how to use SL tab How to use prophylactically Call 911 if 1st tab don't work Have to refill tab every 6 months
Beta Blockers effect on MVO2
Oxygen supply = 0
Oxygen demand (Dec HR, Myocardial contract, Ventricular wall tension)
When are Beta-blockers first line?
Post MI also when no prior MI
What to monitor and ADR w/ Beta-blockers
Monitor: HR, BP, PRN nitrate usage, anginal symptoms, rescue inhaler use, glucose intolerance 9DM)
ADR: Hypotension, bradycardia, high glucose,
Which Beta-blockers should you avoid for chronic ischemia?
Those with intrinsic sympathomimetic activity (ISA)
Are beta-blockers appropriate for Prinzmetals Variant angina?
No, none other
Beta-blocker considerations
Inappropriate for vasospasm
Caution in cocaine induced angina
Abrupt discontinuation of beta-blockers should be avoided…do over 2-3 weeks..could result in reflex tachycardia + ischemia
Which Beta-blocker as renal elimination and should be careful with AKI?
Atenolol
CCB effects on MVO2
Oxygen supply (inc Coronary blood flow)
Oxygen demand (dec HR, myocardial contractility, ventricular wall tension)
*** only Verapamil/Dilt will dec HR, Myocardial contract
CCB indication
2nd line to Beta-blockers
Drug of choice in Prinzmetals variant angina
CCB what to monitor and ADR
Monitor: (HR - non DHP), BP, PRN nitrate usage, anginal symptoms
ADR: constipation, lower extremity edema, Hypotension, bradycardia
Which CCB are more likely to slow HR?
non-DHP
Verapamil and Diltiazem
CCB of choice for ischemia in pt with concurrent HF?
Amlodipine, won’t dec contractility
Which CCB have highest effect of Vasodilation?
Amlodipine or Nifedipine XL
Non-DHP (Verapamil/Diltiazem = moderate effect)
Captopril Dose Frequency
TID
Lisinopril Dose Frequency
Daily
Valsartan Dose Frequency
1-2 Doses
Atenolol Dose Frequency
Daily
Carvedilol Dose Frequency
BID
Metoprolol Dose Frequency
BID
QD for XL
CCBs Dose Frequency
Daily
Isosorbide DN Dose Frequency
2-3 X day
7am/noon/5pm
Isosorbide DN SA tab Dose Frequency
1-2 X day
8am/2pm
Isosorbide MN tab Dose Frequency
bid
7hrs apart
Isosorbide MN ER Dose Frequency
QD
When is Ranolazine (Ranexa) used
3rd/last line
When inadequate response with other anti-anginal agents in combo with standard therapy
Ranolazine MOA
reduces calcium overload by inhibiting late sodium current
Minimal effects on HR and BP
Ranolazine Dosing
500 mg po BID, titrate up to 1000mg BID
Ranolazine Monitor and ADR
ADR: Constipation, headache, nausea, dizziness
Monitor: QT interval, hepatic function
Ranolazine Max dose with Diltiazem or Verapamil?
500 mg BID
Max simvastatin dose with Ranolazine?
20mg
Max Metformin dose with Ranolazine?
1700mg daily, 850 BID
Ranolazine can be max 1000 mg BID
Ranolazine contraindications
CYP3A4 Inhibitors and inducers
Aspirin is 1st line in pt with…..
CAD, class I recommendation
Dosed 81mg daily
NSAID - Aspirin Interactions
Take ibuprofen/Naproxen at least 30 min after or 8 hr before Aspirin dose
interaction with EC unclear
Clopidogrel anti platelet therapy is __ Line
2nd line in pt with CAD
If cant tolerate aspirin
75 mg daily
Risk factors increasing bleeding risk
H/x of GI bleeding, peptic ulcer disease >70+ Female Lean body weight Thrombocytopenia Coagulopathy CKD/DM Using other meds that inc bleeding risk
Only add 3rd anti-anginal drug if…..
2 drugs don’t control symptoms
pt awaiting revascularization
revascularization is not appropriate or acceptable
Revascularization options
PCI - improves symptoms and not mortality
CABG
