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Cardio Exam 2 > lecture 9 > Flashcards

lecture 9 Flashcards

1
Q

chronic stable angina

A
  • substernal chest discomfort that is:
  • typically relieved by NTG &/or rest (no more than 20 min)
  • aggravated by exertion & emotion stress, cold, meals
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2
Q

unstable angina & high risk features

A

rest angina
new onset angina
increasing angina
high risk symptoms

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3
Q

rest angina

A

angina occurring at rest & usually lasting >20min

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4
Q

new onset angina

A

angina of class III (marked limitation of normal activity) in the past 2 months

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5
Q

increasing angina

A

stable angina that is now increasing in duration or frequency

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6
Q

high risk symptoms

A

pulmonary edema
rales
angina w/ hypotension
nocturnal angina

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7
Q

chronic stable angina goals of therapy

A
  • morbidity: provide symptomatic relief from angina that limites exercise & QOL
  • mortality: slow the progression of atherosclerosis leading to CV events & death
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8
Q

chronic stable angina & HTN

A
  • these pts have established coronary artery disease-> compelling indication for ACEI/ARB & beta-blocker
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9
Q

non-pharmacological management of chronic stable angina

A
  • typically reserved for those who have significant symptoms despite optimal medical management
  • percutaneous coronary intervention (PCI): balloon angioplasty &/or stenting
  • CABG- coronary bypass grafting
  • external counterpulsation therapy (ECP/EECP): for those w/ refractory CSA & not candidates for PCI or CABG
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10
Q

Can you titrate anti-anginal/BP medications below the standard target BP (e.g,. 140/90) to reduce symptoms of chronic stable angina?

A

yes

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11
Q

CSA 4 main agents used

A

beta-blockers, CCB. nitrates & ranolazine

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12
Q

wht therapy may be adequate for symptoms that occur rarely or predictably

A

PRN nitrates

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13
Q

chronic antianginal therapy should be up-titrated if patients

A

experience daily episode or symptoms sig. impact QOL

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14
Q

majority of CSA therapy

A

decreased HR and/or BP

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15
Q

minimal HR

A

55bpm

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16
Q

minimal BP

A

100/65

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17
Q

critical side effects

A

orthostatic hypotension, +/-falls, syncope, severe fatigue

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18
Q

Which pharmacological effects would be helpful in reducing anginal episodes?

A

○ Beta-blocker to reduce inotropy, thereby reducing cardiac oxygen demand
○ Beta-blocker to reduce chronotropy, thereby reducing cardiac oxygen demand
○ DHP-CCB/nitrate to cause vasodilation, thereby increasing coronary blood flow
○ DHP-CCB/nitrate to cause vasodilation, thereby reducing afterload and cardiac workload

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19
Q

first line in the management of CSA

A

beta blockers

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20
Q

beta-1 selective

A
  • preferred for unstable asthma/COPD, PVD, DM, sexual dysfunction
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21
Q

mixed alpha/beta blockers

A

(Carvedilol)

- may be used if additional BP control is needed

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22
Q

agents with intrinsic sympathomimetic activity

A

should be avoided

- increase HR

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23
Q

beta blocker dosing

A

titrate BB to HR of ~55bpm as BP & side effects allow

- add additional agents as necessary

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24
Q

BB in combo with nonDHP CCBs

A

avoided due to risk of bradycardia & Heart block

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25
Q

BB in combo with DHP CCBs

A

BB blunts reflex tachycardia that may occur w/ DHPs

- so good

26
Q

BB in combo with nitrates

A

BB blunts reflex tachycardia that may occur w/ nitrates

- so good

27
Q

BB in combo w/ ranolazine

A

no significant issues

28
Q

monitoring of CSA therapy

A
  • BP, HR, appearance of side effects
29
Q

alt first line agents for those who are not candidates for beta blockers

A

non-DHP CCBs

30
Q

consideration for selection of nonDHPs

A
  1. avoid in systolic HF (LV dysfunction/ <EF)
  2. may be reasonable agent in those with relative CI to BB (Asthma, unstable COPD, severe PVD)
  3. appropriate for those with prinzmetal angina
  4. select a formulation that allows for QD or BID doising
31
Q

NonDHP dosing

A

titrate to a HR of ~55bpm as BP & side effects allow

- add additional agents as needed

32
Q

nonDHP in combo with BB

A

avoided due to risk of bradycardia & heart block

33
Q

nonDHP in combo with DHP

A

nonDHP blunt reflex tachycardia that may occur with DHP

34
Q

nonDHP in combo with nitrates

A

nonDHP blunts reflex tachycardia that may occur withnitrates

35
Q

nonDHP in combo with ranolazine

A

-CYP3A4 interaction->max of ranolazine 500mg PO BID

dont titrate up to max dose

36
Q

second line agent for CSA

A

DHP
amlodipine, delodipine, nicardipine
- typically add on therapy

37
Q

consideration in selection of a DHP

A

potential for reflex tachycardia & lack of effect on HR make monotherapy undesirable

38
Q

dosing of DHPs

A

up-titrate DHP to relief of angina symptoms as BP & side effects allow

39
Q

DHP in combo with nitrates

A

no issues as long as BB or nonDHP is ALSO used for reflex tachycardia

40
Q

DHP in combo with ranolazine

A

no issues

41
Q

monitoring of DHP

A

BP, relief of symptoms, side effect (peripheral edema-tk at night to prevent, reflex tachycardia)
- does not reduce HR

42
Q

what should be made available to every pt for CSA?

A

short acting nitrates (SL NTG or translingual NTG)

43
Q

nitrostat

A

0.4mg placed under tongue & allowed to dissolve Q5min, up to 3 doses

44
Q

nitrolingual

A

one spray under the tongue or on the tongue Q5min, up to 3 doses

  • must be primed
  • do not rinse mouth
  • keep at RT
45
Q

third line agents for CSA

A

long acting nitrates

46
Q

long acting nitrates should be reserved for

A

ass-on therapy (w/ BB or nonDHP to blunt reflex tachycardia)

47
Q

long acting nitrates require

A

a nitrate-free interval of 8-12hrs/day (only partial antianginal coverage) due to tachyphylaxis

48
Q
  • Long-acting nitrates should be dosed in which fashion?
A

○ With a ~12 hour nitrate-free interval to avoid development of tolerance
○ Around the clock dosing will lead to tachyphylaxis (tolerance)
○ BID when you wake up, then 6 hours later (so you have your nitrate free interval)

49
Q

long acting isosorbide mononitrate drugs

A

immediate (Ismo, monoket)

sustained (imdur)

50
Q

long acting isosorbide dinitrate

A

sustained (isochron)

51
Q

long acting NTG patch

A

nitrodur

52
Q

monitoring for long acting nitrates

A

BP & relief of symtpoms, reflex tachycardia, decreased efficacy,, HA, orthostatic hypotension

53
Q

CI nitrate use with sildenafil (viagra) & verdenafil (levitra) in

A

24 hours

54
Q

CI nitrate use with tadalafi (cialis) in

A

48 hours

55
Q

newest agent & third line add-on agent

A

(due to cost)

ranolazine (ranexa)

56
Q

ranolazine has almost zero effect on

A

BP & HR

- potential add on for those with low BP or HR

57
Q

safety or ranolazine

A

QT prolongation

  • minimal risk of torsades when used alone
  • do not use with FQ, macrolide, antiarrhythmics, antipsycotics
58
Q

drug interactions with ranolazine

A
  • substrate for CUP3A4, 2D6 & PGP
    1. inc ranolazine: nonDHP-CCBs
    2. digoxin may inc & require close monitoring
    3. simvastatin levels usually DOUBLE with addition of ranolazine
59
Q

ranolazine dosing

A

500mg PO BID titrated to 1000mg PO BID prn anginal symptoms

60
Q

CI to ranolazine

A
  • severe hepatic impairment, strong CYP3A4 inhibitor
61
Q

side effects of ranolazine

A

constipation
nausea
dizziness

Cardio Exam 2 (12 decks)

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