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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
BB in combo with DHP CCBs
BB blunts reflex tachycardia that may occur w/ DHPs | - so good
26
BB in combo with nitrates
BB blunts reflex tachycardia that may occur w/ nitrates | - so good
27
BB in combo w/ ranolazine
no significant issues
28
monitoring of CSA therapy
- BP, HR, appearance of side effects
29
alt first line agents for those who are not candidates for beta blockers
non-DHP CCBs
30
consideration for selection of nonDHPs
1. avoid in systolic HF (LV dysfunction/
31
NonDHP dosing
titrate to a HR of ~55bpm as BP & side effects allow | - add additional agents as needed
32
nonDHP in combo with BB
avoided due to risk of bradycardia & heart block
33
nonDHP in combo with DHP
nonDHP blunt reflex tachycardia that may occur with DHP
34
nonDHP in combo with nitrates
nonDHP blunts reflex tachycardia that may occur withnitrates
35
nonDHP in combo with ranolazine
-CYP3A4 interaction->max of ranolazine 500mg PO BID | dont titrate up to max dose
36
second line agent for CSA
DHP amlodipine, delodipine, nicardipine - typically add on therapy
37
consideration in selection of a DHP
potential for reflex tachycardia & lack of effect on HR make monotherapy undesirable
38
dosing of DHPs
up-titrate DHP to relief of angina symptoms as BP & side effects allow
39
DHP in combo with nitrates
no issues as long as BB or nonDHP is ALSO used for reflex tachycardia
40
DHP in combo with ranolazine
no issues
41
monitoring of DHP
BP, relief of symptoms, side effect (peripheral edema-tk at night to prevent, reflex tachycardia) - does not reduce HR
42
what should be made available to every pt for CSA?
short acting nitrates (SL NTG or translingual NTG)
43
nitrostat
0.4mg placed under tongue & allowed to dissolve Q5min, up to 3 doses
44
nitrolingual
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
third line agents for CSA
long acting nitrates
46
long acting nitrates should be reserved for
ass-on therapy (w/ BB or nonDHP to blunt reflex tachycardia)
47
long acting nitrates require
a nitrate-free interval of 8-12hrs/day (only partial antianginal coverage) due to tachyphylaxis
48
- Long-acting nitrates should be dosed in which fashion?
○ 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
long acting isosorbide mononitrate drugs
immediate (Ismo, monoket) | sustained (imdur)
50
long acting isosorbide dinitrate
sustained (isochron)
51
long acting NTG patch
nitrodur
52
monitoring for long acting nitrates
BP & relief of symtpoms, reflex tachycardia, decreased efficacy,, HA, orthostatic hypotension
53
CI nitrate use with sildenafil (viagra) & verdenafil (levitra) in
24 hours
54
CI nitrate use with tadalafi (cialis) in
48 hours
55
newest agent & third line add-on agent
(due to cost) | ranolazine (ranexa)
56
ranolazine has almost zero effect on
BP & HR | - potential add on for those with low BP or HR
57
safety or ranolazine
QT prolongation - minimal risk of torsades when used alone - do not use with FQ, macrolide, antiarrhythmics, antipsycotics
58
drug interactions with ranolazine
- 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
ranolazine dosing
500mg PO BID titrated to 1000mg PO BID prn anginal symptoms
60
CI to ranolazine
- severe hepatic impairment, strong CYP3A4 inhibitor
61
side effects of ranolazine
constipation nausea dizziness

Cardio Exam 2 (12 decks)

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