Management of CAD Flashcards
what is angina?
insufficient oxygen delivery to heart muscle leading to ischaemia
in 2014, CAD was the single most common cause of death, what was the percentage?
27%
how many people in the UK have CHD, what is the cost yearly for this?
2.3 million costing £9 billion yearly
in the UK, how many admissions are as a result of MI?
100,000
what is the pathology of angina?
- Coronary plaque causes decrease in perfusion pressure, decrease in arterial oxygen content
- Compensates – increase in Hr, preload, afterload, contractibility
describe stable angina?
- Predictable – exertion, exercise, extremes of temp (vasoconstriction)
- Relieved by rest/ nitrates
- Long term management prevent attacks coming on and reducing risk of CAD
describe unstable angina?
- Sudden deterioration in angina symptoms – no ECG changes, no troponin rise
- Result of atheromatous plaque rupture
- Lasts longer and unresponsive
- Symptoms control prevention of progression to an MI
what is acute coronary syndromes?
spectrum of conditions such as unstable angina/ NSTEMI and STEMI
what is troponin?
protein released when cardiac muscle is damaged - not normally present in bloods
what is the pathophysiology in a STEMI MI?
- Plaque ruptures leading to thrombosis
- Fully occluded lumen
- MI with irreversible necrosis of the heat can lead to long term complications
what is the pathophysiology in a NSTEMI MI?
- partially blocked lumen eg atherosclerosis
Myocardial necrosis is evident – risk of progressing to a STEMI - Symptomatic relief of ischaemia prevents further MI and death
name a nitrate used to treat angina and acute heart failure?
glycerol trinitite - GTN spray
what is the action of GTN spray?
- Action – vasodilating improving coronary blood flow
- Decrease after/ pre load
- Decrease myocardial workload
- Decrease oxygen demand
what are the side effects of GTN spray?
headache (means it working as its sublingual), hypotension, syncope (dizziness – take while sat down), facial flushing
what is contra-indicated with GTN spray?
acute circulatory failure, shock, head trauma, severe hypotension, aortic stenosis (likely to cause further syncope)
how many hours free of nitrate do you need a day?
12hrs
in relation to GTN spray when should an ambulance be called?
If no relief after 5 mins of taking spray, repeat if no relief again after 5 mins, call an ambulance
name some anti-platelet drugs?
aspirin, ticagrelor, clopidogrel, plasugrel
what is the action of antiplatelets?
reduces blood viscosity, disrupts platelet activation including inhibition of platelet agonists, adhesion or aggregation
when are anti-platelets used?
revascularisation to restore sufficient blood flow to affected vessel (reperfusion)
- Inhibit clot formation
- Support plaque stabilisation: no thrombus
- Secondary prevention of CV disease, TIA, stroke by aspirin
what are the side effects of antiplatelets?
bronchospasm, GI bleeds (blood not sticking together), GI irritation (aspirin), tinnitus
what are contra-indicated with anti-platelets?
bleeding risk, low platelet count, allergy
what is the normal dose of aspirin? (anti-platelet)
300mg loading, low dose is 75mg
what is the normal dose of ticagrelor? (anti-platelet)
180mg loading then 90mg BD
what is the normal dose of prasugrel? (anti-platelet)
60mg STAT, then 10/5mg daily while awaiting PCI
name some glycoprotein IIb/IIa antagonists?
abicicimab, eptifbratide, tiofibran
what is the action of glycoprotein IIa/ IIb antagonists?
inhibit final pathway involved in platelet aggregation
inhibits fibrogen binding
what is the action of glycoprotein IIa/ IIb antagonists?
inhibit final pathway involved in platelet aggregation
inhibits fibrogen binding
when is glycoprotein IIb/IIa used?
prevention of ischaemic cardiac complications in those undergoing PCI
- Short term prevention of MI in those with unstable angina and waiting for PCI
what are the side effects of glycoprotein IIb/IIa antagonists?
bleeding, back pain, fever, headaches, hypotension, nausea
what are contra-indicated with glycoprotein IIb/IIa antagonists?
active internal bleeding, hypertensive retinopathy, major surgery in last 2 months
name anticoagulants
heparin
what is the action of heparin?
prevents blood from clotting by suppressing synthesis or function of various clotting factors
anti-thrombotic
does not thin blood
what are types of heparin?
low molecular - enoxaparin, daltaparin, tinzaparin (TED)
unfractionated - non seperated
fondaparinux - synthetic heparin
what is the dosage of nicrorandil?
one tablet 10/20mg BD
what is the action of nicrorandil?
nitrate like action (vasodilator), K+ channel opener - increase blood flow due to less resistance
when is nicrorandil used?
prevention and long term management of angina
what are the side effects of nicrorandil?
headaches, ulceration, dizziness, flushing
what is contra-indicated of nicrorandil?
severe hypotension, LV failure, hypovolaemia, acute pulmonary oedema
what is the action of ranolazine?
facilitates myocardial relaxation, reduces flow of Ca2+
does not affect heart rate
when is ranolazine used?
as an adjunct in stable angina
what are the side effects of nicrorandil?
dizziness, headache, constipation, nausea, vomiting
what is the action of ivabradine?
lowers heart rate by acting on sinus node
- Decreased myocardial oxygen demands
- No effect on BP/ contraction
when is ivabradine used?
treatment of angina in patients with normal sinus rhythm
what are the side effects of ivabradine?
GI disturbances, nausea, constipation, diarrhoea
what is contra-indicated in ivabradine?
heart rate <75, acute MI, unstable angina, unstable heart failure
what is the action of statins?
stabilising plaques by HMG-CoA reductase inhibitors
block enzyme involved in cholesterol synthesis
when are statins used?
primary (reduce hypercholestrolaemia/ hypertension) or secondary prevention of CV events
what are the common side effects of statins?
muscle aches and pains
myopathy - rhabdomolysis - muscle tissue releases proteins and electrolytes into blood which can cause permanemt disability/ fatal
nausea, insomnia, vivid dreams
what is contra-indicated with statins?
liver disease
what is the function of reperfusion therapy?
to restore blood stores - posterior MI/ left bundle branch block
what is PCI?
percutaneous coronary intervention - opens up blocked artery
how does PCI work?
balloon/ stent in artery to open it uo
used with drug eluting stent
what are drug eluting stents?
slow release medication to prevent clots around stents
what better thrombolytics or PCI?
PCI -less bleeding, mortality, risk of stroke, re-infarction, infarct angina
name some thrombolytic drugs
streptokinase, tenecteplase, altepase
when do thrombolytic drugs need to be used?
within 6-12 hrs of first symptoms
how do thrombolytic drugs work?
fibrinolytic drug activate plasminogen which turns into plasmin which then degrades the clot, breaking up thrombus
when are thrombolytic drugs used?
acute MI, PE, ischaemic stroke
what are the side effects of thrombolytics?
risk of cerebral bleed
Name at least 5 absolute contra-indications of thrombolytics
haemorrhagic stroke/ stroke at any time. Ischaemic stroke in last 6 months, CNS damage, recent trauma/ surgery, bleed. GI bleeding in last month, known bledding disorders, aortic dissection
what are relative contra-indications of thrombolytics?
TIA in last 6 mths, dementia, oral anticoagulant drugs, pregnancy within 1 week post-patrum, non compressible punctures, traumatic resuscitation, refractory hypertension, advanced liver disease, ineffective endocarditis, active peptic ulcer
what is lifestyle advice of CAD?
ineffective endocarditis, active peptic ulcer
Lifestyle:
* Low dose aspirin – decrease death by 25%
* Statins
* Smoking
* Diet and weight modifications
* DVLA needs informing
* Limit alcohol – less than 14 units a week
* Increased exercise
* Control diabetes, hypetension
what are the secondary medical management 6As?
for CAD
Aspirin – 75mg once a day
Another antiplatelet – eg clopidogrel or tricagrelor (those after PCI, low risk of bleeding)
Atorvastatin – 80mg once a day
ACEi – ramipril titrated as tolerated to 10mg a day
Atenolol- or any beta blocker as high as tolerated
Aldosterone antagonist- for those with heart failure (eplerenone titrated to 50mg once daily)
what are the NICE guidelines for stable angina?
- First line – beta blocker/ CCB
- If symptoms not controlled- consider switching or using combination (DO NOT USE B BLOCKER WITH VERAPAMIL/ DILTIAZEM)
- Third line – long acting nitrate, ivabradine, ranolazine
- If patient can not tolerate CCB/ b blocker then monotherapy or nitrate/ ivabradine/ ranolazine
- Triple therapy while awaiting PCI
in those aged 75+ and awaiting PCI which dual anti-platelet combination is best?
aspirin with ticagrelor/ clopidogrel
what is the management of NSTEMI/ unstable angina?
B- beta blockers
A- anti-platelet - aspirin
T- sTaTins
M - morphine
A- another antiplatelet ( ticagrelor/ clopidogrel)
N - nitrates - GTN spray
give oxygen if needed
define myocardial infarction
necrosis of myocardial tissue following occlusion of coronary artery and subsequent ischaemia
MI is a major manifestation of CAD
what type of pain is associated with MI?
sudden onset, substernal, crushing, tightness, severe, unrelieved by GTN, may radiate to jaw, shoulder, neck, back
what are normal symptoms of MI?
dyspnea, syncope, nausea, vomiting, extreme weakness, diaphoresis, denial, increase in Hr
what is initial MI treatment?
- Pain relief and antiplatelets: diamorphine, morphine, oxygen, sublingual GTN or IV, aspirin, cyclizine or metoclopramide
- Thrombolysis – with or without heparin
- IV beta blockers, IV nitrates
- Asprin, ACEi, oral B blockers, lipid lowering agents, dual antiplatelets
- Angiography as needed
- Revascularization as needed
what is initial MI treatment?
B- b, blockers
A- antiplatelets (dual)
T- thrombolytics
M- morphine
A- aspirin, ACEi
N- nitrates- GTN spray
Give oxygen as needed
what is the role of cardiac rehabilitation?
motivates patients with similar conditions but individually meets everyone’s needs - works around medication and exercise capabilities
who and when should patients get cardiac rehab?
all people regardless of age and should start sessions within 10 days of being discharged
can stenting help restonosis?
30% less restonosis
what drugs help manage stable angina?
GTN, ivabradine, ranolazine, nicrovandril, antiplatelets (aspirin + clopidogrel/ tricagrel)
2nd prevention drugs
what drugs help manage NSTEMI? unstable angina?
antiplatelet (aspirin + clopidogrel/ tricagelor)
PCI route - prasugrel, unfractionated heparin
drug eluting stent
2nd prevention drug
what drugs help manage STEMI?
antiplatelet (aspirin + tricagrelor/ clopidogrel)
PCI route - unfrectionated heparin + parasugrel
drug eluting stent
fibrinolysis route - altepase/ streptokinase/ tenactapase
2nd prevention drugs
when giving another antiplatelet, when is each of them work best (clopidogrel, tricagelor, prasugrel)
prasugrel - when undergoing PCI
clopidogrel - if high bleeding risk
tricagelor - any other time
other than NSTEMI, what else can increase troponin levels?
CKD, sepsis, myocarditis, aortic dissection, PE
