Med management of Chronic stable angina and CAD Flashcards
1
Q
Which of the following is the PREFERRED antiplatelet strategy for patients with established coronary disease? A. Dipyridamole B. Dipyridamole/ASA C. ASA D. Cilostazole
A
- ASA PO daily
2
Q
What are the ABC’s of tx for SA and CAD
A
A-Aspirin, ACEI, Anti-anginals B-Beta blockers, BP control C-Cholesterol and cigarettes D-Diet, DM management, Depression E-Exercise (calorie targets physical activity
3
Q
What is the recommendation for BP according to JNC8 and ADA?
A
Less than 140/90
4
Q
What is the recommended LDL or LDL reduction from baseline?
A
Less than 70 or 40% reduction
5
Q
The cumulative risk redcution of all 4 medication classes used in tx of SA and CAD is 70%. What are those 4 drug classes?
A
Aspirin
B blocker
Ace inhibitor
Lipid lowering
6
Q
What are the Antiplatelet agents used in SA and CAD?
A
Aspirin Clopidogrel Prasugrel Ticagrelor Dipyridamole
7
Q
Which 3 antiplatelet agents have the same MOA?
A
The ones with Grel in them
Clopidogrel
Prasugrel
Ticagrelor
8
Q
What is the MOA of Clopidogrel, Prasugrel, and Ticagrelor
A
Inhibits ADP-platelet activation
9
Q
What is the MOA of Aspirin
A
Inhibition of TxA2 platelets
10
Q
MOA of dipyridamole
A
inhibits platelet adenosine and phosphodiesterase
11
Q
When do we use Aspirin in the scope of SA and CAD?
A
As thromboprotection.
Treatment of ACS (chewed and swallowed)
12
Q
What are major side effects of ASA
A
GI bleeding
13
Q
What can be given as protection from the SE of ASA?
A
PPI
H2
14
Q
What antiplatlet medication is marginally more effective than ASA in PAD?
A
Clopidogrel
15
Q
What options are available for pt’s on omeprazole/PPI for GERD who are put on Clopidogrel?
A
Space 12 hours apart-or switch PPI to H2RA
16
Q
What medication can be used both with ASA or as an alternative to ASA if ASA allergic or intolerant?
A
Clopidogrel
17
Q
How soon before surgery should clopidogrel be d/c’s
A
7 days
18
Q
What medication can be used instead of Clopidogrel, is marginally more effective, and avoids the interaction with PPI’s?
A
Prasugrel
19
Q
contraindication for Prasugrel?
A
Hx of hemorrhagic events
stroke
TIA
20
Q
How long after stent placement is the use of Clopidogrel, prasugrel or ticagrelor indicated for?
A
1 year post
21
Q
Which antiplatelet is not safe for use in hepatic disease?
A
Ticagrelor
22
Q
Which antiplateltes are reversible?
A
Ticagrelor
23
Q
Which antiplatelets are not reversible?
A
Aspirin
Clopidogrel
Prasugrel
24
Q
What is the MOA of Dipyridamole?
A
Platelet adenosine deaminase and phosphodiesterase inhibitor; increases cAMP to vasodilate and inhibits platelets
25
What other medication is Dipyridamole combined with as a fixed combo med?
ASA
26
What is Dipyridamole typically used for?
Very advanced PVD and CAD. Significantly reduces risk of stroke
27
What classes are considered Anti-anginals?
Beta Blockers
CCB's
Nitrates (adjunctive)
28
Which anti-anginal class has the best data for reducing CV events?
Beta-blockers
29
Which anti-anginal class can often be given with a BBlocker and has mixed data/outcomes?
CCB's
30
What are Nitrates used for?
adjunctive tx, only for symptoms
31
What are the 4 benefits that Beta-blockers provide by lowering myocardial oxygen demand?
1. Reduction in ischemic time
2. Decreased heart rate
3. Decreased blood pressure and workload
4. Decreased contractility
32
What group of patients would need following and caution when using a BBlocker?
pt's with pulmonary dz
33
T/F B blockers are relatively contraindicated in pt's with COPD?
True (RELATIVELY)
34
White side effects might be caused by B Blocker?
```
Slowed PR-interval, ventricular rate
Reduction of Renin output (reduced RAAS)
Rebound HTN (if suddenly discontinued)
```
35
t/f Selective Beta 1 may still block beta 2 at high doses?
T
36
What non-selective beta blockers exist?
```
Labetalol
Carvedilol
Nadolol
Sotalol
Timolol
```
37
What is the benefit to using selective B Blockers?
Less likely to cause COPD exacerbation
38
What selective B Blockers exist
```
Atenolol
Metoprolol
Esmolol
Bisoprolol
Nebivolol
```
39
What might occur with a patient who has liver dz if given a B Blocker?
Liver dz may increase bioavailability
40
What might occur with a patient who has renal z if given Beta blockers
slowly clear active metabolites
| Toxicity effect
41
What can BB mask?
thyroid storm or thyrotoxicosis
42
What are the outcome benefits for pt's on BB?
- Reduces mortality in HTN pt's
- Improves survival in HTN patients after recent stroke
- functionally-increases exercise tolerance
43
What other cardiac meds should be avoided when using a BB?
Verapamil/diltiazem (non-dihydropyridines)
44
What should be monitored clinically in pt's who are on BBlocker?
HR
BP
ECG
Physical function
45
What are the indicators to watch for intolerance/toxicity of BB?
```
Activity intolerance (initially ok but should adapt within 30 days)
Postural hypotension
syncope
AV-block
Sexual dysfunction
Fatigue
Depresion
HA
Bronchospasm
```
46
Which BB used in SA and CAD are selective?
Metoprolol
Bisoprolol
Atenolol
Nebivolol (newest)
47
Is BB Carvedilol selective/non-selective?
non-selective PLUS selective for A1 blocker
48
Name the strictly non-selective BB?
Carvedilol
Propanolol
Nadolol
Labetalol
49
Which is one of the most relied upon BB's in practice?
Metoprolol
50
Who does Metoprolol benefit the most?
pt's who need reduction CV events and pt's with HTN, HF, LVD, or CAD
51
Can Metoprolol be given in a pt with liver disease?
Yes-little protein binding
52
What are the indications for bisoprolol?
works well for pt's with HF and HTN
53
Does Bisoprolol require any adjustments?
```
Yes
renal dysfunction (d/t prolonged 1/2 life)
```
54
For a stage III/IV unstable CAD pt is Bisoprolol a good choice?
NO - stage III/IV may precipitate an event on Bisoprolol
55
Which BB is best for use in a pt with LVdysfunction cardiomyopathy?
Carvedilol
56
When can Carvedilol NOT be used?
Liver dz
57
What other benefit does Carvedilol have when giving?
reduced rebound tachy risk
58
What medication, although not commonly used, is useful in pt's with stable CAD and HA?
Propanolol
59
Which BB reduces isotropy, chronotopy, cardiac work, as well as hepatic blood flow, and is therefore useful in pt's with variceal bleeding?
Nadolol
60
Which selective B1B is useful in reducing HR and BP for pt's with asthma and COPD, as well as liver disease, due to it's limited metabolism, but has no CV outcomes that support it's use for HTN pt's with CAD, HF?
Atenolol
61
Which BB is useful for HTN crisis, pre-eclampsia but not for long term angina use.
Labetalol
62
When is Esmolol used?
Ultrashort 1/2 life-reserved for perioperative use
63
which medication is the most selective B1 antagonist with endothelium derived NO depended vasodilation?
Nebivolol
64
Who cannot use Nebivolol?
Liver dz pt's
65
```
Which anti-anginal could be appropriate for a pt with an EF less than 35%?
A. Milrinone
B. Verapamil
C. Diltiazem
D. Felodipine
```
Answer D. Felodipine (vasodilating CCB tolerated better)
A. Milrinone is for pt's with really advanced HF
B. Verapamil and C. Diltiazem are difficult to manage and tolerate with decreased EF pt's
66
What are the 2 types of CCB's
Dihydropyridines
and
Non-dihydropyridines
67
What are the 2 non-dihydropyridines and where do they work in the body?
Verapamil
Diltiazem
Both lower myocardial oxygen demand by working at the heart to improve venous perfusion
68
What are the Dihydropyridines
```
Nefidipine
Amlodipine
Felodipine
Isradipine
nimodipine
nicardipine
nisoldipine
clevidipine
```
69
Which drug is preferable when giving a dihydropyridine.
A. Long acting
B. Short acting?
A. Long acting has less side effects and gives best 24-hour control
B. Short acting associated with more rebound sympathetic activity, rebound HTN w/ tacky, dangerous BP
70
Which is better for most pt's needing better anginal mgmt?
A. Dihydropyrines
B. Non-dihydropyrines?
A. dihydropyridines
71
What are SE of Dihydropyridines?
Peripheral edema
| Bronchiole, Gastric uterine tissue also responds (cramping)
72
Which medications are most effective for vasospastic angina?
Non-dihydropyridines are all equally effective for vasospastic angina, efficacy is increased by adding NTG
73
What are the clinical monitoring parameters for CCB's
```
HR, BP, ECG, Physical function
Watch for intolerance
Hypotension
syncope
AV block
Fatigue
Depression
Peripheral edema
Gingival hyperplasia
Sexual dysfunction
wt. gain
```
74
Which medication is better tolerated: Diltiazem or Verapamil?
Diltiazem
75
What Interactions need to be watched for with use of Diltizem and Verapamil
MANY!!
CYP3A4
PGP
76
What is the Most frequent pt reported ADR with CCB's
Peripheral edema
77
Can CCB Nifedipine be used with BB's?
Yes-carefully
78
Can Nifedipine be used SL or orally in HTN emergencies?
NO-it will increase rebound sympathetic CV mortality in CADpt's
79
Which CCB is very selectively used for CA vasodilation, and has no effect on HR? (almost never used)
Nicardipine
80
Which medication is: a long acting alternative to nifedipine, and works very well for management but has a lot of Peripheral Edema associated with it, and can't be used in Liver Dz?
Amlodipine
81
What med is a good low cost alternative to amlodipine, has no effects on HR but never really took off as a branded product?
Felodipine
82
Which CCB is considered last line and has been associated with LV dysfunction?
Bepridil
83
Which medication would provide the most rapid improvement of myocardial oxygen supply in a pt with acute chest pain?
1. SL NTG now
2. Metoprolol now
4. Captopril PO TID
5. Amlopdipine PO now
1. SL NTG now
84
Where do nitrates primarily work?
on the venous system, although they also work on the arterial side too (just not as much).
85
MOA of nitrates
Increases venous capacity, decreases ventricular preload, improves venous and later arterial filling
86
Benefits of nitrates are primarily?
symptom relief
| NO CV outcome benefits, reduces hospitalizations
87
A pt should not use a nitrate any sooner than ____ hours after taking a dose?
12/24
88
Oral nitrates have a ______ _____ metabolism
extensive first-pass.
89
What is the significance of the extensive first-pass metabolism of Nitrates?
works very rapidly and lasts about 30 min
90
When is it dangerous to take a nitrate?
dehydrated
not moving/upright
while using ETOH
91
CV collapse may occur if taking ______ with a nitrate?
phosphodiesterase inhibitors
92
What are the ADE's of nitrates?
Rebound Tachy
Holding on to NA+
Extreme HA
93
What are the clinical monitoring parameters for nitrates?
Therapeutic: anginal relief, activity tolerance
| Intolerance/toxicity: activity intolerance, worsening angina, HoTN, HA, Blurry vision, edema, falls, reflux
94
after 1 dose of NTG with no relief a pt should _____.
Call for a medic
95
SL duration of NTG.
20-30min
96
TD duration of NTG:
6-8hrs
97
Other than NTG what additional Nitrates exist?
Isosorbide mononitrate
| Isosorbide dinitrate
98
Which of the two additional nitrates is MC used?
Mononitrate (don't use dinatrate anymore Mono is much better med)
99
What medication can be used if the pt is on a b blocker already and the anti-anginal doesn't work to control sx?
Isosorbide mononitrate (as third drug)
100
What cautions must be given to a pt on nitrates:
NO ETOH-CV collapse, arrhythmia
Maintain nitrate free intervals every 12 hours for regeneration to reduce tolerance
poorly tolerated by some-HoTN, Orthostasis, HA
101
What medications CANNOT be given within 24 hours of giving a nitrate?
sildenafil, verdenafil, tadalafil (ED meds)
