Module 8/9 - CAD

Question 1

Pathophys of CAD *

Answer 1

-endothelial injury
-lipid infiltration
-aging
-vascular dynamics
-inflammation

• thrombogenesis forms clot USUALLY OVER RUPTURED PLAQUE causing endothelial injury.
• HTN causes increased lipid infiltration
• inflammation of the plaques increase likelihood of plaque rupture

Question 2

EKG Changes in CAD / STEMI *

Answer 2

Area of ischemia: area consists of viable cells. repolarization is impaired as evidenced by INVERTED T WAVES

Area of injury: potentially viable. cells are not repolarizing due to blockage and lack of blood flow (fire mans hat)

Question 3

LBBB *

Answer 3

New or presumed new left bundle branch block could also be indicative of STEMI

Question 4

Common sites of anginal pain *

Answer 4

• upper chest
• substernally radiating to neck and jaw
• substernally radiating to left arm
• epigastric
• epigastric radiating to neck, jaw, arms
• neck and jaw
• left shoulder
• intracapsular

Question 5

Stable Angina *

Answer 5

• predictable and caused by similar precipitating factors each time such as exercise, emotional upset, tachycardia
• pain control is achieved by rest and admin of sublingual nitro
• can be medically managed for long periods of time

SUBLINGUAL NITRO
- 1 dose of NTG
- Repeat every 3-5 minutes
- Max of 3 doses
- call 911 if symptoms don’t resolve

Question 6

Unstable Angina *

Answer 6

• chest pain that has new onset, occurs at rest, or is worsening in severity
• pain is more intense than stable
• if pain is not improved or worsening after taking 1 NTG, call EMS (EMS IS ALLOWED TO TELL THEM TO REPEAT UNTIL AMBULANCE ARRIVES)
• unstable angina is treated medically as a NSTEMI or NSTE-ACS

Question 7

Long term anginal relief *

Answer 7

BB are first line for long term anginal relief
- s/e may decrease adherence (sexual dysfunction, fatigue, cold extremities)

Beta 1 receptors are preferred (less s/e)
- use: metoprolol atenolol bisoprolol

PAD - use carvedilol

Question 8

Angina: unable to tolerate BB or BB didn’t work? *

Answer 8

CCB can be added (non dihydropyridines) (long acting diltiazem or verapamil)

DONT USE CCB and BB together or with HFrEF
for HFrEF use dihy (amlodipine)

if CCB and BB don’t work that can consider adding long-acting nitrate

ranolazine is last lines, reserved for those who don’t tolerate CCB CBB Long acting nitrates (isosorbide)

Question 9

Antiplatelets in CAD *

Answer 9

Stable heart disease with NO hx of ACS (or > 1yr post ACS), stent or CABG should take aspirin indefinitely
- 81mg/day

clopidogrel 75mg daily alternative for ASA intolerant pts

Pts post ACS, post CABG, or with a stent: Use DAPT for at least 12mo and then ASA indefinitely
ASA + clopidogrel, ticagrelor, prasugrel