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Cardio Exam 2 > Pharmacotherapy of Chronic Stable Angina (CSA) > Flashcards

Pharmacotherapy of Chronic Stable Angina (CSA) Flashcards

1
Q

Defined Chronic Stable Angina

A

Substernal chest discomfort that is typically relieved by nitroglycerin and/or rest (usually 5-10 minutes, less than 20)

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2
Q

CSA is aggravated by

A

Exertion, emotional stress cold, meals

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3
Q

Define rest angina

A

Angina occurring at rest and lasting more than 20 minutes

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4
Q

Define New Onset Angina

A

Angina of Class III (marked limitation of normal activity) in the past 2 months

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5
Q

Define Increasing Angina

A

Stable angina that is now increasing in duration or frequency

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6
Q

High risk symptoms

A

PE, rales, angina with hypOTN, nocturnal angina

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7
Q

Goals of therapy for CSA

A

Provide symptomatic relief form angina that limits exercise and QofL
Slow the progression of atherosclerosis leading to CV events and death

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8
Q

A pt with CSA has a compelling indication for what anti-HTN combo?

A

BB + ACEi/ARB

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9
Q

Non-pharm Management

A

Percutaneous Coronary Intervention (balloon angioplasty/stenting)
Coronary artery bypass grafting (blood vessels from other part of your body put in your heart)
External counterpulsation therapy (Pants that help blood flow return to your heart

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10
Q

Can you titrate anti-anginal/BP medication below the standard target BP to reduce symptoms of CSA?

A

YES

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11
Q

CSA + Nitrates

A

ALL PATIENTS should have this

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12
Q

Minimal HR

A

55 beats/minute

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13
Q

Minimal BP

A

100/65

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14
Q

Critical side effects

A

Orthostatic hypotension +/- falls, syncope, severe fatigue

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15
Q

Beta Blockers

A

First line management of CSA

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16
Q

Beta 1 Selective Preferred for:

A

Unstable asthma/COPD
PVD
DM
Sexual dysfunction

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17
Q

Mixed alpha/beta may be used if:

A

Additional BP Control is needed

Example: Caredilol

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18
Q

Agents with intrinsic sympathomimetic activity

A

Are avoided bc they can cause a tachycardic state inducing angina

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19
Q

BB Dosing

A

Titrate to a HR of 55 beat/min

20
Q

BB must not be combined with

A

Non-DHP CCBs bc of bradycardia and heart block

21
Q

BB can be combined with

A

DHP CCBs blunts tachycardia
Nitrates: blunts tachycardia
Ranolazine

22
Q

BB Monitoring

A

BP and HR

Side effects

23
Q

Non-DHP CCBs

A

Diltiazem and verapil

Alternative first line agents

24
Q

Things to consider with Non-DHP CCBs

A

Avoid in systolic HF
Good if you can’t take BB
Good for Prinzmetal angina
QD or BID dosing to ensure coverage

25
Q

Non-DHP CCBs Dosing

A

Titrate to 55 beat per minute

26
Q

Non-DHP CCBs cannot be combined with:

A

BBs bradycardia and heart blcok

Ranolazine: 3A4

27
Q

Non-DHP CCBs can be combined with:

A

DHPs

Nitrates

28
Q

DHPs

A

Amlodipine, felodipine, nicardipine

Second line agents and typically add ons

29
Q

DHP considerations

A

Potential for reflex tachycardia and lack effect on HR

30
Q

DHP Dosing

A

Up-titrate to relief of angina, if BP allows

31
Q

DHP can be combined with:

A

Nitrates and Ranolazine

32
Q

DHP Monitoring

A

BP
Relief of angina
Appearance of side effects (peripheral edema, tachycardia)

33
Q

How can you avoid peripheral edema with DHP

A

Take at night so all the blood doesn’t get pulled to lower limbs

34
Q

Nitrates Examples

A

Nitrostat 0.4 tablet sublingual

Nitrolingual: spray under tongue

35
Q

Long-Acting Nitrates

A

Third line agents and reserved for add-on therapy with BB or nonDHPCCB to blunt tachycardia

36
Q

Isosorbide mononitrate Immediate

A

Ismo
Monoket
20 mg BID at least 6 hrs apart

37
Q

Isosorbide mononitrate sustained

A

Imdur

30-240 mg daily

38
Q

Isosorbide dinitrate sustained

A

Isochron

40-80 mg daily

39
Q

NTG patch

A

Nitrodur

0.2-0.8 mg/hr applied for 10-12 hrs

40
Q

Long-acting nitrates monitoring

A 
BP and relief
Tachycardia
Decreased efficacy
Headache
Orhtostatic hypotention
41
Q

Long-acting nitrate contraindications

A

Avoid with PDE-5 inhibitors (Sildenafil 24 hrs, Tadalafil 48 hrs, Vardenafil 24 hrs)

42
Q

Long-acting nitrates should be dosed in what fashion?

A

With a `12 hour nitrate-free interval to avoid development of tolerance

43
Q

Ranolazine

A

Third line add on agent

44
Q

Ranolazine consideration

A

No affect on BP and HR
Expensive
Prolongs QT interval
Substrate of 3A4 2D6 and P-gp

45
Q

Ranolazine drug interactions

A

NonDHP-CCB: stop at 500 mg
Digoxin
Simvastatin levels double with ranolazine

46
Q

Ranolazine dose

A

500 mg PO twice daily titrated up to 100

47
Q

Ranolazine contraindications

A

Hepatic impairment

Strong 3A4 inhibitors

Cardio Exam 2 (10 decks)

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