Pharmacotherapy of Chronic Stable Angina (CSA)

Question 1

Defined Chronic Stable Angina

Answer 1

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

Question 2

CSA is aggravated by

Answer 2

Exertion, emotional stress cold, meals

Question 3

Define rest angina

Answer 3

Angina occurring at rest and lasting more than 20 minutes

Question 4

Define New Onset Angina

Answer 4

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

Question 5

Define Increasing Angina

Answer 5

Stable angina that is now increasing in duration or frequency

Question 6

High risk symptoms

Answer 6

PE, rales, angina with hypOTN, nocturnal angina

Question 7

Goals of therapy for CSA

Answer 7

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

Question 8

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

Answer 8

BB + ACEi/ARB

Question 9

Non-pharm Management

Answer 9

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

Question 10

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

Answer 10

YES

Question 11

CSA + Nitrates

Answer 11

ALL PATIENTS should have this

Question 12

Minimal HR

Answer 12

55 beats/minute

Question 13

Minimal BP

Answer 13

100/65

Question 14

Critical side effects

Answer 14

Orthostatic hypotension +/- falls, syncope, severe fatigue

Question 15

Beta Blockers

Answer 15

First line management of CSA

Question 16

Beta 1 Selective Preferred for:

Answer 16

Unstable asthma/COPD
PVD
DM
Sexual dysfunction

Question 17

Mixed alpha/beta may be used if:

Answer 17

Additional BP Control is needed

Example: Caredilol

Question 18

Agents with intrinsic sympathomimetic activity

Answer 18

Are avoided bc they can cause a tachycardic state inducing angina

Question 19

BB Dosing

Answer 19

Titrate to a HR of 55 beat/min

Question 20

BB must not be combined with

Answer 20

Non-DHP CCBs bc of bradycardia and heart block

Question 21

BB can be combined with

Answer 21

DHP CCBs blunts tachycardia
Nitrates: blunts tachycardia
Ranolazine

Question 22

BB Monitoring

Answer 22

BP and HR

Side effects

Question 23

Non-DHP CCBs

Answer 23

Diltiazem and verapil

Alternative first line agents

Question 24

Things to consider with Non-DHP CCBs

Answer 24

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

Question 25

Non-DHP CCBs Dosing

Answer 25

Titrate to 55 beat per minute

Question 26

Non-DHP CCBs cannot be combined with:

Answer 26

BBs bradycardia and heart blcok | Ranolazine: 3A4

Question 27

Non-DHP CCBs can be combined with:

Answer 27

DHPs | Nitrates

Question 28

DHPs

Answer 28

Amlodipine, felodipine, nicardipine | Second line agents and typically add ons

Question 29

DHP considerations

Answer 29

Potential for reflex tachycardia and lack effect on HR

Question 30

DHP Dosing

Answer 30

Up-titrate to relief of angina, if BP allows

Question 31

DHP can be combined with:

Answer 31

Nitrates and Ranolazine

Question 32

DHP Monitoring

Answer 32

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

Question 33

How can you avoid peripheral edema with DHP

Answer 33

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

Question 34

Nitrates Examples

Answer 34

Nitrostat 0.4 tablet sublingual | Nitrolingual: spray under tongue

Question 35

Long-Acting Nitrates

Answer 35

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

Question 36

Isosorbide mononitrate Immediate

Answer 36

Ismo Monoket 20 mg BID at least 6 hrs apart

Question 37

Isosorbide mononitrate sustained

Answer 37

Imdur | 30-240 mg daily

Question 38

Isosorbide dinitrate sustained

Answer 38

Isochron | 40-80 mg daily

Question 39

NTG patch

Answer 39

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

Question 40

Long-acting nitrates monitoring

Answer 40

``` BP and relief Tachycardia Decreased efficacy Headache Orhtostatic hypotention ```

Question 41

Long-acting nitrate contraindications

Answer 41

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

Question 42

Long-acting nitrates should be dosed in what fashion?

Answer 42

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

Question 43

Ranolazine

Answer 43

Third line add on agent

Question 44

Ranolazine consideration

Answer 44

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

Question 45

Ranolazine drug interactions

Answer 45

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

Question 46

Ranolazine dose

Answer 46

500 mg PO twice daily titrated up to 100

Question 47

Ranolazine contraindications

Answer 47

Hepatic impairment | Strong 3A4 inhibitors