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Therapeutics III > Sowinski Angina Lectures > Flashcards

Sowinski Angina Lectures Flashcards

1
Q

Clinical syndromes of chronic coronary disease

A

-Stable angina pectoris: “macrovascular disease”
-Post-ACS; post-revascularization
-Variant or Prinzmetal’s angina: “vasospastic disease”
-Cardiac syndrome X: “microvascular disease”
-Silent myocardial ischemia

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2
Q

Types of angina

A

-Prinzmetal’s variant angina (vasospasm)
-Chronic stable angina (fixed stenosis)
-Unstable angina (thrombus)

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3
Q

What increases O2 supply?

A

-Coronary blood flow
-O2 carrying capacity

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4
Q

What increases O2 demand?

A

-Wall tension
-Contractility
-Heart rate

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5
Q

Pathophysiology of stable angina

A

-Stable angina pectoris is usually associated with large single to multivessel ASCAD
-Approximately 85% of patients with angina pectoris have significant coronary disease in a major epicardial coronary vessel

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6
Q

Pathophysiology of myocardial ischemia

A

-Imbalance between myocardial oxygen supply and demand
-Produces disturbances in myocardial function without causing myocardial necrosis

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7
Q

Pathophysiology of angina

A

Resulting symptoms from ischemia…is a clinical syndrome of chest discomfort

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8
Q

Definition of stable angina pectoris

A

-Discomfort in the chest and/or adjacent areas
-Caused by myocardial ischemia and associated with a disturbance in myocardial function without myocardial necrosis
-“Stable”: characteristics of an anginal episode have not changed recently

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9
Q

Clinical presentation (PQRST)

A

-Precipitating factors: Exertion
-Palliative measures: Rest and/or SL NTG
-Quality and quantity of the pain: Squeezing, heaviness, tightening
-Region and radiation: Substernal
-Severity of the pain: ~subjective, > 5 (out of 10)
-Timing and temporal pattern: Lasts <20 min, usually relieved in 5-10 minutes

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10
Q

Classic clinical characteristics of typical angina

A

-Substernal
-Duration: 0.5-20 min (usually short)
-Relieved by nitroglycerin or rest
-ST-segment depression (during event)

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11
Q

Diagnostic procedures to preform for a patient with angina

A

-History and physical examination
-Electrocardiogram to look for ST segment depression or elevation

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12
Q

Diagnostic procedures for coronary heart disease

A

-Cardiac imaging
-Echocardiography
-Cardiac catheritization and coronary angiography

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13
Q

What are the two desired outcomes for the treatment of chronic coronary disease?

A

-Risk factor modification
-Alleviate acute symptoms

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14
Q

Pharmacotherapy to prevent ACS and death

A

-Anti-platelet therapy
-Statin therapy: see dyslipidemia lectures
-RAS inhibitors: ACE/ARBs
-Colchicine?
-Beta-blockers

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15
Q

MOA of aspirin

A

-Acetylation and irreversible inactivation of platelet COX-1
-Blocking of TXA2 synthesis leading to antiplatelet activity

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16
Q

Aspirin loading dose

A

162-375 mg (typically 375 mg)

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17
Q

Aspirin maintenance dose

A

75-162 mg daily (typically 81 mg)

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18
Q

Clopidogrel loading dose

A

300-600 mg

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19
Q

Clopidogrel maintenance dose

A

75 mg daily

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20
Q

Prasugrel loading dose

A

60 mg

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21
Q

Prasugrel maintenance dose

A

10 mg daily

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22
Q

Ticagrelor loading dose

A

180 mg

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23
Q

Ticagrelor maintenance

A

90 mg BID

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24
Q

Cangrelor dosing

A

IV only

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25
Q

Adverse effects of aspirin

A

-Stomach bleeding
-Bleeding (intracranial and extracranial)
-Hypersensitivity
-Major bleeding: 2-3% in year 1

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26
Q

Which P2Y12 inhibitors are prodrugs?

A

-Clopidogrel
-Prasugrel

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27
Q

Which P2Y12 inhibitors are not prodrugs?

A

Ticagrelor

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28
Q

How long does it take the effect of clopidogrel to dissipate?

A

5 days

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29
Q

How long does it take the effect of prasugrel to dissipate?

A

7 days

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30
Q

How long does it take the effect of ticagrelor to dissipate?

A

5 days

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31
Q

Adverse effects of clopidogrel

A

-Bleeding
-Diarrhea
-Rash

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32
Q

Adverse effects of prasugrel

A

-Bleeding
-Diarrhea
-Rash

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33
Q

Adverse effects of ticagrelor

A

-Bleeding
-Bradycardia
-Heart block
-Dyspnea

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34
Q

Pharmacotherapy to treat chronic coronary disease with no history of a stent implantation

A

-Single-antiplatelet therapy
-Dual-antiplatelet therapy (for certain high-risk patients)

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35
Q

Type of single-antiplatelet therapy

A

-Aspirin 75-100 mg/day indefinitely (preference for 81 mg)
-Clopidogrel 75 mg/day if contraindicated or intolerant to aspirin

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36
Q

Types of stents

A

-Bare metal stents
-Drug-eluting stents

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37
Q

Pharmacotherapy for chronic coronary disease before an elective PCI + drug-eluting stent

A

Aspirin and P2Y12 inhibitor loading dose

38
Q

Pharmacotherapy for chronic coronary disease after an elective PCI + drug-eluting stent when the patient has a low risk of bleeding

A

-Dual-antiplatelet therapy for a minimum of 6 months
-Single antiplatelet therapy indefinitely (81 mg aspirin preference)

39
Q

Pharmacotherapy for chronic coronary disease after an elective PCI + drug-eluting stent when the patient has a high risk of bleeding

A

-DAPT 1-3 months may be reasonable
-P2Y12 inhibitor for 12 months (Clopidogrel, prasugrel, or ticagrelor do not distinguish choice)
-SAPT indefinitely (preference for 81 mg of aspirin)

40
Q

Pharmacotherapy following a CABG

A

Aspirin 81 mg/day indefinitely + clopidogrel 75 mg/day for a year

41
Q

What must be considered if you choose to use aspirin with ticagrelor?

A

Aspirin dose MUST BE 100 mg or less

42
Q

With which patients should an ACEi be considered?

A

-In all patients with CCD
-Especially in patients with LVEF <40%, HTN, DM or CKD

43
Q

With which patients should an ARB be considered?

A

-In those who are intolerant to ACEis due to cough or other adverse effects
-NEVER USE AN ACE AND AN ARB TOGETHER

44
Q

Mechanism of action of organic nitrates

A

-Nitric oxide donors and releasers
-Activation of guanylate cyclase

45
Q

Effects of organic nitrates

A

-Marked vasodilation which causes a decrease in preload
-Less arteriole dilation, coronary and peripheral
-Minor inhibition of platelet aggregation

46
Q

Nitroglycerin sublingual tab dosing

A

0.3-0.6 mg PRN, repeat dose 1-3 times every 5 minutes

47
Q

Nitroglycerin sublingual spray dosing

A

0.4 mg/spray PRN, repeat dose 1-3 times every 5 minutes

48
Q

Counseling points on nitroglycerin sublingual tablets

A

-Keep in original dark glass container
-No safety cap
-Place under tongue, do not swallow tab
-Remove the cotton plug as soon as you pick up the medication from the pharmacy
-Do not store in humid locations such as your bathroom
-Keep on person at all times
-Teach technique on how to use
-Preventative use instructions
-911 procedures

49
Q

Counseling points on nitroglycerin sublingual spray

A

-Spray under tongue, do not inhale
-Do not shake
-Keep on person at all times
-Teach technique on how to use
-Preventative use instructions
-911 procedures

50
Q

Adverse effects of nitroglycerin

A

-Headache
-Hypotension
-Dizziness
-Lightheadedness
-Facial flushing
-APAP use, avoid NSAIDs
-Extreme caution with PDEI

51
Q

Clinical recommendations for nitrates

A

-Should be utilized in all patients
-Products may also be useful for the prevention of angina, when taken just prior to the initiation of exertion or some other event which precipitates angina

52
Q

Pharmacotherapy to prevent recurrent ischemia and angina symptoms

A

-Beta-blockers
-Calcium-channel blockers
-Nitrates

53
Q

Mechanism of action of beta blockers

A

Competitive, reversible inhibitors of beta-adrenergic stimulation by catecholamines

54
Q

Beta blocker desired effects on myocardial oxygen demand

A

-Reduced HR
-Reduce myocardial contractility
-Reduce arterial BP (afterload)

55
Q

Beta blocker undesired effect on myocardial oxygen demand

A

Reduced heart rate leads to an increased diastolic filling time leading to an increased LVEDV resulting in an increased preload

56
Q

Atenolol receptor selectivity

A

beta 1

57
Q

Atenolol maintenance dosage

A

50-100 mg qd

58
Q

Metoprolol receptor selectivity

A

beta 1

59
Q

Metoprolol IR dosage

A

50-100 mg bid

60
Q

Metoprolol XL dosage

A

100-200 mg qd

61
Q

Propranolol receptor selectivity

A

beta 1 and 2

62
Q

Propranolol dosing

A

80-160 mg qd

63
Q

Beta blocker adverse effects

A

-Sinus bradycardia
-Sinus arrest
-AV block
-Reduced LVEF
-Bronchoconstriction
-Fatigue
-Depression
-Nightmares
-Sexual dysfunction
-Exercise intolerance
-Intensification of insulin-induced hypoglycemia
-Peripheral vascular complication
-Beta blocker withdrawal syndrome

64
Q

Beta blocker dosage and monitoring parameters

A

-Initiate at lowest dose and titrate to symptom reduction
-Monitor heart rate
-Monitor amount of painful episodes

65
Q

Calcium channel blockers mechanism of action

A

-Decrease influx of trigger calcium in myocytes
-Decreased chronotropy in nodal cells; inotropy in myocytes
-Vasodilation

66
Q

Dihydropyridine calcium channel blocker adverse effects

A

-Hypotension
-Flushing
-Headache
-Dizziness
-Reduced myocardial contractility
-Peripheral edema
-Reflex adrenergic activation

67
Q

Non-dihydropyridine calcium channel blocker adverse effects

A

-Reduced myocardial contractility (V>D)
-AV/SA nodal conduction disturbances: bradycardia and atrioventricular block (V>D)
-Hypotension
-Flushing
-Headache
-Dizziness
-Constipation (V>D)

68
Q

Calcium channel blockers dosing

A

Initiate at lowest dose and titrate to symptom reduction

69
Q

Monitoring parameters for DHP calcium channel blockers

A

-Edema
-Blood pressure

70
Q

Monitoring parameters for non-DHP calcium channel blockers

A

-Heart rate

71
Q

What is nitrate tolerance?

A

Decreased response in the presence of continued or frequently administered nitrates

72
Q

How long should the nitrate free period?

A

Nitrate free period of at least 10-12 hours

73
Q

Pharmacology of nitrate tolerance

A

-Reversible in absence of drug
-ALDH2 inactivation in mitochondria
-ISMN and ISDN also elicit tolerance but via a slower, less understood process

74
Q

Nitrate patches patient counseling

A

-Discussion of nitrate free period
-Apply patches between elbows and knees
-Apply the patch to clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused
-Choose a different area each day
-You may shower while wearing patch
-Do not cut the patch
-Wash hands before and after

75
Q

Ranolazine mechanism of action

A

Inhibition of late inward Na+ current in ischemic myocytes, decreased intracellular Na+ leads to a decrease in Ca2+ influx

76
Q

What differentiates ranolazine from other anti-ischemic agents?

A

DOES NOT affect HR, BP, inotropy, or perfusion like traditional anti-ischemic agents

77
Q

How to dose ranolazine

A

Titration from 500 BID to 1000 BID over 1-2 weeks

78
Q

When do you use ranolazine?

A

As add-on therapy for the symptomatic treatment of patients with stable angina pectoris who are inadequately controlled or intolerant to first-line antianginal therapies

79
Q

When can you use ranolazine as a monotherapy for the treatment of chronic angina?

A

Only when BP/HR too low with first-line agents

80
Q

Which medications should ranolazine not be used with?

A

Strong CYP3A inducers or inhibitors

81
Q

Adverse effects of ranolazine

A

-Constipation
-Nausea
-Dizziness
-Headache
-Dose related increase in QT-interval

82
Q

Which drug is the first choice of use when selecting an agent for treatment for ischemic heart disease?

A

Beta blockers for patients without contraindications

83
Q

Compelling indications for beta blockers

A

-Stable heart failure
-History of myocardial infarction
-Angina

84
Q

Beta blocker contraindications

A

-Bradycardia
-High degree AV block
-Sick sinus syndrome (with no pacemaker)

85
Q

When are non-DHP CCBs preferred when treating ischemic heart disease?

A

-If the patient has contraindications to beta blockers
-Unacceptable side effects to beta blockers
-Potentially useful in chronic lung diseases, HTN, DM and peripheral vascular disease

86
Q

Contraindications to non-DHP CCBs

A

-HFrEF
-Bradycardia
-High degree AV block
-Sick sinus syndrome

87
Q

Contraindications to DHP CCBs

A

HFrEF (except amlodipine and felodipine)

88
Q

Why is it not recommended to use nitrates as monotherapy?

A

Can be challenging due to nitrate free period and tolerance

89
Q

Cautions to consider when using nitrates

A

-Hypertrophic obstructive cardiomyopathy
-Severe aortic stenosis
-Phosphodiesterase use

90
Q

Why would we use nitrates with beta blockers?

A

To block reflex tachycardia

91
Q
A

Therapeutics III (42 decks)

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