Stable Angina Flashcards
What is stable angina?
Angina pectoris
- squeezing felt in chest caused by myocardial ischemia
What are the main differences between stable and unstable angina?
Stable angina:
Predictable
Familiar pain patterns
Responds to rest
Unstable:
Unpredictable (even at rest)
Changed pain patterns
Does not respond to rest
What is the most common cause of myocardial ischemia?
Coronary artery disease
- buildup of cholesterol plaque
What are non-pharm therapy choices for stable angina?
Aggressive lifestyle intervention
- regular aerobic exercises
- healthy diet
- avoid processed foods containing trans fats
- quit smoking
- alcohol in moderation
- stress management
Revascularization
- PCI or CABG
What should we provide to all patients for acute treatment of angina attack?
Nitrates
- Sublingual nitroglycerin
What are four clinical pearl with nitrates that we have to keep in mind?
Tolerance can develop.
Ensure nitrate-free period for 10-12 hours is in each 24 hours period.
Schedule this period at a time with minimal symptoms (usually at night)
Sit when taking nitrates to reduce the risk of presyncope or syncope
Long-acting formulations can cause headaches
Avoid taking with sildenafil, tadalafil, and vardenafil
How long should we separate the PDE5 inhibitors from nitrates?
Sildenafil/vardenafil= separate by at least 24 hours
Tadalafil= separate by at least 48 hours
Which drugs can decrease or prevent angina?
Beta blockers and calcium channel blockers
Once beta blockers have been started, can we stop them abruptly?
No, can precipitate rebound tachycardia or worsening anginal symptoms
Taper dose over 10-14 days period
What are the two classes of calcium channel blockers that can be used in stable angina?
Non DHP-CCB
- Verapamil
- Diltiazem
DHP CCB
- amlodipine
- nifedipine
- felodipine (not approved by Health Canada)
Which of the two classes of CCBs are more similar to beta blockers and can therefore affect heart rate more?
Non-DHP CCB
What other agents would help treat angina?
Ivabradine
What drug should be started in all patients with stable angina to decrease the risk of cardiovascular death?
Statin
Drug of choice: Atorvastatin 80mg
What is the cholesterol treatment goal for those with stable angina?
LDL below 2mmol/L
or drop of at least 50% in LDL on statin therapy
If a single statin is not enough to control cholesterol, what other add-on therapies are availabe?
Ezetimibe
PCSK9 inhibitors
- alirocumab
- evolocumab
Icosapent ethyl
In order to reduce mortality and prevent CV events, what drug should be started in all patients ?
Antiplatelet agent
ASA 80-160mg
When do we use clopidogrel in patients?
Reserved for stable angina patients who cannot take ASA
When can we consider DAPT with ASA and clopidogrel?
If there is recent acute coronary syndrome or PCI with stent implantation
When does ACEi come into play in stable angina? Is it recommended for all patients?
Not for all patients. Only for patients who can tolerate (no dry cough side effect) and if physician deems it necessary
Dose is typically 10mg/day
In which condition should we avoid using beta blockers?
What agents can we use instead in this condition?
Prinzmetal angina
Use calcium channel blockers and nitrates instead
What is prinzmetal angina?
Coronary artery vasospasm
Which drug is associated with increased risk of MI?
NSAIDs
