Stable Angina

Question 1

stable angina pectoris

Answer 1

chest discomfort after predictably from a certain level of exertion and relieved with rest.

Question 2

three classes of medications to treat stable angina pectoris are:

Answer 2

beta blockers, nitrates, and calcium channel blockers

beta blockers - lower HR and BP to reduce myocardial oxygen consumption

nitrates - coronary vasodilation and improves myocardial oxygen delivery and decrease oxygen consumption by reducing preload and decreases ventricular wall stress (can have reflex tachycardia so works best if paired with BB)

CCB- improve myocardial oxygen delivery by causing coronary vasodilation and reduction in coronary vascular resistance. decrease BP so lowers myocardial oxygen use.

Question 3

chronic nitrate therapy is used to

Answer 3

prevent recurrent anginal episodes and overall improve overall exercise tolerance.

Question 4

what is the potential side effect of chronic nitrate therapy?

Answer 4

can see tolerance to anti-anginal effects of nitrates.

Can be managed by intermittent therapy with short periods of nitrate absence. Adjust the nitrate dosing to allow for nitrate free periods. Ex: if taking qid change doing to bid or tid dosing to restore vascular responsiveness and allow for longer drug free periods.

Question 5

Coronary steal phenomenon refers to:

Answer 5

coronary dilation and absolute decrease in blood flow in the coronary bed distal to coronary stenosis compared to flow in areas without stenosis

Seen in pharmacological stress testing with coronary vasodilators like adenosine, regadenosin, dipyridamole

Question 6

rebound angina is

Answer 6

development of angina or increase in angina in someone with ischemic heart disease after abrupt withdrawal of antianginal agents.

Question 7

ischemic conditioning is

Answer 7

1 or more brief episodes of ischemia and subsequent reperfusion to protect the myocardium from a potentially severe sustained episode of ischemia.

Question 8

Treatment of chronic stable angina is

Answer 8

beta blocker (1st line therapy)

CCB- added when BB monotherapy is not effective and alternate when BB is not tolerated

Nitrates - first line for acute angina and longer acting forms are used as further prevention Ranolazine - can be added or substituted for BB

Question 9

activity limiting chronic stable angina despite medical therapy (on beta blocker, CCB and long acting nitrate) and coronary revascularization should get:

Answer 9

ranolazine as a substitute or with beta blockers

Question 10

what is ranolazine?

Answer 10

late sodium channel blocker that causes decreased influx in calcium into cardiomyocytes and lowers left ventricular wall tension and reduced myocardial oxygen consumption.

Question 11

why do we like ranolazine?

Answer 11

it decreases the frequency and severity of anginal symptoms and improves overall exercise tolerance capacity without significantly affecting heart rate or blood pressure

Question 12

what are the limitations with ranolazine?

Answer 12

it does not improve other cardiovascular outcomes like mortality or incidence of myocardial infarction. don’t forget can cause QTC prolongation.

Question 13

ACE inhibitors role in stable angina

Answer 13

don’t help to improve anginal pain.

Question 14

extended release isosorbide mononitrate is dosed:

Answer 14

once daily

Question 15

lifestyle changes for stable angina

Answer 15

regular physical activity

weight loss

tobacco cessation

dietary changes

BP control <130/80

Question 16

definition of stable angina:

Answer 16

2 months of chest pain or pressure precipitated by exertion or emotional stress and does not worsen

Question 17

medications that help treat stable angina

Answer 17

ASA 75-152 mg daily

statin - cornerstone of secondary prevention - get a LIPID panel to see if they need it. prefer high intensity over moderate

beta blockers - aim for 55-60 HR nitrates as needed if this doesn’t help, then titrate up BB,

add CCB if needed, or nitrates , short then long acting

if maximized on ASA, statin, BB, CCB, nitrates, then add ranolazine

Question 18

when do we add ACEi to stable angina?

Answer 18

when there’s concomitant DM1, CKD, LVEF<40, heart failure and history of MI

Question 19

When do we make the decision to get revascularization?

Answer 19

when there’s progressive anginal symptoms refractory to medical therapy and markedly abnormal stress test results get CT angiography (LHC)

Question 20

is PCI better than medical therapy for stable angina?

Answer 20

no. COURAGE and BARI2D trial showed that there is was no difference in LHC revascularization and medical therapy of stable angina

Question 21

When is CABG beneficial?

Answer 21

improves survival and mortality of pts who have:

-left main dx

- 3 vessel CAD

there is also a survival advantage with pts who have:

- DM2

- left LV dysfunction

Question 22

after a patient is revascularized with either LHC or CABG they must be treated with:

Answer 22

ASA indefinitely P2Y12 inhibitor for DAPT

Question 23

Diagnosis of CAD is based off pre test likelihood (already calculated by sex and age and angina like symptoms (non anginal vs atypical angina vs typical angina)

Answer 23

If there’s HIGH pre-test probability start medical therapy for CAD

If there’s LOW pre-test probability, no additional diagnostic testing.

If there’s intermediate pre-test probability need to get testing.

Testing for CAD depends upon if EKG is normal and if they’re able to exercise.