Stable Angina Flashcards
stable angina pectoris
chest discomfort after predictably from a certain level of exertion and relieved with rest.
three classes of medications to treat stable angina pectoris are:
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.
chronic nitrate therapy is used to
prevent recurrent anginal episodes and overall improve overall exercise tolerance.
what is the potential side effect of chronic nitrate therapy?
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.
Coronary steal phenomenon refers to:
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
rebound angina is
development of angina or increase in angina in someone with ischemic heart disease after abrupt withdrawal of antianginal agents.
ischemic conditioning is
1 or more brief episodes of ischemia and subsequent reperfusion to protect the myocardium from a potentially severe sustained episode of ischemia.
Treatment of chronic stable angina is
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
activity limiting chronic stable angina despite medical therapy (on beta blocker, CCB and long acting nitrate) and coronary revascularization should get:
ranolazine as a substitute or with beta blockers
what is ranolazine?
late sodium channel blocker that causes decreased influx in calcium into cardiomyocytes and lowers left ventricular wall tension and reduced myocardial oxygen consumption.
why do we like ranolazine?
it decreases the frequency and severity of anginal symptoms and improves overall exercise tolerance capacity without significantly affecting heart rate or blood pressure
what are the limitations with ranolazine?
it does not improve other cardiovascular outcomes like mortality or incidence of myocardial infarction. don’t forget can cause QTC prolongation.
ACE inhibitors role in stable angina
don’t help to improve anginal pain.
extended release isosorbide mononitrate is dosed:
once daily
lifestyle changes for stable angina
regular physical activity
weight loss
tobacco cessation
dietary changes
BP control <130/80
definition of stable angina:
2 months of chest pain or pressure precipitated by exertion or emotional stress and does not worsen
medications that help treat stable angina
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
when do we add ACEi to stable angina?
when there’s concomitant DM1, CKD, LVEF<40, heart failure and history of MI
When do we make the decision to get revascularization?
when there’s progressive anginal symptoms refractory to medical therapy and markedly abnormal stress test results get CT angiography (LHC)
is PCI better than medical therapy for stable angina?
no. COURAGE and BARI2D trial showed that there is was no difference in LHC revascularization and medical therapy of stable angina
When is CABG beneficial?
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
after a patient is revascularized with either LHC or CABG they must be treated with:
ASA indefinitely P2Y12 inhibitor for DAPT
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)
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.
