Stable CAD Lecture Flashcards
When should aspirin be chewed and swallowed?
During ACS
What factors influence GI bleeding with aspirin use?
- Age
- Dose
- Drug burden
What should be used with aspirin to protect stomach from bleeding?
- H2 receptor antagonists
- PPIs
What is clopidogrel bioactivated by? What should be avoided because of this?
- CYP 2C19
- Avoid PPIs
What is the advantage of prasugrel over clopidogrel?
- Marginally more effective
- Avoids CYP 2C19 interaction with PPIs
Why should prasugrel be avoided in patients less than 60 kg or older than 75?
Increase in minor bleeding
Which anti-platelet is reversible?
Ticagrelor
When is ticagrelor contraindicated and why?
- Active liver disease
- 99+% protein bound
What class is preferred as anti-anginals? Why?
Beta blockers
-Best data for reducing CV events
What classes are used as anti-anginals?
- Beta blockers
- CCBs
- Nitrates
How do Beta blockers alter electrical conduction in the heart?
PR interval and ventricular rate prolonged
How do beta blockers affect renin?
- Reduction in renin output
- Reduction in RAAS activity (aka decreased BP)
Describe the half life of beta blockers
Short
___ predicts response in beta blocker use
Hepatic metabolism
What are the outcome benefits of beta blockers?
- Reduce mortality in HTN pts w/recent MI
- Improve survival in HTN pts after recent stroke
What is the functional importance of beta blockers?
Improves exercise tolerance (though initially difficult)
Downsides of beta blockers
- Symptomatic bradycardia
- Initial reduction in exercise tolerance (adapts w/in 30 days)
- CNS (fatigue, insomnia, unpleasant dreams)
What type of beta blocker is metoprolol?
Selective b-1 blocker
Which beta blocker can precipitate decompensated HF if used in unstable Stage 3/4 pts?
Bisoprolol
Which beta blocker requires adjustment in renal dysfunction due to long half life?
Bisoprolol
What type of beta blocker is carvedilol?
Non selective plus selective alpha 1 blocker
Which beta blocker has less rebound tachy and why?
Carvedilol and Labetalol
due to alpha blocking effects
Which beta blocker has extensive hepatic metabolism through CYP 2D6?
Carvedilol
Which beta blocker may reduce smooth muscle infiltration in vascular remodeling, limit free radicals, and reduce lipid peroxidation?
Carvedilol
What are the unique features of propranolol?
- Nonselective
- Lipophilic
- Very high 1st pass metabolism
Which beta blocker has a longer duration of action which makes it good for daily dosing?
Nadolol
What type of beta blocker is nadolol?
Nonselective
Which beta blocker has NO CV outcomes data in HTN pts with CAD, HF?
Atenolol
Atenolol is which type of beta blocker?
Selective beta 1 blocker
What type of beta blocker is labetalol?
- Non selective beta blocker
- Selective alpha 1 blocker
Which beta blocker has an ultra short action time?
Esmolol
so it is reserved for perioperative use
What is the most selective beta 1 blocker?
Nebivolol
Which beta blocker results in NO dependent vasodilation?
Nebivolol
Which beta blocker should be dose reduced in Child-Pugh Class B patients and CrCl less than 30?
Nebivolol
When should Nebivolol be dose reduced?
- Child-Pugh Class B patients
- CrCl less than 30
All CCBs are ____ vasodilators
Arterial
Which CCBs are alternatives to BBs?
Verapamil and diltiazem
Which CCBs lower myocardial oxygen demand?
Verapamil and diltiazem
What are examples of dihydropyridine CCBs?
Nifedipine
Amlodipine
Felodipine
Which CCB is long acting and gives the best 24 hr BP control?
Amlodipine
What is a disadvantage to dihydropyridine CCBs?
Can result in edema
Which CCBs are CYP3A4 inhibitors?
Verapamil
Which CCBs are inhibitors of P-glycoprotein?
Verapamil and dilt
Nifedipine
What 2 indications can CCBs be used for?
- Vasospastic angina
- Vasospasm a/w hemorrhagic stroke (nimodipine, nicardipine, verapamil)
Which CCBs should be avoided in heart failure patients?
Non-dihydropyridines (verapamil and dilt)
How is the dose of verapamil adjusted?
BP, HR, exercise tolerance
Which is tolerated better - verapamil or diltiazem?
Diltiazem
MC ADE reported with diltiazem?
Peripheral edema
Which CCBs are strong CYP3A4 substrates?
Diltiazem
How does Nifedipine work?
- Relaxes coronary and peripheral smooth muscle
- Can be used carefully with B blockers
- Never use SL or orally in HTN emergencies (increases rebound activity)
Which CCB can be used in Raynaud’s?
Nifedipine
When can dosing of amlodipine be adjusted?
Every 14 days
What is considered a last line CCB and why?
- Bepridil
- A/w LV dysfunction
Describe nitrates
Mixed venous AND arterial dilating drugs
What is the benefit of nitrates?
- Symptom relief, delays ED/urgent care visits
- No CV outcome benefits
What should we be cautious about with nitrates?
Regular use depletes glutathione which results in tolerance to nitrate
ADEs of nitrates?
- Migraine like HAs (d/t temporal and meningeal artery dilation)
- Rebound tachy
- Enhanced Na retention
What meds should be help for 24 hours after any nitrate and why?
PDE inhibitors (used for ED) -Can cause excessive vasodilation
What is the intended use of nitroglycerin?
Rapid relief of angina
- SL duration = 20-30 mins
- TD duration = 6-8 hrs (remove patch before MRI and defib)
What can nitro be used to prevent?
Exercise induced angina
What is the purpose of isosorbide mononitrate?
XR tablet to allow for treatment of nocturnal angina
Which nitrate has the highest levels of tolerance?
- Isosorbide dinitrate
- Last dose should be no later than 7pm
Why should nitrates and alcohol be avoided?
- CV collapse
- Arrhythmia
How does Ranolazine work?
- Reduces ventricular wall tension and MVO2
- Enhanves metabolic efficiency w/o changing hemodynamics (no effect on BP and HR)
- Improves treadmill exercise tolerance by 30 secs
Where is Ranolazine’s place in therapy?
When BB, CCB and nitrates are maximized
What happens with higher doses of Ranolazine?
Prolongs QT interval
How does Ivabradine work?
- Alternative node blocking agent
- Selective Na blocker
- Hyperpolarizes SA node
What are nicorandil and trimetazidine?
Newer agents not yet available in US
