Stable CAD Lecture

Question 1

When should aspirin be chewed and swallowed?

Answer 1

During ACS

Question 2

What factors influence GI bleeding with aspirin use?

Answer 2

• Age
• Dose
• Drug burden

Question 3

What should be used with aspirin to protect stomach from bleeding?

Answer 3

• H2 receptor antagonists

- PPIs

Question 4

What is clopidogrel bioactivated by? What should be avoided because of this?

Answer 4

• CYP 2C19

- Avoid PPIs

Question 5

What is the advantage of prasugrel over clopidogrel?

Answer 5

• Marginally more effective

- Avoids CYP 2C19 interaction with PPIs

Question 6

Why should prasugrel be avoided in patients less than 60 kg or older than 75?

Answer 6

Increase in minor bleeding

Question 7

Which anti-platelet is reversible?

Answer 7

Ticagrelor

Question 8

When is ticagrelor contraindicated and why?

Answer 8

• Active liver disease

- 99+% protein bound

Question 9

What class is preferred as anti-anginals? Why?

Answer 9

Beta blockers

-Best data for reducing CV events

Question 10

What classes are used as anti-anginals?

Answer 10

• Beta blockers
• CCBs
• Nitrates

Question 11

How do Beta blockers alter electrical conduction in the heart?

Answer 11

PR interval and ventricular rate prolonged

Question 12

How do beta blockers affect renin?

Answer 12

• Reduction in renin output

- Reduction in RAAS activity (aka decreased BP)

Question 13

Describe the half life of beta blockers

Answer 13

Short

Question 14

___ predicts response in beta blocker use

Answer 14

Hepatic metabolism

Question 15

What are the outcome benefits of beta blockers?

Answer 15

• Reduce mortality in HTN pts w/recent MI

- Improve survival in HTN pts after recent stroke

Question 16

What is the functional importance of beta blockers?

Answer 16

Improves exercise tolerance (though initially difficult)

Question 17

Downsides of beta blockers

Answer 17

• Symptomatic bradycardia
• Initial reduction in exercise tolerance (adapts w/in 30 days)
• CNS (fatigue, insomnia, unpleasant dreams)

Question 18

What type of beta blocker is metoprolol?

Answer 18

Selective b-1 blocker

Question 19

Which beta blocker can precipitate decompensated HF if used in unstable Stage 3/4 pts?

Answer 19

Bisoprolol

Question 20

Which beta blocker requires adjustment in renal dysfunction due to long half life?

Answer 20

Bisoprolol

Question 21

What type of beta blocker is carvedilol?

Answer 21

Non selective plus selective alpha 1 blocker

Question 22

Which beta blocker has less rebound tachy and why?

Answer 22

Carvedilol and Labetalol

due to alpha blocking effects

Question 23

Which beta blocker has extensive hepatic metabolism through CYP 2D6?

Answer 23

Carvedilol

Question 24

Which beta blocker may reduce smooth muscle infiltration in vascular remodeling, limit free radicals, and reduce lipid peroxidation?

Answer 24

Carvedilol

Question 25

What are the unique features of propranolol?

Answer 25

- Nonselective - Lipophilic - Very high 1st pass metabolism

Question 26

Which beta blocker has a longer duration of action which makes it good for daily dosing?

Answer 26

Nadolol

Question 27

What type of beta blocker is nadolol?

Answer 27

Nonselective

Question 28

Which beta blocker has NO CV outcomes data in HTN pts with CAD, HF?

Answer 28

Atenolol

Question 29

Atenolol is which type of beta blocker?

Answer 29

Selective beta 1 blocker

Question 30

What type of beta blocker is labetalol?

Answer 30

- Non selective beta blocker | - Selective alpha 1 blocker

Question 31

Which beta blocker has an ultra short action time?

Answer 31

Esmolol | so it is reserved for perioperative use

Question 32

What is the most selective beta 1 blocker?

Answer 32

Nebivolol

Question 33

Which beta blocker results in NO dependent vasodilation?

Answer 33

Nebivolol

Question 34

Which beta blocker should be dose reduced in Child-Pugh Class B patients and CrCl less than 30?

Answer 34

Nebivolol

Question 35

When should Nebivolol be dose reduced?

Answer 35

- Child-Pugh Class B patients | - CrCl less than 30

Question 36

All CCBs are ____ vasodilators

Answer 36

Arterial

Question 37

Which CCBs are alternatives to BBs?

Answer 37

Verapamil and diltiazem

Question 38

Which CCBs lower myocardial oxygen demand?

Answer 38

Verapamil and diltiazem

Question 39

What are examples of dihydropyridine CCBs?

Answer 39

Nifedipine Amlodipine Felodipine

Question 40

Which CCB is long acting and gives the best 24 hr BP control?

Answer 40

Amlodipine

Question 41

What is a disadvantage to dihydropyridine CCBs?

Answer 41

Can result in edema

Question 42

Which CCBs are CYP3A4 inhibitors?

Answer 42

Verapamil

Question 43

Which CCBs are inhibitors of P-glycoprotein?

Answer 43

Verapamil and dilt | Nifedipine

Question 44

What 2 indications can CCBs be used for?

Answer 44

- Vasospastic angina | - Vasospasm a/w hemorrhagic stroke (nimodipine, nicardipine, verapamil)

Question 45

Which CCBs should be avoided in heart failure patients?

Answer 45

Non-dihydropyridines (verapamil and dilt)

Question 46

How is the dose of verapamil adjusted?

Answer 46

BP, HR, exercise tolerance

Question 47

Which is tolerated better - verapamil or diltiazem?

Answer 47

Diltiazem

Question 48

MC ADE reported with diltiazem?

Answer 48

Peripheral edema

Question 49

Which CCBs are strong CYP3A4 substrates?

Answer 49

Diltiazem

Question 50

How does Nifedipine work?

Answer 50

- Relaxes coronary and peripheral smooth muscle - Can be used carefully with B blockers - Never use SL or orally in HTN emergencies (increases rebound activity)

Question 51

Which CCB can be used in Raynaud's?

Answer 51

Nifedipine

Question 52

When can dosing of amlodipine be adjusted?

Answer 52

Every 14 days

Question 53

What is considered a last line CCB and why?

Answer 53

- Bepridil | - A/w LV dysfunction

Question 54

Describe nitrates

Answer 54

Mixed venous AND arterial dilating drugs

Question 55

What is the benefit of nitrates?

Answer 55

- Symptom relief, delays ED/urgent care visits | - No CV outcome benefits

Question 56

What should we be cautious about with nitrates?

Answer 56

Regular use depletes glutathione which results in tolerance to nitrate

Question 57

ADEs of nitrates?

Answer 57

- Migraine like HAs (d/t temporal and meningeal artery dilation) - Rebound tachy - Enhanced Na retention

Question 58

What meds should be help for 24 hours after any nitrate and why?

Answer 58

``` PDE inhibitors (used for ED) -Can cause excessive vasodilation ```

Question 59

What is the intended use of nitroglycerin?

Answer 59

Rapid relief of angina - SL duration = 20-30 mins - TD duration = 6-8 hrs (remove patch before MRI and defib)

Question 60

What can nitro be used to prevent?

Answer 60

Exercise induced angina

Question 61

What is the purpose of isosorbide mononitrate?

Answer 61

XR tablet to allow for treatment of nocturnal angina

Question 62

Which nitrate has the highest levels of tolerance?

Answer 62

- Isosorbide dinitrate | - Last dose should be no later than 7pm

Question 63

Why should nitrates and alcohol be avoided?

Answer 63

- CV collapse | - Arrhythmia

Question 64

How does Ranolazine work?

Answer 64

- 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

Question 65

Where is Ranolazine's place in therapy?

Answer 65

When BB, CCB and nitrates are maximized

Question 66

What happens with higher doses of Ranolazine?

Answer 66

Prolongs QT interval

Question 67

How does Ivabradine work?

Answer 67

- Alternative node blocking agent - Selective Na blocker - Hyperpolarizes SA node

Question 68

What are nicorandil and trimetazidine?

Answer 68

Newer agents not yet available in US