Stable Ischemic Heart Disease Flashcards
Plavix *
clopidogrel
anti-platelet
Bayer *
aspirin
anti-platelet
Dosing: 75-162mg daily
70-100mg daily when combined with Xarelto
Bufferin *
aspirin
anti-platelet
Ecotrin *
aspirin
anti-platelet
Ascriptin
aspirin
anti-platelet
Yosprala
aspirin + omeprazole
delayed release tablet
anti-platelet
Durlaza
aspirin
ER-capsule
anti-platelet
Angina is _________
chest pain, chest pressure, chest tightness
or discomfort usually caused my ischemia of the heart muscle or spasm of the coronary arteries
The chest pain in angina is described as _________
squeezing, grip-like, heavy or suffocating and typically does not vary with position or respiration
Stable Angina, also known as ______
Stable Ischemic Heart Disease (SIHD)
Stable angina aka “Stable ischemic heart disease” is associated with _________, often brought on by _______ or _______. Is relieved within minutes by ________________
predictable chest pain
exertion
emotional stress
rest or with nitroglycerin
Unstable Angina is a type of ___________; this is a medical emergency where chest pain increases (in frequency, intensity, or duration) and is NOT _______________
acute coronary syndrome (ACS)
relieved with nitroglycerin or rest
The classic anginal symptoms of stable ischemic heart disease MAY NOT be present in _______
women, elderly patients, or those with diabetes; this can lead to misdiagnosis (GERD) or a delay in treatment
When chest pain is caused by vasospasm of the coronary arteries, it is called ________
Prinzmetal’s (variant or vasospastic) angina
What type of angina can occur at rest
Prinzmetal’s (variant or vasospastic) angina
Chest pain occurs when there is _________
an imbalance between myocardial oxygen demand (workload) & myocardial oxygen supply (blood flow)
Myocardial oxygen demand increases when ________
the heart is working harder due to an
-increased heart rate
-increased contractility
- or left ventricular wall tension [caused by increased preload (volume of blood returning to the heart) and/or increased afterload (systemic vascular resistance)]
preload
volume of blood “in ventricles” at end of diastole, ready to be pumped out
returning to the heart
afterload
resistance left ventricle must overcome to circulate blood
refers to the pressure against which your heart has to pump that blood
systemic vascular resistance
In Stable angina aka “stable ischemic heart disease”, myocardial oxygen supply is often _______ due to plaque build up within the inner walls of the coronary arteries
decreased
coronary artery disease (CAD), causes _______________ of the arteries and __________
narrowing
reduced blood flow to the heart
Risk Factors for Stable angina aka ‘stable ischemic heart disease’
hypertension
smoking
dyslipidemia
diabetes
obesity
physical inactivity
To assess the likelihood of CAD and diagnose stable ischemic heart disease a _________ is performed
cardiac stress test
The cardiac stress test increases myocardial oxygen demand with either exercise (walking in treadmill or pedaling on a stationary bike) or using ____________.
As myocardial oxygen demand increases, the patient is monitored for the development of symptoms (___)
IV medications
adenosine, dipyridamole, dobutamine or regadenoson(Lexiscan)
(chest pain, dyspnea, lightheadedness), changes in heart rate and blood pressure, transient rhythm disturbances or ST segment abnormalities on an ECG
Drug treatment for stable ischemic heart disease includes: _______ and ____ used together
antiplatelet & antianginal
antiplatelet treatment prevents _____
platelets from sticking together and forming a clot that can block an artery and reduce blood flow to the heart
what is the recommended antiplatelet in SIHD
aspirin
If there is an allergy to aspirin or some other contraindication then what antiplatelet is used
clopidogrel (Plavix)
The combination of aspirin and Plavix is only beneficial in SIHD when _______
there is a history of stent placement or recent CABG
Low dose Xarelto in combination with aspirin is FDA-approved to __________________
reduce the risk of cardiovascular events in patients with coronary artery disease (CAD) or peripheral artery disease (PAD)
Antianginal treatment decreases myocardial oxygen demand or ______
increases myocardial oxygen supply
what is first line as an antianginal for SIHD
beta blockers
what are other agents that can be used as antianginal treatment if beta-blockers are contraindicated or when additional symptomatic relief is needed
CCBs DHP or non-DHP
long-acting nitrates
Short-acting nitroglycerin, as a sublingual tablet, powder or translingual spray is recommended for __________
immediate relief of angina in ALL patients with SIHD
Stable angina aka ‘stable ischemic heart disease’ is one of the __________. So patients should be treated with a ____________
(ASCVD) atherosclerotic cardiovascular diseases
High-intensity statin
Treatment approach for SIHD remember ABCDE
A- antiplatelet AND antianginal drug
B- blood pressure AND beta-blocker
C- cholesterol (high intensity statin) and cigarette (cessation)
D- Diet and diabetes
E- exercise and education
Non-drug treatment
MOA of aspirin:
irreversibly inhibits cyclooxygenase-1 and cyclooxygenase-2 enzymes, which results in decreased prostaglandin (PG) and thromboxane A2 (TXA2) production
thromboxane A2 is a potent ___________ and _______
vasoconstrictor
inducer of platelet aggregation
MOA of clopidogrel
clopidogrel is a Prodrug
which irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation
what are the contraindications/warnings/side effects with aspirin
contraindications: NSAID or salicylate allergy, children and teenagers with viral infection due to the risk of Reye’s syndrome (symptoms include somnolence, N/V, confusion); rhinitis, nasal polyps or asthma (due to risk of urticaria “hives”, angioedema, or bronchospasm)
warnings: Bleeding [including GI bleed/ulceration, increased risk with heavy alcohol use or when used with other drugs that have bleeding risk (NSAIDs, anticoagulants, other antiplatelets], tinnitus (salicylate overdose)
Side effects: Dyspepsia, heartburn, bleeding, nausea
Notes/Pearls with aspirin products
Used indefinitely “unspecified time period” in SIHD (unless contraindicated); decrease incidence of MI, CV events and death
Non-enteric coated, chewable aspirin is Preferred in ACS; if only enteric coated aspirin is available, it should be chewed (325mg)
Durlaza and Yosprala should NOT be used when rapid onset is needed (ACS, pre-PCI)
__________ may be used to protect the gut with chronic aspirin use (Yosprala is indicated for those at risk of developing aspirin-associated gastric ulcers) consider the risks from chronic _____ use (_____________________)
PPIs
PPI
decreased bone density, increased infection risk
Plavix
clopidogrel
Prodrug
Dosing 75mg daily
Indicated for:
ACS
patients with recent MI, stroke, or PAD
Boxed Warnings with Plavix
Effectiveness depends on the conversion to an active metabolite, mainly CYP2C19.
Poor metabolizers of CYP2C19 exhibit higher cardiovascular events than patients with normal CYP2C19 function. Consider alternative treatments in patients identified as CYP2C19 poor metabolizers
Contraindications/Warnings with Plavix
contraindications: active serious bleeding (GI bleed, intracranial hemorrhage)
warnings: Bleeding risk (stop 5 days prior to elective surgery) DO NOT USE with omeprazole or esomeprazole, premature discontinuation ( increase risk of thrombosis),
thrombotic thrombocytopenia purpura (TTP)
Notes/Pearls with Plavix
Used in SIHD when there is a contraindication to aspirin;
can be used in combination with aspirin (Duel Antiplatelet Therapy)
Stable angina aka Stable Ischemic heart disease, is usually treated with a ____________
single antiplatelet drug (aspirin or clopidogrel)
(DAPT) Duel Antiplatelet therapy with ________ and _________ is reserved for those who have had placement of a bare metal stent, (DAPT for at least ______)
aspirin & clopidogrel
1 month
(DAPT) Duel Antiplatelet therapy with ________ and _________ is reserved for those who have had placement of a drug-eluting stent (DAPT for at least _______)
aspirin & clopidogrel
6 months
(DAPT) Duel Antiplatelet therapy with ________ and _________ is reserved for those who are post-CABG (DAPT for _______)
aspirin & clopidogrel
12 months
(DAPT) Duel Antiplatelet therapy with ________ and _________ is reserved for those who have had placement of a __________, ____________ or ________
aspirin & clopidogrel
bare metal stent
drug-eluding stent
post-CABG
aspirin is dosed at _________ in DAPT
81mg daily in Duel Antiplatelet Therapy
Antiplatelet drug interactions are due to additive effects when used with other drugs which can increase bleeding risk. This includes: _________
anticoagulants, NSAIDs, SSRIs, SNRIs, some dietary supplements
Nitrostat
nitroglycerin SL tablet
-Short Acting Nitrate
-0.3mg/0.4mg/0.6mg
-used in SIHD for fast/immediate relief of angina/chest pain
-store nitroglycerin SL tablets in the original amber glass bottle and keep tightly capped after each use (to maintain potency)
*Nitrate tolerance does NOT develop with SL/TL products
NitroMist
nitroglycerin TL(translingual)”Lingual” spray
-Short Acting Nitrate
-medication is sprayed on or under tongue
-prime device before use
-0.4mg/spray
-used in SIHD for fast/immediate relief of angina
Nitrolingual
nitroglycerin TL(translingual)”Lingual” spray
-Short Acting Nitrate
-medication is sprayed on or under tongue
-prime device before use
-0.4mg/spray
-used in SIHD for fast/immediate relief of angina
GoNitro
nitroglycerin SL powder
-Short Acting Nitrate
-0.4mg/packet
-used in SIHD for fast/immediate relief of angina
Nitro-Bid
nitroglycerin ointment 2%
-Long Acting Nitrate
-Dosed BID, 6 hours apart with a 10-12 hour nitrate free interval
Nitro-Dur
nitroglycerin transdermal patch
-Long Acting Nitrate
-0.1/0.2/0.3/0.4/0.6/0.8mg/hr
-wear patch on for 12-14 hours, OFF for 10-12 hours; rotate sites; dispose of safely, away from children and pets
Nitro-Time
nitroglycerin ER capsule
-Long Acting Nitrate
-2.5mg/6m/9mg
isosorbide mononitrate IR
Long Acting Nitrate
10mg/20mg
Dosed BID, 7 hours apart (8am and 3pm)
isosorbide mononitrate ER
Long Acting Nitrate
30mg/60mg/120mg
Dosed: once daily in the morning
Isordil Titradose
isosorbide dinitrate IR
-Long Acting Nitrate
-5/10/20/30/40mg
Dosed BID (same as mononitrate) or TID (take at 8am, 12pm, and 4pm) for a 14-hour nitrate free interval (or similar)
Short Acting Nitrates
Nitrate tolerance DOES NOT develop with SL/TL products
Long Acting Nitrates
Are used when beta-blockers are contraindicated or as add on therapy if symptoms persist:
Require a 10-12 hour nitrate free interval to decrease tolerance ( longer for some products)
Contraindications with Nitrate products
Hypersensitivity to organic nitrates, DO NOT Use with PDE-5 inhibitors or riociguat
Warnings with Nitrate products
Side effects with Nitrate products
hypotension, headache, tachyphylaxis (deceased effectiveness/tolerance with long-acting products),
Headache, flushing, syncope
Nitrate Drug Interactions
isosorbide dinitrate in combination with hydralazine is the preferred combination ____________
for HFrEF
Antianginal Treatment
Counseling on aspirin
can cause:
bleeding/bruising
dyspepsia (indigestion)
tinnitus or loss of hearing with overdose
All Nitroglycerin Products:
Can Cause
Orthostasis (a decrease in blood pressure that happens soon after standing or sitting up)
Flushing and headache. Often a sign the medication is working. Usually goes away with time.
Nitrate-free interval required with long-acting products
Drug interactions with PDE-5 inhibitors
Counseling on Short Acting Nitrates
Take one dose at first sign of chest pain
Call 911 immediately if chest pain persists after the first dose.
Continue to take two additional doses at 5 minute intervals while waiting for the ambulance to arrive. Do not take more than 3 doses within 15 minutes.
