Stable Ischemic Heart Disease

Question 1

TX approach for stable ischemic heart disease

Answer 1

A- antiplatelet and antianginal drugs
B- Blood pressure and beta-blockers
C- Cholesterol (statins) and cigarettes (cessation)
D- Diet and diabetes
E- Exercise and education

Question 2

Antianginal tx

Answer 2

• beta-blockers are first-line
• CCBs (both DHP and non-DHP)
• or long-acting nitrates (when beta-blockers are contraindicated).
• ranolazine can be used for a substitute for beta-blockers or in addition.
• nitroglycerine- short-acting

Question 3

Aspirin

Answer 3

Bayer, Bufferin, Ecotrin

non-enteric coated, chewable aspirin is preferred, if only enteric coat aspirin is available chew it!

Question 4

Aspirin + omeprazole

Answer 4

Yosprala

PPIs may be used to protect the gut with chronic aspirin use but remember the risk, decreased bone density, and increased infection risk

Question 5

Aspirin ER

Answer 5

Durlaza,
delayed-release is Yosprala

Question 6

Clopidogrel

Answer 6

Plavix
prodrug, converted with Cyp450 2C19

stop 5 days prior to surgery, and do not DO NOT use with omeprazole or esomeprazole

Question 7

Ranolazine

Answer 7

Ranexa

decrease myocardial oxygen demand by decreasing ventricular tension and oxygen consumption

Question 8

Beta- Blockers…

Answer 8

• beta-blockers are first-line: decrease HR, decrease contractility, and decrease left ventricular wall tension
• start slow, titrate to resting HR of 55-60 BMP, avoid abrupt withdrawal.
• avoid in prinzmetal’s angina
• preferred: metoprolol, carvedilol

Question 9

CCBs

Answer 9

• CCBs (both DHP and non-DHP): preferred for Prinzmetal’s variant angina.
• non-DHPs decrease HR and contractility,
• DHPs decrease SVR (afterload). all increase blood flow which increases oxygen supply
• avoid shorting DHPs (nifedipine IR)
• preferred use with beta-blockers

Question 10

Nitrates

Answer 10

• long-acting nitrates (when beta-blockers are contraindicated or add-on if symptoms persist). decrease preload, and vasodilation of veins more than arteries
• ## SL tablets, SL powder, or TL spray

Question 11

Ranolazine info more

Answer 11

• ranolazine can be used for a substitute for beta-blockers or in addition.
• contra in liver cirrhosis and do not use with strong CYP 3A4 inhibitor or inducer
  —-> limit dose to 500mg if taking moderate Cyp 3A4 inhibitor like diltiazem, verapamil. limit simva to 20mg/ day
• QT prolongation
• acute renal failure in pt with CrCl < 30ml/min
• not for acute tx of chest pain
• has little to no clinical effect on HR or BP

Question 12

Nitroglycerin
SL tablet

Answer 12

Nitrostat
0.3, 0.4mg!, .6mg
- do not use with PDE-5 inhibitors

Question 13

Nitroglycerin
TL spray

Answer 13

NitroMist, Nintorlingual
0.4mg/ spray
- do not use with PDE-5 inhibitors

Question 14

Nitroglycerin
SL powder

Answer 14

GoNitro
0.4mg/ packet
- do not use with PDE-5 inhibitors

Question 15

Isosorbide dinitrate combo with hydralazine

Answer 15

preferred combo for HFrEF

Question 16

Isosorbide mononitrate IR/ER tab

Answer 16

IR: 10mg, 20mg
ER: 30mg, 60mg, 120mg
- long-acting nitrates

Question 17

NItroglycerin ointment 2%

Answer 17

Nitro-BID

(patch- Nitro-Dur, capsule- Nitro-Time)
- long-acting nitrates