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Therapeutics Humber > Stable Ischemic Heart Disease and ACS > Flashcards

Stable Ischemic Heart Disease and ACS Flashcards

1
Q

Coronary Artery Disease (CAD)
-What’s the main etiology?
-CAD may present as two forms, what are the two Types and the subtypes that belong to them?

A
  1. Atheroschlerosis of the epicardial vessels
  2. Chronic coronary artery disease such as Stable exertional angina (Effort Angina)
  3. Acute coronary syndromes (ACS)
    -Non ST elevation ACS such as unstable angina or Non ST elevation MI
    -ST elevation MI (STEMI)
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2
Q

What are some agents that decrease O2 demand?

A

(HR and contractility)
Beta adrenergic antags
Some Ca2+ entry blockers
(Preload and afterload)
Organic nitrates
Ca2+ entry blockers

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3
Q

What are some agents that INCR O2 supply?

A

Coronary blood flow (vasodilators, especially CA2+ entry blockers)

Regional myocardial blood flow (Also statins, anti thrombotics)

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4
Q

What are 6 risk factors for first time myocardial infarction?

A

ApoB to apoA-1 ratio
current smoking
psychosocial
diabetes
hypertension
abdominal obesity

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5
Q

Anginal Pain is often described as:

-Substernal pain (give some adjectives)

-Sensation of ___ or ___ on chest alone or ___

-Duration ?

-Location??

-Radiates to ???

-Often provoked by ??

-Relieved by ___ within _____

A

Tightness, heaviness, crushing, squeezing, vicelike, aching, “deep”

pressure, heavy weight, with pain

30 secs to 30 mins

epigastric to pharyngeal area, occasionally left shoulder or arm

left arm, shoulder, jaw

exertion or emotional stress

nitroglycerin , 45 secs to 5 mins

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6
Q

Additional workup should include which labs?

A

Hemoglobin
fasting glucose
fasting lipoprotein panel
resting ECG
chest xray
cardiac biomarkers

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7
Q

Cardiac Biomarkers :

Negative in ____
Negative in ___
Positive in ?

A

Stable ischemic heart disease

unstable angina

NSTE-MI or STE-MI

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8
Q

What are the normal values for the following :

  1. Creatinine kinase (CK or CPK)
  2. CK-MB
  3. CArdiac Index
  4. Troponin T Gen 5
A
  1. 0-175 units/L
  2. Males < 4.9 ng/mL
    Females < 2.9 ng/mL
  3. <2.5%
  4. <22 ng/mL
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9
Q

For the following conditions, state what the final diagnosis would be:

CC –> CHEST PAIN

  1. ECG shows ST ELEVATION with POSITIVE biomarkers
  2. ST DEPRESSION OR T WAVE INVERSION with POSITIVE biomarkers
  3. ST DEPRESSION OR T WAVE INVERSION with Negative biomarkers
  4. NON SPECIFIC ECG, NO BIOMARKERS
A
  1. STEMI
  2. NSTEMI
  3. UNSTABLE ANGINA
  4. SIHD (Stable ischemic heart disease) or CCD (cardiac conduction disease)
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10
Q

What’s a definitive diagnosis of CAD?

A

Coronary angiography

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11
Q

Stable Ischemic Heart Disease (Chronic Coronary Disease or CCD) and RF Mods

  1. SMoking?
  2. Blood pressure?
  3. Lipid management
  4. Diabetes
  5. Physical activity
  6. Weight managment
  7. Influenza vax
  8. Alcohol consumption
A
  1. Complete cessation
  2. Below 130/80
  3. High intens statin, goal of >= 50% reduction in LDL-C
  4. Target A1c per diabetes guidelines or pt specific factors such as age, comorbidities… T2D with ASCVD risk , ckd, or HF suggest SGLT2I’s, or GLP1 Agonist
  5. 30-60 mins mod aerobic exercise, at least 5 days and preferably 7 days per week. or >= 75 mins/week of higher intensity aerobic activities
  6. BMI between 18.5 and 24.9, waist circumf for men < 40 inches, and women < 35 inches. initial weight loss should target 5-10% reduction from baseline
  7. annual
  8. Dont drink. Limit exposure to drinks. women 1, men 2
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12
Q

Name 8 agents used in Angina

A

Antiplatelets
ACE/ARBS
Nitrates
beta blockers
ccb’s
Ranolazine (ranexa)
rivaroxaban
statins

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13
Q

ASPIRIN (ASA)
-Reduces incidence of __ and __
-MOA?
Dose?
What if pt’s are allergic to ASA?
-Clinical benefits from aspirin may be at least in part due to which properties?

A

MI , sudden cardiac death

Irreversibly blocks COX1 activity which is enzyme required in platelet formation

81 mg PO daily

sub with Plavix 75 mg PO daily

Anti inflamm properties in pt’s with elevated levels of C-reactive protein

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14
Q

ASA Side effects
-Name six of them
-Name 3 relative CI’s

A
  1. GI ae’s with high dose prominent, but standard dose (150-300 mg/d) reduces incidence to 40%
    2.Dyspepsia
    3.N/V (reduced by using EC ASA or taking w/food)
    4.GI bleeding
    5.Frank Melena
    6.Hematemesis

History of GI bleeding, PUD, or other sources of GI or GU bleeding

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15
Q

ACEi’s /ARBS
-Meta Analysis showed 14% reduction in __ for pt’s on ACEi’s
-Recommended in which pt’s?(4)

A

-MACE
-with SIHD who have HTN, diabetes, LVEF <= 40% or CKD

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16
Q

Nitrates

-Many indications such as?
-Provides exog source of NO which induces?
-Chronic use leads to ?
-What’s the therapeutic use in Angina? (SIHD)
-Therapeutic use in ACS?

A

heart failure, angina, acute coronary syndromes

coronary vasodilation

nitrate tolerance

reduce MVO2 keeping supply-demand scale in balance

Can help in NSTE-ACS and STEMI
-Reduces MVO2 consumption via preload reduction

17
Q

Nitrate Preparations

A

See chart

18
Q

Nitrate Admin :
1. SL
-What’s the onset?
-What’s the dose?
-Protect from ?
-Advise patient to?
-1 tablet or spray SL ____
-Seek medical attention if pain not aborted after ?

A

-1-3 mins
-0.4 mg dose, relieves pain in 3-5 mins
-light, moisture, extreme temps
-sit down against wall before placing under tongue or using spray
-every 5 mins for 3 doses
-1 dose

19
Q

Nitrate Oral Admin
-Prophylaxis against ___
-Which doses are necessary?
-Peak effects in ?
-Duration of effect?

A

Anginal attacks
Higher doses (20 mg or more)
60-90 mins
3-6 hrs but variable

20
Q

Cutaneous Nitrate Admin

2% ointment applied where? Effects within?

USe ___ to measure ointment
Patches gradually release product in cont manner over ___

Patches onset of action is __ than other forms with Cmax in ???

Patches should be applied to ____ remove at ___ to avoid tolerance

Nitrate free intervals of ____ go far to restore responsiveness and prevent devel of tolerance

A

chest in thin layer (1-2 inches).
30 mins

Calibrated papers
24 hrs

slower, 1-2 hrs

hairless area of skin, 7PM

10-14 hrs

21
Q

Common AE”s of Nitrates?
(4)

Serious AE’s ? (5)

A

Headaches (respond to aspirin), facial flushing, Halitosis from SL NTG, Rash (td patch)

Syncope + hyPOtension, tachycardia, unexplained bradycardia, methemoglobinemia, heparin resistance

22
Q

CI for Nitrates

  1. Angina caused by?
  2. Acute ____
  3. Concurrent use of?
A
  1. hypertrophic obstructive cardiomyopathy (HOCM)
  2. R ventricular MI
  3. PDE 5 inhibs (Silden, tadal, varden)
23
Q

Ideal Candidates for B Blockers include those :

Where ___ figures prominently into their anginal attacks

W/Coexisting ___
W/Hx of
W/Post ____
W/___ induced ANgina
W/LVEF <= ___ with or without previous __

especially for pt’s with?

A

Physical exercise

HTN
Supraventricular tachyarrhythmias (SVT)
MI-Angina

anxiety induced

40%, MI

Prior MI , > 1 episode of angina per day, high resting HR

24
Q

TX goals of Beta Blockers :
-Lower resting HR to ?
Limiting max exercise HR to ? or an increase of ___ greater than resting HR w/modest exercise
-Start with __ and titrate
-Avoid these with ____
-Tapering off over ___ is recc if discontinuation necessary
-At higher doses (Metoprolol > 200 mg/day) the drug loses its _____

Duration of therapy :
-Can be chronic therapy in ____
-How long in all pt’s with normal LV function after MI or ACS?
-Indefinitely in all pt’s with ?

A

-50-60 bpm
-<=100 bpm, 20bpm
-Low dose
-ISA (intrinsic sympathomimetic activity which prevents HR from lowering)

-2-3 weeks
-cardio selectivity for beta 1 receptors

-SIHD pt’s with angina
-1 yr
-reduced LV function after MI or ACS

25
Q

See chart for Common B Blockers used in IHD

A

See CHart

26
Q

Major Indications for CCBs
Name 3 relevant ones !

A

CAD (Coronary Artery Disease)
Coronary Spasm
Angina

27
Q

Ideal Candidates for CCB Therapy
1. Patients with CI’s or intolerances to ____
2. Pt’s with coexisting ____
3. Pt’s with periph vascular disease or severe ventric dysfunction should use ___
4. Pt’s with concurrent ___

A
  1. beta blockers
  2. conduction system disease (Only use DHP’s)
  3. Amlodipine
  4. htn
28
Q

What’s used for chronic effort angina or presumed microvascular disease?

-Prolongs what?

-SHOULD BE AVOIDED IN?

-May be used in combo with ____ but usually only after these meds are maximized

A

Ranolazine (Ranexa)

-QTC interval (6-15 msec)

-Long qt syndrome, uncorrected hypokalemia, known hx of ventric tachycardia, other qt prolonging meds

  • amlodipine, beta blockers, nitrates
29
Q

Common AE’s of Ranolazine ? (4)

Starting Dose?
Max Dose?

CI ?

A

Nausea, constipation, dizzy, ha

500 mg po twice daily

may incr to 1000 mg po twice daily in 1-2 weeks if necessary

Hepatic insufficiency, strong CYP inhibitors and inducers.

30
Q

Use CCBS or long acting nitrates in which conditions?

A

Use them as alt therapy when B Blockers are CI or cause unaccepatble SE”s

OR

Use them in addition to beta blockers when initial tx with beta blockers is unsuccessful

31
Q

Myocardial Revascularization
-PCI stands for?
Less invasive than ___ but incr risk of?
Short ____

-CABG stands for?
-Major ___
-Requires?
-I__

A

Percutaneous coronary intervention
-CABG, bleeding
-hospital stay (24-48 hrs)

coronary artery bypass graft
invasive surgery
prolonged hospital stay
intraoperative mortality

32
Q

PCI
-useful for pt’s with ?

A

single and multivessel disease AND symptomatic as well as asymptomatic patients

33
Q

CABG
-Solves which 2 objectives?
-Preferred over PCI in which cases?

A
  1. decr # of symptomatic anginal attacks not controlled with medication or PCI, decr mortality
  2. left main coronary stenosis. 3 vessel disease (especially in pt’s with LVEF <50%)
    -Diabetics?

Therapeutics Humber (14 decks)

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