Stable Ischemic Heart Disease and Peripheral Arterial Disease Flashcards
ischemic heart disease is characterized by?
it is usually due to?
reduced blood supply to heart muscle
coronary artery disease
define angina pectoris
chest pain caused usually by myocardial anoxia caused by blockage of coronary arteries from either atherosclerosis or spasm
what are cardiac-related causes of angina?
coronary artery vasospasm
pericarditis (tissue surrounding heart)
valvulopathy
SCAD
what are noncardiac-related causes of angina?
anemia
anxiety
carbon monoxide
cocaine
esophageal reflux
pneumonia
what makes vasospastic angina different from chronic stable angina?
-generally occurs at rest, especially in the morning
-severe pain
-not caused by physical exertion
exertional angina is another term for? it is defined as what percentage of stenosis?
chronic stable angina
around 50-75%
what are modifiable risk factors for atherosclerosis?
smoking
HPT
low HDL
high LDL
diabetes
physical inactivity
obesity
what are nonmodifiable risk factors for atherosclerosis?
age: men over 45, women over 55
gender (men and postmenopausal women)
family history of CHD
what lab tests do we use to determine chronic stable angina?
fasting lipid panel, creatinine kinase, troponin, metabolic panel, CBC
We can do resting EKG and “exercise” tolerance tests to diagnose chronic stable angina, what are pharmacologic stress tests?
giving pt dobutamine, dipyridamole, or adenosine
what are the CCS grade I-IV for angina classification?
I: ordinary physical activity does not cause angina
II: slight limitation of ordinary activity
III: marked limitation of ordinary physical activity
IV: inability to carry on any physical activity without discomfort, may be present at rest (unstable angina)
what is the class I recommendation for aspirin with stable ischemic heart disease?
aspirin 75-162mg qd should be used indefinitely
treatment with clopidogrel 75mg qd can be used when aspirin is contraindicated
what is the class IIb recommendation for aspirin with stable ischemic heart disease?
treatment with aspirin 75-162mg qd with clopidogrel 75mg qd in high-risk pts
what is the class I recommendation for ACE-Is with stable ischemic heart disease?
should be used in all pts who also have HPT, diabetes, LVEF 40% or less, or CKD
ARBS recommended if can’t use ACE-I
what is the class IIa recommendation for ACE-Is with stable ischemic heart disease?
ACE if pt has both SIHD and other vascular disease
what should be monitored in patients first starting an ACE-I?
potassium, SCr, and hypotension
when is use of ACE-I contraindicated?
-history of angioedema
-unstented bilateral renal artery stenosis
-pregnancy
if we want to give pt an ACE-I but they get angioedema, what is the recommendation?
give them an ARB instead and monitor for angioedema
what is the class I recommendation for statins with stable ischemic heart disease?
moderate-high dose should be prescribed
which drugs interact with statins and you need to monitor for signs of ADE?
diltiazem and verapamil
what is an adverse effect to statins?
rhabdomyalgia
when do we use nitroglycerin for angina?
who should be prescribed nitroglycerin?
what are the effects?
for immediate relief or prevent effort induced angina
al pts with history of angina
-coronary dilation and increased O2 delivery
-decreased pre and afterload
-reflex tachycardia
-cerebral vasodilation = headache
what is the class I recommendation for beta blockers with stable ischemic heart disease?
should be used as initial therapy relief for symptoms of SIHD
why are beta blockers beneficial for ischemic HD/CSA?
decrease heart rate, blood pressure and myocardial contractility
what form of angina should beta blockers not be used with?
vasospastic angina
which beta blocker would be best to avoid CNS side effects? how is it dosed?
atenolol 1-2 times daily
which beta blockers are dosed qd?
metoprolol succinate (toprol XL), bisoprolol, and carvedilol CR
which beta blockers are dosed bid?
metoprolol tartrate and carvedilol
which beta blocker is not useful for CSA due to no cardio-selectivity?
carvedilol
when stopping, beta blockers should be tapered for?
1-3 weeks
what is the class I recommendation for CCBs/long-acting nitrates with stable ischemic heart disease?
CCBs or long-acting nitrates should be used if BBs are contraindicated
CCBs or long-acting nitrates can be used in combo with BBs when initial treatment with BBs is unsuccessful
CCBs are first line for which form of angina?
vasospastic angina
which CCB can not be used for CSA?
immediate-release nifedipine
do not use CCBs with BBs if?
avoid in patients with?
pt is bradycardic (both decrease HR)
heart failure with reduced ejection fraction
when do we used long acting nitrates?
what are the considerations if planning to put pt on a nitrate for chronic use?
in combo with BB or CCB for stable angina
has tolerance or tachyphylaxis (diminished response over time), so pts need a nitrate free period of around 8 hours
what are the 3 nitrate products used for chronic therapy?
nitroglycerin patch
isosorbide dinitrate
isosorbide mononitrate
what is the mechanism of ranolazine?
dosing?
inhibits cardiac late sodium current to dec intracellular Ca overload and decrease diastolic tension
500-1000mg bid
Overall, we want to avoid acute coronary syndrome which is caused by stable ischemic heart disease and angina:
what is the primary prevention for acute coronary syndrome?
what are the preventative drug treatments to prevent stable ischemic heart disease?
what are the drug treatments to treat stable ischemic heart disease?
lifestyle/diet, exercise, no smoking
aspirin 81mg, statins, ACE-Is or ARBS
nitrates, CCBs, BBs, revascularization (restore blood flow), or CABG/stent
patient case
LM - 64 yo female presents with complains of angina after walking 1 block.
Vitals: BP 100/68, HR 58
Meds:
Aspirin 81mg qd
Amlodipine 10mg qd
Metoprolol succinate 50mg qd
Rosuvastatin 20mg qd
what is the most appropriate recommendation to treat this pts angina?
A. increase metoprolol succinate to 100mg daily
B. change amlodipine to diltiazem
C. Add isosorbide
D. Add lisinopril 5mg qd
C -> pts HR is already low, don’t want to increase metoprolol, and here BP is already low, so don’t want to add lisinopril
what is peripheral arterial disease generally caused by?
atherosclerosis
what are comorbidities of PAD?
age over 65
diabetes
hyperlipidemia
HPT
fam history of PAD
smoking status
what is the clinical presentation of PAD?
what if it is advanced?
can be asymptomatic or discomfort on exertion with cramping, pain or numbness
chronic pain at rest, nonhealing wounds on feet and toes
who is at risk for PAD?
-ppl over 50 with DM and 1 other ASCVD risk factor
- ppl b/w 50-64 with ASCVD risk factors or fam history of PAD
-over 65 with known ASCVD risk factors
what tests can we use to diagnose PAD?
ankle-brachial index
exercise treadmill
toe-brachial index
duplex ultrasound
how do we calculate ankle-brachial index?
how do we interpret the score?
highest ankle pressure/highest arm pressure
1-1.4 = normal
0.91-0.99 = borderline
less than 0.90 = PAD
what are the guidelines for treating PAD if pt is a smoker?
advise pt to quit, can put pt on a smoking cessation prescription
what are the guidelines for treating PAD if pt has hypertension?
consider putting pt on an ACE-I or ARB
what are the guidelines for treating PAD if pt has diabetes?
make sure diabetes is well-controlled and they have glycemic control
what are the guidelines for treating PAD if pt has hyperlipidemia?
treat pt with a statin: helps with walking distance, reducing mortality, stroke, and CV events
what are the guidelines for treating PAD with antiplatelet therapy?
if they have symptomatic PAD: aspirin 75-325mg qd or clopidogrel 75mg qd
if asymptomatic with ABI 0.90 or less, antiplatelet therapy is reasonable
what did the CLIPS trial tell us?
low-dose aspirin is effective at reducing CV events for pts with PAD
what did the CAPRIE trial tell us?
clopidogrel is slightly more effective than aspirin at reducing secondary CV events in pts with PAD
what did the EUCLID trial tell us?
ticagrelor is not better than clopidogrel at reducing CV events in pts with PAD
what did the CHARISMA trial tell us?
DAPT (clopidogrel plus aspirin) may be better for pts at high risk of CV disease with low risk of bleeding compared to clopidogrel or aspirin monotherapy in pts with PAD
how does cilostazol help pts with PAD?
MOA?
contraindicated with?
time it takes for symptom improvement?
can increase pain free walking distance
PDE3 inhibition to increase cAMP and promote vasodilation
Heart failure with reduced ejection fraction
may take over 6 weeks for symptom improvement
what are the guidelines for treating PAD with anticoag therapy?
not effective
JM - 49 yo male
He presents with bilateral calf pain with his daily walk. He describes the pain
as “crampy and achy” that is relieved when he sits down to rest.
PMH: DM, HTN, obesity, gout
SH: history of smoking (30 pack-year), quit 6 months ago
PE: feet are cool to the touch, dorsalis pedis and posterior tibial pulses are diminished
Vitals/Labs: BP 149/82 mmHg, HgbA1c 9.2%, LDL 135 mg/dL
Medications:
* Metformin 1000 mg twice daily
* Amlodipine 5 mg once daily
* Gabapentin 100 mg three times daily
Question #1: Which would best evaluate PAD in this patient?
A. ABI
B. No evaluation required
C. Toe-brachial index (TBI)
D. Treadmill exercise test
Question #2: Which best describes this patient’s risk factors for PAD?
A. HTN, gout, age
B. DM, HTN, smoking
C. HTN, peripheral neuropathy, smoking
D. DM, smoking, and peripheral neuropathy
Question #3: According to the ACC/AHA guidelines, which treatment would be best to reduce this patient’s risk of CV events?
A. Aspirin 81 mg daily
B. Aspirin 81 mg daily and clopidogrel 75 mg daily
C. Ticagrelor 90 mg twice daily
D. Rivaroxaban 20 mg daily
Q1: A
Q2: B
Q3: A
what is normal HgbA1c?
what is normal HDL?
what is normal LDL?
below 5.7%
35 to 65 mg/dL for men, 35 to 80 mg/dL for women
Less than 100 mg/dL
