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IDT Winter > Stable Ischemic Heart Disease and Peripheral Arterial Disease > Flashcards

Stable Ischemic Heart Disease and Peripheral Arterial Disease Flashcards

1
Q

ischemic heart disease is characterized by?
it is usually due to?

A

reduced blood supply to heart muscle
coronary artery disease

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2
Q

define angina pectoris

A

chest pain caused usually by myocardial anoxia caused by blockage of coronary arteries from either atherosclerosis or spasm

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3
Q

what are cardiac-related causes of angina?

A

coronary artery vasospasm
pericarditis (tissue surrounding heart)
valvulopathy
SCAD

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4
Q

what are noncardiac-related causes of angina?

A

anemia
anxiety
carbon monoxide
cocaine
esophageal reflux
pneumonia

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5
Q

what makes vasospastic angina different from chronic stable angina?

A

-generally occurs at rest, especially in the morning
-severe pain
-not caused by physical exertion

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6
Q

exertional angina is another term for? it is defined as what percentage of stenosis?

A

chronic stable angina
around 50-75%

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7
Q

what are modifiable risk factors for atherosclerosis?

A

smoking
HPT
low HDL
high LDL
diabetes
physical inactivity
obesity

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8
Q

what are nonmodifiable risk factors for atherosclerosis?

A

age: men over 45, women over 55
gender (men and postmenopausal women)
family history of CHD

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9
Q

what lab tests do we use to determine chronic stable angina?

A

fasting lipid panel, creatinine kinase, troponin, metabolic panel, CBC

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10
Q

We can do resting EKG and “exercise” tolerance tests to diagnose chronic stable angina, what are pharmacologic stress tests?

A

giving pt dobutamine, dipyridamole, or adenosine

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11
Q

what are the CCS grade I-IV for angina classification?

A

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)

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12
Q

what is the class I recommendation for aspirin with stable ischemic heart disease?

A

aspirin 75-162mg qd should be used indefinitely
treatment with clopidogrel 75mg qd can be used when aspirin is contraindicated

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13
Q

what is the class IIb recommendation for aspirin with stable ischemic heart disease?

A

treatment with aspirin 75-162mg qd with clopidogrel 75mg qd in high-risk pts

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14
Q

what is the class I recommendation for ACE-Is with stable ischemic heart disease?

A

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

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15
Q

what is the class IIa recommendation for ACE-Is with stable ischemic heart disease?

A

ACE if pt has both SIHD and other vascular disease

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16
Q

what should be monitored in patients first starting an ACE-I?

A

potassium, SCr, and hypotension

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17
Q

when is use of ACE-I contraindicated?

A

-history of angioedema
-unstented bilateral renal artery stenosis
-pregnancy

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18
Q

if we want to give pt an ACE-I but they get angioedema, what is the recommendation?

A

give them an ARB instead and monitor for angioedema

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19
Q

what is the class I recommendation for statins with stable ischemic heart disease?

A

moderate-high dose should be prescribed

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20
Q

which drugs interact with statins and you need to monitor for signs of ADE?

A

diltiazem and verapamil

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21
Q

what is an adverse effect to statins?

A

rhabdomyalgia

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22
Q

when do we use nitroglycerin for angina?
who should be prescribed nitroglycerin?
what are the effects?

A

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

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23
Q

what is the class I recommendation for beta blockers with stable ischemic heart disease?

A

should be used as initial therapy relief for symptoms of SIHD

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24
Q

why are beta blockers beneficial for ischemic HD/CSA?

A

decrease heart rate, blood pressure and myocardial contractility

25
Q

what form of angina should beta blockers not be used with?

A

vasospastic angina

26
Q

which beta blocker would be best to avoid CNS side effects? how is it dosed?

A

atenolol 1-2 times daily

27
Q

which beta blockers are dosed qd?

A

metoprolol succinate (toprol XL), bisoprolol, and carvedilol CR

28
Q

which beta blockers are dosed bid?

A

metoprolol tartrate and carvedilol

29
Q

which beta blocker is not useful for CSA due to no cardio-selectivity?

A

carvedilol

30
Q

when stopping, beta blockers should be tapered for?

A

1-3 weeks

31
Q

what is the class I recommendation for CCBs/long-acting nitrates with stable ischemic heart disease?

A

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

32
Q

CCBs are first line for which form of angina?

A

vasospastic angina

33
Q

which CCB can not be used for CSA?

A

immediate-release nifedipine

34
Q

do not use CCBs with BBs if?
avoid in patients with?

A

pt is bradycardic (both decrease HR)
heart failure with reduced ejection fraction

35
Q

when do we used long acting nitrates?
what are the considerations if planning to put pt on a nitrate for chronic use?

A

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

36
Q

what are the 3 nitrate products used for chronic therapy?

A

nitroglycerin patch
isosorbide dinitrate
isosorbide mononitrate

37
Q

what is the mechanism of ranolazine?
dosing?

A

inhibits cardiac late sodium current to dec intracellular Ca overload and decrease diastolic tension
500-1000mg bid

38
Q

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?

A

lifestyle/diet, exercise, no smoking

aspirin 81mg, statins, ACE-Is or ARBS

nitrates, CCBs, BBs, revascularization (restore blood flow), or CABG/stent

39
Q

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

A

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

40
Q

what is peripheral arterial disease generally caused by?

A

atherosclerosis

41
Q

what are comorbidities of PAD?

A

age over 65
diabetes
hyperlipidemia
HPT
fam history of PAD
smoking status

42
Q

what is the clinical presentation of PAD?
what if it is advanced?

A

can be asymptomatic or discomfort on exertion with cramping, pain or numbness

chronic pain at rest, nonhealing wounds on feet and toes

43
Q

who is at risk for PAD?

A

-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

44
Q

what tests can we use to diagnose PAD?

A

ankle-brachial index
exercise treadmill
toe-brachial index
duplex ultrasound

45
Q

how do we calculate ankle-brachial index?
how do we interpret the score?

A

highest ankle pressure/highest arm pressure
1-1.4 = normal
0.91-0.99 = borderline
less than 0.90 = PAD

46
Q

what are the guidelines for treating PAD if pt is a smoker?

A

advise pt to quit, can put pt on a smoking cessation prescription

47
Q

what are the guidelines for treating PAD if pt has hypertension?

A

consider putting pt on an ACE-I or ARB

48
Q

what are the guidelines for treating PAD if pt has diabetes?

A

make sure diabetes is well-controlled and they have glycemic control

49
Q

what are the guidelines for treating PAD if pt has hyperlipidemia?

A

treat pt with a statin: helps with walking distance, reducing mortality, stroke, and CV events

50
Q

what are the guidelines for treating PAD with antiplatelet therapy?

A

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

51
Q

what did the CLIPS trial tell us?

A

low-dose aspirin is effective at reducing CV events for pts with PAD

52
Q

what did the CAPRIE trial tell us?

A

clopidogrel is slightly more effective than aspirin at reducing secondary CV events in pts with PAD

53
Q

what did the EUCLID trial tell us?

A

ticagrelor is not better than clopidogrel at reducing CV events in pts with PAD

54
Q

what did the CHARISMA trial tell us?

A

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

55
Q

how does cilostazol help pts with PAD?
MOA?
contraindicated with?
time it takes for symptom improvement?

A

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

56
Q

what are the guidelines for treating PAD with anticoag therapy?

A

not effective

57
Q

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

A

Q1: A
Q2: B
Q3: A

58
Q

what is normal HgbA1c?
what is normal HDL?
what is normal LDL?

A

below 5.7%
35 to 65 mg/dL for men, 35 to 80 mg/dL for women
Less than 100 mg/dL

IDT Winter (19 decks)

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