Stable Ischemic Heart Disease Lec notes

Question 1

Angina:

Answer 1

chest pain which can be described as squeezing, heavy, suffocating, grip like

Question 2

Stable angina is also called _____________

and is defined as ____________

what is the common cause?:

Answer 2

(SIHD) Stable Ischemic Heart Disease

-predictable chest pain brought on by exertion or stress that is reliably relieved by NTG (nitroglycerin) or rest
-due to atherosclerosis

Is different from unstable angina

Question 3

What is the difference between the atherosclerotic plaques within the coronary arteries for someone with stable angina vs unstable angina?

Answer 3

In Stable Angina (aka SIHD) Stable ischemic Heart disease: the buildup of plaques in the coronary arteries overtime reaches a point where is forms a stable fixed atherosclerotic plaque with a thick fibrous cover on it. But, when a patient exercises or experiences stress because there is a narrowing of the artery for the blood to move through, you can get lack of oxygen delivery to the heart, and this can cause chest pain.

In Unstable Angina: the buildup of plaques in the coronary arteries gets disrupted or is ruptured due to being an unstable plaque. This leads to platelet aggregation and formation of a thrombus (clot), which can potentially move and block off the entire coronary artery.

Question 4

How do we manage predictable chest pain and chronic stable angina?

Question 5

Prinzmetals angina:

Answer 5

-due to vasospasm
-can occur at rest

-here you have a coronary artery but with no atherosclerotic plaque present blocking blood flow. Instead the vessel is inspasm, being constricted cutting off the blood supply. Which can cause ischemia, or chest pain, due to the lack of oxygen delivery to the heart.

Question 6

Pathophysiology of SIHD
Why does chest pain occur?

Answer 6

Chest pain occurs when there is an imbalance between myocardial oxygen demand and supply. In someone who has (CAD) coronary artery disease.

someone with atherosclerosis is said to have CAD

Question 7

What impacts oxygen supply to the heart primarily??

Answer 7

blood flow

Question 8

Myocardial oxygen demand will go up when:

Answer 8

heart rate is increased.
blood pressure is increased
contractility is increased
SVR is increased

Question 9

In someone who has ASCVD the coronary artery can’t dilate as easily when there is a build up of plaque, so body can’t compensate fully like it normally could.

Answer 9

The oxygen demand is not being meet. and so patient gets chest pain.

Question 10

Diagnosis of SIHD

• often patient will present and will not have any sign or symptoms upon presentation
• so important to do a complete history and exam
• LOOK for risk factors: _______
  Lab tests to check for certain risk factors

Answer 10

-age
-family history of CAD
-smoke
-overweight or obese
- do they have high BP
- do they have high cholesterol
- do they have diabetes

(BP/A1C/cholesterol/)

Question 11

what is the classic test used for diagnosis of stable angina?

Answer 11

Cardiac stress test
-patient will be exercising while ECG is being monitored, watching heart rate/blood pressure/and patient seeing if chest pain is brought on by exertion.

Question 12

Some patients may not be able to exercise on a walking treadmill or pedal on a bicycle for a cardiac stress test. So in these situations we can use a _____________

Answer 12

pharmacological stress test (drug induced stress test)

Question 13

what medications can we use to do a drug induced stress test?

Question 14

To really determine if a patient has atherosclerosis, have to look inside the coronary arteries, so patient will need to have __________

Answer 14

cardiac catheterization/angiography

Question 15

For Treatment of chronic Stable angina:

Answer 15

“ABCDE model”

A- antiplatelet AND antianginal drugs
B- blood pressure AND beta-blocker
C- cholesterol AND cigarette cessation
D- Diet AND diabetes Tx
E- exercise and education

Core drug Tx:

beta blocker + CCB + nitrates + ranolazine

ASA (if contraindicated then clopidogrel)

nitroglycerin SL PRN

Question 16

Chronic Stable Angina is a clinical ASCVD condition, so patients should be on _______

Answer 16

statin treatment “typically high intensity statin medications”

Question 17

Core Drug treat for SIHD

1st line beta blockers, if patients continue to have pain episodes on a beta blocker, then a CCB or a nitrate or ranolazine can be added.

aspirin is 1st line antiplatelet agent

Then it is important that every patient gets a SL nitrate to keep at home and or on them, in the event they have acute chest pain, for relief.

Answer 17

these drugs work by altering that myocardial oxygen demand and supply balance.

Question 18

Antiplatelet agents

Indications:
1st line:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:

Answer 18

aspirin
Dose range: 75-162mg
MOA: inhibits COX enzymes, in platelets primarily COX1 which prevents the production of Thromboxane A2

Contraindications: salicylate allergy

Be aware of Reyes Syndrome, those most at risk are the teenagers/adolescents with viral infections.

SE: dyspepsia, heartburn, nausea, bleeding

Question 19

Thromboxane A2 is a potent _______ & ______

Answer 19

vasoconstrictor & platelet aggregator (it continuous to activate more platelets)

Question 20

If patient can’t take aspirin, then ______ is alternative.

Answer 20

clopidogrel

Question 21

What does clopidogrel have a Boxed Warning for?

Answer 21

That it is a Prodrug converted by CYP2C19 to its active form
So there are risks in those who are poor metabolizers, those patients will not convert the drug to the active form

Question 22

The drugs esomeprazole and omeprazole are inhibitors of ______

Answer 22

CYP2C19

Question 23

How early should Plavix be stopped prior to having any surgery since it is an antiplatelet with bleeding risk?

Answer 23

5 days before surgery

Question 24

What is the very rare but serious side effect that Plavix can cause?

Answer 24

(TTP) Thrombotic Thrombocytopenic Purpura

Question 25

Should dual antiplatelet therapy be used in patients with Chronic Stable Angina aka SIHD?

Answer 25

No, unless patient has a stent.

Question 26

How long is dual antiplatelet therapy in those with different stent types in chronic stable angina?

Question 28

Beta Blockers

Indications:
1st line:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:

Answer 28

Indications:

1st line: for SIHD

want to titrate to 55-60 BPM

MOA: decrease myocardial oxygen demand due to decreasing the heart rate and contractility

Contraindications:

Warnings: DO NOT STOP abruptly. Can flood the system/receptors with those neurohormones (NE & Epi) which can cause a heart attack.

Side effects:

Monitoring:

Note/Pearls:

Drug-Drug Interactions:

Question 30

CCB DHP

Indications:
1st line:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:

Answer 30

Can be added to a beta-blocker if patient continues to experience symptoms or if patient has a contraindication to a beta-blocker and cannot use.

amlodipine/

Indications: Chronic stable angina

MOA:

Contraindications:

Warnings:

Side effects:

Monitoring:

Note/Pearls:

Drug-Drug Interactions:

Question 31

we don’t use non-DHP CCBs with beta-blockers in someone with chronic stable angina because __________

Answer 31

they also decrease HR and decrease contractility. Can get significant bradycardia and other conduction abnormalities which can be detrimental.

Question 32

For DHP CCBs we avoid ____________ in all cases!!

Answer 32

nifedipine IR

-causes profound blood pressure decrease

Question 33

There is one case where nifedipine IR is preferred which is in ________________

Answer 33

Prinzmetals angina

Question 34

Nitrates

Indications:
Dosing:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions:

Answer 34

Class:

Indications:

Dosing:

MOA:

Contraindications:

Warnings:

Side effects: (HA) headache, hypotension, flushing, dizziness

Monitoring:

Note/Pearls:

Drug-Drug Interactions:

Question 35

Short acting Nitrates

Answer 35

-are for immediate relief
-3 doses given at 5-minute intervals.
-keep SL tablets in the original amber bottle
-do NOT swallow tablets or powder- let dissolve in mouth

-a few different formulations:
Nitrostat is SL tab, DO NOT swallow
Nitrolingual is spray, which is spray on or under the tongue,
NitroMist is spray,
GoNitro is the powder which also goes under tongue, DO NOT swallow

-if patient is still having chest pain after the first dose, Call 911, could be sign patient is having a heart attack

Question 36

Long-acting Nitrates

Answer 36

-to prevent chest pain
-Not for acute onset of chest pain, since they will not have a fast relief
- require a nitrate free interval to prevent tolerance or tachyphylaxis to the drug
-“ if used around the clock without nitrate free interval, eventually it will stop working”

-also has a few different formulations:

Nitro-BID is a 2% ointment, used twice a day. Comes with a dose measuring applicator. Typically measured in inches. You measure dose on the applicator AND use the applicator to spread the dose on chest. Then taping the applicator to chest once finished. doing this twice a day about 6 hours apart.

Question 37

All nitrates are Contraindicated in patients using ___

Answer 37

PDE-5 inhibitors or riociguat

Question 38

what two long-acting nitrate formulations, do not have a nitrate free interval playing a role in part of patients regimen?

Answer 38

-the once daily long-acting nitrate ER tab, isosorbide mononitrate. It is built in the formulation, so do not have to worry about timing

-the combination nitrate, isosorbide dinitrate with hydralazine (BiDil)

Question 40

ranolazine has a unique MOA:

Answer 40

it works on Na currents/electrical currents, increasing intracellular calcium.
essentially helps the heart use oxygen more efficiently.

However it is a QT prolongation drug

Does NOT decrease BP or HR

Question 49

Class:
Indications:
Dosing:
MOA:
Contraindications:
Warnings:
Side effects:
Monitoring:
Note/Pearls:
Drug-Drug Interactions: