Stable Ischemic Heart Disease (SIHD)

Question 1

What is Stable Ischemic Heart Disease (SIHD)?

Answer 1

ischemia (lack of oxygen due to poor blood supply) in the myocardium due to atherosclerosis plaque formation associated with stable angina (predicable chest pain associated with physical activity)

Question 2

How is stable ischemic heart disease diagnosed?

Answer 2

-electrocardiogram (ECG)
-echocardiogram
-stress test
-coronary angiography

Question 3

What are the risk factors for SIHD?

Answer 3

-smoking
-hypertension
-hyperlipidemia
-diabetes
-obesity
-sedentary lifestyle
-psychosocial factors (ex. stress)
-sex (male)
-age (older)
-family history or genetic composition
-environmental influences

Question 4

What can be done to reduce cardiovascular risk?

Answer 4

-BP control
-lipid management
-diabetes management
-physical activity
-dietary modifications
-weight management
-smoking cessation

Question 5

What is the indication of Nitroglycerin in SIHD?

Answer 5

symptom control in acute attacks (onset 1-3 min) or prophylactic 5-10 min before attack-provoking activities

Question 6

What is the dosing of sublingual Nitroglycerin?

Answer 6

take 1 dose promptly- if chest pain continues or worsens after 5 minutes call 911, while waiting continue to take dose every 5 min for max of 3 doses

Question 7

What are important counseling points for sublingual Nitroglycerin tablets?

Answer 7

-place under tongue and allow to dissolve
-do NOT chew, crush, or swallow
-store tightly in original container at room temp, protect from light, heat and moisture
-good through product expiration

Question 8

What drugs may be used for prophylactic treatment for stable ischemic heart disease (SIHD)?

Answer 8

-beta blockers
-calcium channel blockers
-nitrates
-ranolazine

Question 9

What is the first line treatment for symptom prophylaxis in SIHD?

Answer 9

beta blockers

Question 10

Who are ideal candidates for beta blockers in SIHD?

Answer 10

-angina associated with exercise
-HTN
-history of MI
-history of supraventricular arrhythmias
-anxiety
-history of HF

Question 11

What beta blockers are FDA approved for angina?

Answer 11

-atenolol
-metoprolol succinate/tartate
-nadolol
-propranolol

Question 12

What is the goal resting HR when using beta blocker in SIHD?

Answer 12

50-60 beats/min

Question 13

What is the risk of abruptly stopping beta blockers?

Answer 13

increase severity of number of pain episodes and MI

Question 14

What are the adverse effects of beta blockers?

Answer 14

-bradycardia and heart block
-hypotension
-central nervous system (fatigue, depression, cognitive changes)
-sexual dysfunction

Question 15

What is the indication of calcium channel blockers (CCBs)?

Answer 15

-alternative to beta blockers (2nd line)
-first line for variant angina (Prinzmental’s angina)

Question 16

Who are ideal candidates for calcium channel blockers in SIHD?

Answer 16

-contraindication to beta blockers
-inadequate response to beta blocker monotherapy
-variant angina (prinzmetal angina)
-coexisting conduction system disease
-presence of peripheral vascular disease
-HTN

Question 17

What are the adverse effects of calcium channel blockers?

Answer 17

-peripheral edema
-constipation
-bradycardia (non DHP)
-reflex tachycardia (DHP)
-rash
-headache
-dizziness

Question 18

What is the indication of long-acting Nitrates?

Answer 18

long-term prophylaxis in combination with beta blocker or calcium channel blocker

Question 19

What is Nitrate tolerance?

Answer 19

when used alone tolerance can develop so drug free interval needed (10-14h)- event more likely to occur during this time, use in combo therapy

Question 20

What are the counseling points of Nitrate transdermal patch?

Answer 20

12h on, then 12h off

Question 21

What are the adverse effects of Nitrates?

Answer 21

-headache (most common, contributes to discontinuation)
-hypotension
-dizziness
-GI disturbances (nausea)

Question 22

What are the drug interactions of Nitrates?

Answer 22

phosphodiesterase inhibitors lead to profound hypotension

Question 23

What is the indication of Ranolazine?

Answer 23

alternative prophylactic therapy (useful for pt with bradycardia or low BP) or adjunct to other anti-ischemic agents

Question 24

What are the adverse effects of Ranolazine?

Answer 24

-dizziness
-headache
-constipation
-nausea

Question 25

What are the warnings of Ranolazine?

Answer 25

-QTc prolongation
-hepatic impairment (may increase ranolazine levels)
-renal impairment (avoid use in severe renal impairment)

Question 26

What are the drug interactions of Ranolazine?

Answer 26

-CYP3A4, CYP2D6, P-glycoprotein (potential to increase ranolazine concentrations)= limit dose with moderate inhibitors of CYP3A4, diltiazem, verapamil
-avoid combination with other QTc prolonging agents

Question 27

What is the use of Ivabradine in SIHD?

Answer 27

heart failure agent used off label for stable angina in combination with beta blocker or calcium channel blocker but discontinue if no improvement within 3 months of initiation or if HR < 50 bpm

Question 28

What other drugs may be given to minimize disease progression?

Answer 28

-antiplatelet therapy (aspirin or clopidogrel)
-statin
-antihypertensive therapy (1st line beta blocker, ACEI or ARB)

Question 29

What is the goal BP for patient with SIHD?

Answer 29

<130/80mmHg

Question 30

What non-pharmaceutical procedures can be done with patient with SIHD?

Answer 30

-coronary bypass graft (CABG)
-percutaneous coronary intervention (PCI)