Therapeutics - Ischemic Heart Disease Flashcards
what is the most common symptom of chronic coronary disease
angina
general distinction between the angina present in ACS vs IHD
ACS - angina at rest
IHD - angina upon exertion
explain the cause of the angina in CCD/IHD
imbalance between the myocardial supply and demand of oxygen
this is bc of athersclerotic plaques
name some ways that IHD risk factors can be modified
stop smoking
physical activity
manage stress
BP and lipid ctonrol
watch weight
angina pectoris lasts up to how long?
up to 30 mins
what is the scale for grading angina pectoris
when does revascularization start to become a potential?
Class 1 -class IV
class 1 - ordinary things dont cause angina
class 2 - slight limitation of ordinary activies
class 3 - marked limitation of normal activities
class 4 - cant do physical activities. angina at rest
revascularization starts at 3 and 4
true or false
edibles are associated with FEWER acute CV symptoms
true
name some drugs that can induce episodic angina
lot of caffeine
zyrtec
cisapride IV
nicotine
thyroid replacement
triptans
ephedra and pseudoephedrine
nonpharm treatment for IHD:
-vasculoprotective
-anti-ischemic
vasculoprotective - lifestyle changes and immunizations
anti-ischemic - revascularization
pharmacologic treatment for IHD:
-vasculoprotective
-anti-ischemic
vasculoprotective -
ACE/ARB
aspirin or plavix
statin
“AAS:
anti-ischemic
beta blockers
CCB
nitrates
ranolzaine
nonpharm vasculoprotective treatment includes managing weight
how can this be done? what if this isnt working?
DASH diet
may consider GLP-1 antagonists
true or false
the annual flu shot is a vasculoprotective option
true
as a recap, what are the pharmacologic classes that are VASCULOPROTECTIVE for IHD patients
antiplatelets
ACE/ARB
statin (high intensity)
what is considered the GOLD STANDARD vasculoprotective antiplatelet
why?
what is the alternative?
aspirin 75mg-100mg (baby aspirin)
reduced MI and cardiac death incidences in patients with CCD/IHD
alternative is clopidogrel - but really only give is aspirin allergic/intolerant
in a patient with CCD/IHD (NOT ACS), is DAPT done? if so for how long?
yes - DAPT is given only after PCI
the P2Y12 antagonist is stopped after 6 months (12 months at least if ACS), and baby aspirin continued forever
what is stable ischemic heart disease
just another term for chronic coronary disease
pt has stable plaques
as mentioned, ACEI/ARB are shown to be vasculoprotective in CAD patients
explain this further
ace inhibitors - specificallyy ramipril - has been shown to decrease morbidity and mortality in SIHD patients
ARB can be used if AE or intolerance to ACE, but ACE is definitely preferred
role of statins in IHD
they are vasculoprotective
patients with IHD are considered to have clinical ASCVD
therefore, a HIGH INTENSITY STATIN IS STARTED!
statins have a pleiotropic effect, meaning they stabilize plaques. however, these patients with IHD already have stable plaques! therefore, 80mg atorvastatin is not really needed and 40mg may be sufficient
true or false
ALL of these have been shown to decrease morbidity and mortality in IHD patients:
-antiplatelets
ACE/ARB
statin
TRUE
as recap, name the classes of drugs that are anti-ischemic for patients with IHD
beta blockers
calcium channel blockers
nitrates
ranolazine
true or false
beta blockers can reduce anginal symptoms
true
beta blockers work on the supply or demand side to reduce anginal symptoms?
demand side
true or false
beta blockers are 1st line for IHD patients
true!! but calcium channel blockers and nitrates are equally considered 1st line as well
they can be used together if 1 isnt working
name the 3 specific beta blockers used in IHD
metoprolol succinate
carvedilol
bisoprolol
explain the specific times when beta blockers are/arent indicated for IHD
indicated for all IHD patients with angina symptoms
HOWEVER, if the patient does not have anginal symptoms (they usually do tho), beta blockers can only be given in the patient has LVEF less than 50% or if they have a fib or other comorbidities
what is the target heart rate for IHD patients on beta blocker therapy
55-60 bpm
which specific beta blockers MUST BE AVOIDED in patients with IHD
those with intrinsic sympathomimetic activity
caution with metoprolol for IHD patients
be careful with depression! dont want HR to go below 55-60
true or false
if needed, a calcium channel blocker can be added to beta blocker therapy for IHD patients
TRUE
true or false
only non dihydropyridine calcium channel blockers can be used for IHD patients
FALSE any CCB can be used
which therapy has been shown to decrease instances of MVO (microvascular obstruction) after an intervention?
calcium channel blockers
CI to non dihydropyridine calcium channel blockers
EF less than 40%
in general, explain when we would use a DHP CCB vs non DHP CCB for a patient with IHD
normally we would give DHP, unless dealing with an arrhythmia or something that needs a non DHP
does nitroglycerin work on the supply or demand side
supply
for ACUTE ATTACKS, what dosage forms of nitroglycerin are given
sublingual nitroglycerin or translingual spray
true or false
for patients with IHD, they should call 911 after the 3rd dose of NTG doesnt work
true
true or false
isosorbide dinitrate and mononitrate are 2nd line for IHD patients
FALSE - 1 of the 3 first lines
concern with giving nitrates
tachyphylaxis (tolerance)
need a nitrate free interval
if dinitrate - it’s taken BID and patient needs to be told to try to take exactly 12 hours apart
**explain the role of ranolazine in IHD patients and why this is its place in therapy
NOT 1ST LINE!!!!!!!!!
only used as adjunctive therapy after all other therapies have failed/reached max tolerated dose
bc of side effects like QT prolongation** and other DDI concerns with some statins
need to monitor EKG when a patient is on this - extra monitoring parameter
“hemodynamic control effect”
ranolazine
causes QT prolongation tho
**interaction between ranolazine and simvastatin
levels of simvastatin will increase! ranolazine a CYP3A4 inhibitor
low dose aspirin in pregnancy
considered safe for pregnancy in low doses
pregnancy category clopidogrel
B - no toxicity shown in animals but not enough in humans
true or false
aspirin + clopidogrel can be used together in IHD patients
true - especially after ACS
grapefruit juice and clopidogrel
efficacy of clopidogrel decreases - bc its a prodrug and needs to be bioactivated by CYP
*ranolazine DDI with diltiazem
increase blood levels and effects of ranolazine
diltiazem is a CYP3A4 inhibitor
*true or false
ranolazine is CI with CYP3A4 inducers
true
*3 QT prolonging drugs that interact with ranolazine
haloperidol
cipro
azithro
*4 CYP3A4 inhibitors that interact with ranolazine
what is the interaction
azole antifungals
clarithromycin
diltiazem
verapamil
increased blood levels of ranolazine due to CYP3A4 inhibition - INCREASED CHANCE QT prolongation
“starting 5” for stable ischemic heart disease
-antiplatelet (aspirin alone usally cloppidogrel if aspirin cant be used. ONLY COMBINED for STENT/PCI FOR IHD)
-ace inhibitor (preferred - then move to ARB)
-high intensity statin
-beta blocker, CCB, or long acting nitrate
-sublingual NTG
