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IPC Cardiology > Treatment Approach: CCD, Unstable Angina, NSTEMI, STEMI (Wed AM/PM) > Flashcards

Treatment Approach: CCD, Unstable Angina, NSTEMI, STEMI (Wed AM/PM) Flashcards

1
Q

goal of therapy for patients with CCD

A

prevent development of major adverse cardiovascular event (MACE) like a myocardial infarction (ACS), stroke or death due to cardiovascular causes (aka clinical ASCVD)

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2
Q

CCD treatment

non-pharm management

stable angina, diagnosed after acs, ccd diagnosed on screening

A
  1. quit smoking (tobacco)
  2. limit alcohol to 1 or less for women and 2 or less for men
  3. avoidance in other substances with harmful CV effects (cocaine, meth, opioids, marijuana)
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3
Q

CCD treatment: lipid therapy

not at very high risk

A
  1. high intensity statin to lower LDL more than or equal to 50%
  2. moderate intensity statin if high intensity statin not tolerated
  3. on max tolerated statin and LDL greater than or equal to 70 mg/dL, add ezetimibe
  4. on max tolerated statin and LDL less than 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl

mod int statin
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin 80 mg
Pitavastatin 2-4 mg

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4
Q

CCD treatment: lipid therapy

very high risk

A
  1. high intensity statin to lower LDL more than or equal to 50%
  2. on max tolerated statin and LDL greater than or equal to 70 mg/dL, add ezetimibe
  3. on max tolerated statin and LDL lower than 100 mg/dL with fasting TG 150-499 mg/dL, add icosapent ethyl
  4. on max LDL lowering therapy and LDL more than or equal to 70 mg/dL or non HDL more than or equal to 100 mg/dL, a PCSK-9 can be beneficial

PCSK-9s: praluent (alirocumab), repatha (evolocumab)

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5
Q

CCD treatment: antiplatelet therapy

no PCI

A

aspirin 81 mg daily

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6
Q

CCD treatment: antiplatelet therapy

directly after PCI

A

dual antiplatelet therapy (DAPT) for 1-6 months followed by single antiplatelet therapy (SAPT)

SAPT is aspirin or clopidogrel

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7
Q

CCD treatment: antiplatelet therapy

after CABG

A

dual antiplatelet therapy

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8
Q

SAPT

A

low dose aspirin or a P2Y12 inhibitor

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9
Q

DAPT

A

combination of low dose aspirin and a P2Y12 inhibitor

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10
Q

CCD treatment: comorbidity treatment

mental health

A

targeted discussion and treatment for mental health is reasonable to improve CV outcomes

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11
Q

CCD treatment: comorbidity management

blood pressure

A

in patients who meet threshold, for BP therapy, ACEI/ARB or beta blockers are recommended first line

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12
Q

CCD treatment: comorbidity management

diabetes

A

patients with TIIDM should use an SGLT2 inhibitor or GLP1 receptor agonist with proven CV benefit to reduce MACE

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13
Q

anginal chest pain treatment

if attacks are infrequent or prior to activities that cause angina

A

sublingual nitroglycerin
1. sit down
2. dissolve under tongue
3. take up to 3 doses q 5 mins

store in original container & replace q 6 months

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14
Q

anginal chest pain treatment

decreases HR and contractility (decreased O2 demand)

also antiarrhytmic and may slow progression of plaque

A

beta blockers

treatment goals: resting HR 50-60 bpm, max exercise HR 100 bpm

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15
Q

anginal chest pain treatment

as effective as beta blockers in preventing anginal symptoms

A

calcium channel blockers
1. Non-DHP: decreased HR and contractility (avoid w/ beta blockers or severe LV dysfunction)
2. DHP: decreased afterload

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16
Q

anginal chest pain treatment

isosorbide dinitrate or mononitrate
transdermal nitroglycerin patch

A

long acting nitrate
1.lack of efficacy after consistent exposure
2.provide 10-14 hour nitrate free period (usually during sleep)

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17
Q

anginal chest pain treatment

Inhibits persistent/ late inward Na+ current in the ventricles

A

ranolazine
1. anti-ischemic activity related to reduced accumulation of intracellular calcium
2. no effect on HR or BP
3. AE: QT prolongation
4. metabolism: 3A4, 2D6, pGp

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18
Q

acute treatment of ACS

unstable angina and NSTEMI

A

OSNAAP

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19
Q

O of OSNAAP

A

oxygen
1. if arterial O2 saturation is less than 90%
2. respiratory distress
3. other high risk features of hypoxemia

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20
Q

S of OSNAAP

A

statin
1. high intensity statin

atorvastatin 40-80 mg
rosuvastatin 20-40 mg

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21
Q

N of OSNAAP

A

nitroglycerin
1. SL NTG every 5 min × 3 for
continuing ischemic pain and
then assess need for IV NTG
2. Administer IV NTG for
persistent ischemia, HF, or
hypertension
3. Nitrates are contraindicated
with recent use of a phosphodiesterase inhibitor

22
Q

1st A of OSNAAP

A

Aspirin
1. loading dose: non-enteric coated, CHEWABLE aspirin ASAP after presentation. (162-325 mg)

23
Q

2nd A of OSNAAP

A

anticoagulants
* P2Y12i loading dose of ticagrelor: 180 mg
* maintenance dose for ticagrelor: 90 mg bid for 1-6 mos
* P2Y12i loading dose of clopidogrel: 600 mg
* maintenance dose for clopidogrel: 75 mg qd for 1-6 mos
* P2Y12i loading dose of prasugrel: 60 mg
* maintenance dose for prasugrel: 10 mg qd

ticagrelor preferred
prasugrel only if PCI (stent)

24
Q

GIIB/IIIA inhibitors

A

tirofiban (aggrastat), eptifibatide (integrilin), abciximab (reopro)
1. potent antiplatelet agents that block the binding site for fibrinogen
2. used in some catheterization procedures in patients with significant clot burden

Increases bleed risk, especially in combination with aspirin, a P2Y12 inhibitor, and an anticoagulant

25
Q

acute treatment strategies for STEMI

if time to PCI is more than 90 minutes

A

fibrinolytic therapy (thrombolytics)
1. work to degrade fibrin clots and restore blood flow (revascularization)
2. only use clopidogrel
3. alteplase (tPA), reteplase, tenecteplase (tNK)

26
Q

acute treatment of STEMI

just P because everything else is same

A

P from OSNAAP
P2Y12 Inhibitor (P2Y12i):
* Loading dose:
– Ticagrelor: 180 mg x 1
– Clopidogrel: 600 mg x 1
– With a lytic:
– ≤ 75 years: 300 mg
– > 75 years: 75 mg
– Prasugrel 60 mg x 1 (only
after visualization of coronary
anatomy)
* Maintenance dose: P2Y12i x 1-6
months
– Clopidogrel: 75 mg daily
– Ticagrelor: 90 mg twice daily
– Prasugrel: 10 mg daily

ticagrelor or prasugrel preferred

27
Q

long term treatment of ACS

unstable angina, NSTEMI, STEMI

A

SNAP plus BAM

28
Q

S from SNAPBAM

A

high intensity statin indefinitely

29
Q

N from SNAPBAM

A

send SL PRN rx home with patient

30
Q

1st A from SNAPBAM

A

continue maintenance dose of aspirin indefinitely

31
Q

P from SNAPBAM

A

continue maintenance dose of P2Y12i for 1-6 mos

32
Q

B from SNAPBAM

A

beta blocker for 1 year or indefinitely
1. any beta blocker unless signs of acute HF
2. In patients with reduced EF,
use BB proven to reduce mortality in patients with HF (sustained-release
metoprolol succinate, carvedilol, or bisoprolol)

`

If a patient has a normal EF and low BP and can only tolerate a BB or an ACEI/ARB, usually choose BB

33
Q

2nd A from SNAPBAM

A

ACEI/ARB indefinitely
1. ACE inhibitors should be initiated in all patients with LVEF < 40% and in those with hypertension, diabetes mellitus, or stable CKD
2. ARBs are recommended in patients who are ACE inhibitor intolerant

33
Q

MI caused by vasospasm and vasoconstriction of coronary arteries

A

cocaine induced myocardial infarction

34
Q

M from SNAPBAM

A

Mineralocorticoid Receptor Antagonist
1. Patients with an EF < 40%
who are receiving therapeutic doses of ACE inhibitor and beta blocker
2. Contraindicated:
– Serum creatinine >2.5
mg/dL in men
– Serum creatinine >2.0
mg/dL in women
– Potassium >5.0 mEq/L

35
Q

sympathomimetic crisis

A

cocaine inhibits the reuptake of norepinephrine leading to increased norepinephrine concentrations and enhanced alpha 1 mediated vasoconstriction

36
Q

cocaine induced myocardial infarction

chest pain treatment

A

aspirin
benzos

37
Q

cocaine induced myocardial infarction

persistent hypertension treatment

A

benzos
IV nitroglycerin

38
Q

cocaine induced myocardial infarction

other acute ACS treatment

A

possibly avoid acute beta blockers

39
Q

cocaine induced myocardial infarction

long term ACS treatment

A
  • possibly avoid beta specific beta blockers
  • drug abuse counseling
40
Q

cardiovascular mechanism of NSAID induced cardiotoxicity

A
  • NSAIDs block COX-2
  • COX-2 would stimulate vascular vasodilation and decreased platelet aggregation
  • physiologic effects of cox inhibition is MI and stroke
41
Q

intermittent claudication

symptoms and clinical presentation

A
  1. pain when walking in the buttocks, thighs or calves
  2. often relieved with rest
  3. severe cases will have pain at rest
42
Q

chronic limb threatening disease

symptoms and clinical presentation

A
  1. chronic decreased flow that can lead to ulcerations, gangrene, infections
  2. patients with diabetes and smokers highest risk
43
Q

acute limb ischemia

symptoms and clinical presentation

A
  1. medical emergency
  2. requires immediate revascularization to prevent limb loss
44
Q

PAD treatment

lipid lowering therapy

A
  1. High intensity statin
    with a goal of lowering LDL ≥ 50%
  2. If LDL ≥ 70 mg/dL after maximally tolerated statin therapy, add PCKS9 inhibitor and/or ezetimibe
45
Q

PAD treatment

antihypertensive therapy

A
  1. PAD and HTN = first line use of ACEI/ARB
  2. treat to goal < 130/80 mm Hg
46
Q

PAD treatment

diabetes management and smoking cessation

A

DM: more detail to come
SC: as before

47
Q

PAD treatment

preventative foot care

A
  1. foot self care education
  2. foot inspection at every visit clinician
  3. therapeutic footwear
  4. referral to foot care specialist
48
Q

Symptomatic PAD

antiplatelet therapy

dependent on revascularization

A

if recent revascularization
1. low dose aspirin and rivaroxaban 2.5 mg bid
2. DAPT: aspirin 81 mg qd and P2Y12 inhibitor

if no recent revascularizaation
1. low dose aspirin and rivaroxaban 2.5 mg bid
2. SAPT: clopidogrel 75 mg qd or aspirin 81 mg qd

49
Q

symptomatic PAD

potential cilostazol therapy

A

cilostazol helps to improve leg symptoms and improve walking distance
1. inhibits phosphodiesterase III
2. takes 2-4 weeks, may require up to 12 weeks
3. contraindicated in patients with HF
4. AE: headache (~30%), GI upset/diarrhea (~15%)
5. Substrate of: CYP1A2, CYP2C19, CYP2D6, CYP3A4, Weak inhibitor of CYP3A4

50
Q

symptomatic PAD

structured exercise therapy

A
  • Structured exercise therapy (SET) is recommended to improve walking performance, functional status, and quality of life in all patients with chronic symptomatic PAD
  • Can be administered at a rehabilitation facility, clinic, or as
    home therapy through consultation with trained personnel
51
Q

acute limb ischemia

treatment

A

revascularize immediately
1. immediate admin of systemic heparin in any scenario
2. thrombolytics: local admin to site of occlusion
3. endovascular: balloon +/- stenting, thromboectomy
4. surgical: thromboectomy, bypass surgery, amputation if unable to revascularize

IPC Cardiology (6 decks)

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