W5 Topics (Exam 3) Flashcards
race and sex most likely to develop CAD
black men
non-modifiable CAD risk factors
male > 45y/o
female >55y/o
family history of premature CAD event (M <55y/o, F <65y/o)
modifiable CAD risk factors
smoking, HTN, dyslipidemia, DM, obestity, lack of exercise
CAD progression
plaque buildup - vessels vasodilate to make-up for buildup - O2 demand inc above baseline and vessels cannot dilate further - demand > supply = ischemia and angina
Ischemic Heart Disease has 2 subsets:
Stable and Unstable IHD
Unstable IHD has 3 subsets
Unstable angina
NSTEMI
STEMI
all are ACS (acute coronary syndrome)
Stable Angina
chronic angina, precipitated by activity/upset and relieved at rest
Unstable Angina
inc freq/duration of angina @ lower level of activity/at rest
NSTEMI
myocardial necrosis as a result of poor blood supply (from acute thrombosis)
NO ECG changes
STEMI
same as NSTEMI but with ECG changes
cardiac enzymes signaling myocardial necrosis
troponin (most specific)
CK, CKMB (less specific, rise quickly)
angina quality
pressure, crushing, burning, tightness (acute)
angina location
substernal (can radiate to neck, jaw, shoulder, chest, arm, upper abdomen)
angina duration
0.5-20min
angina precipitating factors
exercise, cold weather, stress, postprandial
angina relieving factors
rest, SL nitroglycerin
typical angina
follows angina characteristics
atypical angina
meets only 2 of criteria
women/older adults/DM have a special presentation (anxiety, SOB, weakness, indigestion)
non-cardiac chest pain
does not meet/meets one criteria for angina
treatment of Stable IHD
Moderate/high statin
Aspirin 81mg
Clopidogrel if aspirin CI’d
both aspirin and Clopidogrel if high-risk
(dec risk of developing unstable ihd)
treatment of angina (chest pain)
just improves QOL, does not dec risk of SIHD
1: SL nitro prn
2: beta blocker (SL nitro doesnt work/ >1 anginal episode/day)
3: CCB/long acting nitrate
4: Ranolazine
CCB for anginal chest pain: Non-DHP v DHP
both dec O2 demand
avoid Non-DHP if on beta-blocker, HFrEF, severe LV dysfunction
long acting nitrate for angina
PO isosorbide mono/dinitrate or nitroglycerin patch
Ranolazine for angina
500mg BID
no effect on BP/HR
Unstable angina/STEMI strategies
medical management or early invasive (immediate cardiac catheterization)
OHSNAAP
O (in STEMI and NSTEMI treatment)
Oxygen, only if O2 sat <90%
S (in STEMI and NSTEMI treatment)
Statin (high intensity!)
atorvastatin 40-80
rosuvastatin 20-40
N (in STEMI and NSTEMI treatment)
Nitroglycerin
SL q5min up to 3 times
IV if no response to SL
CI’d within 24hr of Sildenafil/Avanafil and 48hr of Tadalafil
A (in STEMI and NSTEMI treatment)
Aspirin
LD give asap: non-enteric coated, chewable aspirin (324 or 325mg)
A (2) (in STEMI and NSTEMI treatment)
Anticoagulants
IV unfractionated heparin for 48hr/ until PCI performed
OR
SQ enoxaparin for duration of hospital visit/until PCI performed
P (in NSTEMI treatment)
P2Y12 inhibitor
LD: Ticagrelor 180mg, Clopidogrel 600mg
MD: (for 12mon) Ticagrelor 90mg BID Clopidogrel 75mg QD
ticagrelor PREFERRED
only use Prasugrel if PCI
longterm treatment of ACS
SNAP + BAM
B (in long-term STEMI and NSTEMI treatment)
beta-blocker unless pt has signs of acute HF (fluid overload/tachycardia)
use SR metoprolol succinate, carvedilol, bisprolol in pt with EF <40%
A (in long-term STEMI and NSTEMI treatment)
ACEi/ARB
all pt should receive
M (in long-term STEMI and NSTEMI treatment)
MRAs (Spironolactone or Eplerenone)
for pt with EF < 40% who are on ACEi/ARB or beta blocker
CI’d if pt: SCr >2.5mg/dL Males or >2.0mg/dL in Females
K > 5.0mg/dL
P (in STEMI treatment)
LD: same as NSTEMI (Clopidogrel, Ticagrelor)
BUT Prasugrel 60mg can be used only after visualization of coronary anatomy
Ticagrelor and Prasugrel preferred over Clopidogrel
Platelet Patho
Adhesion, Activation, Aggregation
Adhesion
platelets adhere to exposed collagen and Von Willebrand Factor
Activation
release activating factors and GP IIb/IIIa receptors on platelet surface
Aggregation
cross-linking of platelets via GP IIb/IIIa receptor-fibrinogen binding; stabilize fibrin clot
P2Y12 inhibitors
inhibit ADP platelet activation
PO: clopidogrel, prasugrel, ticagrelor
IV: cangrelor
P2Y12 inhibitors recommendations
- given for 1 yr to pt who receive a stent
- clopidogrel/ticagrelor + aspirin for 12mon to ALL ACS pt
Clopidogrel characteristics
P2Y12 inhibitor
- irreversible binding to ADP receptor
- longer time to inhibit platelets 2-6hr 3-40%
Prasugrel characteristics
irreversible binding to ADP receptor
quick platelet inhibition 30min 60-70%
Ticagrelor characteristics
reversible, allosteric binding to ADP receptor
quick platelet inhibition 30min 60-70%
Clopidogrel dosing
LD: 300-600mg medical management, 600mg PCI, 300mg STEMI w thrombolytic
MD: 75mg QD
Prasugrel dosing
N/A for medical management and STEMI w thrombolytic
LD: 60mg PCI
MD: 10mg QD PCI
Ticagrelor dosing
LD: 180mg medical management and PCI
MD: 90mg BID and 60 after 1yr medical management and PCI
N/A for STEMI w thrombolytic
Cangrelor
IV platelet inhibitor
onset within 2min, normal platelet activity 1-1.5hr after discont
*give to pt who have NOT been treated with a P2Y12 inhibitor or GP IIb/IIIa inhibitor
GP IIb/IIIa inhibitors
Abciximab, Eptifibatide, Tirofiban
GP IIb/IIIa inhibitors characteristics
IV agents, block aggregation step
-administer at time of PCI (pt with NSTE-ACS not pre-treated with P2Y12i and pt with STEMI/ACS who were pre-treated with P2Y12i
anticoagulation therapy
unfractionated heparin (UFH)
Low MW heparin (Enoxaparin)
Bivalirudin
Fondaparinux
anticoagulation therapy key points
- pt must be fully anticoagulated at time of PCI (dec risk of thrombus formation)
- discont anticoag when PCI complete
- Bivalirudin only option in pt with early invasive strategy
- Do not use GP IIa/IIIb with bivalirudin (inc bleed risk)
Bivalirudin anticoag key point
only use in pt with planned early invasive strategy
Fondaparinux anticoag key point
contraindicated if CrCl <30ml/min
Intermittent claudication (PAD)
pain when walking, relieved with rest (severe have pain at rest)
Ulceration/infection/skin necrosis (PAD)
pt with DM and smokers at highest risk
Acute Arterial Occlusion
medical emergency! requires immediate revascularization to prevent limb loss
if pain is at buttocks, hips, thighs
blockage at aorta and iliac artery
if pain is at thigh/calf
blockage at femoral artery
if pain is at calf, ankle, foot
blockage at popliteal or tibial artery
ABI 1-1.4
normal
ABI 0.8-0.9
some PAD
ABI 0.5-0.8
moderate PAD
ABI <0.5
severe PAD
Acute Limb Ischemia (from PAD) treatment
immediate admin of heparin, revascularize immediately in 1 of 3 ways
- thrombolytics (local admin to occlusion site)
- endovascular (balloon stenting, thrombectomy)
- surgical (thrombectomy, bypass surgery, amputation if cannot revascularize)
Longterm PAD treatment
- aspirin with symptomatic PAD *+clopidogrel after revascularization
- antiplatelet therapy if asymptomatic
- statin for ALL
- ACEi/ARB if HTN
- Cilostazol if intermittent claudication (symptoms)
