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71 Cards in this Set

  • Front
  • Back
At what percentage of stenosis in the coronary arteries do patients general start to develop symptoms of exertional angina?
50%
Three clinical features of chronic stable angina are?
1.Reversible symptoms 2.Symptoms occur over months to years 3.Repetitiveness of angina attacks
What two organizations are responsible for the most recent management guidelines of ischemic heart disease?
1.ACCF 2.AHA
Coronary Heart Disease is synonymous with what three other disease states?
1.Coronary Arterial Disease (CAD) 2. Stable Ischemic Heart Disease(SIHD) 3.Atherosclerotic Vascular Disease(AVD)
CAD encompasses what three distinct CV diseases?
1.Chronic Stable Angina (CSA) 2.Vasospastic Angina 3.Acute Coronary Syndrome (ACS)
Significant CAD can be categorized via the following two diagnoses
1. ≥50% stenosis of the left main coronary artery 2.At least a 70% stenosis of at least one major epicardial artery segment
Vasospastic Angina typically occurs at____________ in the early____________
rest in the early morning
What is the etiology of Vasospastic Angina?
Spasm of the coronary artery causing ischemia
Three characteristics of Unstable Angina include:
1.Prolonged angina at rest (>20 minutes) 2. Recent (within 2 months) angina caused limitations in activity 3.Increase in severity of Angina to CCS IV based on symptoms
What two factors did the INTER-HEART Study Risk of MI reveal were beneficial in reducing risk of MI?
1.Vegetables and fruits daily 2. Exercise
What are the three characteristics that classify angina as typical (definite)
1.Substernal chest discomfort with a characteristic quality and duration 2. Provoked by external or emotional stress 3. Relieved by rest or nitroglycerin
How many characteristics in typical (definite) angina are required to classify atypical and noncardiac angina?
Atypical = 2 and Noncardiac =1
Define the Class I of the Canadian Cardiovascular Society Functional Angina Classification
Ordinary physical activity does not cause angina such as walking and climbing stairs. Angina with strenuous or rapid prolonged exertion at work or recreation
Define the Class II of the Canadian Cardiovascular Society Functional Angina Classification
Slight limitation of ordinary activity. Walking or climbing stairs rapidly walking uphill waking or stair climbing after meals or in cold or in wind or under emotional stress or only during a few hours after awakening
Define the Class III of the Canadian Cardiovascular Society Functional Angina Classification
Marked limitation of ordinary physical activity. Walking one or two blocks on the level and climbing one flight of stair in normal conditions and at normal pace
Define the Class IV of the Canadian Cardiovascular Society Functional Angina Classification
Inability to carry on any physical activity without discomfort and angina symptoms may be present at rest
What are the three principle presentations of Unstable Angina?
1.Rest Angina 2.New-onset Angina 3.Increasing Angina
Define Rest Angina
Angina occurring at rest and usually prolonged > 20 mins and occurring within 1 week of presentation
Define New-Onset Angina
Angina of at least CCS Class III severity with onset within 2 months of initial presentation
Define Increasing Angina
Previously diagnosed angina that is distinctly more frequent and longer in duration or lower in threshold(ie increased by 1 CCS class within 2 months of initial presentation to at least CCS Class III Severity)
What are the five criteria used in the Seattle Angina Questionnaire?
1.Anginal Stability 2.Anginal Frequency 3.Physical Limitation 4.Treatment Satisfaction 5.Quality of Life
(T/F) A higher Seattle Angina score is better
False lower is better
What are the two subgoals for the management of CSA and the main overarching goal?
1. Disease Modifying: Preventing MI and death 2.Symptom Modifying: Reduce ischemia and relieve angina symptoms. Main goal: Improve Quality of Life
What are the four disease modifying agents used in CSA?
1.Aspirin 2.Statins 3.ACEi’s or ARB’s 4.Beta-blockers post MI
What are the three symptom modifying agents used in CSA?
1.Beta-Blockers without MI 2.CCB’s 3.Nitrates
Using a plus (+) minus (-) or NA sign denote the effect that the following drugs have on HR && Systolic Pressure && Left Ventricular Volume && and Contractility in that order:
Beta-Blocker:
Nitrates:
Dihydropyridine CCB’s:
Non-DHP CCB’s:
Ranolazine:
Beta-Blocker: -- && - && + && -
Nitrates: + && - && -- && NA
Dihydropyridine CCB’s: + && -- && NA or - && NA or -
Non-DHP CCB’s: -- && - && NA or - && NA or -
Ranolazine: NA && NA && NA && NA or +
What drug class is first line in CSA?
Beta-Blockers
It is important to avoid these specific type of Beta-Blockers in CSA therapy:
Intrinsic Sympathomimetics (ISA) BB’s
What is the goal HR in CSA?
55-60 bpm
What is the AHA/ACCF recommendation for Beta-Blockers Class I Evidence Level B?
Beta-blockers as initial therapy for symptom relief in patients with SIHD
What is the AHA/ACCF recommendation for Beta-Blockers Class IIb Evidence Level C?
Beta-Blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease
CCB’s are 1st line treatment in what type of angina?
Vasospastic angina
What are the three main MOA’s of CCB’s?
1. Dilate coronary and systemic arteries 2.Increase coronary blood flow 3.Decrease myocardial oxygen consumption
(T/F)Dihydropyridines and BB combination is contraindicated.
False it is safe to use these together
What are the three dihydropyridines used in angina?
1.Nifedipine 2.Amlodipine 3.Felodipine
Which dihydropyridine is not recommended for use in CSA?
IR nifedipine
(T/F) Non-dihydropyridines can be used in conjunction with BB’s.
False they can cause bradycardia
What are the two AHA/ACCF Class I Evidence Level B recommendations in regards to CCB’s?
1.CCBs or long-acting nitrates are recommended for symptom relief when beta-blockers are contraindicated or cause unacceptable side effects in patients with SIHD 2.CCBs or long-acting nitrates are recommended in combination with BB’s for symptom relief when BB initial therapy is unsuccessful in patients with SIHD
What is the AHA/ACCF Class IIa Evidence Level B recommendation in regards to CCB’s?
Long-acting non-dihydropyridine CCB’s can be used instead of a BB as initial symptom relief therapy in patients with SIHD
The most prominent effect of DHP CCB’s is on?
Increase in Vascular Dilatation
What are the two most prominent effects of Non-DHP CCB’s?
1.Decrease in HR 2.Decrease in Contractility
What drug class is the 1st line in acute relief of angina?
Nitrates
What is the most common dosage form of the nitrates?
Sublingual
75% of patients experience pain relief in____________minutes with SL nitrate use
3 minutes
____________% of patients experience pain relief in 5-15 minutes with SL nitrate use
15%
How long after SL nitrate use should EMS services be contacted if no pain relief is achieved?
5 minutes
What are the three AHA/ACCF recommendations for Nitrates in SIHD Class I Evidence Level B?
1.Sublingual NTG or NTG spray is recommended for immediate relief of angina in patients with SIHD 2.CCBs or Long acting nitrates are recommended for symptom relief when beta-blockers are contraindicated or cause unacceptable sides effects in patients with SIHD 3.CCBs or Long acting nitrates are recommended in combination with beta-blockers for symptom relief when beta-blocker initial therapy is unsuccessful in patients with SIHD
What are the three indications for Ranolazine?
1.CSA patients 2.On beta-blockers and or CCB’s and nitrates 3.Symptomatic
What two characteristics contribute to optimal patients for Ranolazine treatment?
1.Intolerance to beta-blockers 2.Patients with low heart rates or blood pressure
What is the dose and frequency for Ranolazine?
Starting: 500 mg PO BID MAX:1000 mg PO BID)
What is the AHA/ACCF SIHD recommendation for Ranolazine Class IIa Evidence Level B?
Ranolazine can be used as a substitute for beta-blockers as symptom relief in initial treatment with BB’s leads to unacceptable side effects or is ineffective or contraindicated in patients with SIHD
What is the AHA/ACCF SIHD recommendation for Ranolazine Class IIa Evidence Level A?
Ranolazine can be useful in combination with BB’s to help with symptom relief when initial treatment with BB’s is not successful in SIHD.
Provide an escalation of therapy for CSA patients with symptomatic relief drugs:
SL NTG PRN → BB → Add LA nitrate or CCB → Add Ranolazine → Consider Revascularization
What is the AHA/ACCF recommendation for SIHD patients Class I Evidence Level A for Aspirin?
Aspirin 75-162 mg daily in the absence of contraindications in patients with SIHD
What is the AHA/ACCF recommendation for SIHD patients Class IIb Evidence Level B for Aspirin?
Treatment with Aspirin 75-162 daily and clopidogrel 75 mg daily might be reasonable in certain high risk patients with SIHD
All patients with CAD should be on__________lowering therapy to reduce risk of CV events
LDL-C
What is the NCEP ATP III recommendation for SIHD (CSA & CAD & AVD)?
<70mg/dL
What is the AHA/ACCF recommendation for lipid lowering agents in patients with SIHD Class I Evidence Level A?
In addition to therapeutic lifestyle changes a moderate or high dose of a statin should be prescribed in the absence of contraindication or documented adverse effects
What is the AHA/ACCF recommendation for ACEi’s in SIHD patients Class IIa Evidence Level B?
ACEi’s are reasonable in patients with both SIHD and other vascular disease
What is the AHA/ACCF recommendation for Diabetes Management in patients with SIHD Class I Evidence Level C?
Goal A1C 7-9% is reasonable for certain patients according to age and history of hypoglycemia and presence of microvascular or macrovascular complications or presence of coexisting medical conditions
According to the AHA/ACCF guide lines for SIHD patients what diabetic drug is not recommended (Class III Evidence Level C)
Rosiglitazone
What are two additional AHA/ACCF guidelines in SIHD patients Class I?
1.BP goal of <140/90 mm Hg (Evidence Level A) 2. Annual influenza vaccine (Evidence Level B)
What is an additional AHA/ACCF guideline for patients with SIHD Class III Evidence Level A?
Not recommended to give estrogen replacement therapy or vitamin C/E/beta-carotene or folate/B6/B12 to reduce CV risk
According to the COURAGE trial what is considered optimal Antiplatelet therapy?
ASA 81-325 mg daily or Clopidogrel 75 mg dialy
According to the COURAGE trial what is considered optimal Angina therapy?
Metoprolol Succinate or Amlodipine or Isosorbide Mononitrate
According to the COURAGE trial what is considered optimal Angiotensin blocking therapy?
Lisinopril or Losartan
According to the COURAGE trial what three things were considered optimal Lipid Lowering therapy?
1. Use of Simvastatin ±ezetimibe 2.Goal LDL-C of 60-85 mg/dL 3.Secondary goal of raising HDL-C via exercise + niacin ER and fibrate alone or combination
What did the BARI 2D and COURAGE and ISCHEMIA Trials attempt to elucidate?
Outcome data on PCI vs. OMT (optimal medical therapy)
What was the result of both the COURAGE and BARI 2D trials?
Both showed increased mortality when PCI was implemented
What do ABCDE represent in the chronic stable angina card?
A =Aspiring and Antianginal therapy B=Beta-bloker and Blood pressure C=Cigarette smoking and Cholesterol D=Diet and Diabetes E=Education and Exercise
What are the four ways that effectiveness of treatment in CSA therapy be monitored?
1.Vital Signs 2.Use of Sublingual Nitroglycerin 3.Adverse Effects 4.Electrocardiogram if needed