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82 Cards in this Set
- Front
- Back
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name the classes of anti-anginal drugs |
beta blockers CCB (dihydropyridines) CCB (nonhydropyridines) Nitrates Sodium channel blocker |
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what drug can treat angina alone |
Ranolazine (Ranexa) |
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know the algorithm for treating stable angina |
anginal→ NG SL → BB→ ADD CCB or Long-acting nitrate if inadequate relief after titration→ ADD Ranolazine if inadequate relief from long-acting nitrate |
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when do you not give nitro to a pt? |
if they are hypotensive already |
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how many times do you administer Nitro before going to the ER? |
3 times |
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what is the onset and duration of SL, oral, and transdermal NG? |
SL onset: 2 min Duration: 25 min
PO onset: 35 min Duration: 4-8 hrs
Transdermal onset: 30 min Duration: 10-12 hr |
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when do you have to be caution about when using BB |
-moderate/severe CHF -HR <50 -hx of asthma -IDDM -severe peripheral vascular dz |
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CI of BB |
-very severe CHF/PE (Cardiogenic shock) → ACUTE DECOMPENSATION OF CHF -SBP <90 -acute asthma (bronchospasm) -2nd-3rd degree AV block unless they have a pacemaker |
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T or F: CCB do not reduce mortality after MI |
true |
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CCB may be harmful causing ______ ______. |
negative inotrope |
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what can you give 80 mg of during an acute MI/unstable Angina? why? |
Lipitor (Atorvastatin)
-act as an anti-inflammatory and plaque stabilizer in the acute phase and significant benefit seen as early as 30 days |
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when do you initiate statin therapy in non-MI patients? |
LDL >130
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what is the recommendation to keep LDL below what number? |
LDL <100 |
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if you were diagnosed w/ PE, what drug must you be placed on? and for how long? |
Heparin 6 months |
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what is the MOA of Heparin |
indirect thrombin inhibitor (w/ AT II) |
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what are indications for Heparin |
-doing a PTCA or CABG -w/ fibrin-specific lytics -high risk for PE like large anterior MI, a-fib, or LV thrombus |
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what drug must have the symptoms onset be less than 12 hrs? what is time frame actually preferred? |
Fibrinolytic therapy
preferred: 6 hrs |
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what is the MOA of fibrinolytic therapy |
breaks up the fibrin network that binds clots together |
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what are indications for fibrinolytic therapy |
-ST elevation > 1mm in 2 or more continuous leads -New LBBB -new BBB that obscures ST |
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name some fibrinolytic therapies. |
alteplase (tPA, Activase) Antistreplase (Eminase) reteplase (Retavase) Streptokinase (streptase) Tenecteplase (TNKase) |
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start fibrinolytic therapy infusion ASAP w/ _______ |
Heparin |
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what is your leading diagnosis if a young healthy individual develops a PE? |
Cancer |
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what are absolute CI of Fibrinolytic therapy? |
-previous hemorrhagic CVA ever -previous thrombotic CVA within 1 yr -known intracranial neoplasm -active internal bleeding -suspected aortic dissection
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what are relative CI of fibrinolytic therapy? |
-severe uncontrolled HTN >180/110 -hx of CVA or known intracerebral pathology -current use of anticoags (INR>2) -known bleeding diathesis -recent trauma (2-4 wks) including head trauma -for streptokinase: prior exposure to rxn -PG -active peptic ulcer -hx of chronic HTN
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what is the MOA of ACEI? |
-↓ BP by inhibiting ACE -alters post-AMI LV remodeling by inhibiting tissue ACE -↓ PVR by vasodilation -↓ mortality and CHF from AMI |
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when do you start using ACEI in an angina episode? |
-6 hrs after acute phase and if the pt is hemodynamically stable |
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MOA of ACEI is much more useful in the _____ phase to prevent ______ rather than acute phase |
post-MI phase remodeling |
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what's the diff. in medication therapy between barametal stent and drug exuding stent? |
barametal stent: ASA and Plavix @ least 4-6 wks Drug exuding stent: Plavix @ least one year |
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most common manifestation of myocardial ischemia is __________. |
stable angina pectoris |
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myocardial oxygen depends on what 3 things? |
HR contractility intra-myocardial wall tension |
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what will increase LV preload? afterload? |
preload: higher end-diastolic volume afterload: HTN and/or arterial stiffness |
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what's the normal EF? |
55-75%
if you stress test a pt w/ angina, the EF will decrease. |
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what's the clinical presentation of angina? |
-pain over sternum that may radiate to left shoulder or arm, jaw, back, right arm, or neck -pressure or heavy weight on chest, burning, tightness, deep, squeezing, aching, suffocating, crushing |
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how long will a chronic stable angina last? |
5- 30 min |
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what is precipitated by? |
exercise cold weather sexual activity |
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what is it relieved by? |
sL NTG or rest |
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how long do symptoms present in chronic stable angina? |
at least 2 months
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what are lifestyle modifications |
smoking cessation
exercise- 30-60 min of moderate-intensity exercise such as walking 7 days/wk |
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How many mg should all pts w/ chronic Ischemic Heart Dz? |
81 mg daily |
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if ASA is absolutely CI, what is an alternative? |
Clodpidgrel (Plavix) |
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T or F: the combination of Plavix and ASA is indicated in pts w/ stable dz, not PCI. |
False. not indictated in pts w/ stables dz not PCI. |
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what's the MOA of BB? |
-inhibits catecholamine effects → ↓ MVO2 -↓ HR= negative chronotrope effects→ ↓ in conduction through the AV node -↓ contractility -↓ BP -↓ left ventricular afterload |
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who should have always have a BB unless CI? |
pts who had a MI or ACS and CHF |
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does BB cause a direct improvement on oxygen supply? |
no but they ↑ diastolic perfusion time (coronary arteries fill during diastole). this causes ventricular relaxation which increase subendocardial blood flow. |
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BB will cause unopposed alpha stimulating leading to ______ |
coronary vasoconstriction |
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Should BB non-selective or selective be used? examples? |
selective
Metoprolol atenolol bisoprolol nebivolol |
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what drug causes peripheral vasodilation through a-1 receptor blockade? |
Carvedilol
3rd generation BB** |
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what is Carvediolol used for? |
CHF |
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what drug stimulates the release of NO via beta3- receptor stimulation causing peripheral vasodilation and has better selectivity for the beta-1 receptor than the other beta blockades? |
Nebivolol |
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the combination of beta1 and beta 3 receptor blockade has increased _______ |
insulin sensitivity |
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Nebivolol is indicated for _____ |
HTN
*not studied for angina or recent MI yet*** |
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all BB are _____ but not all are FDA ______ |
effective; indicated |
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what class drug improves exercise tolerance and reduce silent ischemic episodes and early morning ischemia and mortality post-MI more effectively than nitrates and CCBs? |
BB |
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BB should be used for 3 years in what kind of pts? |
normal left ventricular function |
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in pts w/ left ventricular dysfunction (EF<40%), what BB should be initiated? |
carvedilol metoprolol bisoprolol |
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what drug has both peripheral and arterial vasodilation? |
nitrates |
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the spray and SL NTG tablet is used for _____ |
acute relief |
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when should long acting nitrates be used? |
as initial therapy to reduce sx only if BB or CCBs are CI |
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nitrates are often combined w/ ______ or ____ for greater effects |
BB or CCBs |
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what is a SE of nitrate that you want to be careful of? |
reflex tachycardia b/c of increase sympathetic tone
BB attenuate this resposne |
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what is the MOA of CCB? |
↓ systemic vascular resistance and arterial BP by vasodilation of systemic arteries
-↓ contractility and O2 requirement verapamil > dilitazem > nifedipine
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indications for CCB? |
- those who can't tolerate BBs or insufficient response -variant angina -PVD |
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what CCBs are 1st line when BBs are CI? |
Nondihydropyridine: dilitiazem and verapamil |
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how should you take the SL NTG? |
sitting. no relief after 5 min, max dose up to 3 tablets. if after 15 minutes, go to ER. |
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you can take Sl NTG prophylatically when the pt anticipates symptoms upon exertion. many min before should you take prior to activity?
this is in the form of ______-release. this is good for pts who have _____. |
5- 10 min.
duration: 30-40 min
sustained release. good for vasospasm. |
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SE of SL NTG? |
postural hypotension HA flushing reflex tachycardia nausea |
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NG must be replaced every _____ to ____ and kept in original container to preserve potency. |
6 to 12 months |
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does tolerance develop w/ prolonged use of nitrates? |
yes |
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what should you do about this tolerance? |
have 8-12 hr nitrate-free period every 24 hrs |
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what is used as 2nd line for angina when other medications are inadequate? |
Ranolazine (Ranexa) |
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Ranolazine's anti-anginal and anti-ischemic effects occur w/o causing any changes in ____ or _____ |
BP or HR |
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MOA of Ranolazine |
inhibit late sodium current, preventing CA overload and ultimately blunting the effects of ischemia by improving myocardial function and perfusion |
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how is ranoazine metabolized? what can it not be given with? |
metabolized by CYP3A
don't given w/ CYP3 A inhibitors (ketoconazole, Clarithryomycin, nefazodone, ritonavir, nelfinavir) or inducers (rifampin, phenobarbital, carbamazepine, phenytoin or st. john's wort) |
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CI of Ranexa |
cirrhosis |
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SE of Ranexa |
QT interval prolongation dizziness HA Nausea constipation |
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pts who have unstable angina and may have ST elevations but normal PCA most likely has _____ |
Printzmetals |
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what is printzmetals |
caused by spasm w/o increased myocardial oxygen |
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what are characteristics of variant angina? |
recurrent, prolonged attacks of severe ischemia mainly at rest or awakens during sleep |
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how old are these pts typically? |
30-40 YO |
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will BB help in this situation? |
nope. can increase painful episodes and prolong ischemia by vasoconstriction |
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tx for prinzmetal |
nitrates are preferred for acute attack.
combine w/ CCBs for more effectiveness (nifedipine, dilitiazem, verapamil) |
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what is CI within 24 hrs of a nitrate? |
Sildenafil (PDE-5) |
