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52 Cards in this Set
- Front
- Back
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What is the definition of stable angina pectoris?
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Chest discomfort on exertion, relieved by rest, most commonly due to CAD
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What is the definition of unstable angina pectoris?
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Chest discomfort both on exertion and at rest
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Define a STEMI
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MI due to TOTAL coronary occlusion, almost always involving a thrombus
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Define a NSTEMI
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MI due to PARTIAL/ TEMPORARY coronary occlusion, may or may not involve a thrombus. Due to an excess of demand
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What other drug should you prescribe with unfractionated heparin (UFH)?
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Antiplatelet therapy - heparin activates platelets
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How fast does UFH work, and how fast is its half-life?
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IV - minutes, SubQ - 1-2hrs
IV Half life = 2 hours |
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What can you give to a patient who starts bleeding after a heparin infusion to reverse its effects?
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Protamine sulfate (but this can cause hypotension, so don't be too ready to use it)
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Apart from bleeding, what is another major risk of UFH?
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HIT - heparin-induced cytopenia, a hypersensitivity in which antibodies are produced to heparin
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Who should NOT receive heparin?
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Active bleeders, recent surgery, trauma, or known history of HIT
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How does UFH work?
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Binds to AT-3, inhibiting thrombin, Factor IIa and Factor Xa
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What is the difference in mechanism of action between UFH and low-molecular weight heparin?
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UFH targets AT-3, thrombin, IIa and Xa
LMWHeparin targets Xa predominately |
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What are the advantages of low-molecular weight heparin over UFH?
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LMWHeparin inhibits circulating thrombin, AND accesses thrombin/fibrin clots already formed
longer half-life, and effective with 1-2 subQ injections daily less platelet activation than UFH, less likely to cause HIT/osteoporosis |
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What are the disadvantages of LMWH over UFH?
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LMWH = $$$
Difficult to reverse with protamine sulfate Renal excretion - higher risk in renal insufficiency |
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What is LMWH's generic or trade name?
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enoxeparin/Lovenox
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How do direct thrombin inhibitors (DTIs) work?
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By binding either thrombin's active, catalytic site, OR
by binding the fibrinogen binding site |
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What are the high molecular weight direct thrombin inhibitors?
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hirudin, bivalirudin (=Angiomax, hirulog)
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What are the low-molecular weight direct thrombin inhibitors?
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argatroban, efegatran
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What is an advantage of direct-acting thrombins over heparin?
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less bleeding
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How do fibrinolytic drugs work
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Convert plasminogen into plasmin, which busts up fibrin, fibrinogen, and any protein with an arginyl-lysine bond hanging around
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How do fibrin-specific agents work?
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They work on fibrin-bound plasminogen ONLY, producing fibrin-bound plasmin to bust up clots
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What are the generations of fibrinolytic drugs?
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G1: Streptokinase, urokinase
G2: recomb tPA (fibrin-specific) G3: rPA (reteplase) TNK-ase (tenecteplase) |
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What complication is high rate in administering fibrinolytics?
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Stroke - 1% ICH rate
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What must we absolutely know about the details of aspirin's MOA?
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Aspirin IRREVERSIBLY DEACTIVATES COX-1, preventing thromboxane A2 synthesis, and therefore platelet activation.
Effects last 7-10 days until all of the COX-1 in platelets circulating when you took the aspirin has been replaced |
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What cardiovascular disease patients should take aspirin.
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Trick question! Pretty much everyone with CVD should take aspirin.
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What do clopidogrel (Plavix) and ticlopidine (Ticlid) have in common with aspirin?
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They are oral antiplatelet agents, but clopidogrel/ticlopidine block platelets via ADP-dependent pathway instead of COX-1.
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How long does it take for clopidogrel (Plavix) or ticlopidine (Ticlid) to work with vs. without a loading dose?
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2 hours, no matter what loading dose you give.
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What are the side effects of ticlopidine (Ticlid) use?
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neutropenia, TTP (purpura)
unless patient is contraindicated, clopidogrel is usually preferred. Ticlid is banned in parts of Europe because of toxicity |
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How is clopidogrel (Plavix) administered?
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Oral, once daily. Everyone gets 75mg, regardless of weight.
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Who should get clopidogrel (Plavix)?
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Anyone with a drug-eluting stent, or percutaneous coronary intervention.
ACS (less recurrence of ischemia) Secondary prevention of CVD |
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What are clopidogrel (Plavix)'s limitations?
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Takes hours to work
CYP polymorphisms cause people respond differently, and poor antiplatelet response = adverse outcomes May increase bleeding May be inhibited by other meds |
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What oral anti-platelet agents are more effective than clopidogrel?
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prasugrel, ticagrelor
*but higher bleed risk, too, so don't give to the elderly, prior strokes, or really thin people |
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What are common side effects of ticagrelor that need to be monitored?
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dyspnea (14% and bradycardia 6%)
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What is the most effective oral anti-platelet regimen for people who can't take clopidogrel (e.g., get Plavis drug rash)? Hint: 2 meds
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Ticagrelor + low dose aspirin
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How is clopidogrel (Plavix) metabolized?
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hepatic - 85% is inactivated in first step of metabolism by CYP
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Why is Glycoprotein (Gp) IIb/IIIa important in platelet aggregation?
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The Gp IIa/IIIb receptor is the landing pad for fibrinogen on activated platelets.
This represents another interaction to block platelet activation, later in the process than COX-1 (aspirin) or ADP-dependent (clopidogrel/ticlopidine/prasugrel/ticagrelor) pathways |
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What is the prototype for Gp IIb/IIIa antagonists?
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Abciximab (ReoPro), indicated only in percutaneous intervention (PCI)
But $$$ and difficult to reverse, less effective in absence of PCI |
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What are the more reversible, small molecule GpIIb/IIIa antagonists?
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tirofibran (Aggrastat) and eptifibitide (Integrilin)
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How do nitrates work?
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2 ways:
1) Vasodilate coronary arteries = increased supply 2) Reduce systemic blood pressure -> LV volume, decreasing O2 demand |
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Who should NOT take nitrates?
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LBP, hypovolemia, RVMI, or Viagra/Cialis (phosphodiesterase inhibitors - remember the drug commercials "Those who are taking nitrates should not take Viagra")
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How long does SL nitroglycerin take to work?
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1-3 minutes
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What is one side effect of taking nitrates long term?
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Tolerance! This is a vasoconstrictive episode when you are taken off of continuous nitro. Can avoid this by having pre-planned time off of nitrates (12hrs on/12hrs off)
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What are the common side effects of nitrates?
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Hypotension and syncope
Also headache and can be potentiated by Viagra/Cialis |
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How do beta blockers work to help ACS/Angina?
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Lower heart rate, blood pressure and contractility.
This does not affect supply, but does decrease demand. |
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What are the calcium channel blockers?
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Nifedipine, amlodipine
Verapamil, diltiazem |
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Which calcium channel blocker works predominately by slowing the heart and increasing contractility?
-Amlodipine -Verapamil -Diltiazem |
Verapamil
VERapamil = VERy strong and slow (heart contractions) |
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Which calcium channel blocker works predominately by vasodilation?
-Nifedipine -Amlodipine -Diltiazem |
Nifedipine
NifedIPINe = NifedOPEN (vessels) |
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How do diltiazem and amlodipine work?
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By both chronotropic/ionotropic AND vasodilation.
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Who should not get verapamil or diltiazem?
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Anyone with bradycardia, heart block, heart failure or liver failure
Do not give Dig or Ranexa with verapamil! |
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Who should not get nifedipine / amlodipine?
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Hypotensive patients
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How does Ranexa work?
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Another trick, nobody knows! It's just an anti-anginal.
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Who should get Ranexa?
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Only patients refractory to triple therapy.
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What is "triple therapy" for angina?
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Nitrate + Ca channel block + beta block
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