Ischemic Heart Disease

Front 1

What is chronic stable angina?

Back 1

When you mow the lawn, get chest pains, take nitro your fine?

Front 2

What are acute coronary syndromes?

Back 2

Unstable angina
Non-ST-segment elevation myocardial infarction (NSTEMI)
Acute issue, only diff is EKG changes
ST-segment elevation myocardial infarction (STEMI)

Front 3

What are risk factors for ischemic heart disease?

Back 3

Age
Men ≥45 years; Women ≥55 years or premature menopause ± ERT

Family history of premature CHD
MI or sudden death ≤55 years (male) or ≤65 (female)

Cigarette smoking (other tobacco too)

Hypertension
≥140/90 mmHg or treated

HDL <40 mg/dL

High LDL (level depends on other risk factors)

Front 4

When do Coronary arteries fill ?

Back 4

during diastole

Front 5

At base lines what are R1 and R2 arterioles at?

Back 5

Baseline resistance - R2 > R1

Front 6

In Atherosclerosis what happens to the arterioles?

Back 6

creates resistance in R1, R2 will dilate to maintain coronary flow
Degree of obstruction drives level of ischemia
>70% = severe stenosis

Front 7

What is clinical presentation of ischemic heart disease?

Back 7

Angina = chest pain

Anginal syndrome:
Nature or quality of pain
Precipitating factors
Duration
Radiation
Response to NTG or rest

Not present in all patients (silent ischemia)

Front 8

Stable angina is what kind of pain, what levels are cardiac enzymes? does it have ECG changes?

Back 8

Predictable (if present)

Normal

None

Front 9

Unstable Angina
is what kind of pain, what levels are cardiac enzymes? does it have ECG changes?

Back 9

Exertional

+/-

None

Front 10

NSTEMI
is what kind of pain, what levels are cardiac enzymes? does it have ECG changes?

Back 10

Acute; At Rest

+

Slight; T-wave inversions

Front 11

STEMI
is what kind of pain, what levels are cardiac enzymes? does it have ECG changes?

Back 11

Acute; At Rest

+

ST-segment elevation

Front 12

What cardiac enzymes do we check when look at ischemic heart disase?

Back 12

CK
(0 - 249 U/L)

CK-mb
(0 – 5 ng/mL)

Troponin
(0 – 1.5 ng/mL)

Front 13

Which enzymes are cardiac specific?

Back 13

ck-mb
tropinin

Front 14

What are 5 tools that we use for ischemic heart disease?

Back 14

Electrocardiogram (ECG)
Normal in most patients not presenting with acute attack

Exercise tolerance testing
Recommended for intermediate-risk pre-test probability

Cardiac imaging
Newer technology used to detect coronary perfusion and myocardial functioning

Echocardiography
Recommended if suspect valvular or myocardial dysfunction

Cardiac catheterization and coronary angiography
Gold standard for detecting presence and extent of disease

Front 15

what is the guideline that Combination of class of recommendation and level of evidence is from?

Back 15

ACC/AHA Guidelines

Front 16

What do the ACC/AHA guidelines classes mean?

Back 16

Class I, IIa, IIb, III
Benefit > Risk declines as you go from I – III
Class 1 far out weighs the risk

Front 17

What do the ACC/AHA guidelines evidence mean?

Back 17

Evidence A, B, C
Types of evidence and lots of lots of control studys
A = multiple RCTs with large numbers of patients
B = limited number of RCTs with small #s, observational studies, careful analyses of nonrandomized trials
C = Expert consensus

Front 18

What is the general approach to a patient with ischemic heart disease?

Back 18

Risk factor modification is #1 (weight loss, no etoh, if have hyperlipidemia add statin)
Aspirin - 1A every one should get it
β-blockers if prior MI - 1A - def should have a beta blocker
beta 1 selectives are preferred,:Acebutolol (Sectral®) Atenolol (Tenormin®) Betaxolol (Kerlone®, Betoptic®) Bisoprolol (Zebeta®) Esmolol (Brevibloc®) Nebivolol (Bystolic®) Metoprolol (Lopressor®, Toprol-XL®).
ACEI (if DM or LV dysfxn) - 1A
LDL-lowering therapy if LDL >130 mg/dL - 1A
SL NTG for immediate relief - 1B
CCB or LA nitrate if β-blocker contraindicated - 1B
Add CCB or LA nitrate if β-blocker monoTx unsuccessful - 1C

Front 19

B-Blockers decrease what 3 components? What do they improve? what do they reduce?

Back 19

↓ HR, ↓ contractility, slight/moderate ↓ BP
Improve symptoms ~80% of the time decrease signs and symptoms of angina
Improved exercise duration and delay ECG changes
Reduced oxygen demand

Front 20

What is HR goal with B-blockers?

Back 20

HR goal of 50-60 bpm
If pt is symptomatic at 70 bpm stop meds!

Front 21

What are SEs of B-blockers?

Back 21

Bradycardia
Heart Block
Dizzieness, tiredness, CNS (happens at first then goes away)
DON’T ABRUPTLY STOP! Angina episodes will be worse

Front 22

What do nitrate therapy alleviate inischemic heart disease?

Back 22

Alleviate episodes of angina quickly 5 to 15 minutes

Front 23

what do long acting oral or transdermal products do for ischemic heart disease?

Back 23

Prevention of symptoms with long-acting oral or transdermal products

Front 24

What are nitrate therapies MOA?

Back 24

Venodilation through NO-mediated mechanisms
Reduced myocadial oxygen demand

Front 25

What is a 1A recommendation for nitrate therapy in ischemic heart disease?

What can be added to therapy?

Back 25

SL NTG for immediate relief

Add to β-blocker therapy (1B) or can use if β-blocker therapy contraindicated or unsuccessful (1C)

Front 26

Fast-acting nitrates are given how?

How fast does pain relief come?

If not relieved in 20-30 minutes, suspect what?

Back 26

Sublingual given as 0.4mg

Pain relief in 5 minutes (75% of patients)

If not relieved in 20-30 minutes, suspect Acute Coronary Syndrome

Front 27

What are counseling points of fast acting nitrates?

Back 27

Keep in original container
Replace every 6 months (expiration date if un-opened)

Front 28

What are 3 Long-acting Nitrates and staring doses?

Back 28

Isosorbide mononitrate (ISMN) 20 mg daily or BID
Isosorbide dinatrate (ISDN) 5-20 mg TID
Transdermal NTG patch

Front 29

Long acting nitrates have half lives? VD size, clearnace, large variation in ___/___ levels

Back 29

Extensive first-pass, short half-lives, large Vd, high clearance, large variations in plasma/blood levels

Front 30

Where are ISMN and ISDN activated?

Back 30

ISMN and ISDN are activated in the liver

Front 31

What are long acting nitrates AEs?

Back 31

Postural hypotension
Headaches
Flushing
Nausea
Reflex tachycardia

Front 32

What happens with nitrate tolerance? How fast can it happen? How are ISMN, ISDN, and the patch dosed?

Back 32

Need 6-8 hours free
Can happen in first 24 hours
ISMN - dosed BID
ISDN - dose TID (not Q8hrs)
Patch - 12 hours on, 12 hours off

Front 33

Calcium channel blockers do what in ichemic heart disease?

Back 33

Direct vasodilation of systemic arterioles and coronary arteries

Front 34

What are the differences between DHP or non-DHP?

Back 34

DHP are different from non-DHP No heart block and no effects on HR
DHP has more edema (amlodipine, fedepine

Front 35

When do you add CCB in ischemic heart disease?

Back 35

Add to β-blocker therapy (1B) if unsuccessful or can use if β-blocker therapy contraindicated or unsuccessful (1C)

Front 36

what does Ranolazine (Ranexa®) inhibit? what does this decrease?

Back 36

Inhibits myocardial late sodium channels (INa) which decreases oxygen demand

Front 37

Ranolazine (Ranexa®) improves what in patients?

Back 37

Improves exercise time of about 15-45 seconds in placebo controlled trials
No benefit in mortality, MI, or recurrent ischemia

Front 38

Ranolazine (Ranexa®) is metabolized how? What will it interact with?

Back 38

Extensively metabolized via 3A4
Potent inhibitors will interact (azole antifungals, diltiazem, verapamil)

Front 39

Ranolazine (Ranexa®) carries the risk for what? How is it dosed?

Back 39

Carries the risk of QT-interval prolongation
Results in torsadin--> twisting of the points-->found on EKG arrhythmias
Dose: 500-1,000 mg BID

Front 40

What are 2 Nonpharmacologic Therapy for ischemic heart disease?

Back 40

Percutaneous Coronary Intervention (PCI)

Coronary Artery Bypass Grafting (CABG)

Front 41

What are advantages of PCI?

Back 41

Opens up blockage-->Restores coronary blood flow
Less invasive than CABG--> check where blockage is occuring

Front 42

What are disadvantages of PCI?

Back 42

Abrupt closure of vessel – arterial puncture or thrombosis of guidewire.
Re-stenosis
Ischemic complications

Front 43

What patients get CABG?

Back 43

Occlusion of Left Main coronary artery
Severe multiple vessel disease (>2)

Front 44

What are disadvantages of CABG?

Back 44

Invasive procedure – open chest wall, anesthesia
Infection – sternal wound and harvest site in leg

Front 45

What is used for Left main disease? what is the recommendation?

Back 45

CABG
PCI

I/A
III/C

Front 46

What is used for Left main disease, non CABG candidate

what is the recommendation?

Back 46

PCI
IIb/C

Front 47

What is used for 3 Vessel, EF <50%

what is the recommendation?

Back 47

CABG
I/A

Front 48

What is used for Multivessel, EF <50% or DM

what is the recommendation?

Back 48

CABG
PCI

I/A
IIb/B

Front 49

What is used for Multivessel, EF >50%
what is the recommendation?

Back 49

PCI
I/A

Front 50

What is used for 1-2 vessel, w/o proximal LAD involvement, large areas of ischemia on testing


what is the recommendation?

Back 50

CABG or PCI

I/B

Front 51

What is used for 1 vessel with proximal LAD

what is the recommendation

Back 51

CABG or PCI
IIa/B

Front 52

What is used for 1-2 vessel, w/o proximal LAD, small areas of ischemia

what is the recommendation

Back 52

CABG or PCI
III/C

Front 53

What is used for Insignificant stenosis

what is the recommendation

Back 53

CABG or PCI
III/C