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71 Cards in this Set
- Front
- Back
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Presents as:
Chronic Stable Angina Acute Coronary Syndrome (ACS) Unstable Angina (USA) Non-ST-Elevation MI (NSTEMI) ST-Elevation MI (STEMI) |
Ischemic Heart Disease (IHD)
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Atherosclerosis Risk Factors Lead to?
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Atherosclerosis Risk Factors Lead to Endothelial Dysfunction and Atherosclerosis
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Unalterable Atherosclerosis Risk Factors
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Gender
Age Family Hx Environmental DM |
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Alterable Atherosclerosis Risk Factors
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Smoking
Hypertension Obesity Hyperlipidemia Sedentary lifestyle Medications Alcohol Consumption Stress/Personality DM |
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Primary Prevention for CAD
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STOP SMOKING
Lower TC, LDL, Trig – per ATP III Raise HDL – per ATP III Lower High Blood Pressure – per JNC VII Control DM – per ADA and AACE Maintain a Healthy Body Weight Exercise – per AHA/ACC Reduce Stress Limit Alcohol |
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Recurrent chest discomfort associated with myocardial ischemia and dysfunction without death to the myocardium
Stable Plaque!!!!! Produced on exertion Fixed supply: symptoms with increased demand Relieved with NTG |
Stable Angina
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This is the sign that occurs when you see a patient present with a fist on their chest.
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Levine Sign
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What are the types of qualities associated with chest pain?
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Quality Pressure, Heavy Weight, Burning, Tightness, SOB, Deep, Gradual
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What are the types of radiation associated with chest pain?
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Radiation Left arm, Left shoulder, Jaw, Right arm, Back
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What types of duration are seen with chest pain in an ischemic attack?
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Duration ½ to 30 minutes
(> 30 minutes indicative of infarct!!!!!) |
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What precipitating factors can be associated with chest pain?
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Precipitating Factors Exertion, Cold, Fright, Anger, Coitus, Walking against wind
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How does chest pain typically react to NTG?
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NTG relief 45 seconds to 5 minutes
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What are the locations of chest pain?
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Location Sternum, Epigastria to Pharynx, Left shoulder or arm, Lower Jaw, Lower cervical or upper spine, Left interscapular/suprascapular, Rarely Right arm
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What are the subjective signs and symptoms of ischemia?
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CP
SOB DOE Diaphoresis Palpitations Lightheaded Impending Doom Nausea |
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What are the objective signs and symptoms of ischemia?
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HR
BP Vomiting Oxygenation ECG changes |
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What is a strong diagnostic to diagnose ischemic heart disease?
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Stress Test
Physical (ETT or Exercise Tolerance Test) Chemical Dobutamine Adenosine Persantine |
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What is a very bad sign in a physical stress test?
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If HR/BP go down
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What are two things to absolutely avoid if being given a chemical stress test via the chemical vasodilator adenosine?
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Don't drink coffee or be on theophyline
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Adenosine and Persantine should not be used in what patients when giving a chemical stress test?
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Don't use in patient's who are asthmatic.
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This is a chemical agent used in chemical stress test that blocks the break down of adenosine in the body?
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Persantine
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Which type of stress test provides the most information?
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Physical
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ACC/AHA Class I “A Must” Therapy
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ASA
HTN Management JNC-VII Smoking Cessation AHCPR DM Management ADA, AACE Exercise Lipid Lowering (LDL > 130) ATP III Weight Reduction |
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ACC/AHA Class II “Might be beneficial”
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Clopidogrel for patients that can not take ASA
Folate Therapy Treatment of Depression Stress Reduction |
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ACC/AHA Class III “Harmful”
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Hormone Replacement
HERS Trial, Women’s Health Initiative Chelation Therapy Vitamin E Annals of Internal Medicine Volume 142(1); January 4, 2005; pp 37-46 Vitamin C Garlic Acupuncture |
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are considered Class 1 by the ACC for
the treatment of Stable Angina |
Beta Blockers
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Beta-blockers are effective in the treatment of ANGINA because they
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they decrease heart rate, blood pressure, contractile force, and cardiac work load which reduces myocardial oxygen consumption, enhances coronary artery blood flow and improves myocardial perfusion
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Metoprolol tartrate (Lopressor)
Selectivity? Typical Dose? |
Beta-1
12.5-200 mg BID |
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Metoprolol Succinate (Toprol XL)
Selectivity? Typical Dose? |
Beta-1
50-400 mg daily |
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Atenolol
Selectivity? Typical Dose? |
Beta-1
25-100 mg daily |
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Carvedilol
Selectivity? Typical Dose? |
Beta-1 & Alpha-1
6.25-50 mg BID |
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Adverse drug reactions associated with beta blockers?
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Bradycardia
Hypotension Fatigue Masks insulin induced hypoglycemia Bronchospasm Alopecia Impotence Insomnia |
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These drugs are CYP 2D6 inhibitors that cause an interaction with beta blockers, there are three examples, what are they?
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CYP 2D6 Inhibitors
Cimetidine Fluoxetine Diphenhydramine |
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This drug when withdrawn causes an interaction with beta blockers.
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Clonidine-BP med
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If a patient has portal HTN what is an appropriate beta blocker to use?
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Propranolol
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This beta blocker lowers HR and helps to increase vasodialation.
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Carvedilol
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What considerations should be made with the following when giving beta blockers?
1.Bronchospasm 2.CHF 3.AV Block 4.Bradycardia 5.Depression 6.Renal Failure 7.MI 8.Clonidine |
1.Use with caution, beta-selective, lower doses
2.Toprol XL, Carvedilol (decrease mortality) – not for acute exacerbation 3.Generally contraindicated, Partial agonists 4.Generally contraindicated, Use with caution, Partial agonists 5.Avoid highly lipophilic agents, i.e. propranolol 6.Use caution with renally cleared agents or active metabolites, i.e. atenolol, propranolol 7.Improves morbidity and mortality 8.May exacerbate rebound HTN when abruptly stopped |
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are considered ACC Class 1
for the treatment of Stable Angina when: BB are contraindicated or can’t be used due to side effects (replace BB) In combo with BB, when BB alone is not effective (adjunct to BB) |
Long Acting Nitrates
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Increased cyclic-GMP ---- decreases intracellular Calcium ----smooth muscle relaxation
Mostly causes dilation to the veins and coronary arteries |
Nitrates
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IV Nitro
Onset Duration Initial Dose |
IV Nitro
Immediate 3-5 minutes 5 mcg/min |
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SL Nitro
Onset Duration Initial Dose |
SL Nitro
1-3 minutes 30-60 minutes 400 mcg q 5 min x 3 doses |
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Imdur
(mononitrate) Onset Duration Initial Dose |
Imdur
(mononitrate) 45-60 minutes ~12 hours 30 – 60 mg PO QD |
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Nitro Patch
Onset Duration Initial Dose |
Nitro Patch
30-60 minutes 8-10 hours 0.1-0.4 mg/hour QD |
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Nitro Paste
Onset Duration Initial Dose |
Nitro Paste
15-60 minutes 2-12 hours ½-2 inches TID-QID |
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This form of nitrate does not cause major hemodynamic changes
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Transdermal preps do not cause major hemodynamic changes
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This form of nitrate can be used in place of a beta blocker, it is a salt that lasts longer, it doesn't cover nights and it is also good if you need something not to drop HR and blood pressure.
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Imdur
(mononitrate) |
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What is associated with nitrate tolerance?
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“Tachyphylaxis”
Reduction in tissue C-GMP Decreases conversion of organic nitrates to NO Occurs within 24 hours of continuous therapy Nitrate free period: 8-12 hours “Silent ischemia” |
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You can't take nitro with these drugs because it can lead to ischemia and death?
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Sildenafil (Viagra) as well as other ED medications.
Antihypertensives are also discouraged with nitrate therapy. |
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What are the typical adverse effects of nitrates?
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HEADACHE
Hypotension Syncope Lightheadedness Flushing Nausea Increased urination |
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are considered ACC Class 1
for the treatment of Stable Angina when: BB are contraindicated or can’t be used due to side effects (replace BB) In combo with BB, when BB alone is not effective (adjunct to BB) |
Calcium Channel Blockers
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CCB
Reduces frequency/severity of attacks by 75% - Reduces nitrate consumption by 70% - Improves exercise tolerance - Improves ECG evidence of ischemia - Up to 80% of patients controlled pain-free on monotherapy |
Amlodipine
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CCB
increases myocardial oxygen supply and reduces myocardial oxygen demand secondary to decreasing heart rate and afterload (Opie, 1980). Verapamil efficacy in variant angina is secondary to its ability to increase myocardial oxygen supply, whereas in angina of effort, beneficial effects are secondary to reduced myocardial oxygen demand. |
Verapamil
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CCB
include a dose-related reduction in myocardial oxygen consumption, cardiac work, blood pressure, and heart rate Reflex B stimulation – counteracts much of negative inotrope effect |
Diltiazem
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Which CCB is a great antianginal?
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Amlodipine
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What is the typical dose regimen for CCB amlodipine?
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2.5-10mg PO qd
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What is the typical dose regimen for CCB Verapamil?
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80mg PO TID
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What is the typical dose regimen for Diltiazem?
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180-360mg daily
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This CCB is not good for anyone with heart failure?
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Verapamil
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What is a very common adverse drug effect with CCB?
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Peripheral edema
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What are adverse effects with Diltiazem/verapamil
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Bradycardia
AV block Hypotension CHF exacerbation Constipation |
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What are adverse effects with Amlodipine
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Dizziness
Headache Peripheral edema Hypotension Consitpation |
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What are drug interactions associated with CCB's?
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Antihypertensives
Diltiazem CYP 3A4 substrate and inhibitor CSA, cimetidine, ERY… Verapamil CYP 3A4 inhibitor |
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Improve endothelial function
Decrease morbidity and mortality in high risk patients HOPE Trial New AHA Guidelines for BP lowering First line HTN treatment (in combo with BB) for patients with known CAD Decreases remodeling post-MI ARB is an alternative if unable to tolerate |
ACEI
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All patients with CAD and DM, LV
Dysfunction (heart failure) and/or HTN* should be on an ? |
ACEI
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What are the adverse reactions associated with ACEI?
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Adverse Reactions
Cough (5-20% of patients) Hyperkalemia Rash Loss of taste Angioedema (0.1-1% of patients) Hypersensitivity Contraindicated in 2nd and 3rd trimester of pregnancy Contraindicated in Bilateral Renal artery stenosis |
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What is important to know about ACEI and pregnancy?
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Contraindicated in 2nd and 3rd trimester of pregnancy as well as in people trying to get pregnant
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What is an adverse effect of ACEI that you have to vigilant for because it can cause a decrease in GFR that can cause serious problems?
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Hyperkalemia
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What are the monitoring parameters for a patient on ACEI?
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BP
BUN, SCr, K Symptoms of adverse effects Cough Angioedema Etc… |
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Anti-inflammatory properties
Plaque stabilization Reversal of endothelial dysfunction Inhibition of monocyte recruitment Decreased thrombogenicity |
Statins
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In addition to ACEI, what helps protect endothelial health?
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Statins
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This can help to increase HDL by up to 35%
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Niaspan – extended release niacin
500 mg qhs May increase in 4 wk intervals up to a max of 2000 mg* |
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All in all, what agents would you add for a patient with stable angina?
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Aspirin
Beta-blocker ACE I (CAD with DM, LV dysfunction, and/or HTN) LDL lowering therapy (statins) SL Nitroglycerin CCB and/or long-acting NTG to replace BB (BB contraindication or side effects) CCB and/or long-acting NTG as adjunct to BB (BB ineffective alone) |
