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90 Cards in this Set
- Front
- Back
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What causes IHD?
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Plaque buildup that results in an imbalance between blood supply and demand
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What is a sign of mycardial ischemia?
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Chest pain
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What is CHD and the results of it?
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Coronary heart disease is atherosclerotic narrowing of one or more coronary artery
Results in ACS (unstable angina, acute MI) Sudden cardiac death Chronic stable angina (angina pectoris) |
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What is the single leading cause of death in the US?
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CHD/IHD
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What are the etiologies of chronic angina?
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Atherosclerosis
Mitral stenosis Aortic stenosis Hypertrophic cardiomyopathy HTN |
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What is systolic (intramyocardial) wall tension?
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Tension w/n the heart wall
affected by changes in ventricular volume and pressure |
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What is preload?
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The initial stretching of the cardiac myocytes just prior to contraction
Ventricular EDV |
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What is afterload?
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The "load" or pressure that the heart must eject blood against
Systemic vascular resistance (SVR) |
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What does the double product calculate?
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Myocardial Oxygen demand (MVO2)
DP=SBP*HR |
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Which artery is the major blood supply in the heart?
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Left Main coronary artery
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Stable angina is what type of lesion?
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Stenotic compensated lesion
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Nonstenotic lesions lead to?
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MI
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T/F:
Angina can occur w any degree of stenosis |
True
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When is stenosis considered clinically significant?
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When 50% of the left main or 75% of the other major coronary arteries are blocked
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When stenosis is >90% there is virtually no ______
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When stenosis is >90% there is virtually no _flow_
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What is Prinzmetal?
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Vasospasmic or variant angina
imbalance of autonomic control |
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What happens in an ECG during prinzmetal?
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ST segment elevation
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Who and when does prinzmetal usually occur?
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Younger pt usually during night and early morning hours
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T/F:
Prinzmetal can potentially cause arrythimias and sudden cardiac death |
True
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What are some nonmodif. risks of stable angina?
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Fam Hx of premature CV events
Age M>45 F>55 or premature menopause |
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What are some mod. risk factors for stable angina?
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Dylipidemia, DM, HTN, seditary LS, obesity, Smoking
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What are some accompanying SxS of stable angina?
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N/N, dypsnea, tachycardia, diaphoresis, syncope
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What type of heart sound variations could be present in stable angina?
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decrease intensity of S2 (decrease in LV contractility)
S4 (atrial gallop, reduced ventricular compliance) |
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What are the classifications for Angina?
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I: angina w strenuous exercise
II: w/ >1 flight of stairs or 2 bks III: w/ >1 flight or 2 blocks IV: minimal activity or rest |
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What are some other causes of chest pain that isnt angina?
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Nonischemic CV
Pulmonary GI Psychiatric |
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What test are used in the diagnosis of angina?
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ECG, ECHO, exercise stress test, angiography
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T/F:
Every pt w angina has abnormal ECG |
False only about 50% present w an abnormal ECG
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What are the goals of therapy in pt with stable angina?
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decrease chance of ACS
increase QOL by relieving and preventing Sx |
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What are some lines of tx for stable angina?
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Revascularization
Rx TLC |
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When should revascularization technique PCI be used?
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Pt w multiple vessle disease and NORMAL LV fxn or when meds fail
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When should revascularization technique CABG be used?
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When theres sign disease of L main or multiple vessel, and abnormal LV fxn or when meds fail
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What are the ABCDE of angina?
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A- ASA or antianginal
B- BB and BP C- Cholesterol/cigarettes D- Diet and DM E- Education and exercise |
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What is the goal of anti anginal?
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improve exercise capacity
reduce exercise induce ST segment changes decrease frequency of Sx |
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What are antianginal tx?
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BB
CCB (DHP and NDHP) Nitrates |
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T/F:
BB affect myocardial O2 supply |
False
DO NOT effect O2 supply! |
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What effects do BB have on the demand of the heart?
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Decrease:
HR, Contractility, SBP Increase: LV volume |
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What effects do DHP CCB have on the demads of the heart?
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Decrease:
Contractility (can increase), SBP, LV vol. (can increase) Increase: HR |
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What effects do NDHP CCB have on the demand of the heart?
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Decrease:
HR, contractility, SBP, LV vol |
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What effects do nitrates have on heart demand?
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Decrease:
SBP, LV volume Increase: HR Dont effect contractility |
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What is the 1st line of tx for pt w/o contraindication in stable angina?
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BB
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BB used in angina are good for what population of pt?
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PT with limited exercise capacity due to agina
HTN Anxiety Surpavascular arrythmias HF post MI |
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What type of drug selective in available in BB?
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Cardioselective -B1 selective
(metropolol, atenolol) Nonselective- (propanolol, nadolol) Alpha2 B blockers- (carvedilol, labetalol) |
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Which BB should be avoided in angina that have ISA? why?
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Acebutolol and pindolol
can increase BP and HR |
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What are the dosings for atenolol and metopolol?
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Atenolol: 25-100 mg 1-2/day
Metopolol: 25-400mg 1-2/d (use long acting doses in both) |
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What are the contraindications for BB?
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HR<60 bpm
SBP<100mmHg AV block (PR prolongation) Sick sinus syndrome Acute decompensated heart failure |
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When should precautions be taken BB?
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Reactive airway disease
Systolic heart failure DM PVD |
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What are some ADRs of BB?
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Hypotension
Bradycardia Hyperglycemia Dyslipidemia Sexual dysfuction Nightmares Fatigue Worsened claudication |
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What are the 2 NDHP CCB?
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Verapamil Diltiazem
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What are the 3 DHP CCB?
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Nifedipine
Amlodipine Felodipine |
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When should a NDHP CCB be used in stable angina?
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When a BB is contraindicated or not tolerated, use as monotherapy from BB
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When should a DHP CCB be used in stable anggina?
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Should be used in COMBO with BB when initiall tx w BB is not successful
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Can CCB be used in combo w long acting nitrates?
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Yes but avoid short acting
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When are CCB good to Rx a pt w stable angina?
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If the pt has:
intolerance/contraindications to BB Vasospastic angina* Severe PVD asthma* Uncontrolled DM* depression* LV dysfxn (amlodipine or felodipine only) |
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What are the dosing for the NDHP CCB?
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Verapamil SR: 120-480mg/d
Diltiazem SR: 90-360mg/d |
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What are the dosing for the DHP CCB?
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Amlodipine/Felodipine: 2.5-10mg/d
Nifedipine SR: 30-120 mg/d |
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When are CCB contraindicted?
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SBP<100
HR<60 (verapamil and diltiazem) AHF (LV dysfxn, NDHP) EF<40% (LV dysfxn, NDHP and nifedipine) AV block (NDHP) |
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What are some precautions taken in the use of CCB?
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Use of NDHP w BB
Verapamil is a CYP3A inhibitor*********** |
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What are some ADRs of CCB?
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Hypotension
DHP: HA, flushing, Peri edema NDHP: bradycardia, dizziness, heart block, worsening HF, constipation (verapamil) |
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What should be monitored in NDHP?
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HR
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What sort of education should you conseul a pt on?
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Checking pulse
dizziness constipation |
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T/F:
Nitrates have antithrombic and antiplatelet effects |
True
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What is the main use of short acting nitrates?
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Relieve acute sx of myocardial ischemia
Prevent effort induced angina |
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What are the dosings for short acting nitrates?
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0.3-0.4mg Q 5 min until EMS or relief
Take one call 911 Dont exceed 3 doses in 15 min |
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What are some pt education points for short acting nitrates?
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Sitting or standing may enhance effect
Store in original package (cool dry space) Replace tab every 3-6 months after opening Sprya has a longer shelf life (3 yrs oppose to 6 months) apply under or onto tongue Preemptive dose if Sx anticipated, esp in morning Remove plug and cotton Do not mix w other meds |
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What is the dosing for long acting nitrates?
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Isosorbide mononitrate SR: 60-240mg QD
onset 30 min duration 6-8 hrs Isosorbide mononitrate: 10-20mg BID (7hrs apart) Isosorbide dinitrate: 5-60mg TID@ 8-1-6 or BID@ 8-4 onset 15-30min last 3-6 hrs |
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What should pts know about the ointment formulation of a long acting nitrate?
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1/2-2" dose
TID w 8 hr or 12 hrs on 12 hrs off Spread onto chest in a thin layer Keep area covered w app. paper Wipe off previous dose before next dose or if hypotensive |
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What should pts know about the patch formulations of long acting nitrates?
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Needs to be 12 hr on and 12 hr off
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What are some ADRs of long acting nitrates?
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HA
flushing postural hypotension reflex tachycardia |
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What are the contraindications of nitrates?
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Aortic valve stenosis
obstructive cardiomyopathy concurrent use of PDE inhibitors (viagra, cialias, levitra) PDE inhibitors prevent degradation of cGMP which can result in severe hypotension in pts using both Viagra/Levitra wait 24 hrs Cialis wait 48 |
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What should be given in a pt w stable angina who has:
HTN Prior MI LV dysfxn Bradycardia/AV block DM Asthma What should be avoided? |
What should be given in a pt w stable angina who has:
HTN- BB, NDHP Prior MI- BB LV dysfxn- BB, amlopdipine Bradycardia/AV block- DHP, LA nitrate DM-NDHP, LA nitrate, CSBB Asthma- NDHP, CSBB What should be AVOIDED: HTN Prior MI- CCB LV dysfxn- other CCB Bradycardia/AV block-NDHP, BB DM- NCSBB Asthma-NCSBB |
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What is the MOA of Ranolazine?
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Not really known, thought to reduce FA and oxidation increasing glucose oxidation
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What is the indicated use of Ranolazine?
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Tx of chronic stable angina in pts who failed to respond optimally to or intolerant of other antianginal agents
1st line in DM |
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Can Ranolazine be used in combo w other antianginal drugs?
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Yes EXCEPT NDHPs*
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What is the dosing of Ranolazine?
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500-100mg BID
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What are the ADRs of ranolazine?
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QT prolongation
dizziness constipation Nausea HA Asthenia dypepsia Ab pain |
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What are the contraindications of Ranolazine?
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Preexisting QT prolongation
Drugs that prolong QT segement or CYP3A4 inhibitors Uncorrected HYPOkalemia Hx of ventricular tachycardia Hepatic impairment |
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Should ranolazine be used w precaution in renal impariment?
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Yes
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What should be monitored when a pt is taking ranolzine?
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ECG, LFT, SCr and BUN, SMg and Spotassium
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What agents prevent ACS and slow the progression of CHD?
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ACEI
Antiplatelet Lipid lowering |
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When should ACEI be used?
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All pt with CAD and DM or LV dysfxn or both
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Do ACEI relieve the Sx of angina?
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No
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What drug is used in all pt who have IHD as long as theres no contraindications?
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ASA
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What is the drug dosing for ASA?
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81-325mgQD
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What is given in place of ASA if the pt has an allergy?
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Clopidogrel or Prasugril
Both 75mgQD |
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What are the ppx antianginal tx?
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BB, CCB, LA nitrates
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What should be monitored and documented on a followup evaluation of a pt w stable angina?
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Sx frequency
Severity NTG use Physical activity intolerance, CCS classificatio Med adherence and tolerance risk factor mods |
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What tx relieves acute Sx of myocardial ischemia?
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SA nitrates
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What tx prevents sx of myocardial ischemia?
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BB, CCB, LA nitrates, ranolzine
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What tx prevents unstable angina and MI?
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ASA, clopidogrel, ACEI
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What tx prevents the progression of atheroschlerotic lesions?
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Lipid lowering tx
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