Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
82 Cards in this Set
- Front
- Back
Angina pectoris
|
chronic condition characterized by episodic chest discomfort that occurs during transient coronary ischemia-- increased oxygen demands are not met.
|
|
Stable angina
|
attacks have similar characteristics and occur under the same circumstances always
|
|
Unstable angina
|
Attacks increase in frq and severity and often prelude MI
|
|
Variant angina
|
AKA Prinzmetal's angina. Due to acute coronary vasospasm and often occurs during rest or sleep. No relation to oxygen demand.
|
|
Myocardial infarction
|
Complete occlusion of coronary artery which can cause tissue death.
|
|
Characteristics of angina
|
Pain secondary to ischemia, sudden/severe/substernal pain which radiates to L shoulder. Induced by stress/exercise/emotion/eating/cold.
|
|
Why vasodilate to treat angina?
|
Increase perfusion to meet oxygen demands of the heart muscle.
|
|
Why decrease contractility of the heart as treatment of angina?
|
To decrease oxygen demand of the muscle-- make the heart work less.
|
|
Are B blockers effective treatment for variant angina?
|
NO-- cannot counteract vasospasm (cause of angina in this case)
|
|
Adjunct treatments for angina
|
Stabilize atherosclerotic plaques (statins), manage/treat modifiable RFs
|
|
First line tx typical angina
|
Beta blockers "olol" drugs.
|
|
MOA beta blockers
|
Block beta 1-- decrease HR, decrease BP, decrease contractility... decrease myocardial oxygen demand.
|
|
Indications B blockers
|
HTN, CHF, typical angina, MI, some arrhythmias, migraine
|
|
CI B blockers
|
sinus brady, SBP <100, heart block, cardio shock, ADHF. **If non-selective-- COPD, asthma, DM
|
|
DDIs B blockers
|
verapamil-- greatest potential for decreased contractility.
|
|
Titrated HR for B blockers
|
50 to 60
|
|
B1 selective agents
|
Metoprolol, Atenolol, Nebivolol
|
|
Non-selective B blockers
|
Propranolol, nadolol
|
|
a1/B blockers
|
Carvidilol, labetolol
|
|
MOA CCBs
|
bind to calcium ion channels in smooth muscle and cardiac tissue. Smooth muscle relaxation and suppression of cardiac activity. Decrease oxygen demand.
|
|
Indications CCBs
|
HTN, angina (*variant), arrhythmias
|
|
CIs non-DHP CCBs
|
SBP <100, HR <60, ADHF, EF <40%, AV block
|
|
Non-DHP CCBs
|
Verapamil, diltiazem
|
|
ADRs immediate release nifedipine/short acting CCBs
|
Increased risk MI, CHF, death due to CHD
|
|
Preferred tx for variant angina
|
non-DHP CCB
|
|
Non-DHP CCBs
|
Verapamil, diltiazem
|
|
DHP CCBs
|
Amlodipine, felodipine, nifedipine
|
|
Indication for CCB as monotherapy for angina
|
Pts w/ CI to BB
|
|
MOA nitros
|
release nitric oxide. diffusion into vascular smooth muscle cells. form cGMP. venous dilation. venous pooling. decrease preload. decrease ventricular diasolic vol. decrease ventricular pressure. decrease myocardial wall tension/oxygen demand
|
|
Main problem with chronic use of nitros
|
Tolerance develops
|
|
MOA high doses nitros
|
Arterial dilation, decrease PVR and afterload.
|
|
Indications nitros
|
angina, MI, CHF
|
|
CI nitros
|
aortic stenosis, concurrent use with other vasodilating agents.
|
|
Tx for reflex tachy due to nitro overdose
|
B blocker
|
|
Tx for HA refractory to nitro use
|
tylenol
|
|
DDI nitros
|
PDE 5 inhibtors-- severe hypotension/death. Isosorbide-- substrate.
|
|
Indication SL/PO nitro
|
relieve sx of acute myocardial ischemia, prevent effort enduced angina.
|
|
Indication long acting nitros
|
maintenance tx of angina
|
|
Formulations organic nitrates
|
Amyl nitrate (INH, X), nitroglycerine (SL/PO/IV/buccal/topical/TD, C), Isosorbide (PO/SL, C)
|
|
Amyl nitrate
|
Inhaled. Rapid onset. Brief DOA. Used for cyanide poisoning.
|
|
Storage of nitroglycerine SL/PO tabs
|
Dark, cool place in amber bottle-- deactivated by sun light.
|
|
Ointment form of nitroglycerine
|
Complicated use-- calibrated paper-- 1.5-2" Spread on chest wall TID w/ 8h free interval
|
|
Patch form of nitroglycerine
|
Available in several doses. Good for compliance. 0.1 to 0.8 mg/h dependent upon patch strength. On AM. Off PM.
|
|
PO form nitroglycerine
|
Must be administered QD or BID to minimize tolerance.
|
|
IV form nitroglycerine
|
Need special tubing-- Non-PVC. Must be nitrate free QHS. Acute use only.
|
|
MOA Ranolazine
|
Sodium current inhibitor
|
|
Indications Ranolazine
|
chronic stable angina in combo w/ CCB, BB, nitros.
|
|
CI Ranolazine
|
pre-exisitng QT interval prolongation, uncorrected hypokalemia, hepatic failure, drugs which prolong QT (FQs, psychotropics)
|
|
Precautions Ranolazine
|
Can prolong QT and induce Torsades de Pointes
|
|
ADRs Ranolazine
|
HA, dizziness, constipation, less effect on HR/BP. Prolong QT
|
|
DDI Ranolazine
|
CYP450 substrate
|
|
1st Line Adjunct tx angina
|
ASPIRIN
|
|
Role of ACE-I in angina
|
Help delay progression of CAD.
|
|
Goals of angina tx
|
Relieve acute sx, prevent ischemic attack, reduce risk MI/CV problems.
|
|
Tx occassional episodes of angina
|
SL NTG
|
|
Tx predictable episodes of angina upon exertion
|
SL NTG, isosorbide prophylaxis, BB can be used in reflex tachy
|
|
Tx frequent episodes requiring regular SL NTG
|
Long term NTG, BB, CCB. May need angioplasty or CABG
|
|
Preferred tx angina in asthmatics
|
non-DHP CCB, cardio selective BB
|
|
Preferred tx angina in DM pts
|
non-DHP CCB, nitrates/cardioselective BB are alternatives.
|
|
Preferred tx angina in heart failure pts
|
BBs/NTG most preferred. LEAST PREFERRED = non-DHP CCB-- decrease contractility.
|
|
Preferred tx angina in HTN pts
|
BB, non-DHP CCB
|
|
Preferred tx angina in pts w/ PMHx MI
|
BB
|
|
Preferred tx angina in pts w/ bradycardia/HB
|
DHP CCB
|
|
Goals of tx of acute STEMI
|
Limit infarct size, reperfuse obstructed coronary arteries, reduce morbidity and mortality, prevent post-MI cx
|
|
Pharm management STEMI
|
MONA Likes To Help STEMIs-- metoprolol/morphine, oxygen, nitros, aspirin/ACE-I, LMWH, tPA/thienopyridines, heparin, statin
|
|
Dose of aspirin for tx acute MI
|
162-325 mg PO stat. Continue with 81-325 mg PO QD indefinitely.
|
|
CI IV nitroglycerine in acute MI
|
SBP <90, HR <50.
|
|
Recommended window of use for IV NTG in acute MI
|
1st 24-48h
|
|
Dosing IV morphine in acute MI
|
2-4 mg/5min-- some pts req. 25-30 mg before pain subsides. Assists in vasodilation.
|
|
Adjunct analgesic tx to morphine
|
oxygen, NTG, reperfusion, BB
|
|
Recommended timing of initiation of BB tx in acute MI
|
start IV dose ASAP and continue post MI PO doses unless CI.
|
|
Rationale of use of BB as tx for acute MI
|
Reduction in morbidity and mortality-- reduces magnitude of infarct/incidence of assoc. cx in pts w/o tPA and reduce rate of reinfarction in pts w/ tPA
|
|
Effect of CCB on morbidity and mortality in tx of acute MI
|
None proven. Controversial use.
|
|
LMWHs approved for tx in non-Q wave MI
|
Enoxaparin and Dalteparin
|
|
# days thienopyridines are to be held prior to CABG
|
5 days
|
|
# days plavix should be added to meds post acute MI
|
14
|
|
MOA thrombolytics
|
plasminogen activator-- dissolve existing clots
|
|
Absolute CI of fibrinolytics in pts w/ MI
|
Previous hemorrhagic stroke, other strokes or CVA w/in 1 year, intracranial neoplasm, suspected aortic dissection, active bleed.
|
|
Relative CI fibrinolytics in pts w/ MI
|
Severe uncontrolled HTN (>180/110), recent trauma, head trauma, major surgery, pregs, active PUD, hx chronic severe HTN
|
|
MC thrombolytic used
|
Alteplase (tPA)-- 100 mg over 90 min total
|
|
Indication of statins for pts s/p acute MI
|
long term to delay progression of plaque formation, improves mortality
|
|
Indications for ACE-I in pts s/p acute MI
|
long term tx to delay progression and improve mortality.
|