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104 Cards in this Set

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what are the other names for CAD?

ischemic heart disease IHD or coronary artery disease CHD

what disease does CAD include?

stable/unstable angina and MI


define atherosclerosis. how is it related to CAD?

a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls...CAD is caused by the narrowing of arteries by atherosclerosis

define chronic stable angina

chronic occurrence of chest discomfort due to transient myocardial ischemia with physical exertion or other conditions that increase oxygen demand

what can CAD cause?

chronic stable angina or acute coronary syndrome

what consists of acute coronary syndrome? how does it all start

unstable angina and MI, comes form the rupture of atherosclerosic plaque

Describe how patients find out they have CAD?

Half have chronic stable angina the other half will have an MI

What are the main coronary arteries? what do they break up into?

left main and right coronary artery. the left main splits into the left anterior descending and the circumflex

what is prinzmetals angina?

vasospasm that causes a narrowing of the coronary arteries, not caused by atherosclerosis

what are the modifiable risk factors for CAD?

smoking, dyslipidemia, diabetes, HTN, physical activity, obesity, low consumption of fruit and veggies, alchohol

what are the non modifiable risk factors for CAD?

age greater than 45 for men, age greater than 55 for women, men or postmenopausal women, family history of premature CAD (aka first degree relative had it if male was less than 55 or female was less than 65)

what determines oxygen supply to the heart?

arterial P02, diastolic filling time (shorter), plaques vasospasm or thrombus

what determines oxygen demand/consumption

HR, contractility, ventricular wall tension (and this depends on BP, volume, wall thickness)

when exactly will you experience the symptoms of chronic stable angina?

during exercise or when atherosclerotic plaque occludes 50-70% of coronary artery

how much do unstable plaques occlude an artery?

asymptomatic, occlude less than 50%

Describe the quality, location, duration of CAD?

pressure/tightness/pain, anterior or chest (neck jaw shoulder and back of arm), several minutes

what can accompany CAD pain? what can make it worse?

dyspepsia, nausea, vomiting, diaphoresis


big meals or cold

how would cardiac enzymes appear for a chronic stable angina patient?

normal

what does a stress test, test for? what do you do if it is positive? what does that test look for?

monitor EKG for signs of ischemia during exercise


undergo coronary angiography


visualize coronary anatomy to identify narrowing of coronary arteries due to atherosclerotic plaques



how can you determine between chronic stable angina and acute coronary syndrome?

CSA is experienced in a pattern and is reproducible with exertion


ACS has prolonged symptoms that are unexpected and unrelieved by NTG

what are the 6 treatment goals of treatment?

prevent ACS/death, alleviate acute symptoms, prevent progression, reduce complications, minimize adverse treatment effects, prevent recurrent symptoms

what drugs are used to treat chronic stable angina and reduce oxygen demand of the heart?

short acting nitrates, BB, CCB, LA nitrates

what are the treatments that increase oxygen supply of CSA?

PCI which is subcutaneous coronary intervention or angioplasty


CABG which is coronary artery bypass grafting

describe PCI surgery

catheter into blood vessel into coronary artery, balloon inflation which is usually followed by stent placement

three disease states that are major risk factors for CAD?

htn, dm, dyslipedmia

what drugs are used for acute coronary syndrome?

anti-platelet agents, statins, acei/arb, SA NTG

what should you give if a patient cannot not take ASA?

clopidegrel

when is dual antiplatelet therapy used?

following acute coronary syndrome or PCI with stent placement

when can you use anti-platelet agents for primary prevention?

if they have a history of CAD

who should receive a statin? what else should all these patients get?

all patients with CAD regardless of baseline LDL


a ACE or ARB

what should all patients with angina be prescribed?

NTG

should patients take NTG before exercise?

not recommended, no studies and may cause more dizziness

what should be used for patients that have frequent angina?

BB, CCb, or LA nitrates

what happens when a nitrate is combined with a PDE inhibiotr?

severe hypotension which can reduce blood flow to vital organs

what are the SL NTG counseling points?

use in seated position, call 911 if symptoms do not improve/worsen after 5 minutes of the dose, store in glass container, do not store in the same container as other meds, no long term S/E do not hesitate to use, do not sue if sidenafil/vardenafil in 24 hours or tadalafil in 48 hours

do BB prevent cardiac arrhythmias?

yes but only during the time around an acute coronary syndrome event

are BB good for long term?

no there is no mortality benefit

what are the contraindications for BB

bradycardia less than 50bpm, asthma/copd, depression

can BB be abruptly stopped?

no, taper if they are hemodyamically stable, but you can d/c completely if they have hypotension or bradycardia

what CCB's are best to use?

verapamil and diltiazem

what drug can be combined with a DHP CCB to prevent reflex tachycardia?

BB

what should be used first, a BB or a CCB?

use a BB first unless intolerable, then go for the CCB

a patient is using a BB but still has angina symptoms, what should you do?

add a LA DHP CCB

what should be used to treat prinzmetals angina?

CCB's over BB

what are the better CCB's to use if you have HF?

ammlodipinde or felodipine, they have less negative inotropic effects

what should never be used to treat angina?

short acting nifepidine or nicardipine

how do you avoid tolerance of nitrates?

do not use them for 8-12 hours during the day

why do we avoid nitrate monotherapy?

reflex tachycardia and increase o2 consumption, and you will not be protecting during the off time

can you use monotherapy nitrates in those with low BP?

yes

why is ranolazine last line?

excessive cost and can cause QT prolongnation

should a women with acute coronary syndrome recieve HRT?

no, can increase thromboembolic events

what NSaid should a patient with CAD use for a headache?

naproxen only for shortest duration possible

how should you administer aspirin and an nsaid?

nsaid at least 30 mins after the aspirin or 8 hours before the aspirin

what should be avoided in variant angina?


what should be used?

BB b/c it can worsen vasospasm


use CCB or nitrate

what should you monitor for CSA patients?

symptoms, BP, HR, risk factors, kidney function, adherence, drug therapy

what is essential in patient education?

what to do if anginal symptoms occur and when to seek emergent care

what is the underlying cause of acute coronary syndrome?

the rupture of an atherscelortic plaque and eventual clot formation

what is a STEMI? what is usually done if a patient has one?

it is an MI characterized by ST elevation (flat part) on an EKG




reperfusion therapy with PCI within 12 hours of symptom onset

what drugs should a STEMI patient receive?


Anything else if they undergo PCI?

intranasal O2, SL NTG, ASA, P2Y inhibitor (clopidorgrel, prasugrel, ticagrelor), and an anticoagulation




add a GPIIb/IIIa inhibitor(abciximab or tirofiban) and UFH if undergoing PCI

are the drugs used for the treatment of NSTEMI any different?

initial therapy is the same but P2Y inhibitor is not used until later

what drugs should all STEMI/NSTEMI patients receive indefinitely?

ASA, BB ACEI and may add statin

Under what conditions do you use PY2 inhibitor for a year?

if patient undergoes PCI, or had a NSTEMI

Under what condiitions would you use PY2 inhibitor for 14 days?

non-PCI treatments and STEMI

what proteins cause platelet adhesion and activation?

Tissue factor and collagen on exposed smooth muscle

Why is ventricular remodeling bad? What drugs can slow it?

can lead to HF, ACEI, ARBS, B and aldosterone antagonists can work

What may indicate ACS on an EKG?

ST elevation, ST depression or t-wave inversion

what are the two cardiac biomarker? which one is preferred?

troponin and CK-MB




Troponin is preferred

How should be troponin be checked?

once in ED, then 6-9 hours later, and again 12-24 hours later if negative on the first two



What should be done as soon as ST elevation is observed? How long can you wait for the treatments/

fibrinolytics within 30 mins or PCI within 90 mins?

Short term goals for ACS?




long term

restore blood flow, prevent further cardiac injury, prevent death , relieve chest discomfort




reduce modifiable risk factors, prevent CV events, improve QOL

General approach of treating an ACS?

oxygen, avoid valsalva maneuver, pain management, chew ASA, anticoagulant, continuous EKG monitoring, and vital signs

what are the anticoagulants used?

UFH, enoxaparin, or bivalirudin

when do you call a PCI secondary?

after 12 hours since symptom onset

what is the goal door to balloon time for STEMI?

less than or equal to 90 minutes

what is different about PCI in NSTEMI?

usually do angiography first

what is the other term for PY2 inhibitors?

thienopyridine

the contraindications of fibrinolytics are?

acute internal bleeding, previous intracranial hemorrhage or ischemic stroke in the last 3 months, intracranial neoplasm, vascular lesions, aortic dissection, closed head or facial trama in the last 3 months

what is the treatment option if PCI is not done for STEMI? how quickly should this be done?

use fibriolytic, door to needle time is less than or equal to 30 minutes

what are the fibrinolytics?




Of these, which one is not preferred?

alteplase, reteplase, tenecteplase, and streptokinase




streptokinase, has worse outcomes

what P2Y inhibitors are prodrugs

clopidogrel and ticagrelor

For patient who do not undergo PCI and could get a fibrinolyti, what is the door to needle time?

less than 30 mins

what are the indications for ASA?

prevent stent thrombosis, reduce risk of death, recurrent MI and stroke

How soon should patient with ACS get ASA?

within 24 hours of hospital admission

what are common drug interactions of with the thienopyridines?

NSAIDs and Warfarin

What is prasugrel contraindicated in? why?

patients with prior CVA or TIA due to increased risk of intracranial hemorrhage

how long should clopedigrel be used for if ACS and noninvasive strategy (thrombolysis)?

1 month but should go for a whole year

how long should clopedigrel be used for if STEMI and treated with thrombolytic?

14 days but should go for 28 days

what kind of stent should you use if there is a good chance the patient wont be compliant?

use a bare metal for low adherent patients



how long should you wait to have surgery if you had a bare metal stent placed?




what about a drug eluting stent?

delay surgery for 4-6 weeks after BMS




Delay surgery 12 months after DES

If you have a CABG coming up and you are on clopidogrel, how long before surgery should you stop using it?




what if you were on prasugrel?

5 days pre op




7 days pre op

what thienpydrodine is dose twice a day?

ticagrelor is BID all other are QD

what are the glyoprotein IIB/IIIa receptor inhibitors?




what is the MOA?

abciximab, eptifbatide, and tirofiban




prevent cross linking between the IIb/IIIa receptors on platelets

what gp IIb/IIIa receptor inhibitors get redosed based on kidney function?

eptifibatide and tirofiban

when are the gp IIa/IIIb inhibtors most commonly used?

in combo with UFH following PCI

What are the anticoagulants?




which ones do you need to watch kidney function?

UFH, enoxaparin, bivalirudin, and fondaparinux (not used in stemi)




enox, biva, fonda

what may be better than the UFH gp IIb/IIIa inhibitor combo for post PCI?

bivalirudin, and it is cheaper

when are anticoagulants usually discontinued?

following PCI, may use 2-3 days if ACS w/o reperfusion

common side effect of nitrates? what is done to combat this?

headache, use APAP

when should a patient call 911 when refering to NTG use?

if their angina/discomfort is not resolved within 5 minutes after the first dose

do ACS patients usually get CCB's? When do they?

no, only if discomfort persists despite nitrate use and contraindication of BB




aka use BB first

when should you use an aldosterone antagonist?

when patient is on ACE and BB and LVEF (left ventricular ejection fraction) is less than or equal to 40 percent

what is the main difference in treating Stemi versus nstemi?

nstemi acs do not get fibrinolytics

what are the long term goals following MI?

control modifable risk factors, prevent HF, recurrent MI or stroke, death, stent thrombosis after PCI

what should all these patients get

statin, asa, bb, acei