Ischemic Heart Disease Therapies

Question 1

SL NTG indication

Answer 1

if anginal attacks are infrequent or use prior to activities that cause angina

Question 2

storage of SL NTG

Answer 2

original container, replace tablets every 6 months and spray every 3 years

Question 3

how to take SL NTG

Answer 3

sit down and dissolve under tongue, may repeat up to three doses every 5 minutes and call 911 if pain is not relieved

Question 4

beta blocker indications

Answer 4

chronic prophylaxis for patients with 1 or more anginal episodes per day

Question 5

how do beta blockers work for angina

Answer 5

decreases HR and contractility therefore decreasing oxygen demand

Question 6

beta blockers treatment goal

Answer 6

resting HR between 50-60 BPM and max exercise HR of 100 bpm

Question 7

additional protective effects of beta blockers

Answer 7

antiarrhythmic and may slow the progression of plaques

Question 8

mechanism non-DHP calcium channel blockers for angina

Answer 8

decrease HR and contractility, decreasing the oxygen demand

Question 9

mechanism of DHPs for angina

Answer 9

decrease afterload, decrease oxygen demand

Question 10

when to avoid non-DHPs

Answer 10

concomitant beta blocker and severe LV dysfunction (HFrEF)

Question 11

when to use a CCB over a beta blocker

Answer 11

beta blockers are first line because of their additional anti-arrhythmic benefits

Question 12

long acting nitrate indications

Answer 12

a third line agent for anginal chest pain (equal to CCBs) that can be used as a substitute or in addition to a beta blocker

Question 13

nitrate intolerance

Answer 13

nitrate intolerance is when there’s a lack of efficacy after consistent exposure, must provide a 10-14 hour nitrate free period (usually during sleep)

isosorbide dinitrate is usually dosed TID every 6 hours so that there isn’t any drug at night, isosorbide mononitrate is dosed in the morning and wears off at night

the idea is to give the patient the nitrate free period while they are asleep and unable to feel any chest pain

Question 14

ranolazine MOA

Answer 14

inhibits persistent/late inward Na current in the ventricles which will decrease contractility

Question 15

ranolazine effect on HR and BP

Answer 15

ranolazine has no effect on HR or BP

Question 16

AEs of ranolazine

Answer 16

QT porlongation

Question 17

metabolism of ranolazine

Answer 17

CYP3A4, 2D6, and pGp

Question 18

if a patient has diabetes and IHD, list the three agents that can be used to get dual benefit

Answer 18

1. metformin
2. GLP 1 antagonists (dulaglutide, liraglutide)
3. SGLT2 inhibitors (empagliflozin, canaglifozin)

Question 19

pneumonic for medical treatment of acute ACS (NSTEMI and UA)

Answer 19

O - oxygen
S - statin
N - NTG
A - aspirin
A - anticoagulant
P - P2Y12 inhibitor

Question 20

indication for oxygen in ACS

Answer 20

only if the patient has an arterial oxygen saturation less than 90%, if the patient is in respiratory distress, or has other high risk features of hypoxemia

Question 21

dosing for a statin during ACS

Answer 21

initiate or continue a high intensity statin in all patients, earlier the administration the better!

atorvastatin 40/90
rosuvastatin 20/40

statins have significant pleiotropic effects and can help to stabilize an thrombus in the coronary artery

Question 22

dosing for NTG in treatment of ACS

Answer 22

SL NTG every 5 minutes for 3 doses, then assess need for IV NTG. Administer IV NTG for persistent ischemic, HF, or HTN

Question 23

nitrate contraindications

Answer 23

recent use of phosphodiesterase inhibitor (sildenafil/avanafil = 24 hours, tadalafil = 48 hours): reason for the contraindication is that these PDE5 inhibitors work on the same pathway as NTG and can cause profound HTN so severe the patient loses a pulse

Question 24

dosing for aspirin in treatment of ACS

Answer 24

should be CHEWED
should not be enteric coated
162-325mg loading dose immediately for quick administration and action

Question 25

dosing for anticoagulants for the treatment of ACS

Answer 25

IV unfractionated heparin for 48 hours or until PCI is performed OR subcutaneous enoxaparin for duration of hospitalization or until PCI is performed

Question 26

loading doses of P2Y12 inhibitors for the treatment of ACS

Answer 26

ticagrelor (Brilinta) 180mg x 1 | clopidogrel 600mg x 1

Question 27

maintenance doses of P2Y12 inhibitors

Answer 27

patient should be on P2Y12 inhibitor for 12 months after UA or NSTEMI: ticagrelor: 90mg BID clopidogrel 75mg daily

Question 28

why is ticagrelor preferred over clopidogrel

Answer 28

preferred because it has increased amount of platelet inhibition and better cardiac outcomes

Question 29

what's the P2Y12 inhibitor for PCI

Answer 29

prasugrel, ONLY used if the patient has a PCI/catheterization!

Question 30

loading dose of prasugrel

Answer 30

60mg x1

Question 31

maintenance dose of prasugrel

Answer 31

10mg daily

Question 32

mechanism of GIIB/GIIIA inhibitors

Answer 32

potent antiplatelet agents that block the binding site for fibrinogen, increase patient's bleeding risk

Question 33

pneumonic for LONG TERM treatment of ACS

Answer 33

SNAP BAM

Question 34

what are the drugs in BAM for long term treatment of ACS?

Answer 34

B- beta blocker for at least three years or indefinitely A- ACEi/ARB indefinitely M- mineralocorticoid receptor antagonist indefinitely

Question 35

indication for beta blockers

Answer 35

long term treatment in all patients after ACS, any beta blocker is okay unless the patient has HF (should use metoprolol succinate, carvediol, or bisoprolol)

Question 36

indication for ACEi/ARBs

Answer 36

long term treatment of ACS for patients who have LVEF less than 40% and those with HTN, diabetes, or stable CKD. May use ARB instead of ACE in patients who are intolerant. HOPE trial shows mortality benefit in patients with a normal EF, if the patient can tolerate, the patient should receive! If the patient can't tolerate BB and ACEi/ARB, use only BB.

Question 37

indication for mineralocorticoid receptor antagonist

Answer 37

long term treatment of ACS, spironolactone or eplerenone, patients with an EF <40% who are also on an ACEi and beta blocker

Question 38

when are mineralocorticoid receptor antagonists contraindicated?

Answer 38

SCr >2.5 mg/dl in men, >2mg/dL in women | Potassium >5 meq/L

Question 39

treatment plan for a patient with a STEMI?

Answer 39

MUST have early invasive treatment: immediate cardiac catheterization or fibrinolytic administration in addition to OSNAAP (simultaneously)

Question 40

mechanism of fibrinolytic therapy

Answer 40

work to degrade fibrin clots and restore blood flow, considered revascularization, and will significantly increased bleeding risk. Works by activating plasminogen to plasmin that will degrade fibrin clots

Question 41

what is the only P2Y12 agent that can be administered with a fibrinolytic?

Answer 41

only use clopidogrel as a P2Y12 agent because clopidogrel has lower antiplatelet potency and theoretically lowers bleeding risk

Question 42

when to use a fibrinolytic

Answer 42

fibrinolytics are less effective than PCI and so a PCI is preferred but in the situation where a time to PCI is greater than 90 minutes, a fibrinolytic should be used (better than nothing)

Question 43

fibrinolytic specificity for plasmin

Answer 43

alteplase (tPA) is the least specific and will bind to both free plasmin and fibrin bound plasmin reteplase is slightly more specific for plasmin bound to firbin tenecteplase is the most specific for plasmin bound to fibrin

Question 44

what drugs in SNAP BAM will improve mortality?

Answer 44

``` everything except NTG! Statin aspirin P2Y12 inhibitor beta blocker ACEi/ARB MAR = all improve mortality ```