3 CAD

Question 1

Ca Channel Blockers (CCB): MOA

Cardiac
- decreased ___ of trigger Ca in myocytes, decreased ___ in nodal cells; ___ in myocytes

Vascular
- vaso ___

Answer 1

• influx, chronotropy, inotropy
• vasodilation

Question 2

DHPs

HR: reflex ___
Contractility: ___ / ___ (nifedipine)
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

Answer 2

more potent vasodilators

Question 3

Verapamil

HR: ___
Contractility: ___
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

Answer 3

• decrease
• super decrease
• super decrease
• (++)
• (+)

Question 4

Diltiazem

HR: ___
Contractility: ___
AV Nodal Conduction: ___

Vasodilation
- peripheral: ___
- coronary: ___

Answer 4

decrease
decrease
decrease
(+)
(++)

Question 5

which CCBs are short acting (2)

Answer 5

nifedipine (Procardia, Adalat)
nicardipine (Cardene)

these are not used, but the XL/ER versions are

Question 6

CCB AE

DHP - primarily work in ___ space
- hypotension, flushing, headache, and dizziness
- peripheral edema likely related to arteriolar ___
- reduced myocardial ____
- reflex adrenergic activation

Answer 6

vasculature
- vasodilation
- contractility

Question 7

CCB AE

Non-DHPs - potent reducers of ___, contraindicated in ___
- reduced myocardial contractility ( V ___ D)
- AV/SA nodal conduction disturbances: ___ and ___ block (V ___ D)
- hypotension, flushing, headache, and dizziness
- constipation (V ___ D)

Answer 7

ionotropy, HF
- >
- bradycardia, AV, >
- >

Question 8

CCB Monitoring

initiate at lowest dose and titrate to symptom reduction

Painful episodes
- ___ use

Monitoring paramerters
- DHP: assess ___ and ___
- Non-DHP: ___ and HR ___ - ___ and < ___ at exercise

Answer 8

• NTG
• BP, edema
• constipation, 50-60, 100

Question 9

Nitrate Tolerance

• ___ response in the presence of continuous/frequently administered nitrates
• occurs in ___ - ___ days depending on the patient, will require higher doses as time goes on

Examples:
- __ hour application of transdermal NTG
- ___ infusions of IV NTG
- ISDN administered ___ times daiy

Prevention of nitrate tolerance
- nitrate free period of at least ___ - ___ hours

Answer 9

• decreased
• 1-3
• 24
• continuous
• four
• 10-12

Question 10

Pharmacology of Nitrate Tolerance

• ___ inactivation in mitochondria
• ISMN and ISDN also elicit tolerance but via a slower, less understood process

Answer 10

ALDH2

Question 11

Nitrates: Dosing

NTG: patch
dosing interval: ___ daily

Answer 11

once

example: on for 12-14 hours, off 10-12 hours
- on 7 am off, off 7-9 pm

Question 12

Nitrates: Dosing

ISDN tabs
dosing interval: ___ - ___ times/day

Answer 12

2-3

example: 8 am, 12 pm, 4 pm
10 mg TID

Question 13

Nitrates: Dosing

ISMN tabs
dosing interval: ___ times/day, ___ hours apart

Answer 13

2, 7
example: 8 am and 3 pm
20 mg BID

Question 14

Nitrates: Dosing

ISMN SR tabs
dosing interval: ___ daily

Answer 14

once
examples: 8am
30 mg once daily

Question 15

Patient counseling: Nitrate Patches

• discuss nitrate ___ interval

Patches
- apply patch between ___ and ___
- choose a different area each day
- you can shower while wearing

Answer 15

• free
• elbows, knees

Question 16

Patient counseling: NTG Ointment

• do not ___ ointment
• do not ___ area
• used in hospital setting, a bit easier to titrate vs patch

Answer 16

rub/massage
cover

Question 17

Vasodilator induced Tachycardia

we dont want tachycardia to occur because an increase in ___ will lead to higher O2 ___ which leads to more ___

Answer 17

CO
demand
angina

Question 18

Cellular Events During Ischemia

1) ischemia
2) drop in ___ and ___ supply, decrease in ___ function
3) influx of ___
4) influx of ___
5) increased ___ activation
6) increased ___ and ___ wall tension, increased ___ and ___ consumption
7) ___ microcirculation

cycles and leads to more angina

Answer 18

• O2, ATP, LV
• Na
• Ca
• myofilament
• LVEDP/LV, O2, ATP
• decreased

Question 19

Ranolazine (Ranexa)

MOA: inhibition of late inward ___ current in ischemic ___ which prevents ___ influx
- does not affect ___ , ___ , ___ or ___ like traditional anti-ischemic agents

Answer 19

Na, myocytes, Ca
- HR, BP, inotropy, perfusion

Question 20

Ranolazine

Brand: ___ 500 mg ER tablets
- titration from 500 mg ___ to ___ mg BID over 1-2 weeks
- combo therapy: add to ___ , ___ , or ___ when inadequate response
- monotherapy only when ___ / ___ too low for first line agents

Answer 20

Ranexa, BID, 1000 mg
beta-blockers, CCB, nitrates
BP/HR

Question 21

Ranolazine

metabolized via CYP ___ and CYP ___ , substrate for ___
- should not be used with strong ___ inhibitors ( ___ , ___ , ___ ) or inducers ( ___ , ___ , ___ )
- limit dose ( ___ mg BID) with moderate inhibitors ( ___ , ___ , ___ , and ___ )

ranolazine inhibits ___ and ___

Answer 21

• 3A4, 2D6, Pgp
• 3A, (ketoconazole, itraconazole, protease inhibitors)
• carbamazepine, rifampin, St. John’s Wort
• 500 mg, diltiazem, verapamil, erythromycin, fluconazole

CYP3A, Pgp

Question 22

Ranolazine: AE

constipation, nausea, dizziness, headache
- dose related increase in ___ interval; should not be used with other drugs that prolong ___ interval

Answer 22

QT, QT

Question 23

Answer 23

B

Question 24

Selecting a Treatment option

if possible ___ are first line, but initial drug should be based upon pateint characteristics
- CCB and nitrates can also be used

Answer 24

beta blockers

Sowinski wouldnt use beta blockers in patients with severe asthma

Question 25

# Place in therapy: Beta Blockers should be selected as ___ therapy in patients without CIs - compelling indications: stable ___ , history of ___ - useful in AFib, high resting ___ , migraine - avoid in ___ / Prinzmetal's angina, conduction disturbances - CIs: bradycardia (HR < ___ ); high degree ___ block or sick ___ syndrome (with no pacemaker)

Answer 25

- initial - HR, MI - HR - vasospastic - 50 - AV, sinus

Question 26

# Place in Therapy: CCBs ___ CCBs preferred, instead of B-blockers if ... - CI to BB - undesirable side effects to BB - potentially useful in chronic lung diseases, HTN, DM, and peripheral vascular disease CI - Non-DHPs: HFrEF, bradycardia (HR < ___ ); high degree ___ block or sick ___ syndrome (with no pacemaker) - DHPs: HFrEF (except ___ and ___ )

Answer 26

non-DHP 50, AV, sinus amlodipine, felodinpine

Question 27

# Place in Therapy: Nitrates monotherapy not preferred due to tolerance and required nitrate free period - combo with ___ / ___ (to blunt nitrate induces increase in HR) - short acting ___ nitrates to relieve discomfort or prevent ischemia before exertion - cautions: ___ , severe aortic stenosis, ___ use

Answer 27

Beta-blockers, non-DHP PRN HOCM, PDI

Question 28

# Clinical Conditions that Favor use Beta Blockers - prior ___ / ___ (non-ISA) - HF/LVD - sinus ___ , SV ___ , AFib - ventricular ___ - migraines - ___ thyroidism

Answer 28

- ACS/MI - tachycardia, tachycardia - arrhythmias - hyperthyroidism

Question 29

# Clinical Conditions that Favor use DHP CCB - HTN - ___ / AV block - diabetes - PVD/Raynaud's - severe ___ / ___ - ___ angina

Answer 29

- bradycardia - asthma/COPD - Prinzmetal's

Question 30

# Clinical Conditions that Favor use Verapamil/Diltiazem - HTN - sinus ___, SV ___, A Fib - diabetes - PVD/Raynaud's - severe ___ / ___ - ___ angina

Answer 30

- tachycardia, tachycardia - asthma/COPD - Prinzmetal's

Question 31

# Clinical Conditions that Limit use Beta-Blockers - ___ / AV Block - sick ___ syndrome - HF ___ - severe ___ - severe asthma/COPD

Answer 31

- bradycardia - sinus - decompensation - depression

Question 32

# Clinical Conditions that Limit use CCBs - ___ / AV block - sick ___ syndrome ( ___ ) - HF - severe ___ - severe aortic ___

Answer 32

- bradycardia - sinus, non-DHP - HOCM - stenosis

Question 33

# Clinical Conditions that Limit use Nitrates - ED treated with ___ - severe ___ - severe aortic ___

Answer 33

PDE5 HOCM stenosis

Question 34

# combo therapy - beta-blockers and ___ should be avoided - triple therapy: ___ , ___ , and ___ - can add ranolazine with other agents if they arent effective

Answer 34

- non-DHP CCBs - beta-blockers, nitrates, DHP CCB

Question 35

Answer 35

C

Question 36

Answer 36

Question 37

# algorithm

Answer 37

Question 38

Answer 38

Aspirin appropriate, need ACEi, atorvastatin at appropriate high dose. Increase metoprolol to 50 mg. Can use colchicine if high C protein. Only use dual antiplatelet therapy 1 year post MI

Question 39

Answer 39

- Anginal symptoms: sublingual nitroglycerin, metoprolol 25 mg BID - Risk reduction: 81 mg aspirin, ACEi, high intensity statin - metoprolol might make him cranky bc of not being able to exert himself as much during pickleball

Question 40

Answer 40

C - Metoprolol: not going to mess around bc heart rate is at goal - Reduce aspirin to 81 mg (lower risk of bleeding and GI upset) - Need additional BP control: DHP CCB would be most logical AND add low dose lisinopril - Low dose amlodipine and low dose lisinopril

Question 41

# Not Approved in the US: Ivabradine HCN channel inhibitor - reduces diastolic depolarization - slows ___ - prolongs ___ and improves ventricular ___ - reduces myocardial oxygen ___ - no hemodynamic or conduction abnormalities FDA approved for ___ , but not SIHD - brand: ___ , ___

Answer 41

- HR - diastole, filling - consumption HF Procoralan, Corlanor

Question 42

# Therapies with no benefit/potentially harmful fo CCB - postmenopausal ___ - antioxidants (scam, just do ___ ) - homocysteine/Folic acid, Vit B6 or B12 - herbal supplemets - ___ / ___ inhibitors - ___ glitazone - ___ therapy

Answer 42

- HRT - one-a-day - NSAIDs/COX-2 - Rosiglitazone - chelation

Question 43

# ASA with NSAIDs NSAIDs compete with ASA at ___ site that diminishes the effect of ASA

Answer 43

COX-1

Question 44

# Use of NSAIDs in CV Disease - shared dicision making - consider GI, renal, and AE - prioritize non-PCOL - use ___ dose for ___ time - select ___ or ___ as first alternatives with gastroprotection ( ___ ) - ___ doses up to 200 mg per day have similar CV risk , but poorer analgesic effects. - avoid ___

Answer 44

- lowest, shortest - ibuprofen, naproxen, PPI - celecoxib - diclofenac

Question 45

# Systemic NSAID is Chosen - take ASA at least ___ hours prior to NSAID - adjunctive ___ may minimize NSAID needs - within 1 week, review benefits of NSAID use - prioritize non-PCOL

Answer 45

- 2 - APAP

Question 46

# Vasospasm - ___ angina - ischemia/angina usually occurs at ___ , not precipitated by physical exertion or emotional stress - associated with ECG ___ segment elevation - not necessarily associated with ___

Answer 46

- Prinzmetal's - rest - ST - atherosclerosis

Question 47

# Management of Vasospastic Angina acute: ___ chronic: ___ , ___ , or combo therapy - NO ___

Answer 47

SL NTG CCB, nitrates - beta-blocker

Question 48

Answer 48

A,E