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Flashcards in 42. Chronic Stable Angina Deck (14):
1

Select the statements that accurately describe stable angina pain: (Select ALL that apply.)

A. Angina is chest pain or discomfort that occurs when an area of the heart muscle does not get enough blood.
B. Angina mainly stems from coronary artery disease.
C. Stable angina is due to vasospasm in the blood vessel.
D. The pain is typically predictable and usually brought on by exertion or stress.
E. Angina is due to an imbalance between myocardial oxygen supply and demand.

A, B, D, E. Angina is chest pain or discomfort that occurs when an area of the heart muscle does not get enough blood. Stable angina is a symptom of underlying heart disease and the problem usually stems from coronary artery disease (CAD). The coronary arteries that carry blood to the heart become narrowed by plaques, which restrict blood flow. As a result, less oxygen reaches the heart creating an imbalance of supply and demand, and angina pain or discomfort results.

2

Jason is a 67 year old male with hypertension, dyslipidemia and coronary heart disease. He has been prescribedNitrolingual Pumpspray. What are the indications for nitroglycerin sublingual tablets and spray? (Select ALL that apply.)

A. They are used for hypertensive urgency.
B. They are used for prophylaxis 5-10 minutes prior to an activity which might precipitate chest pain.
C. They are used for chronic hypertension in patients with coronary heart disease.
D. They are used for acute chest pain.
E. They are used to control heart rate.

B, D. Nitroglycerin sublingual (SL) tablets or spray are used for acute chest pain, or taken (for prophylaxis) 5-10 minutes prior to an activity which might precipitate chest pain.

Nitrates: forms free radical nitric oxide which produces vasoldilation of veins more than arteries, resulting in reduced myocardial oxygen demands due to decreased preload; improves collateral blood flow. CI: hypersenitivity to organic nitrates, concurrent use with PDE-5 inhibitors, increased intracranial pressure, severe anemia. SE: headache, dizziness, lightheadedness, flushing, hypotension, tachyphylaxis (decrease effectiveness, tolerance), syncope. All need a 10-12 hour nitrate-free period.

nitroglycerin SL (Nitrostat): keep in original amber glass bottle

nitroglycerin translingual spray (NitroMist, Nitrolingual Pump Spray)

nitroglycerin IV: prepare in glass bottles or polyolefin bags (non-PVC) due to sorption of the drug in PVC.

nitroglycerin ointment 2%: dosed BID, 6 hours apart with 10-12 hours nitrate-free interval. dose is based on dosing card by inches that the patient require. apply and tape to chest. medication may stain clothing.

nitroglycerin transdermal patch (Nitro-Dur, Minitran): on for 12-14 hours, off for 10-12 hours, rotate sites. place patch above elbows or knees (because patients with atherosclerosis may not have perfusion below these areas)

isosorbide mononitrate (Monoket): IR form dosed BID 7 hours apart. ER form dosed QAM

isosorbide dinitrate (Isordil): IR form dosed BID-TID need 14 hours nitrate-free period. ER form dosed daily in morning or BID need 18 hour nitrate free period. preferred in HF.

3

Which of the following drug classes is preferred for treatment of Prinzmetal's (variant) angina?

A. Nitrates
B. Antiplatelets
C. Beta blockers
D. Calcium channel blockers
E. Ranolazine

D. Calcium channel blockers are the preferred agents for treating variant angina.

Calcium is required for muscle cells to contract, hence blocking calcium would prevent the spasms.

Anti-anginals

1st line: beta blockers: reduce myocardial oxygen demand by decreasing HR, contractility, and LV wall tension. avoid beta blocker with intrinsic sympathomimetic activity (ISA). more effective than nitrates and CCBs in silent ischemia. avoid in Prinzmetal's angina

calcium channel blockers: preferred agent for Prinzmetal's (varient) angina. produces vasodilation, decrease SVR and BP, improves myocardial oxygen supply; decrease oxygen demand by decreasing contractility. used when BBs are CI or as add on therapy. avoid short acting CCBs (nifedipine IR), use slow-release or long-acting DHP and non-DHP CCBs

nitrates: forms free radical nitric oxide which produces vasoldilation of veins more than arteries, resulting in reduced myocardial oxygen demands due to decreased preload; improves collateral blood flow. SL tablets or spray: recommended for all patients for fast relief of angina. Call 911 if chest pain does not go away after thef irst SL tab or first spray. Long-acting nitrates: used as add-on therapy with beta blockers and/or CCBs and require a nitrate free interval to prevent tolerance.

ranolazine (Ranexa): selectively inhibits late phase Na current to decrease intracellular Ca; may decrease myocardial oxygen deman. CI: hepatic cirrhosis, concurrent use of strong 3A4 inhibitos and inducers. Warning: QT prolongation, acute renal failure when CrCl <30. SE: dizziness, constipation, headache, nausea. Has little to no effects on HR or BP.

4

Henry uses the following medications daily: isosorbide mononitrate BID for chronic angina due to coronary artery disease, enalapril daily for hypertension, simvastatin QHS for dyslipidemia and finasteride daily for benign prostatic hypertrophy. Based on the medication profile, the pharmacist should make the following suggestion to the perscriber:

A. He must be counseled about the risk of PML from isosorbide.
B. He will need a 6-hour nitrate-free period to reduce the risk of tolerance.
C. Nitrates are not used alone for chronic therapy for stable angina.
D. The physician should be called concerning the interaction between isosorbide and simvastatin.
E. The physician should be called concerning the interaction between isosorbide and finasteride.

C. Nitrates are used in combination with other drugs and should not be used first-line for chronic angina. A 6-hour nitrate free period is not long enough to decrease tolerance. Simvastatin and finasteride do not interact with nitrates.

Treatment of Chronic Stable Angina

Anti-anginal agent(s) + Antiplatelet agent

Anti-anginal: beta blockers (without ISA) ± CCB ± nitrates ± ranolazine

Antiplatelet: aspirin (clopidogrel if aspirin is CI)

Moderate or high intensity statin therapy, manage other co-morbidities (HTN, HF, DM), NTG SL tablets or spray prn for immediate relief.

5

A pharmacist is counseling a patient beginning therapy with clopidogrel. The pharmacist tells the patient that if he develops purplish bruises on the skin or mucous membranes or pin-point red or purple dots on the skin, fever and/or unexplained weakness or confusion, he should seek medical help right away. The pharmacist is informing the patient of warning signs of the following rare but serious adverse reaction that can be due to clopidogrel therapy:

A. Multi-organ hypersensitivity reaction
B. Stevens Johnson syndrome
C. Thrombotic thrombocytopenic purpura
D. Toxic epidermal necrolysis
E. Agranulocytosis

C. Thrombotic thrombocytopenic purpura (TTP) has been reported rarely with clopidogrel, including fatal cases. TTP can occur within 2 weeks of starting therapy. TTP is a serious condition that requires urgent treatment including plasmapheresis. It is characterized by thrombocytopenia, hemolytic anemia, neurological findings, renal dysfunction and fever.

clopidogrel (Plavix): inhibits P2Y12 ADP-mediated platelet activation and aggregation. Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.

6

Samuel is a 65 year old male with known atherosclerotic disease.  His past medical history is significant for diabetes, obesity, hypertension and chronic stable angina.  His current medications include Accupril 20 mg daily, Fortamet 1,000 mg daily, Tanzeum 30 mg weekly, Coreg 12.5 mg BID, hydrochlorothiazide 25 mg daily, and Adalat CC 30 mg daily.   He is not currently experiencing any anginal symptoms.  His BP today is 138/87 mmHg, HR is 87 BPM and RR is 18 BPM.  Which of the following medications should be added to Samuel's regimen?  (Select ALL that apply).

A. Valsartan
B. Amlodipine
C. Aspirin
D. Rosuvastatin
E. Ranolazine

C, D. Patients with stable chronic angina should be on aspirin therapy (if no contraindications). Plus, the ADA guidelines would recommend aspirin therapy for this patient as well. ACC/AHA lipid guidelines as well as the stable ischemic heart disease guidelines would recommend high-intensity statin therapy for this patient.

Treatment of Chronic Stable Angina

Anti-anginal agent(s) + Antiplatelet agent

Anti-anginal: beta blockers (without ISA) ± CCB ± nitrates ± ranolazine

Antiplatelet: aspirin (clopidogrel if aspirin is CI)

Moderate or high intensity statin therapy, manage other co-morbidities (HTN, HF, DM), NTG SL tablets or spray prn for immediate relief.

7

Jason has been prescribed the Nitrolingual Pumpspray. What is the dose of nitroglycerin provided with each spray?

A. 400 micrograms
B. 0.4 micrograms
C. 40 micrograms
D. 4 micrograms
E. 4 milligrams

A. Each spray of the Nitrolingual Pumpspray provides 400 micrograms, which is 0.4 milligrams. Nitrostat (nitroglycerin sublingual) tablets come in 0.3, 0.4 and 0.6 milligrams. The typical dose is the same-the 0.4 milligram dose.

Nitrates: forms free radical nitric oxide which produces vasoldilation of veins more than arteries, resulting in reduced myocardial oxygen demands due to decreased preload; improves collateral blood flow. CI: hypersenitivity to organic nitrates, concurrent use with PDE-5 inhibitors, increased intracranial pressure, severe anemia. SE: headache, dizziness, lightheadedness, flushing, hypotension, tachyphylaxis (decrease effectiveness, tolerance), syncope. All need a 10-12 hour nitrate-free period.

nitroglycerin SL (Nitrostat): keep in original amber glass bottle

nitroglycerin translingual spray (NitroMist, Nitrolingual Pump Spray)

nitroglycerin IV: prepare in glass bottles or polyolefin bags (non-PVC) due to sorption of the drug in PVC.

nitroglycerin ointment 2%: dosed BID, 6 hours apart with 10-12 hours nitrate-free interval. dose is based on dosing card by inches that the patient require. apply and tape to chest. medication may stain clothing.

nitroglycerin transdermal patch (Nitro-Dur, Minitran): on for 12-14 hours, off for 10-12 hours, rotate sites. place patch above elbows or knees (because patients with atherosclerosis may not have perfusion below these areas)

isosorbide mononitrate (Monoket): IR form dosed BID 7 hours apart. ER form dosed QAM

isosorbide dinitrate (Isordil): IR form dosed BID-TID need 14 hours nitrate-free period. ER form dosed daily in morning or BID need 18 hour nitrate free period. preferred in HF.

8

Jason is a 67 year old male with hypertension, dyslipidemia and coronary heart disease. He has been prescribedNitrolingual Pumpspray. What is the correct way to use this medication? (Select ALL that apply.)

A. First, prime the pump. Prime again if it has not been used for 6 weeks.
B. Press the button firmly with the forefinger to release the spray onto or under the tongue.
C. Shake the spray.
D. Do not inhale the spray.
E. Do not eat or drink 5-10 minutes after the dose.

A, B, D, E. For the Nitrolingual Pumpspray: Instruct patients to spray 5 times into the air to prime the pump the first time they use it, and prime it again with 1 spray if they have not used it for 6 weeks. Do not shake. Press the button firmly with the forefinger to release the spray onto or under the tongue. Do not inhale the spray and try not to swallow too quickly afterwards.

9

Henry has had coronary heart disease for many years. His other conditions include heart failure and depression. He has been prescribed ranolazine, in addition to his other medications. Choose the correct statement concerning ranolazine:

A. Ranolazine can increase the risk of arrhythmias.
B. Ranolazine is only indicated as monotherapy for treating chronic angina, not as combination therapy.
C. Ranolazine is a safe agent with severe liver disease.
D. Ranolazine has no significant drug interactions.
E. The brand name of ranolazine is Rasuvo.

A. Ranolazine is an oral agent used in chronic angina. It can prolong the QT interval. The arrhythmia risk is higher with strong CYP 3A4 inhibitors; do not use these drugs together with ranolazine. These include grapefruit products, azole antifungals, non-dihydopyridine calcium channel blockers, and others.

ranolazine (Ranexa): selectively inhibits late phase Na current to decrease intracellular Ca; may decrease myocardial oxygen deman. CI: hepatic cirrhosis, concurrent use of strong 3A4 inhibitos and inducers. Warning: QT prolongation, acute renal failure when CrCl <30. SE: dizziness, constipation, headache, nausea. Has little to no effects on HR or BP.

10

Which of the following statements best describes the mechanism of action of aspirin?

A. Binds irreversibly to COX-1 and COX-2 resulting in a decrease of prostaglandin synthesis and a decrease in thromboxane A2 synthesis.
B. Binds reversibly to COX-1 and COX-2 resulting in a decrease of prostaglandin synthesis and thromboxane A2 synthesis.
C. Binds irreversibly to COX-1 and COX-2 resulting in a decrease of prostaglandin synthesis and an increase in thromboxane A2 synthesis.
D. Binds reversibly to COX-1 and COX-2 resulting in an increase of prostaglandin synthesis and thromboxane A2 synthesis.
E. Binds irreversibly to COX-1 and COX-2 resulting in an increase of prostaglandin synthesis and an increase in thromboxane A2 synthesis.

A. Aspirin work by binding irreversibly to COX-1 and COX-2 resulting in a decrease of prostaglandin synthesis and a decrease in thromboxane A2 synthesis.

Antiplatelets

aspirin (Bayer, Ascriptin, Bufferin, Ecotrin): Irreversibly binds COX-1 and COX-2 enzymes which results in decrease prostaglandin (PG) and thromboxane A2 (TXA2) production. CI: NSAIDs or other salicylate allergy, patients with syndrome of asthma, rhinitis, nasal polyps, children <16 years of age with viral infection. SE: dyspepsia, heartburn, GI upset, GI bleed/ulceration, bleeding, renal impairment, tinnitus (in toxicty)

11

Armando is a 70 year old male with coronary heart disease. He has been prescribed nitroglycerin sublingual tablets to take at the first sign of chest pain. Which of the following counseling instructions should be provided to the patient?

A. Place one tablet under the tongue; do not chew or swallow the tablet.
B. Wait five minutes and if chest pain persists, take a second dose. If chest pain does not go away after 4 doses, call 911 (or go to the emergency room).
C. This medication is not sensitivity to light or moisture and can be stored in the bathroom.
D. The medication is good for 60 days after the bottle has been open.
E. The medication is good for 90 days after the bottle has been open.

A. Instruct patients to place 1 tablet under the tongue or in the area between the inside of the cheek and the gums. Allow it to dissolve completely. Do not chew or swallow the tablet. Please note that the instructions to take up to 3 doses (before calling 911 or going to the emergency department) may be in the package insert, but the ACC/AHA guidelines state to go to the ED if one dose does not relieve pain after 5 minutes. If a patient is experiencing a myocardial infarction, faster treatment can be life-saving. Nitroglycerin tablets should be kept in the original amber glass bottle, which is kept tightly capped. The medication is good until the expiration date on the bottle.

12

What is the mechanism of action of clopidogrel?

A. Inhibits platelet activation and aggregation
B. Renin-angiotensin-aldosterone antagonist
C. Non steroidal anti-inflammatory
D. Inhibits clotting factors Xa and IIa
E. Blocks platelets from binding to arterial smooth muscle

A. Clopidogrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the ADP receptors, specifically the P2Y12 subunit, on platelets.

clopidogrel (Plavix): inhibits P2Y12 ADP-mediated platelet activation and aggregation. Boxed warning: effectiveness depends on the activation to an active thiol metabolite mainly by 2C19. Poor metabolizes exhibit higher cardiovascular events than patients with normal 2C19 function. CI: active bleed (PUD, ICH). Warning: avoid 2C19 inhibitors (omeprazole, esomeprazole), thrombotic thrombocytopenic purpura (TTP) has been reported (fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin/eyes, neurological changes. SE: bleeding, bruising, rash, pruritus. Discontinue 5 days prior to major surgery.

13

Harry is a 59 year old male with dyslipidemia, coronary heart disease, erectile dysfunction and mild memory impairment. His medications include lovastatin, atenolol, vardenafil and aspirin. He has just brought in a new prescription for nitroglycerin SL 0.4 milligrams #100. Which statement concerning nitroglycerin SL tablets is correct?

A. He can put the tablets in his pill box.
B. He should swallow the tablet with 4 ounces (1/2 cup) of water.
C. He can use nitroglycerin SL tablets safely with his other medicines.
D. He should take this medication regularly twice per day.
E. Nitroglycerin can commonly cause headache, lightheadedness or dizziness.

E. Nitroglycerin can cause lightheadedness and dizziness, due to orthostasis. The patient must be counseled to take the medication while seated. Nitrates also commonly cause headache. Any nitrate-containing product is contraindicated with phosphodiesterase inhibitors, such as the vardenafil that the patient is taking. The pharmacist cannot dispense the nitroglycerin; the provider should be contacted.

14

Marvin was just diagnosed with chronic stable angina. Which of the following agents should be used first-line for the treatment of chronic stable angina? 

A. Verapamil
B. Metoprolol
C. Amlodipine
D. Acebutolol
E. Ranolazine

B. Beta-blockers (without ISA) are first-line agents in treating chronic stable angina.

Treatment of Chronic Stable Angina

Anti-anginal agent(s) + Antiplatelet agent

Anti-anginal: beta blockers (without ISA) ± CCB ± nitrates ± ranolazine

Antiplatelet: aspirin (clopidogrel if aspirin is CI)

Moderate or high intensity statin therapy, manage other co-morbidities (HTN, HF, DM), NTG SL tablets or spray prn for immediate relief.

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