CAD Flashcards
ischemic heart disease (IHD)
-Complication that occurs secondary to CAD (atherosclerosis)
-2 primary forms of IHD
-1. Angina pectoris – chronic condition characterized by episodic chest discomfort that occurs during transient coronary ischemia
-Typical angina:
-stable angina – attacks have similar characteristics and occur under same circumstances
-unstable angina – attacks increase in frequency and severity (often preclude MI)
-Variant angina (unstable) (aka Prinzmetal angina)- Due to acute coronary vasospasm and often occurs during rest or sleep
- myocardial infarction
angina
-pain secondary to ischemia
-can be sudden, severe, substernal, and radiating to the left shoulder
-can be induced by exercise, emotions, eating, or cold temperature
-waste products build
rationale of tx of angina: restore balance b/w myocardial O2 supply and demand
-increase O2 supply
-determined by coronary blood flow, regional blood flow and O2 extraction
-vasodilators (nitrates and CCBs) used to increase total coronary flow
-beta blockers can improve distribution of coronary flow by reducing intraventricular pressure (slow it down)
tx of angina: decrease myocardial O2 demand
-determined by HR, cardiac contractility and myocardial wall tension
-beta blockers and CCBs decrease HR, decrease BP and decrease contractility
-vasodilators reduce wall tension via their effects on ventricular volume and pressure
-decrease pre and after load
angina tx: differences in treating typical angina vs variant angina
-typical - vasodilators and beta-blockers work to decrease O2 demand via mechanism outlined above
-typical- increase O2 demand with limited O2 supply
-variant – vasodilators increase O2 supply by relaxing coronary smooth muscle and restoring normal coronary flow
-Beta-blockers NOT effective b/c they can’t counteract vasospasm
-variant- O2 supply is low (its a spasm) -> spasm is causing less O2 to tissue not
-can present weirdly
angina: adjunct tx
-Stabilize atherosclerotic plaques to prevent ACS
-Manage/treat the modifiable risk factors
-i. HTN
-ii. Hyperlipidemia
-iii. DM – optimize glycemic control
-iv. Smoking cessation
non pharm tx for angina
Revascularization (PCI and CABG)
stable ischemic heart disease tx chart
tx of angina: beta blockers
-“OLOL” drugs; (pregnancy category C/D) (first-line for typical angina if no contraindications)*
-MOA - decrease HR, decrease BP and decrease contractility -> myocardial O2 demand
-Indications – HTN, CHF, typical angina, MI, certain arrhythmias, migraine (certain agents)
-NOT used for variant/prinzmetal angina or acute angina attacks.
-Contraindications – sinus bradycardia (HR < 60), SBP < 100, heart block, cardiogenic shock, ADHF.
-Non-selective agents are contraindicated in COPD, asthma, DM.
-Precautions, Reactive airway disease, DM, PVD
-ADRs – fatigue, insomnia, dizziness, bradycardia, CHF, edema, hypotension, mental depression, hypercholesterolemia, sexual dysfunction
-DDIs – Verapamil (greatest potential for decrease contractility and decrease CO, other CCBs safer to combine), see HTN handout for other DDIs.
-Monitoring Parameters – BP, HR (titrate to HR 50-60) **
-Specific drugs used: (beta1 specific/cardioselective and non-ISA preferred)
-beta 1 specific/cardioselective*
-Metoprolol succinate (Toprol XL)
-Atenolol (Tenormin)
-Nebivolol (Bystolic)
-Non selective:
-Propranolol (Inderal)
-Nadolol (Corgard)
-α1/beta blockers:
-Carvedilol (Coreg)
-Labetalol (Trandate)
beta blocker
-improve mortality post MI
-titrate HR to 50-60
tx of angina: CCB
-MOA – bind to calcium ion channels in smooth muscle and cardiac tissue -> smooth muscle relaxation & suppression of cardiac activity -> increase O2 supply and/or decrease myocardial O2 demand
-indications – HTN, angina (esp useful for variant angina); arrhythmias (diltiazem and verapamil)
-Contraindications (mostly for non-DHPs) – SBP < 100, HR < 60, ADHF, EF < 40%, AV block
-ADRs – constipation, fatigue, headache, flushing, dizziness, hypotension, bradycardia, reflex tachycardia, edema. Immediate release forms of nifedipine and other short-acting CCBs have increased risk of MI, CHF and death due to coronary heart disease.
-DDI – see HTN handout
-Monitoring Parameters – BP, HR, EKG (w/ certain agents)
-Role in angina management:
-Use non-DHPs as initial therapy when BBs are contraindicated
-Use DHPs as add on therapy to BBs
-Use in combo w/ nitrates
-Non-DHP preferred for variant angina
specific CCB used
-Non-DHPs
-Verapamil (Calan, Isoptin)
-Diltiazem (Cardizem, Tiazac)
-DHPs
-Amlodipine (Norvasc)
-Felodipine (Plendil)
-Nifedipine (Procardia XL) – avoid IR formulation
angina tx: organic nitrites and nitrates
-tolerance develops*
-MOA: release of nitric oxide -> diffusion into vascular smooth muscle cells -> formation of cyclic GMP -> venous dilation -> venous pooling -> decrease preload, decrease ventricular diastolic volume and decrease ventricular pressure -> decrease myocardial wall tension and decrease myocardial O2 demand.
-At higher doses: arterial dilation -> decrease PVR and left ventricular ejection pressure (afterload).
-Indications: angina, MI, CHF
-Contraindications: aortic valve stenosis, concurrent use with Sildenafil, Vardebafil, Tadalafil; angle-closure glaucoma, head trauma or cerebral hemorrhage, severe anemia and severe hypotension (SBP < 90)
-ADRs: H/A, dizziness, weakness, postural hypotension, rash, tolerance and anxiety. With overdose – reflex tachycardia and arrhythmias.
-DDI: PDE 5 inhibitors (Sildenafil, Vardebafil, Tadalafil) – severe hypotension and death have occurred; isosorbide is CYP3A4 substrate
-Monitoring parameters – blood pressure, heart rate
-Role in angina management:
-SL/PO to prevent effort-induced angina (prophylaxis)
-Long acting formulations for maintenance therapy (if CIs to BBs and CCBs or as add on to BB or CCB to optimize angina control)
-Formulations
-Amyl nitrate (INH) (X)
-nitroglycerin
-isosorbide
Organic Nitrites and nitrates: nitroglycerin
-IV, PO, SL, buccal, topical, transdermal
-SL form (Nitroquik, Nitrostat) and buccal form (Nitrogard) - Deteriorates in sunlight. Replace bottle every 3-6 months after opening
-Ointment form (Nitro-Bid 2% or Nitrol 2%) -messy only inpatient
-Patch form (NitroDur, Nitrek) – available in several doses -> 12 hr intervals to prevent tolerance
-PO form (Nitro-Time ER) – must be administered QD or BID only to minimize tolerance
-IV form – contains propylene glycol, need special tubing
-cool dry place, fridge, keep in container
-0.4mg every 5mins (3 doses max) - sublingual
-if first does doesnt provide any relief call 911
Amyl nitrate (INH) (X)
i. Rapid onset and brief DOA.
ii. Used for cyanide poisonings
-poppers
Organic Nitrites and nitrates: isosorbide
-PO, SL
-not as much tolerance
-dinitrate form (Isordil) – available PO or SL, give TID at 8am, 1pm, and 6pm.
-mononitrate form – available PO only -> Longer acting metabolite of dinitrate form:
-Ismo: BID – give 7 hrs apart
-Imdur: Once daily
ranolazine
-MOA – sodium current inhibitor
-last choice
-Indications – Used for chronic stable angina in combination with CCB, beta-blockers or nitrates.
-Contraindications – pre-existing QT prolongation, uncorrected hypokalemia, hepatic failure, if taking drugs that prolong QT interval or drugs that are potent CYP3a4 inhibitors.
-Precautions - can prolong QT interval and induce torsades de pointes
-ADRs – dizziness, headache, constipation. Less effects on HR and BP than other classes. Prolongs QT interval
-DDIs – CYP450 substrate
adjunct treatment: antiplatelets
-Aspirin
-MOA – inhibits synthesis of prostacyclin and thromboxane A2 -> prevent platelet aggregation -> decrease thrombosis.
-Role in angina - primarily used to prevent ACS in patients with unstable angina.
-Other agents:
-Clopidogrel (Plavix)- same efficacy as aspirin
-Prasugrel (Effient) – for UA
-Ticagrelor (Brilinta) – for UA
optimize manageable risk factors
key
-htn, smoking, diet, lifestyle, exercise, lipids, diabetes
adjunct tx: ACE inhibitors
-Role in angina:
-Use in all pts w/ CAD to help delay progression of CAD
-Do not relieve angina symptoms b/c do not directly affect O2 supply and demand
overall management of angina
-1. Modification of cardiac risk factor
-2. Goals of treatment:
-Relieve acute symptoms
-Prevent ischemic attacks
-Reduce risk of MI and other cardiovascular problems
-3. Consider Type and severity of angina:
-Occasional episode- SL nitroglycerin
-Predictable episodes upon exertion - prophylaxis (mono,nitro,iso)
-Frequent episodes requiring regular SL NTG – beta blocker, CCB, nitrate + SL nitrate
-Angioplasty, stents or bypass may be necessary
-4. Consideration of Concomitant disease states:
-Asthma – non-DHP CCB or cardioselective BB most preferred
-DM – non-DHP CCB most preferred, nitrates/cardioselective BB are alternatives
-Heart failure – BBs and nitrates most preferred, non-DHP CCB least preferred
-HTN – BB & non-DHP CCB most preferred
-Prior MI – BB most preferred
-Bradycardia/heart block – DHP CCB preferred
management of acute STEMI (ACCF/AHA STEMI guidelines)
-Goals of Therapy
-limit infarct size
-reperfuse obstructed coronary arteries
-reduce morbidity and mortality
-prevent post-MI complications
pharm management of acute STEMI: aspirin
-antiplatelet agent.
-Dose: 162 - 325mg STAT, then 81-325mg QD
-Use for all MI patients unless contraindicated. Start ASAP, continue indefinitely
-reduces morbidity and mortality associated with MI
pharm management of acute STEMI: IV nitroglycerin
-Recommended for the first 24 to 48 hours in patients with acute MI. Do not give if SBP < 90 or HR < 50
-NTG alleviates ischemic myocardial pain
-can take it prophylactically if you know you do something and get pain
