CAD, MI (ACS) Flashcards by Daniella Erfanian

IHD- ischemic heart ds
- 2 types

Angina Pectoris and MI (ACS)

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Angina Pectoris
- types

Typical v. Variant/Atypical

typical:
- stable: attack occurs w exertion, relieve w rest, occur under same circumstances
- unstable: attack inc in freq and severity

variant/atypical:
- prinzmetal/vasospastic: due to acute coronary vasospasm, occurs during rest or sleep

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angina characteristics
- where, radiation, how is it induced

substernal or left precordial pain
- radiate to L shoulder
- induced by exercise or cold temps

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goals for tx angina

inc our O2 supply (BB, CCB, vasodilators)
dec myocardial O2 demand
(BB and CCB to dec HR, CO, and contractility)

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tx typical vs. atypical angina

typical- stable angina first line is BB

atypical- prinzmetal first line is CCB (DO NOT GIVE BB, it cannot counteract vasospasm)

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adjunct tx

stabilize atherosclerotic plaques to prevent ACS
manage modifiable RFs
- HTN, HLD, DM, smoking cessation

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non pharm tx

PCI and CABG

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ANGINA

beta blockers
- names and categories

B1 selective: metoprolol, atenolol, nebivolol (M.A.N)

non selective: propanolol, nadolol

a1/B blockers: carvedilol, labetalol

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ANGINA

Beta Blockers
- MOA
- indications
- CI

-olol
- first line for typical angina if no CI

MOA- dec HR, BP, CO, and myocardial O2 demand

Indications- HTN, CHF, typical angina, Mi, certain arrythmias, migraine

NOT FOR PRINZMETALS ANGINA or ACUTE angina attack

CI- sinus bradycardia, SBP <100, heart block, cardiogenic shock
- selective agents CI in COPD, asthma, DM

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ANGINA

Beta Blockers
- ADRs
- DDIs
- monitoring parameters

ADRs- hypotension, bradycardia, bronchospasm, hypercholesteremia

DDIs- verapamil (dec CO and contractility too much)

monitor- BP, HR

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ANGINA

CCBs
- names and categories

Non-DHPs (Central acting)
- verapamil, diltiazem

DHPs (peripheral acting)
- amlodipine, nifedipine, felopdipine

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ANGINA

CCBs
- MOA
- indications
- CI

MOA- smooth muscle relaxation, suppress cardiac activity, inc O2 supply/dec myocardial O2 demand

indications- HTN, angina (prinzmetals), arrhythmias (central acting)

CI- SBP <100, Hr <60, EF <40% (neg inotrope bad for HFrEF)

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ANGINA

CCBs
- ADRs
- DDI
- monitoring

ADRs- constipation, bradycardia, flushing, reflex tachy, periph edema
- CHF, heart block, hypotension w CENTRAL acting

DDI- dixgoxin, amiodarone, azoles (w verap and diltiaz)

monitor- BP, HR, EKG

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ANGINA

CCB in angina management
when to use:
- DHP initial tx?
- other use for DHP
- combo with?
- non DHP for?

use DHP as initial tx when BB are CI
DHP as add on therapy to BB
combo w nitrates
non DHP for atypical/prinzmetal

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ANGINA

organic nitrites and nitrates
- names and routes

amyl nitrates (INH), nitroglycerin (IV, PO, SL, buccal, topical, transdermal), isosorbide (PO, SL), Ranolazine

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ANGINA

nitrites and nitrates
- MOA
- higher doses ?
- indications
- CI

MOA- release NO to dec preload, ventricular diastolic vol, ventricular pressure and myocardial wall tension & O2 demand
- higher doses: can dec LV afterload

indications- angina (that persists w monotherapy), MI, CHF

CI- aortic valve stenosis, concurrent use w sildenafil/tadalafil (for PAH and ED), close angle glaucoma, severe hypotension and anemia

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ANGINA

nitrites/nitrates
- ADRs
- DDI
- monitoring

ADRs- tolerance develops, syncope, orthostat hypotension
- overdose—> reflex tachy and arrhythmias

DDIs- PDE 5 inhibitors (sildenafil), isosorbide is CYP3A4 substrate

monitor- BP, HR

ANGINA

nitrites/nitrates
- role in angina managment

SL formulation to relieve acute SS of Myocardial Ischemia
- SUBLINGUAL NITRO IS IMMEDIATE EFFECTIVE

SL/PO to prevent effort induced angina
- prophylaxis

long acting for maintenance tx

ANGINA

nitrites/nitrates
- Amyl Nitrate
- onset, DOA, use

rapid onset, brief DOA
used for cyanide poisoning

angina

nitrites/nitrates
- nitroglycerin
- SL, buccal ointment, patch, PO, IV uses

SL and buccal- deteriorates in sunlight, replace bottle 3-6 month after opening
ointment- nitrobid 2%
patch- several doses
PO- administer QD or BID to minimize tolerance
IV- contains propylene glycol, need special tubing

ANGINA

nitrites/nitrates
- Isosorbide
- dinitrate v. mononitrate

dinitrate- PO or SL, give TID (8am, 1, 6)
mononitrate- Po only, longer acting
- ismo BID 7 hrs apart
- imdur QD

ANGINA

Ranolazine
- MOA
- CI
- Precautions

MOA- sodium current inhibitor
Indications- chronic stable angina in combo w CCB, BB, or nitrates

CI- pre existing QT prolongation, uncorrected hypokalemia, hepatic failure , potent CYP3A4 inhibitors

precaution- can prolong QT, induce torsades de pointe!!!!!!!!!!!!

ranolazine will PROLONG QT

ANGINA

ranolazine
- ADRs
- DDIs

ADRs- dizzy, HA, constipation, PROLONGS QT INTERVAL
(less HR/BP effect than other classes)
DDIs- CYP450 substrate

ANGINA

adjunct tx for angina
- categories

antiplatelet drugs, ACEi, and optimizing RFs

# ANGINA adjunct tx- Antiplatelet - use in what pts?

Aspirin - prevents platelet aggregation and thrombosis - used to prevent ACS in UNSTABLE ANGINA PTS other agents: - clopidogrel, prasugrel, ticagrelor optimize modifiable RFs

ANGINA management overview - asthma - DM - HF - HTn - prior MI - bradycardia/heart block

- asthma: non DHP/central CCB or cardioselective BB - DM: non DHP CCB, nitrates/cardioselective BB alternative - HF: BB and nitrates, nonDHP CCB least preferred - HTN: BB and Non DHP CCB - prior MI: BB - bradycardia/heart block: DHP CCB

# ACUTE STEMI Acute STEMI pharm tx -names

CAMONABAS - CCB - ACEi - morphine/analgesics - Oxygen - NTG IV - Aspirin - BB - Anticoag (UFH, LMWH) - Statins additional - (P2y-12 inhibitors) antiplatelet agents/thrombolytics - clopidogrel, prasugrel - fibrinolytics - PCI

# ACUTE STEMI CCBs - which CCB - indicated for what kind of pts

- do NOT affect morbidity and mortality - give to pts intolerant to BB - diltiazem (pts w non Q wave Mi w out LV dysfunction)

# ACUTE STEMI ACEi - indicated for what pts

recc for all post MI pts with LV dysfunction or CHF

# ACUTE STEMI Morphine/analgesics

IV morphine for pain relief if NTG did not alr relieve pain

# ACUTE STEMI NTG - when should it be administered - purpose

IV NTG recc for first 24-48 hrs of acute MI - do NOT give if SBP <90 or HR <40 - alleviates ischemic myocardial pain

# ACUTE STEMI Aspirin - when to administer - what pts - freq

- antiplatelet - use for all MI pt unless CI - start ASAP, continue indefinitely

# ACUTE STEMI BB - when to administer - freq continued

- start IV dose ASAP, continue post Mi with PO unless CI - reduces morbid/mortality

Anticoag/UFH or LMWH

duration of tx depends on type of reperfusion UFH, LMWH (10a inhib)

# ACUTE STEMI Statins

start pt on statins post MI for long term reduction CV events, morbidity, and mortality

# ACUTE STEMI P2Y-12 inhibitiors/antiplatelet agents | dose and duration?

- clopidogrel, prasugrel, ticagrelor - dose and duration depends on revasc therapy (PCTA/PCI - DES vs. BMS) - continued as DAPT for maintenance (dual antiplatelet therapy) ## Footnote DES- 12 month DAPT BMS- 1 month min to 12 month DAPT

# ACUTE STEMI reperfusion- fibrinolytics - what do they do - MOA - types - CI (absolute v. relative)

- acheive RAPID thrombolysis - plasminogen activators dissolve existing clots - types: streptokinase, alteplase, reteplase absolute CI---> previous hemorrhagic stroke, other CVA within 1 yr, incranial neoplasm, suspected aortic dissection relative CI---> uncontrolled HTN, recent trauma or internal bleeding,m pregnancy, PUD, hx chronic severe HTN

# ACUTE STEMI Reperfusion PCI vs. Fibrinolytics

- if hospital has PIC capability, treat w primary PCI within 90 mins of medical contact - if no PCI and cannot be transfered to hopsital w PCI within 90 mins, tx with fibrinolytics within 30 mins in hospital unless CI

# ACUTE STEMI PCI

- stent placement - some pts require CABG

# ACUTE STEMI if pt requires CABG, what must you stop

must stop antiplatelets for 5-7 days if possible

major diff in tx stemi vs nstemi?

NSTEMI-- fibrinolytics are NOT USED

CAD, MI (ACS) Flashcards

drugs for IHD (ischemic heart disease)