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Therapeutics II (Spring) > CCD Lecture1-6 > Flashcards

CCD Lecture1-6 Flashcards

1
Q

Chronic Coronary Disease

A

-stable angina
-stable ischemic heart disease (SIHD)
-post-ACS

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2
Q

Clinical syndromes of CCD

A

-stable angina (macrovascular disease)
-stable outpatient post ACS
-variant/prinzmetal’s angina (vasospastic disease)
-INOCAD/Cardiac syndrome X
-silent myocardial ischemia

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3
Q

Types of angina

A

-prinzmetal/variant (vasospastic): artery closes bc spasm
-stable angina (fixed stenosis): plaque
-unstable: thrombus

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4
Q

Myocardial supply and demand

A

-imbalance = ischemia
-Contractility
-HR
-Preload
-Afterload

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5
Q

factors increasing demand

A

-inc HR
-inc afterload (from vasoconstriction)
-inc preload (from vasoconstriction)

-all = more O2 used

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6
Q

Factors decreasing supply

A

-inc HR
-inc preload

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7
Q

stable angina patho

A

-associated w ASCAD
-85% of pt have significant CAD (>70-75% reduction)
-most pt have at least one occlusion
-ischemia caused by fixed obstruction in epicardial artery

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8
Q

epicardial vessels

A

-Right Coronary Artery (RCA): big one on left side
-Left Main (LM): goes down back of heart
-Left circumplex (LCX): goes down right side towards back
-Left Anterior Descending (LAD): big one in middle also where widowmaker happens

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9
Q

Myocardial Ischemia

A

-imbalance between supply and demand
-effort induced when low supply
-disturbs heart function w/o necrosis
-presents as angina

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10
Q

Stable Angina

A

-resulting sx from ischemia
-chest discomfort
-relieves itself

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11
Q

Angina pain

A

-chest, left arm, jaw
-women and diabetics (nerve damage) often don’t present w pain

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12
Q

Angina ECG

A

-ST depression only during event

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13
Q

Diagnosis of angina

A

-hx and physical exam
-st depression during ischemia (elevation in variant angina tho)
-cardiac imaging (stress test, PET scan, heart scan that gives ca score but kinda sketchy)
-echocardiography (ultrasound)
-catheterization and angiography (dye in arteries)

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14
Q

Some true statements

A

-women and diabetes have atypical sx
-angina is discomfort associated w ischemia
-prinzmetal’s/variant angina is associated w vasospasm
-CCD is usually associated w ASCAD

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15
Q

Angina tx goals in dyslipidemia and HTN

A

-50% reduction of LDL
-BP < 130/80

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16
Q

angina risk factor mods

A

-respiratory virus vax
-minimize alc consumption (2 drinks/day for men 1 for women)

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17
Q

CCD treatment goals

A

-reduce ACS risk
-manage angina

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18
Q

Tx to reduce heart risk

A
  1. Antiplatelets
  2. Statin
  3. ACE/ARB
  4. Colchicine maybe
  5. Beta Blockers
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19
Q

Antiplatelet tx options

A

-Aspririn
-P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor, cangreor (IV only))

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20
Q

Aspirin

A

-COX-1 but COX-2 at high doses (bad)
-81mg maintenance dose
-bleeding side effects
-Ecotrin

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21
Q

COX-1 inhibition

A

-block TXA2 synthesis
-interferes w platelet aggregation and blocks thrombi
-COX-2 blocks PGI tho which is an anticoagulant = higher thrombotic risk if COX-2 blocked

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22
Q

P2Y12 inhibitors

A

-block P2Y12
-blocks ADP induced platelet activation/aggregation
-no effect on TXA2
-prodrugs are activated by CYP
-must stop 5-7days before surgery
-peak in 2-4 hours
-all increase bleeding risk when combo w aspirin

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23
Q

Clopidogrel (Plavix)

A

-P2Y12 prodrug (thienopyridine)
-75mg maintenance
-CYP dependent
-bleeding, diarrhea, RASH
-1% inc in bleeding risk w ASA

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24
Q

Prasugrel (Effient)

A

-P2Y12 prodrug (thienopyridine)
-10mg maintenance
-less CYP dependent than clopidogrel
-bleeding, diarrhea, RASH
-0.6% in bleeding risk w ASA
-DO NOT use in hx of TIA, ICH, stroke

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25
Ticagrelor (Brillinta)
-direct acting P2Y12 (cyclopentyl-traizole-pyrimidine) -90mg BID! maintenance -bleeding -bradycardia -heart block -dyspnea
26
Antiplatelet tx in different scenarios
1. CCD no stent = SAPT, DAPT for high risk pt 2. CCD PCI + drug stent (DES) = DAPT 6 months (1-3 months for high bleeding risk) 3. CCD and CABG = DAPT 12 months 4. Post-ACS (discussed ACS lectures)
27
Single Antiplatelet therapy (SAPT)
-all pt w CCD -81mg ASA for life -75mg clopidogrel if can't take ASA (or maintenance of other P2Y12)
28
Dual-Antiplatelet therapy (DAPT)
-ASA + P2Y12 (clopidogrel 75mg preferred) -prasugrel 10mg qd or ticagrelor 90mg BID -some high risk CCD pt no stent -6 months if PCI + stent (1-3 if high risk) -12 months for CABG
29
CCD no stent tx for secondary prevention
-SAPT ASA (81mg) for life -DAPT for certain high risk pt but not necessarily better
30
Intracoronary Artery stents
-bare metal (uncommon) -drug eluting (reduce inflammation at site): names end in -olimus 1-3 generations
31
CCD PCI + DES tx for 2' prevention
-BEFORE procedure: ASA and P2Y12 at LOADING dose (ACS lectures) -DAPT 6 months for low risk -DAPT 1-3 months for high bleed risk or SAPT w P2Y12 for 12 months??? -SAPT indefinitely -guidelines prefer clopidogrel as P2Y12
32
CCD w CABG secondary prevention
-DAPT 12 months (some controversey) -SAPT indefinitely -clopidogrel may be reasonable for 12 months
33
Notes about antiplatelets
-for pt that don't require antiCOAGULANTs for other probs -ASA must be <100mg with ticagrelor -use of PPI with DAPT might reduce GI bleeding risk -must stop 5-7 days before a surgery
34
ACEs and ARBs
-stbailize plaque (prevent rupture) -improve ET function -inhibit vasc smooth muscle cell growth -dec macrophage migration -some antiox properties -does NOT improve sx ischemia (angina) -for all pt with CCD (esp LVEF<40%, DM, HTN, CKD) -ARBs if cough -dont combo ACE and ARB
35
Colchicine
-tx GOUT -reduce inflammation (IL-1B and IL-18) -large clinical trials evaluating benefit -might reduce risk of MI, stroke, coronary revasc, and CV deaths in adults -unclear role (hsCRP>2 high risk) -CYP substrate -do NOT use in renal and hepatic disease
36
Targets to relieve sx of ischemia/angina
-increase supply: dilation -decrease demand: HR, contractility, preload (LVEV), afterload (systolic)
37
Nitrate effect on demand
-inc HR -dec systloic pressure (afterload) -dec LV volume (preload)
38
B-blocker effect on demand
-dec HR -dec contractility -dec systolic pressure (afterload) -inc LV volume? (preload)
39
DHP CCB effect on demand
-inc HR -no or dec contractility -dec systolic pressure the most (afterload) -no change or dec LV volume
40
non-DHP CCB effect on demand (verapamil and diltiazem)
-dec HR (more w verapamil) -no or dec contractility -dec systolic pressure (afterload) -no or dec LV volume
41
Tx options to relieve angina
-Nitrates -Beta Blockers -CCBs -Ranolazine
42
Nitrate MOA
-NO donors/releasers -activate guanylate cyclase (GTP to cGMP = relaxation of vasc smooth muscle= dilation) -venodilation =. dec preload -less arteriole dilation, coronary and peripheral -minor inhibition of platelet aggregation -slide 74
43
Nitrate clinical effects
-dec demand by dec preload and dec LV volume via vasodilation -inc supply by vasodilation of coronary vessels
44
Nitrate acute agents
-NTG tabs (Nitrostat) 0.4mg -NTG spray (Nitromist) 0.4mg -NTG packets (GOnitro) 0.4mg -PRN repeat dose 1-3 time q5 min, call 911 if first dose doesn't work
45
NTG tabs vs spray
-tabs lower shelf life, keep cool so NTG doesn;t evaporate --spray can be stored anywhere -either way keep on person at all times and sit down before taking in case pass out
46
NTG tabs education
-keep in og DARK GLASS container -no safety cap -place UNDER tongue NO SWALLOW -don't store in humid bathroom -refill q6months
47
NTG spray education points
-spray UNDER tongue NO inhale -do NOT shake -refill q3 years
48
Nitrates adverse effects and monitoring
-headache -hypotension -dizziness -lightheadedness -flushing -reflex tachycardia that could make angina worse -use acetaminophen? -caution w PDE5i
49
PDEi and nitrates
-inc ability of nitrates to dec BP -if angina happens during intercourse do NOT take nitrate, call 911 -potentially fatal -wait 12-48h from taking PDE to take nitrate (12h for avanafil, 24h for slidenafil and vardenafil and 48h for tadalafil)
50
Pharmacotherapy to PREVENT RECURRENT ischemia and angina sx
1. B-blockers 2. CCBs 3. Nitrates 4. Ranolazine maybe Combos: -nitrates and BBs -nitrates and NON-dhp ccbs -DHP-ccb and BB -triple
51
B-blocker MOA
-block NE or EPI mediated activation of B1/B2 that inc HR, contracility, conduction velocity -competitive, REVERSIBLE inhibitors of B-andreergic stimulation by catecholamines
52
B-blocker effects
-dec HR during sympathetic stimulation -reduce contractility -reduce arterial BP (afterload) -undesired inc in preload bc reducing HR inc filling time which inc LVEDV = inc demand -reduced ventricular arrhythmias and remodeling -use B1 over nonselective in pt w airway disease -high doses of B1 will block B2
53
B-Blocker drugs
-Atenolol (tenormin) -Bisoprolol (Zebeta) -Carvedilol -Metoprolol succinate (toprol) -metoprolol tartrate (Lopressor) -Propranolol (Inderal)
54
Atenolol
-Tenormin -B1 -100mg max until B2 effects -low lipid solubility -renal elimination
55
Bisoprolol
-Zebeta -B1 -low lipid solubility -renal elmination
56
Carvedilol
-Coreg -B1, B2, a1 (more effect on BP) -BID -high lipid solubility -hepatic elimination
57
Metoprolol succinate and tartrate
-Lopressor and Toprol -B1 -max 200mg (succinate)until B2 effects -Tartrate is BID -mod lipid solubility -hepatic elimination
58
Propranolol
-Inderal -TID or LA qd -high lipid solubility -hepatic elimination
59
B-blockers to avoid
-Pindolol and acebutolol -intrinsic sympathomimetic activity = inc HR at rest
60
B-blocker adverse effects
-sinus bradycardia -sinus arrest -AV block -reduced LVEF -bronchoconstriction -mask hypOglycemia -fatigue -depression -nightmare -sexual dysfunction -exercise intolerance -withdrawal
61
B-blocker withdrawal syndrome
-up regulation of B receptors -inc response to SNS = angina -taper off
62
B-blocker monitoring
-start at lowest dose and titrate up -goal HR: 50-60bpm, <100bpm during exercise or 75% of HR that causes angina -use NTG for painful episodes
63
CCB MOA
-dec influx of Ca in myocytes -dec chronotropy (rate) in nodal cells (less in non-DHPs) -dec inotropy (contractility) in myocytes -vasodilation
64
Myocardial vs vascular selectivity
-non-DHPs have myocardial selectivity = similar effect as B-blockers but also w vasodilation -DHPs bind more in vasculature than heart = vasodilation -nifedipine and amlodipine (DHPs) 10:1 vasc:myocardial selectivity -100:1 in felodipine, isradipine, nicardipine
65
short-acting DHP CCBs
-DO NOT USE EVER -TID versions of nifedipine and nicardipine
66
medium-acting DHP CCBs
-nicardipine BID -isradipine BID -prob not using as often as long acting
67
Long acting DHP CCBs
-amlodipine (Norvasc) -felodipine (Plendil) -nifedipine-CC or XL -Nisoldipine -all qd
68
non-DHP CCBs
-Verapamil -Diltiazem -lots of dif dosage forms
69
DHP adverse effects
-more vascular -hypotension -flushing -HA -dizziness -peripheral edema from arteriolar vasodilation (not fixed by diuretics, lower the dose) -reduced contractility -reflex adrenergic activation
70
non-DHP adverse effects
-more heart related, similar to B-blockers -Verapamil worse than diltiazem -dec contractility -bradycardia -AV block -CONSTIPATION -hypotension -flushing -HA -dizziness
71
CCB monitoring
-lowest dose then titrate up -use NTG for painful episodes -DHP: BP -non-DHP: BP and HR
72
Nitrates
-NitroDur (patch) -NitroBid (ointment) -ISDN tabs (Isordil and ) -ISMN tabs (Ismo and monoket) -other quizlet for dosing
73
Nitrate tolerance
-dec response in presence of continuous nitrates -take a nitrate free period of 10-12 hours (concentration of zero)
74
Nitrate patch education
-apply between elbows and knees -apply to clean, dry, hairless, unbroken skin -dif area each day -ok to shower -do not cut patch
75
NTG ointment education
-like patched -do not rub or masage ointment -dont cover the area
76
Nitrate monitoring
-start at lowest dose and go up -NTG for episodes -reflex tachycardia -dec BP
77
Ranolazine MOA
-inhibit lare Na current in ischemic myocytes -dec intracellular Na = dec Ca influx -does NOT affect HR, BP, inotropy, or perfusion
78
Ranolazine
-500mg BID go up to1000mg BID over 1-2 weeks -add-on therapy when first-lines dont work -add to CCBs, BBs, nitrates -monotherapy only when BP/HR too low w first-line agents
79
Ranolazine stuff
-metabolized by CYP3A4 and CYP2D6 -prone to drug interations -do NOT give w 3A inhibitors: KTZ, ITZ, PIs clarithromycin or inducers: CBZ, RIF, st.johns -limit dose to 500mg BID w moderate inhibitors (DILT!!, VER!!, ERY, FLZ) -inhibits CYP3A
80
Ranolazine adverse effects
-constipation -nausea -dizziness -HA -dose related inc in QT interval (dont use w other drugs w QTC prolongation): arrhythmia and severe tachycardia
81
Case for selecting B-blockers for angina prevention
-first choice if no Contraindications -good for stable HF or hx of MI -good in AFib, high HR, migraines -AVOID in: vasospatiz/prinzmetal's angina, conduction disturbances, cocaine induced MI
82
B-blocker contraindications
-bradycardia (HR<50) -high degree of AV block or sick sinuse syndrome w no pacemaker
83
Place of CCBs in angina prevention
-non-DHPs preferred if containdiactions/AEs to B-blockers -good for chronic lung diseases, HTN, DM, and PVD
84
nonDHP CCB contraindications
-HRrEF -bradycardia -high degree of AV block or sinus syndrome
85
DHP CCB contraindications
-HFrEF -except amlodipine and felodipine u can use those
86
Nitrate place in therapy for angina prevention
-rarely as monotherapy -combo w BB/non-DHPS to reduce nitrate induce HR inc -short acting PRN nitrates are for discomfort
87
Nitrate cautions
-HOCM -severe aortic stenosis -PDI use
88
Clinical conditions that favor BB use
-prior ACS/MI!!! -HF/LVD!!!! -tachycardia -Afib -arrhythmias -migraines -Hyperthyroidism (block SNS response tot thyroid horomones)
89
Clinical conditions that favor CCBs
-HTN -DM -PVD/Raynaud' -severe asthma/COPD -prinzmetal's angina -bradycardia/AV block (DHP) -tachycardia and Afib (non-DHP)
90
Clinical conditions that may limit BB use
-bradycardia -AV block -HF decompensation -severe depression -severe asthma/COPD
91
clinical conditions that may limit CCB use
-bradycardia/AV block, sick sinus syndrome (nonDHPs) -HF -severe hypertrophic obsturctive CM -severe aortic stenosis
92
clinical conditions that may limit use of nitrates
-ED w PDE5 -severe hypertrophic obstructive CM -severe aortic stenosis
93
combo therapies for angina prevention
-nitrates + BB: BB block tachycardia from nitrates -nitrates + non-DHPs: non-DHPs block tachycardia from nitrates -BB and DHP: BB blocks tachycardia from DHPs -AVOID BB and non-DHP bc of reduce HR, inc BB first -triple therapy -add on ranolazine if its not working or HR and BP too low
94
NSAIDs and ASA
-weigh risk benefit -potential GI, CV, and renal impacts -use lowest dose for shortest time -make patient keep a pain/effect diary -try ibuprofen and naproxen w gastroprotection first (low dose) -celecoxib up to 200mg lowkey not that effective,>200mg inc risk -AVOID diclofenac -take ASA at least 2 hours before NSAID -adjunctive tylenol may minimize NSAID needs -weight benefits within a week
95
Tx w no benefit or w potential harm
-postmenopausal HRT (inc thrombo risk) -antioxidants and vitamins -homocysteine/folic acid/B6 or B12 -herbals -NSAIDs -rosiglitazone -chelation therapt
96
Prinzmetal's/Variant?Vasospastic angina
-ischemia/angina occurs at rest -ST elevation -episodes happen in morning usually -not necessarily associated w ASCAD
97
Management of vasospastic angina
-SL NTG for acute -CCBs -Nitrates -combo -AVOID beta blockers

Therapeutics II (Spring) (51 decks)

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