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Pamela - Naplex 2023 > Chapter 29 - Ischemic Heart Disease > Flashcards

Chapter 29 - Ischemic Heart Disease Flashcards

1
Q
  • What is another term for ischemic heart dx?
  • How is it described?
A
  • Angina
  • Chest pain, pressure, tightness or discomfort, usually caused by ischemia of the heart muscle or spasm of the coronary arteries.
  • The chest pain is described as “squeezing,” “grip-like,” “heavy” or “suffocating,” and typically does not vary with position or respiration.
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2
Q

What are the types of angina?

A

1- Stable angina, Stable ischemic heart dx (SIHD)
- Predictable chest pain
- Often triggered by exertion or emotional stress
- Relieved within minutes by rest or with nitroglycerin

2- Unstable angina (UA):
- A type of acute coronary syndrome (ACS);
- A medical emergency
- Chest pain increases (in frequency, intensity or duration)
- Not relieved with nitroglycerin or rest

3- Prinzmetal’s (variant or vasospastic) Angina:
- Chest pain caused by vasospasm of the coronary arteries
- Can occur at rest
- Can be caused by illicit drug use, particularly cocaine.

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3
Q

When are the classic symptoms of SIHD not present?

A

The classic symptoms of SIHD may not be present in:

  • Women
  • Elderly
  • Diabetes

This can lead to misdiagnosis (GERD) or a delay in ttmt.

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4
Q

PATHOPHYSIOLOGY

A
  • Imbalance between myocardial O2 demand (workload) and supply (blood flow)
  • In SIHD, myocardial O2 supply is often decreased due to plaque build up (atherosclerosis) within the inner walls of the coronary arteries.
    – This is known as coronary artery dx (CAD); it causes narrowing of the arteries and reduced blood flow to the heart
  • Myocardial O2 demand inc when the heart is working harder due to an inc HR, contractility or L ventricular wall tension [caused by inc preload (volume of blood returning to the heart) and/or afterload (systemic vascular resistance, or SVR)].
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5
Q

Risk factors for SIHD

A
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Diabetes
  • Obesity
  • Physical inactivity.

To assess the likelihood of CAD and diagnose SIHD, a CARDIAC STRESS TEST is performed.

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6
Q

Diagnosis

A

Cardiac stress test increases myocardial oxygen demand with either:
- Exercise (walking on a treadmill or pedaling a stationary exercise bicycle) or
- IV meds (adenosine, dipyridamole, dobutamine or regadenoson (Lexiscan)

As myocardial O2 demand inc, the pt is monitored for:
- Development of sx (chest pain, dyspnea, lightheadedness)
- Changes in HR and BP
- Transient rhythm disturbances
- ST segment abnormalities on an ECG

  • When the diagnosis of SIHD is certain, coronary angiography can be performed to assess the extent of atherosclerosis & need for revascularization.
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7
Q

EVALUATION OF SIHD
What should you monitor

A
  • History and physical
  • CBC, CK-MB, troponins (I or T), aPTT, PT/INR, lipid panel, glucose
  • ECG (at rest and during chest pain)
  • Cardiac stress test/stress imaging
  • Cardiac catheterization/ angiography
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8
Q

NON-DRUG TREATMENT

A

1) Heart healthy diet
- Saturated fats < 7 % and trans fats < 1 % of total calories
- Adequate intake of fresh fruits and vegetables
- Low-fat dairy products

2) Maintain a BMI of 18.5 - 24.9 kg/m2, and maintain a waist circumference < 35 inches in females and < 40 inches in males.

3) Patients should engage in 30 - 60 min of moderate- intensity aerobic activity 5 - 7 d/w

4) Medically supervised programs, such as cardiac rehabilitation, are encouraged for at-risk patients at 1st diagnosis.

5) Patients who smoke should quit, and secondhand smoke should be avoided.

6) Alcohol intake should be limited to 1 drink/day (4 oz wine, 12 oz beer or 1 oz of spirits) for women and 1- 2 drinks/day for men.

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9
Q

What are the treatment goals for SIHD?

A
  • Improve function (by eliminating chest pain)
  • Prevent future cardiovascular events (MI, HF)
  • Reduce the risk of cardiovascular death
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10
Q

Drug treatment

A
  • Antiplatelet + antianginal drug regimen
  • Antiplatelet ttmt prevents platelets from sticking together & forming a clot that can block an artery & reduce blood flow to the heart.
  • Antianginal ttmt dec myocardial O2 demand or inc myocardial O2 supply
  • Aspirin is the recommended antiplatelet; clopidogrel (Plavix) is used when there is an allergy or other CI to aspirin.
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11
Q
  • When do you combine aspirin with clopidogrel?
  • When do you combine low dose rivaroxaban with aspirin?
A
  • Aspirin + clopidogrel: history of stent placement or recent CABG
  • Low-dose rivaroxaban (Xarelto) + aspirin is FDA-approved to reduce the risk of cardiovascular events in patients with CAD or peripheral artery disease (PAD)
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12
Q

What drugs are first line? What do you use other drugs?

A

1) BB are 1st line

2) If BB are CI or when additional Sx relief is needed use:
– CCBs (DHP and non-DHP), or
– Long-acting nitrates

3) Ranolazine is used as a substitute or in addition to BB

4) Short-acting nitroglycerin (SL) powder or translingual (TL) spray, is recommended for immediate relief of angina in all patients.

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13
Q

2) With what should pts be treated with also?
4) What vaccine should you do

A

1) SIHD is one of the atherosclerotic cardiovascular diseases (ASCVD).

2) Patients should be treated with a high-intensity statin.

3) Hypertension, heart failure and diabetes should be aggressively managed with guideline-recommended treatments, including the use of an ACE inhibitor or ARB to manage hypertension in patients with SIHD and diabetes.

4) An annual influenza vaccine is recommended; pneumococcal vaccines should be administered per ACIP recommendations

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14
Q

Ttmt approach for SIHD

A

A- Anti platelet and antianginal drugs

B- Blood pressure and beta-blockers

C - Cholesterol (statins) and cigarettes (cessation)

D - Diet and diabetes

E- Exercise and education

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15
Q

Antiplatelet drugs MOA

A

1- Aspirin:
- Irreversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes
- This results in dec prostaglandin (PG) and thromboxane A2 (TXA2) production.
– TXA2 is a potent vasoconstrictor & inducer of platelet aggregation.

2- Clopidogrel:
- Prodrug that irreversibly inhibits P2Yl2 ADP-mediated platelet activation and aggregation

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16
Q

Aspirin

  • Brands
  • Dose
A
  • Bayer, Bufferin, Ecotrin

+Omeprazole (Yosprala)

  • Rx: ER capsule (Durlaza), delayed-release tablet (Yosprala)
  • Dose: 75-162 mg daily
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17
Q

Aspirin CI

A
  • NSAID or salicylate allergy
  • Children & teens with VIRAL INFECTION
    —> Due to the risk of Reye’s syndrome (sx: somnolence, N/V, confusion)
  • Rhinitis, nasal polyps or asthma (due to risk of urticaria, angioedema or bronchospasm)
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18
Q

Warnings with aspirin

A
  • Bleeding
    – Including GI bleed/ulceration
    – Inc risk with heavy alcohol use or use with other drugs with bleeding risk (NSAIDs, anticoagulants, other antiplatelets)
  • Tinnitus (salicylate overdose)
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19
Q

Aspirin SE & Monitoring

A
  • SIDE EFFECTS
    Dyspepsia, heartburn, bleeding, nausea
  • MONITORING
    Symptoms of bleeding, bruising
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20
Q

Aspirin:
1) Do we use it for SIHD? Why?
2) Why is aspirin used with low-dose xarelto?
3) What dosage form is preferred in ACS?
5) What is a risk with chronic nsaid use?
6) What is yosprala indicated for?

A

1) Used indefinitely in SIHD (unless contraindicated); dec incidence of Ml, CV events and death

2) Used with low-dose rivaroxaban to reduce the risk of major cardiovascular events (Ml, stroke)

3) Non-enteric coated, chewable aspirin is preferred in ACS; if only enteric-coated (EC) aspirin is available, it should be chewed (325 mg)

4) Durlaza and Yosprala should not be used when rapid onset is needed (ACS, pre-PCI)

To dec nausea, use EC or buffered product or take with food

5) PPls may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (dec bone density, inc infection risk)

6) Yosprala is indicated for those at risk of developing aspirin-associated gastric ulcers

21
Q

Clopidogrel Brand & Dose

A
  • Plavix
  • 75 mg daily

Used in SIHD when there is a CI to aspirin; can be used in combination with aspirin

22
Q

BBW with clopidogrel

A

Poor cyp 2c19 metabolizers

  • Clopidogrel is a prodrug.
  • Effectiveness depends on the conversion to an active metabolite, mainly by CYP450 2C19.
  • Poor metabolizers of CYP2C19 exhibit higher cardiovascular events than patients with normal CYP2C19 function.
  • Tests to check CYP2C19 genotype can be used as an aid in determining a therapeutic strategy.
  • Consider alternative treatments in patients identified as CYP2C19 poor metabolizers.
23
Q

CI with clopidogrel

A

Active serious bleeding (GI bleed, intracranial hemorrhage)

24
Q

Warning with clopidogrel

  • What should you do if the pt had an elective surgery and is on clopidogrel
  • DDI?
A
  • Bleeding risk
  • Stop 5 days prior to elective surgery
  • Do not use with omeprazole or esomeprazole
  • Premature discontinuation (inc risk of thrombosis), thrombotic thrombocytopenic purpura (TTP)
25
Q

SE & monitoring with clopidogrel

A

SE: Generally well tolerated, unless bleeding occurs

Monitoring: Sx of bleeding, Hgb/Hct as necessary

26
Q

Dual Antiplatelet Therapy

A
  • SIHD is usually treated with a single antiplatelet drug (aspirin or clopidogrel}.
  • Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is reserved for those who have had placement of:
    – A bare metal stent (DAPT for at least one month)
    – A drug-eluting stent (DAPT for at least six months)
    – Post-CABG (DAPT for 12 months)
  • Clopidogrel is the only P2Yl2 inhibitor recommended in SIHD.
  • Aspirin is dosed at 81mg daily in DAPT regimens and is continued indefinitely at 75 - 162 mg daily after the course of DAPT is complete.
27
Q

Antiplatelet Drug Interactions

A

■ Most drug interactions are due to additive effects with other drugs that can inc bleeding risk (anticoagulants, NSAIDs, SSRis,SNRis, some herbals).

■ Aspirin: use caution in combination with other ototoxic drugs

■ Clopidogrel: avoid in combination with CYP2Cl9inhibitors omeprazole and esomeprazole (other PPis interact less) and use caution with other CYP2Cl9inhibitors.

28
Q

ANTIANGINAL TREATMENT

A

1) Beta-Blockers: 1st line in SIHD
2) CCB: Preferred for Prinzmetal’s (variant) angina
3) Nitrates
4) Ranolazine (Ranexa)

29
Q

Beta-Blockers moa and clinical notes
- Should you titrate? Can you stop abruptly?
- What beta blocker is preferred?
- When should you avoid them?

A

Reduce myocardial oxygen demand:
- Dec HR
- Dec contractility
- Dec left ventricular wall tension

CLINICAL NOTES
- Start low, go slow
- Titrate to resting HR of 55-60 BPM
- Avoid abrupt withdrawal

  • Beta-blockers without ISA are preferred (metoprolol, carvedilol);
  • Can be used as monotherapy or in combination with DHP CCBs, long-acting nitrates and/or ranolazine
  • Provide mortality reduction and sx improvement
  • More effective than nitrates and CCBs in silent ischemia;
  • Avoid in Prinzmetal’s angina

Beta blockers without ISA:
- Atenolol
- Bisoprolol
- Metoprolol
- Nebivolol
- Esmolol

30
Q

CCB:

  • When are they preferred?
  • How do they work?
  • When are they used?
  • Do we prefer short acting or long acting DHPs?
  • Do we prefer combining BB with dhp or non dhp and why?
A
  • Preferred for Prinzmetal’s (variant) angina
  • Reduce myocardial oxygen demand:
    – non-DHPs dec HR and contractility;
    – DHPs dec SVR (afterload)
  • Increase myocardial O2 supply:
    – All CCBs inc blood flow through coronary arteries
  • Generally used when beta-blockers are CI or as add-on therapy to beta-blockers if continued symptoms
  • Slow-release or long-acting DHPs and non-DHPs are effective;
  • Avoid short-acting DHPs (Nifedipine IR)
  • DHPs are preferred when CCBs are used in combination with beta-blockers
    —> Due to the risk of excessive bradycardia when non-DHPs are used with beta-blockers
31
Q

Nitrates

A
  • Reduce myocardial oxygen demand:
    – Dec preload (free radical nitric oxide produces vasodilation of veins more than arteries)
  • Increases myocardial oxygen supply:
    – Inc blood flow through collateral (non-atherosclerotic) arteries
  • SL tablets, SL powder or TL spray
    – Recommended for all patients for fast relief of angina
  • Long-acting nitrates
    – Long-acting nitrates are used when beta-blockers are contraindicated or as add-on therapy, if continued symptoms; a nitrate-free interval is required to prevent tolerance
32
Q

Ranolazine (Ranexa)

  • MOA
  • CI
  • Warning
  • SE
  • Monitoring
  • Notes
A
  • Selectively inhibits the late phase Na current and dec intracellular Ca;
  • Can decrease myocardial oxygen demand by decreasing ventricular tension and oxygen consumption
  • CI: Liver cirrhosis, do not use with strong CYP3A4 inhibitors or inducers
  • WARNINGS
    – Can cause QT prolongation
    – Acute renal failure observed when CrCI < 30 mL/min
  • SE: Dizziness, headache, constipation, nausea
  • MONITORING: ECG, K, renal function
  • NOTES
    – Not for acute treatment of chest pain
    – Can use in place of beta-blockers or as add-on treatment
    – Has little to no clinical effects on HR or BP
33
Q

Nitroglycerin Formulations Used in SIHD:
Short-Acting Nitrates

A
  • Nitroglycerin SL tablet (Nitrostat)
  • Nitroglycerin TL spray (NitroMist, Nitrolingual)
  • Nitroglycerin SL powder
34
Q

Nitroglycerin Formulations Used in SIHD:
Long-Acting Nitrates

A
  • Nitroglycerin ointment 2% (Nitro-Bid)
  • lsosorbide mononitrate IR/ER tablet
35
Q

Nitroglycerin Formulations Used in SIHD:
CONTRAINDICATIONS

A
  • Hypersensitivity to organic nitrates,
  • Do not use with PDE-5 inhibitors or riociguat

Short-acting nitrates:

  • Inc intracranial pressure
  • Severe anemia
  • Circulatory failure and shock (SL powder only)
36
Q

Nitroglycerin Formulations Used in SIHD:
WARNINGS

A
  • Hypotension
  • Headache
  • Tachyphylaxis (dec effectiveness/tolerance with long-acting products)
  • Can aggravate angina caused by hypertrophic cardiomyopathy
37
Q

Nitroglycerin Formulations Used in SIHD:
SE & Monitoring

A

SIDE EFFECTS
Headache, flushing, syncope, dizziness

MONITORING
BP,HR, chest pain

38
Q

Short-acting nitrates notes

A
  • Used PRN for immediate relief of chest pain
  • Store nitroglycerin SL tablets in the original amber glass bottle and keep tightly capped after each use (to maintain potency)
  • Nitrate tolerance does not develop with SL/TL products
39
Q

Long-acting nitrates notes

A

Require a 10-12 hour nitrate-free interval to dec tolerance (longer for some products)

■ Patch: wear on for 12-14 hours, off for 10-12 hours; rotate sites; dispose of safely, away from children and pets

■ Ointment: dosed BID, 6 hours apart with a 10-12 hour nitrate-free interval

■ lsosorbide mononitrate: IR dosed BID, 7 hours apart (e.g.,8 AM and 3PM)

■ lsosorbide dinitrate: IR dosed BID (same as above) or TID, take at
8 AM, 12 PM and 4 PM for a 14-hour nitrate-free interval (or similar)

■ Take ERdaily in the morning or BID with an 18-hour nitrate-free interval

lsosorbide dinitrate in combination with hydralazine is the preferred formulation for HFrEF

40
Q

Nitrates DDI

A
  • Do not use long-acting nitrates in combination with PDE-5 inhibitors and riociguat;
  • use caution with other antihypertensive medications and alcohol, as these combinations can cause a significant decrease in BP.
  • If only short-acting nitrates are used, they should not be used if a PDE-5 inhibitor was taken recently
    – Avanafil in the past 12 hours
    – Sildenafil or vardenafil in the past 24 hours
    – Tadalafil in the past 48 hours
  • Occasionally, and with careful monitoring, nitrates can be used in an acute emergency in a patient who has recently taken a PDE-5 inhibitor.
    (They both lower BP which is dangerous)
41
Q

Ranolazine Drug Interactions

A

■ Ranolazine is a major substrate of CYP3A4 and a minor substrate of CYP2D6 and P-gp.
It is a weak inhibitor of CYP3A4, 2D6 and P-gp.

  • Do not use with strong CYP3A4 inhibitors or inducers.
  • Limit the dose to 500 mg BID if taking moderate CYP3A4 inhibitors (Diltiazem, verapamil).
  • Limit simvastatin to 20 mg/day if used together.
42
Q

ASPIRIN
counseling

A

■ Can cause:

o Bleeding/bruising
o Dyspepsia
o Allergy
o Tinnitus or loss of hearing with overdose

43
Q

CLOPIDOGREL
counseling

A

■ Cancause:
□ Bleeding/bruising.
□ Thrombotic thrombocytopenic purpura (TTP).

44
Q

ALL NITROGLYCERIN PRODUCTS
counseling

A

■ Can cause:
o Orthostasis.
o Flushing and headache. Often a sign the medication is working. Usually goes away with time.

■ Nitrate-free interval required with long-acting products.

■ Drug interactions with phosphodiesterase-5 inhibitors.

45
Q

SHORT-ACTING NITRATES
counseling

A

■ Take one dose at first sign of chest pain.

■ Call 911 immediately if chest pain persists after the first dose.

– Continue to take two additional doses at 5 min intervals while waiting for the ambulance to arrive.
– Do not take more than three doses within 15 min

46
Q

Nitroglycerin SL Tablets
counseling

A

■ Place the tablet under the tongue or between the inside of the cheek and the gums/teeth, and let it dissolve.
Do not chew, crush or swallow.

■ Slight burning or tingling sensation is not a sign of how well the medication is working.

■ Keep tightly capped in the original amber glass bottle and store at room temperature. Shake out one tablet only; do not let the other tablets get wet

47
Q

Nitroglycerin TL Spray

A

■ Prime before first use and if not used within six weeks.
- Do not shake.
- Press the button firmly to release the spray onto or under the tongue.
- Close your mouth after the spray.
- Do not inhale the spray, and try not to swallow too quickly afterward.
- Do not spit or rinse the mouth for 5- 10 min after the dose.

48
Q

NITROGLYCERIN PATCH

A

■ The chest is the preferred application site, though any area can be selected except the extremities below the knees or elbows.

49
Q

NITROGLYCERIN OINTMENT

A
  • Measure the dose of ointment with the dose-measuring applicator provided.
  • Place the applicator on a flat surface, squeeze the ointment onto the applicator and place the applicator (ointment side down) on the chest or other desired area of the skin.

■ Spread the ointment, using the dose-measuring applicator, lightly onto the skin. Do not rub into the skin. Tape the applicator into place.

■ Can stain clothing. Cover the applicator completely.

Pamela - Naplex 2023 (32 decks)

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