CV 16 Flashcards by Aleena Unknown

Obstructive CAD

greater than 50% diameter stenosis and fractional flow reserve less than 0.8 during coronary angiography

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INOCA

ischemia with no obstructive coronary arteries. Syndrome of pts with either symptoms and/or signs or ischemia but found to have no obstructive coronary artery disease (CAD)

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Vasospastic Angina

reproduction of angina symptoms, ischemic ECG changes with greater than 90% constriction in major epicardial artery

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Microvascular Angina

No obstructive CAD plus objective evidence of coronary microvascular dysfunction (as defined by abnormal response to intracoronary acetylcholine and/or systemic adenosine)

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CAD

build up of fat and cholesterol which causes plaques in the coronary arteries, resulting in blocks of blood flow to the heart

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what is angina/ischemia

chest pain or discomfort caused by CAD, when the heart muscle doesnt get adequate blood supply

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Class 1 recommendation

Benefit > risk , is recommended, strong

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Class 2a recommendation

benefit > risk, moderate, suggested

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Class 2b

Weak, benefit greater than or equal to risk, can be considered.

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class 3 moderate

no benefit, benefit = risk. not recommended

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class 3 strong

risk > benefit, potentially harmful

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risk factors for MACE

age, male sex, poor social support, poverty, access

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Risk factors for MACE Medical history

elevated BMI, previous MI, HF, AF, DM, dyslipidemia, CKD, smoking, depression, poor adherance to therapy

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4 goals of treatment for CCD

decrease cardiac death, nonfatal ischemic events, disease progression, symptoms and functional limitations

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In patients with CCD, no NHP and supplements help

NO!

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what type of diets should be recommended to CCD patients

vegetables, fruits, whole grains, lean protein.

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Anti-anginal therapy for symptom relief

nitrates (SL and long acting products)
Beta Blockers
Calcium Channel Blockers
2nd line: Novel anti-anginals (ranolazine, ivabradine only if HFrEF

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Therapy to prevent MI/Death

Anti-platelets (ASA +/- Clopidogrel/ticagrelor)
anti thrombotic agents (riveroxaban)
beta blockers (only if recent MI or HFrEF)
RAAS blockers (ACEI or ARB)
Immunization
Colchicine

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what do you do if someone has vasospastic angina

dont treat with beta blockers, first with CCB then nitrates if still symptomatic

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which drugs to avoid in vasospastic angina

drugs that cause vasospasm
- non selective beta blockers
- triptans for migraines
- 5-fluorouracil

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NYHA classifications Class 1

Mild, no symptoms, can perform ordinary activities without any limitations

NYHA Class II

mild - light limitation of ordinary activity, no symptoms at rest, ordinary activity results in symptoms

NYHA class III

moderate - Marked limitation of physical activity, no symptoms at rest, less than ordinary activity results in symptoms.

NYHA Class 4

severe - unable to do any physical activity without discomfort
symptoms at rest

CCS Classification, more specific for Class 2 ad CLass 3

Class 2 - symptoms with walking greater than 2 level blocks and climbing greater than 1 flight of stairs at normal pace in normal conditions Class 3 - symptoms with walking less than/=to 2 blocks or climbing less than/=to 1 flight of stairs at normal pace in normal conditons

main goal of anti-anginal therapy

prevent episodes of angina and relieve symptoms

main goal of secondary prevention treatment

prevent CV events and death

what class of agents is most effective in preventing angina

none, but more SE with beta blockers

3 Steps for medical therapy for angina patients with CCD

BB, CCB, LAN, then if symptoms continue, add a second antianginal from a differnet class, then add ranolazine for patients who remain symptomatic.

what is recommended for short term immediate relief of angina

sublingual nitroglycerin or nitroglycerin spray.

is ivabradine recommended?

only in patients with HFrEF, can be harmful in those with normal LV function.

three main CI of beta-blockers

heart rate less than 60bpm systolic arterial pressure <100mmHg asthma mod or severe LV failure

which is the most cardioselective agent

bisoprolol

Beta 1 side effects

hypotension, bradycardia, cardiac failiure

beta 2 effects

bronchospasm, vasoconstriction, cold extremities, hyperglycemia, hypoglycemia

two non dihydropridine agents CCB + side effects

verapamil, diltiazem decreased AV node conduction Decreased intropy and chronotropy

3 dihydropyridine CCB + SE

amlodipine, felodipine, nifedipine XL peripehral vasodilation

main side effects and CI with CCB

constipation dont use SL or Short acting Nifedipine due to reflex tachycardia Avoid use of non DHP CCB with other AV nodal blocking agents like beta blockers Avoid use of non-DHP CCB in HFrEF

nitrate tolerance

continuous use of nitrates >24 hours decreases hemodynamic effects and antianginal effects, recommend 10-12 hours of nitrate free interval and dont use as MONOTHERAPY

Nitrate CI

severe hypotension interaction with phosphodiesterase inhibitors - sildenafil, vardenafil, tadalfil.

Ivabradine key points

direct and selective inhibitor of the IF current in the sinoatrial node. limits its use to patients iwth sinus rhythm(exludes pts in AF or atrial flutter)

If HR is fast, which CCB is preferred

non-DHP CCB

If no indication for OAC, what is recommended

ASA 81mg, if they have had ACS, DAPT

what is recommended as an alternative to aspirin

clopidogrel 75mg daily

when can ASA + Clop be used in combo

post MI or PCI

BB recommendations

if you are more than a year out from your MI, you should not be on a BB. no benefit of a BB in pts who haveavnt had an MI and dont have HFrEF

ACE evidence

in pts with hypertension and DM, ACE, ARBS should be used! In pts without, can be considered.

Low DAPT score

less than 2

high dapt score

greater than or equal to 2

adding a second antithrombotic drug to aspirin for long-term secondary prevention should be considered in pts with

high risk of ischaemic events and without high risk of bleeding.

for patients starting warfarin, what should be considered

stop ASA if no recent ACS or extensive symptoms.