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Cardiovascular Therapeutics > Ischemic Heart Disease > Flashcards

Ischemic Heart Disease Flashcards

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1
Q

Ischemic Heart Disease Definition

A

narrowing of one or more coronary arteries due to atherosclerosis

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2
Q

What is the most known outcome of ischemic heart disease?

A

Heart attack (or myocardial infarction)

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3
Q

What diseases are due to artherosclerosis?

A

Ischemic heart disease (IHD)
Cerebrovascular disease (CVD)
Peripheral arterial disease (PAD)

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4
Q

The major cause of myocardial infarction is….

A

Artherosclerosis in coronary artery –> Coronary artery disease

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5
Q

One cause of cerebrovascular Accident (CVA) or stroke is….

A

Artherosclerosis in cerebral arteries –> Cerebrovascular disease

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6
Q

Peripheral Arterial Disease (PAD) is due to….. and can cause…

A

Artherosclerosis in arteries of the limb and can cause poor circulation, pain, numbness, etc.

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7
Q

Symptoms of Coronary artherosclerosis can present as….

A

Silent (asymptomatic) disease –> most patients!!

Chronic, stable (exertional) angina

Acute coronary syndromes (ACS)

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8
Q

Acute Coronary Syndrome includes…..

A

Unstable angina, NSTEMI, STEMI

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9
Q

Angina Sx

A

Dull, retrosternal discomfort/ache/heaviness

May or may not radiate to jaw, neck, shoulders, arms

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10
Q

What are the two types of angina? What are they a result of?

A

Stable angina is a problem of “demand exceeding supply”

Unstable angina is a result of inadequate “supply regardless of demand

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11
Q

Fixed Obstruction Angina (stable angina) is defined as…

A

An increase in demand that cannot be accommodated with increased supply.

“Demand” for oxygen increases when cardiac myocytes increase energy expenditure

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12
Q

Is stable angina pain associated with plaque rupture?

A

NO

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13
Q

What happens if we increase pre-load?

A

Increase workload

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14
Q

An increase in demand means an increase in these body functions…

A

Heart rate (HR)
Venous return
Blood pressure (BP)
Contractility
(exertion, emotion, mental stress)

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15
Q

An important factor to consider in unstable angina is….

A

Rate of increase of myocardial work (quick onset) can be very important

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16
Q

When are coronary arteries supplied with blood?

A

Diastole

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17
Q

In fixed obstruction, what other vascular problems may present?

A

Endothelial dysfunction (↓ N.O. production)

Microvascular dysfunction (poor response to N.O.)

The role of vasospasm

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18
Q

Stable angina can be relived by….

A

Rest and Nitroglycerin

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19
Q

Nitrates cause….

A

Vasodilation

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20
Q

All nitrates are….

A

Pro-drugs

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21
Q

Nitrates are converted to….

A

Nitric Oxide

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22
Q

What is Nitric Oxide? What does it do?

A

NO is a paracrine hormone synthesized by endothelial cells to signal smooth muscle cells ‘next door’

Relaxes smooth muscle in blood vessel walls (vasodilation)

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23
Q

Do Nitrates drop arterial blood pressure?

A

NO

Targets veins

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24
Q

How does NTG treat stable angina?

A

Primary effect is by reducing pre-load. Blood pools in the veins. Reduce workload of the heart.

High pre-load, greater venous return, frank-starling law, increase workload of heart

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25
Pre-load Definition
Preload is the degree to which the myocardium is stretched before it contracts
26
What is the Frank Starling Law?
The energy (force) of contraction is proportional to the initial length of the cardiac muscle fiber” 
27
An increase preload equals
Increased workload of the heart
28
Class I Angina
- Ordinary physical activity does not cause angina. Occurs with strenous, rapid or prolonged exertion
29
Class II Angina
Slight limitation or ordinary activity. Walking, climbing stairs rapidly
30
Class III ANgina
Marked limitations of ordinary physical activity
31
Class IV Angina
Inability to carry on physical activity w/t discomfort --> angina sx present at rest
32
S-T Depression is indicative of...
S-T depression is a classic sign of cardiac ischemia
33
What is a common way to notice stable angina?
S-T Depression
34
Does S-T depression indicate if myocardial cell death has occured?
Does NOT indicate if myocardial cell death has occurred (i.e., myocardial infarction)
35
ST depression indicates...
ischemia) – does not tell you if any cardiac myocytes have died
36
ST elevation indicates.....
Infarction
37
If the QT interval is delayed, greater the risk for...
Time for ventricular depolarization and repolarization If process is delayed ↑’s risk for ventricular arrhythmias
38
Is stable angina a medical emergency?
NO
39
Cardiac Catheterization and Angiography are used to.....
Commonly performed to evaluate coronary artery blood flow and identify locations of narrowed vessels due to atherosclerosis
40
What is the Core Medication Therapy for patients with cornary artery disease?
ABCDEK Antiplatelets Blood pressure medications (not necessarily for BP) Cholesterol-lowering medications Diabetes medications Exercise/diet/ lifestyle changes (stress, alcohol, tobacco) K-CKD (CKD often present with CAD so always check!)
41
Beta-blockers can be used to help prevent.....
Angina
42
ACE Inhibitors in CAD???
“Consider” in all patients with stable IHD
43
ACE inhibitors should be used in CAD when.....
Prescribe” in all patients with the following indications: Ejection fraction < 40% (i.e., LVSD) *one exception- if they take valsartan/saccubitril Hypertension Chronic kidney dz
44
if a patient has an intolerance to an ACE, what drug can be used?
ARB's
45
In regards to angina, goals of tx should include?
goals of therapy must include BOTH symptom relief AND protection against disease progression and disease outcomes
46
Anti-angina therapy alternatives include....
The following drugs have an indication to prevent or reduce the frequency/intensity of stable angina episodes Beta-blockers DHP CCBs Non-DHP CCBs Nitrates Ranolazine (CorzynaTM) (secondary therapy)
47
Are beta-blockers useful in angina? Why?
Prevents angina through↓ demand
48
When are beta-blockers used first line in stable-angina?
Should be used first-line for stable angina in people with another indication for BB: Post MI (indication for BB) Systolic HF (indication for BB) Typically used first-line for other patients due to evidence in conditions above.
49
Beta-Blockers Dose in Stable Angina?
Dose titrated to a resting HR of 55 to 60 bpm
50
What beta-blockers should be used to prevent angina? Which are preferred? Why?
All BB are effective equally to prevent angina (Class ´ffect) B1 selective agents preferred due to lower risk of: Erectile dysfunction (B2-blockade) Peripheral circulation problems (esp pts with PAD) Interaction with B-2 agonists (i.e., Ventolin) Metoprolol, carvedilol and bisprolol in HfreF Cardioselective if asthma, COPD, DM, or PAD
51
Which Beta-blockers should be avoided?
Avoid BB with ISA (e.g., acebutolol, pindolol)
52
Beta Blockers should be monitored for.....
↓Heart Rate and BP AV block or low HR Signs of poor cardiac output  Exercise tolerance or ↓ Renal perfusion (RAAS / edema etc) Reduced circulation  Caution in Raynaud’s / PAD (esp B2) Respiratory disease (Asthma)  generally safe Diabetes  Can mask hypoglycemia; Blood sugar ↑?
53
Non-slective beta and alpha blockers examples. BP Effect, useful in stable angina?
Carvedilol (Coreg) and Labetalol (Trandate) Non-selective (B1 and B2 inhibition) AND Alpha1-receptor inhibition (vasodilatory effect) Greater fall in BP expected compared to other beta-blockers Not typically used for stable angina (unless complications exist)
54
Non-DHP CCB's Examples
Diltiazem and Verapamil
55
Non-DHP CCB's tx effect compared to BB's
Same therapeutic effect as BBs - Main difference is intensity of action (reducing cardiac workload, peak HR does not get as high, prevent heart attack)
56
Non-DHP CCB Adverse Effect
Constipation can occur in 1/10 patients ESPECIALLY VERAPAMIL
57
Non-DHP CCB's inhibit....
Inhibits 3A4 (also a substrate)
58
Avoid Non-DHP CCB's in....
systolic dysfunction (low EF/systolic HF)  Can increase the risk of HF exacerbation (One key difference between BB and Non-DHP CCBs) Already using BB (not an ideal combination) Bradycardia or AV block
59
Heart Block/AV Block is diagnosed by....
AN ECG
60
1st Degree AV Block ECG
-P-R interval Delay --> Time from atrial contraction to ventricular contraction is delayed AV Nodal conduction
61
2nd Degree AV Block
Intermittently dropped QRS
62
3rd Degree AV Block
P and QRS are independent
63
What types of AV Block are C.I. to beta-blockers and/or Non-DHP CCB?
2nd or 3rd degree AV block is a contraindication to beta-blockers and/or non-DHP Calcium channel blockers **UNLESS a ventricular pacemaker is present
64
What can occur in a pt from Non-DHP CCB's and/or BB's?
Bradycardia or first degree heart block can occur from Non-DHP CCB or BB
65
DHP CCB's for stable angina?
Vasodilator Good tolerability
66
BB and DHP CCB's Interaction with each Other
Can be safely combined with BB if symptoms persist (notwithstanding BP lowering effects)
67
DHP CCB's over BB's are a good alternative for...
Good alternative as monotherapy for patients with bradycardia or intolerance to BB
68
Considretaions for which CCB to use for stable angina?
All CCbs are equally effective DHP's have less decraesed HR than non-DHP DHP's useful if HR is already low If already on BB, add DHP-CCB rather than non-DHP AVoid non-DHP in HF Less constipation with diltiazem vs Verapamil
69
Nitrates can be used....
Can be used as: treatment (prn use – spray/s/l tablets) or prevention (typically with NTG patch*) Nitrate-free interval required to maintain efficacy
70
Why is a nitrate-free interval required?
Tolerance is possible - Varies from patient to patient (not predictable) Nitrate-free interval of 10-14 hours every day appears to prevent tolerance from occurring
71
How long does it take for NTG to work? When should it be taken?
PRN NTG can be used BEFORE activities that are known to cause angina (take 2-5 min before – should last 30 min)
72
S/e of NTG
Headache most common s/e – quite common. Tolerance to headache usually occurs within 2 weeks (acetaminophen may be used) Low blood pressure/orth hypotension possible but not common Patches may cause skin irritation, redness, etc. Rotate site every day.
73
C.I. of Nitrates
PDE5 inhibitors 24hrs for sildenafil/vardenafil; 48hrs for tadalafil) Caution with BP lowering drugs
74
Combo Options to consider for help if angina pain persists
Metoprolol + NTG patch Metoprolol + Amlodipine Increase Metoprolol dose (Reasonable approach not like HTN) Switch metoprolol to monotherapy of another agent Ranolazine…. Add on BB + NTG BB + DHP-CCB Increase BB
75
If blood pressure is low, DOC
Nitro
76
If blood pressure is high, DOC
Amlodipine
77
What are the common options to treat coronary artherosclerosis?
Medical therapy Continue with drugs Revascularization
78
What are the types of revascularization?
Coronary artery bypass grafting (CABG) Percutaneous Coronary Intervention (angioplasty/stent implantation) Fibrinolytic medications (only for acute emergencies such as myocardial infarction – used much less frequently currently)
79
CABG
Invasive  Requires open heart surgery
80
PCI is
percutaneous coronary intervention
81
What is the most common medical tx for stable angina? What does it treat?
PCI Very effective  Increasing supply  Will cure the angina but not the the coronary artery disease
82
DAPT stands for and is....
Dual Antiplatelet Therapy Refers to the use of ASA + a P2Y12 inhibitor (ADP inhibitor)
83
What is the difference between BMS and DES?
Originally, only bare metal stents were used (BMS) Stents often elute drug now (Drug Eluting Stents - DES) Drug coating (in DES) is usually an immunosuppresant to ↓ inflammatory cytokines and cell proliferation following stent implantation
84
What is thr risks associated with longer and shorter DAPT durations?
Longer DAPT = ↑ risk of bleeding Shorter DAPT = ↑ risk of events
85
How long do people often get DAPT for?
1 Year
86
In the setting of SIHD (stable ischemic heart disease) DAPT ise recommended....
In the setting of SIHD, DAPT is recommended after PCI
87
All DAPT evidence is based on....
Clopidogrel + ASA
88
Monitoring DAPT includes....
Clinical signs of bleeding Bloody stools, melena (dark stools), hematemesis, bruising**, oozing from injuries General tolerability GI upset Laboratory testing RBC, Hb, Hct, platelet count (q6 months)

Cardiovascular Therapeutics (5 decks)

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