Ischemic Heart Disease Flashcards
(98 cards)
0
Q
What is a localized spasm or pain?
A
angina
1
Q
[SATA] Which of the following can increase oxygen demand? A. Hyperthyroidism B. Sickle cell disease C. Tachycardia D. Hypertension
A
A,C,D
B. decreases oxygen supply
2
Q
What is pain or discomfort in the chest caused by plaque that narrows or blocks the coronary arteries?
A
Angina pectoris
3
Q
How is angina diagnosed?
A
- Clinical history
- Noninvasive testing (resting ECG, exercise ECG, exercise and pharmacologic stress echocardiogram)
- Coronary angiography
4
Q
What do all of these have in common: Hyperthyroidism HTN Sympathomimetic toxicity (cocaine use) Aortic Stenosis Tachycardia Anxiety Hyperthermia
A
INCREASE O2 demand
5
Q
What do all of these have in common: Anemia Hypoxemia (pneumonia, asthma, COPD, pulmonary HTN, OSA) Sickle cell disease Hyperviscosity Leukemia Thrombocytosis Aortic stenosis
A
DECREASE O2 supply
6
Q
What is myocardial O2 supply dependent on?
A
coronary blood flow
perfusion pressure
arterial O2 content (decrease in anemia, CO, poisoning, cyanotic congenital heart disease)
7
Q
__________ varies with HR, SBP, contractility, LV wall stress.
A
Myocardial O2 demand
If you decrease these factors, you decrease myocardial O2 demand
9
Q
What are three types of angina?
A
- Chronic stable angina (CSA)
- Unstable angina (UA)
- Prinzmetal’s variant angina
10
Q
Ischemia
A
condition in which the blood flow restricted to a part of the body
11
Q
myocardial ischemia
A
. . .
12
Q
IHD
A
Ischemic Heart Disease: inadequate circulation of blood to the myocardium which is caused by narrowed coronary arteries aka: CHD and CAD
13
Q
Angina pectoris
A
pain or discomfort in the chest caused by plaque that narrows or block the coronary arteries
14
Q
CSA
A
chronic stable angina
15
Q
UA
A
unstable angina
16
Q
variant angina
A
Prinzmetal’s variant angina
17
Q
Risk factors of IHD
A
HTN Dyslipidemia obesity metabolic syndrome cigarette smoking physical inactivity DM microalbuminuria eGFR < 60 mL/min Age FH of premature CVD
18
Q
What determine myocardial oxygen supply?
A
O2 carrying capacity
Coronary vascular resistance
Diastolic perfusion pressure
19
Q
What determine myocardial oxygen demand?
A
Heart rate
Contractility
Intramyocardial wall tension
20
Q
Myocardial O2 demand varies with:
A
HR
SBP (Afterload)
Contractility
LV wall stress (preload)
21
Q
Myocardial O2 supple depends on:
A
Coronary blood flow
perfusion pressure
arterial O2 content
22
Q
When is arterial O2 content decreased?
A
anemia
CO poisoning
cyanotic congenital heart disease
23
Q
[SATA] Which of the following can exacerbate ischemia by increasing myocardial O2 demand? A. Aortic stenosis B. tachycardia C. hyperthermia D. anxiety E. Sickle cell disease
A
A. B. C. D.
24
Q
[SATA] Which of the following can exacerbate ischemia by decreasing myocardial O2 supple? A. Aortic stenosis B. tachycardia C. hypoxemia D. leukemia E. Sickle cell disease
A
A, C, D, E
25
Pneumonia, Asthma and COPD can all decrease O2 supply and are examples of __________.
hypoxemia
26
Angina
a localized spasm or pain
27
How can you diagnose angina?
Clinical history
noninvasive testing (ECG)
coronary angiography
28
MC is a 66 year old male who presents to clinic with pressure or burning over the sternum that radiates to his back and left shoulder. He says his chest discomfort lasts 5-7 minutes. It is usually brought on by exercise and cold weather and the intensity is always the same. His PMH includes HTN, Dyslipidemia, and DM. Result of resting ECG is normal.
• Which statement is the MOST likely diagnosis for MC?
A. Unstable angina
B. Chronic stable angina
C. Silent ischemia D. Variant angina
B
29
Describe CSA.
when a pt has increased O2 demand but not enough O2 supply
symptoms are the same each time
chest discomfort is usually predictable
30
What are some symptoms in CSA?
pressure, heaviness or squeezing in the anterior chest area, pain may radiate to the neck, jaw, shoulder, back or arm
Chest discomfort +/- SOB, N/V, sweating
31
What can you treat a patient with CSA to relieve symptoms?
rest
sublingual NTG
(pain should be relieved in minutes)
32
When does chest discomfort usually occur in pts with CSA?
Physical exertion (running, sex)
Mental or emotional stress
Cold weather
33
What are signs of CSA?
– PE often normal (CSA)
– During episodes of ischemia may be abnormal heart
sounds
– Splitting of the 2nd heart sound, loud 4th heart sound (may be present)
34
Describe UA.
pain lasts longer ( > 20 min)
came on quickly and each time the pain occurs, it is worse
harder to treat with rest/meds
35
When will you see ECG abnormalities?
in high risk UA pts
36
CSA is primarily caused by:
increase in O2 demand (usually with exertion)
37
_____ has a greater risk for MI and death and requires more aggressive treatment.
A. CSA
B. Variant Angina
C. UA
C. UA
38
What usually causes UA?
acute decrease in coronary blood flow --> LOW O2 supply
39
Describe Prinzmetal's variant angina.
• Unpredictable and spontaneous
• Occurs in patients without CHD
• Due to spasm of the coronary artery
• Usually occurs at rest
• Painful attacks usually occur between midnight and 8 am
– Chest and jaw pain, SOB
• ST elevation on ECG; when given NTG, ECG
returns to normal
• Patients are usually younger or smokers
40
Typical angina is classified as:
(1) Substernal chest discomfort
(2) Characteristic quality and duration that is provoked by exertion or emotional stress
(3) relieved by rest or nitroglycerin
41
Atypical angina is classified as
2 of the following characteristics:
(1) Substernal chest discomfort
(2) Characteristic quality and duration that is provoked by exertion or emotional stress
(3) relieved by rest or nitroglycerin
42
Non-cardiac chest pain is classified as
≤ 1 of the following characteristics:
(1) Substernal chest discomfort
(2) Characteristic quality and duration that is provoked by exertion or emotional stress
(3) relieved by rest or nitroglycerin
43
The five components commonly used to characterize chest pain are:
– Quality
– Location
– Duration of pain
– Factors that provoke pain – Factors that relieve pain
44
What are the goals of therapy for pts with angina?
* Relieve Symptoms
* Reduce or eliminate risk factors
* Reduce the risk of mortality and morbidity
* Prevention or slowing of disease progression
* Prevention of future cardiac events (MI, unstable angina, need for revascularization)
* Improvement in survival
45
How do we achieve therapeutic goals for angina pts?
Variety of ways:
• Non-pharmacologic & lifestyle measures
• Medical therapy
• Interventional approaches
– Percutaneous coronary intervention (PCI)
– Surgical revascularization with CABG
46
What are some primary and secondary prevention therapies for angina?
```
Lifestyle ∆
anti-platelet therapy (ASA, Plavix)
ACEI/ARB
BB
Statin
```
47
What are some anti-angina therapies?
BB
CCB
Nitrates
48
What are 3 of the primary strategies for preventing ACS and death?
1. modify CV risk factors (lifestyle ∆ & drug therapy)
2. slow progression of coronary atherosclerosis
3. stabilize existing atherosclerotic plaques
49
List 6 of the class I recommendations for treatment of IHD risk factors.
* Treat HTN
* Smoking Cessation
* DM management
* Lower LDL
* Weight reduction
* Influenza vaccination
50
What are 2 interventional approaches to IHD?
• Percutaneous Coronary Intervention (PCI)
– Bare metal stent placement – Drug-eluting stent
• Coronary Artery Bypass Graft Surgery (CABG)
51
According to ACC & AHA all patients with stable exertion angina pectoris should be given which drugs unless contraindicated: (IA recommendation)
```
ASA (aspirin)
BB
ACEI/ARBs
LDL lowering therapy (statins)
SL NTG (Ib)
CCB/ long acting nitrates (Ib)
```
52
What is the MOA of aspirin?
inhibits cyclooxygenase and inhibits platelet activation and aggregation
53
_____ should be considered for all patients with CSA especially if they have a history of MI.
ASA
54
What is the proper dose for ASA?
81 mg/ day (cardioprotective)
55
If aspirin is contraindicated what anti-platelet can you give your CSA pt?
Clopidogrel (plavix)
56
Which drug class is effective for both primary & secondary prevention of IHD- related events?
statins
57
```
ACEIs should be considered in IHD pts who have:
A. DM
B. LV dysfunction
C. history of MI
D. all of the above
```
D
58
What are the most effective agents in anti-angina or IHD therapy? Why?
BB
CCBs
Nitrates
They provide symptomatic relief by decreasing myocardial O2 demand
59
• Which of the following medications should be given to MC (in the previous case) to relieve his chest discomfort acutely?
A. Diltiazem
B. Immediate release Nifidipine C. Sublingual Nitroglycerin
D. Atenolol
C
60
```
_____________ are 1st line treatment to terminate acute episodes of angina.
A. BB
B. Short-acting nitrates
C. Long-acting nitrates
D. ASA
```
B. Short-acting nitrates
61
How do nitrates effect exercise tolerance and time to onset of angina?
increase both
62
How do nitrates decrease O2 demand?
VD (decrease preload and afterload) which decreases cardiac work --> decreases O2 demand
63
How do nitrates increase O2 supply?
by dilating epicardial coronary arteries and relieving vasospasm
64
What are some drug-drug interactions with nitrates?
Antihypertensives,CCBs,phenothiazines, vasodilators: additive hypotensive effects.
65
What are some drug-lifestyle interactions that can occur with nitrates?
alchohol (additive hypotensive effects)
Nitrates + phosphodiesterase type 5 inhibitors [sildenafil (Viagra),vardenafil (Levitra), tadalefil (Cialis)] →↑ cyclic GMP mediated vasodilation → serious hypotension and even death.
66
What are some contraindications with nitrates?
nitrates+ sildenafil or vardenafil within 24 hours, and tadalefil within 48 hours.
67
SL NTG is the therapy of choice for:
– Acute anginal episodes
| – Prophylactically for activities known to elicit angina
68
What is the onset of action for SL NTG?
works within several minutes
69
What is the initial dose for SL NTG?
0.3 mg
70
How do you counsel your pts on using SL NTG?
you can used 0.3 mg sublingually q 5 min prn up to 3 doses before calling EMS
71
According to the 2004 ACC/AHA guidelines when should you contact EMS with chest pain?
if chest pains do not improve after the first dose of SL NTG
72
If you are counseling your pts on how to take SL NTG to prevent angina, what should you tell them?
take 2-5 min before the activity known to cause angina
73
If pts cannot take SL NTG, what other drug can you give them?
SL-ISDN
74
What does SL-ISDN mean?
Sublingual Isosorbide dinitrate
75
What is the proper dose for SL-ISDN?
2.5-5 mg every 5-10 minutes x 3 doses/15-30
| min
76
What is the onset of action for SL-ISDN?
~3 min
77
What is the duration of action for SL-ISDN?
~1-2 hours
78
What is the half-life for SL-ISDN?
~1 hour for parent drug
79
Why would you treat a pt with chronic nitrate therapy?
* to prevent or decrease the frequency of angina
| * to improve exercise tolerance
80
what is problem that can occur with chronic nitrate therapy?
Tolerance (needs a 12-14 h nitrate free interval daily to work)
81
What is the proper dose range for ISDN immediate release?
10-40 mg 2-3 times daily
– 10 mg at 8 AM, 1 PM, 6 PM (14 hr free interval)
– Alternate dose: bid at 8 AM and 4 PM
82
What is the proper dose range for ISDN sustained release?
40 mg 1-2 times daily (nitrate free interval of 18 hours is recommended)
83
What is the onset of action for Isosorbide mononitrate?
30-60 min
84
What is the proper dose range for ISMN regular release?
5-20 mg BID (at least 7 hours
| apart ex. 20 mg at 8 am and 20 mg at 3 pm)
85
What is the duration of action for regular release Isosorbide mononitrate?
≥ 6 hours
86
What is the proper dose range for ISMN extended release?
30 mg once daily → 60 mg once daily in AM
87
How many days should you wait before increasing the dose for ISMN?
3 days
88
What is the max dose for ISMN?
240 mg once daily
89
What is the duration of action for extended release Isosorbide mononitrate?
≥ 12-24 hours
90
When is ISMN useful?
in pts with effort-induced angina
91
If a pt has a transdermal NTG patch, how long must they remove it for the nitrate free period?
10-12 hours
92
How should you counsel a pt with a transdermal NTG patch?
must remove patch of 10-12 hours (ex. apply at 8 am and remove and 8 pm)
93
For pts with nocturnal angina, what should you suggest for patch removal?
Apply at 8 pm and remove at 8 am
94
What is the dose regimen for pts with a transdermal NTG patch?
begin with 0.2 mg/hr and increase to 0.8 mg/hr prn
95
What are side effects of NTG?
```
• Due to vasodilation
– Headache (sometimes throbbing)
– Light headedness, dizziness, weakness
– Flushing, orthostatic hypotension, tachycardia, ankle edema
• Tends to improve with time
```
96
Slide 64
. . .
97
______ consistently lower morbidity and mortality in HF and MI
ACE Inhibitors
98
Albuterol : Asthma :: _______ : Angina
SL NTG
