Ischemic heart disease

Question 1

modifiable risk factors

Answer 1

smoking 
dyslipidemia
diabetes
hypertension 
chronic kidney disease
physical inactivity 
poor diet
obesity 
depression 
drugs

Question 2

nonmodifiable risk factors

Answer 2

men over 40 
women over 50 or postmenopausal 
male sex
family history of premature CV disease
ethnicity

Question 3

difference between stable and unstable angina

Answer 3

in stable there is a fixed atherosclerotic plaque that has a thick fibrous cap
in unstable the plaque is disrupted

Question 4

define ischemia

Answer 4

mismatch between coronary oxygen supply and demand

Question 5

what can increase myocardial oxygen demand

Answer 5

heart rate
contractility
intramyocardial wall tension

Question 6

3 examples of causes of increased oxygen demand

Answer 6

tachycardia
hypertension
hyperthyroidism

Question 7

what can affect myocardial oxygen delivery

Answer 7

coronary blood flow
oxygen extraction
oxygen availability

Question 8

examples of decrease oxygen delivery

Answer 8

coronary artery disease, anemia, COPD

Question 9

clinical symptoms of chronic stable angina

Answer 9

chest pain - pressure, squeezing, crushing, tightness
shortness of breath 
sweating 
nausea
weakness
gradual onset

Question 10

where and how long do the symptoms last

Answer 10

.5-30min

left sided radiation to arm, shoulder, jaw

Question 11

precipitating factors for chronic stbale angina

Answer 11

exercise
cold
walking after a large meal 
emotions
coitus

Question 12

chronic stable angina response to nitro

Answer 12

relief of pain within 45s to 5 min

Question 13

describe ccs class 1 angina

Answer 13

ordinary physical activity doesnt cause angina

angina with strenuous exertion

Question 14

describe ccs class 2 angina

Answer 14

slight limitation of ordinary activity

angina from walking more than 2 blockd or climbing more than 1 flight of stairs

Question 15

ccs class 3 angina

Answer 15

marked limitations of ordinary physical activity

angina walking 1-2 blocks and climbing 1 set of stairs

Question 16

ccs class 4 angina

Answer 16

inability to carry any physical activity without discomfort anginal symptoms at rest

Question 17

what is the diagnosis of stable angina based on

Answer 17

symptoms
risk factors
diagnostic tests

Question 18

what is the stress test

Answer 18

measures the hearts reaction to increased oxygen demand
exercise or pharmacologic agents to induce stress
ECG and BP taken before during an after stress induced

Question 19

what is the mibi stress test

Answer 19

use of radioisotope with stress test
imaging taken to record pattern of radioactivity distribution to various parts of myocardium
difference in uptake in certain areas indicate potential ischemic sites

Question 20

what is echocardiography and when is it indicated

Answer 20

measures left ventricular systolic function

indicated when heart failure suspected

Question 21

what is an angiogram

Answer 21

contrast material that can be seen using xray equipment is injected into the coronary arteries to visualize blood flow through the heart
catheter through the femoral up to the heart
provides real time visualization of coronary blood flow

Question 22

who is angiogram indicated for

Answer 22

patients with high risk features during stress test or if severe angina, diabetic

Question 23

how do you describe pain (PQRST)

Answer 23

provoking factors 
quality of pain 
region 
severity 
timing

Question 24

goals of therapy

Answer 24

relieve acute symptosm 
prevent recurrent symptoms 
maintain activity level and quality of life 
reduce CV complications 
minimize risk of death

Question 25

how do beta blockers reduce cardiac oxygen demand

Answer 25

decrease heart rate, contractility, and intramyocardial wall tension

Question 26

what is first line for treatment of chronic stable angina

Answer 26

beta blocker

Question 27

abrupt withdrawal of BB may increase severity and number of pain episodes so what should you do

Answer 27

taper over 10-14 days

Question 28

what might beta blockers worsen the symptoms of

Answer 28

reactive airway disease | peripheral artery disease

Question 29

what can happen after chronic use of beta blockers

Answer 29

changes the beta receptors, if dont taper off could have rebound ischemia

Question 30

why should you caution beta blockers in diabetes

Answer 30

may worsen hyperglycemia by inhibiting insulin release on pancreatic beta cells masks symptoms of hypoglycemia**

Question 31

which beta blockers should you avoid in severe angina

Answer 31

agents with intrinsic sympathic activities

Question 32

what dose does metoprolol lose its selectivity

Answer 32

200mg/day

Question 33

which beta blockers have evidence for decreasing mortality post mi

Answer 33

timolol propranolol metoprolol

Question 34

cardio selective beta blockers

Answer 34

atenolol bisoprolol metoprolol

Question 35

non selective beta blockers

Answer 35

nadolol propranolol timolol

Question 36

mixed alpha and beta blocker

Answer 36

carvediol | note: more orthostatic hypotension

Question 37

cardioselective and vasodilatory beta blocker

Answer 37

nebivolol

Question 38

atenolol dose

Answer 38

25-100mg daily

Question 39

bisoprolol dose

Answer 39

2.5-10mg daily

Question 40

metoprolol dose

Answer 40

50-200 mg daily

Question 41

nadalol dose

Answer 41

40-120mg daily

Question 42

propranolol dose

Answer 42

40-160mg daily

Question 43

propranolol LA dose

Answer 43

80-320mg daily

Question 44

timolol dose

Answer 44

10-40mg daily

Question 45

carvedilol dose

Answer 45

25-50mg daily

Question 46

nebivolol dose

Answer 46

5-20mg daily

Question 47

how do ccb decrease cardiac oxygen demand

Answer 47

decrease conduction veolcity through sa and av nodes decrease bp through atrial dilation decrease wall tension and myocardial contractility

Question 48

how do ccb improve coronary blood flow

Answer 48

vasodilates coronary arteries decrease coronary vascular resistance precents vasospasm

Question 49

ccb is as effective as beta blockers in preventing angina but why isnt it first line

Answer 49

hasnt been shown to improve survival after mi

Question 50

difference between dihydropyridine and non dihydropyridines

Answer 50

dhp - do not decrease av node conduction or contractility, more peripheral vasodilation non dhp: act more centrally decreasing contractility

Question 51

example of dihydropyridine

Answer 51

amlodipine | nifedipine

Question 52

example of non dihydropyridine

Answer 52

verapamil and diltiazem

Question 53

what ccb can you use in combo with beta blockers

Answer 53

dihydropyridines only | nondhp would double the effects on the heart

Question 54

side effects of ccb

Answer 54

``` hypotension flushing headache dizziness peripheral edema ```

Question 55

non dhp side effects

Answer 55

bradycardia worsening heart failure verapamil - constipation

Question 56

diltiazem dosing

Answer 56

IR: 60mg tid ER: 120-360 daily

Question 57

verapamil dosing

Answer 57

IR: 80 mg tid SR: 120-180 daily

Question 58

amlodipine dosing

Answer 58

5-10mg daily

Question 59

nifedipine dosing why only use XL

Answer 59

30-60 daily avoid IR due t increased risk of mi/stroke

Question 60

how do nitrate reduce myocardial oxygen demand

Answer 60

venodilation and arterial-arteriolar dilation | dilate coronary arteries - increase coronary blood flow

Question 61

how and what nitreates are used for acute anginal attacks

Answer 61

sublingual, buccal, spray rapidly absorbed | relieves pain in 3-15 min

Question 62

how are nitrates used to prevent effort or stress induced attacks

Answer 62

use 5 min prior to activity lasts for 30 min

Question 63

long acting nitrates are used for what

Answer 63

3rd line for controlling angina symptoms | combo with beta blocker or ccb

Question 64

2 long acting formulations

Answer 64

isosorbide dinitrate | transdermal nitroglycerin

Question 65

why arent nitrates first line

Answer 65

havent been shown to reduce mortalitiy in patients with CAD | relieves symptoms but does not improve outcomes

Question 66

side effects of nitrates

Answer 66

headache - take tylenol normally subsides flushing hypotension

Question 67

tolerance can develop i taking nitrates for 7-10 days how do you manage this

Answer 67

nitrate free period 8-12 hr | recommend taking in the morning then wont need it at night so that can be nitrate free period

Question 68

interaction with nitrates

Answer 68

phosphodiesterase inhibitors - sildenafil

Question 69

dosing not nitro sublingual/spray

Answer 69

.4mg q5min prn

Question 70

nitro transdermal dosing

Answer 70

.2mg/h patch removed daily start | max .8mg/h patch daily

Question 71

isosorbide dinitrate dosing

Answer 71

SL: 5mg q5min prn IR: 10-30mg tid

Question 72

isosorbide mononitrate dosing

Answer 72

ER: start 30-60 mg daily | max 240g daily

Question 73

***** COUNSELLING FOR NITRO PUMP SPRAY

Answer 73

do not shake, store away from light prime by spraying 5 times be seated release spray onto or under tongue, close mouth, do not inhale the spray do not expectorate or rinse the mouth for 10-15 min contact 911 if does not relieve angina prime again if unused for 6 weeks use prophylactically as needed make sure not expired and refill when needed

Question 74

**** counselling for nitro sublingual tablet

Answer 74

``` keep in original dark container, do not store in bathroom be seated put under tongue do not swallow contact 911 if does not relieve angina use prophalactically as needed good for 6 months after opened ```

Question 75

what are secondary prevention agents

Answer 75

antiplatelet - asa, clopidogrel statins acei revascularization - ptca, cabg

Question 76

what is the use for antiplatelets in ischemic heart disease

Answer 76

prevent thromus formation

Question 77

dose for asa

Answer 77

75- 325 mg daily

Question 78

dos of clopidogrel and when do you use it

Answer 78

75mg daily | when cant tolerate asa

Question 79

should you use asa and clopidogrel together

Answer 79

no benefit compared to asa alone and increase bleeding events - no

Question 80

what do statins do in ischemia heart disease

Answer 80

decrease cv death and nonfatal mi in patients with established chd

Question 81

what is the recommended target with statins

Answer 81

<2mmol/L or 50% reduction from baseline - wrong

Question 82

what doses of simvastatin and atorvastatin are recommended

Answer 82

sim - 40 daily | ator - 80 daily

Question 83

how do acei help in ischemic heart disease

Answer 83

decrease sympathetic adrenergic transmission decrease afterload by lowering bp increase coronary blood flow

Question 84

which acei should reduction of cv death, nonfatal mi, and nonfatal stroke and at what dose

Answer 84

ramipril 10mg daily | perindopril 8mg

Question 85

benefit of acei beyond bp control in low risk chd patients is questionable so when is it indicated for ischemia

Answer 85

``` bp control in addition to bb prior mi lv dysfunction diabetes chronic kidney carrier ```

Question 86

what arb is used at what dose

Answer 86

telmisartan 80

Question 87

when are arbs recommended for patients at high risk of cv events

Answer 87

intolerant to acei

Question 88

when is revascularization indicated

Answer 88

in symptomatic high risk patients unlikely to benefit from medical treatment alone no improvement after maximization on medications

Question 89

whats triple vessel disease

Answer 89

plague in many of the main coronary arteries, often many other risk factors

Question 90

see risk factor modications

Answer 90

ok