Ischemic Heart Disease, Angina, and Myocardial InfarctionCIS Flashcards
(38 cards)
You initiate treatment with an oral agent that should reduce the frequency of chronic angina episodes by decreasing myocardial O2demand without causing systemic vasodilation. Which drug best fits this description?
metoprolol
Drugs for Angina Prophylaxis
Cardioselective beta blockers
Calcium channel blockers
Long-acting nitrates
- Choice of drug depends on presence of contraindications and individual response of patient
- Combinations may be more effective than monotherapy
Cardioselectivebeta blockers
–E.g., atenolol, metoprolol
–Nonselective agents also frequently used
Calcium channel blockers
–Long-acting dihydropyridine, e.g. amlodipine or felodipine
–Non-dihydropyridine, e.g. verapamil or diltiazem
Long-acting nitrates
–Oral: isosorbidedinitrateor nitroglycerin (NTG)
–Sublingual (tablet or spray): NTG as needed
55 y/o female presents to the emergency room with two episodes of retrosternal chest pain, each lasting 20 minutes and over the last 4 hours. She has never had anything like this before. Her EKG shows T-wave flattening and her initial CPK and troponin levels are negative. She has no history of hypertension or diabetes. There is no heart disease in her family. Her LDL cholesterol is 98. While in the emergency room she has a third episode of chest pain that is associated with ST depression and relieved with nitroglycerin. Her EKG findings return to her baseline with T-wave flattening. Her blood pressure is 130/70 her heart rate is 70. What is your management approach?
Admission to the hospital and treatment with anti-anginal agents and stress test evaluation
carvedilol and labetalol are beta blockers that cause
vasodiatlion by blocking alpha blockesr
The patient’s anti-anginal medications are adjusted as discussed and she is placed on an exercise treadmill with a standard Bruce protocol and reaches her maximum heart rate and has no ST changes. Your clinical approach should be to:
Discharge her from the hospital with a follow up in two weeks.
78 y/o woman presents to the hospital on a Saturday in rural Colorado. She has 45 minutes of retrosternal chest pain associated with nausea and diaphoresis. The pain is relieved after two sublingual nitroglycerin tablets. She has a history of NIDDM, HTN and hypercholesterolemia. The local hospital does not have a cath lab. The closest referral hospital is three hours away. Her EKG and cardiac enzymes are unremarkable. Her serum creatinine is 1.8. Her blood pressure is 138/88 pulse is 64 and her HBA1C is 8.5. Her cholesterol is 250 with an LDL of 170.
•Current medications are
–Metformin 500mg twice daily (for diabetes)
–Lovastatin 20mg daily (for elevated cholesterol)
–Celecoxib 200mg twice daily (for arthritis)
–Lisinopril 10 mg daily (for HTN)
•Your approach should be to:
•How would you classify (diagnose) this patient based upon how she first presented to the hospital?
Which of the patient’s current medications should be stopped immediately?
As a part of your risk stratification you choose which of the following work up options?
Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management
unstable angina
Celecoxib
Perform a stress test
Unstable angina definition
–New onset
–At rest
–Crescendo
In addition to the sublingual NTG already administered and O2, which of the following is recommended as initial therapy for this patient’s acute unstable angina?
Aspirin
Drugs for Acute Angina
•Oxygen, especially if O2saturation
•Aspirin for antiplatelet effects
–Clopidogrelis an alternative if aspirin is contraindicated
•Nitroglycerin to produce systemic vasodilation
–Reduces myocardial O2demand by reducing preload
–Increases O2delivery by dilating coronaries
•Morphine
–If chest pain is unresponsive to nitroglycerin
–Also relieves anxiety
–Associated with increased mortality in unstable angina/NSTEMI
also can dialate a little bit so it helps with that
NSAID Cyclooxygenase (COX) Selectivity
Non-selective
- Inhibit both COX-1 (aka platelet COX) and COX-2
- Diclofenac, ibuprofen, indomethocin, naproxen, sulindac, many others
- Aspirin is an irreversibleCOX inhibitor
- Acetaminophen is a weak inhibitor of COX-1 and COX-2, but is not an NSAID because it has no significant anti-inflammatory effects
NSAID Cyclooxygenase (COX) Selectivity
COX-2 Selective
- Celecoxib and meloxicam
- Several other “coxibs” withdrawn from the market
- No effect on platelets or bleeding time
- Significantly less GI ulcers
NSAID Cyclooxygenase (COX) Selectivity, why do you stop both with a heart problem
increase cv risk with both thats why you stop it immediately
NSAIDs and Cardiovascular Risk
- BothCOX-2 selective andnon-selective NSAIDs are associated with increased risk of adverse cardiovascular events
- Risk increases at higher doses
- New studies continue to evaluate whether the risk is higher or lower with any particular NSAID
NSAIDs and Cardiovascular Risk
exception
aspirin is cardioprotectiveat low doses (75-325 mg daily) where antiplatelet effects predominate
Perform an image augmented stress test with
lbbb
The patient is treated with aspirin, nitrates and on a standard Bruce protocol exercise stress test has ST segment depressions in leads V1-4 that resolve by stopping the stress test. She did not reach her maximum heart rate. What should be your next approach?
coronary angiogram
- 70 y/o male with long standing history of diabetes and hypertension presents to the emergency room with chest pain, worsening shortness of breath and diaphoresis. This has become progressively worse over the last month.
- On physical exam he is cyanotic, blood pressure is 160/94, pulse is 80 and respirations 20. He has crackles is his lungs at the bases bilaterally, +3 edema, and an S3.
- His HBA1C is 9.0, his LDL cholesterol is 170, and serum creatinine is 1.1.
- He is currently on metoprolol succinate 100mg qd, and nitroglycerin patch 0.4mg/hrchanged daily.
- His EKG is shown after he walks 200 feet in the ER hallway. st depression in 2356,
You are concerned about the nitroglycerin patch being “changed daily.” Which statement best summarizes your concern? Continuous treatment may lead to
Which of the following drugs are indicated to treat his worsening heart failure and uncontrolled hypertension?
After optimizing his CHF and blood pressure. Which diagnostic or therapeutic modality is most indicated?
In addition to coronary risk evaluation and treatment, your choices to reduce mortality should include:
nitrate tolerance
IV NTG and furosemide
coronary angiography
lisinopril and insulin
Drugs Shown to Prevent MI and Death
- Beta-blockers: timolol, metoprolol, and propranolol
- Anti-platelet drugs: aspirin, ADP receptor blockers (e.g., clopidogrel)
- HMG-CoA reductase inhibitors (the –statins)
- ACE inhibitors (the –prils) and ARBs (the –sartans)
