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Flashcards in lecture 9 Deck (61):
1

chronic stable angina

-substernal chest discomfort that is:
-typically relieved by NTG &/or rest (no more than 20 min)
- aggravated by exertion & emotion stress, cold, meals

2

unstable angina & high risk features

rest angina
new onset angina
increasing angina
high risk symptoms

3

rest angina

angina occurring at rest & usually lasting >20min

4

new onset angina

angina of class III (marked limitation of normal activity) in the past 2 months

5

increasing angina

stable angina that is now increasing in duration or frequency

6

high risk symptoms

pulmonary edema
rales
angina w/ hypotension
nocturnal angina

7

chronic stable angina goals of therapy

- morbidity: provide symptomatic relief from angina that limites exercise & QOL
- mortality: slow the progression of atherosclerosis leading to CV events & death

8

chronic stable angina & HTN

- these pts have established coronary artery disease-> compelling indication for ACEI/ARB & beta-blocker

9

non-pharmacological management of chronic stable angina

- typically reserved for those who have significant symptoms despite optimal medical management
- percutaneous coronary intervention (PCI): balloon angioplasty &/or stenting
- CABG- coronary bypass grafting
- external counterpulsation therapy (ECP/EECP): for those w/ refractory CSA & not candidates for PCI or CABG

10

Can you titrate anti-anginal/BP medications below the standard target BP (e.g,. 140/90) to reduce symptoms of chronic stable angina?

yes

11

CSA 4 main agents used

beta-blockers, CCB. nitrates & ranolazine

12

wht therapy may be adequate for symptoms that occur rarely or predictably

PRN nitrates

13

chronic antianginal therapy should be up-titrated if patients

experience daily episode or symptoms sig. impact QOL

14

majority of CSA therapy

decreased HR and/or BP

15

minimal HR

55bpm

16

minimal BP

100/65

17

critical side effects

orthostatic hypotension, +/-falls, syncope, severe fatigue

18

Which pharmacological effects would be helpful in reducing anginal episodes?

○ Beta-blocker to reduce inotropy, thereby reducing cardiac oxygen demand
○ Beta-blocker to reduce chronotropy, thereby reducing cardiac oxygen demand
○ DHP-CCB/nitrate to cause vasodilation, thereby increasing coronary blood flow
○ DHP-CCB/nitrate to cause vasodilation, thereby reducing afterload and cardiac workload

19

first line in the management of CSA

beta blockers

20

beta-1 selective

- preferred for unstable asthma/COPD, PVD, DM, sexual dysfunction

21

mixed alpha/beta blockers

(Carvedilol)
- may be used if additional BP control is needed

22

agents with intrinsic sympathomimetic activity

should be avoided
- increase HR

23

beta blocker dosing

titrate BB to HR of ~55bpm as BP & side effects allow
- add additional agents as necessary

24

BB in combo with nonDHP CCBs

avoided due to risk of bradycardia & Heart block

25

BB in combo with DHP CCBs

BB blunts reflex tachycardia that may occur w/ DHPs
- so good

26

BB in combo with nitrates

BB blunts reflex tachycardia that may occur w/ nitrates
- so good

27

BB in combo w/ ranolazine

no significant issues

28

monitoring of CSA therapy

- BP, HR, appearance of side effects

29

alt first line agents for those who are not candidates for beta blockers

non-DHP CCBs

30

consideration for selection of nonDHPs

1. avoid in systolic HF (LV dysfunction/ 2. may be reasonable agent in those with relative CI to BB (Asthma, unstable COPD, severe PVD)
3. appropriate for those with prinzmetal angina
4. select a formulation that allows for QD or BID doising

31

NonDHP dosing

titrate to a HR of ~55bpm as BP & side effects allow
- add additional agents as needed

32

nonDHP in combo with BB

avoided due to risk of bradycardia & heart block

33

nonDHP in combo with DHP

nonDHP blunt reflex tachycardia that may occur with DHP

34

nonDHP in combo with nitrates

nonDHP blunts reflex tachycardia that may occur withnitrates

35

nonDHP in combo with ranolazine

-CYP3A4 interaction->max of ranolazine 500mg PO BID
(dont titrate up to max dose)

36

second line agent for CSA

DHP
amlodipine, delodipine, nicardipine
- typically add on therapy

37

consideration in selection of a DHP

potential for reflex tachycardia & lack of effect on HR make monotherapy undesirable

38

dosing of DHPs

up-titrate DHP to relief of angina symptoms as BP & side effects allow

39

DHP in combo with nitrates

no issues as long as BB or nonDHP is ALSO used for reflex tachycardia

40

DHP in combo with ranolazine

no issues

41

monitoring of DHP

BP, relief of symptoms, side effect (peripheral edema-tk at night to prevent, reflex tachycardia)
- does not reduce HR

42

what should be made available to every pt for CSA?

short acting nitrates (SL NTG or translingual NTG)

43

nitrostat

0.4mg placed under tongue & allowed to dissolve Q5min, up to 3 doses

44

nitrolingual

one spray under the tongue or on the tongue Q5min, up to 3 doses
- must be primed
-do not rinse mouth
- keep at RT

45

third line agents for CSA

long acting nitrates

46

long acting nitrates should be reserved for

ass-on therapy (w/ BB or nonDHP to blunt reflex tachycardia)

47

long acting nitrates require

a nitrate-free interval of 8-12hrs/day (only partial antianginal coverage) due to tachyphylaxis

48

- Long-acting nitrates should be dosed in which fashion?

○ With a ~12 hour nitrate-free interval to avoid development of tolerance
○ Around the clock dosing will lead to tachyphylaxis (tolerance)
○ BID when you wake up, then 6 hours later (so you have your nitrate free interval)

49

long acting isosorbide mononitrate drugs

immediate (Ismo, monoket)
sustained (imdur)

50

long acting isosorbide dinitrate

sustained (isochron)

51

long acting NTG patch

nitrodur

52

monitoring for long acting nitrates

BP & relief of symtpoms, reflex tachycardia, decreased efficacy,, HA, orthostatic hypotension

53

CI nitrate use with sildenafil (viagra) & verdenafil (levitra) in

24 hours

54

CI nitrate use with tadalafi (cialis) in

48 hours

55

newest agent & third line add-on agent

(due to cost)
ranolazine (ranexa)

56

ranolazine has almost zero effect on

BP & HR
- potential add on for those with low BP or HR

57

safety or ranolazine

QT prolongation
- minimal risk of torsades when used alone
- do not use with FQ, macrolide, antiarrhythmics, antipsycotics

58

drug interactions with ranolazine

- substrate for CUP3A4, 2D6 & PGP
1. inc ranolazine: nonDHP-CCBs
2. digoxin may inc & require close monitoring
3. simvastatin levels usually DOUBLE with addition of ranolazine

59

ranolazine dosing

500mg PO BID titrated to 1000mg PO BID prn anginal symptoms

60

CI to ranolazine

- severe hepatic impairment, strong CYP3A4 inhibitor

61

side effects of ranolazine

constipation
nausea
dizziness