Flashcards in MKSAP 2: CAD Deck (52):
Name the components of typical angina:
(1) substernal chest pain or discomfort (2) provoked by exertion or emotional stress (3) relieved by rest or nitro
What group of patients is stress testing most useful for?
At intermediate pretest probability of CAD (10%-90%)
What 2 categories of medicines are the regimen broken in to for guideline directed medical therapy?
Cardioprotective & antianginal meds
What are the 5 medications included in GDMT for stable angina?
Long acting nitrate
moderate to high intensity statin
What are the recommendations for aspirin therapy in CAD?
All patients with established CAD should be on at least 81mg ASA daily unless contraindicated. In patient allergic to ASA, clopidogrel is recommended as alternative.
New antiplatelet agents as monotherapy (prasugrel, ticagrelor) has not been tested in stable angina.
What is the indication for DAPT?
ASA + (clopidogrel, prasugrel or ticagrelor) is only recommended following PCI or ACS.
What is the dose titration recommendation for BB in chronic stable angina?
Resting HR 55-60 bpm.
What are the contraindications to BB therapy?
symptomatic bradycardia, high grade AV block, acute decompensated HF, severe reactive airway disease
What are the indications for ACEi in chronic stable angina?
ACEi are indicated in the treatment of stable angina, especially in patients with DM and LV systolic dysfunction
State the cholesterol management guidelines for moderate to high intensity statins.
Moderate to high intensity statins are recommended for all patients with
(1) LDL chol > 190
(2) DM or
(3) > 7.5% 10 year ASCVD score
What are the antianginal medications of GDMT?
B-blockers, nitrates, CCB, ranolazine
Describe the indications for CCB in GDMT?
Second line therapy in patients with chronic stable angina who are intolerant of BB or who have continued symptoms on BB and nitrates.
Describe the mechanism of CCB and specifically nondihydropyridine CCB?
All CCBs vasodilate systemic and coronary arteries. Nondihydropyridine CCBs (diltiazem and verapamil) reduce HR
What is the indication for ranolazine in GDMT?
Selective inhibitor of the late inward sodium channel in the myocardium, indicated for patients symptomatic still on BB, nitrates and CCB.
Use with caution in patients with advanced liver disease or kidney disease.
what are the indications for PCI in chronic, stable angina?
For patients with refractory symptoms while on optimal medical therapy, those who are unable to tolerate optimal medical therapy or those with high risk features on noninvasive exercise and imaging tests.
What is the indication for CABG in chronic, stable angina?
Generally indicated for those who remain symptomatic with optimal medical therapy and have specific angiographic findings (either LM disease or multivessel disease with involvement of the proximal LAD artery), concomitant reduced systolic function or DM.
Describe the guidelines for DAPT and duration for the following conditions:
- stable angina who undergo PCI or CABG
- PCI with BMS
- PCI with DES
- stable angina who undergo PCI or CABG: ASA indefinitely
- BMS: DAPT for at least one month
- DES: DAPT for at least one year; extended therapy can be considered
Define STEMI, NSTEMI and UA.
STEMI: presence of ischemic chest pain (or an equivalent) and the presence of greater than 1mm ST segment elevation in 2 or more consecutive leads or new LBBB on ECG
NSTEMI: abnormal cardiac biomarkers with ischemic chest pain but the notable absence of ST segment elevation on ECG, although has ST segment depression or TWI
UA: ischemic chest pain, ECG changes but no abnormal biomarkers
What is the initial medical therapy indicated for STEMI?
ASA, BB, nitrates, heparin
What is the treatment algorithm for patients that present to a non-PCI capable facility?
If <120 min to facility -> urgent transfer
If >120 min to facility -> thrombolytics and still transfer in case of thrombolytic failure
Name the absolute contraindications to thrombolytics for STEMI
Any previous ICH
Known cerebrovascular lesion
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head or facial trauma within 3 months
Name the thrombolytic agents used in treatment of STEMI in order of less effective to most effective
What reperfusion arrythmia are thrombolytic patients prone to? And when should a repeat ECG be obtained after thrombolysis?
Accelerated idioventricular rhythm - considered benign when it occurs within 24 hrs of reperfusion
ECG at 60 min after
What patients do you want to avoid nitrates and analgesics? Why?
Inferior STEMI patients with evidence of RV infarction bc can lead to reduced preload and hypotension
What patients do you avoid BB in in STEMI?
Evidence of heart failure, hypotension, bradycardia, advanced AV block
Dosed with IV metoprolol, 5mg increments q5 min up to 15mg then oral therapy
What is the recommendation for DAPT after STEMI?
Should be continued in STEMI patients for a full year regardless of intervention or stent used
Name the platelet P2Y12 agents and their indication in STEMI treatment?
Plavix the most widely studied and its use with concomitant PCI and thrombolytic therapy is associated with improved outcomes
Name the platelet glycoprotein IIb/IIIa inhibitors and their role in STEMI?
reserved for administration in the cath lab in patients who undergo primary PCI
Use in patients who get thrombolytics without PCI is not recommended
What are the blood glucose goals for patients with STEMI and DM?
What is the long term medical therapy recommended after STEMI?
ASA, BB, ACEi, nitrates, statin, P2Y12 inhibitor
What are the most common complications of STEMI?
arrhythmias, heart failure, vascular access issues
What additional therapy is indicated in patients with heart failure following STEMI?
Diuretics for preload reduction and nitrates or ACEi for afterload reduction
What triad of findings would lead you to diagnose R ventricular infarction after STEMI? Treatment?
hypotension, clear lung exam, elevated JVP
referfusion, aggressive volume resuscitation, and use of inotropes until RV function improves
What is the diagnosis? 3-7 days after STEMI: hemodynamic compromise, new loud holosystolic murmur, and palpable thrill
ventricular septal defect
How does papillary muscle rupture present after STEMI?
3-7 days after; hemodynamic compromise, pulmonary edema, loud systolic murmur
What are the risk factors for left ventricular free wall rupture and how does it present after STEMI?
Advanced age, female sex, anterior MI, incomplete reperfusion
Most commonly present with pericardial tamponade, PEA, and death
what is the treatment for LV thrombus after STEMI?
Therapeutic warfarin for 3-6 months
What risk calculator is used in patients with NSTEMI to guide early invasive vs medical management therapy?
TIMI risk score:
(1) Age > 65 years
(2) 3 or more traditional CAD RFs
(3) Documented CAD with greater than 50% stenosis
(4) ST segment deviation
(5) 2 or more anginal episodes in the last 24 hrs
(6) ASA use in the past week
(7) Elevated cardiac biomarkers
0-2 low risk
3-4 intermediate risk
5-7 high risk
What is the recommended initial management and workup for someone with NSTEMI or UA?
ASA, BB, nitrates, statin and Plavix (P2Y12 inhib)
Calculate risk stratification
Intermediate or high risk consider anticoagulant agents or GP IIb/IIIa inhibitor
What is the recommended dosing of ASA for ischemic chest pain?
325mg at presentation and 81mg QD after especially if in combo with Plavix
What is the recommendation for DAPT in NSTEMI?
All patients with NSTEMI should receive DAPT regardless of TIMI score unless increased risk of bleeding
What is the dosing for Plavix?
300 or 600mg loading dose at admission and 75mg QD after
What are the advantages to prasugrel and ticagrelor over clopidogrel
Found to be superior to Plavix in NSTEMI and UA patients; do not require hepatic metabolism, are more potent, faster onset of action; but not as thoroughly studied and need to be stopped 5-7 days prior to CABG
What is the indication for use of GP IIb/IIIa inhibitors in NSTEMI/UA?
Only in high risk features: ongoing angina, evidence of ischemia after initiation of standard antiplatelet and antianginal meds, reinfarction or heart failure. Indicated along with UFH at the time of PCI because of potent antiplatelet activity.
What is the first step in the NSTEMI algorithm?
Initiate ASA, BB, nitrate, statin
What are the meds and doses for high intensity statin therapy?
What are other non-cardiac causes of ischemic type chest pain presentation?
Coronary vasospasm due to illicit drugs
How is coronary vasospasm treated long term?
Long term nitrates, CCB and avoidance of triggers
Review the guidelines for DAPT for the following patients:
- ACS patient treated medically
- ACS with PCI DES
- ACS with PCI BMS
- ACS treated medically: ASA indefinitely and DAPT one year
- ACS with PCI DES: ASA indefinitely and DAPT one year
- ACS with PCI BMS: ASA indefinitely and DAPT at least 4 weeks, up to one year as tolerated
What other meds should ACS patients be on?
ACEi and statins indefinitely as tolerated; BB at least 3 years, but usually indefinitely as tolerated
What guideline differences exist in managing CAD in women compared to men?
Women are more likely to present with atypical symptoms such as fatigue, dyspnea, nausea and abd complaints.
In women with CAD, GDMT is recommended first prior to consideration for revascularization.