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Stable Angina Flashcards

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1
Q

How may angina present in females/older adults/ with other comorbidities?

A
  1. dyspnea
  2. back pain
  3. pain that mimics indigestion/GERD (burning/stabbing)
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2
Q

What is stable angina?

A

Type of chronic coronary disease (CCD) with predictable chest pain brought on by exertion/stress, and is relieved in minutes by rest

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3
Q

What is unstable angina?

A

Type of acute coronary syndrome (ACS) and is a medical emergency; chest pain at rest increases and is not relieved by nitroglycerin/rest

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4
Q

Why does chest pain occur is stable angina?

A
  1. Increased myocardial oxygen demand (activity/stress); increases HR, contractability, left ventricular wall tension
  2. Decreased oxygen supply due to atherosclerosis of the coronary artery (coronary artery disease); reduces blood flow to the heart
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5
Q

What type of stable angina can occur at rest?

A
  1. Coronary artery vasospasm/ Vasospastic angina
  2. Caused by illicit drug use, usually cocaine
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6
Q

What are RFs for stable angina?

A
  1. HTN
  2. smoking
  3. dyslipidemia
  4. DM
  5. obesity
  6. physical inactivity
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7
Q

How is stable angina dx?

A
  1. Cardiac stress test with exercise or drugs to increase oxygen demand
  2. Coronary angiography used to visualize atherosclerosis/ischemia
  3. History/physical
  4. CBC (anemia can decrease O2)
  5. Troponins I or T/ CK-MB (should be negative)
  6. ECG (should be normal)
  7. aPTT/PT/INR
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8
Q

What may be present in vasospastic angina that is not present on lab tests with stable angina

A

transient ST segment and T wave changes

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9
Q

What are lifestyle modifications to tx stable angina?

A
  1. Heart-healthy diet
  2. BMI 18.5-24.9
  3. Waist circumference <40 in (men) and <35 in (women)
  4. ≥150 min aerobic activity
  5. Quit smoking
  6. Limit alcohol
  7. Avoid NSAIDs
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10
Q

What is the 1st line treatment algorithm for stable angina?

A
  1. Antiplatelet therapy: Aspirin or Clopidogrel (DAPT not useful)
  2. Lipid lowering: High intensity statin
  3. Antianginal: Beta blocker, all CCBs, long-acting nitrate
  4. Treat comorbid HTN and DM
  5. Vaccines: flu, pneumococcal, COVID
  6. Rescue therapy: short acting nitrate
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11
Q

Which 1st line antianginal agents should not be used together?

A

Beta blockers + non-DHP CCBs; too much hypotension

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12
Q

What is the MOA of aspirin?

A

Irreversibly inhibits COX 1 and COX 2, resulting in decreased PG and TXA2 production; thromboxane 2 is a potent vasoconstrictor and induces platelet aggregation

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13
Q

What is the MOA of clopidogrel?

A

Prodrug irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

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14
Q

What are CIs with aspirin?

A
  1. NSAID/ salicylate allergy
  2. Children/teenagers with viral infection (risk of Reye’s; somnolence/N/V/confusion)
  3. rhinitis/nasal polyps/asthma (due to risk of urticaria, angioedema, bronchospasm)
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15
Q

What are warnings with aspirin?

A
  1. Bleeding: GI bleeding/ulceration
  2. Tinnitus (sign of salicylate over dose)
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16
Q

What are SEs with aspirin?

A
  1. Dyspepsia
  2. Heartburn
  3. Bleeding
  4. nausea
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17
Q

How long is aspirin continued for acute angina?

A

Continued indefinitely to decrease CV events and death

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18
Q

How is aspirin dosed/administered for stable angina?

A
  1. 75-100mg QD
  2. PPIs may be used to protect the GI tract from chronic NSAID use, consider risks of PPI use (increased risk of infections/decreased bone density)
  3. Use EC/buffered product or take with food to decrease nausea
  4. Non-enteric coated, chewable aspirin preferred in ACS; if only EC available chew 325mg
  5. Durlaza (ER aspirin) should not be used when rapid onset necessary (ACS/ pre-PCI)
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19
Q

What forms of aspirin are available OTC?

A
  1. EC tablets/ chewable tablets
  2. liquid filled capsule
  3. suppository
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20
Q

What forms of aspirin are available Rx?

A

ER capsule (Durlaza)
ER capsule + omeprazole (Yosprala)

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21
Q

Aspirin

A

Bayer
Bufferin
Ecotrin
Ascription
Durlaza
Vazalore

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22
Q

What are BBWs with clopidogrel?

A

Conversion to active metabolite is dependent on CYP2C19; poor metabolizers have more CV events. Testing can be used as an aid for therapeutic strategy

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23
Q

What are CIs with clopidogrel?

A

Active serious bleeding (GI bleed, intracranial hemmorhage)

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24
Q

What are warnings with clopidogrel?

A
  1. DO NOT use with omeprazole/ esomeprzole
  2. Bleeding risk: stop 5 days before elective surgery
  3. Thrombotic thrombocytopenia purapura (need to D/C)
  4. Do not prematurely D/C
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25
What are SEs with clopidogrel?
Generally well tolerated except bleeding occurs
26
Wht should be monitored with clopidogrel?
1. sx bleeding 2. Hgb/Hct as needed (Thrombotic thrombocytopenia purapura; RBC rupture)
27
How is clopidogrel dosed for stable angina?
75mg QD when there is a CI to aspirin
28
What are DIs with antiplatelet agents?
1. Additive bleeding risk (SSRIs/SNRIs, NSAIDs, anticoagulants, dietary supplements
29
How do beta blockers reduce pain from angina?
Reduce HR/contractility/ left ventricular wall tension
30
What are warnings with beta blockers and angina?
1. AVOID in vasospastic angina 2. Better for treating silent ischemia vs. CCBs/nitrates
31
How do CCBs reduce pain from angina?
1. All: increase blood flow thru coronary arteries 2. non-DHP: Decrease HR and contracability 3. DHP: Decrease SVR (afterload)
32
What are warnings with CCBs and angina?
1. Avoid nifedipine IR (short-acting); slow-release or long acting effective 2. DHPs preferred when used with a beta blocker due to the risk of excessive bradycardia 3. Preferred for vasospastic angina
33
How do nitrates reduce chest pain from angina?
1. Reduces preload (free radical nitric oxide produces vasodilation of veins > arteries 2. Increased blood flow through nonatheroscloerotic arteries
34
How does ranolazine work to reduce chest pain?
Selectively inhibits the late phase Na current and decreases intracellular Ca; can decrease myocardial O2 demand by decreasing ventricular tension and oxygen consumption
35
What are CIs with ranolazine?
1. Strong CYP 3A4 inhibitors/inducers 2. liver cirrhosis
36
What are warnings with ranolazine?
1. QT prolongation 2. acute renal failure when CrCl<30 3. Not for acute treatment of chest pain
37
What are SEs with ranolazine?
1. dizziness 2. headache 3. constipation/nausea ***Little/no clinical effects on HR/BP
38
What should be monitored with ranolazine?
1. ECG 2. K 3. renal fxn
39
Ranolazine
Aspruzyo Ranexa
40
Nitroglycerin SL tablet
Nitrostat
41
Nitroglycerin TL spray
NitroMist Nitrolingual
42
Nitroglycerin ointment 2%
Nitro-Bid
43
Nitroglycerin transdermal patch
Nitro-Dur
44
Nitroglycerin ER capsule
Nitro-Time
45
Isosorbide dinitrate IR
Isordil
46
What are CIs with nitrates?
1. HSR to organic nitrates 2. DO NOT use with PDE-5 inhibitors or soluble guanylate cyclase stimulators (riociguat) 3. Increased intracranial pressure/ severe anemia/ circulatory failure/shock (short-acting)
47
What are warnings with nitrates?
1. Hypotension 2. Tachyphylaxis 3. aggrevate hypertrophic cardiomyopathy causing angina
48
What are SEs with nitrates?
1. Headache 2. Flushing 3. Syncope/dizziness 4. Orthostasis
49
What should be monitored with nitrates?
1. BP/HR 2. chest pain
50
How are short acting nitrates dosed?
1. PRN for immediate relief of chest pain 2. Call 911 immediately if chest pain persists; take 2 more doses at 5 min intervals while waiting for ambulance; do not take more than 3 doses in 15 min
51
How is SL Nitroglycerin adminnistered?
1. Place tablet under the tongue/ between cheek/gums and let dissolve; do not swallow, chew, crush 2. Slight burning/tingling is not a sign of potency 3.
52
How should SL Nitroglycerin be stored?
In original glass amber container with cap tightly sealed at room temperature
53
How is TL Nitroglycerin spray administered?
1. Prime before 1st use and if not used after 6 wk 2. Do not shake 3. Press button firmly to spray onto or under the tongue and close your mouth, do not inhale/ swallow 4. Do not spit rinse mouth for 5-10 min after the dose
54
How long of a nitrate free interval is required to prevent tolerance?
10-12h or longer
55
How is Nitroglycerin patch administered?
1. Wear on for 12-14h off 10-12 h 2. Rotate sites 3. Chest is best; can place anywhere except extremities below knees/elbows
56
How is Nitroglycerin ointment administered?
1. BID 6h apart with a 10-12h nitrate free interval 2. Measure with dose applicator; lightly spread ointment on the chest but do not rub into skin, tape the applicator in place 3. Can stain clothing,cover applicator immediatly
57
How is isosorbide mononitrate administered?
IR: BID 7h apart (8am/3pm) ER: QAM
58
How is idosorbide dinitrate administered?
IR: BID 7h apart (8am/3pm) or TID (8/12/4) for 14h nitrate free interval
59
How long should short-acting nitrates and PDE-5 inhibitors be separates?
Avanafil: 12h Sildenafil/Vardenafil: 24h Tadalafil: 48h
60
What are DIs with ranolazine?
Avoid strong CYP3A4 inhibitors (protease inhibitors, cobicistat)

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