Stable Angina

Question 1

Pathophysiology

Answer 1

-Imbalance between myocardial oxygen demand (workload) and supply (blood flow)
-MOD increases when the heart is working harder due to increased HR, contractility or LV wall tension (increased pre-load)
-Supply often decreased due to atherosclerosis (CAD, narrowing of arteries, reduced blood flow to heart)

Question 2

Non-Drug Treatment

Answer 2

-Heart healthy diet (fruits, veg, legumes, nuts, whole grains, lean proteins, < 2300 g sodium, no trans fat)
-BMI 18.5-24.9
-Waist < 35 inches in females, < 40 inches in males
-Moderate intensity aerobic activity > 150 min (or high intensity > 75 min)
-Quit smoking
-Alcohol 1 drink/day women, 1-2 drinks/day men
-NO NSAIDs

Question 3

Treatment Approach for Stable Angina

Answer 3

A - antiplatelet, antianginal
B - blood pressure
C - cholesterol (statins), cessation (smoking)
D - diet, diabetes
E - exercise, education

BB CCB Nitrates Ranolazine

Question 4

Aspirin (Bayer, Bufferin, Ecotrin)

Answer 4

Dosing: 75-100 mg daily

CI:
-NSAID, salicylate allergy
-Reye’s (children/teenager with viral infection)
-Rhinitis, nasal polyps, asthma (angioedema and bronchospasm risk)

Warnings:
-Bleeding (GI/ulceration, may use PPIs)
-Tinnitus (sigh of OD)

AE: dyspepsia, heartburn, bleeding

Used indefinitely
-Non-enteric coated, chewable aspirin is preferred in ACS - if only enteric-coated aspirin is available, it should be chewed

STRAN B

Question 5

Clopidogrel (Plavix)

Answer 5

Dosing: 75 mg daily

Used when CI to aspirin

Prodrug, CYP450 2C19 testing for poor metabolizers

CI: active serious bleeding (GI, hem)

Warning:
-Stop 5 days prior to elective surgery
-Thrombotic thrombocytopenic purpura (TTP)

DDI: no omeprazole, esomeprazole

Question 6

Beta-blockers

Answer 6

Reduce HR, contractility, LV wall tension

Avoid in vasospastic angina

Question 7

Calcium Channel Blockers: MOA In Angina

Answer 7

Non-DHPs: reduce HR, contractility

DHPs: reduce SVR (after load)
-Preferred when in combo with BB

Preferred in vasospastic angina

Avoid nifedipine IR

Question 8

Nitrates: Overview/MOA

Answer 8

Reduce preload

SL tablets or TL spray: rec for all patients for fast relief

LA: nitrate-free interval required to prevent tolerance

Question 9

Ranolazine: CI, Warnings

Answer 9

CI: liver cirrhosis, CYP3A4 inh/ind

Warning: QTcP, acute renal failure if < 30

Not for acute treatment of chest pain
-Little to no effect on HR or BP

not a cute QR Code 3A4

Question 10

Nitroglycerin ointment 2%

Answer 10

Nitro-Bid

-Comes with measuring applicator, can stain clothing
-Dosed BID, 6 hours apart (10-12 hours from each dose)

Question 11

Nitrates: SA vs LA, CI, Notes

Answer 11

CI: PDE5 inhibitors, riociguat

Warning: hypotension, tachyphylaxis (tolerance)

AE: HA, flushing, syncope

Short-acting: store SL in original amber glass bottle
-Do not take more than 3 doses within 15 min

Long-acting: 10-12 hour nitrate free interval to decrease tolerance
-Patch: wear 12-14 hours, off 10-12 hours, rotate sites (preferred on chest)

Do not shake spray (lingual/mist)

Question 12

lsosorbide dinitrate (preferred when?)

Answer 12

In combination with hydralazine is the preferred combination for HFrEF