Stable Angina

Question 1

What is angina?

Answer 1

Chest pain, pressure, tightness caused by ischemia of the heart muscle or spasm of the coronary arteries

Question 2

What is the difference between stable and unstable angina?

Answer 2

Stable: predictable typically induced by stress and relieved with rest

Unstable: type of ACS that is not relieved with nitroglycerin or rest

Question 3

What instigates chest pain?

Answer 3

Imbalance in myocardial oxygen demand and blood supply → ↑ tension, heart rate, contractility

Question 4

What is coronary artery disease?

Answer 4

Reduced blood flow to the heart due to narrowing of arteries

Question 5

What are the primary causes of vasospastic angin

Answer 5

Illicit drug use (cocaine)

Question 6

How do we diagnose angina?

Answer 6

Cardiac stress test (exercise or IV medication)

Coronary angiography

Question 7

Non drug treatment for angina?

Answer 7

1. Heart healthy diet
2. BMI: 18.5-24.8
3. Waist circumference <35 in (females) and <40 in (males)
4. Aerobic activity
5. Smoking cessation
6. Reduce alcohol intake
7. Chronic NSAIDs should not be used

Question 8

What is the treatment approach for stable angina?

Answer 8

Antiplatelet and antanginal drugs
Blood pressure
Cholesterol (statins) and cigarette cessation
Diet and diabetes
Exercise and education

Question 9

Types of antianginals

Answer 9

BB, Non-DHP CCB, long-acting nitrates

Question 10

MOA of aspirin

Answer 10

Irreversibly inhibit COX1 and 2 decreasing PG and TXA1

Question 11

MOA of Plavix

Answer 11

Prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

Question 12

CI of asprin

Answer 12

Salicylate allergy
Avid in children and teenagers due to Reyes syndrome

Question 13

What is a sign of ASA OD

Answer 13

Tinittis

Question 14

ADR of ASA

Answer 14

Dyspepsia (acid), heartburn (acid), bleeding

Question 15

Preferred ASA dosing for ACS

Answer 15

Non-enteric coated chewable tablet, however EC ASA (325 mg) can be chewed if needed

Question 16

Duration of ASA for angina

Answer 16

Indefinitely

Question 17

How to mitigate nausea when on ASA

Answer 17

Take with food

Question 18

Importance of PPIs while on ASA

Answer 18

Protect the GI tract with chronic use

However chronic PPI → ↓ bone mineral density and ↑ infection risk

Question 19

BBW of Clopidogrel

Answer 19

Requires CYP2C19 for activation → patient must test to check genotype for possible poor metabolizers

Question 20

ADR of Plavix

Answer 20

Serious bleed (stop 5 days prior to surgery)
TTP
Premature dc → ↑ thrombosis

Question 21

DDI of Plavix

Answer 21

Additive bleeding risk with other drugs that cause bleeding

CI with aspirin

Avoid CYP2C19 inhibitors (Omeprazole and esomeprazole)

Question 22

Purpose of BB

Answer 22

Reduce myocardial oxygen demand by decreasing HR, contractility, and LV wall tension

Question 23

Indication for BB

Answer 23

Avoid in vasospastic angina

Question 24

Purpose of CCB

Answer 24

Reduce myocardial oxygen demand by:

Non-DHP: ↓ HR and contractility
DHP: reduce SVR

↑ O2 supply by increasing blood flow to coronary arteries

Question 25

Purpose of nitrates

Answer 25

Reduce myocardial oxygen demand by reducing preload (Free radical nitric oxide produces vasodilation of veins more than arteries)

Question 26

Which CCB are preferred?

Answer 26

DHP and used in combo with BB (due to risk of bradycardia from non-DHP)

Question 27

When are CCBs usd

Answer 27

Vasospastic angina

Question 28

What is the purpose of a nitrate free interval

Answer 28

Prevent nitrate tlerance

Question 29

CI of ranolazine

Answer 29

Strong CYP3A4 inhibitors and inducers

Question 30

Can ranolazine be used acutely

Answer 30

No Only used as add ons

Question 31

ADR of Ranolazine

Answer 31

QTc prolongation

Question 32

Purpose of ranolazine

Answer 32

Decreasing ventricular tension and oxygen consumption → ↓ myocardial oxygen demand No clinical effects on HR and BP

Question 33

Standard dose of short acting Nitrates

Answer 33

0.4 mg

Question 34

CI of nitrates

Answer 34

Avoid PDE5I or sGCs

Question 35

ADR of nitrates

Answer 35

Hypotension, tachphylaxis (tolerance/decreased effectiveness) HA, flushing, syncope

Question 36

Counseling of short acting nitrates

Answer 36

Used for PRN chest pain Store SL table in original container Call 911 immediately if persists after 1st dose 3 doses within 15 min (5 min apart)

Question 37

Counseling of SL tabs

Answer 37

Place under tongue and let dissolve Slight burning or tingling is not a sign of the medication working Keep in original container

Question 38

Counseling of TL spray

Answer 38

Prime Q6W if not used Don't shake Spray under tongue

Question 39

How long is a nitrate free interval

Answer 39

10-12 hrs

Question 40

Counseling on path

Answer 40

Wear 12-14 hrs, off 10-12 hrs Rotate sight

Question 41

Counseling of nitrate ointment

Answer 41

BID 6 hrs apart with 10-12 nitrate free interval Measure dose using applicator and place on chest ointment side down Can stain clothing

Question 42

Nitroglycerin SL tab

Answer 42

Nitrostat

Question 43

Nitroglycerin TL spray

Answer 43

NitroMist, Nitrolingual

Question 44

Nitroglycerin ointment 2%

Answer 44

NitroBid

Question 45

Counseling of isosorbide mononitrate

Answer 45

IR is BID 7 hrs apart ER QAM

Question 46

Counseling of isosorbide dinitrate

Answer 46

IR BID (7 hrs apart) or TID (8AM, 12 PM, and 4PM) 14 hr interval

Question 47

What nitrate is preferred for HFrEF

Answer 47

Isosorbide dinatrate with hydralazine