Stable Ischemic Heart Disease and ACS Flashcards
(33 cards)
Coronary Artery Disease (CAD)
-What’s the main etiology?
-CAD may present as two forms, what are the two Types and the subtypes that belong to them?
- Atheroschlerosis of the epicardial vessels
- Chronic coronary artery disease such as Stable exertional angina (Effort Angina)
- Acute coronary syndromes (ACS)
-Non ST elevation ACS such as unstable angina or Non ST elevation MI
-ST elevation MI (STEMI)
What are some agents that decrease O2 demand?
(HR and contractility)
Beta adrenergic antags
Some Ca2+ entry blockers
(Preload and afterload)
Organic nitrates
Ca2+ entry blockers
What are some agents that INCR O2 supply?
Coronary blood flow (vasodilators, especially CA2+ entry blockers)
Regional myocardial blood flow (Also statins, anti thrombotics)
What are 6 risk factors for first time myocardial infarction?
ApoB to apoA-1 ratio
current smoking
psychosocial
diabetes
hypertension
abdominal obesity
Anginal Pain is often described as:
-Substernal pain (give some adjectives)
-Sensation of ___ or ___ on chest alone or ___
-Duration ?
-Location??
-Radiates to ???
-Often provoked by ??
-Relieved by ___ within _____
Tightness, heaviness, crushing, squeezing, vicelike, aching, “deep”
pressure, heavy weight, with pain
30 secs to 30 mins
epigastric to pharyngeal area, occasionally left shoulder or arm
left arm, shoulder, jaw
exertion or emotional stress
nitroglycerin , 45 secs to 5 mins
Additional workup should include which labs?
Hemoglobin
fasting glucose
fasting lipoprotein panel
resting ECG
chest xray
cardiac biomarkers
Cardiac Biomarkers :
Negative in ____
Negative in ___
Positive in ?
Stable ischemic heart disease
unstable angina
NSTE-MI or STE-MI
What are the normal values for the following :
- Creatinine kinase (CK or CPK)
- CK-MB
- CArdiac Index
- Troponin T Gen 5
- 0-175 units/L
- Males < 4.9 ng/mL
Females < 2.9 ng/mL - <2.5%
- <22 ng/mL
For the following conditions, state what the final diagnosis would be:
CC –> CHEST PAIN
- ECG shows ST ELEVATION with POSITIVE biomarkers
- ST DEPRESSION OR T WAVE INVERSION with POSITIVE biomarkers
- ST DEPRESSION OR T WAVE INVERSION with Negative biomarkers
- NON SPECIFIC ECG, NO BIOMARKERS
- STEMI
- NSTEMI
- UNSTABLE ANGINA
- SIHD (Stable ischemic heart disease) or CCD (cardiac conduction disease)
What’s a definitive diagnosis of CAD?
Coronary angiography
Stable Ischemic Heart Disease (Chronic Coronary Disease or CCD) and RF Mods
- SMoking?
- Blood pressure?
- Lipid management
- Diabetes
- Physical activity
- Weight managment
- Influenza vax
- Alcohol consumption
- Complete cessation
- Below 130/80
- High intens statin, goal of >= 50% reduction in LDL-C
- Target A1c per diabetes guidelines or pt specific factors such as age, comorbidities… T2D with ASCVD risk , ckd, or HF suggest SGLT2I’s, or GLP1 Agonist
- 30-60 mins mod aerobic exercise, at least 5 days and preferably 7 days per week. or >= 75 mins/week of higher intensity aerobic activities
- BMI between 18.5 and 24.9, waist circumf for men < 40 inches, and women < 35 inches. initial weight loss should target 5-10% reduction from baseline
- annual
- Dont drink. Limit exposure to drinks. women 1, men 2
Name 8 agents used in Angina
Antiplatelets
ACE/ARBS
Nitrates
beta blockers
ccb’s
Ranolazine (ranexa)
rivaroxaban
statins
ASPIRIN (ASA)
-Reduces incidence of __ and __
-MOA?
Dose?
What if pt’s are allergic to ASA?
-Clinical benefits from aspirin may be at least in part due to which properties?
MI , sudden cardiac death
Irreversibly blocks COX1 activity which is enzyme required in platelet formation
81 mg PO daily
sub with Plavix 75 mg PO daily
Anti inflamm properties in pt’s with elevated levels of C-reactive protein
ASA Side effects
-Name six of them
-Name 3 relative CI’s
- GI ae’s with high dose prominent, but standard dose (150-300 mg/d) reduces incidence to 40%
2.Dyspepsia
3.N/V (reduced by using EC ASA or taking w/food)
4.GI bleeding
5.Frank Melena
6.Hematemesis
History of GI bleeding, PUD, or other sources of GI or GU bleeding
ACEi’s /ARBS
-Meta Analysis showed 14% reduction in __ for pt’s on ACEi’s
-Recommended in which pt’s?(4)
-MACE
-with SIHD who have HTN, diabetes, LVEF <= 40% or CKD
Nitrates
-Many indications such as?
-Provides exog source of NO which induces?
-Chronic use leads to ?
-What’s the therapeutic use in Angina? (SIHD)
-Therapeutic use in ACS?
heart failure, angina, acute coronary syndromes
coronary vasodilation
nitrate tolerance
reduce MVO2 keeping supply-demand scale in balance
Can help in NSTE-ACS and STEMI
-Reduces MVO2 consumption via preload reduction
Nitrate Preparations
See chart
Nitrate Admin :
1. SL
-What’s the onset?
-What’s the dose?
-Protect from ?
-Advise patient to?
-1 tablet or spray SL ____
-Seek medical attention if pain not aborted after ?
-1-3 mins
-0.4 mg dose, relieves pain in 3-5 mins
-light, moisture, extreme temps
-sit down against wall before placing under tongue or using spray
-every 5 mins for 3 doses
-1 dose
Nitrate Oral Admin
-Prophylaxis against ___
-Which doses are necessary?
-Peak effects in ?
-Duration of effect?
Anginal attacks
Higher doses (20 mg or more)
60-90 mins
3-6 hrs but variable
Cutaneous Nitrate Admin
2% ointment applied where? Effects within?
USe ___ to measure ointment
Patches gradually release product in cont manner over ___
Patches onset of action is __ than other forms with Cmax in ???
Patches should be applied to ____ remove at ___ to avoid tolerance
Nitrate free intervals of ____ go far to restore responsiveness and prevent devel of tolerance
chest in thin layer (1-2 inches).
30 mins
Calibrated papers
24 hrs
slower, 1-2 hrs
hairless area of skin, 7PM
10-14 hrs
Common AE”s of Nitrates?
(4)
Serious AE’s ? (5)
Headaches (respond to aspirin), facial flushing, Halitosis from SL NTG, Rash (td patch)
Syncope + hyPOtension, tachycardia, unexplained bradycardia, methemoglobinemia, heparin resistance
CI for Nitrates
- Angina caused by?
- Acute ____
- Concurrent use of?
- hypertrophic obstructive cardiomyopathy (HOCM)
- R ventricular MI
- PDE 5 inhibs (Silden, tadal, varden)
Ideal Candidates for B Blockers include those :
Where ___ figures prominently into their anginal attacks
W/Coexisting ___
W/Hx of
W/Post ____
W/___ induced ANgina
W/LVEF <= ___ with or without previous __
especially for pt’s with?
Physical exercise
HTN
Supraventricular tachyarrhythmias (SVT)
MI-Angina
anxiety induced
40%, MI
Prior MI , > 1 episode of angina per day, high resting HR
TX goals of Beta Blockers :
-Lower resting HR to ?
Limiting max exercise HR to ? or an increase of ___ greater than resting HR w/modest exercise
-Start with __ and titrate
-Avoid these with ____
-Tapering off over ___ is recc if discontinuation necessary
-At higher doses (Metoprolol > 200 mg/day) the drug loses its _____
Duration of therapy :
-Can be chronic therapy in ____
-How long in all pt’s with normal LV function after MI or ACS?
-Indefinitely in all pt’s with ?
-50-60 bpm
-<=100 bpm, 20bpm
-Low dose
-ISA (intrinsic sympathomimetic activity which prevents HR from lowering)
-2-3 weeks
-cardio selectivity for beta 1 receptors
-SIHD pt’s with angina
-1 yr
-reduced LV function after MI or ACS
