•          Nitrates

–        Short acting (immediate relief)

–        Long acting

•          Beta Antagonists (beta blockers) 1rst line prevention of chronic stable angina

•          Calcium channel blockers

–        Use in variant angina 1rst line prevention of variant angina

•          Goals

–        Prevent MI and Death

Alleviate symptoms, frequency of attacks and improve QOL

•          MOA: reduce O₂   demand by reducing contractility, HR and blood pressure

•          Often preferred agent for chronic prophylactic therapy

•          Metoprolol XL Toprol

•          Additional benefits of beta blockers 

–        Start in pts with ACS, MI and left vent. Dysfunction and continue indefinitely

•          Basics in angina

–        Rest HR 50-60bpm

–        Exercise HR 100bpm

•          AE

–        See ANS and HTN lectures

–        Bradycardia, heart failure, bronchospasm, peripheral vasoconstriction, heart block

–        Diltiazem and verapamil not in severe heart failure or heart blocks

–        Constipation

–        HR elevation with nifedipine and dihydropyridines

–        DO NOT USE short acting nifedipine as it may precipitate myocardial ischemia

•          Ranolazine (Ranexa) add on therapy for chronic angina

•          MOA

–        Unique modulator of metabolic pathways in myocardial tissues

•          Administration= 500 mg po BID

•          AE:

–        Dizzy, HA, N

–        Watch EKG (QT interval prolongation)

•          Lifestyle modifications

•          Acute attacks

–        SL or lingual nitroglycerin spray

•          > 1 episode/day à chronic tx with Beta-blockers

•          Contraindications to BB à calcium channel blocker

•          Add or substitute as clinically indicated

•          Long acting nitrates less effective with tolerance problems but can be added to other meds

•          Variant angina

–        Calcium channel blocker

–        Long acting nitrate therapy

•          Unstable angina

•          NSTEMI (non-ST-elevation MI)

•          ST- elevation MI (STEMI)

–        New onset angina

–        More frequent and longer lasting

–        May respond less to rest and nitroglycerin

–        Rest angina (severe)

–        Treatment similar to NSTEMI

–        ECG does not show ST segment elevation but elevated cardiac markers (cardiac troponins etc.) are necessary for diagnosis

–        Therapy is the same as AMI EXCEPT no thrombolysis

•          Morphine sulfate

–        Morphine sulfate (1 to 5 mg intravenously [IV]) is recommended for patients whose symptoms are not relieved after 3 serial sublingual NTG tablets or whose symptoms recur despite adequate anti-ischemic therapy

•          Oxygen via NC to maintain O2 saturation above 90%

•          Nitrates

–        Reduces myocardial oxygen demand and improves supply

–        Intravenous NTG may be initiated at a rate of 10 mcg per min through continuous infusion with nonabsorbing tubing and increased by 10 mcg per min every 3 to 5 min until some symptom or blood pressure response is noted.

•          Aspirin

–        Beta-blockers competitively block the effects of catecholamines on cell membrane beta-receptors (Metoprolol)

–        Beta-blockers should be started ASAP in the absence of contraindications.

•          oral administration

•          Reduce infarct size and reduced mortality esp if given early

–        ACEIs have been shown to reduce mortality rates in patients w/ HTN or LV dysfunction persists after nitrates and BB

–        An ACE inhibitor should be administered orally within the first 24 h to UA/NSTEMI patients with pulmonary congestion or LV ejection fraction (LVEF) less than or equal to 0.40,

•          in the absence of hypotension (systolic blood pressure less than 100 mm Hg or less than 30 mm Hg below baseline) or known contraindications

•          Patients with

–        marked first-degree AV block (i.e., ECG PR interval [PR] of greater than 0.24 s),

–        any form of second- or third-degree AV block in the absence of a functioning pacemaker,

–        a history of asthma

–        or severe LV dysfunction with CHF should not receive beta-blockers on an acute basis

•          Aspirin –(YES)

–        Plavix (clopidogrel)

•          Role:  Add to ASA therapy since both inhibit platelets in different ways in patients with planned percutaneous coronary intervention (PCI)

–        Plavix continued for at least 1 month with metal stents and several months with drug implanted stents

(GP IIb/IIIa) Inhibitors

•          Abciximab (Reopro), tirofiban (Agrostat) and Eptifibatide (Integrilin)

–        MOA:

•          Role: used with ASA and heparin for

–        patients with UA/NSTEMI and AMI who undergo PCI

•          Bivalirudin (direct thrombin inhibitor) and fondaparinux (factor Xa inhibitor) are acceptable alternatives to unfractionated heparin and should be added to therapy in patients going for invasive cardiac interventions

•          In patients not going for invasive therapy use enoxaparin, UFH, or fondaparinux

•          UFH is preferred for CABG pts

•          MONA again

•          Beta- blocker

–        Oral within 24 hours and long term use for most patients (metoprolol 200mg/day)

•          Reperfusion ASAP!!!

–        PCI (percutaneous coronary intervention)

–        Fibrinolysis (< 3hours is preferable but up to 12 hours of pain/sx onset)

•          tPA, rPA, TNKase

•          Unfractionated heparin, enoxaparin or fondaparinux (if can’t use heprin)

–         simultaneously with tPA, rPA or tenecteplase (if applicable)

–        PCI patients also get anticoagulants

–        Fondaparinux- if used initially need another anticoag during PCI

•          ACEI- oral

–        in first 24 hours after admission in pts with stable BP, SBP > 100mmHg and after fibrinolytic agent

–        STEMI presentation within 24hrs of CP onset

–        Assess for C/I and start within 30 minutes of hospital arrival

•          Types

•          tPA (alteplase) , streptokinase, anistreplase, reteplase, tenecteplase (IV)

•          MOA

•          Consider cost

•          Given with UFH, enoxaparin or fondaparinux

–        (heparin bolus than infusion, weight based )

–        UFH for CABG pts

–        If given within first 2 hours may abort MI      

–        Longer ischemia = more likely infarction with necrosis

–        Previous hemorrhagic stroke, other strokes or CVAs within 1 year

–        Known intracranial neoplasm

–        Active internal bleeding

–        Suspected aortic dissection

•          Emergent treatment (ED, hospital)

–        MONA and other therapies such as antiplts and anticoagulants

–        Thrombolytics (ST ELEVATION MI w/o contraindications)

–        PCI 

•          Long term treatment (secondary prevention)

–        ACE Inhibitors

–        Beta blockers

–        Antiplatelet agents

–        hypolipidemics

•          Hypotension

–        IV fluids, vasopressors such as dopamine and possibly NE (IV with arterial BP monitoring)

•          Cardiogenic shock

•          Low output state

–        Order echo, start dobutamine and possibly vasodilators to reduce afterload

•          Pulmonary edema

–        Oxygen, Morphine, ACEI, Nitrates (if BP is > 100mm Hg or 30mm above baseline)

–        Loop diuretics (careful with hypovolemia and lyte imbalances)

•          Arrhythmias

•          Pump failure usually due to extensive LV infarct

–        Hypotension

–        Signs of poor perfusion

–        Pulmonary edema

•          Need immediate revascularization usually with CABG

•          Medical stabilization

•          used to INCREASE PVR and BP

•          Dopamine (IV) is precursor of NE

–        Acts at low doses to dilate renal and coronary arteries

–        Higher doses stimulate alpha1 receptors causing vasoconstriction AND beta1 receptors causing increased contractility

•          Norepinephrine

–        Potent vasoconstrictor for severe hypotension

stimulate the HEART to PUMP

–        Dobutamine is a B1 agonist used as IV infusion to increase cardiac output

–        Onset is rapid with short half life requiring infusion

•          VF and pulseless VT à cardiovert

–        Shock 200J, shock200J-300J , shock 360J

–        Refractory à amiodarone 5mg/kg IV

•          Sustained polymorphic V- tach

–         200J, 300J and 360J

•          Sustained monomorphic VT with symptoms

–        100J initial shock

•          Sustained VT without

–        Without symptoms

–        Amiodarone 150mg IV over 10min repeat q10-15min as needed