Term
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Definition
| BB is indicated in patients with stable CHD/HF or post-MI |
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Term
| What are the therapeutic efficacy of using BB to treat angina? |
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Definition
1. Resting HR < 60 bpm
2. Decrease symptoms of chest pain (subjective measure of efficacy) |
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Term
| What are the safety/tolerability of BB used to treat angina? |
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Definition
1. BP
2. Fatigue - if patient is too fatigued, that means that the heart isn't pumping enough oxygenated blood to the body and we need to lower the dose on the BB |
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Term
| What are the side effects of BB? |
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Definition
1. Insomnia/nightmares
2. Impotence
3. Depression (propranolol)
4. Metabolic side effects
5. Mask effects of hypoglycemia (increases BG)
6. claudication |
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Term
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Definition
1. Overt HF (indicated in stable HF)
2. Bradycardia
3. Sick sinus syndrome
4. Cardiogenic Shock
5. Pulmonary edema
6. 2nd/3rd degree block w/out pacemaker |
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Term
| Which disease states should we be cautious in when using BB? |
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Definition
USE B-1 SELECTIVE BB for:
1. RAD (reactive airway disease - asthma)
2. PVD
3. DM
4. HLD |
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Term
| Which type of BB should you AVOID in patients with angina? |
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Definition
BB w/ positive ISA (intrinsic sympathomimetic activity) such as:
1. Acebutolol
2. Pindolol
3. Penbutolol
4. Carteolol |
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Term
| Why should BB w/ positive ISA be avoided in patients with angina? |
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Definition
| Because the therapeutic goal is to lower HR (lower oxygen demand), but BB w/ positive ISA increases HR! |
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Term
| What increases oxygen demand? |
|
Definition
1. Hyperthyroidism
2. HTN
3. Anxiety
4. Tachycardia
5. Sympathomimetics
6. Cardiomyopathy
5. Aortic Stenosis |
|
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Term
| What decreases oxygen supply? |
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Definition
1. Sympathomimetics
2. Anemia
3. Pulmonary Disease
4. Polycythemia (too much Hb in the blood) |
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Term
| If BB are CI in patients, what alternative can be used to treat angina? |
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Definition
| NDHP CCB (Verapamil, Diltiazem) |
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Term
| What are CIs to NDHP CCB? |
|
Definition
CI include:
1. SEVERE HF
2. Bradycardia
3. A.fib/Atrial flutter associated with accessory conduction pathway
4. Cardiogenic shock
5. Sick Sinus Syndrome
6. 2nd/3rd degree AV Block |
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Term
| What do you need to monitor in patients taking BB? |
|
Definition
1. HR
2. Orthostatic hypotension
3. Fatigue
4. Liver and renal functions
5. Depression
6. worsening of lung functions |
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Term
| What do you need to monitor in patients taking NDHP CCB? |
|
Definition
1. HR (bradycardia)
2. Constipation (esp Verapamil)
3. Worsening of HF
4. AV block |
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Term
| If patient is at HR goal while taking BB/NDHP CCB, but angina is still not controlled, what else can you give the patient for additional control of angina? |
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Definition
| 1. DHP CCB (in combo with BB, or when BB and NDHP CCB are CI) |
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Term
| What are the SE of DHP CCB? |
|
Definition
Side effects have to do with vasodilation:
1. Peripheral edema
2. Flushing
3. HA
4. Palpitations (avoid in patients with acute MI)
5. dizziness |
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Term
| If patient has HF, what can you give to treat angina? And what should you avoid? |
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Definition
| 1. Give DHP CCB like Amlodipine & Felodipine (do not worsen HF) 2. Overt HF is CI in BB and Severe HF is CI in NDHP CCB |
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Term
| When can nitrates be used to treat angina? |
|
Definition
1. Nitrates PRN SOB (SL, buccal, chewables)
2. Daily nitrates in combo with other anti-anginal agents (BB/CCB) |
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Term
|
Definition
SE associated with vasodilation:
1. HA
2. Dizziness
3. Hypotension
4. Flushing
5. N/V
6. tachycardia |
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Term
| What should you include in patient education when talking about nitrates? |
|
Definition
1. Take PRN nitrates sitting down
2. Do not take Viagra-like drugs (Sildenafil) within 24 hrs of taking any nitrates (do not abruptly stop taking nitrates bc that will increase risk of cardiac ischemia)
3. Must have a min. 8 hr nitrate free period (12-14 hrs preferred)
4. Do not use daily nitrates for acute attack
5. Do not stop taking abruptly
6. Avoid EtOH and excessive heat |
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Term
| What is Ranolazine used for? |
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Definition
| Ranolazine is used along with BB/amlodipine/nitrates when angina is not controlled. An advantage is that it does not lower HR, or BP (other antianginals and ACEI all do) |
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Term
| If a patient has BP and HR under control, but still experiences angina, what medication can we give them? |
|
Definition
| Ranolazine! Doesn't lower BP or HR! |
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Term
| If a patient is on BB and has HR at goal, but still experiences angina, what can we give them? (BP is slightly above goal) |
|
Definition
Give Add-On therapy:
1. DHPCCB
2. Daily nitrates
3. Ranolazine |
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Term
| What are SE of Ranolazine? |
|
Definition
1. Dizziness
2. Nausea
3. Asthenia (abnormal weakness or lack of energy)
4. Constipation
5. QT prolongation |
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|
Term
| What are non-pharmacological strategies for reducing angina? |
|
Definition
1. PCI (Percutaneous Coronary Intervention)
2. CABG (Coronary Artery Bypass Graft) |
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Term
| For PCI, what are the dual antiplatelet therapy (DAT)? (Standard of care vs therapy for patients w/ ACS) |
|
Definition
1. Standard of therapy:
ASA + Clopidogrel
2. Patients w/ ACS:
ASA + Prasugrel/Ticagrelor |
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Term
| What therapy is required for patients who have undergone PCI or CABG? Why? |
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Definition
| DAT (dual antiplatelet therapy) is required for all patients who have done a PCI or CABG because the body will naturally want to heal itself at the area of stent placement, which may result in platelet aggregation and activation. So we want DAT to prevent formation of thrombus. |
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|
Term
What is the duration of DAT for:
1. BMS (and high risk of bleeding)?
2. DES (and high risk of bleeding)? |
|
Definition
1. BMS: 12 months minimum
BMS + high risk for bleed: 2-4 weeks
2. DES: 12 months minimum
DES + high risk of bleed: 6 months |
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Term
| What are the 2 types of PCI? |
|
Definition
| BMS (Bare Metal Stent): thrombus formation more likely to occur within 30 days after PCI DES (drug eluting stent): thrombus formation most likely to occur within 1 year after PCI (behaves like BMS after drug is gone in 3-6 months) |
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Term
| What do you need to give to a patient before doing PCI? |
|
Definition
1. If patient is already taking daily ASA, then give patient ASA 75-325 mg before PCI
2. If patient is not already taking daily ASA, give patient ASA 300-325mg at least 2 hrs before PCI (preferably 24 hrs)
3. Give loading dose of Clopidogrel 600 mg before PCI |
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Term
| What should you give patients post-PCI? |
|
Definition
1. ASA 162-325mg QD x 1 month for BMS/x 3-6 months for DES AND Clopidogrel 75 mg QD
2. After 1 month, ASA 81-162 mg QD indefinitely (at least 12 months) |
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Term
| For patient with CHD, what is the BP goal? |
|
Definition
|
|
Term
| What are the pharmacological strategies to prevent CV event (MI, stroke, death)? |
|
Definition
Add:
1. ACEI
2. Lipid lowering therapy (statin)
3. Anti-platelet therapy (ASA or Clopidogrel if ASA is not tolerated)
4. BB (only for patients post-MI, ACS or LVSD w/ or w/out HF) |
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Term
| What is the first line therapy of BP lowering agent for preventing CV event? |
|
Definition
| ACE Inhibitor! If allergice to ACEI, then can use ARB as alternative 1st line |
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Term
| What are the monitoring parameters for ACEI? |
|
Definition
1. SCr
2. K+ levels
3. BP
4. Angioedema
5. Cough |
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Term
| What are the AHA/ACC guidelines for starting ACEI? |
|
Definition
1. Start and continue ACEI in all patients with LVEF 40% and in those with HTN, DM, CKD, unless CI
2. Consider for all other patients
3. ACI may be optional for those at low risk w/ normal LVEF and CV risk factors are well controlled
4. Use ARBs in those intolerant of ACEI and have HF or MI w/ LVEF 40% |
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|
Term
| What is first line agent for lipid lowering therapy? Alternates? |
|
Definition
First line: Statins!
Alternates: niacin, fibric acid derivatives, bile acid resins |
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|
Term
| Per AHA/ACC Guidelines, what are the dietary adjustments that need to be made to lower lipids? |
|
Definition
1. Reduce intake of saturated fats, trans-FA, and cholesterol
2. Add plant stanol/sterols and viscous fiber
3. Promote daily physical activity and weight management
4. Encourage consumption of omega-3-FA |
|
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Term
| Per AHA/ACC Guidelines, what does lipid management include? (LDL goal, non-HDL goal, TG > 500mg/dL) |
|
Definition
1. LDL Goal <100mg/dL (<70mg/dL is reasonable)
2. If baseline or on-treatment LDL = 100mg/dL, either initiate or intensify lipid lowering therapy
3. IF TG = 200-499 mg/dL, non-HDL goal <130mg/dL (<100mg/dL is reasonable)
4. Therapeutic options to reduce non-HDL:
- intensify LDL lowering therapy
- Niacin/fibrate (after LDL lowering therapy)
5. If TG > 500 mg/dL, therapeutic options to prevent pancreatitis are: fibrate or niacin before LDL lowering therapy |
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Term
| What are the agents that can be used in anti-platelet therapy? |
|
Definition
1. ASA 81-325mg QD
2. Thienopyridine: Clopidogrel, Prasugrel, Ticlopidine |
|
|
Term
|
Definition
1. allergy
2. bleeding tendencies
3. anticoagulation therapy, unless required
4. recent GI bleed
5. active hepatic disease |
|
|
Term
| What are major ADRs of ASA? |
|
Definition
1. Bleeding risk
2. GI ulceration
3. Hypersensitivity reactions
4. angioedema |
|
|
Term
| What should you include in patient education for ASA? What if the patient wants to take dietary supplements? |
|
Definition
Avoid:
1. garlic
2. high doses of Vit E
3. Ginseng
4. Gingko
5. Stop ASA therapy 7-10 days before elective surgery
6. Avoid in patients < 21 yo |
|
|
Term
| What are CIs for Thienopyridine? |
|
Definition
|
|
Term
| What are ADRs of Thienopyridines? |
|
Definition
1. Bleeding risk
2. Thrombotic Thrombocytic Purpura (TTP) - rare |
|
|
Term
| Per AHA/ACC Guidelines, what are the doses of ASA that should be taken to prevent CV event? |
|
Definition
ASA 81-162mg QD should be continued indefinitely in all patients, unless CI
- If CI, then Clopidogrel 75 mg can be taken instead |
|
|
Term
| What are risk factors for CHD? |
|
Definition
1. HTN
2. Cigarette smoking
3. HLD
4. DM
5. FH of premature CHD |
|
|
Term
| How do you characterize chest discomfort? |
|
Definition
1. Quality of Pain (usually described as severe pain)
2. Timing (what brings it on, what helps it go away)
3. Location (substernal, may radiate to arms, shoulders and jaw) |
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