Term
| What are the three presentations of Ischemic Heart Disease? |
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Definition
- Chronic Stable Angina
- Acute Coronary Syndrome
- Ischemia w/o symptoms |
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Term
| What is coronary artery disease? |
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Definition
| Most common form of coronary heart disease. Accumulation of plaques within the walls of arteries. |
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Term
| What types of angina exist? |
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Definition
- Chronic Stable Angina
- Unstable Angina
- Prinzmetal's Angina |
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Term
| What causes the decreased supply associated with angina? |
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Definition
- Fixed Stenosis
- Thrombus
- Vasospasms |
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Term
| What causes increased demand associated with angina? |
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Definition
| - HR, Contractility, afterload and preload |
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Term
| How is angina clinically evaluated? |
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Definition
- P - precipitating factors
- Q - quality of pain
- R - Region/radiation of pain
- S - Severity
- T - Temporal pattern - when it occurs |
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Term
| How does atypical angina present and in who does it occur? |
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Definition
- Knife-like pain, chest is tender to palpation, random onset, can last for long periods. Not relieved by NTG or rest.
- Occurs in the elderly, women, or diabetics |
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Term
| How does normally presenting angina present? |
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Definition
| Radiates to the shoulders, subsides with rest and NTG, does not last for long periods. |
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Term
| How is Class I angina characterized? |
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Definition
Does not present with ordinary activity
Presents with prolonged and strenuous exertion - marathon or playing |
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Term
| How is class II angina characterized? |
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Definition
Ordinary activity slightly impacted
Angina on walking or climbing stairs rapidly, walking uphill, after meals/in cold weather/under stress/upon awakening |
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Term
| How is Class III angina characterized? |
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Definition
Marked limitation of normal activity
Angina on walking on level surfaces, one flight of stairs at a normal pace |
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Term
| How is Class IV angina characterized? |
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Definition
Can't Carry out any physical activity without angina
Angina at rest |
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Term
| What are the main risk factors of Stable Angina? |
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Definition
| Smoking, HTN, Hyperlipidemia (Goal becomes <100), Diabetes, Stress, BMI > 25, Obesity, Alcohol intake, Exercise and diet |
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Term
| What conditions that further increase oxygen demand may exacerbate angina? |
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Definition
Sympathomimetics, anxiety
Hyperthyroidism
Tachycardia, Aortic Stenosis, Cardiomyopethy |
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Term
| What conditions that further decrease oxygen supply may exacerbate angina? |
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Definition
| - anemia, sickle cell, stenosis/myopathy |
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Term
| What laboratory testing should be done in all stable angina patients? |
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Definition
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Term
| What is the primary class of medications to be used in all stable angina cases? |
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Definition
Beta blockers: Atenolol, Metoprolol XL or not, or Propranolol
- Cardioselectivity when bronchospasms or COPD present |
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Term
| What is the goal heart rate when on a beta blocker? |
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Definition
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Term
| What adverse effects and contraindications exist with BBs? |
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Definition
AE: Bradycardia, hypotension, fatigue, bronchspams
Contraindicated: AV block, severe bradycardia, SSS, shock, Prinzmetal's angina |
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Term
| When should calcium channel blockers be considered in stable angina patients? |
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Definition
When BBs are contraindicated or when unacceptable side effects are seen or in combination. Can use in Prinzmetal's Angina.
Can use DHP and non-DHP however always avoid non-DHP in patients with HF and bradycardia. |
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Term
| What are adverse effects and contraindications to calcium channel blockers? |
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Definition
AE: HA, edema, hypotension, bradycardia
Contraindicated: decompensated HF, bradycardia, shock, AV block |
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Term
| How are nitrates dosed to patients and why? |
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Definition
Given to ALL patients to manage acute attacks or to manage symptoms brought on by predictable activities.
- SL: relieves in 5-10 min
- Ointment: Apply 1-2 inches to chest, use gloves, lasts 6 hrs
- Patch: leave on 12 hours |
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Term
| How should SL NTG be counseled on? |
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Definition
Can use for a total of 3 doses
Call 911 if chest pain not relieved after first dose
Keep nitroglycerin in original, tightly closed glass container
Check expiration date regularly |
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Term
| When is the use of long acting nitrates appropriate? |
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Definition
| Can be used initially when beta blockers are contraindicated, are unsuccessful, or can be added when pts are having one attack/day and maxed out on other medicines |
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Term
| What adverse effects and contraindications are seen with nitrates? |
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Definition
AE: Flushing, HEADACHE, nausea, hypotension, rash
- must have a nitrate free period of 8-14 hours = not useful as monotherapy
Contraindication: Anemia, hypotension, PDE inhibitor use, sensitivity |
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Term
| How is Ranexa/Ranolazine used in stable angina? |
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Definition
Add-on therapy when all other medications have failed or maximized
- Prolongs QT interval, hepatic impairment |
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Term
| How should Aspirin be used in stable angina therapy? When should Plavix be used instead? |
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Definition
- Use in ALL patients without contraindication
- Use Plavix in patients unable to tolerant ASA |
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Term
| When should Ace Inhibitors be used in Stable Angina patients? |
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Definition
- Use in patients with history of MI, HTN, HF, diabetes, or impaired renal function who are not contraindicated.
- Use an ARB if AceI not tolerated
- Captopril/Capoten, Enalapril/Vasotec, Lisinopril/Prinivil, Ramipril/Altace |
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Term
| What risk factors can be reduced to improve Stable Angina prognosis? |
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Definition
- Quit Smoking
- LDL goal of <100
- BMI < 25 and waist reduction, weight loss goal of 10%
- A1C < 7%
- Exercise 30-60 min/day every day |
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Term
| When is revascularization considered in Angina? |
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Definition
| DOES NOT improve morbidity/mortality in stable angina, not helpful |
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Term
| What are the ABCDEs of Stable angina? |
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Definition
- A: Aspirin and anti-anginal meds
- B: Beta Blocker --> CCB --> AceI
- C: Cigarette smoking and cholesterol mngmt
- D: Diet and Diabetes mngmt
- E: Exercise and education |
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