Unit 3 Lesson 2 CAD Treatments

What do nitrates do to blood vessels, and what type of vessels do they affect?

Nitrates are direct vasodilators that relax smooth muscle in:

1. Veins

2. Arteries

3. Arterioles

How do nitrates affect preload and myocardial oxygen requirements?

They decrease right and left ventricular preload, which lowers myocardial oxygen requirements.

How do nitrates affect afterload and cardiac workload?

They decrease afterload, which decreases cardiac workload.

What effect do nitrates have on coronary blood flow?

They increase coronary flow

When are nitrates the first drug of choice, and do they improve MI survival?

• First drug of choice for symptomatic CAD/angina

• No evidence of improved survival rates in MI

List the 3 side effects of nitrates.

• Headaches

• Hypotension

• Reflex tachycardia

How are nitrates given for acute attacks versus chronic therapy?

• Acute attack: Sublingual or spray

• Chronic therapy: Tablets or transdermal patch

List the 3 nitrate drugs given.

• Nitroglycerin

• Isordil — isosorbide dinitrate

• Nitro-bid — ointment

How do beta blockers affect heart rate, and how does this help coronary perfusion?

They decrease HR at rest and during exercise, which:

1. Prolongs diastole

2. Augments perfusion

How do beta blockers affect contractility and myocardial oxygen demand?

They decrease contractility, which decreases myocardial oxygen demand.

What effect do beta blockers have on systemic vascular resistance and SBP?

They decrease systemic vascular resistance and systolic blood pressure.

List the 4 beta blockers given.

• Propranolol — Inderal

• Nadolol — Cogard

• Metoprolol — Lopressor

• Atenolol — Tenormin

List the 5 side effects of beta blockers.

• Bronchospasm

• Fatigue

• Sexual dysfunction

• Marked bradycardia

• Potential to intensify heart failure

How do dihydropyridine calcium channel blockers affect preload, afterload, and myocardial oxygen demand?

They are potent vasodilators that:

1. Decrease preload and afterload

2. Decrease myocardial oxygen demand

How do dihydropyridines affect coronary circulation?

They are coronary vasodilators that:

1. Increase myocardial perfusion

2. Increase myocardial oxygen supply

List the 2 dihydropyridine drugs given.

• Nifedipine — Procardia

• Amlodipine — Norvasc

How do non-dihydropyridine calcium channel blockers affect HR and contractility?

They decrease HR and contractility, decreasing myocardial oxygen demand.

Their vasodilator effect is not as potent as dihydropyridines

List the 2 non-dihydropyridine drugs given.

• Diltiazem — Cardizem

• Verapamil — Calan

List the 5 side effects of calcium channel blockers.

• Headache

• Marked decrease in LV contractility

• Marked bradycardia

• Edema

• Constipation

List the 5 effects or uses of digitalis glycosides.

• Increase peripheral and coronary vascular resistance

• Increase myocardial contractility

• Decrease HR

• Promote elimination of fluid from tissues

• Treat some arrhythmias

What digitalis drug is listed?

Digoxin — Lanoxin

List the 6 side effects of digitalis glycosides.

• Nausea

• Vomiting

• Anorexia

• Abdominal pain

• Cardiac irritability

• Marked bradycardia

How do antiplatelet agents reduce the risk of MI, and what drug is listed?

They inhibit platelet activation and aggregation.

Drug: Aspirin.

List the 5 side effects of aspirin given.

• Dyspepsia

• Nausea

• GI bleed

• Asthma exacerbation

• Allergic reactions

List the 6 effects of lipid-lowering agents.

• Lower LDL

• Lower triglycerides

• Increase HDL

• Stabilize atherosclerotic plaques

• Improve endothelial cell dysfunction

• Lower MI death rates in patients with CAD

List the 4 statin drugs given.

• Atorvastatin — Lipitor

• Lovastatin — Mevacor

• Rosuvastatin — Crestor

• Simvastatin — Zocor

List the 6 types of non-statin lipid-lowering agents.

• PCSK9 inhibitors

• Citrate lyase inhibitors

• Bile acid sequestrants

• Fibrates

• Niacin

• Omega-3 fatty acids

List the 6 side effects of lipid-lowering agents.

• GI upset

• Sleep disturbances

• Hepatotoxicity

• Fatigue, anorexia, and weight loss

• Myalgia

• Muscle weakness

What are ACE inhibitors, and what do they do to blood vessels?

Angiotensin-converting enzyme inhibitors that prevent constriction of blood vessels.

How do ACE inhibitors affect afterload and contractility?

• Decrease afterload/BP

• Increase contractility

List the 5 side effects of ACE inhibitors.

• Hypotension

• Hyperkalemia

• Renal failure

• Cough

• Side effects are listed as rare

What 2 types of medications are included in antithrombotic therapy, and what is their purpose?

1. Antiplatelet agents — aspirin

2. Anticoagulant agents

Purpose: Prevent further occlusion of the coronary artery.

What anticoagulant is listed, and what does it do?

Heparin:

1. Inhibits additional coagulation factors

2. Reduces the likely progression of MI

What does thrombolytic therapy do?

• Accelerates lysis of the intracoronary thrombus — “clot buster”

• Restores coronary blood flow

• Limits myocardial damage

What is the major adverse effect of thrombolytic therapy?

Bleeding

List the 4 contraindications for thrombolytic therapy.

• Active peptic ulcers

• Underlying bleeding problems

• Recent stroke

• Recent surgery

List the 4 thrombolytic drugs given

• Streptokinase

• Alteplase — tPA

• Reteplase — rPA

• Tenecteplase — TNK-tPA

How is PTCA performed?

A balloon catheter is advanced through a peripheral artery to the affected lesion and inflated to dilate and “fracture” the stenosis.

What 2 benefits does PTCA provide?

• Relieves angina

• Eliminates exercise-induced RWMAs

What is the reocclusion risk after PTCA, and how does coronary stenting help?

• Risk of reocclusion within about 6 months

• Coronary stenting reduces restenosis

• The vessel may remain patent for years

How do vein bypass grafts and internal mammary artery bypass grafts differ in atherosclerosis risk?

• Vein graft: Vulnerable to accelerated atherosclerosis

• Internal mammary artery: More resistant to atherosclerosis

Where is a CABG graft placed, and what does it restore?

It is placed distal to the critical stenosis and restores perfusion distal to the lesion.

Does CABG prevent MI or reduce ventricular arrhythmias?

No.

• Does not prevent MI

• Not beneficial in reducing ventricular arrhythmias

How effective is CABG for relieving pain?

It is very effective, improving pain in >90% of patients.