6.2: coronary vascular disorders & myocardial infarction

Coronary Artery Disease (CAD)

Atherosclerosis

• ___

Causes _____

• Leading to: ____

Coronary Atherosclerosis

• Accumulation of ___

• Blocks and narrows ___

• Reduced ___

-Symptoms occur when ___ 

-Ischemia occurs: Left Main Artery- reduced by 50%, any vessel- reduced by 75% 

-Goal: alter progression of atherosclerosis

Coronary Artery Disease (CAD)

Atherosclerosis

• Narrowing or obstruction of 1 or more coronary arteries

Causes decreased perfusion of myocardial tissue & inadequate myocardial oxygen supply

• Leading to: hypertension (HTN), myocardial infarction (MI), heart failure (HF), + death

Coronary Atherosclerosis

• Accumulation of fatty plaque on artery walls

• Blocks and narrows coronary vessels

• Reduced Blood flow to myocardium and plaques can rupture

-Symptoms occur when enough blockage to have ischemia 

-Ischemia occurs: Left Main Artery- reduced by 50%, any vessel- reduced by 75% 

-Goal: alter progression of atherosclerosis

Risk Factors for CAD 

Modifiable	Non-modifiable
• BMI >30 • Diabetes Mellitus  • Hypertension • Alcohol Use • High LDL (bad cholesterol, more sticky) and Low HDL (good cholesterol) • Smoking	• Age 65+ • Family History

Medications

Nitrates	Calcium Channel Blockers	Cholesterol-Lowering Medications
• ____ • ___	• ___ • ___	• HMG-CoA: ___ • Nicotinic Acids • Fibric Acid • Bile Acid Sequestrants • Cholesterol Absorption Inhibitors • Omega 3 Fatty Acids

Risk Factors for CAD 

Modifiable	Non-modifiable
• BMI >30 • Diabetes Mellitus  • Hypertension • Alcohol Use • High LDL(bad cholesterol, more sticky) and Low HDL (good cholesterol) • Smoking	• Age 65+ • Family History

Medications

Nitrates	Calcium Channel Blockers	Cholesterol-Lowering Medications
• Dilate coronary arteries • Decrease preload and afterload	• Dilate coronary arteries • Decrease vasospasms	• HMG-CoA: Statins • Nicotinic Acids • Fibric Acid • Bile Acid Sequestrants • Cholesterol Absorption Inhibitors • Omega 3 Fatty Acids

Angina Pectoris

Chest Pain resulting from ___

Imbalance between ___

-occurs when body is ___ 

Stable	___	Occurs when ____ Ex: exercise/ strenuous activity (could also be emotional)
Unstable	___	Occurs when ___
Prinzmetal’s/ variant	___	Pain when ___

Angina Pectoris

Chest Pain resulting from myocardial ischemia, in one major artery

Imbalance between oxygen demand and supply

-occurs when body is overexerted 

Stable	Predictable/ has a pattern	Occurs with exertion Ex: exercise/ strenuous activity (could also be emotional)
Unstable	Preinfarction	Occurs at rest & more frequently
Prinzmetal’s/ variant	Coronary artery vasopasm	Pain at rest with reversible ST-elevation

Variant (Prinzmetal Angina)

Etiology	___ -strong association with ___
Symptoms	• Occurs ___ • Triggered by ___ • ___ during pain • Associated with ___ • With or without presence of CAD
Treatment	• Stop smoking • ___

Variant (Prinzmetal Angina)

Etiology	Coronary Vasospasm -strong association with cocaine and smoking use
Symptoms	• Occurs at rest without anything provoking it • Triggered by smoking • Transient ST segment elevation during pain (temporary, severe reduction in blood flow to the heart muscle) • Associated with AV block or V. arrhythmias • With or without presence of CAD
Treatment	• Stop smoking • Calcium Channel Blockers (prevent vasoconstiction & promote vasodilation)

Stable angina

Etiology	___
Symptoms	• ____ • Aggravated by ____ • ___ • Relieved by ___
Treatment	• ___ • ___ • ___ • Aspirin

Stable angina

Etiology	Myocardial Atherosclerosis
Symptoms	• Exertional, 5-10 min • Aggravated by exercise, exposure to cold (bc of vasoconstriction), emotional stress • Stable pattern of onset, duration, severity, and relieving factors • Relieved by rest
Treatment	• Nitrates: nitroglycerine (a vasodilator that provides immediate relief that immediately reprofuses their heart/ arteries) • Beta Blockers (alter bloodflow & improve CO) • Calcium Channel Blockers • Aspirin

Unstable angina (pre-infaction Angina)

Etiology	___
Symptoms	• ___ • Occurs ____ • Longer than __ min • ___
Treatment	• Oxygen • Pain Medication • Nitrates • Beta Blockers • Aspirin • Statins • tPA

Unstable angina (pre-infaction Angina)

Etiology	Ruptured or thickened plaque with platelet and fibrin thrombus
Symptoms	• Angina of increasing intensity, frequency, or duration • Occurs at rest or with minimal activity • Longer than 15 min • Pain unresponsive to nitroglycerin (NTG)
Treatment	• Oxygen • Pain Medication • Nitrates • Beta Blockers • Aspirin • Statins • tPA

Medications for Angina

Nitrates:	Beta Blockers:	Calcium Channel Blockers:	Antiplatelet
• ___ • ___	• ___	• ___ • ___ • ___	• ___

Medications for Angina

Nitrates:	Beta Blockers:	Calcium Channel Blockers:	Antiplatelet
• Vasodilators • Decrease ischemia= decreased pain	• Decrease myocardial oxygen consumption	• Relaxes blood vessels • Increase oxygen supply to heart • Decrease workload of heart	• Prevents platelet aggregation + thrombosis formation

Antianginal-Nitrates (Nitro-Bid, nitrostat)

Why	• ___
Patho	• ___ • Does not ___ • Improve ___ • Decrease ___
Side effects	• CNS: HA, dizziness, weakness • CV: hypoTN, flushing, pallor, increase perspiration
CI	• ___
Pearls	• Sublingual: under tongue until dissolved • ___ • Store: dark, tightly caped bottle • Check ___ before and after administering

Antianginal-Nitrates (Nitro-Bid, nitrostat)

Why	• Chest pain associated with angina
Patho	• Vasodilation to increase O2: veins + large arteries • Does not dilate coronary arteries • Improve blood delivery to heart muscle + decrease work of the heart decreasing demand of O2 • Decrease preload + afterload
Side effects	• CNS: HA, dizziness, weakness • CV: hypoTN, flushing, pallor, increase perspiration
CI	• Hepatic/renal disease, hypoTN, hypovolemia, ICP
Pearls	• Sublingual: under tongue until dissolved • 1 tab for pain up to 3 times (if it doesn't work, call 911 bc pt may have unstable instead of stable angina) • Store: dark, tightly caped bottle • Check BP before and after administering

Myocardial Infarction

definition: ____

MI Risk Factors

___ 

___

Elevated ___ levels

___ 

Hypertension (HTN) 

Obesity

___ lifestyle 

Stress

Myocardial Infarction

Blockage of blood flow to area of body that causes cell injury

MI Risk Factors

Atherosclerosis 

Coronary Artery Disease (CAD)

Elevated cholesterol levels

Smoking 

Hypertension (HTN) 

Obesity

Sedentary lifestyle 

Stress

Acute Chest Pain Presentation Differential

• ___ → ___ → ___

• Myocardial tissue abruptly and severely ___

• Sudden, crushing chest pain radiating to shoulder men

• NV

• Shortness of breath, sweating

Atypical Signs and Symptoms

Women	Older adult
• ___ • ___ • ___ • ___	• Shortness of Breath • ___ • Dizziness • ___ • Dysrhythmias

Acute Chest Pain Presentation Differential

• Atherosclerosis → Angina (initially stable, then unstable) → MI

• Myocardial tissue abruptly and severely deprived of oxygen

• Sudden, crushing chest pain radiating to shoulder men

• NV

• Shortness of breath, sweating

Atypical Signs and Symptoms

Women	Older adult
• Shortness of Breath • Fatigue • Indigestion • Nausea SNIF	• Shortness of Breath • Pulmonary Edema • Dizziness • Altered Mental Status • Dysrhythmias

Lipid-Lowering Agents

Dyslipidemia: LIPOPROTEINS: Produced by ___

Low Density Lipoproteins(LDL)- Bad

•Enters circulation as __

•Carried by ___

•Broken down for energy or stored for future

High Density Lipoprotein(HDL)- Happy/ good

•Enter circulation as ___

•Used for ___

•What’s helpful about it? ___

Cholesterol Levels

Hypercholesterolemia ___

Hypertriglyceridemia

Hyperlipidemia ___

Lipid-Lowering Agents

Dyslipidemia: LIPOPROTEINS: Produced by liver

Low Density Lipoproteins(LDL)- Bad

•Enters circulation as tightly packed cholesterol, triglycerides, and lipids

•Carried by proteins that enter circulation

•Broken down for energy or stored for future

High Density Lipoprotein(HDL)- Happy/ good

•Enter circulation as loosely packed lipids

•Used for energy

•Pick up remanent of fats + cholesterol left in periphery by LDL breakdown

Cholesterol Levels

Hypercholesterolemia (typically high LDL)

Hypertriglyceridemia

Hyperlipidemia (high level of lipids: triglycerides & cholesterol)

HMG-CoA Reductase Inhibitors- ATORVASTATIN (Lipitor)

Ends in “-statin”

Why	•___ •Primary prevention: ___ •Secondary prevention: ___
Patho	•___ •___
Side effects	•GI: flatulence, abdominal cramps, constipation •Neuro: Dizziness, HA •Liver: elevated enzymes, pruritis, muscle cramps* + fatigue, hepatotoxicity
Drug-drug	____ & ____
Pearls	•Monitor ____ •Report ___ immediately •Pregnancy- Category X (is not safe for pregnancy/ breastfeeding)

HMG-CoA Reductase Inhibitors- ATORVASTATIN (Lipitor)

Ends in “-statin”

Why	•Hyperlipidemia •Primary prevention: at risk for CAD •Secondary prevention: stabilizes fatty plaques in those with CAD
Patho	•Blocks enzyme HMG-CoA; rate limiting step for cholesterol synthesis •Plaque stabilization (keep it from getting bigger), reduction in plaque inflammation
Side effects	•GI: flatulence, abdominal cramps, constipation •Neuro: Dizziness, HA •Liver: elevated enzymes, pruritis, muscle cramps* + fatigue, hepatotoxicity
Drug-drug	Grapefruit juice (increases risk for toxicity) Fibrates (myopathy/ muscle weakness)
Pearls	•Monitor liver levels: should lower LDL and increase HDL •Report muscle pain immediately* •Pregnancy- Category X (is not safe for pregnancy/ breastfeeding)

Bile Acid Sequestrants- Cholestyramine

Why	•Prevention of CAD by ___ •___ •___
Patho	•Bile made + secreted in __, stored in _ •Once emulsified, ___ •Bile acid resins binds to ____ •Excreted in ___ •Decreases bile acid = ___ = decrease ___
Side effects	•Constipation •Increase risk for ___ related to ___ •___Deficiencies
Drug-drug	•malabsorption of fat-soluble vitamins (AK, E, D), TZD, diuretics, digoxin, warfarin, thyroid hormones, corticosteroids
Pearls	•___

Bile Acid Sequestrants- Cholestyramine

Why	•Prevention of CAD by decreasing serum cholesterol levels, usually combo with statin •Gallstone dissolution •Pruritus associated with partial biliary obstruction
Patho	•Bile made + secreted in Liver,  stored in Gallbladder •Once emulsified, fats + lipids absorbed in intestines •Bile acid resins binds to the bile acid to form an insoluble substance (can’t be absorbed) •Excreted in feces •Decreases bile acid = Liver uses Cholesterol to make more bile = decrease cholesterol
Side effects	•Constipation •Increase risk for bleeding related to vitamin K malabsorption •Vitamin A + D Deficiencies
Drug-drug	•malabsorption of fat-soluble vitamins (AK, E, D), TZD, diuretics, digoxin, warfarin, thyroid hormones, corticosteroids
Pearls	•Comes in gritty powder, must be dissolved, taken with lots of fluids

Cholesterol Absorption Inhibitors- Ezetimibe (Zetia)

Why	•__ •___ •___
Patho	•___
Side effects	•GI: abdominal pain, diarrhea •Muscle aches + pain
Drug-drug	•Caution combo with ___ •___, __, __, warfarin

Cholesterol Absorption Inhibitors- Ezetimibe (Zetia)

Why	•Lower serum cholesterol levels •Treat familial hypercholesterolemia •Treat homozygous sitosterolemia (congenital)
Patho	•Works in the small intestine to inhibit the absorption of cholesterol
Side effects	•GI: abdominal pain, diarrhea •Muscle aches + pain
Drug-drug	•Caution combo with statin (can cause more muscle related SE) •Cholestyramine, fenofibrate, gemfibrozil, warfarin

Others

Niacin	Fenofibrates	Omega 3 fatty acids
•Vitamin B3: inhibits ___ •Increases ___ •SE: GI disturbance, flushing, hepatotoxic	•Inhibits __ •Increased ___	•Omega 3-acid ethyl esters (___): inhibits ___ •Omega 3-carboxylic acid (___): fish oil mixture of free fatty acid approved as an adjunct to diet to reduce ___

Others

Niacin	Fenofibrates	Omega 3 fatty acids
•Vitamin B3: inhibits release of free fatty acids from adipose tissues •Increases rate of triglyceride removal from plasma •SE: GI disturbance, flushing*, hepatotoxic	•Inhibits triglyceride synthesis in liver-lower LDL •Increased uric acid secretion, stimulate triglyceride breakdown	•Omega 3-acid ethyl esters (Lovaza): inhibits liver enzyme system to decrease synthesis of triglyceride •Omega 3-carboxylic acid (Epanova): fish oil mixture of free fatty acid approved as an adjunct to diet to reduce triglyceride levels with severe hypertriglyceridemia