Stable Ischemic Heart Disease

Angina: unstable vs stable

chest pain, pressure, tightness

Stable: stable ischemic heart disease (SIHD), is associated with predictable chest pain, often brought on by exertion or emotional stress and relieved within minutes by rest or with nitroglycerin

Unstable: acute coronary syndrome (ACS); this is a medical emergency where not relieved with nitroglycerin or rest

Prinzmetal's Angina

chest pain is caused by vasospasm of the coronary arteries

can occur at rest

can be cause by illicit drugs

Angina: Pathophysiology

- imbalance between myocardial oxygen demand (workload) and supply (blood flow)

- demand increases when heart is working harder due to: increased heart rate, contractility or left ventricular wall tension

inability to reach oxygen supply can be caused by atherosclerosis (ACS) --> reduced blood flow to the heart

What are the risk factors for SIHD?

hypertension, smoking, dyslipidemia, diabetes, obesity and physical inactivity.

How is SIHD diagnosed?

Cardiac stress test

- Physical exercise: treadmill, stationary bike

- IV Medications: Adenosine, Dipyridamole, Dobutamine, Regadenoson

pt is monitored for development of sx

What is Lexiscan?

Regadenoson

med used during cardiac stress test

SIHD: Non-drug tx

- heart healthy diet

- BMI of 18.5 - 24.9 kg/m2 (normal)

- waist circumference < 35 inches in females and < 40 inches in males

- moderate- intensity aerobic activity

- Patients who smoke should quit

- Alcohol intake should be limited

SIHD: Drug tx

antiplatelet + antianginal (maintenance and PRN)

1) ASA

- clopidogrel if Cid (salicylate allergy, child, teen, Reye's)

+

1) beta blockers

- CCBs or LA nitrates when CId (hepatic impairment, severe bradycardia, cardiac failure, cariogenic shock)

PRN - SA nitroglycerin as SL tab

Since SIHD is ASCVD: make sure pt on statin (low-key regardless of levels)

SIHD Summarized tx

ABCDE

A - antiplatelet + antianginal

B - BP and beta blockers

C - cholesterol (statins) and cigarettes (cessation)

D - diet and DM

E - exercise and education

What dose of ASA for SIHD?

75 - 162 mg PO daily

What is the rx ASA product?

a delayed release capsule

ASA: MOA

irreversibly inhibits cyclooxygenase-1 and 2 (COX-1 and COX-2) --> decreased prostaglandin (PG) and thromboxane A2 (TXA2) production

Clopidogrel: MOA

prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation.

ASA: CIs

- salicylate allergy

- children and teenagers

- Reye's syndrome

What is the generic for Bayer?

ASA

What is the generic for Bufferin?

ASA

What is the generic for Ecotrin?

ASA

What is the generic for Plavix?

clopidogrel

ASA: Warnings

Bleeding

Tinnitus (salicylate overdose)

ASA: SEs

dyspepsia, heartburn, bleeding

How long should ASA be used for SIHD?

indefinitely

What formulations of ASA are preferred in ACS?

Non-enteric coated, chewable aspirin

if only enteric-coated (EC) aspirin is available, it should be chewed (Bayer, Ecotrin)

What should be given along with ASA to pt taking it for SIHD?

PPIs

(be careful of long term use of these like decreased bone density and increased infection risk)

What is the dose of clopidogrel when given for SIHD?

15 mg PO daily

Clipidogrel: BBW

- check genetic tests for CYP2C19 defects --> if poor metabolizer its metabolism can be affected b/c its a prodrug

Clopidogrel: Warnings

- Bleeding risk (stop 5d before surgeries)

- premature discontinuation can increase risk of thrombosis

- thrombotic thrombocytopenia purpura (TTP)

Clopidogrel: Drug Interactions

avoid with omeprazole or esomeprazole (inhibits CYP 2C19)

Clopidogrel: SEs

generally well tolerated unless bleeding occurs

In what cases is DAPT used for SIHD?

- pt had bare metal stent placed give DAPT x1 month

- pt had drug-eluding stent placed requiring give DAPT x6months

- pt is post Coronary artery bypass grafting (CABG) give DAPT x12months

ASA is dosed at low 81mg PO QD when used as DAPT (75 - 162 mg PO daily w/ monotherapy)

Why are beta blockers useful for SIHD?

- decrease HR

- decrease contractility of heart

- decrease left ventricular wall tension

--> lowers myocardial oxygen demand

Why are CCBs useful for SIHD?

USED WHEN BETA BLOCKERS Cid (not first line)

Non-DHPs: decrease HR and contractility (diltiazem, verapamil)

DHPs: decreases SVR (after load) (amlodipine, nicardipine, nifedipine)

--> lowers myocardial oxygen demand

What CCBs should be avoided in SIHD?

short acting DHPs like nifedipine IR

What CCBs are preferred if a pt is already on them for something else but needs a beta blocker to be added for SIHD?

DHP (amlodipine, nicardipine, nifedipine)

What SIDH medication should be avoided in Prinzmetal's angina?

beta blockers

What is the benefit of nitrates/nitroglycerin for SIHD?

- decreases preload by --> vasodilation of veins > arteries --> lowers myocardial oxygen demand

What is recommended for fast relief for all pts with angina (of any type)?

nitrites/nitroglycerin

When are long acting nitrates used?

when beta blockers Cid or as add on therapy if sx persist

What is the recommended dose for short acting nitroglycerin?

Sl, tongue spray, SL powder all 0.4 mg PRN

What are the long acting nitrates?

nitroglycerin 2% ointment (Nitro-Bid)

Isosorbide mononitrate IR/ER

What is Nitrostat?

SL nitroglycerin

What is NitroMist?

nitroglycerin tongue spray

What is Nitrolingual?

nitroglycerin tongue spray

What is Nitro-Bid?

long acting nitroglycerin 2% ointment

Nitrates: CIs

do not use with PDE-5 inhibitors

Nitroglycerin: SEs

Hypotension, headache, tachyphylaxis (decreased effectiveness/tolerance with long-acting products)

Nitroglycerin SL tabs: Storage

Store nitroglycerin SL tablets in the original amber glass bottle

Store at RT

Why do long acting nitroglycerin products require a nitrite-free interval?

to decrease tolerance

Nitroglycerin patch: Counseling

- wear on for 12-14 hours then remove x10-12h

- rotate sites (chest is preferred)

Nitroglycerin 2% ointment/NitroBid: Counseling

- dosed BID, 6 hours apart + 10-12h nitrate-free interval

- Measure the dose of ointment with the dose-measuring applicator

- Can stain clothing

If a pt is on hydroxyzine for HFrEF, what long-acting nitroglycerin is recommended for SIDH when beta blocker is Cid?

isosorbide dinitrate

Nitrate: Drug Interactions

- Do not use long-acting nitrates in combination with PDE-5 inhibitors due to risk significant decrease BP

What is ranolazine used for and describe drug interactions, warnings

antianginal when other options CId. no effect on HR or BP

Do not use with strong CYP3A4 inhibitors or inducers (G-PACMAN and statin)

Warnings: an cause QT prolongation

Short Acting Nitroglycerin: Counseling

1) Call 911 immediately if chest pain persists after the first dose

2) take two additional doses at five minute intervals

3) Do not take more than three doses within 15 minutes.

SL Nitroglycerin Tabs: Counseling

- Place the tablet under the tongue

- Slight burning or tingling sensation is not a sign of how well the medication is working

Nitroglycerin Spray: Counseling

1) prime

2) Do not shake. Spray onto or under the tongue. Do not inhale the spray

What is the generic for Prilosec?

Omeprazole

What is the brand name for Nexium?

esomeprazole

What is the generic name for Protonix?

pantoprazole

What PPI can a pt take if they are clopidogrel?

pantoprazole (Protonix)

How is isosorbide mononitrate IR dosed?

BID around 7 hours apart (not 12)

Which is the recommended beta blocker from SIHD?

metoprolol

What antianginal is recommended for Prinzemetal's?

CCBs

What are the s/x that indication TTP?

thrombocytopenia, hemolytic anemia, neurological findings, renal dysfunction, fever and purpura (purple-colored spots)

What medications are used in a cardiac stress test?

- adenosine

- dipyrimadole

- dobutamine

- regadenoson