Stable Ischemic Heart Disease

Stable angina is also called

Stable Ischemic Heart Disease

Unstable angina

type of ACS that is not relieved with NG or rest

Chest pain caused by vasospasm

prinzmetal's angina: can occur at rest, and be caused by drugs like cocaine

effect of atherosclerosis on workload (O2 demand) and supply (blood flow)

atherosclerosis typically is plaque build up that decreases myocardial oxygen supply, known as coronary arty disease, narrowing arteries and reducing blood flow to the heart

How is likelihood of CAD assessed

cardiac stress test

Medications used in a cardiac stress test

adenosine, dipyridamole, dobutamine, regadenoson (Lexiscan)

Waist circumference recommendations for M and F

M: <40 in.

F: <35 in.

Exercise recommendation

moderate intensity aerobic, 5-7 days a week

preferred antiplatelet

aspirin

antiplatelet when aspirin is contraindicated (allergy or other reason)

clopidogrel

When is dual antiplatelet therapy (aspirin and clopidogrel etc.) used

stent placement or cabg

All options for antianginal medications

beta blockers, CCBs (both types), long-acting nitrates, ranolazine, nitroglycerin

Purpose of antianginal medication

decreases O2 demand or increases oxygen supply

First line anti-anginal medication option

beta-blockers

Which SIHD patients should get NG

all patients

when are long-acting nitrates used

When beta-blockers are contraindicated or as add-on therapy for treatment of symptoms

Statin intensity for SIHD

It is ASCVD, high-intensity

ABCDE of stable ischemic heart disease management

A: antiplatelet and antianginal

B: blood pressure and beta blockers

C: cholesterol (statins) and cigarette cessation

D: diet and diabetes

E: exercise and education

MOA of aspirin

Irreversibly blocking cyclooxygenase 1 and 2, decreasing Prostaglandin and thromboxane 2 (TXA2) production.

Action of thromboxane 2 (TXA2)

it is a potent vasoconstrictor and inducer of platelet aggregation

it's reduced production by aspirin administration reduces platelet aggregation and vasoconstriction

True/False clopidogrel is a prodrug

true

MOA of clopidogrel

irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

Bufferin generic

aspirin

aspirin dosing

75-162

Contraindications of aspirin

salicylate allergy, children and teenagers with viral infection (risk of Reye's syndrome)

warnings/side effects for aspirin

bleeding, tinnitus (with overdose), dyspepsiea, heartburn, bruising

Type of aspirin preferred in ACS

chewable, non-enteric coated

If only enteric-coated aspirin is available, should it be taken for ACS? if so? How?

it can be taken, it should be chewed

True/false aspirin is used indefinitely in SIHD unless contraindicated to reduce MI, CV, and death

true

Durlaza and Yosprala should not be used _____

when rapid action is needed

(they are delayed release aspirin formulations)

Counseling for patients on aspirin

can take with food to reduce nausea

PPIs can be used to protect the gut, but consider risks of long-term PPI use

Risks of long-term PPI use

decreased bone density, increased infection risk

Enzyme that converts clopidogrel to active form

CYP450 2C19

contraindications to clopidogrel

serious bleed

When should clopidogrel be stopped for elective surgery

5 days prior to surgery

Drug interactions with clopidogrel

omeprazole, esomeprazole

How long is a bare metal stent treated with DAPT

1 months

How long is a drug-eluting stent treated with DAPT

6 months

How long is post-CABG pt treated with DAPT

12 mos

Dose of aspirin in DAPT

81mg

CYP2C9 inhibitors

omeprazole, esomeprazole

Preferred antianginal in prinzmetal's angina

calcium channel blockers

Considerations for Beta blockers in SIHD

titrate to HR 55-60

beta blockers without ISA are preferred

avoid in prinzmetals

drug class to avoid in prinzmetals angina

beta blockers

Heart rate target for beta blocker titration

55-60

Beta blockers without ISA

metoprolol, carvedilol

When are CCBs preferred

in combination with Beta blockers when there's risk of excessive bradycardia

Which calcium channel blockers should be avoided

short-acting DHPs (nifedipine IR), slow release and long-acting, and non-dhps are effective

Nitrates help by

vasodilation of veins more than arteries (reducing preload)

When are nitrates used

when beta-blockers are contraindicated or as add-on therapy

Ranolazine contraindications

Strong CYP3A4 inhibitors and inducers

True/False ranolazine increases the QT interval

true

True/False ranolazine can be used for the acute treatment of chest pain

False: Do not use for acute chest pain treatment

What is ranolazine's effect on heart rate and blood pressure

little to no clinical effects on HR or BP

Nitroglycerin dose

0.4mg

nitroglycerin contraindications

PDE-5 inhibitors

warnings with NG

hypotension, headache (tachyphylaxis w/ long-acting products), headache, flushing, syncope

Warnings w/ nitrates

hypotension, headache (tachyphylaxis w/ long-acting products), headache, flushing, syncope,

How to store NG

in original amber glass bottle, tightly capped, at room temp

recommended nitrate-free interval

10-12 hours to decrease tolerance

Nitrostat formulation

SL tablet

Nitrolingual formulation

spray

Counseling on nitrate patch

wear 12-14 hours, off 10-12 hours, rotate sites

counseling on nitrate ointment

BID, 6 hours apart, 10-12 hour nitrate free interval

dosing frequency of isosorbide mononitrate IR and ER

IR: 7 hours apart (i.e. 8am and 3pm)

ER once daily

Isosorbide dinitrate plus hydralazine is preferred in

HFrEF

PDE-5 inhibitors plus long-acting nitrates can cause

a significant drop in BP

Preferred site for NG patch

chest

how to measure dose of NG ointment

always use dose-measuring device

counseling on NG ointment

can stain clothing

Thrombotic thrombycytopenic purpura (TTP) is a possible side effect of

clopidogrel

True/False All NG products can cause orthostasis

true

When to call 911 for acute chest pain

call immediately if chest pain persists after the first dose, then can continue to take two additional doses at five minute intervals waiting for ambulance

max amount of NG doses a patient can take in acute episode

3 doses in 15 minutes

Counseling how to take SL NG

place tablet under tongue, let dissolve, don't crush chew or swallow

may tingle or slightly burn, this is not a sign of how well the medication is working

Counseling on NG spray

don't shake

spray onto or under the tongue

don't inhale the spray