CAD management

What is angina?

It is a symptom, chest pain

What is the difference between stable angina and unstable angina?

Stable: Angina only happens during exertion

Unstable: blood clot is blocking the coronary artery partially or fully
needs PCI. Can cause angina during rest or exertion.

Stable vs Unstable CAD

stable plaque: lumen narrowed by lipid pool

unstbale plaque: Rapture plaque, many inflammatory cells, thrombus forms

Non-ST segment elevation MI vs ST-segment elevation MI

Non-ST: not complete occlusion by the thrombus

ST elevation: complete occlusion of the artery by the clot

What is released when there is cardiac muscle death?

increase in troponin
increase in AST

What are the typical characteristics of angina?

1. constricting discomfort in the front of the chest, neck, jaw, arm
2. Precipitated by physical exertion
3. relieved by nitrates within 5 min.

Typical angina meets at least 2 of these

What to do when you suspect someone of acute MI?

Repeated measurement of Troponin
Full blood count
Renal function (Creatinine)
A lipid profile (when there is a suspicion of any ASCVD)
Thyroid function (TFT)
ECG (repeat every 5 min if suspecting STEMI)

What is the gold standard to diagnose AMI?

Coronary angioplasty
Angiogram

What are the agents used in treating angina?

Nitrates
Beta blocker
DHP-CCB
Non-DHP CCB
Ivabradine
Ranolazine

What is the MOA of Nitrates?

Biotransformation and release of NO causing vasodilation
Decreasing the demand of oxygen through the reduction in preload, myocardial wall tension and MVO2 (myocardial oxygen extraction)

Increases oxygen supply through the vasodilation of stenotic vessels

What is the purpose of nitrates?

It is used to prevent and relieve the symptoms of angina
It isnt really part of the anti-angina therapy

What are some common side effects of nitrates?

hypotension, dizziness and headache

What are some contraindications of nitrates?

Concomitant administration of PDE-5 inhibitor (for erectile dysfunction)

24h: Sildenafil, vardenafil
48h: Tadalafil

Can cause life-threatening hypotension
Need to space it apart

What is nitrate tachyphylaxis?

repeated chronic use leading to reduced sensitivity to nitrates

Happens in long acting nitrates

How to prevent nitrate tachyphylaxis?

Nitrate free period 10-14h

try to have ntirate free interval at night (angina less likely to happen at night, no exertion)

Dosage forms of nitrates?

Short acting
Sublingual (fastest) 1-3min onset
Spray (fast) 2-4min onset

long acting
Patch
IR
SR

What to counsel patients on the use of nitrates>

If you find yourself taking GTN more, schedule meeting with your doctor

Dont swallow the sublingual tablet

Ask patient to be seated when they take the GTN

Take GTN at 1st sign of angina, dont wait until the pain is very bad

If pain doesnt go away in 5min, call 995
Keep taking nitrate every 5min on the way to the hospital

storage:
Bring it along with you all the time
Dont keep it too close to ur body, will sublime if too hot
Once opened, discard after 8 weeks, dont take any more

What is the first-line therapy agent in standard patients with angina?

Beta blocker
CCB

second:
DHP-CCB+Beta blocker

Fourth: Ranazoline

What is the first-line therapy agent in high heart rate >80bpm patients with angina?

Beta blocker or Non-DHP CCB

second: BB and Non-DHP CCB (only diltiazem)

Third: Add ivabradine

Fourth: Ranazoline

What is the first-line therapy agent in low heart rate patients

DHP-CCB

second: Long acting nitrates (it doesnt decrase HR)

Third: DHP-CCB+LAN

Fourth: Ranazoline

What is the first-line therapy agent in heart failure with angina?

BB

second: add LAN or ivabradine

Third: add ranazoline

What is the first-line therapy agent in low blood pressure patients with angina?

Low dose BB or Non-DHP CCB

Second: Low dose LAN

third: Ivabradine, ranazoline

What is the target heart rate in angina patients?

55-60bpm

only push for lower HR if patient is still experiencing angina

How does beta blocker work in angina?

Reducing HR, Decreases contractility
Reducing Bp, decreases the intra-myocardial wall tension
all factors affecting MVO2, decreases.
reducing myocardial oxygen demand

any beta blocker is fine, beta 1 doesn't improve efficacy

Which special BB to choose for
HF
AFib
Renal CKD
COPD, asthma?

HF (bisoprolol, metoprolol XL, carvedilol)
AFib (sotalol)
Renal CKD (avoid atenalol)
COPD, asthma (choose B1 selective)

Which are the more lipophilic BBs?

Carvedelol
Nebivolol
Propranolol

How does CCB work in angina?

Blocking the CCB, reducing calcium influx into the smooth muscle cells as well as the myocyte

Recuding MVO2, increasing supply by inducing coronary vasodilation and preventing vasospasm

What is the MOA of ivabradine?

specific inhibition of funny receptor blocker within the SA node, slows the SA node firing, reducing the heart rate

What are some ADR with Ivabradine?

Phosphene : vision

What are some contraindications with ivabradine?

Cannot use in pacemaker dependent
concomitant non-DHP CCB
Strong CYP3A4 (amiodarone, itraconazole)
Useless in Afib

What are some ADR with ranolazine?

Constipation, nausea, diziness, QTc prolongation

competing for clearance with metformin (diabetic patientO

What are the LDL-c targets for CCS ACS?

What are the BP targets for CCS ACS?

Goal

what is the antiplatelet therapy in ACS CCS?

Aspirin
Clopidogrel (alterantive to aspirin)
important for following a PCI