Angina Pharmacotherapy (L20)

CAD symptoms are due to decreased oxygen ___________ and increased oxygen __________

supply, demand

CAD symptoms are due to __________ oxygen demand and _________ oxygen supply

increased, decreased

clinical presentation of CAD requires 3 of 3 hallmark features

1/3: Precipitating factors are ________ and _________ (what makes it worse)

exertion and exercise

clinical presentation of CAD requires 3 of 3 hallmark features

2/3: Palliative measures are ________ and _________ (what makes it better)

rest, nitroglycerin (SL)

clinical presentation of CAD requires 3 of 3 hallmark features

3/3: Quality of pain described as ________, __________, or _________ in the ___________ Region

squeezing, heaviness, tightness, substernal (most pts have a hard time describing it)

__________ (age), ___________, (gender), and ____________ (disease state) patients may have atypical CAD presentations

older, women, diabetes

older adults, women, and patients with diabetes may have atypical CAD presentations

some patients in these populations will experience ___________ discomfort and nausea/vomiting

midepigastric (upper abdomen)

older adults, women, and patients with diabetes may have atypical CAD presentations

some patients in these populations will experience midepigastric discomfort and ________ or ________

nausea or vomiting

older adults, women, and patients with diabetes may have atypical CAD presentations

some patients in these populations will experience effort intolerance, or excessive _________ or ___________

fatigue, sweating (diaphoresis)

older adults, women, and patients with diabetes may have atypical CAD presentations

some patients in these populations will experience miepigastric discomfort, N/V, effort intolerance, _________, excessive fatigue, or daphoresis

dyspnea

precipitating factor(s) in stable angina are ___________ with consistent amount of _______

reproducible, effort

precipitating factor(s) in __________ angina are reproducible with consistent amount of effort

stable (chronic)

precipitating factor(s) in unstable angina are symptoms with _______

rest

precipitating factor(s) in _________ angina are symptoms at rest

unstable

palliative measures and timing in stable angina are symptoms that are consistently relieved by ________ or _______ and last for < 20 mins

SL NG, rest

palliative measures and timing in stable angina are symptoms that are _________ relieved with SL NG or rest

consistently

palliative measures and timing in stable angina are symptoms that are consistently relieved by SL NG or rest and last for ___________

<20 mins

palliative measures and timing in unstable angina are symptoms that are _________ relieved with SL NG or rest

inconsistently

palliative measures and timing in _________ angina are symptoms that are inconsistently relieved with SL NG or rest and last for >20 mins

unstable

palliative measures and timing in unstable angina are symptoms that are inconsistently relieved with _______ or _______ and last >20 mins

SL NG, rest

palliative measures and timing in unstable angina are symptoms that are inconsistently relieved with SL NG or rest and last ___________

>20 mins

Frequency of symptoms in stable angina are ________

consistent

Frequency of symptoms in _______ angina are consistent

stable

Frequency of symptoms in unstable angina are ________ frequent, ________ duration, and _______ symptom relief with SL NG or rest

more, longer, less

Frequency of symptoms in ________ angina are accelerating, more frequent, longer duration, take less exertion to induce, and less symptom relief with SL NG or rest

unstable

the assessment and workup for angina/CAD that occurs ___________ (how often) includes symptoms, vital signs, physical exam, risk factor control, and adherence or AEs

each encounter (every time you see the pt!)

the assessment and workup for angina/CAD that occurs each encounter includes ________, _______ signs, physical exam, ______ ________ control, and adherence or AEs

symptoms, vital, risk factor

the assessment and workup for angina/CAD that occurs each encounter includes symptoms, vital signs, physical exam, risk factor control, and __________ or ________ ________

adherence, adverse effects

the assessment and workup for angina/CAD that occurs ___________ (how often) includes labs, ECG, stress test, coronary angiogram, and myocardial prefusion imaging or cardiac MRI/CT scan

as needed

the assessment and workup for angina/CAD that occurs as needed includes labs like __________, _______, hemoglobin _____, and _____-_______ protein

cardiac troponin, lipids, A1C, C-reactive (CRP)

one category of treatment options for CAD includes methods to reduce ________ _______ _______ ________

Major Adverse Cardiac Events (MACE)

one category of treatment options for CAD includes methods to control _____ ______

risk factors

one category of treatment options for CAD includes methods to reduce __________

symptoms

one category of treatment options for CAD includes methods to reduce MACE

like ______, drugs, or __________

diet, immunizations

one category of treatment options for CAD includes methods to reduce MACE

like diet, _______-inhibitors or __________-agonists, aspirin ± P2Y12-inhibitor, BB, ACE-I or ARB, and immunizations

SGLT-2, GLP-1 receptor

one category of treatment options for CAD includes methods to reduce MACE

like diet, SGLT-2-inhibitors or GLP-1 receptor agonists, ________ ± ___________, BB, ACE-I or ARB, and immunizations

aspirin ± P2Y12 inhibitor

one category of treatment options for CAD includes methods to reduce MACE

like diet, SGLT-2-inhibitors or GLP-1 receptor agonists, aspirin ± P2Y12-inhibitor, ________, _________ or _________, and immunizations

BB, ACE, ARB

one category of treatment options for CAD includes methods to reduce _____________

like diet, SGLT-2-inhibitors or GLP-1 receptor agonists, aspirin ± P2Y12-inhibitor, BB, ACE-I or ARB, and immunizations

MACE

one category of treatment options for CAD includes methods to control risk factors

like _______ _________ (lifestyle kinda), high-intensity statin, keeping BP <____/___, diabetes management, and weight management

smoking cessation, 130/80

one category of treatment options for CAD includes methods to control risk factors

like smoking cessation, ______-intensity statin, keeping BP <130/80, diabetes management, and weight management

high

one category of treatment options for CAD includes methods to control risk factors

like smoking cessation, high-intensity statin, keeping BP <130/80, ________ management, and ________ management

diabetes, weight

one category of treatment options for CAD includes methods to control risk factors

like smoking cessation, high-intensity statin, keeping BP <130/80, diabetes management (with _________ or _____________), and weight management

SGLT-2 inhibitor or GLP-1 receptor agonist

one category of treatment options for CAD includes methods to _________________

like smoking cessation, high-intensity statin, keeping BP <130/80, diabetes management, and weight management

control risk factors

one category of treatment options for CAD includes methods to reduce symptoms

like BB, CCBs, nitrates, ranolazine, or _____________

revascularization

one category of treatment options for CAD includes methods to reduce symptoms using these 4 classes of drugs:

BB, CCBs, nitrates, Ranolazine

to reduce MACE and control risk factors in a patient with diabetes we could recommend which 4 classes of drugs

SGLT2, GLP1, ACE, ARB

to reduce MACE and control risk factors in a patient with HTN we could recommend which 4 classes of drugs (+thiazides +aldosterone antagonists)

ACE, ARB, BB, CCB

to reduce MACE and control risk factors in a patient with dyslipidemia we could recommend which class of drugs

high-intensity statin

to reduce MACE in a patient with a previous MI we could recommend which 3 classes of drugs

BB, ACE, ARB

to reduce MACE in a patient with HFrEF (<40%) we could recommend which 4 classes of drugs

BB, ACE, ARB, SGLT2 (Regardless of diabetes)

to reduce MACE in ALL patients we should recommend _________

aspirin (81mg daily)

to reduce MACE in ALL patients we should recommend Aspirin ____mg daily

81

to reduce MACE in ALL patients we should recommend Aspirin 81mg daily ± _____________

P2Y12 inhibitor (add if pt had PCI or MI)

to reduce MACE in ALL patients we should recommend Aspirin 81mg daily ± P2Y12 inhibitor (for patients who had _____ or ______)

MI, PCI

to reduce MACE in ALL patients we should recommend Aspirin 81mg daily

± P2Y12 inhibitor for ___-___ months (for patients who had MI or PCI)

6-12

one 1st-line treatment to reduce symptoms in patients with CCD and angina is antianginal therapy with either a _______, ________, or _________

CC, CCB, LA nitrate (all are equivalent options, depends on pt specifics)

one 1st-line treatment to reduce symptoms in patients with CCD is ____________ for intermediate short-term relief

SL NG (or NG spray)

2st-line treatment in patients with CCD and angina who remain symptomatic after initial treatment is the addition of a second antianginal agent from a _______________ (BB, CCB, LA nitrate)

different class

3rd-line treatment in patients with CCD who remain symptomatic despite treatment with BB, CCB and/or LA nitrates is ____________

Ranolazine

_____________ will treat symptoms happening now and will NOT prevent symptoms from happening in the future

nitrates

Nitrostat or Nitrolingual can be given ______ time(s) daily

3

which type(s) of nitrates will NOT lead to tolerance (desensitization)

short-acting (SL or lingual spray)

which type(s) of nitrates can lead to tolerance (desensitization)

long-acting (Nitro-Dur, Ismo, Monoket, Imdur)

Long-acting nitrates require a ___-___ hours nitrate-free interval

8-14

which type(s) of nitrates do NOT allow for 24-hour control

long-acting (require a 8-14 hour nitrate-free interval)

ALL patients should be prescribed ____________ for acute relief of angina symptoms PRN

nitroglycerin (NOT intended to prevent angina symptoms)

the dose of SL NG is 0.4mg every _____ _______, up to 3 doses PRN

5 minutes

the dose of SL NG is 0.4mg every 5 minutes, up to ___ doses PRN

3

patient education for SL NG: if no relief ___________ after 1st dose, call 911 prior to redosing

5 minutes (that way they can take at least 2 more doses while EMS is on the way)

patient education for SL NG: if no relief 5 minutes after ____ dose, call 911 prior to ________

1st, redosing (that way they can take at least 2 more doses while EMS is on the way)

adverse effects of NG include ________, dizziness, and cutaneous flushing

headaches

adverse effects of NG include headaches, ________, and cutaneous flushing

dizziness

adverse effects of NG include headaches, dizziness, and _________ ________

cutaneous flushing

NG should be avoided in combination with ___________ (drug class)

PhosphoDiEsterase-inhibitors (-denafil)

adverse effects of beta-blockers include ______cardia, ______tension, fatigue and bronchoconstriction

bradycardia, hypotension (d/t decreased HR and BP)

adverse effects of ___________ include bradycardia, hypotension, fatigue and bronchoconstriction

beta-blockers

adverse effects of CCBs include ______tension, peripheral edema, headache and flushing

hypotension (d/t decreased BP)

adverse effects of ______________ include hypotension, peripheral edema, headache and flushing

CCBs (both DHP and Non-DHPs)

one adverse effect of DHP CCBs is _______cardia

tachycardia (reflex, since DHPs can slightly increase HR)

one adverse effect of ________ CCBs is tachycardia

DHP (reflex tachycardia d/t slight increased HR)

one adverse effect of Non-DHP CCBs is _______cardia

bradycardia (d/t decreased HR)

one adverse effect of __________ CCBs is bradycardia

Non-DHP (d/t decreased HR)

one adverse effect of Non-DHP CCBs is worsening _______ ________

heart failure (do not give in LVEF <40%)

one adverse effect of __________ CCBs is worsening heart failure (do not give in LVEF <40%)

Non-DHP

Ranolazine is extensively metabolized in the _________

liver (hepatic)

Ranolazine is extensively metabolized hepatically via __________ enzymes

CYP3A4

___________ is extensively metabolized hepatically via CYP3A4 enzymes

ranolazine

adverse effects of ___________ include dizziness, constipation, peripheral edema, and rarely QT prolongation

ranolazine

Ranolazine has drug interactions with ________ inducers and inhibitors, and with ___________ substrates

CYP3A4, Pgp

__________ has drug interactions with CYP3A4 inducers and inhibitors, and with P-glycoprotein substrates

ranolazine

monitoring for patients in antianginal/CCD therapy should be done every ___-___ _______ UNTIL their treatment goals are achieved (then less often after that)

1-2 months

monitoring for patients in antianginal/CCD therapy should be done every 1-2 months UNTIL their _________________ (then less often after that)

treatment goals are met

monitoring for patients in antianginal/CCD therapy should be done every ___-___ _______ once their treatment goals have been met

6-12 months

monitoring for patients in antianginal/CCD therapy should be done every 6-12 months once their ______________

treatment goals are met