Pharm 2 - Cardio (HLD & Angina)

What are the high intensity statin med names?

atorvastatin 40-80

rosuvastatin 20

What are the moderate intensity statin med names?

atorvastatin 10

rosuvastatin 10

simvastatin 20-40

pravastatin 40

What are the low intensity statin med names?

simvastatin 10

pravastatin 0-20

What are the different drug classes for hyperlipidemia?

HMG-CoA reductase

Cholesterol Absorption inhibitor

bile acid resins

fibrates

PCSK-9 inhibitors

Niacin

Fish oil

What is the MOA of statins?

inhibit HMG-CoA reductase

What are the ADEs of statins?

constipation, diarrhea, nausea, abdominal pain, myopathy, hepatotoxicity, new onset diabetes, teratogenic

What levels do you need to get before starting a statin?

- CK baseline and then again if symptoms reappear

- LFTs, follow up if clinically indicated

- lipid panel baseline 4-6 weeks after starting treatment, then annually

What do statins interact with?

grapefruit juice - increase absorption and decrease metabolism of statins

gemfibrozil

If someone is intolerant to statins what do you switch them to?

ezetimibe

If a patient has a drug or food interaction what should you choose to prescribe?

pravastatin

if need high intensity - rosuvastatin

What are the names of the cholesterol absorption inhibitor drug names?

ezetimibe

What is the MOA of ezetimibe?

blocks cholesterol absorption in small intestine

What is ezetimibe contraindicated in?

active liver disease or persistent elevations in lots

What are the names of adenosine triphosphate citrate lyase inhibitors meds?

bempedoic acid

What is the MOA of bempedoic acid?

inhibits cholesterol synthesis in the liver with a target, ACL, which is further upstream from HMG CoA reductase

What are the names of the bile acid resins meds?

cholestyramine

colesevelam

What are the MOA of bile acid resins?

bind bile acids in the intestine, forming a complex that is excreted in the feces

Who do you not use bile acid resins in?

TG > 300 mg/dL can reflex cause systemic effects

What are the ADEs of bile acid resins?

not absorbed through GI tract so devoid of systemic effects

constipation

decrease fat soluble vitamin absorption (ADEK) - cholestyramine

What are the names of fibrates meds?

fenofibrate

gemfibrozil

What is the MOA of fibrates?

decreased in VLDL which will cause decrease in TG

What are fibrates contraindicated in?

severe liver disease

gall bladder disease

What are the ADEs of fibrates?

increase LFTs

myopathy - increased with statin use (gemfibrozil)

gallstones - tell patient to let you know if they develop symptoms

What do you need to monitor with fibrates?

LFTs

renal function

What is the name of the PCSK9 inhibitors?

alirocumab

evolocumab

What is the MOA of PCSK9 inhibitors?

net effect of increased LDL clearance

What happens when you combine PCSK9 and stains?

dramatic decrease in LDL

What do you need to monitor with PCSK9 inhibitors?

LDL at baseline then 4-8 weeks to assess response

What are the ADEs of PCSK9 inhibitors?

injection site reactions

nasopharyngitis

What is the MOA of niacin?

decreases rate of hepatic synthesis of VLDL and LDL

What symptoms are common with niacin?

flushing - premeditate with aspirin or other NSAID

When do you give patients OTC fish oil?

TG > 500

What are the ADEs of OTC fish oil?

fishy burp

reduction in platelet aggregation (increased risk of bleeding)

caution in patients with fish or shellfish allergy

What statin do you use for secondary prevention clinical ASCVD?

high intensity

What statin do you use for primary prevention LDL >190?

high intensity

What statin do you use for primary prevention age 40-75 with DM with multiple ASVD risks?

high intensity

What statin do you use for primary prevention age 40-75 with DM regardless of ASVD risks?

moderate intensity

What station do you use for primary prevention ASCVD risk and/ or multiple ASCVD risk enhancers with a 10 year ASCVD risk > 20%?

high intensity

What station do you use for primary prevention ASCVD risk and/ or multiple ASCVD risk enhancers with a 10 year ASCVD risk 7.5-19%?

moderate intensity

What relieves anginal pain, angina pectoris, chest pain?

rest or nitroglycerin

What is aspirin used for in angina?

prevents platelet activation and aggregation

What is the MOA of aspirin?

irreversible inhibitors of thromboxane production via COX-1

Do higher doses of aspirin have more benefits?

no

What are the ADEs of aspirin?

dyspepsia

nausea

bleeding/bruising

What is an alternative anti platelet med?

clopidogrel

What are the ADEs of clopidogrel?

bleeding/ bruising

When do you use aspirin and clopidogrel?

recent MI or stent placement

What are the pain relief mechanisms of nitrates?

vasodilation of coronary arteries

reduced preload and afterload

improved oxygen supply demand balance

What are the pain relief mechanisms of beta blockers?

reduced heart rate

decreased myocardial contractility

improved oxygen supply demand balance

What are the pain relief mechanisms of CCBs?

relaxation of coronary artery smooth muscle

vasodilation

reduced heart rate

improved oxygen supply demand balance

What are the pain relief mechanisms of ranolazine?

inhibition of late sodium current

improved myocardial oxygen utilization

decreased anginal pain

What is the MOA of nitrates?

smooth muscle relaxation

What is the name of the nitrate med?

glyceryl trinitrate

What is the use of nitrates?

rescue therapy

quickly halt episode of angina once it has begun

What is first line therapy for acute angina attacks?

glyceryl trinitrate - want sublingual to avoid GI absorption and hepatic first pass metabolism

When do you use beta blockers with ischemia? What do you titrate to?

reduce symptomatic and silent episodes of ischemia

titrate to resting heart rate of 55-60 beats/min

Why do you use CCBs with angina?

decrease oxygen demand by the heart

Which CCBs are more effective antianginal medications? Which can you use for stable angina?

Non- DHP

both for stable

What are the ADEs of non-DHP CCBs?

bradycardia

hypotension

heart block

constipation

What are the ADEs of DHP CCBs?

ankle/ leg edema

reflex tachycardia

What are the names of long acting nitrate meds?

nitroglycerin

isosorbide mononitrate

isosorbide dinitrate

What is the MOA of long acting nitros?

reflex sympathetic activity -> increased heart rate -> increased oxygen demand

What can decrease the reflex sympathetic activity with nitros?

beta blocker

What happens when nitrate tolerance develops?

- decreased efficacy when treating anginal pain with in 1-7 days of continuous therapy

- dose increase will not overcome tolerance

- dose and time dependent

What is the recommended nitrate free interval?

10-14 hours

When is long acting nitrates normally used?

during nighttime or during sleeping hours

When should a long acting nitrate patch be removed?

after 12 hours

What are the side effects of long acting nitrates?

headache, flushing, dizziness, weakness, postural hypotension, syncope, reflex tachycardia, rebound HTN and angina

What are the ADEs of ranolazine?

QT prolongation

palpitations

peripheral edema

angioedema

Who should you use ACEi/ARBs in for angina?

diabetes

hypertension

CKD

heart failure

history of MI

What is the treatment algorithm for angina?

sublingual nitroglycerin + long acting antianginal drug

1. BB preferred

2. if inadequate or contraindications

2a. substitute NDHPs

2b. add or substitute: DHPs are safer with BB if combo needed

3. add or substitute a long acting nitrate (need a nitrate holiday)

4. if adequate or contraindications: add/ substitute ranolazine

What do you use for angina in a patient with asthma?

verapamil or diltiazem

avoid BB

What do you use for angina in a patient with hyperthyroidism?

BB preferred

What do you use for angina in a patient with depression?

CCB preferred

avoid BB

What is the rescue therapy for angina?

SL nitro or spray as needed

What do you use for vasospastic angina?

CCbs or long acting nitrates

Which drug binds bile acids in the intestine, thus preventing their return to the liver via the enterohepatic circulation

What happens with BB in vasospastic angina?

induce alpha reflex vasoconstriction

Which CCB is more peripherally acting compared to centrally acting?

amlopidine

Which of the following patients medications should be prescribed to all angina patients to have on hand for an acute attack?

nitroglycerin SL

A patient with T1DM has been diagnosed with prinzmetal angina. What management for angina is recommended?

felodipiine will be more effective than verapamil

Which drug decreased cholesterol synthesis by inhibiting HMG-CoA reductase?

rosuvastatin

Which drugs binds to bile acids in the intestine, thus preventing their return to the liver via the enterohepatic circulation?

cholestyramine

A 42 yo patient is started unsustained released niacin. He reports an uncomfortable feeling of warmth and itching following taking this. What can help manage the AE?

take aspirin 30 minutes prior

A 55 yo patient with pre diabetes, HTN, and obesity has a ASCVD risk of 6.5%. Fasting lipid panel reveals triglycerides at 655. What treatment would be important to start?

fish oil

A patient is diagnosed with stable angina. What is the most appropriate intensity of a statin to start?

high