PATHO/PCT LECTURE 46&47 DUNN (10/5-10/6) [EXAM 4]

Dunn CCS

what are some modifiable risk factors for ischemic heart disease

HTN, dyslipidemia, DM, cigarettes, physical inactivity and obesity (BMI > 30), alcoholism, poor diet, hyperuricemia, psychosocial factors

what are age risk factors for ischemic heart disease

· Men ≥ 45 years

· Women ≥ 55 years

what are family history of premature CVD in first degree relative risk factors for ischemic heart disease

· < 55 years of age if male family member

· < 65 years of age if female family member

with stable plaque, what is the size of the lipid core and how can the fibrous cap be described vs unstable plaque

stable plaque - small lipid core and thick fibrous cap

unstable plaque - large lipid core and thin fibrous cap

what is mnemonic to remember steps for obtaining patient history for diagnosis of angina

PQRST

describe the P in PQRST

P - precipitating factor or palliative measure

· Brought on by exercise/exertion and relieved by rest with or without SL NTG

describe the Q in PQRST

Q - quality of pain

· Squeezing, heaviness, or tightness (usually see this with acute too)

describe the R in PQRST

R - region or radiation

· Substernal and may radiate to shoulder, arm, neck, or back

describe the S in PQRST

S - severity of pain

· Those with pain report 5 or higher on 10 point scale (less severe than ACS)

describe the T in PQRST

T - timing or temporal pattern

· < 20 minutes and usually relieved in 5-10 minutes

how long does angina typically last with chronic stable angina

lasts for several minutes to < 20 minutes

T/F: chronic stable angina is predictable and brought on by physical activity, exertion, and stress

true

T/F: there are no specific lab tests to dx chronic stable angina

true

what are major goals for angina management

reduce risk of ischemic events and decrease symptoms to improve quality of life

what is mnemonic for management of IHD/chronic stable angina

ABCDE

describe the A in ABCDE

ASA and anti-anginal (BB, CCB, nitrates, ranolazine) [and ACEi - mainstay if prior MI or presence of CKD or DM]

describe the B in ABCDE

beta blockers (critical in addition if prior MI)

describe the C in ABCDE

cholesterol reduction and cigarette cessation

· Cholesterol - data does not detail LDL targets

· Smoking cessation - goal of complete cessation

describe the D in ABCDE

diet and diabetes management

· Diabetes - goal HbA1c of ≤ 7% (7-9% reasonable in certain patients)

describe the E in ABCDE

education and exercise

· Exercise - 30 to 60 minutes, 7 days per week (minimum 5 days)

what is goal BP for management of ischemic heart disease/chronic stable angina

< 130/80 mmHg

what goal BMI for management of ischemic heart disease/chronic stable angina

Goal BMI of 18.5-24.9

(Waist circumference of < 35in for women and < 40in for men)

what two therapies may be recommended for anyone with chronic stable angina

ASA 81mg/day and high intensity statin

remember what are the high intensity statins

Atorvastatin 40-80mg or rosuvastatin 20-40mg

what are the options for anti-anginal therapy

BBs, CCBs, nitrates, ranolazine

what are the selective beta 1 adrenergic antagonist (cardioselective) BBs

· Atenolol, bisoprolol, metoprolol, esmolol (IV)

what is the selective beta 1 adrenergic antagonist and vasodilatory BB

nebivolol

what are the non-selective beta adrenergic antagonist BBs

· Nadolol, propranolol, timolol

what are the mixed alpha 1-beta adrenergic antagonist BBs

Labetalol, carvedilol

what drug class is recommended as first line in chronic stable angina requiring daily maintenance therapy

BBs

T/F: BBs can be used as mono therapy or combination with nitrate and/or dCCB or ranolazine

true

who are ideal candidates for BB therapy with angina

o Physical activity triggers angina

o Co-existent HTN

o History of supraventricular arrhythmias or post-MI angina

o Anxiety associated with angina

what is goal HR with BB use in angina

50-60bpm

what is goal exercise HR with BB use in angina

≤ 100bpm

what should be monitored with BB

symptoms, HR, and BP

who are good candidates for CCBs for angina

contraindications/intolerance to BBs, prinzmetal's angina (non-dCCB), PVD, concurrent HTN, coexisting conduction system disease, such as underlying arrhthymia (non-dCCB), combo for additive anti-ischemic effects

what is counseling for transdermal nitrate to ensure nitrate free interval

put on in the morning and take off at night

T/F: all CAD patients should receive SL NTG prescription

true

what is nitrates place in therapy

terminate acute anginal attacks, prevent stress/effort induced attack, long term prophylaxis

what are counseling points for SL NTG

- Place under tongue (do NOT swallow)

- Remain seated to avoid syncope

- Keep in manufacturer bottle... Store in cool, dry place (do NOT refrigerate)...Once opened, refill every 6 months due to loss of potency

what are counseling points for spray NTG

o Apply to tongue (do NOT swallow or inhale)

More convenient and longer shelf life (about 3 years

when should most patients call 911 with NTG

call 911 if pain not subsiding after 1 NTG...can still continue taking doses after call

what does ranolazine lack

effects on hemodynamics

what drugs should be avoided with ranolazine

strong CYP3A4 inducers and inhibitors

what are examples of strong CYP3A4 inducers to avoid with ranolazine

phenytoin, rifampin, St. John's Wort, phenobarbital, carbamazepine

what are examples of strong CYP3A4 inhibitors to avoid with ranolazine

clarithromycin and telithromycin, HIV protease inhibitors, ketoconazole and itraconazole

when should ranolazine dose be limited to 500mg PO BID

when combined with moderate CYP3A4 inhibitors such as:

o Diltiazem and verapamil, grapefruit juice or grapefruit-containing products, fluconazole, and erythromycin

T/F; Limit simvastatin dose to 20mg QHS and metformin dose to 1700mg/day if on ranolazine 1000mg PO BID

true

what are indications for ranolazine use

combo with CCBs, BB, or nitrates (for anginal relief, reduced exercise induced ischemia, reduction in recurrent ischemia) OR as monotherapy for relief of angina sx

for monotheray of ranolazine who is it reserved for

o patients with refractory angina to other antianginal medications due to cost

or if patient cannot tolerate other agents due to hemodynamic or other AE

what is initial dosing of ranolazine

500mg PO BID

what is max recommended dose of ranolazine

1000mg PO BID

T/F: vorapaxar should be avoided with strong CYP3A4 inhibitors and inducers

true

what should be avoided with vorapaxar due to increased bleeding risk

NSAIDs, warfarin, or other anticoagulants

what is indications for use of vorapaxar

· Reduce risk of MI, stroke, CV death, and the need for revascularization in patients with previous MI or PAD (WITHOUT history of stroke)

is vorapaxar used with primary or secondary prevention

secondary - known stable atherosclerotic disease already receiving dual antiplatelet therapy with ASA and clopidogrel

do BBs or CCBs lower frequency of anginal attacks better

BBs

what are two drug combos to avoid

BBs + nondCCBs; nitrates + PDE5 inhibitors

with what drug class should ranolazine only be used as 500mg PO BID

non-dCCB (diltiazem and verapamil)

if vasospastic angina like prinzmetals what is good option for sx relief

non-dCCB and/or long acting nitrate

if not vasospastic angina, what good option for sx relief

BB or non-dCCB...if not controlled still, add dCCB if HTN or ranolazine or nitrate if no HTN

in what type of angina should BB be avoided

prinzmetal's

with microvascular angina, what drug classes beneficial and are BB more or less effective than CCBs or nitrate

ACEi and statins...BB more effective