Cardio Exam 3

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Typical angina (Jin)

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1

Typical angina (Jin)

Results from atherosclerosis and is provoked by a variety of factors like food, exercise, and emotions

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2

Variant (acute) angina (Jin)

Results from a sudden spasm in the coronary artery unrelated to atherosclerosis

Can occur at rest (i.e. unprovoked)

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3

Therapy of angina (Jin)

Alleviate and prevent anginal attacks by dilating coronary artery

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4

Three classes of antianginal drugs (Jin)

Organic nitrates

CCBs

B-adrenergic blockers

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5

What is the class of choice to treat acute angina? (Jin)

Organic Nitrates

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6

What are organic nitrates? (Jin)

Esters formed from simple organic alcohols with nitric acid

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7

5 organic nitrate drugs (Jin)

Nitroglycerin

Amyl nitrite

ISDN

Pentaerythritol tetranitrate

Erythrityl Tetranitrate

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8

Chemical nature of organic nitrates (Jin)

Volatile

The ester bond in these drugs are hydrolyzed by moisture

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9

T/F: nitrates are effective for all types of angina (Jin)

True

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10

How does oxygen nitrate lead to decreased preload? (Jin)

Vasodilates veins, leads to pooling of the blood in the veins, decreased venous return to the heart

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11

How do organic nitrates lead to decreased afterload? (Jin)

Vasodilates the arteries leading to decreased resistance of peripheral tissues

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12

MOA of organic nitrates (Jin)

Releases NO, which activates guanylate cyclase and increases cGMP levels, and reduces contractions

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13

Dosage forms of nitrates (Jin)

Inhalation (amyl nitrite)

Injections

Tablets

Capsules

Transdermal disks

Ointments

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14

SL nitroglycerin therapeutic effects (Jin)

Provides relief within 2 min with duration of 30 minutes

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15

Amyl nitrite inhalation therapeutic effects (Jin)

Fast acting, onset of 15-30 seconds, lasts only 1 minute

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16

Long acting organic nitrates (Jin)

ISDN

PETN (pentaerythritol tetranitrate)

ETN (erythrityl tetranitrate)

Long acting nitroglycerin

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17

Adverse effects of organic nitrates (Jin)

Headache

Dizziness

N/V

Rapid pulse

Restlessness

Tolerance with long term use of nitrates

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18

Drug interactions with organic nitrates (Jin)

Agents that cause hypotension

Sympathomimetic amines like ephedrine and norepinephrine may decrease efficacy of organic nitrates

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19

What is an arrhythmia? (Jin)

Altered electrical impulse sequence

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20

What part of the heart controls arrhythmias? (Jin)

Pacemaker cells in the AV and SA nodes

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21

What causes arrhythmias? (Jin)

Pacemaker cell dysfunction

Blocks in transmission through the AV node

Atherosclerosis, hyperthyroidism, lung disease

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22

What class of drugs are Class I antiarrhythmic drugs? (Jin)

Sodium channel blockers

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23

What class of drugs are Class II antiarrhythmic drugs? (Jin)

B-adrenergic receptor blockers

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24

What class of drugs are Class III antiarrhythmic drugs? (Jin)

K+ channel blockers

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25

What class of drugs are Class IV antiarrhythmic drugs? (Jin)

Calcium channel blockers

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26

What drug is the prototype for Class I antiarrhythmics? (Jin)

Quinidine

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27

What drugs are in Class Ia antiarrhythmics? (Jin)

Quinidine, quinine, procainamide HCl, procaine HCl, disopyramide

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28

Indications of quinidine (Jin)

Ventricular and supraventricular arrhythmias

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29

Adverse effects of quinidine (Jin)

N/V, diarrhea, headache, dizziness, anti-cholinergic effects

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30

Adverse effects of procainamide (Jin)

Drug-induced lupus syndrome, anticholinergic effects

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31

What drugs are in Class Ib antiarrhythmics? (Jin)

Lidocaine, tocainide, mexiletine, phenytoin

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32

Adverse effects of lidocaine (Jin)

Dizziness, paresthesia, epileptic seizures in severe cases

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33

What drug form is lidocaine for antiarrhythmias? (Jin)

IV injection

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34

What are the side effects of tocainide? (Jin)

GI disturbance, CNS effects

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35

What is the main use of lidocaine? (Jin)

treatment and prevention of ventricular arrhythmias

Also drug of choice in emergency treatment

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36

What is the main use of tocainide? (Jin)

Treatment and prevention of ventricular arrhythmias

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37

What is the main use of mexiletine? (Jin)

Treatment and prevention of ventricular arrhythmias

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38

Adverse effects of mexiteline (Jin)

CNS effects (similar effects to lidocaine and tocainide)

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39

What is the main use of phenytoin? (Jin)

Treatment of atrial and ventricular arrhythmias resulting from digitalis toxicity

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40

What is an issue with phenytoin? (Jin)

It is highly plasma bound, which means that any agent that liberates phenytoin may cause toxicity

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41

What drugs are Class Ic antiarrhythmics? (Jin)

Flecainide, Encainide

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42

Adverse effects of flecainide (Jin)

Can aggravate existing arrhythmias

Blurred vision, headache, headache, nausea, abdominal pain

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43

How is encainide similar to flecainide? (Jin)

Very similar, but with less negative inotropic effect

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44

What was the prototype of Class II Antiarrhythmic drugs (B-blockers)? (Jin)

Propranolol

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45

MOA of class II antiarrhythmics drugs? (Jin)

Blocks effects of NE/E, decreases sympathetic activity, which decreases cAMP levels, which decreases Ca2+ influx

Also decreases conduction through AV node

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46

Use of Class II antiarrhythmic drugs (Jin)

Treatment of supraventricular arrhythmias and digitalis-induced ventricular arrhythmias

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47

What are the two main drugs of Class III antiarrhythmic drugs? (Jin)

Bretylium tosylate

Amiodarone

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48

How is bretylium tosylate administered? (Jin)

Injection, only used in a hospital setting

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49

Indication of bretylium tosylate (Jin)

The acute management of ventricular tachycardia and ventricular fibrillation

Used after 1st line treatments like defibrillation or lidocaine

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50

Adverse effects of bretylium tosylate (Jin)

hypotension

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51

Indication for amiodarone (Jin)

Recommended only for significant ventricular arrhythmias

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52

Adverse effects of amiodarone (Jin)

Tired, tremor, nausea, constipation

Serious AE: lung toxicity, liver problems, heart arrhythmias, vision problems, thyroid problems

Can also cause problems in baby during both pregnancy and breastfeeding

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53

Prototype for Class IV antiarrhythmic drugs (Jin)

Verapamil

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54

Side effects of IV verapamil (Jin)

hypotension, bradycardia, asystole with AV block

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55

What is CHF? (Jin)

The inability of the heart to adequately supply the body with sufficient blood flow

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56

What is one of the most important drugs to treat CHF? (Jin)

Cardiac glycosides

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57

Cardiac glycosides MOA (Jin)

Inhibits Na/K/ATPase pump

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58

Drugs that interact with digoxin (Jin)

Laxatives, cholestyramine, antacids, antidiarrheal, drugs that bind plasma proteins like thyroid hormones

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59

Signs of mild-moderate toxicity of cardiac glycosides (Jin)

Anorexia, N/V, muscular weakness, bradycardic

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60

Signs of severe toxicity of cardiac glycosides (Jin)

Blurred vision, disorientation, diarrhea, ventricular tachycardia

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61

Treatment of cardiac glycoside toxicity (Jin)

Discontinue drug

Administer a potassium salt

- administering K+ stimulates the Na/K/ATPase pump which decreases the intracellular Na level and decreases intracellular Ca

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62

Positive inotropic agents (Jin)

Amrinone and milrinone

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63

Indication of amrinone (Jin)

used in patients with severe HF refractory to other measures

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64

Adverse effects of amrinone (Jin)

GI disturbances, thrombocytopenia, impairment of liver function

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65

MOA of amrinone (Jin)

inhibits a phosphodiesterase, which leads to elevated cAMP, which leads to an increase in muscle contractility

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66

Indication for milrinone (Jin)

inhibits a phosphodiesterase, which leads to elevated cAMP, which leads to an increase in muscle contractility

milrinone is a analog of amrinone

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67

Adverse effects of milrinone (Jin)

Better tolerated than amrinone, no thrombocytopenia or GI problems

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68

Prototype of B-adrenergic receptor agonists (Jin)

Dobutamine (IV only)

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69

Major limitation of B-adrenergic receptor agonists (Jin)

Myocardial B-receptor desensitization

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70

What is the leading cause of death in the US? (Jacobsen)

CVD (cardiovascular disease)

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71

ASCVD conditions include: (Jacobsen)

CHD

Cerebrovascular disease

Peripheral artery disease

Aortic atherosclerosis

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72

CHD includes: (Jacobsen)

Myocardial Infarction (NSTEMI or STEMI)

Coronary Artery Bypass Graft

Percutaneous Transluminal Coronary Angioplasty

Percutaneous Coronary Intervention

Stable or Unstable Angina Heart Failure

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73

Cerebrovascular includes: (Jacobsen)

Ischemic Stroke

Transient ischemic attack (TIA)- mini stroke

Carotid artery disease

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74

Peripheral artery disease includes: (Jacobsen)

Intermittent claudication

Critical limb ischemia

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75

Major risk factors for ASCVD (Jacobsen)

- High LDL and Low LDL

- Smoker

- HTN

- DM

- Age (males older than 45, females older than 55)

- Obesity (BMI >30)

-Physical inactivity

- Diet high in saturated fats

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76

Modifiable risk factors for ASCVD (Jacobsen)

High cholesterol

HTN

Smoking

Obesity

Diabetes

Nutrition, diet, inactivity

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77

What is primary prevention of ASCVD? (Jacobsen)

Prevent initial development of ASCVD

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78

What is secondary prevention of ASCVD? (Jacobsen)

Prevent further progression or death from ASCVD

Adding medications like aspirin, cholesterol medications, and diabetes therapy is most favorable in this population

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79

When should risk assessment for ASCVD begin? (Jacobsen)

At a young age- elevated risk factor levels are detectable in adolescents and young adults

Higher risk= greater benefit of preventative measures

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80

Lifestyle management to reduce ASCVD risk (Jacobsen)

Diet- rich in vegetables, fruits, whole grains, low fat dairy; limit sodium, sweets, trans fats, red meats, saturated fats

Physical activity- 2 h 30 min, moderate-intensity

Healthy weight

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81

ABCDs of ASCVD (Jacobsen)

A- Aspirin, for select patients only

B- Blood pressure, achieve treatment goals in patients with HTN

C- Cholesterol, statin therapy in patients

D- Diabetes, Metformin, SGLT-2 inhibitors, or GLP-1 agonists

S- Smoking cessation

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82

Net ASCVD benefit increases as the absolute risk ___________. (Jacobsen)

Increases

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83

What were the results of the ARRIVE trial? (Jacobsen)

There was no difference between aspirin and the placebo

GI bleed rates were higher with aspirin

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84

What were the results of the ASPREE trial? (Jacobsen)

There was no difference in CVD between aspirin and placebo

Risk of major hemorrhages higher with aspirin

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85

What were the results of the ASCEND trial? (Jacobsen)

There were lower rates of efficacy with aspirin compared to placebo

Higher rates of AEs with aspirin

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86

How many US adults have some form of CVD? (Jacobsen)

1 in 3

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87

What causes stable ischemic heart disease? (Jacobsen)

Caused by an obstructive atherosclerotic plaque in coronary vessel(s)

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88

What is the main symptom of myocardial ischemia in patients with SIHD? (Jacobsen)

Chest pain (angina pectoris)

Is initial manifestation in ~50% of patients

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89

Causes of increased O2 demand (Jacobsen)

tachycardia

HTN

anxiety

left ventricular hypertrophy

aortic stenosis

hyperthyroidism

cocaine, meth

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90

Causes of O2 supply (Jacobsen)

atherosclerosis

pulmonary hypoxemia

anemia

left ventricular dysfunction

aortic stenosis

cocaine

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91

Clinical characteristics of angina (Jacobsen)

Pain (heavy, crushing, suffocating)

generally lasts a few minutes

does not change with respiration or position

most often due to CAD-related ischemia

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92

Only evidence of myocardial ischemia (Jacobsen)

ECG of evidence (some patients may have silent ischemia)

ST segment depression is a sign of myocardial ischemia

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93

Testing methods for myocardial ischemia and CAD (Jacobsen)

ECG

Stress Test

Cardiac CT or MRI

Coronary angiogram or cardiac catheterization

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94

Types of SIHD (Jacobsen)

Stable exertional angina- most common

Variant Angina- at rest and in younger patients

Silent myocardial ischemia

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95

Goals of treatment of SIHD (Jacobsen)

Decrease morbidity and mortality

eliminate chest pain and return to normal activities

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96

Importance of shared decision making (Jacobsen)

The patient remains involved in key decisions, this is high quality care

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97

Substance abuse and CCD (Jacobsen)

Alcohol

Cocaine, meth- stimulate SNS, platelet aggregation, increased O2 demand

Opioids

Marijuana- stimulate SNS, platelet activation, endothelial dysfunction

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98

GDMT in CCD (Jacobsen)

Lipid management: lifestyle changes, moderate or high-intensity statin

Blood pressure management: lifestyles changes,

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99

Antiplatelet therapy in CCD (Jacobsen)

Aspirin 81 mg continued indefinitely unless contraindicated

Clopidogrel 75 mg is a reasonable alternative if aspirin is contraindicated

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100

MOA of aspirin (Jacobsen)

Irreversibly blocks COX in platelets, which decreases clot formation

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