What is Coronary Artery Disease (CAD) or Coronary Heart Disease (CHD)?
complete or partial blockage of the blood vessels that bring oxygenated blood to the myocardium, usually due to atherosclerosis
What is Ischemic Heart Disease (IHD)?
caused by coronary atherosclerotic plaque formation that leads to an imbalance of O2 supply and demand resulting in myocardial ischemia (death of tissue)
What are the characteristics of chronic stable (exertional) angina?
discomfort of the the chest, jaw, shoulder, back, or armreproducable pattern of pain associated with a certain level of physical activityimbalance between myocardial O2 supply and demand
What are the characteristics of variant angina?
coronary restriction results in reduced blood flow and ischemic painnormal or non-obstructed coronary arteriestypically associated with younger pts with fewer risk factorsearly morning painusually at restrelieved with nitroglycerintriggers include: hyperventilation, exercise, cold climate, smoking, alcohol, amphetamines, cocaine, non-rx vasoconstrictors
What are the characteristics of unstable angina?
chest pain while at rest or for prolonged duration compared with the pt's typical chronic anginaprogression in severity and intensityoccurrence at a lower exertional threshold than the pt's typical chronic anginarecent onset of severe angina that results in marked limitation of ordinary activity
What is the initial presentation of angina in women?
angina
What is the initial presentation of angina in men?
MI
How much coronary blood flow availability during exertion is usually sufficient to be asymptomatic?
<50%
What is the usual level of obstruction in pts with chronic stable angina?
at least 70%
What are the determinants of myocardial O2 demand?
HRcontractilityleft ventricular wall tension
What are the determinants of O2 supply?
coronary blood flowO2-carrying capacity of the blood
What are the non-modifiable risk factors associated with angina?
family hx of premature CAD (55yo male or 65 yo female)age (45yo male or 55yo female)hx of cerebro- or perpheral vascular disease
What are the modifiable risk factors associated with angina?
smokinghyperlipidemiadiabetesHTNstressobesitysedentary lifestyle
What are the characteristics of the pain associated with chronic stable angina?
pressure pain (discomfort)squeezingchest feels heavysubsternal and can radiate to jaw and armlasts minutes - fleeting sensation of painexertion provokes the painrest and nitroglycerin can relieve the pain
What are the goals of treatment for chronic stable angina?
relief of sximprove quality of life and exercise capabilityprevention of complications of CAD such as MI, heart failure, or strokeprevention of atherosclerotic progressionreversal of modifiable risk factors
How is treatment monitored?
frequency of angina attacksnitroglycerin useexercise tolerance
What are the nonpharmacologic tx for chronic stable angina?
revascularization (CABG, Percutaneous Coronary Intervention [PCI])Therapeutic Lifestyle Changes (TLC): diet, wt management, physical activity
What drug classes are used to treat chronic stable angina?
B-blockersCCBsNitratesRanolazineAntiplateletsLipid lowering agentsantihypertensives
What is the effect of B-blockers on oxygen supply and demand?
negative chronotrope + negative inotrope = decreased demand
What is the effect of CCBs on oxygen supply and demand?
negative chronotrope + negative inotrope = decreased demand
What is the effect of nitrates on oxygen supply and demand?
vasodilation decreases myocardial workload = decreased demand
What is the effect of ranolazine on oxygen supply and demand?
reduces calcium overload in ischemic myocytes = decreased demand
How do CCBs work?
block L-type (slow) calcium ion channels = decreased contraction of both smooth and cardiac muscle and cells within the SA and AV nodesnon-DHP: less vasodilator activity
How do nitrates decrease oxygen demand?
converted to NO which activates cGMP and vasodilationperipheral venodilation leads to decreased venous returndecreased ventricular end-diastolic pressuredecreased peripheral arteriolar resistancedecreased afterloaddecreased myocardial work and O2 demand
What is the goal for BP in a pt with chronic stable angina?
< 130/80
What are the goals for lipids in a pt with chronic stable angina?
LDL <100 (<70 if possible)non-HDL < 130 (<100 if possible)HDL > 40TGs < 150
What is the goal heart rate associated with dose adjustment of B-blockers?
55-60 bpm
What B-blockers are used for chronic stable angina?
atenololmetoprolol tartratemetoprolol succinatepropranololnadolol
When are B-blockers used for chronic stable angina?
as initial therapy in pts with no contraindications
How do you counsel a pt on B-blockers?
do not stop abruptlytitration requiredcould mask sx of hypoglycemia so keep close tabs on blood glucosemay cause fatiguemay cause orthostatic hypotensionmonitor BP and HR
What are the SE associated with B-blockers?
hypotensionbradycardia/heart blockbronchospasmfatiguedecreased exercise tolerancedepressionimpotenceglucose and lipid abnormalitiesperipheral vasoconstriction
What are the SE associated with CCBs?
peripheral edema (DHP)HA (DHP)flushing (DHP)dizziness (DHP)bradycardiaAV blockdo not stop abruptlyconstipation (verapamil)
What monitoring is required for CCBs?
BP and HRBP (DHP)
What are the CCBs used for treating chronic stable angina?
diltiazemverapamilamlodipine (DHP)nicardipine (DHP)nifedipine (DHP)
What are the nitrates used for treating chronic stable angina?
nitroglycerin SL, spray, oral SR, patch, ointmentisosorbide dinitrateisosorbide mononitrate
When are CCBs used in treating chronic stable angina?
when B-blockers are CIwith BBL when the BBL are unsuccessfulwith nitro if BBL SE are unacceptable(if CCB for monotherapy, use non-DHP)
When are nitrates used for treating chronic stable angina?
EVERY pt for immediate relief of angina (SL or spray)SL can be used prophylactically 5 min prior to exercisewhen B-blockers are CI (long-acting)with BBL when the BBL are unsuccessful (long-acting)with CCB if BBL SE are unacceptable (long-acting)
What are the SE associated with nitrates?
HA!!flushingpostural hypotension (high doses or 1st dose after nitrate-free period)drug rashreflex tachycardia
How do you counsel a pt on SL nitrates?
take 1 at first sign of attack, repeat q 5min if needed (total 3 in 15 min) seek medical attention if no relief on 1st dosedo not swallow ittake while sitting (dizziness)keep it with you at all timeskeep in original containerprotect from light and heatdon't use child-proof containerreplace q 3-6 mo once openedmay cause HAdo not eat, drink, or smoke within 5-10 min of use
How do you counsel a pt on long-acting nitrates?
NOT for acute attacksHA may occurtake oral products on empty stomachremove patch for 10-12h/d for nitrate-free period to allow replenishment of sulfhydryl groupsremove old patch before applying newrotate patch sites
When is ranolazine used in treatment of chronic stable angina?
reserved for pts who have not achieved adequate response with other antianginalspts who can't tolerate reduction in BP or HR
What are the SE associated with ranolazine?
QT prolongationdizzinessHAconstipationnausea
How do you counsel a pt on ranolazine?
NOT for acute angina attacksECG monitoringwith or without foodswallow wholelimit or avoid grapefruit juiceask before starting any new meds (DIs)
When is clopidogrel used?
when aspirin is absolutely CI
When should ASA be taken in regard to ibuprofen?
at least 30 min before ibprofen or at least 8h after ibuprofen