Chronic Stable Angina

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giddyupp
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52981
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Chronic Stable Angina
Updated:
2011-01-13 12:59:57
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Chronic Stable Angina PHPR522
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Chronic Stable Angina
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  1. 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
  2. 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)
  3. What are the characteristics of chronic stable (exertional) angina?
    • discomfort of the the chest, jaw, shoulder, back, or arm
    • reproducable pattern of pain associated with a certain level of physical activity
    • imbalance between myocardial O2 supply and demand
  4. What are the characteristics of variant angina?
    • coronary restriction results in reduced blood flow and ischemic pain
    • normal or non-obstructed coronary arteries
    • typically associated with younger pts with fewer risk factors
    • early morning pain
    • usually at rest
    • relieved with nitroglycerin
    • triggers include: hyperventilation, exercise, cold climate, smoking, alcohol, amphetamines, cocaine, non-rx vasoconstrictors
  5. What are the characteristics of unstable angina?
    • chest pain while at rest or for prolonged duration compared with the pt's typical chronic angina
    • progression in severity and intensity
    • occurrence at a lower exertional threshold than the pt's typical chronic angina
    • recent onset of severe angina that results in marked limitation of ordinary activity
  6. What is the initial presentation of angina in women?
    angina
  7. What is the initial presentation of angina in men?
    MI
  8. How much coronary blood flow availability during exertion is usually sufficient to be asymptomatic?
    <50%
  9. What is the usual level of obstruction in pts with chronic stable angina?
    at least 70%
  10. What are the determinants of myocardial O2 demand?
    • HR
    • contractility
    • left ventricular wall tension
  11. What are the determinants of O2 supply?
    • coronary blood flow
    • O2-carrying capacity of the blood
  12. 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
  13. What are the modifiable risk factors associated with angina?
    • smoking
    • hyperlipidemia
    • diabetes
    • HTN
    • stress
    • obesity
    • sedentary lifestyle
  14. What are the characteristics of the pain associated with chronic stable angina?
    • pressure pain (discomfort)
    • squeezing
    • chest feels heavy
    • substernal and can radiate to jaw and arm
    • lasts minutes - fleeting sensation of pain
    • exertion provokes the pain
    • rest and nitroglycerin can relieve the pain
  15. What are the goals of treatment for chronic stable angina?
    • relief of sx
    • improve quality of life and exercise capability
    • prevention of complications of CAD such as MI, heart failure, or stroke
    • prevention of atherosclerotic progression
    • reversal of modifiable risk factors
  16. How is treatment monitored?
    • frequency of angina attacks
    • nitroglycerin use
    • exercise tolerance
  17. What are the nonpharmacologic tx for chronic stable angina?
    • revascularization (CABG, Percutaneous Coronary Intervention [PCI])
    • Therapeutic Lifestyle Changes (TLC): diet, wt management, physical activity
  18. What drug classes are used to treat chronic stable angina?
    • B-blockers
    • CCBs
    • Nitrates
    • Ranolazine
    • Antiplatelets
    • Lipid lowering agents
    • antihypertensives
  19. What is the effect of B-blockers on oxygen supply and demand?
    negative chronotrope + negative inotrope = decreased demand
  20. What is the effect of CCBs on oxygen supply and demand?
    negative chronotrope + negative inotrope = decreased demand
  21. What is the effect of nitrates on oxygen supply and demand?
    vasodilation decreases myocardial workload = decreased demand
  22. What is the effect of ranolazine on oxygen supply and demand?
    reduces calcium overload in ischemic myocytes = decreased demand
  23. 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 nodes
    • non-DHP: less vasodilator activity
  24. How do nitrates decrease oxygen demand?
    • converted to NO which activates cGMP and vasodilation
    • peripheral venodilation leads to decreased venous return
    • decreased ventricular end-diastolic pressure
    • decreased peripheral arteriolar resistance
    • decreased afterload
    • decreased myocardial work and O2 demand
  25. What is the goal for BP in a pt with chronic stable angina?
    < 130/80
  26. 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 > 40
    • TGs < 150
  27. What is the goal heart rate associated with dose adjustment of B-blockers?
    55-60 bpm
  28. What B-blockers are used for chronic stable angina?
    • atenolol
    • metoprolol tartrate
    • metoprolol succinate
    • propranolol
    • nadolol
  29. When are B-blockers used for chronic stable angina?
    as initial therapy in pts with no contraindications
  30. How do you counsel a pt on B-blockers?
    • do not stop abruptly
    • titration required
    • could mask sx of hypoglycemia so keep close tabs on blood glucose
    • may cause fatigue
    • may cause orthostatic hypotension
    • monitor BP and HR
  31. What are the SE associated with B-blockers?
    • hypotension
    • bradycardia/heart block
    • bronchospasm
    • fatigue
    • decreased exercise tolerance
    • depression
    • impotence
    • glucose and lipid abnormalities
    • peripheral vasoconstriction
  32. What are the SE associated with CCBs?
    • peripheral edema (DHP)
    • HA (DHP)
    • flushing (DHP)
    • dizziness (DHP)
    • bradycardia
    • AV block
    • do not stop abruptly
    • constipation (verapamil)
  33. What monitoring is required for CCBs?
    • BP and HR
    • BP (DHP)
  34. What are the CCBs used for treating chronic stable angina?
    • diltiazem
    • verapamil
    • amlodipine (DHP)
    • nicardipine (DHP)
    • nifedipine (DHP)
  35. What are the nitrates used for treating chronic stable angina?
    • nitroglycerin SL, spray, oral SR, patch, ointment
    • isosorbide dinitrate
    • isosorbide mononitrate
  36. When are CCBs used in treating chronic stable angina?
    • when B-blockers are CI
    • with BBL when the BBL are unsuccessful
    • with nitro if BBL SE are unacceptable
    • (if CCB for monotherapy, use non-DHP)
  37. 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 exercise
    • when B-blockers are CI (long-acting)
    • with BBL when the BBL are unsuccessful (long-acting)
    • with CCB if BBL SE are unacceptable (long-acting)
  38. What are the SE associated with nitrates?
    • HA!!
    • flushing
    • postural hypotension (high doses or 1st dose after nitrate-free period)
    • drug rash
    • reflex tachycardia
  39. 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 dose
    • do not swallow it
    • take while sitting (dizziness)
    • keep it with you at all times
    • keep in original container
    • protect from light and heat
    • don't use child-proof container
    • replace q 3-6 mo once opened
    • may cause HA
    • do not eat, drink, or smoke within 5-10 min of use
  40. How do you counsel a pt on long-acting nitrates?
    • NOT for acute attacks
    • HA may occur
    • take oral products on empty stomach
    • remove patch for 10-12h/d for nitrate-free period to allow replenishment of sulfhydryl groups
    • remove old patch before applying new
    • rotate patch sites
  41. When is ranolazine used in treatment of chronic stable angina?
    • reserved for pts who have not achieved adequate response with other antianginals
    • pts who can't tolerate reduction in BP or HR
  42. What are the SE associated with ranolazine?
    • QT prolongation
    • dizziness
    • HA
    • constipation
    • nausea
  43. How do you counsel a pt on ranolazine?
    • NOT for acute angina attacks
    • ECG monitoring
    • with or without food
    • swallow whole
    • limit or avoid grapefruit juice
    • ask before starting any new meds (DIs)
  44. When is clopidogrel used?
    when aspirin is absolutely CI
  45. When should ASA be taken in regard to ibuprofen?
    at least 30 min before ibprofen or at least 8h after ibuprofen

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