Modifiable risk factors for CAD
- Diet
- Exercise
- Smoking
- Alcohol
- Dyslipidemia
- HTN
- DM
Non-modifiable risk factors for CAD
- Age Men >45 Women >55 - Gender - Family Hx - Personality type - Menopausal status
goals of therapy for chronic stable angina
- Acute sx relief
- Prevention of further chest pain episodes
- Improved quality of life
- Minimize adverse effects of tx
- Prevent serious morbidity and mortality
Two antiplatelet therapies for chronic stable angina list
ASA
Clopidogrel
Chronic stable angina ASA dose
75 - 325 mg daily
Chronic stable angina ASA measures to decrease GI bleeding risk
81 mg ASA + PPI
Clopidogrel dose for chronic stable angina
75 mg daily
- P2Y12 receptor inhibitor
- 2nd line behind ASA
When use dual ASA clopidogrel tx with chronic stable angina
only if have had recent ACS or PCI/stent placement
MoA of nitrates, how it relieves/prevents ischemic chest pain
- Relax smooth muscle = dilated veins = reduced preload, ventricular wall stress, myocardial oxygen demand
- Reduced myocardial oxygen demand accounts for most of the anti-ischemic effects of nitrates
3 determinants of myocardial O2 demand
- wall stress
- heart rate
- contractility
Preload def
- left ventricular end diastolic volume
- load present before contraction has started
- amt of blood in ventricle at the end of diastole
Afterload def
pressure resistance left ventricle must overcome to circulate blood
dosing instructions (dose and frequency) for nitroglycerin for secondary prevention of chest pain in chronic stable angina
0.3-0.6 mg (0.4 is most common) every 5 minutes up to 3 doses
Counseling points for correct use of SL nitroglycerine
- Keep in original container, lid on tight, room temperature
- If tablets crumble easily, don’t use
- If still potent, will feel tingling/burning under tongue when use
- When receive, remove cotton stopper (easier access when have chest pain and cotton absorbs the nitro)
- Once open bottle, use within 6 months
- Take at onset of pain, if do not get usual response after 1st tablet, call 911
- Saliva is needed, if have dry mouth, drink water before taking
ADR ASA
bleeding
ADR Clopidogrel
- bleeding (less than ASA)
- neutropenia
ADR Nitroglycerine
- HA and flushing (vasodilation)
- Sl tingling
- Postural hypotension
- Nausea
- tachycardia
ADR Beta Blockers
- Fatigue
- Bradycardia
- Hypotension
- Acute heart failure
- Bronchoconstriction
- Erectile dysfunction
- CNS effects (nightmares, insomnia, hallucinations)
ADR Calcium Channel Blockers
- Constipation – verapamil
- Peripheral edema – mostly dihydropyridines
- Hypotension
- Bradycardia – verapamil and diltiazem
- Dihydropyridines: HA, lightheadedness, flushing
- Non- dihydropyridines: worsening cardiac output
ADR Nitrates
- Postural hypotension
- HA
- Reflex tachycardia
- Flushing
- Lightheadedness
- **same as nitroglycerine ☺
appropriate dosing regimen for metoprolol tartrate (Lopressor) for the treatment of chronic stable angina
50-100 mg BID
MoA BB to relieve or prevent ischemic chest pain
- Antagonist for beta adrenergic receptors, blocks binding of norepinephrine and epinephrine
- Reduce MVO2 by decreasing HR, contractility, and wall stress
Contraindications for Beta-blocker in tx of chronic stable angina
- 2nd or 3rd degree AV block
- bradycardia
- sick sinus rhythm
- decompensated heart failure
Contraindications for nitrates in tx of chronic stable angina
Concurrent use with phosphodiesterase-5 (Viagra, Cialis, etc.)
