Term
| 3 typs of Angina pectoris: |
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Definition
Stable angina
Acute Coronary Syndrome
Other – Prinzmetal’s angina |
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Term
Stable Angina - Symptoms
_____ chest pain
squeezing, pressure-like in quality (closed fist =____)
builds to a peak and lasts ___-____ minutes
radiation to ...(4) |
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Definition
mid-substernal
Levine’s sign
2-20
left arm, neck, jaw or back |
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Term
Stable Angina - Symptoms contd.
associated with shortness of breath, sweating, or nausea
exacerbated by exertion, cold, meals or stress
relieved by rest, NTG
Females, elderly and diabetic patients may present with different complaints.
The nerve may not be working as well
Could have silent ischemia (ischemia equivalent) = SOB, sweating, nausea but w/o pain |
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Definition
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Term
| Acute Coronary Syndrome consists of 3 conditions: |
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Definition
Unstable Angina (UA)
Non-Transmural Myocardial Infarction (NTMI)
Transmural Myocardial Infarction (AMI) |
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Term
| With unstable angina, symptoms occur with ___ cardiac demand or previously ___ activities elicit symptoms. |
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Definition
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Term
| Unstable Angina is “_____” -> episodes are less or un-responsive to ____ or ____. |
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Definition
"Angina at rest"
nitroglycerin or rest. |
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Term
| Stable angina does not occur at ___ |
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Definition
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Term
| Unstable Angina -> will see ___ On EKG and No ___ release b/c do not have damamge |
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Definition
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Term
ACS: Non-Transmural Myocardial Infarction (NTMI)
Will see _____, ______ or normal EKG
No __ waves |
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Definition
ST depression, T Wave inversion
Q |
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Term
ACS: Non-Transmural Myocardial Infarction (NTMI)
Release of ezymes: (3) |
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Definition
CPK Creatine phosphokinase
LDH Lactate dehydrogenase
+ Troponin release -> Indicates cell death |
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Term
| ST depression indicates ____ |
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Definition
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Term
ACS: Transmural Myocardial Infarction (AMI)
Will see ______ on EKG
__ waves present |
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Definition
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Term
ACS: Transmural Myocardial Infarction (AMI)
Release of ezymes : (3) |
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Definition
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Term
Myocardial cells have two major actvities
1.
2.
Both processes are _____ and require ____ |
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Definition
1. Contraction
2. Relaxation
aerobic (need O2) and require energy |
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Term
| Resting O2 extraction of Cardiac muscle is ___ ml/100 g/min |
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Definition
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Term
| The ____ extracts oxygen to a greater extent than any other organ. Can only get more O2 to the heart with increased _____. |
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Definition
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Term
The heart can only minimally increase O2 extraction.
Thus, increases in O2 demand must be met by increased coronary ____. |
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Definition
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Term
The coronary blood flow occurs during ____.
The duration of ___ is important for determining blood flow. |
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Definition
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Term
Heart gets blood during ___-> all other organs get blood during ___
If want to get more blood then ____ heart rate so spend more time in ____ |
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Definition
diastole
systole
decrease
diastole |
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Term
The harder the myocardium works the more oxygen it requires.
When the oxygen supply cannot keep up with the energy requirements of the heart then ___ and maybe cardiac ___ can occur. |
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Definition
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Term
| ______: Occurs when myocardial oxygen demand exceeds myocardial oxygen supply. |
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Definition
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Term
| nitroglycerin will __________ of the heart |
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Definition
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Term
| Propranolol will _______ of the heart |
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Definition
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Term
| Diltiazem & verapamil will ______ of the heart |
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Definition
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Term
| Nitroglycerin is what type of drug? |
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Definition
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Term
| Isosorbide dinitrate is what type of drug? |
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Definition
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Term
| Isosorbide mononitrate is what type of drug? |
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Definition
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Term
| Amyl Nitrate is what type of drug? |
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Definition
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Term
| The nitrovasodilators relax almost all smooth muscle by releasing___ which then stimulates the release of ____ |
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Definition
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Term
| Nitrovasodilators Primary function? |
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Definition
Peripheral venodilatation especially large venous capacitance vessels
this reduces venous return which reduces cardiac preload and thus myocardial workload |
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Term
| Nitrovasodilators Secondary function? |
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Definition
| Secondary - Arteriolar dilatation: reducing cardiac afterload and thus myocardial work and oxygen demand |
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Term
| Nitrovasodilators Third function? |
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Definition
Third - Increasing oxygen supply to ischemic areas of the myocardium.
Relax blood vessels in heart |
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Term
| Drug of choice in acute angina attack? |
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Definition
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Term
| Other than an acute angina attack, nitroglycerine can be used for _____ |
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Definition
| Prinzmetals angina –> relief of coronary artery vasospasm |
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Term
In healthy subjects, nitric oxide (NO) dilates coronary arteries
Old hypothesis was that NO improved perfusion to hypoxic areas of heart. This hypothesis is incorrect.
Direct infusion of NTG into heart does not relieve angina, but sublingual NTG does.
How do you explain this? |
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Definition
| I don't know, didn't take notes and couldn't find it online |
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Term
Nitroglycerin tablets – *____ mg
Once opened the tablets have shelf-life of __ months
Will not blow up if beaten, heated, etc. |
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Definition
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Term
|
Definition
Nitroglycerin tablets – o.4 mg
Spray - NTG
Amyl nitrate - inhalant |
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Term
NTG - Directions to Patients
First tablet (or spray) sublingual. Wait 5 minutes and if pain remains
Take second tablet (or spray). Wait 5 minutes and if pain remains
Take third tablet (or spray). Wait 5 minutes and if pain remains – go to hospital!
(One spray = one tablet, do not shake the spray prior to using.) |
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Definition
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Term
| Nitrovasodilators – long acting (3) |
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Definition
NTG – other delivery systems:
2% ointment
slow release – transdermal patch
Isosorbide dinitrate
Take twice a day (di = 2)
Isosorbide mononitrate
Take once a day (mono = 1) |
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Term
| To minimize development of tolerance, ensure daily nitroglycerin-free interval of ___-___ hr is provided. |
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Definition
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Term
| Caution patient not to crush, chew, or swallow sublingual ____ tablets. |
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Definition
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Term
| During administration of NTG sublingual tablets and translingual spray, patient should ___, preferably in the ____ position. |
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Definition
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Term
Discard any unused NTG tablets __ months after the bottle is initially opened.
Discard sublingual spray ___. |
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Definition
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Term
NTG – Transdermal FYI
Remove patch from foil pouch immediately prior to application.
Remove protective liner from patch and apply to any area of the body except the extremities below the knee or elbow; the chest is preferred site.
Apply only to area that is clean, dry, and hairless. If hair is likely to interfere with patch adherence, clip, do not shave, the area before application. |
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Definition
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Term
NTG – Transdermal FYI
Do not apply patch to skin areas with cuts or irritation or immediately after showering or bathing.
If the patch becomes dislodged, discard it and put a new one on at a different skin site.
Do not discharge cardioverter/defribrillator through paddle electrode that overlies a transdermal patch. May cause current arching that can damage the paddles and burn the patient. |
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Definition
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Term
| NTGs _____ develops rapidly |
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Definition
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Term
| NTGs Undergoes extensive .... |
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Definition
| first pass hepatic metabolism |
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Term
| NTGs May elicit an attack of angina via “_____” or ____ |
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Definition
stealing effect
reflex tachycardia.
Steel effect – ex. If have two good blood blood vessels and a poor perfused vessel – NTG will go to the well profused and dilate them and will steal blood away from the poorly perfused blood vessel |
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Term
NTGs - Adverse Reactions
_______ -> so Increase dose slowly
_______ -> Syncope
_______ -> Increased oxygen demand |
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Definition
Headache
Postural Hypotension
Reflex tachycardia and /or contractility |
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Term
| Don't give NTGs to people on ______ |
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Definition
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Term
Drugs for erectile dysfunction -- sildenafil, tadalafil & vardenafil (the “afil” class)
Inhibit phosphodiesterase-5 enzymes
Leads to reduced breakdown of _____
Nitrates enhance production of _______ = dramatically enhanced vascular effects, including severe ________
Therefore, “afils” PDE5 inhibitors are contraindicated with nitrates used for coronary perfusion. |
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Definition
cyclic GMP
cyclic GMP
hypotension |
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Term
β-blockers antagonize the effect of circulating and neuronally released catecholamines –
How does this help w/ angina? |
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Definition
| β-blockers reduce heart rate and increase duration of diastole, which allows more coronary perfusion. |
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Term
By blocking the effects of catecholamines on the heart, β-blockers reduce ____.
Reduction in ____in turn reduces LV ___, resulting in lower myocardial ______. |
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Definition
contractility
contractility
wall tension
O2 demand |
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Term
| β-blockers decrease the ___ of anginal episodes and raise the anginal ____. |
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Definition
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Term
| β- blockers reduce mortality and re-infarction in ___ patients |
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Definition
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Term
| *Abrupt withdrawal of β-blockers can precipitate ___ & ___ in patients with chronic CAD. so must titrate off slowly |
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Definition
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Term
| Therapeutic Use - Beta Blockers (2) |
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Definition
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Term
| Cardioselective B1 blockers: (3) |
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Definition
Atenolol
Metoprolol
Nevibolol |
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Term
| non-cardioselective (b1, B2) blockers: (2) |
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Definition
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Term
| At lower doses, cardioselective beta-blockers, such as atenolol and metoprolol, preferentially block the beta-1 receptors which populate heart. Because of this characteristic, beta-1 selective agents may be better tolerated in pts with underlying ____ or _____. At high dosages, however, cardioselective properties are ___. |
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Definition
asthma or peripheral vascular disease
abolished |
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Term
| Beta blockers such as ____ & ____ possess intrinsic sympathomimetic activity (ISA). Beta blockers with ISA are weak partial beta adrenoreceptor agonists which exert their effect by competitively blocking the beta receptor from more potent endogenous catecholamines. Because of this partial agonist quality, beta blockers with ISA tend to cause less bradycardia and negative inotropic effect when pts are at rest. With increasing levels of physical activity and concomitant increase in intrinsic catecholamine tone, the beta adrenoreceptor “shielding” property of this drug class prevails thus attenuating exercise associated increases in heart rate and contractility. Agents with ISA are effective in improving angina. However, there is concern that beta blockers with ISA may increase mortality in pts immediately post-MI. Because of this, beta blockers with ISA are generally not considered first line agents in the treatment of ischemic heart disease. |
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Definition
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Term
| Labetolol and carvedilol are nonselective beta blockers which also inhibit alpha-adrenoreptors, thus preventing unopposed alpha- adrenergic stimulation in the peripheral circulation when peripheral beta-2 receptors are inhibited. Because of this, these agents are particularly helpful in the treatment of hypertension. Because this category of beta blockers tends to vary in the potency of their beta receptor blocking activitiy, they are in general not used as first line agents in the primary management of CAD. |
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Definition
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Term
| Atenolol is what type of drug? |
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Definition
| cardioselective b1 blocker |
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Term
| Metoprolol is what type of drug? |
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Definition
| cardioselective b1 blocker |
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Term
| Nevibolol is what type of drug? |
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Definition
| cardioselective b1 blocker |
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Term
| Nadolol is what type of drug? |
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Definition
| noncardioselective (b1 b2) blocker |
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Term
| Propranolol is what type of drug? |
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Definition
| noncardioselective (b1 b2) blocker |
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Term
Metoprolol tartrate is taken ____ a day
Metoprolol succinate is taken ____ a day |
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Definition
Twice
Once
remember Succinate = sustained = once a day |
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Term
| Beta Blockers - Side Effects: (7) |
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Definition
Bronchospasm
Diminished exercise capacity
Negative inotropy
Sexual dysfunction
Bradyarrhythmia
Masking of hypoglycemia
Fatigue |
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Term
| ____ are Contraindicated in patients with Prinzmetal’s Angina |
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Definition
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Term
| Verapamil is what type of drug? |
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Definition
| calcium channel blocker - 1o cardiac - for angina |
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Term
| Diltiazem is what type of drug? |
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Definition
| calcium channel blocker - 1o cardiac - for angina |
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Term
| Nifedipine is what type of drug? |
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Definition
| calcium channel blocker - 1o vascular - for bp |
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Term
| Amlodipine is what type of drug? |
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Definition
| calcium channel blocker - 1o vascular - for bp |
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Term
| Calcium Channel Blockers - Actions: (5) |
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Definition
Arterial dilation/after-load reduction
Coronary arterial vasodilation
Prevention of coronary vasoconstriction
Enhancement of coronary collateral flow
Slowing of heart rate with diltiazem, verapamil (increasing diastolic duration) |
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Term
Calcium Channel Blockers effectiveness in VASCULATURE
_____ >> ______ ≈ ______ |
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Definition
Nifedipine >> Diltiazem ≈ Verapamil
(DHPs) |
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Term
Calcium Channel Blockers effectiveness in MYOCARDIAL TISSUE
______ ≥ _______ >>> ______ |
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Definition
| Verapamil ≥ Diltiazem >>> Nifedipine |
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Term
| CCBs - Adverse Drug Reactions |
|
Definition
Peripheral edema -> Causes swelling in legs
Headache
Flushing
Palpitation
Gingival hyperplasia -> With virapimil
Constipation -> With virapimil |
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Term
Prinzmetals is an angina and occurs in pts w/ ____ coronary vessels
They may have atherosclerosis but nothing that causes much of a constriction
It is believed that it will ___ & ____ in the morning = reduction in blood flow |
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Definition
non-narrowed
constrict and spasm |
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Term
| What drugs can treat Prinzmetals/variant angina? |
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Definition
CCBs & Nitrates
Beta blockers will not reduce spasm |
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Term
| Most patients with Prinzmetals angina have angiographic evidence of ____ disease. Spasm typically occurs within 1 cm of an identified obstruction. |
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Definition
| atherosclerotic coronary artery |
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Term
| Prinzmetals angina is associated with ST ____ rather than ST _____ |
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Definition
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Term
PRINZMETAL'S ANGINA Treatment:
1.___________ – DHPs such as nifedipine and amlodipine reduce frequency
2._____ - good for acute symptoms or long- acting nitrates if CCBs don’t work. |
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Definition
calcium channel blockers
nitrates |
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Term
| Why are DHPs better for prinzmetals angina? |
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Definition
| DHPs are better b/c they work on the vasculature |
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Term
| Nifedipine & Amlodipine are _______ |
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Definition
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Term
ANTIPLATELET AGENTS IN TREATMENT OF ANGINA
Aspirin
Decreased platelet aggregation dramatically decreases probability of____ .
clearly demonstrated to decrease mortality in patients with ____, reducing incidence of MI and death
decreased incidence of MI in ____ due to inhibition of platelet aggregation |
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Definition
M.I
unstable angina
chronic stable angina |
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Term
ANTIPLATELET AGENTS IN TREATMENT OF ANGINA
Clopidogrel
Alternate to, or additive with, aspirin
Inhibits ___ pathway in platelets
Reduces platelet aggregation
NO EFFECT ON _____ – so preferred over aspirin
if loop diuretic is being used
if kidney disease is present |
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Definition
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|
Term
Drugs used in angina
Abciximab
glycoprotein IIb/IIIa receptor antagonist; thus, inhibits platelet aggregation
approved for treatment of ____ angina when ___ or ____ planned within 24 hrs. |
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Definition
unstable
angioplasty or atherectomy |
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Term
Unstable Angina Pharmacologic Therapy
____ & _____ beneficial for acute coronary syndromes ( UA, NTMI, AMI) |
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Definition
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Term
Unstable Angina Pharmacologic Therapy
Decrease ____ with Nitrates, Beta-blockers, Ca channel blockers, and Ace inhibitors |
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Definition
| MVO2 = myocardial oxygen consumption |
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Term
Unstable Angina Pharmacologic Therapy
consider platelet glycoprotein 2b / 3a inhibitor and / or low molecular weight heparin |
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Definition
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Term
| Patients whose chest pain symptoms are suggestive of serious illness need immediate assessment in a monitored area of the emergency department (ED) and early therapy to include .... (5) |
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Definition
intravenous (IV) line
oxygen
aspirin
nitroglycerin
morphine. |
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Term
| Beta-Blockers - Beta-blockers reduce mortality, readmission, and reinfarction for both ___ & ___ |
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Definition
|
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Term
| ACE inhibitors - ACE inhibitors (ACEI) are indicated for most patients following ___. |
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Definition
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Term
| From notes: Following acute MI,, Start w/ ___, then ___ and then once stable, put on ___ |
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Definition
ASA
ACE inhibitor
betablocker |
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Term
| ___ reduce mortality and morbidity associated with large infarcts |
|
Definition
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