NAPLEX - Chronic Stable Angina

CYP2C19 inhibitors: AVOID concomitant use of

*Omeprazole (Prilosec) or Esomeprazole (Nexxium)*

How long does the nitrate free period need to be?

10-12 hours

What is the dose of ranolazine when taking simvastatin (Zocor)

20mg/day

Plavix causes increased bleeding, how long do we discontinue it before a surgery?

5 days

With BBers you start low and go slow what do you try and titrate your resting heart rate to?

55-60BPM; avoid abrupt withdrawal

How many hours apart do you have to take Isosorbide mononitrate IR and what time of day?

7 hours apart - 8am and 3pm take the first dose when you wake up and then take 7 dose 7 hours later. DO NOT change dosing times. The HA should become less bothersome as your body gets used to the medicine

What is the ABCDE approach to treating chornic stable angina?

A - antiplatelet and antianginal drugs B - blood pressure and beta blocker C - cholesterol (statin) and cigarettes (cessation) D - Diet and diabetes E - Exercise and educaiton

Notes: shown to decrease incidence of MI, CV events, and death; used in all acute and chronic ischemic heart disease patients indefinitely (unless CI'ed)

Aspirin

What is the recommended antiplatelet in stable angina to prevent an acute coronary syndrome (unstable angina/myocardial infarction)? antihypertensive?

Aspirin; if allergic use clopidogrel (Plavix). Beta blocker 1st line for stable angina; if can't use these use CCB or long-acting nitrates.

Aspirin 6 common brands and dosage for CSA

Bayer, Ascriptin, Bufferin, Durlaza, Ecotrin, Halfprin - 75-162mg daily

What's the 1st line treatment for stable angina?

Beta-blockers

SE of Plavix - 3

Bleeding, bruising, pruritis

What is the preferred agents for prinzmetals angina?

CCBs can also be used when BBers are C/I or as add-on therapy for treatment of symptoms in stable angina

Warning for Ranexa?

Can cause QT prolongation

How do we diagnose a patient with Chronic Stable Angina or CAD?

Cardiac Stress test either by a physical test or if physical disability by pharmacologic stress testing

CI to nitrates - 1

Concurrent use with PDE-5 inhibitors or riociguat

NTG spray counseling points

DO NOT INHALE the NTG spray and try not to swallow too quickly afterwards. Spray onto or under the tongue. Do not eat or drink or rinse the mouth for 5-10 mins after the dose. Can use 1 spray every 5 mins prn for chest pain but NO MORE than 3 sprays in 15 mins

For the nitrolingual pump spray; do you shake the spray and how many times must you spray it to prime it?

DO NOT SHAKE, spray 5 times into the air to prime pump before use. Can be sprayed onto or under tongue

Mechanism of clinical effect of CCBs?

Decrease oxygen demand by decreasing HR and contractility (non-DHP); produce vasodilation, decrease SVR and BP to improve myocardial oxygen supply (DHPs)

Which aspirin should, not to be used when rapid onset is needed (ACS, pre-PCI)

Durlaza is a new, extended-release capsule

What is a big thing to know about taking aspirin if a patient is having an ACS?

Enteric coated aspiring MUST BE CHEWED so it works immediately

Mechanism of clinical benefit for nitrates

Forms free radical nitric oxide which increase cGMP, producing vasodilation of veins more than arteries; decrease myocardial oxygen demand by decreasing preload; improves collateral blood flow

Warnings for aspirin - 2

GI bleed and Renal impairment

SE of Ranexa - 4

HA, constipation, nausea, Dizziness

SE of nitroglycerin - 7

HA, dizziness, lightheadedness, flushing, hypotension, tachyphylaxis (decreased effectiveness/tolerance), syncope

Does Ranexa have a lot of effect on the HR or BP?

Has little to no clinical effects on HR or BP

CI to Ranexa?

Hepatic impairment, concurrent use of STRONG 3A4 inhibitors and inducers

Isodorbide dinitrate IR/ER 2 brand and when is it preferred

Isordil Titradose, Dilatrate-SR

Isosorbide mononitrate IR/ER tablet 2 brands no dosage

Monoket, Imdur IR: BID, at least 7 hours apart (8am and 3pm, etc) ER: Qam

SE of aspirin - 4

Nausea, HA, dyspepsia, bleeding

Nitroglycerin translingual spray 0.4 mg/spray - 2 brand

NitroMist and Nitrolingual Pump Spray

What is recommended for immediate relief in all patients?

Nitroglycerin

Theres also Nitroglycerin IV, Nitroglycerin ointment 2% (Nitro-BID), and Nitroclygerin transdermal patch (Nitro-Dur, Minitran)

Nitroglycerin formulations

Nitroglycerin SL tablets

Nitrostat - 0.3, 0.4, 0.6mg

MOA of clopidogrel?

PRODRUG that IRREVERSIBLY inhibits P2Y12 ADP-mediated platelet activation and aggregation.

Clopidogrel

Plavix - 75mg daily

Notes: do not start in patients likely to under _______________ Used in patients with CI to aspirin or addition to aspirin in certain high-risk patients with SIHD for mortality reduction

Plavix - CABG surgery

Angina can also be present in patients with normal coronary arteries, where symptoms are caused by VASOSPASM in the arteries. This type of angina is called PRINZMETALS ANGINA, which is often caused by illicit drug use, particularly cocaine. Some patients may not experience the classic symptoms of angina and recognize the need for medical attention. This is known as silent ischemia as it is unnoticed by the patient

Prinzmetal's Angina

*Clopidogrel* is a *prodrug*. Effectiveness depends on the activation to an active metabolite mainly by *CYP 2C19*. Poor metabolizers exhibit higher cardiovascular events than patients with normal CYP 2C19 function. Tests to check CYP 2C19 genotype can be used as an aid in determining a therapeutic strategy. Consider alternative treatment in determining a therapeutic strategy. Consider alternative treatment strategies in patients identified as 2C19 poor metabolizers. The CYP 2C19 allele corresponds to fully functional metabolism, while the CYP 2C191 and 2C192 alleles have reduced function. Patients with the 2C192 and 3 are poor metabolizers.

Prodrug, 2C19, 2C19, 2C19, 2C19, 2C19, 2C19*1, 2C19*2 and *3, 2C19*2 and *3

Notes: Can use in place of beta blockers or add on therapy for treatment of symptoms Do not crush, break, or chew

Ranexa

What is the brand name of Ranolazine and what does it do?

Ranexa - Selectively inhibits the late phase Na current; decreasing intracellular Ca; may decrease myocardial oxygen demand

When do we use the SL tablets or spray nitrates? When would we call 911

Recommended for all patients for fast relief of angina. Call 911 if chest pain does not go away after the first SL tablet or first spray. Nitrate tolerance does not develop with SL tablets

Mechanism of clinical benefit of BBers?

Reduce myocardial oxygen demand by decreasing HR (negative chronotropic effect) and decrease contractility (negative inotropic effect) and decrease left ventricular wall tension with long-term use

How many hours apart do you have to take Isosorbide mononitrate SR/ER and what time of day?

SR/ER taken daily in the morning or divided BID for an 18 hour nitrate-free interval

What is the only places you can't apply the nitroglycerin patches

Select any area of the skin on the body EXCEPT THE EXTREMITIES BELOW THE KNEE OR ELBOW. Chest is the preferred site Wear a patch for 12-14 hrs on and then off

All nitroglycerin products should not be used with: ______________ d/t dangerous drop in BP could occur

Sildenafil (Viagra, Revatio), tadalafil (Cialis, Adcirca), Vardenafil (Levitra, Staxyn) or Avanafil (Stendra)

T or F thrombotic thrombocytopenic purpura (TTP) has been reported with the use of Plavix

T

How often do you have to take isodorbide dinitrate and at what times?

TID - 8am, 12pm, 4pm keep a 14 hr nitrate-free interval

When would we use long acting nitrates?

When beta blockers are contrainidacted or as add-on therapy for treatment of symptoms. These require nitrate-free interval to prevent tolerance.

CI to Plavix?

active bleed

When are you going to want to make sure you avoid the use of BBers in angina?

avoid use in Prinzmetal's angina

Angina is chest pain, pressure, tightness or discomfort due to ischemia of the heart muscle or spasm of the coronary arteries. The chest pain is described as "squeezing," "grip-like""heavy" or "suffocating," and typically does not vary with position or respiration. Angina is categorized as stable angina or unstable angina (UA). UA is a medical emergency where the chest pain is relieved with nitroglycerin or rest. Stable angina, also known as stable ischemic heart disease (SIHD), is associated with predictable chest pain often brought on by exertion or emotional stress and relieved within minutes by rest or with nitroglycerin. Stable angina is due to plaque build up within the inner walls of the coronary arteries (atherosclerosis), causing narrowing of the arteries and reduced blood flow to the heart. The reduced blood flow causes ischemia to the heart which causes the chest pain.

background info

MOA of aspirin

binds IRREVERSIBLY to cox 1 and 2 enzymes which results in decreased PG and decreased thromboxane A2 (TxA2) production; TxA2 is a potent vasoconstrictor and increases platelet aggregation.

If a person can't exercise for the cardiac stress test what 4 drugs can we give them?

dipyridamole, adenosine (Adenoscan), regadenoson (Lexiscan) or dobutamine

Do not use a BB with ISA

in stable angina (it seems like BB with ISA are not used anywhere in heart disease) acronym CAPP

chronic stable angina

is one of the ASCVD factors and warranted for moderate intensity if >75yo or high if </= high

Which isosorbide nitrate is preferred for systolic HF

isosorbide dinitrate

With the nitroglycerin ointment,

it can stain the clothing. use the measuring applicator. DO NOT rub into the skin

NItroglycerin SL tabs

keep in original amber glass bottle IV-prepare in GLASS BOTTLES OR POLYOLEFIN BAGS (non-PVC) due to sorption of the drug in PVC

CI to aspirin?

patients with asthma, rhinitis, and nasal polyps....children and teenagers with viral infection (due to risk of Reye's syndrome)

What CCBs do we want to avoid?

short acting like Nifedipine IR. long-acting CCBs are more effective

Transient myocardial ischemia without Sx of angina

silent ischemia

Ranexa counseling points

this medication is used to decrease the number of times you may get chest pain. Use this medication regularly to get the most benefit from it. HA, dizziness can constipation may occur. Watch out for QT prolongation, it can cause the heart rhythm to beat fast/irregular

Do BBers provide mortality reduction?

yes They are more effective than nitrates and CCBs in silent ischemia