CAD

CAD Prevention

HDL levels: >40 for men, >50 for women
LDL levels: <150
Drugs for LDL lowering: statins, bile acid sequestrants, monoclonal antibodies, and ezetimibe
Statins:
- Most effective for lowering LDL and total cholesterol
- Can raise HDL and lower triglycerides
- Promote atherosclerotic plaque stability, reduce inflammation, and improve endothelial function
- Most effective when given in the evening due to cholesterol synthesis at night
- Lifelong treatment; if stopped, cholesterol levels return to baseline
- Recommended for diabetes patients with LDL > 100
- Adverse effects: hepatotoxicity, nephrotoxicity, myopathy, and teratogenicity
Nicotinic acid or niacin:
- Increases HDL, reduces LDL and triglycerides
- Adverse effect: severe flushing; take ASN prior
Bile acid sequestrants (colesevelam, cholestyramine, and colestipol):
- Reduce LDL; used as adjuncts to statins
- Adverse effect: GI (constipation)
- Oral meds that interact should be administered 1 hour before or 4 hours after sequestrant
Ezetimibe:
- Inhibits dietary cholesterol absorption and reabsorption
- Reduces total cholesterol, LDL, triglycerides, and apolipoprotein B; increases HDL
- Adverse effects: myopathy, rhabdomyolysis, hepatitis, pancreatitis, and low platelet count
- Interacts with statins, bile acid sequestrants, fibrates, and cyclosporine
Bempedoic acid:
- New non-statin medication; approved for patients with familial hypercholesterolemia maxed on statins
- Adverse effects: joint swelling, pain, or rupture
Bempedoic acid/ezetimibe:
- Should be saved for patients with true statin intolerance
Gemfibrozil:
- Decreases triglycerides and raises HDL; does not reduce LDL significantly
- Limited to patients who have not responded to weight control and diet modification
- Adverse effects: gallstones, myopathy, and liver injury
- Displaces warfarin, increasing anticoagulant effects; warfarin may need to be reduced
- Increases risk of statin-induced myopathy
Alirocumab and evolocumab (PCSK9 inhibitors):
- Subcutaneous administration
- Hypersensitivity reactions: vasculitis, rash, urticarial
- Risk of developing antibodies due to protein composition

Drugs for Angina

Organic nitrates, beta blockers, and calcium channel blockers can be used to increase cardiac oxygen supply or decrease oxygen demand
Ranolazine can be combined with these drugs to supplement their effects

Stable Angina

Decrease cardiac oxygen demand
Avoid factors that precipitate angina and correct risk factors
Beta blockers:
- First-line treatment for exertional angina
- Not effective against variant angina
Nitrates:
- Act directly on vascular smooth muscle
- Decrease pain of exertional angina by decreasing cardiac oxygen demand
- In variant angina: acts by relaxing or preventing spasm in coronary arteries, increasing oxygen supply
- Adverse effects: headache, orthostatic hypotension, and reflex tachycardia
- Caution when used with drugs that lower blood pressure, avoid alcohol
- Tolerance to nitrate-induced vasodilation can occur; use lowest dose, long-acting formulation, and intermittent schedule
Calcium channel blockers:
- Can be used in both stable and variant angina

Variant Angina

Increase cardiac oxygen supply
Vasodilators: calcium channel blockers and nitrates
Process for antianginal therapy:
1. Initial: calcium channel blockers or long-acting nitrate
2. If either drug alone is inadequate, combine therapy with calcium channel blockers + nitrate
3. If combination fails, consider CABG