CAD:ANGINA.docx

[CAD PREVENTION ] HDL: \>40 men, \>50 women LDL: \150 HMG-CoA (statins), bile acid sequestrants, nicotinic acid, and fibrates (Just for Tx of triglycerides, NOT LDL). Drugs that lower LDL levels: statins, bile acid sequestrants, monoclonal antibodies, and ezetimibe - Statins (HMG-CoA reductas...

[CAD PREVENTION ] HDL: \>40 men, \>50 women LDL: \150 HMG-CoA (statins), bile acid sequestrants, nicotinic acid, and fibrates (Just for Tx of triglycerides, NOT LDL). Drugs that lower LDL levels: statins, bile acid sequestrants, monoclonal antibodies, and ezetimibe - Statins (HMG-CoA reductase inhibitors) - Most effect for lowering LDL and total cholesterol. They can raise HDL and lower TGs - Promotes atherosclerotic plaque stability, reduce inflammation at the plaque site, slow progression of CA calcification, improve endothelial function, enhance ability for vessels to dilate, reduce risk of afib, and reduce risk of thrombosis by inhibiting plt deposition/aggregation and suppressing production of thrombin - Most effective when given in the evening due to cholesterol synthesis happening at night - If statin is stopped cholesterol levels will go back to baseline tx is lifelong - Recommend a statin for DM w/ LDL \> 100 - AE: hepatoxicity, nephrotoxicity and myopathy (can injure muscle tissue) can progress to myositis, risk for developing new onset dm, teratogenic - Rosuvastatin - Highest risk for rhabdo - Monitor in Asians - If a 30%-40% reduction in LDL is indicated, any statin will do. If \>40% is indicated atorvastatin or simvastatin - Pts w/impaired renal function atorvastatin and fluvastatin - Rosuvastatin, atorvastatin, pravastatin have higher bioavailability - Nicotinic acid or niacin - Increases HDL, reduces LDL and triglycerides. Despite these favorable effects clinical outcomes were not changed - s/e: severe flushing take ASN prior - Bile acid sequestrants (colesevelam, cholestyramine, and colestipol) - Reduced LDL. Used as adjuncts to statins - AE: GI (constipation) - Oral meds that are known to interact should be admin 1 hr before sequestrant or 4 hr after - Ezetimibe - Inhibits dietary cholesterol absorption and inhibits reabsorption of cholesterol secreted in the bile - Reduces total cholesterol, LDL, TGs and apolipoprotein B. Can inc HDL a little - AE: myopathy, rhabdo, hepatitis, pancreatitis, and low plt - w/statin liver damage. Other interactions: sequestrants, fibrates, and cyclosproine +-----------------------------------+-----------------------------------+ | Bempedoic Acid | \- a new non-statin med | | | | | | \- approved for pt w/familial | | | hypercholesterolemia maxed on | | | statins | | | | | | \- AE: joint swelling, pain or | | | rupture | +===================================+===================================+ | Bempedoic Acid/Ezetimibe | Should be saved for pts with true | | | statin intolerance | +-----------------------------------+-----------------------------------+ | Gemfibrozil | \- decreases TG and raises HDL. | | | Does not reduce LDL significantly | | | | | | \- pts w/high TG can increase LDL | | | | | | \- limited to pts who have not | | | responded to weight control and | | | diet mod. | | | | | | \- AE: gallstones, myopathy, and | | | liver injury | | | | | | \- displaces warfarin inc | | | anticoagulant effects PT should | | | be monitored. Warfarin may need | | | to be reduced | | | | | | \- increases risk of statin | | | induced myopathy | +-----------------------------------+-----------------------------------+ | Alirocumab and evolocumab PCSK9 | \- subQ | | inhibitors | | | | \- hypersensitivity reactions: | | | vasculitis, rash, urticarial | | | | | | \- because this class is composed | | | of a protein risk for developing | | | antibodies | +-----------------------------------+-----------------------------------+ [DRUGS FOR ANGINA ] Organic nitrates (nitroglycerin), BB, and CCB. Ranolazine can be combined with these drugs to supplement their effects Need to increase cardiac oxygen supply or decrease oxygen demand! - Stable angina: - decrease cardiac oxygen demand - avoid factors that precipitate angina and RF should be corrected - BB - First line for exertional angina - NOT EFFECTIVE AGAINST VARIANT ANGINA! - Variant angina (spasm): - increase cardiac oxygen supply - vasodilators CCB and nitrates - Nitrates (Nitroglycerin) - Acts directly on VSM. - Decreases pain of exertional angina by decreasing cardiac oxygen demand - In variant: acts by relaxing or preventing spasm in ca increases oxygen supply - AE: HA, orthostatic hypotension, and reflex tachy can give BB, CCB - Caution when used w/drugs that lower bp, avoid alcohol - Tolerance to nitro-induced vasodilation can occur, pts who develop tolerance display cross-tolerance to all other nitrates use lowest does, long-acting formulation should be used on intermittent schedule that allows at least 8 drug free hours (usually at night). If pain occurs during drug free hour sublingual nitrate or by adding BB or CCB to regimen - Isosobide mononitrate and dinitrate - Same as nitro except should have 12 hrs of drug free time - CCB can be used in both stable and variant Process for antianginal therapy for variant is as follows: 1. Initial: CCB or long-acting nitrate 2. If either drug alone is inadequate then combined therapy w/CCB + nitrate 3. If combination fails CABG Ranolazine: - New class of antianginal agents. Works by reducing accumulation of Na and Ca in myocardial cells - Unlike others, it does not reduce HR, bp, or vascular resistance - Can prolong QT - w/ CYP inhibitors risk of Torsades OTHER POINTS - should utilize antiplt aspirin (75-162mg daily) or clopidogrel