+ Therapeutics 1 Tutoring Sarah Darby August 18, 2016

+ Lectures Covered Atherosclerosis and Dyslipidemia Ischemic Heart Disease

+ Atherosclerosis and Dyslipidemia Using available assessment tools, classify a patient’s risk of cardiovascular disease.

+ ASCVD Risk Factors Modifiable Smoking Diabetes mellitus Hypertension Obesity Sedentary lifestyle Hyperlipidemia Non-modifiable Age Gender Family history Increased risk of MI and stroke

+ Risk Assessment Assess 10 year CHD risk ACC/AHA and NLA – Pooled Cohort Equation ATP III and NLA – Framingham Framingham Gender Age TC HDL Smoking HTN or Tx Pooled Cohort Gender Age TC HDL Smoking HTN or Tx DM Race

+ Atherosclerosis and Dyslipidemia Remember…. Cholesterol is good! Density Chylomicrons > VLDL (triglycerides) > LDL > HDL Lipoprotein = phospholipid, cholesterol, protein, triglycerides Apo = the protein portion of the lipoprotein Assists with binding to receptor Which Apo molecules are associated with which lipoproteins?

+ Atherosclerosis and Dyslipidemia Remember…. Cholesterol is good! Density Chylomicrons > VLDL (triglycerides) > LDL > HDL Lipoprotein = phospholipid, cholesterol, protein, triglycerides Apo = the protein portion of the lipoprotein Assists with binding to receptor Which Apo molecules are associated with which lipoproteins? ApoA = HDL (think A for awesome) ApoB = LDL and VLDL (think B for bad)

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+ Atherosclerosis and Dyslipidemia Compare and contrast recommendations from current evidence-based and consensus guidelines for managing dyslipidemia.

+ Atherosclerosis and Dyslipidemia Which of the following makes no recommendation regarding specific cholesterol (LDL or non-HDL) target levels for primary or secondary prevention of ASCVD? A. Adult Treatment Panel III B. ACC/AHA C. National Lipid Association

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines

+ 63 yo male admitted for CP and SOB Confirmed STEMI Physician asks for your recommendation on statin therapy. A. No therapy recommended B. High intensity statin C. Moderate intensity statin D. Low intensity statin

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines 45 yo female visits the clinic for a routine check-up History of T2DM for 3 years, currently taking Metformin 1000mg BID No history of CVD This is your first encounter with the patient. What are your thoughts on her need for statin therapy? A. No therapy recommended B. High intensity statin C. Moderate intensity statin D. Low intensity statin

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines 69 yo male visits the clinic for a routine check-up History of T2DM for 3 years, currently taking Metformin 1000mg BID His lipid panel shows LDL-C = 230 mg/dl Physician asks for your recommendation on statin therapy. A. No therapy recommended B. High intensity statin C. Moderate intensity statin D. Low intensity statin

+ Atherosclerosis and Dyslipidemia Apply current recommendations regarding the use of statin and non-statin therapy in the management of dyslipidemia.

+ Atherosclerosis and Dyslipidemia You MUST know statin intensities!

+ Atherosclerosis and Dyslipidemia Which of the following agents is considered moderate intensity? A. Atorvastatin 20mg B. Atorvastatin 40mg C. Rosuvastatin 20mg D. Pravastatin 20mg

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines 63 yo male admitted for CP and SOB Confirmed STEMI Physician asks for your recommendation on statin therapy. A. Pravastatin 80mg B. Lovastatin 40mg C. Rosuvastatin 20mg D. Atorvastatin 20mg

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines 45 yo female visits the clinic for a routine check-up History of T2DM for 3 years, currently taking Metformin 1000mg BID No history of CVD This is your first encounter with the patient. What do you recommend for statin therapy? A. Atorvastatin 20mg B. Atorvastatin 40mg C. Simvastatin 10mg D. Lovastatin 20mg

+ Atherosclerosis and Dyslipidemia ACC/AHA Guidelines 69 yo male visits the clinic for a routine check-up History of T2DM for 3 years, currently taking Metformin 1000mg BID His lipid panel shows LDL-C = 230 mg/dl Physician asks for your recommendation on statin therapy. A. Atorvastatin 20mg B. Pravastatin 80mg C. Rosuvastatin 20mg D. Simvastatin 40mg

+ Ischemic Heart Disease Describe the basic mechanisms of ischemic heart disease (IHD); including stable ischemic heart disease, Prinzmetal’s angina, and silent ischemia and the recommended drug and non- drug therapies to manage IHD. Distinguish major signs and symptoms of stable angina, Prinzmetal's angina and silent ischemia.

+ Ischemic Heart Disease Ischemia = oxygen demand > oxygen supply Why might increased oxygen be demanded? Increased heart rate Increased blood pressure Increased contractions Why might decreased oxygen be supplied? Decreased coronary artery diameter (atherosclerosis!) Collateral blood flow Decreased blood pressure Decreased heart rate

+ Ischemic Heart Disease

+ Chronic stable angina Silent ischemia Prinzmetal’sMicrovascular ACS Unstable angina NSTEMI STEMI

+ Ischemic Heart Disease Prinzmetal’s Focal spasm NO increase in myocardial oxygen consumption Recurrent symptoms Prolonged acute, severe attacks Younger population (30-40s) Transient ST elevation on EKG

+ Ischemic Heart Disease Prinzmetal’s Prophylaxis CCBs (both DHP and non-DHP) Acute Nitrates Do NOT use beta-blockers

+ Ischemic Heart Disease Silent ischemia How do we know? EKG, ETT, after a PCI or MI Altered pain perception, autonomic neuropathy Look for different sx Dyspnea, palpitations, diaphoresis, n/v, weakness Make lifestyle changes! Pharmacologic therapy: Aspirin 81mg daily Beta-blockers CCBs Long acting nitrates

+ Ischemic Heart Disease Stable ischemic heart disease QualityLocationOther SxDuration Precipitating factor Relieving factor

+ Ischemic Heart Disease Stable ischemic heart disease Typical Substernal CP w/ characteristic quality and duration Relieved by rest or NTG Caused by exertion or emotional stress Atypical: 2 Noncardiac: 0 or 1

+ Ischemic Heart Disease Management of chronic stable angina BP goal of <140/90 Agents Beta-blockers ACE inhibitors Thiazides Possibly CCBs History of MI? Beta-blocker, ACEI, statin

+ Ischemic Heart Disease Recommend optimal drug therapy for a patient with SIHD. Know which medications have mortality benefit!

+ Ischemic Heart Disease Antiplatelets Aspirin Inhibits thromboxane formation Mortality benefit 325mg chew and swallow for acute attack 81mg daily for maintenance therapy (ALL patients unless CI) Clopidogrel Inhibits P2Y12 75mg daily Used when Aspirin is CI, possibly dual therapy for high risk Pts

+ Ischemic Heart Disease Beta-Blockers Mortality benefit in post-MI and HF Decreases myocardial oxygen demand by… Decreasing HR Decreasing contractility Decreasing BP Do not use in Pts with... Severe bradycardia Severe hypotension High degree AV block Left ventricle failure Sick sinus syndrome

+ Ischemic Heart Disease CCBs DHP = peripheral vasodilation Non-DHP = reduce contractility and HR Chosen second to beta-blockers Nitrates Converted to nitric oxide to induce smooth muscle relaxation Does NOT reduce mortality! Use nitrate free interval Sublingual is drug of choice for acute attack Preferred in Prinzmetal’s

+ Ischemic Heart Disease

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+ ACE inhibitors Blocks conversion of angiotensin 1 to 2, inhibits RAAS Mortality benefit Given to all patients who also have… HTN DM LVEF less than or equal to 40% CKD ARBS can also be used if patient does not like ACEI but are not as beneficial

+ Ischemic Heart Disease JR is a 44 yo male who has struggled with HTN for the past few years. He takes Lisinopril 10mg daily. To help with his BP, he enjoys running around his neighborhood with his dog, Bone. Together they are training for a half marathon. Two months ago, JR woke up in the middle of the night with his heart racing and he couldn’t catch his breath. This happened again recently. What type of IHD does JR have? A. Silent B. Prinzmetal’s C. Chronic stable angina

+ Ischemic Heart Disease JR is a 44 yo male who has struggled with HTN for the past few years. He takes Lisinopril 10mg daily. To help with his BP, he enjoys running around his neighborhood with his dog, Bone. Together they are training for a half marathon. Two months ago, JR woke up in the middle of the night with his heart racing and he couldn’t catch his breath. This happened again recently. What do you recommend for prophylaxis? A. SLG Nitroglycerin B. Amlodipine C. Metoprolol D. Increase his Lisinopril to 20mg daily APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease SH is a 63 yo female who experienced a tightness in her chest located just beneath her sternum while she was pulling weeds in her front yard. She went inside to sit down, and the pain went away after 10 minutes. Classify her symptoms. A. Typical angina B. Atypical angina C. Noncardiac APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease DD is a 64 yo male who loves flying a kite with his grandchildren. One day he began experiencing a stabbing pain in his chest with every breath he took in. He became concerned and sat down on a bench to rest. The pain continued for over half an hour so he went to see his PCP. Classify his symptoms. A. Typical angina B. Atypical angina C. Noncardiac APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease CM is a 68 yo male who recently experienced a MI. His physician asks for your recommendation concerning initiation of treatment upon discharge. Which is most appropriate? Metoprolol 50mg BID Metoprolol 200mg BID Verapamil 180mg daily at bedtime Isosorbide mononitrate 60mg daily APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease Nitrates increase MVO2. True False BK is a 80 yo female. She comes to your pharmacy to pick up her Rx for Metoprolol. She tells you that she’s so thankful she hasn’t experience any chest pain for over a year now, but having a bottle of nitroglycerin in her bathroom at home keeps her at ease in case she does. What is your concern?? APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease ME is a 58 yo male in the emergency room for crushing chest pain relieved by sublingual nitroglycerin. HR is 58 bpm. BP is 130/85. Home meds include Sildenafil PRN. What do you recommend for initial outpatient therapy? Atenolol Verapamil Amlodipine Nitrates APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease What drug class is useful in hyperthyroidism? Beta blocker What drug class is favored in DM? Either type of CCB What drug class is favored in asthma and COPD? Either type of CCB APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease Which of the following effects on myocardial oxygen demand is NOT affected by beta-blockers? A. Decreased HR B. Decreased BP C. Decreased contractility D. Peripheral vasodilation E. Decreased conduction through AV node APhA Complete Review for Pharmacy 11 th Ed.

+ Ischemic Heart Disease 64 yo male with SIHD complains of angina that occurs after walking 2-3 blocks. No lesions detected on his coronary angiogram (cardiac cath) are amenable to intervention (stent of CABG). HR is bpm. BP is 130/68. Current Rx Aspirin 81mg daily Rosuvastatin 40mg HS Metoprolol 50mg BID Ramipril 10mg daily Tadalafil PRN Which of the following will most benefit his angina? A. Add isosorbide mononitrate 60mg daily B. Add Diltiazem 180mg daily C. Increase Metoprolol to 100mg BID D. Add Amlodipine 5mg daily APhA Complete Review for Pharmacy 11 th Ed.

+ Therapeutics 1 Tutoring Questions? Sarah Darby August 18, 2016