Chest Pain Diagnosis Algorithm
Use of Exercise Tolerance Testing
Antiplatelet Therapy in Coronary Artery Disease
- Stable CAD patients and those without a stent only need aspirin.
- All patients with acute coronary syndromes (ACS) should receive 2 antiplatelet medications immediately upon arrival in the emergency room.
- The antiplatelet medications should be a combination of aspirin and a second agent, either clopidogrel, prasugrel, or ticagrelor.
- All 3 are inhibitors of the P2Y12 receptor on the platelet.
- Two-drug therapy is specific to acute presentations and especially to the use of coronary stenting.
- The use of 2 antiplatelet medications does not apply to chronic or stable coronary artery disease.
- When angioplasty and stenting is planned, the answer is ticagrelor or prasugrel.
- Although all 3 P2Y12 inhibitors are beneficial, the restenosis of stenting is best prevented by prasugrel or ticagrelor.
- A thienopyridine medication in the same class as clopidogrel, ticagrelor, and ticlopidine, prasugrel
- It is indicated as an antiplatelet medication that has its best evidence for use in those undergoing angioplasty and stenting.
- Prasugrel is dangerous in patients 75 and older because of an increased risk of hemorrhagic stroke.
- Used to inhibit platelets in the rare patient who is intolerant of both aspirin and clopidogrel.
- You cannot use ticlopidine if the reason for aspirin and clopidogrel intolerance is bleeding, since ticlopidine will inhibit platelets as well.
- Ticlopidine causes neutropenia and TTP.
Use of Hydralazine in ACS
- Hydralazine is a direct-acting arterial vasodilator.
- Hydralazine will decrease afterload and has been shown to have a clear mortality benefit in patients with systolic dysfunction.
- Hydralazine should be used in association with nitrates to dilate the coronary arteries so that blood is not “stolen” away from coronary perfusion when afterload is decreased with the use of hydralazine.
CAD equivalents (goal of LDL is below 70, and statins should be used in all of them:
- Peripheral artery disease (PAD)
- Carotid disease
- Aortic disease (the aortic artery, not the valve)
- MI or stenting
- Any arterial disease
- 10-year risk of CAD more than 7.5%
S/E of Statins
- At least 1% of patients taking statin medications will develop elevation of transaminases to the level where you will need to discontinue the medication.
- Myositis, elevation of CPK levels, or rhabdomyolysis will occur in less than 0.1% of patients.
- It is very rare to have to stop statins because of myositis.
- There is no recommendation to routinely test all patients for CPK levels in the absence of symptoms.
- On the other hand, all patients started on statins should have their AST and ALT tested as a matter of routine monitoring, even if no symptoms are present.
Associated with glucose intolerance, elevation of uric acid level, and an uncomfortable “itchiness” from a transient release of histamine, niacin is an excellent drug to add to statins if full lipid control is not achieved with statins
- Fibric acid derivatives lower triglyceride levels somewhat more than statins; however, the benefit of lowering triglycerides alone has not proven to be as useful as the straightforward mortality benefit of statins.
- Use caution in combining fibrates with statins because of an increased risk of myositis
- Evolocumab and alirocumab inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9).
- PCSK9 inhibitors block the liver’s clearance of LDL from the blood.
- These are injectable medications.
- PCSK9 inhibitors can bring down enormously elevated levels of LDL in familial hypercholesterolemia.
- They massively increase hepatic clearance of LDL, but do not lower mortality.
- PCSK9 inhibitors are the answer when the question says a statin is used at the maximum dose and the LDL is not controlled in severe hyperlipidemia.
Lipid Lowering Drugs and ADRs
Treatment Differences between Cardiac Events
Management summary of ACS
What is the most likely Diagnosis?
What is the answer if the patient is still dyspneic after using ACE inhibitors, beta blockers, diuretics, digoxin, and mineralocorticoid inhibitors?
- Ivabradine: SA nodal inhibitor of “funny channels” that slows the heart rate. Add it to systolic dysfunction if the pulse is over 70 bpm or beta blockers can’t be used. Ivabradine decreases symptoms.
- Sacubitril/valsartan: Used instead of an ACE inhibitor. Sacubitril is added only to an ARB. This neprilysin inhibitor does provide a mortality benefit for systolic dysfunction.
- Hydralazine/nitrates: Used when neither an ACE inhibitor nor an ARB can be used as vasodilator therapy. May add efficacy to ACE inhibitor or ARB in some patients.
Murmurs and Effects Of Manuevers