-Aspirin 75 162 mg daily unless contraindicated!

-If patient allergic to aspirin, 75mg clopidogrel instead.

-Dose ibuprofen dose 40 minutes or long after aspirin IR ingestion or more than 8 hours before
-ACE inhibitors do not effect individual episodes of chest pain.t hey just reduce left ventricular
and vascular hypertrophy and stabilize atherosclerotiz plaque that will decrease plaque rupture
risk and thrombosis.
-Prescribe ACE inhibitors for patients with: hypertension, diabetes, <40% EF. Basically prescribe
ARB to these same people but if they fcant tolerate ace inhibitors

-
-For meds listed above, if potassium is >5.5, bilateral renal artery stenosis or >
mg/dl renal function they are CONTRAINDICATED
-BETA BLOCKERS FIRST LINE THERAPY FOR PREVENTION OF CHEST PAIN IN STABLE ANGINA.
They also decrease mortalitity. Contraindication with this drugs are same as listed above.
Diabetics can still use beta blockers though but be careful because beta blockers can mask
tachycardia for hypoglycemia. Goal heart rate with people on this drug is 55-60 so titrate as
needed.
KNOW: CARVEDILOL: 3.125-25MG BID AND METOPROLOL 25-100 BID
-Abrupt withdrawal of beta blockerscan cause rebound increase in HR and BP.

CALCIUM CHANNEL BLOCKERS ARE SECOND LINE THERAPY FOR TREATMENT OF STABLE
ANGINA OR FIRST LINE IF BETA BLOCKERS ARE CONTRAINDICATED (pulmonary
disease/bradycardia. FIRST LINE OF THERAPY FOR VASOSPASTIC ANGINA**no effect on
mortality like beta blockers.
-only non-dihydropyridines increase diastolic filling time because they decrease HR.Once again,
only Non-DHPs decrease HR b/c the DHPs can cause reflex tachy. CCBs increase myocardial
oxygen supply by coronary vasodilation.
-IR Nifedipine is not to be used for people with CAD b/c of reflex tachy and it can lead to myo
ischemia.
-CCBs only added to Beta blockers b/c of continued chest pain despite max doses or beta
blocker is fucking with HR so in this one case we end up adding DHPs not non-DHPs

NITRATES FIRST LINE FOR ACUTE ANGINAL ATTACK TREATMENT AND THIRD FOR PREVENTION
OF ANGINA EPISODES. RANOLAZINE ALSO 3RD TO 4TH LINE
-Call 911 if first dose of nitrate isnt effective.
-Ranolazine has minimal effects on heart rate and blood pressure so used in patients who cant
be uptitrated on other antianginals b/c of hypotension/bradycardia. Also increases excersie
tolerance. Dont use ranolazine with strong CYP3A4 inhibitors or if hepatic impared/qt
prolonged.
-Ranolazine dose no higher than 500mg BID when used with non DHPs, erythromycin,
fluconazone, grapefruit juice.
-Ranolazine increases digoxin concentration
-Normal ranolazine dose is 500mg bid uptitrated to 1g BID

For Prinzmetal angina, vasospastic, or variant, ou use nitrate and/or CCB. Avoid Beta blockers
-For silent ischemia, may use CCB as first line if spasm is suspected cause.
-For stent placement post-therapy, dual therapy recommended. Aspirin 81 indefinitely with a
P2Y12 inhibitor like clopidogrel 75mg QD with 300mg Loading.
-P2Y12 therapy should be 12 months for everyone.
 HEART FAILURE

-Increased BNP peptide = increased HF symptoms

-Negative inotropic effect only aggravates HFrEF
-Sodium and water retention aggravates both preserved and reduced EF
-

-give loop diuretics for acute therapy for ppl in respiratory distress b/c of pulmonary edema to
get rid of fluid quickly. Loop diuretics indicated for all patients with signs and symptoms of fluid
overload though. Cause symptomatic relief
-thiazide diuretics like metazolone, hydrochloro, chlorthalidone for mild NaCl retentention
-Loop diuretics for moderate-severe retention
-thiazide diuretics lose effect at <30 CrCl besides metazolone that is used with very poor renal
function and in combo with loop diuretics for best effects. As an alternative use chlorthalidone
and hydrochloro (for metazolone)
-you get distal tubular hypertrophy with chronic loop diuretic use.
-Dont use loops with NSAIDS, probenecid,
-if patient gets hypotension from loops, decrease dose or discontinue diuretic if there arent
signs of fluid overload and/or hypotensive
-glucose elevations can happen with thiazide diuretics.. in that case, alter antidiabetic
therapeutics
-Thiazides can also cause uric acid increase so watch for that
-Avoid high dose IV loops because can cause ototoxicity. No IV furosemide >4mg/min
--Use CCB with people that are intolerant of beta blockers (diltiazem or verapamil) ((ppl with
preserved EF)
-ACE inhibitors used to be first line for HF reduced EF. Now that sacubitril/valsartan is out, its a
decision. ACE inihbitors great b/c inhibits vasoconstriction, decreases preload/afterload, and
myocardial workload. Decreases mortality.
- Dehydration increases risk of renal dysfunction from ACE inhibitor. FiX VOLUME DEPLETION
TO FIX Scr
-EVERY PATIENT WITH EF <40% NEEDS ACE INHIBITOR OR SACUBITRIL/VALSARTAN
-Angiotension 2 antagonists block A2 and vlocks the relase of aldosterone. This differs from ACE
inhibitors because ACCEs have effect on bradykinin.
-Clinical trials favor ACE over ARB but theyre similar
-KNOW CARDESARTAN DOSE OF 4-6 MG QD (MAX DOSE 32 MG QD)
-Avoid triple combo of ACE, ALDOSTERONE ANTAGONISTS, AND ARBS)
-Neprilysin inhibitor like sacubitril inhibits the enzyme that destroys natriuretic peptides.. the
only things that the body does good with like mocardial relaxation, diuresis etc.
-NEPRILYSIN INHIBITORS WILL INCREASE ANGIOTENSIIN 2 LEVELS SO YOU NEED ARB TO
COUNTER IT HENCE SACUBITRIL/VALSARTAN
--NYHA CLASS 2 OR 3 who tolerate ACE/ARB, Repalce with neprilysin inhibitor to reduce
mortality/morbidity.
-Need 6 hour washout period when switching from or to ACE inhibitor for neprilysin inhibitor
-Monitor for hyperkalemia on neprilysin inhibitor.also still watch for dry caugh.
-Angioedema in PARADIGM trial was 2x higher in neprilysin vs enalapril group
-ADD ALDOSTERONE ANTAGONIST IF NYHA 2-4 WITH <35% (decreases mortality). Benefits due
to neurohormal and potassium sparing effect
-Because of aldosterone antagonist benefit in mortality, always add for NYHA 2-4 as part of 2
drug regimen unless contra
-Every patients with an EF < 40% should receive a beta blocker unless contraindicated.
-Carvedilol and metoprolol are CYP2D6 substrates. Careful with other aagents that use that
enzyme
-BETA BLOCKERS MASK SYMPTOMS OF HYPOGLYCEMIA EXCEPT FOR SWEATING. QUALITY OF
LIFE IMPROVED AFTER AROUND 3 MONTHS OF THERAPY
-DIRECT ACTING VASODILATORS (HYDRALAZINE/NITRATES) DECREASE AFTERLOAD AND
PRELOAD. THEY DECREASE MORTALITY VS PLACEBO BUT NOT VS ACE
-FOR BLACKS ALREADY MAXED ON BETA BLOCKER + ACE = DIRECT ACTING VASODILATOR WILL
REDUCE MORTALITY/HOSPITALIZATIONS
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-