20 - Pharmacotherapy Angina

Question 1

• *CAD**
• *What ↑Oxygen Demand?**

Answer 1

↑Preload

↑Double product = HR x SBP

↑Myocardial Contractility

↑Ventricular Wall Tension

Question 2

STABLE ANGINA
Classification of Chest Pain

Answer 2

CONSISTENCY

Reproducible with consistent amount of activity
groceries up the stairs / walking

• *Relieved** in a consistent manner
• *rest / 1 SL ntg**

consistent frequency

Question 3

Cautions with
CCBs

HypoTension

Answer 3

CCBs –> ↓BP

• *AVOID USE OF IR PRODUCTS**
• *Nifedipine IR**

Question 4

Angina
LABS

Answer 4

Lipid** & **LFTs

Glucose
assess for DM / glycemic control

Hemoglobin

hsCRP
inflammation marker

Question 5

Drug Therapy to Reduce MACE
Major Adverse Cardiac Event = MI / CVA / Death / Revascularization

ACE & ARBs

Answer 5

Clinical Use:

• NOT* an Anti-Anginal
• Add to regimen to ↓*MACE=even if NORMAL BP

CAD Effects:
↓Risk of Death MI & Stroke in HIGH RISK PATIENTS:
H/o CAD / Stroke / PVD
DIABETES + Risk factors
(HTN / HyperLipidemia / Smoking / Microalbuminuria)

Prevents Endothelial Dysfunction -> ↑ Vasodilation
↓PAI-I activity

Question 6

Ranolazine = Ranexa

Clinical Use / Cautions

Answer 6

• *Chronic Stable Angina**
• *ADD ON**

MINIMAL EFFECT ON BP

Cautions:
QT INTERVAL prolongation
Liver / Renal Impairment

CYP3A4 & P-GP Substrates

Question 7

DHP CCBs = Amlodipine
Effects on O2 Demand:

HR

Afterload (BP)

Preload

Contractility

Answer 7

DHP CCBs

↑↑ HR ↑↑

↓↓↓↓ AFTERLOAD (BP) ↓↓↓↓

• • Preload -*
• 0 Contractility 0*

↑↑↑ Coronary Blood Flow ↑↑↑
↓↓ Diastolic Filling time ↓↓

Question 8

Controllable RISK FACTORS

Answer 8

Smoking Cessation

HTN treatment

Dyslipidemia / DM

Diet / Weight Loss / Exercise

Question 9

Calcium Channel Blockers

AntiAnginal Effects / Clinical Use

Answer 9

Chronic Prophylaxis of Angina

Potent Vasodilators

Relief for
VASOSPASM

↓BP

Verapamil / Diltiazem –> ↓HR & ↓Contractility

Question 10

Beta Blockers

AntiAnginal Clinical Use

Answer 10

Prolong life** & ↓**Ischemic Events
in patients with h/o MI –> start BB & use >3 years
no history of MI –> BB @ MD’s discretion

Chronic Prophylaxis of ANGINA

Goals of therapy:
Resting HR ~60bpm
Exercise HR < 100 bpm

↓BP for HTN

Question 11

Drug Therapy to Reduce MACE
Major Adverse Cardiac Event = MI / CVA / Death / Revascularization

Anticoagulants = Rivaroxaban

Answer 11

Patients with Stable CAD
Xarelto 2.5mg BID + Aspirin

↓CV Death / Stroke / MI

no benefit in ↓MACE
In study of patients with HF + stable CAD

Question 12

• *Classic Symptoms**
• *Angina**

Answer 12

Substernal CHEST
Pain / Heaviness / Discomfort
associated with Exercise

Radiates –> L-arm or Jaw

Duration:
30sec - 30min

Relieved w/ REST +/- NTG

Question 13

Drug Therapy to Reduce MACE
Major Adverse Cardiac Event = MI / CVA / Death / Revascularization

ASPIRIN

Answer 13

Clinical Use:

• *ALL PATIENTS WITH CAD**
• *75-162 mg QD**

↓Risk of Death & MI

Question 14

Unstable Angina
Classification of Chest Pain

Answer 14

Angina AT REST

prolonged/ongoing > 20 Minutes

Acceleration of Symptoms
less activity
↑frequency
↑use of SL NTG

Question 15

Nitrates
Effects on O2 Demand:

HR

Afterload (BP)

Preload

Contractility

Answer 15

Nitrates

0/↑ HR 0/↑

0/↓ Afterload (BP) 0/↓

↓↓↓ PRELOAD ↓↓↓

0 Contractility 0

↑↑↑↑ Coronary Blood Flow ↑↑↑↑

Question 16

Drug Therapy to Reduce MACE
Major Adverse Cardiac Event = MI / CVA / Death / Revascularization

Beta Blockers

Answer 16

For NORMAL LV function
Start BB @ time of event (MI / ACS)
and continue for 3 Years

• Reduced LV Function* (<40%)
• *BB INDEFINITELY**

Beta Blockers = 1st choice for Angina
↓Angina & ↓MACE

Question 17

• *Atypical or Associated Symptoms**
• *Angina**

Answer 17

More common in
Women / DM / Elderly

Dyspnea** / **Fatigue** / **LightHeaded

Isolated JAW/NECK pain

Epigastric Burning

BACK pain/discomfort

Nausea / Vomitting

SWEATING
diaphoresis

Question 18

Angina
WORKUP / Diagnosis Test

Answer 18

EKG
changes can be seen if prior MI or current symptoms

• *Exercise Tolerance Testing**
• *+ stress test**
• *treadmill** or drugs to induce angina

Cardiac Cath/Angiogram
visualizes coronary arteries for obstructive lesions

Cardiac MRI
shows scarring from prior events

Question 19

Non-DHP CCBs = Verapamil/Diltiazem
Effects on O2 Demand:

HR

Afterload (BP)

Preload

Contractility

Answer 19

Non-DHP CCBs = Verapamil/Diltiazem

↓↓ HR ↓↓

↓↓ Afterload (BP) ↓↓

- Preload -

↓↓ Contractility ↓↓

↑↑↑ Coronary Blood Flow ↑↑↑
↑↑ Diastolic Filling Time ↑↑

Question 20

When should we NOT use
Non-DHP CCB?
Verapamil / Diltiazem

Answer 20

Bradycardia** / **Heart Block

Avoid in CHF

_AVOID COMBINATION WITH
BETA BLOCKER_

Both will ↓↓HR↓↓ too much

Question 21

Which AntiAnginal can cause

REFLEX TACHYCARDIA?

Answer 21

DHP CCBs

do NOT use MONOTHERAPY

because:
Reflex Tachycardia –> ↑↑Heart Rate↑↑

Use with BETA BLOCKER
because BB –> ↓↓↓↓HR >>

Question 22

• *CAD**
• What ↓*Oxygen Supply?

Answer 22

↓Oxygen Supply
caused by….

↓Coronary Blood Flow

↓Diastolic Filling Time

↓Arterial pO₂

Question 23

Ranolazine = Ranexa
Effects on O2 Demand:

HR

Afterload (BP)

Preload

Contractility

Answer 23

Ranolazine = Ranexa

• HR*
• Afterload*
• Preload*
• Contractility*
• *↑ Coronary Blood Flow ↑**
• *INDIRECTLY**

Improves Diastolic Wall Tension

Question 24

Beta Blockers
Effects on O2 Demand:

HR

Afterload (BP)

Preload

Contractility

Answer 24

Beta Blockers

↓↓↓↓ HR ↓↓↓↓

↓ Afterload (BP) ↓

- Preload -

↓↓↓↓ Contractility ↓↓↓↓

↑↑↑↑ Diastolic Filling Time ↑↑↑↑

Question 25

Drug Therapy to Reduce MACE
Major Adverse Cardiac Event = MI / CVA / Death / Revascularization

CLOPIDOGREL

Answer 25

Clinical Use:
ALTERNATIVE
for patients with Contraindications or Intolerance to ASPIRIN

Also:
Combination WITH ASPIRIN
for
S/p Intracoronary Stent Placement

Question 26

• *Drug therapy to AVOID**
• will NOT* ↓MACE or NO BENEFIT

Answer 26

ROSIGLITAZONE –> HARMFUL

Estrogen Therapy

Vitamin C / E / Beta-carotene

Homocysteine
+ Folate or Vitamin B6 / B12

Garlic

CoQ10

Selenium / Chromium

Question 27