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PHRM 5001 > 8. Anti-anginal Agents > Flashcards

8. Anti-anginal Agents Flashcards

1
Q
  1. what is myocardial ischemia?
  2. how is this experienced by patients?
  3. what are 3 strategies to relieve anginal pain?
A
  1. Imbalance between O2 supply and consumption
  2. painful, chest crushing sensation
  3. ↓ in physical activity, Cardiac revascularization surgery, Drug therapy
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2
Q
  1. what are the 3 unique features of the myocardium?
  2. what does the relationship between blood flow and oxygen lead to? (hint: 2)
  3. what are 3 factors that can contribute to tissue ischemia?
A
  1. Cannot accumulate O2 debt, Significant and relatively constant O2 needs, Inverse relationship between blood flow and O2 delivery
  2. Blood flow ↓ as HR and workload ↑ and Extracts most of the available oxygen
  3. Intolerance of metabolic wastes, ↑ O2 demand, ↓ blood flow at elevated HR
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3
Q
  1. what does “striking a balance” refer to?
  2. what is the equation for this?
  3. what is relatively constant? at what pressure? what is near maximal?
  4. what 3 factors affect myocardial O2 consumption?
A
  1. O2 uptake/consumption in the tissues
  2. MVO2 = CBF (coronary blood flow) x (CaO2 – CvO2)
  3. O2 delivery @ 100 mmHg, myocardial extraction
  4. ↑ contractility (SV), ↑ HR, Ventricular wall stress
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4
Q
  1. what is angina pectoris?

2. what are the 3 types of angina?

A
  1. “choking of the chest” (tightness in the chest)

2. Classic, Variant, Unstable

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5
Q
  1. exertional angina is classified as what type of angina?
  2. what is exertional angina? what does this lead to? what does this type of angina respond well to
  3. what is this type of angina caused by? what is this condition defined as?
  4. what is the problem with plaques associated with this condition?
A
  1. classic
  2. inadequate O2 delivery with physiologic stress (e.g., exercise, emotional stress) leading to intense chest pain that responds well to nitrates
  3. Caused by atherosclerosis/arteriosclerotic vascular disease which is thickening of the arterial wall
  4. Plagues significantly ↓ BF in affected vessels
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6
Q
  1. what is atherosclerosis characterized by? what can this lead to?
  2. what are plaques primarily made of?
A
  1. elevated LDL and cholesterol, low HDL leading to plaque formation
  2. Fatty deposits, Cholesterol, Calcium
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7
Q
  1. what is variant angina also known as?
  2. this type of angina causes ____ _____ _____
  3. what are the 4 distinguishing characteristics of this type of angina?
  4. decreased CBF is related to ______ ______ ______
  5. not triggered by _____ _____ ______
  6. this type of angina can also be referred to as?
  7. this type of angina responds well to what medication?
A
  1. Prinzmetal’s angina
  2. significant chest pain
  3. Prolonged attacks, Cyclical occurrence, Not effort dependent, Can lead to infarction and sudden death
  4. coronary artery system
  5. increased O2 demands
  6. Angiospastic/vasospastic angina
  7. calcium channel-blockers
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8
Q

Acute coronary syndrome is defined as? what are the 3 states involved?

A

Collection of 3 cardiac disease states classified according to ECG:

  • ST elevation myocardial infarction (STEMI)
  • NSTEMI
  • Unstable angina
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9
Q
  1. unstable angina is defined as? what pattern is this associated with? what does this pattern mean?
  2. what is NOT seen on the ECG?
  3. what 2 problems is this type of angina associated with?
  4. what 3 medications does this angina respond well to?
  5. what are the 5 contributing endothelial factors?
A
  1. Prolonged anginal symptoms at rest; crescendo pattern –> Changing intensity, duration or frequency
  2. No ST elevation seen on ECG
  3. Coronary artery spasm and ↑ O2 demand
  4. Responsive to nitrates, b-blockers and calcium channel-blockers
  5. Tearing of plaque, Platelet aggregation, Thrombosis, Embolization, Vasospasm
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10
Q
  1. plaque can shear away from ____ _____. what can this lead to?
  2. what can the resultant ischemia progress to? this can happen if what is not restored?
  3. what are the two options for resolving a blockage?
A
  1. vessel wall. Leading to an embolus that travels downstream creating occlusion
  2. acute infarct if perfusion is not restored quickly
  3. removed or bypassed
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11
Q
  1. what are the 2 goals of drug therapy?

2. what are the 3 anti-anginal drug classifications?

A
  1. ↑ O2 supply to the myocardium by improving coronary blood flow AND Reducing tissue O2 demands by ↓ workload on the heart
  2. Nitrates, Calcium channel-blockers and Beta-blockers
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12
Q
  1. nitroglycerin is what type of vasodilator? introduced in what year?
  2. what can this drug help decrease? (hint: 2)
  3. what are the 5 ways this drug can be administered?
  4. what is the onset for short acting nitroglycerin? duration?
  5. how long is the duration for long acting nitroglycerin?
A
  1. prototype vasodilator introduced in 1879
  2. Decreasing preload and afterload
  3. Oral, Buccal, Sublingual, Transcutaneous, IV
  4. 1-3 min onset, 10-30 min duration
  5. Long-acting 6-8 hr duration
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13
Q
  1. what cells do nitroglycerin act on? what does this induce?
  2. describe the 5 phases of how nitroglycerin behaves in the body.
  3. where are the effects of this drug more pronounced? causing a decrease in what? this will result in what?
  4. can nitrates be used to treat all forms of angina?
A
  1. Acts on smooth muscle cells to induce relaxation of arteries and veins
  2. Nitrates –> Nitric oxide –> ↑ cGMP –> ↓ Ca2+ –> vasodilation
  3. Effects more pronounced on venous side causing a ↓ venous return & preload resulting in ↓ ventricular wall stress & O2 demands
  4. yes!
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14
Q
  1. how are nitrates helpful in treating classic angina? (hint: 2)
  2. how are nitrates helpful in treating variant angina? (hint: 1)
  3. how are nitrates helpful in treating unstable angina? (hint: 2)
  4. what else can nitrates be helpful in treating (non-anginal)? when treating this what are nitrates also administered with?
A
  1. ↓ ventricular wall stress and ↓ O2 demands
  2. ↓ angiospasm
  3. improved O2 delivery and ↓ O2 demands
  4. administration with cardiotonics to treat CHF
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15
Q
  1. what are the 3 contraindications to using nitroglycerin?
  2. what are the 3 precautions to using nitroglycerin?
  3. what are the 4 adverse reactions when using nitroglycerin?
  4. other nitrates available are available with the same ______ ____ ______.
  5. available in a ______ of formulations, both ____ and _____ ______.
  6. what are the other 2 nitrates available?
A
  1. Shock, Hypovolemia, Hypotension
  2. Reflex tachycardia that ↑ O2 demands, Erectile dysfunction meds, Tolerance
  3. ↑ HR, Orthostatic hypotension, Migraine-like headaches, “blushing” above the clavicles
  4. mechanism of action
  5. different, short and long acting
  6. Isosorbide dinitrate (Isordil ®) and Isosorbide mononitrate
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16
Q
  1. what 3 conditions are calcium channel blockers used to treat?
  2. how does this type of drug work? what does this prevent and produce?
A
  1. Angina pectoris, Cardiac arrhythmias, Hypertension
  2. Bind to Ca2+ channel and block influx into muscle cell preventing muscle contractions and producing relaxation in smooth and cardiac muscle cells
17
Q
  1. verapamil is what type of calcium channel blocker? developed from what?
  2. what is very sensitive to this drug? what does this cause? (hint: 3)
  3. what type of angina is this drug specifically helpful in treating? why? (hint: 3)
A
  1. prototype, developed from papaverine (vasodilator found in the poppy)
  2. Arterioles very sensitive to verapamil causing ↓ SVR and afterload and consequently ↓ myocardial O2 demand
  3. variant angina because it ↓ coronary artery tone and vasospasm, restoring CBF
18
Q
  1. Verapamil exerts what other additional effect? what does this help to do?
  2. what two negative effects does this drug produce? what does each specifically cause?
  3. what are two contraindications to using this drug?
  4. what is the only precaution when using this drug? this happens when verapamil is combined with what type of drug?
A
  1. anti-arrhythmic which helps to ↓ oxygen requirements
  2. Negative inotropic effect –> ↓ contractility & CO
    Negative dromotropic effect –>↓ SA node impulses and slows conduction velocity through AV node
  3. Sinus bradycardia and CHF
  4. Cardiodepressant effect (SA and AV node blockade when combined with b-blockers)
19
Q
  1. Diltiazem is similar to what drug?
  2. pronounced _____ _______ effect
  3. what type of antagonist is this drug? therefore leading to what?
  4. _______ predominates, _____ ______ dilation
A
  1. verapamil
  2. negative dromotropic
  3. sympathetic leading to little reflex tachycardia
20
Q
  1. amlodipine is on which list of essential medicines? what type of drug is this?
  2. indicated in the treatment of which two problems?
  3. what is the only contraindication to using this drug?
  4. what are the 3 precautions to using this drug?
  5. this drug is cleared by the _______.
  6. what are the 4 adverse effects of this drug?
A
  1. WHO, calcium channel blocker
  2. CAD and Hypertension
  3. those sensitive to amlodipine
  4. Hypotension, Worsening angina and acute MI, Hepatic failure
  5. liver!
  6. Edema, Dizziness, Flushing, Palpitation
21
Q
  1. Nifedipine is what type of drug?
  2. this drug is a potent _____ _______.
  3. there are no __________ effects.
  4. Nicardipine is what type of drug?
  5. what can this drug be combined well with?
  6. _______ ______ selectivity.
A
  1. calcium channel blocker
  2. arteriolar dilator
  3. dromotropic
  4. calcium channel blocker
  5. beta blockers
  6. increased vascular
22
Q
  1. mechanism of action of beta blockers?
  2. exert what type of effects? how do these drugs do this? (hint: 3) what specific effects are involved when doing this including their receptors?
  3. how do beta-blockers impact cardiac activity? (hint: 4)
  4. how do beta-blockers impact vascular effects? (hint: 3)
A
  1. Antagonize catecholamines by competitively binding at b-adrenergic receptors
  2. anti-anginal by reducing cardiac workload, ventricular afterload and O2 demand via: Cardiac effects (b1 receptors) and Vascular effects (b2 receptors)
  3. ↓ force of contraction, ↓ HR, ↓ conduction velocity, Improves myocardial relaxation (lusitropic effects)
  4. Less pronounced than cardiac effects, Basal vascular tone controlled primarily by a1 receptors and Some b2 receptors found in vascular smooth muscle (b-blockers antagonize NE and E at these receptors to inhibit vasoconstriction)
23
Q
  1. what type of drug is propranolol?
  2. this drug occupies which receptor(s)?
  3. exerts what type of effects? (hint: 3) what does this result in? (hint: 3)
  4. what does this drug help to increase? via?
  5. this drug causes a significant decrease in what?
A
  1. non-selective calcium channel blocker
  2. occupies both b1 and b2 receptors
  3. Exerts negative chronotropic, inotropic and dromotropic effects –> Reduced rate, strength and conductivity
  4. ↑ myocardial perfusion via prolonged diastole
  5. significant ↓ in BP
24
Q
  1. what are the 4 indications to using propranolol?
  2. what are the 4 contraindications to using this drug?
  3. what are 3 precautions to using this drug?
  4. what are 3 adverse effects associated with this drug?
A
  1. Refractory unstable angina, HTN, Cardiac arrhythmia
    and Glaucoma
  2. Variant and exertional angina (can ↑ ventricular wall stress), Asthma, Acute CHF with ↓ BP
  3. Transient rise in BP –> unopposed alpha response,
    ↑ airway resistance, Upregulation of b receptors with prolonged use
  4. Related to ↑ ventricular wall stress caused by ↓ HR and resultant ↑ EDV, Also ↑ O2 consumption, Minimized with concurrent use of nitrates
25
Q
  1. Metoprolol and Atenolol are relatively selective for which type of receptors?
  2. therapeutic dose is better tolerated by who?
  3. what can a higher dose of this drug lead to? what can this cause?
A
  1. cardiac b1-adrenergic receptors
  2. asthmatics
  3. block b2 receptors causing Bronchospasm
    and Hypertension
26
Q
  1. what 6 heart attack warning signs should we look for in men?
  2. what 6 heart attack warning signs should we look for in women?
  3. what are the 5 PQRST general questions we want to ask our patients when suspecting an MI?
  4. Now that we know what each letter stands for, what are the specific questions we should ask within each letter?
A
  1. Chest pressure or pain, Cold sweat, Pain in arms/neck/back/jaw/stomach, Nausea, SOB, Light-headedness
  2. Chest pressure or pain*, Cold sweat, Pain in lower chest/upper abdomen/back, Nausea, SOB, Light-headedness
  3. P = Palliative and provocative factors
    Q = Quality of the pain
    R = Radiation?
    S = Severity?
    T = Timing
  4. P = What makes the pain worse? What makes it better?
    Q = Where is the pain? Is it sharp, squeezing, stabbing etc.?
    R = Does the pain extend anywhere else? If so, where? What is the quality of that pain?
    S = On a scale of 1 to 10, 1 being no pain and 10 being the worst pain of your life, how would you rate this pain?
    T = Is the pain constant? Episodic? What are the duration of the episodes? When did the pain begin?
27
Q
  1. what are the 4 clinical signs of instability?
  2. what are the 3 FIRST priorities when treating chest pain?
  3. what medication can be given if there are no contraindications?
  4. what can be given to help treat symptoms?
  5. what medication do we need to be sure our patient is NOT taking when giving nitroglycerin?
A
  1. Chest pain at rest*, Decreased level of consciousness, Difficulty breathing, Cardiac arrest
  2. Assess level of consciousness , Support cardio and respiratory needs if appropriate , Rest, lie or sit down
  3. low dose Aspirin
  4. nitrates
  5. erectile dysfunction medications
28
Q
  1. what 2 things can help us identify if our treatment is working?
  2. what 3 things are essential when treating these patients?
  3. in regards to post MI treatment, what 2 things things are we preventing with drug therapy?
  4. what other 2 non-drug regimens are important in post MI treatment?
A
  1. Patient re-assessment and Symptoms
  2. Ongoing assessment of chest pain severity (rating scale), serial ECGs and ***Continuous monitoring of patient’s BP essential
  3. Further ischemia and CHF
  4. Rehabilitation and Lifestyle modifications
29
Q
  1. what 3 lifestyle modifications are important for this patient population?
  2. what are the 5 improvements to overall health when following the above lifestyle changes?
A
  1. Avoid cigarette smoke, ↑ physical activity and Improve nutritional habits
  2. Improves cardiac function, Improves respiratory function, Improves cholesterol, Improves glucose control, and Improves immunity

PHRM 5001 (12 decks)

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