8. Anti-anginal Agents Flashcards
1
Q
- what is myocardial ischemia?
- how is this experienced by patients?
- what are 3 strategies to relieve anginal pain?
A
- Imbalance between O2 supply and consumption
- painful, chest crushing sensation
- ↓ in physical activity, Cardiac revascularization surgery, Drug therapy
2
Q
- what are the 3 unique features of the myocardium?
- what does the relationship between blood flow and oxygen lead to? (hint: 2)
- what are 3 factors that can contribute to tissue ischemia?
A
- Cannot accumulate O2 debt, Significant and relatively constant O2 needs, Inverse relationship between blood flow and O2 delivery
- Blood flow ↓ as HR and workload ↑ and Extracts most of the available oxygen
- Intolerance of metabolic wastes, ↑ O2 demand, ↓ blood flow at elevated HR
3
Q
- what does “striking a balance” refer to?
- what is the equation for this?
- what is relatively constant? at what pressure? what is near maximal?
- what 3 factors affect myocardial O2 consumption?
A
- O2 uptake/consumption in the tissues
- MVO2 = CBF (coronary blood flow) x (CaO2 – CvO2)
- O2 delivery @ 100 mmHg, myocardial extraction
- ↑ contractility (SV), ↑ HR, Ventricular wall stress
4
Q
- what is angina pectoris?
2. what are the 3 types of angina?
A
- “choking of the chest” (tightness in the chest)
2. Classic, Variant, Unstable
5
Q
- exertional angina is classified as what type of angina?
- what is exertional angina? what does this lead to? what does this type of angina respond well to
- what is this type of angina caused by? what is this condition defined as?
- what is the problem with plaques associated with this condition?
A
- classic
- inadequate O2 delivery with physiologic stress (e.g., exercise, emotional stress) leading to intense chest pain that responds well to nitrates
- Caused by atherosclerosis/arteriosclerotic vascular disease which is thickening of the arterial wall
- Plagues significantly ↓ BF in affected vessels
6
Q
- what is atherosclerosis characterized by? what can this lead to?
- what are plaques primarily made of?
A
- elevated LDL and cholesterol, low HDL leading to plaque formation
- Fatty deposits, Cholesterol, Calcium
7
Q
- what is variant angina also known as?
- this type of angina causes ____ _____ _____
- what are the 4 distinguishing characteristics of this type of angina?
- decreased CBF is related to ______ ______ ______
- not triggered by _____ _____ ______
- this type of angina can also be referred to as?
- this type of angina responds well to what medication?
A
- Prinzmetal’s angina
- significant chest pain
- Prolonged attacks, Cyclical occurrence, Not effort dependent, Can lead to infarction and sudden death
- coronary artery system
- increased O2 demands
- Angiospastic/vasospastic angina
- calcium channel-blockers
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
9
Q
- unstable angina is defined as? what pattern is this associated with? what does this pattern mean?
- what is NOT seen on the ECG?
- what 2 problems is this type of angina associated with?
- what 3 medications does this angina respond well to?
- what are the 5 contributing endothelial factors?
A
- Prolonged anginal symptoms at rest; crescendo pattern –> Changing intensity, duration or frequency
- No ST elevation seen on ECG
- Coronary artery spasm and ↑ O2 demand
- Responsive to nitrates, b-blockers and calcium channel-blockers
- Tearing of plaque, Platelet aggregation, Thrombosis, Embolization, Vasospasm
10
Q
- plaque can shear away from ____ _____. what can this lead to?
- what can the resultant ischemia progress to? this can happen if what is not restored?
- what are the two options for resolving a blockage?
A
- vessel wall. Leading to an embolus that travels downstream creating occlusion
- acute infarct if perfusion is not restored quickly
- removed or bypassed
11
Q
- what are the 2 goals of drug therapy?
2. what are the 3 anti-anginal drug classifications?
A
- ↑ O2 supply to the myocardium by improving coronary blood flow AND Reducing tissue O2 demands by ↓ workload on the heart
- Nitrates, Calcium channel-blockers and Beta-blockers
12
Q
- nitroglycerin is what type of vasodilator? introduced in what year?
- what can this drug help decrease? (hint: 2)
- what are the 5 ways this drug can be administered?
- what is the onset for short acting nitroglycerin? duration?
- how long is the duration for long acting nitroglycerin?
A
- prototype vasodilator introduced in 1879
- Decreasing preload and afterload
- Oral, Buccal, Sublingual, Transcutaneous, IV
- 1-3 min onset, 10-30 min duration
- Long-acting 6-8 hr duration
13
Q
- what cells do nitroglycerin act on? what does this induce?
- describe the 5 phases of how nitroglycerin behaves in the body.
- where are the effects of this drug more pronounced? causing a decrease in what? this will result in what?
- can nitrates be used to treat all forms of angina?
A
- Acts on smooth muscle cells to induce relaxation of arteries and veins
- Nitrates –> Nitric oxide –> ↑ cGMP –> ↓ Ca2+ –> vasodilation
- Effects more pronounced on venous side causing a ↓ venous return & preload resulting in ↓ ventricular wall stress & O2 demands
- yes!
14
Q
- how are nitrates helpful in treating classic angina? (hint: 2)
- how are nitrates helpful in treating variant angina? (hint: 1)
- how are nitrates helpful in treating unstable angina? (hint: 2)
- what else can nitrates be helpful in treating (non-anginal)? when treating this what are nitrates also administered with?
A
- ↓ ventricular wall stress and ↓ O2 demands
- ↓ angiospasm
- improved O2 delivery and ↓ O2 demands
- administration with cardiotonics to treat CHF
15
Q
- what are the 3 contraindications to using nitroglycerin?
- what are the 3 precautions to using nitroglycerin?
- what are the 4 adverse reactions when using nitroglycerin?
- other nitrates available are available with the same ______ ____ ______.
- available in a ______ of formulations, both ____ and _____ ______.
- what are the other 2 nitrates available?
A
- Shock, Hypovolemia, Hypotension
- Reflex tachycardia that ↑ O2 demands, Erectile dysfunction meds, Tolerance
- ↑ HR, Orthostatic hypotension, Migraine-like headaches, “blushing” above the clavicles
- mechanism of action
- different, short and long acting
- Isosorbide dinitrate (Isordil ®) and Isosorbide mononitrate
16
Q
- what 3 conditions are calcium channel blockers used to treat?
- how does this type of drug work? what does this prevent and produce?
A
- Angina pectoris, Cardiac arrhythmias, Hypertension
- Bind to Ca2+ channel and block influx into muscle cell preventing muscle contractions and producing relaxation in smooth and cardiac muscle cells
17
Q
- verapamil is what type of calcium channel blocker? developed from what?
- what is very sensitive to this drug? what does this cause? (hint: 3)
- what type of angina is this drug specifically helpful in treating? why? (hint: 3)
A
- prototype, developed from papaverine (vasodilator found in the poppy)
- Arterioles very sensitive to verapamil causing ↓ SVR and afterload and consequently ↓ myocardial O2 demand
- variant angina because it ↓ coronary artery tone and vasospasm, restoring CBF
18
Q
- Verapamil exerts what other additional effect? what does this help to do?
- what two negative effects does this drug produce? what does each specifically cause?
- what are two contraindications to using this drug?
- what is the only precaution when using this drug? this happens when verapamil is combined with what type of drug?
A
- anti-arrhythmic which helps to ↓ oxygen requirements
- Negative inotropic effect –> ↓ contractility & CO
Negative dromotropic effect –>↓ SA node impulses and slows conduction velocity through AV node - Sinus bradycardia and CHF
- Cardiodepressant effect (SA and AV node blockade when combined with b-blockers)
19
Q
- Diltiazem is similar to what drug?
- pronounced _____ _______ effect
- what type of antagonist is this drug? therefore leading to what?
- _______ predominates, _____ ______ dilation
A
- verapamil
- negative dromotropic
- sympathetic leading to little reflex tachycardia
20
Q
- amlodipine is on which list of essential medicines? what type of drug is this?
- indicated in the treatment of which two problems?
- what is the only contraindication to using this drug?
- what are the 3 precautions to using this drug?
- this drug is cleared by the _______.
- what are the 4 adverse effects of this drug?
A
- WHO, calcium channel blocker
- CAD and Hypertension
- those sensitive to amlodipine
- Hypotension, Worsening angina and acute MI, Hepatic failure
- liver!
- Edema, Dizziness, Flushing, Palpitation
21
Q
- Nifedipine is what type of drug?
- this drug is a potent _____ _______.
- there are no __________ effects.
- Nicardipine is what type of drug?
- what can this drug be combined well with?
- _______ ______ selectivity.
A
- calcium channel blocker
- arteriolar dilator
- dromotropic
- calcium channel blocker
- beta blockers
- increased vascular
22
Q
- mechanism of action of beta blockers?
- exert what type of effects? how do these drugs do this? (hint: 3) what specific effects are involved when doing this including their receptors?
- how do beta-blockers impact cardiac activity? (hint: 4)
- how do beta-blockers impact vascular effects? (hint: 3)
A
- Antagonize catecholamines by competitively binding at b-adrenergic receptors
- anti-anginal by reducing cardiac workload, ventricular afterload and O2 demand via: Cardiac effects (b1 receptors) and Vascular effects (b2 receptors)
- ↓ force of contraction, ↓ HR, ↓ conduction velocity, Improves myocardial relaxation (lusitropic effects)
- 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
- what type of drug is propranolol?
- this drug occupies which receptor(s)?
- exerts what type of effects? (hint: 3) what does this result in? (hint: 3)
- what does this drug help to increase? via?
- this drug causes a significant decrease in what?
A
- non-selective calcium channel blocker
- occupies both b1 and b2 receptors
- Exerts negative chronotropic, inotropic and dromotropic effects –> Reduced rate, strength and conductivity
- ↑ myocardial perfusion via prolonged diastole
- significant ↓ in BP
24
Q
- what are the 4 indications to using propranolol?
- what are the 4 contraindications to using this drug?
- what are 3 precautions to using this drug?
- what are 3 adverse effects associated with this drug?
A
- Refractory unstable angina, HTN, Cardiac arrhythmia
and Glaucoma - Variant and exertional angina (can ↑ ventricular wall stress), Asthma, Acute CHF with ↓ BP
- Transient rise in BP –> unopposed alpha response,
↑ airway resistance, Upregulation of b receptors with prolonged use - Related to ↑ ventricular wall stress caused by ↓ HR and resultant ↑ EDV, Also ↑ O2 consumption, Minimized with concurrent use of nitrates
25
Q
- Metoprolol and Atenolol are relatively selective for which type of receptors?
- therapeutic dose is better tolerated by who?
- what can a higher dose of this drug lead to? what can this cause?
A
- cardiac b1-adrenergic receptors
- asthmatics
- block b2 receptors causing Bronchospasm
and Hypertension
26
Q
- what 6 heart attack warning signs should we look for in men?
- what 6 heart attack warning signs should we look for in women?
- what are the 5 PQRST general questions we want to ask our patients when suspecting an MI?
- Now that we know what each letter stands for, what are the specific questions we should ask within each letter?
A
- Chest pressure or pain, Cold sweat, Pain in arms/neck/back/jaw/stomach, Nausea, SOB, Light-headedness
- Chest pressure or pain*, Cold sweat, Pain in lower chest/upper abdomen/back, Nausea, SOB, Light-headedness
- P = Palliative and provocative factors
Q = Quality of the pain
R = Radiation?
S = Severity?
T = Timing - 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
- what are the 4 clinical signs of instability?
- what are the 3 FIRST priorities when treating chest pain?
- what medication can be given if there are no contraindications?
- what can be given to help treat symptoms?
- what medication do we need to be sure our patient is NOT taking when giving nitroglycerin?
A
- Chest pain at rest*, Decreased level of consciousness, Difficulty breathing, Cardiac arrest
- Assess level of consciousness , Support cardio and respiratory needs if appropriate , Rest, lie or sit down
- low dose Aspirin
- nitrates
- erectile dysfunction medications
28
Q
- what 2 things can help us identify if our treatment is working?
- what 3 things are essential when treating these patients?
- in regards to post MI treatment, what 2 things things are we preventing with drug therapy?
- what other 2 non-drug regimens are important in post MI treatment?
A
- Patient re-assessment and Symptoms
- Ongoing assessment of chest pain severity (rating scale), serial ECGs and ***Continuous monitoring of patient’s BP essential
- Further ischemia and CHF
- Rehabilitation and Lifestyle modifications
29
Q
- what 3 lifestyle modifications are important for this patient population?
- what are the 5 improvements to overall health when following the above lifestyle changes?
A
- Avoid cigarette smoke, ↑ physical activity and Improve nutritional habits
- Improves cardiac function, Improves respiratory function, Improves cholesterol, Improves glucose control, and Improves immunity