ACS/Stable Angina Pharm

Question 1

Determinants of myocardial oxygen demand

Answer 1

HR, contractility, preload, afterload

*angina occurs when there is an imbalance between oxygen supply and oxygen demand in cardiac myocytes

Question 2

Nitrate drugs used in stable angina and MOA

Nitroglycerin, Isosorbide dinitrate/mononitrate

Answer 2

MOA: metabolic activation to NO, increased cGMP, myosin-LC dephosphorylation, smooth muscle relaxation

*venous dilation leads to reduced preload and therefore decreased myocardial O2 demand

Question 3

Ca channel blockers used in stable angina and MOA

Dihydropiridines: Amlodipine, Nifedipine, Nicardipine

Cardioactive: Diltiazem, Verapamil

Answer 3

Block Ca entry into cell, decreasing ability to contract

• Dihydropiridines only act on vascular smooth muscle, causing dilation
• Cardioactive act on vascular smooth muscle and cardiac muscle and pacemakers, causing vasodilation, decreased HR and decreased contractility

Question 4

Which drugs decrease preload via venodilation, therefore decreasing myocardial oxygen demand?

Answer 4

nitrates

Question 5

Which drugs decrease afterload and peripheral vascular resistance via vasodilation (arteries>veins) while also decreasing contractility and HR, therefore decreasing myocardial oxygen demand?

Answer 5

Cardioactive Ca channel blockers

Verapamil, Diltiazem

Question 6

Which drugs decrease afterload and peripheral vascular resistance via vasodilation (arteries>veins) but have NO direct affect on the myocardum and pacemakers, therefore decreasing myocardial oxygen demand?

Answer 6

Dihydropyradine Ca channel blockers (-dipine)

Amlodipine, Nifedipine, Nicardipine

Question 7

Beta blockers used in stable angina and MOA

Propranolol, Nadolol, Metoprolol, Atenolol

Answer 7

Decrease myocardial oxygen demand by decreasing HR, contractility and blood pressure

Question 8

Ranolazine MOA

Answer 8

inhibits late Na current in cardiomyocytes (Na/Ca exchanger, or NCX)

• normalizes repolarization and mechanical dysfinction, reducing compression of coronary vessels in diastole
• use in angina refractory to other treatments, improves exercise tolerance in pts taking other drugs for angina

Question 9

Stable angina treatment algorithm 1st line, 2nd line, 3rd line

Answer 9

1. BB or CCB or LA nitrate
2. Add second class (double therapy)
3. Add third class or ranolazine

*if all fails consider CABG

Question 10

Nitrates alone can cause reflex ____ and ____

Answer 10

reflex tachycardia and contractility

• nitrates + CCB or BB have lower likelyhood of cardio side effects when treating angina
• using BB or CCB alone can cause increased EDV and ejection time

Question 11

Drug choice to treat vasospastic angina (prinzmetal)

Answer 11

CCBs, diltiazem or amlodipine most common

*if CCBs are contraindicated use LA nitrates

Question 12

Nitrates are contraindicated in patients taking what drug class?

Answer 12

PDE-5 inhibitors

• Sildenafil, Vardenafil, Tadalafil
• may cause dramatic drop in BP or MI

Question 13

Thrombus type that is fibrin-rich and forms in low pressure veins and in the heart

Answer 13

Red thrombus

*anticoagulants prevent clots from forming in veins by inhibiting coagulation factors

Question 14

Thromus type that is platelet-rich and forms in high pressure arteries, cause of ACS when in coronary arteries

Answer 14

White thrombus

*antiplatelet drugs prevent clots from forming in arteries by inhibiting platelet function

Question 15

Antiplatelet drugs:

P2Y12 (ADP) receptor blockers, prevent platelet aggregation

Answer 15

Clopidogrel, Prasugrel, Ticagrelor

*start as soon as possible in ACS along with aspirin

Question 16

Antiplatelet drugs:

TxA2 synthesis inhibitor via inhibition of COX

Answer 16

Aspirin

*start as soon as possible in ACS along with P2Y12 blocker

Question 17

Antiplatelet drugs:

Platelet glycoprotein (GP IIb/IIIa) receptor blockers

Answer 17

Abciximab, Eptifibatide, Tirofiban

*no longer used very often clinically

Question 18

Clopidogrel resistance mechanism

Answer 18

Nonfunctional CYP2C19 allele

*does not allow drug to be metabolized to active form

Question 19

Thrombolytic drugs:

t-PA drugs

Answer 19

Alteplase, Reteplase, Tenecteplase (-plase)

Question 20

MOA and indication for t-PA drugs and streptokinase

Answer 20

convert endogenous plasminogen to plasmin

*used when PCI cannot be performed in timely manner