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Angina Flashcards

1
Q

Pathophysiology
Angina

A

The result of an imbalance between the myocardial oxygen supply and the myocardial oxygen demand

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2
Q

Signs and symptoms
Angina

A
  • Dizziness
  • Fatigue
  • Nausea
  • Shortness of breath
  • Sweating
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3
Q

Rationale for drug use
Angina

A

Provide symptom relief.

Reduce risk of death or MI.

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4
Q

Drug treatment plan
Angina

A
  1. beta blocker (atenolol OR metoprolol - HFrEF)
  2. nonhydropyridine calcium channel blocker (diltiazem, verapamil)
  3. Beta blocker + dihydropyridine calcium channel blocker (amlodipine)
  4. Add long-acting nitrate (transdermal glyceryl trinitrate to (1) OR (2)

For a patient with stable angina, beta blockers are usually first-line therapy to prevent episodes of angina, unless contraindicated. There is some evidence that beta blockers reduce incidence of recurrent myocardial infarction. Use:

**1atenolol 25 mg orally, daily, increasing if required up to 100 mg daily **

pts with left ventricular function <40% (HFrEF) should use beta blockers with cardiac benefits (metoprolol)

Nondihydropyridine calcium channel blockers (diltiazem, verapamil) used if beta blockers aren’t tolerated

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5
Q

What is stable angina

A

Angina is defined as retrosternal chest discomfort (pain or tightness) that lasts 10 minutes or less and subsides promptly with rest. It occurs when myocardial oxygen demand exceeds supply, which is usually restricted by atherosclerotic obstruction. Angina is commonly triggered by physical activity or emotional stress.

Angina is considered stable if the pattern of symptoms has not changed during the past month (eg the distance walked before the development of angina, when allowing for terrain, meals or cold weather).

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6
Q

Two kinds of Calcium channel blockers

A

Dihydropyridines
Non-dihydropyridines

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7
Q

suffix
Dihydropyridines Calcium channel blocker

A

Pine

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8
Q

Generic names of Dihydropyridines Calcium channel blocker

A

Amlodipine
Amlodipine with atorvastatin
Amlodipine with valsartan
Amlodipine with valsartan and hydrochlorothiazide
Clevidipine
Felodipine
Lercanidipine
Lercanidipine with enalapril
Nifedipine
Nimodipine

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9
Q

Generic names of Non-dihydropyridines Calcium channel blockers

A

Diltiazem
Verapamil
Trandolapril with verapamil

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10
Q

Indication
Calcium channel blockers

A

Hypertension
Angina

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11
Q

MOA
Calcium channel blockers

A

Block inward current of calcium into cells in vascular smooth muscle, myocardium and cardiac conducting system via L‑type calcium channels.

Act on coronary arteriolar smooth muscle to reduce vascular resistance and myocardial oxygen requirements, relieving angina symptoms.

Dihydropyridines act mainly on arteriolar smooth muscle to reduce peripheral vascular resistance and BP. They have minimal effect on myocardial cells.

Non-dihydropyridines: diltiazem and verapamil act on cardiac and arteriolar smooth muscle. They reduce cardiac contractility, heart rate and conduction, with verapamil having the greater effect. Diltiazem has a greater effect on arteriolar smooth muscle than verapamil.

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12
Q

Precautions
Calcium channel blockers

A

Myasthenia-like neuromuscular disease—calcium channel blockers may increase risk of muscle weakness and respiratory depression (most case reports with verapamil).

Peritoneal dialysis—cloudy peritoneal fluid (with no signs of infection) has been reported, mostly with lercanidipine; it is not clear if this is a class effect.

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13
Q

Adverse effects
Calcium channel blockers

A

Most listed adverse effects occur with all calcium channel blockers.

Adverse effects vary between the calcium channel blockers according to their relative effects on vascular, myocardial and conducting tissue.

Dihydropyridines have more pronounced vasodilatory effects than diltiazem and verapamil. Verapamil, and to a lesser extent, diltiazem, reduce cardiac contractility, heart rate and conduction.
Peripheral oedema
Dihydropyridines commonly cause peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention); this does not respond to treatment with diuretics, which may put patient at risk of volume depletion.

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14
Q

Practice points
Calcium channel blockers

A

vasodilatory adverse effects usually subside with continued treatment (may require dose reduction)

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15
Q

Drug class and indication

Amlodipine

A

Dihydropyridine Calcium channel blocker
Hypertension
Angina

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16
Q

Drug class and indication

Amlodipine with atorvastatin

A

Dihydropyridine Calcium channel blocker + statin / HMG-CoA reductase inhibitors
Hypertension or angina, in patients with hypercholesterolaemia or multiple cardiovascular risk factors

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17
Q

Drug class and indication

Amlodipine with valsartan

A

Dihydropyridine Calcium channel blocker + sartan (ARA)
Hypertension

Sartan a.k.a. angiotensin II antagonists and angiotensin receptor antago

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18
Q

Drug class and indication

Amlodipine with valsartan and hydrochlorothiazide

A

Dihydropyridine Calcium channel blocker + Sartan (ARA / ARB/ angiotensin II receptor blocker + Thiazide diuretic
Hypertension

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19
Q

Drug class and Indication

Clevidipine

A

Dihydropyridine calcium channel blocker
Hypertension (short-term use when oral treatment not appropriate)

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20
Q

Drug class and indication

Felodipine

A

Dihydropyridine calcium channel blocker
Hypertension

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21
Q

Drug class and indication

Lercanidipine

A

Dihydropyridine calcium channel blocker
Hypertension

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22
Q

Drug class and Indication

Lercanidipine with enalapril

A

Dihydropyridine calcium channel blocker + ACE inhibitor
Hypertension

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23
Q

Drug class and indication

Nifedipine

A

Dihydropyridine calcium channel blocker
Hypertension
Angina

24
Q

Drug class and indication

Nimodipine

A

Dihydropyridine calcium channel blocker
Prevention and treatment of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage

25
# Drug class and indication Diltiazem
**Non-Dihydropyridine calcium channel blocker** Angina Hypertension (controlled release tablet)
26
# Drug class and indication Verapamil
**Non-dihydropyridine calcium channel blocker** SVT AF or atrial flutter (ventricular rate control) Hypertension Angina
27
# Drug class and indication Trandolapril with verapamil
**ACE inhibitor + Non-dihydropyridine calcium channel blocker** Hypertension
28
# Suffix: Beta-blocker
lol
29
# Drug class lol
Beta-blockers
30
**Indication** Beta-blocker
Hypertension Angina Tachyarrhythmias MI Chronic heart failure with reduced ejection fraction as part of standard treatment Prevention of migraine
31
**MOA** Beta-blocker
Competitively **block beta receptors** in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver. **Beta-blockers reduce heart rate, BP and cardiac contractility**; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.
32
**Precautions / adverse effects** Beta-blockers
**Shock** (cardiogenic and hypovolaemic)—contraindicated. **Hyperthyroidism**—beta-blockers may mask clinical signs, eg tachycardia. **Phaeochromocytoma**—beta-blockers may aggravate hypertension; an alpha-blocker should be given first. **History of anaphylactic reactions**—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis. **Myasthenic symptoms**—may worsen. **CARDIAC**Contraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure. **Respiratory** contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD | Myasthenic symptoms (muscle weakness)
33
**Adverse effects** Beta-blockers
* bradycardia, * hypotension, * orthostatic hypotension * bronchospasm, * dyspnoea, * fatigue, dizziness * Mask Hypoglycemia ## Footnote Can mask signs of hypoglycemia in diabetics
34
**Counselling / practice points** Beta-blockers
Counselling This medicine **may cause dizziness or tiredness** **Do not stop** taking this medicine suddenly **Practice points** **beta-blockers are not usually recommended first line for uncomplicated essential hypertension**; they are associated with reduced protection against stroke in the elderly **when stopping treatment, reduce dosage gradually
35
# Drug class and indication Atenolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias MI
36
# Drug class and indication Bisoprolol
**Beta-blocker** Chronic heart failure with reduced ejection fraction as part of standard treatment
37
# Drug class and Indication Carvedilol
**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment
38
# Drug class and indication Labetalol
**Beta-blocker** Hypertension Hypertensive emergency
39
# Drug class and Indication Metoprolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias MI Prevention of migraine Chronic heart failure with reduced ejection fraction as part of standard treatment
40
# Drug class and Indication Nebivolol
**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment
41
# Drug class and indication Propranolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias Tetralogy of Fallot, seek specialist advice MI Prevention of migraine Essential tremor Phaeochromocytoma (with an alpha-blocker)
42
**Generic drug names** Beta-blockers
Atenolol Bisoprolol Carvedilol Esmolol Labetalol Metoprolol Nebivolol Propranolol Sotalol
43
**Generic drug names** Nitrates
Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate
44
**Suffix** Nitrates
itrate
45
"itrate" **Drug class**
Nitrates
46
**Indication** Nitrates
Angina
47
**MOA** Nitrates
Provide exogenous source of nitric oxide (which mediates vasodilator effects). **Predominantly venodilators; reduce venous return and preload to the heart**, reducing myocardial oxygen requirement.
48
**Precautions** Nitrates
Hypovolaemia—contraindicated. Raised intracranial pressure—contraindicated.
49
**Adverse effects** Nitrates
**Most are due to vasodilator effects:** **headache**, flushing, palpitations, **orthostatic hypotension, fainting, peripheral oedema**
50
**Counselling** Nitrates
This medicine may make you **feel dizzy on standing**. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy.
51
**Practice points** Nitrates
**tolerance to nitrates (with loss of effect) occurs with continuous exposure**; avoid by ensuring a nitrate-free interval from long-acting nitrates (see Glyceryl trinitrate, Isosorbide mononitrate); sublingual nitrates can be used if needed during the nitrate-free interval
52
# Drug class and indication Glyceryl Trinitrate
**Nitrates** Prevention and treatment of stable **angina** Heart failure associated with **acute MI** (infusion)
53
# Drug class and indication Isosorbide dinitrate
**Nitrates** Prevention and treatment of **angina**
54
# Drug class and indication Isosorbide mononitrate
**Nitrates** Prevention of **angina**
55
**Drug interactions** Nitrates
Nitrates (including sodium nitroprusside), as well as amyl nitrite, cause **hypotension** and, if given with other drugs* that reduce BP, may have additional hypotensive effects.

Pharmacology 2 (41 decks)

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