Angina Flashcards

1
Q

Angina (definition)

A
  • Chest pain due to inadequate delivery of oxygen to the cardiac muscle.
  • Imbalance between cardiac oxygen supply and cardiac oxygen demands
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2
Q

Ischemia

A

Deficient supply of blood to a body part that is due to obstruction of the inflow of arterial blood.

  • in some individuals the ischemia is not accompanied by pain (slient angina)
  • In severe cases the pain migrates to the left arm
  • Pain is caused by accumulation of metabolites in the myocardium
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3
Q

Angina (characteristics)

A

You will have:

  • ST depression, T wave depression (85% of the time); or ST elevation, T wave elevation (much less common)
  • Increase in troponin C
  • Decreased cardiac contraction
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4
Q

Coronary circulation

A
  • The heart has a smaller blood supply compared to its O2 demand
    1. Arterial pressure
    1. Cardiac cycle- flow occurs mainly in Diastole and less during systole.
    1. Direct sensitivity of arterioles to aneaerobic metabolites (adenosine and ADP)
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5
Q

Stable angina

A
-chronic stable angina- exertional
(O2 demand > than the O2 supply)
-most common
- cause:  artherosclerotic narrowing
Treatment Goal:  Increase O2 supply and decrease O2 demand
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6
Q

Unstable angina

A
  • worsening of stable
  • -AMI
  • sudden death
  • O2 supply decreased when demand is unchanged (at rest)
  • Causes: plaque rupture
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7
Q

Variant angina (Prinzmetal’s)

A

Recurrent episodes of RESTING pain with REVERSABLE ST elevation and preserved exercise tolerance
-Cause: Coronary vasospasm
TREATMENT GOAL: Increase O2 Supply

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8
Q

Risks for Ischemic Heart Disease

A
  • HTN
  • smoking
  • hyperlipidemia
  • hyperglycemia
  • male
  • post menopausal female ( low estrogen)
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9
Q

Angina precipitating factors

A
  • Exercise
  • Stress
  • Sex
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10
Q

Purpose of treatment

A
  • relieve symptoms
  • stop the disease process
  • regression of the process
  • prevent MI
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11
Q

Basis of Drug Therapy

A
Decrease the O2 demand by reducing workload:
-decrease HR
-decrease force of contraction
-decrease afterload
Increasing the SUPPLY of O2
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12
Q

Antianginal Drugs (6 classes)

A
  • Nitrates
  • Beta antagonists
  • Calcium channel blockers
  • Ranolazine
  • Antithrombotic
  • Anti lipidemic
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13
Q

Organic Nitrates (MOA)

A
  • relaxation of smooth muscle, mostly venous but some arterial dilation as well
  • nitrate (NO2) is converted to NO, causes an increase in cGMP formation which leads to Ca2+ sequestration (prevents contraction / mechanism of vasodilation)
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14
Q

Nitrates (therapeutic effects)

A
  • Arteriolar dilation (decreases afterload)
  • Venous dilation (decreases preload)
  • relieves vasospasm
  • redistrubutes myocardial blood flow
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15
Q

Nitrates Side Effects

A

-headache
-hypotension
-fainting risk
Contraindicated : hypersensitivity, hypotension, Increased ICP, constrictive pericarditis/ tamponade, severe anemia

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16
Q

Nitrates FYI

A
  • dose/effect is inversely related to vessel diameter; smallest dose will dilate veins, largest dose needed for arteriolar dilation
  • tolerance can develop
  • extensive 1st pass metabolism
  • stimulation of SNS
  • may ellicit angina attack “steeling effect/ reflex tachy”
17
Q

Isorbide (isordil)

A
  • organic nitrate
  • SE: flushing methlaemoglobinaemia (at high doses only), headache, orthostatic hypotension

-interaction with phosphodiesterase 5 inhibitors (sildenafil/VIAGRA): DO NOT USE WITH NITRATES: (nitrates increase cyclic CMP; phosphodiesterase-5 inhibitors increase cGMP by preventing its breakdown; phosphodiesterase 5 breaks down cGMP)

18
Q

Beta blockers (effects)

A

-blockade of sympathetic stimulation
-decrease HR
-decrease contractility
-decrease systolic wall tension
- Increases time spent in diastole / prolonging perfusion
Decrease incidence of MI in patients with CAD

19
Q

Beta blockers (therapeutic use)

A

-angina
-post MI
-CHF
Contraindicated in prinzmetal’s angina
Avoid non selective in patients with asthma (bronchospasm)

20
Q

Beta blockers (Side effects)

A
  • fatigue
  • lethargy
  • impotence
  • bradycardia
  • bronchospasm
21
Q

Calcium channel blockers (ther. effects)

A
  • decrease HR
  • decrease contraction (limits Ca entry during plateau)
  • inhibits ectopic beats

-decreases afterload (arterial vasodilation)

22
Q

Calcium channel blockers (list)

A
  • nifedipine (works only on vascular NOT heart)
  • diltiazem
  • verapamil
  • bepridil
23
Q

Calcium Channel Blockers (therapeutic uses)

A
  • angina
  • variant angina
  • HF
  • HTN in SAH hemorrhage
  • arrhythmias
24
Q

Calcium Channel Blockers (side effects)

A

-dizziness
-flushing
-headache
-transient hypotension
-per. edema
-bradycardia
-AV block
Do not use with beta blocker combo due to INcrease risk of AV block

25
Ranolazine (Ranexa)
- treatment of chronic stable angina - blocker of late Na+ channels - metabolized by cytochrome 450(CYP3A4) - 3 days to become effective - Do not use in patients with prolonged QT, hepatic or renal impairment - Do not combine with dlitiazem (decreases absorption), or potent CYP3 inhibitors (ketoconozale, simvastatin)
26
Ranolazine Side Effects
- constipation - dizziness - headache - nausea - peripheral edema - asthenia (loss of strength)
27
other agents for Angina
- ASA 325 mg/day | - statins
28
Nitrates and beta blocker combo
nitrates attenuate adverse cardiovascular effects of beta blockers. Beta blockers inhibit the tachy and positive inotropic effects of nitrates
29
nitrates and calcium channel blockers
- only in supervised clinics - use for severe exertional or vasospastic angina - severe hypotension and bradycardia can occur
30
Beta blocker and calcium channel blockers
- only in patients with heart disease when with nifedipine or amiodipine are used (they work only on vascular). - Do not combine with calcium blockers that work on heart because of AV BLOCK