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Pharm II > Angina > Flashcards

Angina Flashcards

0
Q

What are the major determinants of myocardial oxygen consumption?

A
  1. Ventricular wall stress
    - both preload (end diastolic pressure) and afterload (end-systolic pressure) affect ventricular wall stress
  2. Heart Rate
  3. Inotropic state (contractility)
  4. Myocardial metabolism (glucose vs fatty acids)
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1
Q

Coronary blood flow is essentially negligible during systole and is therefore determined by:

A
  1. perfusion pressure during diastole (aortic diastolic pressure)
  2. Duration of diastole
  3. Coronary vascular resistance
    - atherosclerosis
    - intracoronary thrombi
    - metabolic produducts that vasodilate coronary arterioles
    - autonomic activity
    - extravascular compression
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2
Q

what is the commonly used non-invasive index of myocardial oxygen demand

A

“double product”

  • Heart rate X systolic blood pressure
  • also known as the rate pressure product
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3
Q

How do organic nitrate treat angina?

end results!

A

vasodilate coronary arteries

reduce preload and afterload

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4
Q

How do calcium channel blockers treat angina

A

vasodilate coronary arteries
reduce afterload
the non-dydropyridines (verapamil and diltiazem) also decrease heart rate and contractility

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5
Q

how do beta blockers treat angina

A

decrease heart rate and contractility
decrease afterload secondary to a decrease in cardiac output
improve myocardial perfusion secondary to a decrease in heart rate

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6
Q

describe in detail the mechanism of nitrates in vasodilation:
NO activates a ________ form of _______ in smooth muscle.

A

cytosolic form of guanylate cyclase in smooth muscle

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7
Q

NO:

activated guanylate cyclase catalyzes ____.

A

formation of cGMP

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8
Q

NO:

cGMP activates _____

A

cGMP-dependent protein kinase

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9
Q

NO:
Activaiton of the cGMP-dependent protein Kinase results in _______ that reduce _____ and ____ the plasma membrane causing ____.

A

phosphorylation of several proteins* that reduce the intracellular calcium and hyperpolarize the plasma membrane causing relaxation

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10
Q 
The 3 major effects of Nitrovasodilators are 
1. Peripheral Vasodilation
2. Increased Coronary Blood Flow
3. Inhibition of platelet function
Descibe each of the three in detail.
A
  1. dilation of veins predominates over that of arterioles
  2. decreased preload improves subendocardial perfusion
    - little or no effect on total coronary blood flow in patients with typical angina due to atherosclerosis
  3. this is why it is so good at treating unstable angina
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11
Q

What is coronary steal phenomenon?

A

Effect of nitrovasodilators due to increased coronary blood flow - dilation of coronary arteries can paradoxically result in aggravation of angina

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12
Q

which nitrates can hepatic blood flow and disease affect their pharmacokinetics?

A

GTN & ISDN

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13
Q

which nitrate is a gas?

onset and duration?

A

Amyl Nitrate
inhalation
rapid onset, duration 3-5 min

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14
Q

which nitrate is not suitable for maintenance therapy and is metabolized by first pass?
onset?
duration?

A

GTN & ISDN
rapid onset of action 1-3 min sublingually
duration 20-30 min
not suitable for maintence therapy

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15
Q

which nitrate can be used to treat SEVERE RECURRENT UNSTABLE ANGINA?

A

IV nitrogylcerin

16
Q

Which nitrates can be used to provide prolonged prophylaxis?

A

nitrovasodilators
oral, buccal, transdermal
3-10 hours
but can lead to tolerance (tachyphylaxis)

17
Q

vasodilators can develop complete tolerance. what is recommended to prevent this?

A

transdermal GTN may provide therapeutic levels of drug for 24 hours, but efficacy only lasts 8-10 hours
–Nitrate free periods of at least 8 hours (overnight) are recommended to avoid or reduce TACHYPHYLAXIS

18
Q

industrial (occupational) exposure to organic nitrates has been associated with ______

A

monday disease & physical dependence manifested by variant angina occuring 1-2 days after withdrawl
**has resulted in myocardial infarction in some patients

19
Q

what are the 6 major acute diverse effects due to excessive vasodilation?

A
  1. orthostatic hypotension
  2. tachycardia
  3. severe throbbing headache
  4. dizziness
  5. flushing
  6. syncompe
20
Q

what patients are organic nitrates contraindicted in?

A

patients w/ elevated intracranial pressure

21
Q

which drugs can potentiate teh actions of nitrovasodilators?

A

Sildenafil (Viagra) and other PDE-5 Inhibitors used for erectile dysfunction can potentiate the actions of vasodilators b/c they inhibit the breakdown of cGMP
***THEY SHOULD NOT BE TAKEN W/IN 6 HOURS of taking a NITROVASODILATOR

22
Q

THe 2 desired effects in treating angina w/ calcium channel blockers is what? describe each

A
  1. improve oxygen delivery to ischemic myocardium
    - vasodilate coronary arteries (not veins!)
    - may inhibit aggregation
    - particularly useful in treating vasospastic angina
  2. Reduce myocardial oxygen consumption
    - decrease AFTERLOAD (NOT preload)
    - non-dihydropyridines also lower heart rate and decrease contractility
    - 9*Dihydropyridines may aggravate angina in some patients due to reflex increases in heart rate and contractility
23
Q

Which patients should not be treated with verapamil or diltiazem?

A

pt’s with ventricular dysfunction, SA node or AV conduction disturbances, WPW syndrome, and systolic blood pressures below 90 mmHg

24
Q

Which Ca Channel blockers may increase mortality in pt’s w/ myocardial ischemia?

A

immediate release forms of dihydropyridines

25
Q

which Ca Channel Blocker drug interaction causes

Bradycardia, AV Block, depression of inotropic state

A

Beta Blockers with Verapamil or Diltiazem

26
Q

Which calcium Channel Blocker drugs can causes an increase in plasma digoxin levels?

A

Verapamil and Diltiazem

27
Q

Which calcium channel blocker drug interaction can cause AV Block with concurrent treatment?

A

calcium channel blockers and digitalis

28
Q

Which CCB drug interaction results in decreased clearance of both and an increased risk of brandycardia and AV nodal block?

A

Quinidine

29
Q

What are the 2 large desired effects of beta-blockers in the treatment of angina?

A
  1. reduce myocardial oxygen consumption by reducing contractility and heart rate
    - reducing cardiac output also reduces AFTERLOAD
    - some B-blockers can cause vasodilation directly or by acting as alpha blockers
  2. improve myocardial perfusion by slowing heart rate (more time spent in diastole)
30
Q

Which drug used in treatment of angina can exacerbate heart failure and is contraindicated in pt’s with asthma?

A

beta blockers

31
Q

In which patients should Beta-Blockers be used with caution when treating angina?

A

diabetics since hypoglycemia-induced tachycardia can be blunted or blocked

32
Q

Which drug interaction with Beta Blockers may depress contractility & heart rate and produce AV block?

A

non-dyhydropyridine calcium channel blockers

  • Verapamil
  • Diltiazem
33
Q 
What are the effects of Nitrates alone ; Beta blockers or CCB alone; and nitrates w/ Beta Blockers or CCB in relation to each of the following:
Heart Rate
Arterial Pressure
EDV
Contractility
Ejection Time
A

Nitrates: degreases all EXCEPT HR & Contractility in which it has a reflex increase
BB or CCB alone: decreases all except EDV & Ejection time in which they have a reflex increase
Together: Decrease HR, AP,
-none or decrease in EDV
none in contractility & Ejection time

34
Q

What is used in the treatment of Chronic Angina?

A

Ranolazine (Ranexa)

35
Q

What is the MOA of Ranolazine (Ranexa)?

A

unknown
- at therapeutic levels can inhibit the cardiac late sodium current
however, the relationship of this inhibition to angina symptoms is uncertain

36
Q

What are the drugs that are contradictations with Ranolazine

A

CYP 3A inhibitors (Ketoconazole, clarithromycin, nelfinavir)
CYP 3A inducers (rifampin, phenobarbital, St. John’s wort)
Liver Cirrhosis

37
Q

T/F Ranolazine can cause dizinness, headache, constipation, nausea

A

true

Pharm II (13 decks)

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