Angina

Question 0

Goals of angina drug therapy

Answer 0

Prevention of myocardial infarction and death, prevention of myocardial ischemia and anginal pain

Question 1

Angina pectoris

Answer 1

Sudden pain beneath the sternum, often radiating to left shoulder and arm; oxygen supply to the heart is insufficient to meet oxygen demands

Question 2

Drugs for Angina Pectoris

Answer 2

Three families of antianginal agents: organic nitrates, beta blockers, calcium channel blockers
-Ranolazine: can be combined with other drugs, newer drug with limited indications

Question 3

Determinants of Cardiac Oxygen: Oxygen demand

Answer 3

Heart rate, myocardial contractility, intramyocardial wall tension (preload/afterload)

Question 4

Determinants of Cardiac Oxygen: Oxygen Supply

Answer 4

Myocardial blood flow, myocardial perfusion only in diastole

Question 5

Chronic Stable Angina (Exertional)

Answer 5

Pathophysiology: Emotional excitement, large meals, cold exposure, Coronary artery disease (CAD)
Treatment strategy: increase cardiac oxygen supply, decrease oxygen demand
Therapeutic agents (provide symptomatic relief): organic nitrates, beta blockers, calcium channel blockers, ranolazine
Nondrug therapy: avoid factors that can precipitate angina, decrease risk factors

Question 6

Variant Angina (Prinzmetal’s: Vasospastic)

Answer 6

Pathophysiology: coronary artery spasm
Treatment strategy: increasing cardiac oxygen supply
Therapeutic agents: calcium channel blockers, organic nitrates

Question 7

Unstable Angina: Medical Emergency

Answer 7

Severe CAD complicated by vasospasm;
Pathophysiology: symptoms of angina at rest, new onset exertional angina, intensification of existing angina
Treatment strategy: maintain oxygen supply, decrease oxygen demand

Question 8

Therapeutic agents for acute management of unstable angina

Answer 8

Anti-ischemic therapy, antiplatelet therapy, anticoagulant therapy

Question 9

Anti-ischemic therapy

Answer 9

Nitroglycerin, beta blocker, supplemental O2, IV morphine, ACE inhibitors

Question 10

Antiplatelet/anticoagulant therapy

Answer 10

Aspirin (indefinitely): clopidogrel (plavix), abciximab (reopro), eptifibatide (integrilin); anticoagulant therapy: subcutaneous LMW heparin or IB unfractionated heparin

Question 11

Organic Nitrates

Answer 11

Nitroglycerin: stable and variant angina, vasodilator

Adverse effects: headache, orthostatic hypotension, reflex tachycardia

Question 12

Beta Blockers

Answer 12

Decrease cardiac oxygen demand (propranolol, metoprolol)
Adverse effects: bradycardia, decreased AV conduction, reduction of contractility, asthmatic effects, use with caution in pt with diabetes, insomnia, depression, bizarre dreams, sexual dysfunction

Question 13

Calcium Channel Blockers

Answer 13

Verapamil, diltiazem, nifedipine; block calcium channels in vascular smooth muscle (VSM), used for stable and variant angina
Adverse effects: dilation of peripheral arterioles, reflex tachycardia, hypotension, beta blockers, bradycardia, heart failure, AV block

Question 14

Ranolazine

Answer 14

Belongs to first new class of antianginal agents approved in more than 25 years; benefits modest and greater in men than in women, does not reduce heart rate, blood pressure, or vascular resistance; can prolong QT; multiple drug interactions
-Exact mechanisms unknown, not a first line therapy; combine with first-line agents for inadequate respone to other first-line medications

Question 15

Revascularization Therapy

Answer 15

Coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), comparison of CABG surgery with percutaneous coronary intervention (PCI)

Question 16

Drugs used to Prevent Myocardial Infarction and Death

Answer 16

Antiplatelet drugs, cholesterol-lowering drugs, angiotensin-converting enzyme (ACE) inhibitors, antianginal agents