Angina

Question 1

What is angina pectoris (CAD)?

Answer 1

Acute chest pain due to insufficient oxygen to myocardium

Question 2

What is the most common cause of CAD?

Answer 2

Atherosclerosis

Question 3

What is the major problem with CAD?

Answer 3

Narrowing or occlusion of coronary artery, which causes Myocardial ischemia

Question 4

Ischemia

Answer 4

Not enough Oxygen delivered to tissue

Question 5

What is a major sign/symptom of Angina Pectoris?

Answer 5

Pain radiating to left shoulder, left arm, spine, neck and jaw

Question 6

What are the 4 types of Angina Pectoris?

Answer 6

1. Stable angina
2. Variant (unstable) angina
3. Vasospastic angina
4. Silent angina

Question 7

Stable angina

Answer 7

Fairly predictable, intensity& duration. Pain usually relieved by rest; pain caused by increased O2 demand, blood supply limiting

Question 8

Variant (unstable) angina

Answer 8

Occurs unexpectedly, even at rest; due to transient platelet aggregation or coronary thrombosis, often precursor to MI; decreased O2 supply-unchanged demand

Question 9

Vasospastic angina

Answer 9

↓ myocardial blood flow caused by spasms of coronary arteries

Question 10

Silent angina

Answer 10

Occurs in absence of angina pain

Question 11

What are the primary determinants of myocardial O2 supply?

Answer 11

A. Coronary blood flow
B. O2 content of the blood
C. O2 extraction by the myocardium

Question 12

What are the primary determinants of myocardial O2 requirement (demand)

Answer 12

A. Wall stress [Ventricular systolic pressure (afterload), ventricular radius (volume or preload) and wall thickness]
B. Heart rate
C. Myocardial contractility

Question 13

What are the goals of pharmacotherapy of angina pectoris?

Answer 13

Decrease O2 demand, increase blood supply

Question 14

Decrease O2 demand, increase blood supply treatment needs:

Answer 14

1. Slow the heart rate
2. Reduce contractility
3. Dilate veins so heart receives less blood (decrease preload)
4. Lower BP (will decrease afterload/ work of heart)
5. Increase coronary blood flow and oxygen supply (use nitroglycerin)

Question 15

What are the 3 major classes of drugs used to tx angina?

Answer 15

1. Organic nitrates
2. Ca2+ channel blockers
3. Beta-adrenergic antagonists

Question 16

Organic nitrates

Answer 16

Used most commonly for CAD. Members of this class include prototype - Nitroglycerin

Question 17

Nitrate MOA

Answer 17

• Act by increasing nictric oxide (NO) production
• NO activates guanylate cyclase to increase formation of cyclic GMP
• This results in dephosphorylation of myosin light chain (Myosin is a protein involved in relaxation of smooth muscle)

Question 18

Actions of Nitrate

Answer 18

1. Dilate veins more than arteries

2. Dilate some small arteries/atrioles

Question 19

Pharmacologic effect of Nitrate

Answer 19

Rapid onset, short time to reach maximal effect for sublingual or spray forms (NTG)

Question 20

Adverse effects of Nitrats

Answer 20

Postural hypotension, dizziness, blurred vision, xerostomia and headache

Question 21

Pharmacokinetics of Nitrate

Answer 21

• Hepatic first-pass metabolism is high and oral bioavailability is low for nitroglycerin and isosorbide dinitrate.
• Isosorbide mononitrate (long-acting) is not subject to first-pass metabolism and is 100% available after oral administration

Question 22

What inhibitor should you not use with Nitroglycerin?

Answer 22

PDE5 inhibitor (if taken 24 hours prior to appt)

Question 23

What are some dental implications of an acute angina attack?

Answer 23

1. Prepare to treat an acute angina attack in patient with history of angina
2. Ensure that patient has personal supply of sublingual or spray form of NTG
3. Appreciate that long-acting nitrates or nitrate formulations are not useful for treating an acute attack
4. Confirm that patient has not used a PDE5 inhibitor in last 24 hr
5. Ensure that patient is seated before taking NTG