Angina

Question 1

Goal of treatment for angina

Answer 1

Treatment is aimed at:
Increasing myocardial oxygen supply
Reducing myocardial oxygen demand
Minimizing or removing the occlusion

Question 2

Coronary Vasodilators

Answer 2

Nitrates (nitroglycerin, isosorbide)

Calcium channel blockers

Question 3

Low doses of NTG

Answer 3

Dilate the veins, decreasing venous return to the heart.

Decreases preload.

Question 4

Higher doses of NTG

Answer 4

Dilate arterial vessels.
Decreased vascular resistance (afterload).
Some dilation of coronary arteries.
NOTE: Atherosclerotic vessels do not dilate.

Question 5

Nitrates

Answer 5

S/E:
Headache, orthostatic hypotension, syncope, tachycardia
Hypotension may lead to decrease in diastolic filling pressure and tachycardia may lead to decrease in diastolic filling time, which may lead to myocardial ischemia, arrhythmias, and rebound hypertension.
Drug interactions:
Concurrent use with the vasodilators, or erectile dysfunction drugs sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) = contraindicated
Caution:
Additive hypotension with antihypertensives, alcohol, BBs, CCBs
Pregnancy category C

Question 6

Nitrates for long-term control

Answer 6

Monotherapy generally should be avoided, as pts are unprotected during nitrate-free period each day
Combine with either BB or CCB

Question 7

Eccentric dosing schedule

Answer 7

Eccentric dosing schedule of nitrates:
Separate doses by 7 hours due to need to have nitrate-free period.
Take at 7 to 8 a.m. and 2 to 3 p.m. rather than “usual” twice daily regimen.
Need nitrate-free interval of 10 to 12 hours.

Question 8

Beta Blockers for Angina

Answer 8

Beta blockers (BBs) decrease the force of myocardial contractility and decrease heart rate and conduction velocity.
BBs decrease systemic vascular resistance and BP (afterload).
Decreased myocardial oxygen demand = decreased anginal pain.

Question 9

Calcium Channel Blockers for Angina

Answer 9

Calcium channel blockers (CCBs) cause arterial smooth muscle relaxation, which leads to peripheral vasodilation and decreased afterload.
CCBs may cause coronary vasodilation.
NOTE: Atherosclerotic vessels do not dilate.

Question 10

ACEI for Angina

Answer 10

Decrease peripheral vascular resistance, and
Decrease afterload.
ACEIs indirectly reduce the secretion of aldosterone.
= Decreased sodium and water retention
= Reduced extracellular fluid volume and preload.

Question 11

Ranolazine for Angina

Answer 11

Anti-ischemic agent for management of chronic angina.
MOA:
Reduces sodium-induced calcium overload in myocytes (that causes myocyte dysfunction & angina).
Effects:
Reduces angina symptoms
Increases exercise capacity
Minimal effects on HR or BP
May prolong QT interval
Reserved for pts refractory to other meds (expensive)
Drug interactions: ketoconazole, clarithromycin, rifampin
ADRs: Dizziness, constipation, h/a, nausea

Question 12

Aspirin for Angina

Answer 12

Aspirin decreases platelet aggregation to prevent cycle of vasoconstriction and platelet buildup.

Question 13

Statins for Angina

Answer 13

Preventative.
Reduces LDL
Plays a significant role in decreasing the formation of atherosclerotic plaque.

Question 14

NYHA Class I

Answer 14

Proven coronary artery disease without symptoms

Question 15

NYHA Class II

Answer 15

Mild symptoms: angina and slight limitation during ordinary activity

Question 16

NYHA Class III

Answer 16

Marked limitations: angina during less-than-routine physical activity (walking short distances)

Question 17

NYHA Class IV

Answer 17

Severe limitations: angina during minimal activity or rest