Angina

Question 1

The 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease recommends that patients with ejection fractions of less than 40% or those with hypertension, diabetes, or kidney disease be placed on

Answer 1

ACEI unless contraindicated, then ARB

Question 2

ACE inhibitors are contraindicated in

Answer 2

pregnancy and should be avoided in patients with bilateral renal artery stenosis or unilateral stenosis.

Adverse Effects

Question 3

MOA of nitrates

Answer 3

The nitrates cause dilation throughout the vasculature—in the peripheral arteries and veins as well as the coronary arteries. When dilated, the veins return less blood to the heart, thereby reducing LV filling volume and pressure (preload). This decreases the workload of the heart.

Question 4

MOA of B-blockers in angina

Answer 4

Beta-blockers are very effective in managing angina.

• Beta1-receptor blockade is desirable in a patient with angina because it causes a slowing of the heart rate and a reduction in myocardial contractility. These effects reduce myocardial oxygen demand and therefore improve and prevent anginal symptoms.
• Blockage of beta2 receptors can lead to bronchoconstriction; therefore, nonselective beta-blockers should be used with caution in patients with uncontrolled or unstable reactive airway disease. At low to intermediate doses, cardioselectivity is demonstrated by atenolol (Tenormin) and metoprolol (Lopressor). Propranolol (Inderal) is an example of a nonselective beta-blocker.

Question 5

MOA of dihydropyridine calcium channel blockers

Answer 5

potent dilators of the coronary and peripheral arteries. Due to the vasodilatory effect of these agents, they may cause reflex tachycardia due to a reduction in systemic blood pressure. Since dihydropyridines do not alter conduction, they do not slow the sinus rate.

Question 6

MOA of nondihydropyridine calcium channel blockers

Answer 6

• Verapamil has a pronounced effect on cardiac conduction, reducing the rate of electrical conduction through the AV node. Verapamil also exerts negative inotropic and chronotropic effects, suppressing contractility, reducing heart rate, and therefore causing a reduction in oxygen demand
• Like verapamil, diltiazem reduces the heart rate but to a lesser extent. Diltiazem also has a less potent effect than verapamil on conduction and contractility, but it is a more potent vasodilator. Diltiazem has immediate- and sustained-release formulations. The immediate-release formulation usually is taken four times a day before meals; the sustained-release formulation is taken daily on an empty stomach.

Question 7

First line choice acute angina episodes?

Answer 7

In the absence of contraindications, beta-blockers are the agents of choice for prevention of acute anginal episodes in patients with or without a history of MI

Question 8

If the B-blocker is not effective as first line, what is second line for acute angina?

Answer 8

When initial treatment with a beta-blocker is not successful, either a calcium channel blocker or a long-acting nitrate may be added to beta-blocker therapy.