Anti-angina Meds Flashcards
Which drugs has anecdotal evidence of efficacy?
Nitrates
Nitrates will do what to the systemic circulation?
- Venodilation
- Arteriolar vasodilation
- Arterial vasodilation
Nitrates will effect the coronary circulation by
Increasing the coronary blood flow and reducing the diastolic blood pressure
What does nitrates activate? What odes it result in?
It activates Guanylate Cyclase leading to an increase in cGMP
Nitrates ultimately is an agent that
Reduce myocardial oxygen demand
What is the significance of dose response of oral nitrates?
As we increase nitrate dose, there is a difference in the opening of the veins and arteries.
Capacitance veins have a great effect and will show immediate dilation, conductance arteries will have a gradual widening and resistance artery takes a while for ir to dilate
Will nitrates reduce preload and afterload?
Yep
What is the bottom line for nitrates to work on dilating coronary arteries?
You need functional smooth muscle cells around the circumference of the artery for coronary dilation
Will smaller coronary arteries dilate proportionally more than larger coronary arteries with the administration of nitrates?
Yep
Which dilate more with the administration of nitrates: a eccentrically diseased heart or concentrically diseased heart
Eccentrically diseased heart
Nitrates tolerance… tell me about it
There are multiple potential mechanism for tolerance one of them is due to the depletion of R-SH but the best way to avoid tolerance with chronic administration is have nitrate free interval
when are nitrates contra-indicated?
when patient has taken sildenafil since it also leads to vasodilation
this combination can results in severe hypotension and death
what to give to a patient who has been given both sildenafil and nitrates?
receive fluid administration, vasopressors and be monitored closely for hemodynamics
sildenafil works by
inhibiting the breakdown of cGMP thus leads to increased levels of it
Beta blockers effects (4)
- reduce heart rate
- reduce BP
- reduce contractility
- increases wall tension in patients with left ventricular dysfunction
net effect of beta blockers
reduces myocardial oxygen demand
when are beta blockers particularly useful in anti-angina effects?
conditions of heightened SNS activity
can coronary blood flow go down with beta blockers?
yep
classification of beta blockers (3)
which one is not used for angina?
- beta-1 selective
- non-selective
- combined alpha/beta blockers
- neither non-selective or combined is used
some side effects of beta blockers
- bradycardia
- aggravation of heart failure
- fall in HDL
are beta blockers used in acute MI?
yea, reduces risk fo sudden death, reacurrent MI and progression to heart failure
beta blockers with intrinsic sympathomimetic activity are
not benefitcial
which calcium channel blockers have myocardial effects
non-dihydropyridine
what is the mechanism of non-dihydro calcium blockers
lenghten the conduction time and prolong the refractoriness of the atrio-ventricular node
examples of non-dihydro calcium blockers
- verapamil
2. diltiazem
mechanism of dihydropyridine calcium blockers
effect on vascular smooth muscle at the concentrations used clinically
examples of dihydropyridine calcium blockers
- amlodopine
2. nifedipine
calcium channel blockers effects (4)
- reduce HR
- reduce BP
- reduce contractility
net overall effect of calcium channel blockers
reduced myocardial oxygen demand
verapamil and diltiazem in addition to increasing coronary blood flow, lowering coronary resistance, reducing afterload, reducing coronary spasms like all calcium blockers they also
- reduce HR
2. reduce contractility
adverse effect of verapamil and diltiazem
- bradychardia
2. AV block
nifedipine adverse effects
- edema
2. headache
treatment for variant angina
- calcium channel blocker
2. long-acting nitrates
tailored medical therapy after nitrates:
sinus brady
Dihydro CCB
tailored medical therapy after nitrates:
Sinus tachy
B-blocker
tailored medical therapy after nitrates:
supraventricular tachy
verapamil and B-blocker
tailored medical therapy after nitrates:
Afib
verapamil, diltiazem or B-blocker
tailored medical therapy after nitrates:
L.ventricular dysfunction
B-blocker
tailored medical therapy after nitrates:
COPD
CCB
what should always be part of all anginal patients’s regimen
NG sublingual
which medication enhances the efficacy of dihydro CCB
B-blockers
aspirin in angina treatment:
- stable angina
- primary prevention
- secondary MI prevention
- unstable angina
- yes, reduction in adverse CV events
- recommended for high risk patients
- yes, reduces both mortality and reinfarction
- yes, reduction in MI and mortality
Aspirin blocks
cyclo-xygenase leading to decreased platelet aggregation
aspirin side effects
GI bleeding
treatment guideline of aspirin
75-162
ranozaline
can inhibit the cardiac late sodium current
which ion channel is enhanced in ischemia
late sodium channel
late sodium channel actiation has been associated with
intracellular sodium and calcium loading, leading to cellular and reperfusion injury
does ranolazine increase QT?
modest increase but there is no increaae in risk for torsade de Pointes
ranolazine has multiple drug interactions
yes
Class 1 angina meds
- beta blockers
- CCB
- long acting nitrates
- NG
Class IIa angina meds
- long acting non-dihydro CCB
2. ranolazine
nicorandil, ivabradine and trimetazidine
meds available outside of USA
