Anti-Anginal Drugs (12a)

Question 1

What is the pathophysiology of Ischemic heart disease?

Answer 1

Imbalance between cardiac oxygen needs and supply

Question 2

What is chronic stable angina?

Answer 2

chronic, stable pattern chest pain with known inducers

- stable atherosclerotic plaque >= 70% narrowing

Question 3

Explain what unstable angina is

Answer 3

• It is an increase in frequency, severity, duration

- Plaque rupture with platelet and fibrin thrombus

Question 4

What are the acute therapies for chronic stable angina?

Answer 4

nitroglycerin

Question 5

Long term therapies for chronic stable angina are

Answer 5

Isosorbide dinitrate
Beta blockers
Calcium channel blockers
Sodium channel inhibitor (ranolazine)
ASA/Clopidogrel

Question 6

What are the vasodilators used for angina

Answer 6

• Nitrates

- Calcium channel blockers

Question 7

What are the sympatholytics that are used for angina?

Answer 7

• Beta blockers

Question 8

What are other therapies that can be used for chronic stable angina?

Answer 8

ACE inhibitors/ ARBs

HMG- CoA reductase inhibitors (“statins”)

Question 9

Nitroglycerin is used for what?

Answer 9

Angina

CHF

Question 10

MOA of nitroglycerin

Answer 10

Smooth muscle dilation of arteries and veins

Question 11

What is the major S/E of taking nitro?

Answer 11

Headache

also, hypotension and tachycardia

Question 12

The drugs that you should not use with nitro are what?

Answer 12

PDE-5 inhibitors (Viagra, Cialis)

Question 13

What are the different types of calcium channel blockers?

Answer 13

• Dihydropyridines (Amlodipine, Nifedipine)

- Nonhydropyridines (Diltiazem, Verapamil)

Question 14

What are the Dihydropyridine calcium channel blockers used for?

Answer 14

• Angina

- HTN

Question 15

What are the non-dihydropyridines used for?

Answer 15

• Angina
• HTN
• AFib
• Aflutter
• PSVT (paroxysmal ventricular tachycardia)

Question 16

What is the MOA of calcium channel blockers?

Answer 16

Vasodilation due to blocking calcium channels in vascular smooth muscle myocardium

Question 17

Can you use nondihydriopyridine calcium channel blockers and B blockers at the same time?

Answer 17

NO!!

Question 18

Can you use nondihydriopyridine calcium channel blockers in CHF?

Answer 18

NO!!

Question 19

Which of the calcium channel blockers cause more cardiac depression?

Answer 19

The nondihydropyridines

Question 20

What do you need to watch out for when using the dihydropyridines CCB?

Answer 20

Elderly hypotension

Question 21

Which of the two DHP CCBs will more likely cause hypotension?

Answer 21

Nifedipine

The major difference from amlodipine

Question 22

What are the B Blockers?

Answer 22

Propranolol
Metoprolol
Atenolol
Carvedilol

Question 23

Is Propranolol selective or nonselective B blocker?

Answer 23

Non-selective

Question 24

What is the MOA of propranolol?

Answer 24

Reduces myocardial O2 demand

Question 25

What are the two selective beta blockers?

Answer 25

Metoprolol and Atenolol

Question 26

Metoprolol and Atenolol is used for what?

Answer 26

Angina
HTN
Hemodynamically stable MI

Question 27

What do you need to remember about dosing in the Beta 1 selective Beta blockers?

Answer 27

That you shouldn’t give more than 100mg/day, in order to avoid losing the B1 selectivity

Question 28

Comparing Metoprolol and Atenolol, which one do you have to adjust the dose for in patients with CKD?

Answer 28

Atenolol.

50% is excreted unmetabolized in CKD patients, causing higher serum levels

Question 29

In the beta blockers that are non-selective, what must you always consider when it comes to comorbidities of patients?

Answer 29

If they have asthma/COPD, the B2 receptors can be inhibited, triggering bronchospasm

Question 30

What is the SODIUM channel inhibitor?

Answer 30

Ranolazine

Question 31

What is the MOA of Ranolazine?

Answer 31

It inhibits inward sodium channel function in ischemic cardiac myocytes, relaxing cardiac muscle and reducing myocyte O2 consumption

Question 32

What is prolonged on the EKG when taking Ranolazine?

Answer 32

QT interval

Question 33

What is the anti platelet drug that irreversibly inactivates COX1 which in turn inhibits synth of thromboxane A2, preventing platelet aggregation

Answer 33

Aspirin! Of course

Question 34

The drug clopidogrel is given for what?

Answer 34

2ndary prevention of AMI, CVA, PAD

Question 35

what is the MOA of Clopidogrel?

Answer 35

Irreversibly blocks ADP receptor on platelets, preventing platelet aggregation

Question 36

The half-life of diltiazem is increased in what disease?

Answer 36

Cirrhosis
(What is the class of this drug?? Dihydropyradine Ca++ channel blocker)

Question 37

A patient is taking amlodipine (Ca++ channel blocker) for HTN, but has noticed 1+ pitting edema her lower legs has developed? What do you do?

Answer 37

Take her off the Ca++ channel Blocker and start on a B Blocker (Metoprolol or Atenolol).

CCBs have a S/E of Peripheral Edema and Headache!

Question 38

A patient with HTN, Angina on exertion 2-3x week (relieved by rest), and CKD Stage 3 is taking Metoprolol Tartate for BP control. However, his blood pressure is very low and he is getting dizzy frequently. What can we do to help his symptoms.

Answer 38

We should downtitrate the Metoprolol and start on a CCB (amlodipine).

Because he has CKD, his kidneys aren’t clearing the drug, resulting in increased serum [metoprolol].

We could also switch him to Met Succinate, which is more expensive, but has been shown to decrease mortality and morbidity