Anti-anginal Drugs

Question 1

4 types of drugs used to treat angina

Answer 1

b blockers, ca ch blockers, others (2), and organic nitrates

Question 2

organic nitrates used to treat angina

Answer 2

nitroglycerin
isosorbide dinitrate
isosorbide 5 mononitrate

Question 3

b blockers used to treat angina

Answer 3

propanolol, sotalol, atenolol

Question 4

ca ch blockers used to treat angina

Answer 4

verapimil
diltiazem
nifedipine
nimodipine

Question 5

two other drugs for angina

Answer 5

trimetazidine

ranolazine

Question 6

stable angina

Answer 6

deep, poorly localized chest arm discomfort associated with stress/exertion
no serum changes or necrosis
treat with rest and nitroglycerin

Question 7

variant (prinzmetal) angina

Answer 7

at REST, due to transient increases in coronary tone/vasospasms at site of atherosclerotic change
*ST elevations

Question 8

unstable angina

Answer 8

atleast one of the following

1) at rest, >20 min
2) severe and new onset (1 mo)
3) crescendo pattern (more frequent, severe, prolonged)

Question 9

NSTEMI

Answer 9

form of unstable angina, without ST elevation

not fully occluded

Question 10

AMI (acute Mi)

Answer 10

acute total thrombotic occlusion of coronary artery

Question 11

angina

Answer 11

ischemic heart disease symptom, substernal discomfort (rarely pain) that can extend to left arm/shoulder/jaw

Question 12

what is angina due to?

Answer 12

imbalances in oxygen demand-supply –> ischemia

Question 13

what does unstable angina usually feature?

Answer 13

ruptured coronary atherosclerotic plaque with platelet aggregation –> less BF

Question 14

BF in coronary circulation

Answer 14

only flows in LV coronaries during diastole
in systole, sub endocardium P>subepicardium P so endo need more time to fill
since RV has smaller forces, RV perfusion continues through diastole AND systole

Question 15

Ca2+ induces….

NO induces…

Answer 15

vascular contraction

vasodilation

Question 16

trimetazidine

Answer 16

FA oxidation inhibitor –> enhances glucose oxidation by preventing ATP decrease –> myocardium can function well despite O2 decline

Question 17

what drug is a FA oxidation inhibitor? effects?

Answer 17

trimetazidine
increases coronary BF, delays ischemia, does not affect HR
better LV function

Question 18

ranolazine

Answer 18

inhibits late inward Na current in heart –> reduces wall tension and less O2 demand
DONT use with liver disease or CYP3A inhibitors

Question 19

why not use ranolazine with CYP3A inhibitors? or liver disease?

Answer 19

it is metabolized by CPY3A

increased QT with liver disfunction

Question 20

what drug inhibits late inward Na channel in heart?

Answer 20

ranolazine

Question 21

organic nitrates

Answer 21

act on vessels, mostly venous!
release NO
oral/inhalation to avoid first pass
tolerance (break at night) and withdrawal
interacts with PDE5 inhibitors(sildenafil = viagra)
uses: angina, CHF. MI
do not use with: patients on sildenafil/viagra, with hypotension, diastolic heart failure

Question 22

why cant someone using sildenafil/viagra use an organic nitrate?

Answer 22

sildenafil degrades cGMP

organic nitrates increase cGMP so it would just make the drug ineffective

Question 23

how do organic nitrates work?

Answer 23

release NO
activate guanylyl cyclase –> increase cGMP
phosphatase dephosphorylates myosin light chain and myosin/actin are uncoupled
=vasodilation!!

Question 24

difference between organic nitrates and ca ch blockers?

Answer 24

ON - just vasculature, mainly dilate veins, does not change contractility of heart
Cach - vasculature AND myocardium, mainly dilate arteries, lower heart contractility!

Question 25

How do organic nitrates avoid coronary steal?

Answer 25

they mostly affect the LARGE epicardial coronary vessels --> so they avoid the coronary steal when all vessels are dilated

Question 26

nitroglycerin vs isosorbide dinitrate and isosorbide 5 mononitrate

Answer 26

nitroglycerin has SHORT half life(2-8 min) and low bioavailability ID - chewable, 2-3 hrs duration I5M - 5 hrs, cervical ripener in delivery

Question 27

what drug can be used to ripen cervix in delivery?

Answer 27

isosorbide 5 mononitrate

Question 28

ca channel blockers

Answer 28

vasculature (mainly arteriodilation) AND myocardium block Ltype Ca channels --> inhibit ca influx and relax arteries = decreased coronary resistance and increases BF DECREASES contractility DONT USE with heart failure patients side effects: cardiac depression, AV block, bradycardia, CHF

Question 29

what anti-anginal type drugs decrease heart contractility?

Answer 29

ca channel blockers and B blockers

Question 30

what anti-anginal drug should you NOT use with heart failure patients

Answer 30

ca channel blockers!

Question 31

dihydropyridines vs non-dihydropyridines

Answer 31

types of ca channel blockes dy- coronary and peripheral vasodilation BUT reflex increase in HR and contractility non-dy- dilate BUT also decrease HR, contractility, recovery, and AV conduction

Question 32

what type of ca ch blocker can cause decreased AV conduction? two drugs that do it?

Answer 32

nondihydropyridine | verapamil and diltiazem

Question 33

verapamil

Answer 33

a phenylalkylamine | less potent than dihydropyridines but decreases HR, contratility, recovery, and AV conduction

Question 34

diltiazem

Answer 34

a benzothiazepine nonspecific antagonist of sympathetic NS inhibits AV conduction

Question 35

what do you treat supraventricular reentry tachy and atrial flutter/fib/tachy with? why?

Answer 35

verapamil and diltiazem | they decrease AV node conductivity

Question 36

nifedipine

Answer 36

dihydropyridine relaxes smooth muscles at lower loses than cardiac cells decreases arterial resistance and BP doesnt affect AV node reflex increase in CO

Question 37

what to treat subarachnoid hemorhage with?

Answer 37

nimodipine - high affinity for cerebral vessels! | reduces vasospasms

Question 38

b blocker mechanisms to reduce O2 demand

Answer 38

1) reduce HR (conduction velocity) 2) reduce contractility 3) reduce arterial BP

Question 39

where do B blockers work?

Answer 39

B1 - heart/renal | B2 - everywhere else (vessels, lungs, bladder, GI)

Question 40

side effects of B blockers?

Answer 40

erectile dysfunction and CNS effects (insomnia and depression)

Question 41

B blockers effect on BP - up and down!?

Answer 41

initially increase resistance/BP --> net effect is a combination that decreases BP (- inotropism lowers CO, renin inhibition, CNS)

Question 42

what drug category can cause erectile disfunction?

Answer 42

b blockers

Question 43

propanolol/sotalol

Answer 43

nonselective B inhibitor (B1 and B2) treat HTN, angina, arrhythmias NOT FOR VARIANT ANGINA OR asthma/COPD patients!

Question 44

why cant you use propanolol/sotalol for variant angina or patient with breathing issues?

Answer 44

B2 blocking causes 1) unapposed alpha 1 vasocontriction --> increased resistance, afterload, and O2 demand = less coronary flow 2) B2 blocking can cause bronchoconstriction

Question 45

two nonselective B blockers? contraindications?

Answer 45

propanolol, sotalol | variant angina/asthma and copd

Question 46

atenolol

Answer 46

B1 selective | can be used in patients with copd and asthma

Question 47

what to treat angina patients who have breathing issues with?

Answer 47

atenolol | B1 selective!