Antianginal agents Flashcards
what is angina pectoris
recurrent chest pain or discomfort when part/some of the heart does not get enough oxygen
where is angina pectoris located
Retrosternal or slightly to the left of Midline
occasionally limited to extra thoracic sites
where does angina pectoris radiate
neck, throat (‘choking’ sensation)
Jaw, teeth (‘toothache’)
left shoulder, arm (ulnar distribution)
epigastrium (heart burn)
a patient presents with new onset, increase in intensity, frequency or duration occurs at rest - what are you thinking
unstable angina or evolving acute MI
what is the quality and quantity (description) of angina
tightness, pressure, squeezing, heaviness, burning, aching, fullness
“heavy weight” or “band across my chest”
dull and deep
what is angina aggravated by
physical exertion
emotional stress
after eating heavy meals
environment
lying down
what is angina relieved by
rest
activity cessation
withdrawal of stressor
pharmacotherapy
What are alternative names for effort angina
“classic angina”
“Stable angina”
what is the presentation of effort angina
short lasting; heavy, burning, squeezing in chest
does not change - pattern stays the same
most common form
what is the cause of effort angina
inadequate blood flow in the presence of CAD
reduction of perfusion due to FIXED obstruction of coronary artery
what are the treatment options for effort angina
nitrates or rest
what are other names for vasospastic angina
variant angina
prinzmetal angina
what causes vasospastic angina
coronary artery spasm causing decreased blood flow of the heart muscle - uncommon patter, episodic
what are precipitators for vasospastic angina
occurs at rest, unrelated to physical activity, heart rate or blood pressure
what are the treatment options for vasospastic angina
coronary vasodilators (nitrates and CCB)
when does unstable angina occur
progressively less effort causes more increased frequency, duration and intensity of pain
what is the treatment for unstable angina
HOSPITAL ADMISSION, aggressive therapy to prevent progression to MI
what usually results from rupture of atherosclerotic plaque and partial/complete thrombosis of coronary artery
Acute Coronary Syndrome (ACS) - EMERGENCY
NSTEMI, STEMI, Unstable Angina
what causes an increase in biomarkers
necrosis of CV tissue
what are major determinants of cardiac oxygen consuption
wall stress/tension - IVP, ventricular radius (Volume), thickness
Heart rate
contractility
what is preload
initial stretchign of cardiac muscle cells proior to contraction
change affect ventricular stroke
what is afterload
force or load against which the heart contracts to eject the blood
what is contractility
strength of cardiac muscle
what changes and affects the force of contraction
change in preload
what is the ventricular wall tension based on
thickness of the ventricular myocardium
what is the most important factor affecting myocardial oxygen demand
Heart rate
what increases heart oxygen consuption
increased heart rate
what is influenced by a variety of forces including calcium concentration
contractility
what is needed with more powerful contractions
more energy is needed
what are chronotropic drugs
changes in heart rate
both positive and negative
what kind of drugs decrease heart rate
negative heart rate
what are inotropic drugs
alter the strength of the contraction of the heart
Positive and negative
what strengthens the force of the heartbeat
positive inotropic drugs
what are anginal relief medication types
BB
CCB
nitrates
sodium channel-blocking drug (ranolazine)
interventional therapy
what are selective beta 1 blocker medicatiosn
Metoprolol
Atenolol
what are calcium channel blockers
amlodipine
felodipine
nefidipine
diltizaem
verapamil
what are organic nitrates
isosorbide mononitrate
nitroglycerin
isosorbide dinitrates
what are b1 selective BB effective for
effort and unstable angina
what medicatiosn decrease oxygen demands on the myocardium which decreases the HR, contractility, CO and blood pressure
B1-adrenergic Beta Blockers
what are the contraindications for BB
severe bronchospasm - asthma
vasospastic angina (ineffective and can make it worse)
Bradycardia
pindolol should be avoided in pts with prior MI/angina due to sympathominmetic effects
what are the side effects of BB medications
cold hands/feet
fatigue
nausea, weakness and dizziness
dry mouth, skin and eyes
weight gain
what is the recommended initial antianginal therapy
beta - adrenergic blockers
what are the effects of BB with patients with chronic renal disease
less effective - CCB/nitrates more effective
what can occur with abrupt discontinuation of BB
rebound angina, MI, HTN
what is metoprolol
cardioselective
causes less bronchial constriction than propranolol
extensively metabolized
short half life (4-6 hrs)
what is atenolol
cardioselective
not extensively metabolized and excreted primarily in urine
half life 6 hours
less effective than metoprolol in preventing complications of HTN
what are the CCB medications
effective in effort and vasospastic angina
amlodipine
felodeipine
verapamil
nifedipine
diltiazem
what is the MOA for CCB
inhibits enterence of calcium into cardiac and smooth muscle cells of the coronary and systemic arterial beds
dilates arterioles, causes decrease in smooth muscle tone and vascular resistance
what are contraindications for CCB
pre-existing conduction disorder
symptomatic hypotension
ACS
grapefruit juice
what are the side effects of CCB
lightheadedness
low BP
slower HR
constipation
swelling in feet and ankles
what are the non-dihyrophyridine CCBs
Verapamil and diltiazam
what are the dihydrophyridine CCB
amlodipine
nifedipine
felodipine
what is amlodipine
dihydropyridine
greater effect on smooth muscle in peripheral vasculature
minimal effect on cardiac conduction
second generation dihydropyridine derivative
not recommended in pts with HF
what is felodipine
second generation dihydropyridine derivative
not recommended in pts with HF
what is nifedipine
dihydropyridines
treat vasospastic angina
can increase HR; risk for tachycardia and increase O2 demand
peripheral dilatory effects can decrease coronary perfusion
what are the side effects of Nefedipine
dizziness, lightheadedness, LE edema
what is diltiazem
non-dihydropyridine
immediate in its actions
monitor closely when using with other meds for angina as effects are additive
monitor for bradyarrhythmias and heart block
what is verapamil
non-dihydropyridine
mainly affects the myocardium
greater negative inotropic effects than amlodipine
monitor for bradyarrhythmias and heart block
what patients is verapamil not recommended for
pts with sick sinus syndrome, AV nodal disease or heart failure
what are the organic nitrates
isosorbide mononitrates
nitroglycerin
isosorbide dinitrates
effects in effort, vasospastic and unstable angina
what is the MOA for nitrates
venous dilation - reduces preload and myocardial wall tension, decrease oxygen requirements (demand)
reduction of arteriolar resistance - reduces afterload and decreases oxygen demand
what are the contraindications with nitrates
coadministration of PDE-5 inhibitors (viagra)
severe anemia
increased ICP
circulatory failure and shock
what are the SE of nitrates
HA
dizziness
lightheadedness
nausea
flushing
low BP
what is nitroglycerine
considered prototype drug
administered sublingually usually
treatment of anginal attacks
fast onset of action
stays in the body for short duration and broken down by liver
what is isosorbide mononitrate
taken daily
for prevention of angina
onset 60-120 min
duration 5-12 hours
what is isosorbide dinitrate
sublingual tablet or immediate release
prophylaxis for acute angina
sublingual: onset 2-5min; duration 1-2 hours
immediate release: onset 20-40 min; duration 4-6 hours
what is the sodium channel blockers
ranolazine
what is ranolazine
inhibits the late phase of sodium current improving oxygen supply and demand
improves diastolic function
antianginal and anti-arrhythmic properties
used when others hav failed
what are the risks with ranolazine
risk of drug interactions and can prolong QT interval
when are combination therapy used
used if there is intolerance or angina symptoms persist despite the optimal dosage of a single drug
treatment tailored to how frequent angina episodes/attacks occur within a given week
aimed at alleviating symptoms and supporting the heart
what is the benefit of combining nitrates with BB or CCB
decrease the degree of cardiac ischemia and improves exercise intolerance
what medications when used with BB have additive effects on SA and AV nodes
diltiazem or verapamil (CCB)
why is the combination of nitrate and sildenafil potentially dangeous
both cause vasodilation
this can lead to lowering of BP and blood flow that can precipitate a heart attack
what considerations are made to determine medical therapy and surgical therapy for angina
patient dependent
- testing results
-pt age
-symptom severity
-stage/level of heart disease
-peripheral artery disease
what is interventional therapy used for
primarily to improve symptoms when optimal medication therapy has failed
beneficial when coronary arteries are significantly narrowed, there are many coronary arteries that are narrowed and when left main coronary artery is narrowed
has standing been shown to prolong life compared to medication therapy
no
