Antianginal agents Flashcards
What is a common symptom of CAD
Angina pectoris
If a patient has chest pain that radiates to the neck, what symptoms will they have
choking
If a patient has ulnar distribution, where is their angina most likely radiating to
left shoulder / arm
What symptoms will a patient present with that has unstable angina or an acute MI
New onset
increase in intensity / frequency
increase in duration
occurs at rest
What are the types of angina
effort angina
vasospastic angina
unstable angina
What is the most common form of angina
effort / stable
How will a patient with stable angina present
short lasting
heavy
burning
squeezing in chest
relieved at rest
What is the cause of stable angina
inadequate blood flow in the presence of CAD
How do you best treat effort angina
nitrates or rest
What are other names for vasospastic angina
prinzmetal
variant
What are the causes of vasospastic angina
coronary artery spasm causing decreased blood flow to the heart muscle
*uncommon pattern, episodic
What is the treatment for vasospastic angina
coronary vasodilators
-nitrates
-Ca2+ blockers
Why is ACS an emergency
from a rupture of atherosclerotic plaque and partial / complete thrombosis of coronary artery
What happens if ACS isn’t treated
necrosis can occur leading to an MI
Necrosis in the heart leads to an increase in which biomarkers
troponins
creatinine kinase
How do you determine cardiac oxygen consumption
Wall stress/tension (Volume, pressure, thickness)
Heart rate
contractility
What occurs in the heart when preload is changed
the ventricular stroke volume will chance
force of contraction will change
What factors increase preload
Increased atrial contractility
Increase ventricular compliance
Decrease HR
Increased aortic pressure
Increased central venous pressure
-Decrease venous compliance
- Increase thoracic venous blood volume
What is the most important factor affecting myocardial oxygen demand
Heart rate
What is contractility influenced by in the heart
calcium
What strategies can be used for angina relief
beta blocker
calcium channel blocker
organic nitrates
Na+ blockers
Interventional (IR / Cath lab / CABG)
What are metoprolol and atenolol useful for
stable and unstable angina
What is the MOA for beta-1 blockers
Decrease oxygen demand of the myocardium = decrease HR, CO,BP, Contractility
**will work at rest and during exertion
Which patients should you avoid non-selective beta blockers in and why
patients with asthma because it will cause severe bronchospasm
Which type of angina should beta blockers not be used in
vasospastic
Why should Pindolol be avoided in patient with a prior MI / angina
because of its sympathomimetic affects
What are the side effects of beta blockers
Cold hands / feet
fatigue
Weight gain
What is recommended as the initial antianginal therapy (unless vasospastic)
Beta blockers
Why should beta blockers not be stopped abruptly
needs to be tapered over 2-3 weeks to avoid rebound angina, MI, hypertension
Which types of angina are calcium channel blockers useful for
stable and vasospastic angina
What is the MOA of Ca2+ blockers
dilate arterioles causing a decrease in smooth muscle tone and vascular resistance
What are contraindications of calcium channel blockers
AV block
sick sinus syndrome
symptomatic hypotension
ACS
grapefruit juice
What are the side effects of Ca2+ blockers
lightheadedness
hypotension
bradycardia
constipation
swelling in feet / ankles
When are non-dihydropyridines beneficial
in patients with atrial tachyarrhythmia
When are non-dihydropyradines contraindicated
Risk for heart block
heart failure
how quickly does diltiazem work and where is it frequently used
immediately
In the ER with afib+RVR
Where in the body does verapamil have the greatest effect
myocardium
When are organic nitrates indicated
stable, vasospastic, and unstable angina
What is the MOA of nitrates
Venous dilation (decrease O2 requirement and preload)
decrease in arteriolar resistance (decrease after load and O2 demand)
What are the contraindications of nitrates
coadministration of PDE-5 inhibitors (viagra)
severe anemia
increased ICP
circulatory failure / shock
What are the side effects of nitrates
headaches
dizziness
hypotension
flushing
When is nitro utilized
anginal attacks
Which sodium channel blocker is useful in angina
ranolazine
How does Ranolazine help with angina
Inhibits late phase of Na+ currents which improves oxygen supply and demand
What are the risks with ranolazine
Drug interactions
prolonged QT
When is isosorbide dinitrate useful
can be taken before exercise in anticipation of angina when mononitrate isn’t wanted
When is a combination therapy utilized with angina
when there is an intolerance or angina symptoms persist despite optimal dosage of single drug
What determines the combination therapy someone is on
How frequently angina attacks occur within a given week
Comorbidities and type of angina
Which combination will help decrease cardiac ischemia and improve exercise tolerance
nitrate with beta blocker or calcium channel blocker
What is sildenafil
PDE-5 inhibitor
What is the MOA of Sildenafil
binds to guanylate cyclase receptors, increasing cGMP causing smooth muscle relaxation (vasodilation)
What are the indications for sildenafil
erectile dysfunction
PAH
Why should Nitrate and sildenafil never be combined
it lead to hypotension and blood flow which can precipitate a heart attack
