Antianginals

Question 1

Myocardial ischemia results from an imbalance between…

Answer 1

O2 supply vs O2 demand

Question 2

Classic or atherosclerotic angina is caused by…

Answer 2

Atheromatous obstruction of large coronary vessels esp with exercise

May require coronary bypass or angioplasty

Question 3

Variant, angiospastic, or Prinzmetal’s angina is caused by…

Answer 3

Spasm or constriction in atherosclerotic coronary vessels

Reversible by nitrates or CCBs (NOT BBs)

Question 4

Any increase in heart rate or contractility will…

Answer 4

Increase the need for O2

O2 demand depends on cardiac workload, determined by HR, contractility, and ventricular wall tension

Question 5

Coronary flow may be decreased by…

Answer 5

Shortening diastole when HR increases

Increased ventricular end-diastolic pressure

Reduced diastolic arterial pressure

Question 6

MOA for Nitrates/Nitrites in angina

Answer 6

Vasodilation via NO —> cGMP

Causes UNEVEN vasodilation - large veins are markedly dilated —> increased capacitance and reduced preload; arterioles and precapillary sphincters less dilated but will still decrease afterload

Question 7

DOC for any acute anginal attack

Answer 7

Nitrates/nitrites

Provide relief by reducing myocardial O2 requirement

Question 8

Why is nitroglycerin administered sublingually?

Answer 8

High first pass metabolism

Rapid absorption

Immediate relief (within 1-3 min, lasting 10-30 min)

Question 9

What is the main adverse effect of nitroglycerin?

Answer 9

Throbbing headaches (can also get orthostatic hypotension and tachycardia)

Frequent repeated exposure —> tolerance or marked reduction in effect

Question 10

Which drug is connected to “Monday Disease”?

Answer 10

Nitroglycerin

Explosive manufacturers —> chronic exposure to nitrate —> headaches/dizziness on Monday but symptoms gone by Friday, reappear after weekend break

Question 11

Which CCB is indicated only in HTN (not for angina)

Answer 11

Nifedipine

May provoke angina, esp if there is any underlying narrowing of the arteries

Question 12

In general CCBs are good for _________ of angina

Answer 12

Chronic treatment, not immediate relief

Because you need VENOdilation

Question 13

How do beta blockers provide anginal relief?

Answer 13

Reduced sympathetic activity —> direct decrease in HR and vasoconstriction —> hypotension/bradycardia —> decreased cardiac workload —> decreased myocardial O2 demand

The bradycardia also increases myocardial perfusion time

They are NOT vasodilators!

Question 14

Which anti anginal drug is contraindicated in Prinzmetal’s angina?

Answer 14

Beta blockers

Because they don’t cause vasodilation

Question 15

Side effect of BBs used in angina

Answer 15

Bronchoconstriction

Increased plasma TGs

Decreased insulin and hypoglycemic response

CNS side effects

Question 16

What does Ranolazine (Ranexa) do for angina?

Answer 16

Partial fatty-acid oxidation inhibitor —> reduces O2 consumption in ischemic tissue

Also inhibits late inward Na current —> decreased contractility

Basically, it IMPROVES CORONARY CIRCULATION

Used when other antianginal drugs don’t work

Question 17

Effective therapy for angina pectoris will…

Answer 17

Increase exercise tolerance

Decrease frequency and duration of myocardial ischemia

For variant or angiospastic angina:
Nitrates and CCBs preferred b/c BBs will not dilate vessels

Question 18

Patients with angina and PEPTIC ULCERS should use what drugs?

Answer 18

BBs or organic nitrite/nitrate

NOT CCBs b/c relaxing the smooth muscles will reduce gastric emptying and increase acid effects

Question 19

Drug originally developed as an antianginal agent but found to be more effective for ED

Answer 19

Sildenafil (Viagra)

Selective inhibitor of cGMP-specific phosphodiesterase type 5

Question 20

Why does viagra cause visual impairment?

Answer 20

B/c PDE is also in the retina —> mild and transient blue color tinge to vision, photophobia, or blurred vision

Pilots can’t take 8 hours before flying

Question 21

Contraindications for Sildenafil (Viagra)

Answer 21

Pregnant or lactating women 😂

Patients concurrently using organic nitrates/nitrites in any form (b/c vasodilation —> LOC)

Concurrent dosing with alpha blockers may lead to symptomatic hypotension

Inhibitors of CYP3A4 —> toxicity

Question 22

Other PDE5s besides Sildenafil

Answer 22

More selective for PDE5 than PDE6, so less visual disturbances

Vardenafil and Avanafil (work “V”ery soon)
Tadalafil (works “T”omorrow) - good for a whole weekend of fun