Block 2-Reymann (Angina)

Question 1

Classes of Angina

Answer 1

1. Normal = Patent lumen, Normal endothelial function, Platelet aggregation INHIBITED
2. Stable angina= Lumen NARROWED & Inapporoprate vasoconstriction
3. Unstable angina=Plaque rupture, platelet aggregation, thrombus formation, UNopposed Vasoconstriction
4. Variant angina= NO overt plaques w/INTENSE vasospasms

Question 2

UNstable Angina

Answer 2

• Acute chest pain
• Elevated ST segement w/ECG
• NO elevated ST =Troponin Serum test
• Test (-) & less then 6 hours of chest pain
• Treatments:
• Nitrates
• B-blockers
• CCB
• Most drugs are going to work on O2 demand = Heart rate, Contractile state, Wall tension^{<u><strong> (LV pressure &amp; ventricular vol)</strong></u>}
  *

Question 3

Nitrates (nitroglycerine)

Answer 3

• Glyceryl trinitrate, Isosorbide dinitrate ^{<u><strong>(ISDN)</strong></u>}, Isosorbide mononitrate ^{<strong>(ISMN)</strong>}
• PD:
• Relaxation of ALL smooth muscle (large vascular)=Venous tone:
• Enhances venous cap.
• Reduction of cardiac Preload = ^{<u><strong>Lowered CO &amp; O2 demand</strong></u>}
• Gradual decrease in arteriolar resistance:
• Reduction of Miocardial O2 demand
• Improvement of regional distrubution of coronary flow
• PK:
• Sublingual, Patch, IV
• NOT ORAL HIGH 1st pass

Question 4

Nitrates SE & USE

Answer 4

• SE:
• Vasodialation: Headaches & flushing
• Hypotension: Reflex Tachy = LOW BP-INcrease SNS tone-Cerebral ischemia
• Nitrate tolerance ^{<u><strong>(tachyphalaxis)</strong></u>}
• USE:
• Acute agina attacks
• Anticipate attacks
• Prolonged preventive therapy ^{<u><strong>(ISMN,ISDN)</strong></u>}
• Paroxysmal nocturnal dyspnea in CHF^{<u><strong>(pulm edema)</strong></u>}
• Spasmolytic in colic pain(biliary, renal)
• ISMN preferred due to low bio-avail @ 1st pass longer onset & longer 1/2 life

Question 5

Na+ Nitroprusside

Answer 5

• Ferrocyanide compound
• PD:
• Direct NO-Donator
• Very efficacious w/^{<strong>IMMEDIATE </strong>}vasodialation
• PK:
• IV infusion w/1/2 life less then 3min
• Protect from light ^{<u><strong>(black infusion line)</strong></u>}Converted to cyanide THEN Thiocyanide
• USE:
• in ICU hypertensive emergencies
• Controlled hypotension during surgery ^{<u><strong>(CONTROL BLOOD LOSS)</strong></u>}
• Special forms of severest Cardiac failure

Question 6

Na+ Nitroprusside SE

Answer 6

• SE:
• Severe nausea
• Headache OTHER CNS disturbances
• Extreme Caution:
• Borderline systolic BP
• MI
• Hepatic or renal issues
• Toxicity of cyanide (light exposure)
• Only use for short burst and DIScontinue

Question 7

Na+ Nitroprusside (coronary steal)

Answer 7

1. Branches of coronary artery compete for blood flow
2. Tissues distal to partial obstructed branch MAY maintain suff perfusion due to MAX dialation of arteriolar vessels (Reflex AVOID ischemia)
3. Distal to unobstructed vessel arterioles maintain NORMAL tone. Keeps perfusion pressure up in coronary artery (supply both obstructed & un-obstructed)
4. Presence of DIALATOR unobstructed arterioles DIALTE=Perfusion pressure of coronary artery DROPS
5. Distal to obstructed vessel-Compens mech are USED up - Tissue perf fall below normal

Question 8

CCB

Answer 8

• Verapamil, Dilitiazem, Nifedipine
• PK:
• Oral, IV
• Bound tightly to hepatic proteins
• PD:
• Block L-ype channels=
• Cardio depressent state
• Arteriolar vasodialation
• SE:
• Excessive vasodialation=Dizziness, digital numbness, peripheral EDEMA
• Reflex tachy
• Verapamil&dilitiazem = ^{<u><strong>Slow SA-AV nodal conduction</strong></u>}
• Increase digoxin LVLS
• DO NOT USE nifedipdine(dihydro) in ^{<u><strong>ARRHYTHMIAs</strong></u>} Excessive ^{<u><strong>VASODIALATION</strong></u>}

Question 9

Beta-Blockers

Answer 9

• Propranolol, atenolol, metoprolol
• Used in prevention of extertional angina & Unstable angina
• PD:
• Negative ionotropic & chronotropic
• Reduced systolic BPduring exercise
• NET effect=^{<u><strong>Reduced O2 demand to heart</strong></u>}
• Use:
• Post MI-pts B1-blocker
• NO CHF pts
• INEFFECTIVE in vasospastic angina due to worsening condition