Cardio: Drugs for Stable Angina

Question 1

Are pharmological drugs the #1 choice for increasing coronary blood flow in ACS?

Answer 1

Nope. Treat w PCI (Stent or balloon)

The vessels are usually maximally dilated so giving a vasodilator does not help.

Question 2

What are the ways to reduce O2 demand in stable angina?

Answer 2

Decrease HR and Contractility

Decrease Pre and Afterload

Question 3

MOA of Nitrates

Answer 3

1. Broken down into NO, which activates cGMP
   * *2. cGMP activates Protein Kinase G
   - causes Relaxation of smooth muscle
   - also blocks K+ entry to hyperpolarize cells

Question 4

MOA of Nitrates specifically for Stable Angina?

Answer 4

Vasodilators of Veins

-Reduce preload=reduced O2 demand

Question 5

Should people take a day off of nitrates?

Answer 5

Yes, they quickly develop tolerance and increase generation of superoxide radicals (reduce Thiols)

Additionally cause Na and water retention

Question 6

What are the clinical uses of nitroglycerin and the oral forms, Isosorbide mononitrate and dinitrate?

Answer 6

Sublingual nitro is great for relieving acute angina

Oral forms are longer acting and can prevent attacks

Question 7

Adverse effects of nitrates?

Answer 7

Headache
Orthostatic hypotension
Increased Na and H20 retention

Question 8

What is nitrates effect on HR?

Answer 8

Increased

-reflex tachy

Question 9

Would you give nitrates along with PDE-5 inhibitors, such as sildenafil, vardenafil, and tadalafil?

Answer 9

No! Causes a severe drop in BP

Question 10

Which Ca+ channel blockers work in the vascular smooth muscle and which work in the heart?

Answer 10

Both Dihydropyridines and Non-dihydropyridines dilate arterioles

Only Non-dihydropyridines work on the cardiac muscle and pacemaker cells

Question 11

What are the dihydropyridine CCBs?

Answer 11

-dipines

Amlodipine (long acting), nifedipine, and nicardipine

Question 12

What are the non-dihydropyridine CCBs?

Answer 12

Verapamil and diltiazem

Question 13

What CCBs decrease cardiac contractility and reduce HR?

Answer 13

1. Verapamil (most potent)

2. diltiazem

Question 14

MOA of CCBs?

Answer 14

Decrease PVR and Afterload (both)

Decrease cardiac contractility and HR (non-dihydropyridine only)

Question 15

Major adverse effects of cardioactive CCBs?

Answer 15

Cardiac depression, arrest, HF, bradyarrythmias and AV block

Severe hypotension

Question 16

Which CCB increases risk of MI in patients with hypertension?

Answer 16

Nifedipine

Question 17

MOA of B-blockers?

Answer 17

Reduce sympathetic activity
-decrease HR, cardiac contractility, and drop BP (decrease afterload)

All leads to increased heart perfusion

Question 18

Adverse effects of B-blockers?

Answer 18

Reduced CO
Bronchoconstriction
Impaired glucose mobilization
Increase LDL, decrease HDL

Withdrawl syndrome!

Question 19

Contraindications of B-blockers

Answer 19

Asthma and COPD*
PVD
Type 1 diabetics
Bradyarrythmias
Severe cardiac depression

Question 20

MOA of Ranolazine

Answer 20

Closes late Na+ in ischemic myocardium to reduce Ca overload

-normalizes repolarization of cardiac myocytes

Question 21

Does ranolazine affect HR or vasodilation?

Answer 21

NO!

Question 22

When would you use ranolazine?

Answer 22

Refractory stable angina

-decrease anginal episodes and improves exercise tolarance in those taking nitrate, amlodipine, atenolol

Question 23

What effect to nitrates alone have on contractility?

Answer 23

Reflexive increase

-just like HR

Question 24

What effect do BB or CCBs have on EDV and Ejection time?

Answer 24

Reduces contractility, so increases EDV and ejection time

-reduces everything else (HR, BP)

Question 25

What is best approach when prescribing BB, nitrates or CCBs for angina?

Answer 25

Combine Nitrates with either BB or CCBs to reduce the reflexive tachy and contractility

Question 26

First line in treating prinzmetal angina?

Answer 26

Diltiazem or amlodipine

-long acting nitrates are used when CCBs contra

Question 27

MOA of asparin

Answer 27

COX 1/2 irreversible inhibitor to reduce TBXA2

-reduces aggregation of platelets

Question 28

MOA of clopidogrel, prasugrel, and ticagrelor?

Answer 28

Blocks P2Y12, increases cAMP=reduced platelet activation

-reduces aggregation by reducing GIIb/IIIa on receptor of platelets

Question 29

What are the thrombolytic drugs?

Answer 29

TPA drugs (end in -plase)
-alteplase, reteplase, and tenecteplase

Streptokinase

Question 30

Anti-platelet drugs prevent ___ thrombi formation

Answer 30

White thrombi

Question 31

When would you use asparin?

Answer 31

Started as soon as possible in Acute coronary events

-also prevents secondary coronary events

Question 32

Adverse effects of asparin

Answer 32

GI bleeds

Hypersensitivity to Asparin

Question 33

What CYP can predispose someone to clopidogrel resistance?

Answer 33

nonfunctional CYP2C19

-needed for activation of clopidogrel

Question 34

Clinical use of Clopidogrel?

Answer 34

Dual antiplatelet therapy or alone if pts allergic to asparin

Question 35

What are the GIIb/IIIa inhibitors?

Answer 35

Abciximab
Eptifibatide
Tirofiban

Question 36

MOA of the GIIb/IIIa inhibitors?

Answer 36

block GIIb/IIIa to prevent platelet aggregation

Question 37

Are the GIIb/IIIa inhibitors used much now?

Answer 37

Only really in PCI in high risk pts

Question 38

Adverse effects of GIIb/IIIa inhibitors

Answer 38

Bleeding and thrombocytopenia (more abciximab)

Question 39

When are the thrombolytics used?

Answer 39

Used in STEMI/NSTEMI when PCI isnt available

-goal is within 3-4.5 hours

Question 40

Adverse effects of thrombolytics?

Answer 40

Bleeding and allergic rxns (streptokinase mainly)