Cardiovascular Meds: chest pain Flashcards
Specify the cause of cardiac chest pain
The cause is inadequate oxygen to the heart muscle
Important point to think: is it a demand issue or a supply issue?
Cardiac chest pain feels differently to individuals! (It does not always feel like a pain)
- pressure, fullness, burning or tightness in your chest
- crushing/searing pain that radiates to your back, neck, jaw, shoulders, and arms
- cold sweats
- dizziness/weakness
- shortness of breath
- nausea/vomitting
List 4 families of anti-anginal agents with examples of each
- organic nitrate (e.g. nitroglycerin)
- beta blockers (propranolol, metoprolol)
- calcium channel blockers (verapamil)
- renolazine (a newer drug!)
Compare the 3 types of angina pectoris: Prinzmetal’s angina, chronic stable angina, and unstable angina
Prinzmetal (variant) angina
- caused by vasospasm
- supply ischemia
Chronic stable (exertional) angina
- ppt has a fixed stenosis due to coronary artery disease or something –> feel chest pain when they do physical exercises
- demand ischemia (O2 demand exceeds normal O2 supply)
Unstable angina
- medical emergency! –> do not want it to become the infarct
- caused by thrombus
- supply ischemia
List 3 factors that affect the oxygen supply to the heart
- Heart rate –> too fast & too low will cause some issues with oxygen supply
- oxygen content of blood (e.g. lung disease)
- coronary perfusion
Identify the drugs used to treat the following causes of angina: vasospasm, fixed stenosis, thrombosis, high heart rate, increased afterload, and increased preload
Vasospasm: nitrates, CCBs
Fixed stenosis: nitrates, CCBs, beta blockers, angioplasty or stents
thrombosis: thrombolytics, antiplatelets
high HR: CCBs and beta blockers
increased afterload: CCBs, beta blockers, anti-hypertensive drugs
increased preload: CCBs, beta blockers, ranolazine!
Chronic stable angina
List the four triggers
- emotional excitement
- large meals
- cold exposure
- coronary artery disease (CAD)
Don’t shovel snow on the snow day!
Chronic stable angina
List 4 drugs that provide symptomatic relief in chronic stable angina
- nitrates
For daily basis,
2. CCBs
3. beta blockers
4. ranolazine
Chronic stable angina
Specify 2 non-drug interventions for chronic stable angina
- Avoid risk factors
- Consider PCI (percutaneous coronary intervention; angioplasty or stent) OR CABG (coronary artery bypass graft)
Prinzmetal (variant) angina
Describe the pathophysiology of variant/Prinzmetal’s angina
Caused by coronary artery spasm
<– damage / dysfunction of endothelial cells
smooth muscle hyperactivity
Happens most often at night (that’s creepy!)
<–because vagal tone is higher at night
Prinzmetal (variant) angina
List 2 therapeutic agents used for variant angina
- nitrates
- CCBs
Beta blockers NOT USED for variant angina!!!
Unstable angina
Describe the 4 immediate priorities of the acute treatment of unstable angina to prevent infarction
MONA
Morphine (use if pain not relieved by nitroglycerin)
Oxygen (use if sat is below 90%, respiratory distress)
Nitrates
Aspirin
***the clot can be a rupture of plaque + platelet aggregation = thrombus
Describe the role of nitroglycerin when used in stable & unstable angina
Decreases cardiac O2 DEMAND !!!
Nitroglycerin dilates veins
–> more blood stays in the extremities
–> preload (blood returning to the heart) decreases
–> cardiac O2 demand decreases!
Describe the role of nitroglycerin when used in variant angina
Decreases cardiac O2 SUPPLY!
Nitroglycerin can relaxes coronary arteries
–> oxygen supply increases
List 3 side effects of nitrates
Headaches
Hypotension (low BP)
reflex tachycardia (baro reflex)
List other options of organic nitrates besides nitroglycerin
Isosorbide mononitrate
Isosorbide dinitrate
Amyl nitrate (ultrashort-acting agent used to treat acute angina)
Identify the routes of administration of nitroglycerin for the treatment of acute angina
Sublingual tablets OR translingual spray
Identify the routes of administration of nitroglycerin for the long-term prophylactic treatment of angina
Transdermal patches OR sustained-release oral capsules
Identify the routes of administration of nitroglycerin for abortion of the ongoing attack and anticipation of exertion
Sublingual tablets OR translingual spray
identify the interactions of nitroglycerin with phosphodiesterase type 5 inhibitors
Taking erectile dysfunction drugs (sildenafil, tadalafil, avanafil) with NTG can cause life-threatening hypotension
Recognize the drug interaction between nitroglycerin and beta blockers, verapamil, and diltiazem
BBs, verapamil, and diltiazem can be used to treat NTG induced reflex tachycardia
Specify the 3 therapies used in the acute treatment of unstable angina
- Anti-ischemic therapy
***ischemia = inadequate blood supply to heart muscles - Anti-platelet therapy
- Anti-coagulant therapy
List 4 drugs used for the anti-ischemic therapy of unstable angina
- nitroglycerin
- oxygen
- beta-blocker
- ACE inhibitor OR ARBs (patients with LV dysfunction)
Describe the role of beta blockers in the acute treatment of unstable angina
Directly decreases HR and contractility
–> workload of the heart decreases
–> less need for oxygen
Also used for post MI
**Describe 4 drugs used for anti-platelet therapy in unstable angina
- Aspirin indefinitely
- Clopidogrel for 2 months
- Abciximab only if angioplasty is planned
- Eptifibatide when angioplasty is not planned
Describe 3 drugs used for anticoagulant therapy in unstable angina
- SubQ LMW heparin (e.g. enoxaparin) or IV UF heparin
- Direct thrombin inhibitor (bivalirudin)
- Factor Xa inhibitor (fondaparinux)
List 4 drug classes that are prophylactically used long term to prevent myocardial infarction and death, along with an example drug in each drug class
- Antiplatelets drug
- Anti-anginal agents
(BB, CCB, long-acting nitrates) - ACE inhibitors
- cholesterol-lowering drugs
Give an example of a vasodilator that targets arterioles
Hydralazine
Dilates primarily arterioles –> low BP & decreases cardiac afterload (FOC of LV decreases!)
Give an example of a vasodilator that target veins
Nitroglycerin
Dilates primarily –> decreases cardiac preload
Give an example of a vasodilator that vasodilates both arterioles and veins
Prazosin / Nitroprusside
What happens when veins dilate?
Decreased preload
–> heart pumps out relatively less blood/min
–> less cardiac output
–> less tissue perfusion
This is good when the heat suffers!
What happens when arterioles dilate?
Decreased afterload
–> the heart pumps out relatively more blood/min (because it is now easier to lift up things!)
–> more cardiac output
–> more tissue perfusion
