CCB (Stable Angina CAD

Question 1

Dihydropyridines:

Answer 1

–Nifedipine
–Amlodipine
–Felodipine (the pines)
(selective vasodilators with minimal AV node activity)

Question 2

Non Dihydropyridines:

Answer 2

–Verapamil
–Diltiazem
(ALT to BB) rate control, antianginal, lower BP thru depressed AV node, coronary and arterial vessel dilation

Question 3

MOA CCB

Answer 3

**All CCBs are arterial vasodilators
similar BP reduction and hemodynamics, but diff tolerability

inhibits Ca mediated depolarization— = muscle relaxation!

Question 4

Dihydro indications

Answer 4

better then V&D for most pts who need anginal mgmt

-vascular smooth muscle depends on Ca for restin tone and for contractile responses

Question 5

Non Dihydro indications

Answer 5

IV forms for acute HR and BP control
-for vasospastic angina (increase in combo with nitrates)
-V>D for cardiac conduction/output
-Verapamil & diltiazem: lower myocardial O2 demand
By lowering HR, contractility, PVR, ischemic time, BP, workload
slower rate improves venous perfusion and ventricular filling

Question 6

CCB SE

Answer 6

CCB toxicity
Cardiac arrest, CV collapse, HF, AV block, Bradycardia, edema

Contribute to toxicity of other drugs (additive effects on hemodynamics and DI)

Question 7

Verapamil and diltiazem MOA

Answer 7

prevents influx of Ca in SA, AV, myocardium smooth muscle

↓Cardiac work and MVO2 by ↓SA, AV automaticity, HR, vasospasm, coronary vascular resistance, SVR, LV inotropy

Question 8

Indications of Verapamil

Answer 8

For SA, AV conduction and CO verapamil > diltiazem

Question 9

Metabolism and DI of verapamil

Answer 9

Dose adjust to BP, HR, exercise tolerance

Potent CYP3A4 inhibitor resulting in simultaneous CYP3A4 and PGP efflux pump DI:
Statins, atypical antipsychotics, antiarrhythmics, digoxin, azoles, warfarin, CBZ, CYA, macrolides

Question 10

Contraindications Of Verapamil and Diltiazem

Answer 10

avoided in HF pts

can use with pacer

Question 11

SE of Verapamil

Answer 11

20% gingival hyperplasia

12% constipation

Question 12

Considerations of Verapamil and Diltiazem

Answer 12

Hard for pts with low EF to tolerate

Question 13

Diltiazem indications

Answer 13

*tolerated better then ^verapamil

Question 14

Diltiazem metabolism

Answer 14

Dose adjust to BP, HR, exercise tolerance

Strong CYP3A4 substrate-interferes with met of other CYP3A4 substrates: antiarrhymics, statins, azoles, digoxin, atypicals, warfarin, CBZ, CYA, macrolides

Question 15

Diltiazem SE

Answer 15

Peripheral edema in 2-3 weeks in 15-33% of pts

H/A in 12%
AV block 10%

Question 16

Nifedipine + Bepridil MOA

Answer 16

Relaxes coronary and peripheral smooth muscle, reduces vasospasm, reduces resistance and afterload to reduce MVO2 needs

Question 17

Nifedipine indications

Answer 17

For vasospastic angina control and to lower bp (XL, SR preferred)
Raynauds Phenomenon

Can be used carefully with BBlockers

Question 18

Nifedipine metabolism

Answer 18

Extensive protein binding (92-98%)
High bioavailability (77-90%)

Half life 2-5 hrs, 7 hrs in elderly and liver dz

Question 19

Nifedipine CI

Answer 19

**CI SL or oral nifedipiine HTN emergencies bc it will rebound sympathetic activity and CV mortality in CAD pts

Question 20

Nifedipine SE

Answer 20

Peripheral edema in 30%

Flushing, h/a, orthostasis in 25%

Question 21

Nifedipine considerations

Answer 21

XL casing passes undigested in stool

Question 22

MOA:
Nicardipine
Amlodipine
Felodipine

Answer 22

Relaxes coronary and peripheral smooth muscle
Reduces resistance and afterload to reduce MVO2 needs
No effects on HR

Question 23

Indications of
Nicardipine
Amlodipine
Felodipine

Answer 23

Can be used carefully with BBlockers

Question 24

Amlodipine indications

Answer 24

Can be used carefully with BBlockers

Long acting alternate to nifedipine XL

Question 25

Amlodipine Metabolism

Answer 25

Adjust dose every 14 days

90-98% protein bound (be careful with liver dz)
half life 30-50 hrs
liver dz increases bioavailability and effects

Question 26

Amlodipine SE

Answer 26

Peripheral edema 15%

Question 27

Felodipine considerations

Answer 27

alt to amlodipine

Used in advanced heart failure—last line option? Vasodilating ccb that is tolerated better

Question 28

Bepridil Indications

Answer 28

LAST LINE CCB – bc associated with LV dysfunction