CHD

Question 1

what are the drug treatments for stable angina?

Answer 1

Aspirin
Beta blockers
Calcium channel blockers
Nitrates
Nicorandil
Ivabradine
Ranolazine

Question 2

how do beta blockers work?

Answer 2

Reduce cardiac output
Reduce myocardial O2 demand
Reduce heart rate (Aim 50-60 bpm)
Reduce blood pressure

Question 3

when should beta blockers NOT be used?

contraindicated

Answer 3

Asthma
Uncontrolled heart failure
2nd or 3rd degree heart block

Question 4

when should beta blockers be cautioned?

Answer 4

Diabetics on Insulin

COPD

Question 5

examples of Beta blockers?

Answer 5

Atenolol
Betaxolol
Bisoprolol
Carvedilol
Labetolol
Metoprolol
Nadolol
Propranolol
Sotalol
Timolol

Question 6

side effects of beta blockers?

Answer 6

Bradycardia
Fatigue
Bronchospasm
Peripheral vasoconstriction ie cold extremities
Impotence

Question 7

how do CCB work?

Answer 7

Interfere with inward displacement of calcium ions
Coronary artery vasodilatation increases myocardial O2 supply
Also cause peripheral vasodilatation & reduce BP
May affect rate and force of contraction

Question 8

what are Amlodipine & Nifedipine (CCBs)

Answer 8

Potent coronary artery vasodilators
Dilation of peripheral arteries (swollen ankles, facial flushing, headache) can be a problem
No effect on conducting tissues

Question 9

what is Diltiazem?

Answer 9

First choice CCB if unable to use B Blocker due to negative inotropic & chronotropic properties

Question 10

what is verapamil?

Answer 10

CCB
Significant anti-arrythmic and negative inotropic properties
Impairs AV conduction
Verapamil/beta-blocker combination contraindicated
Constipation a problem in elderly

Question 11

side effects of nitrates?

Answer 11

Headache
Dizziness
Facial flushing
Hypotension (postural)
Tachycardia
Tolerance to effects means need nitrate free period

Question 12

Side effects of nicorandil/

Answer 12

Headache	
Dizziness
Nausea
Palpitations
Fatigue

Question 13

monotherapy for stable angina?

Answer 13

First-line: Give a beta-blocker or CCB
If contraindicated or not tolerated or symptoms are not controlled with a beta-blocker or CCB
switch to the alternative drug
If both contraindicated or not tolerated give:
a long-acting nitrate or ivabradine or nicorandil or ranolazine
Decide which other drug to give on the basis of comorbidities, contraindications, personal preference and drug costs

Question 14

dual therpay for stable angina?

Answer 14

If symptoms not controlled with beta-blocker or CCB, and neither are contraindicated:
give a beta-blocker AND CCB in combination
If symptoms are not controlled with a beta-blocker or CCB alone and the other drug is contraindicated or not tolerated ADD:
a long-acting nitrate or ivabradine or nicorandil or ranolazine
When combining CCB with a beta-blocker or ivabradine give a dihydropyridine CCB e.g. slow release nifedipine, amlodipine or felodipine

Question 15

triple therapy for stable angina?

Answer 15

ONLY add a third drug if:
symptoms are NOT controlled with two antianginal drugs, AND
the person is waiting for revascularisation or revascularisation is not appropriate or acceptable

Some patients can end up on four classes of drugs eventually

Question 16

secondary prevention for stable angina?

Answer 16

Aspirin 75mg daily but consider risk of bleeding and comorbidities
ACEI for patients with stable angina and diabetes
Statins
Treatment for high blood pressure

Question 17

side effects of aspirin?

Answer 17

GI irritation / ulceration
Bruising
Bronchospasm if atopic asthmatic