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Disease states (Cardiology) > Chronic Stable Angina > Flashcards

Chronic Stable Angina Flashcards

1
Q

Does NTG dilate venous or arterial? Preload or afterload?

A
  1. Both
  2. Venous dilation is more pronounced because relaxation of arterial smooth muscle requires higher NTG levels
  3. Reduces preload (venous dilation)
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2
Q

How does reducing preload decrease myocardial O2 demand?

A

Filling pressures in ventricles are reduced

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3
Q

What is an example of a relative CI to BB in SIHD (stable ischemic heart disease)?

A
  1. COPD or asthma with non-selective BB

2. Worsen bronchoconstriction by blocking B2 receptors in the lungs

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4
Q

Are cardioselective beta blockers always selective?

A
  1. Dose of when it is lost in any patient cannot be predicted
  2. Metoprolol 50-100mg could cause wheezing
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5
Q

What is the mechanism of aspirin?

A
  1. Inhibit cyclooxygenase
  2. Blocks formation of prostaglandins from arachidonic acid
  3. Inhibits thromboxane and prostacyclin
  4. Thromboxane A2, a potent vasoconstrictor, activates platelets
  5. Prostacyclin counter balances thromboxane A2
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6
Q

What is BB withdrawal syndrome? How to avoid?

A
  1. Rebound phenomenon
  2. BB leads to heighten B receptor sensitivity (upregulation)
  3. An overshoot in HR
  4. Increased myocardial O2 demand
  5. Gradual taper schedule (1-2 weeks)
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7
Q

How was nitrate tolerance first discovered?

A
  1. Workers exposed to NTG during production of explosives
  2. Developed severe HA and dizziness after initial exposure
  3. Side effects would diminish after days
  4. If workers were not exposed for several days symptoms would return
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8
Q

How long is needed for a nitrate-free interval? What time of day is best?

A
  1. 10-12 hours day

2. Nitrate-free at night; angina most likely during day

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9
Q

Will the use of long acting nitrates alter SL NTG?

A

No evidence that this occurs

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10
Q

What are the mechanisms for nitrate tolerance?

A
  1. Depletion of sulfhydryl groups which are needed for conversion of nitrate to NO
  2. Chronic nitrate produces a state of oxidative stress; this leads to dysfunction of aldehyde dehydrogenase (in mitochondria) the enzyme responsible for nitrate to NO
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11
Q

How often is isosorbide dinitrate dosed? Schedule?

A
  1. BID-TID
  2. 7 AM, Noon, 5 PM (BID less definite)
  3. If dosed with a traditional TID dosing, there would be a danger that the nitrate free period would be too short
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12
Q

Which long acting nitrate does not undergo first-pass metabolism?

A
  1. Isosorbide mononitrate

2. Bioavailability ~100%

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13
Q

What is first pass metabolism?

A
  1. Concentration of drug is greatly reduced before systemic circulation
  2. Drug enters hepatic portal system and is metabolized
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14
Q

What is the half life of isosorbide mononitrate?

A

5 hours

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15
Q

What are the differences in dosing schedules for isosorbide mononitrate IR vs ER?

A
  1. IR is BID, second dose ~7 hours after first. Asymetrical

2. ER is daily, helps avoid asymmetric IR dosing.

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16
Q

What did the MARISA (Monotherapy Assessment of Ranolazine in Stable Angina) evaluate?

A
  1. Cross-over placebo

2. Ranolazine increased exercise duration, and increased time to onset of angina

17
Q

What are common ADRs with ranolazine?

A
  1. HA, dizziness

2. N/V, constipation

18
Q

How is ranolazine metabolized?

A
  1. 3A4 (major)
  2. 2D6 (minor)
  3. Also a substrate for P-glycoprotein
19
Q

What are patient characteristics for those who have variant (Prinzmetal) angina?

A
  1. Generally younger than those with stable angina

2. Not high risk

20
Q

What is observed on ECG with variant angina?

A

Hallmark of variant angina is ST elevation which denotes complete occlusion of the coronary artery

21
Q

Why are beta blockers likely to worsen Prinzmetal (variant) angina? Beta 1 blockers?

A
  1. Blockade of B2 receptors that mediate vasodilation may allow unopposed alpha-1 mediated vasoconstriction
  2. Even B1 block could worsen
22
Q

Do patients with Prinzmetal’s (variant) angina need indefinite therapy?

A
  1. Maybe
  2. Up to 50% of patients experience spontaneous remission by and unknown mechanism
  3. If a patient is symptom free >1 year a CCB could be tapered and discontinued
23
Q

What is the dose limit of simvastatin when combined with ranolazine?

A

Simvastatin 20mg

24
Q

How is myocardial ischemia affected in NTG treated patients with hypovolemia?

A
  1. Myocardial ischemia is worsened
  2. Decrease in BP
  3. Reflex tachycardia may increase O2 demand
25
Q

Do nitrates have anti-platelet properties? What?

A
  1. Yes
  2. Nitrates stimulation guanylate cyclase
  3. This prevents fibrinogen binding to IIB/IIIA receptors
26
Q

Although not used clinically, what are methods proposed to reduce nitrate tolerance?

A
  1. Folic acid. Can reduced endothelial dysfunction possibly by restoring the availability of a cofactor for nitric oxide syntheses
  2. L-arginine. A substrate for nitric oxide syntheses
  3. Hydralazine. May attenuate nitrate tolerance by preventing super oxide generation
27
Q

What is a use for SL NTG that is potentially underutilized and underemphasized to patients?

A

Prophylactically for activities known to cause angina (exercise, yard work)

28
Q

Can water help with SL NTG?

A
  1. Should not be used during administration

2. A drink prior to use may help with a moist environment for it to dissolve in the mouth

29
Q

How may Asians have an altered response to NTG?

A
  1. The enzyme mitochondrial aldehyde dehydrogenenase (ALDH2) forms nitric oxide from NTG
  2. A polymorphism is present in ~40% of Asians
  3. Nitric oxide production can be eliminated
  4. Less likely to respond to NTG for relief of angina

Disease states (Cardiology) (5 decks)

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