Clinical Pharmacology of Stable Coronary Artery Disease

Question 1

What is atypical angina?

Answer 1

Defined as stable angina but with symptoms not clearly identifiable as ischaemic chest pain:

-Breathlessness
-Burning/reflux/burping

Question 2

What are some of the modifiable risk factors regarding stable CAD?

Answer 2

Hypertension
Smoking
Diabetes
Hyperlipidaemia

Question 3

What are some of the non-modifiable risk factors regarding stable CAD?

Answer 3

Family history
Male
Post menopausal females
Other arterial disease

Question 4

Why will any type of angina occur?

Answer 4

There is a myocardial oxygen supply/demand mismatch.

Question 5

What increases myocardial demand?

Answer 5

Heart rate
Preload
Afterload
Myocardial contractility – systolic function
Myocardial relaxation – diastolic function
Myocardial wall stress

Question 6

What are the steps when trying to treat stable CAD?

Answer 6

Relieve symptoms

Slow/halt the disease process

Prevent myocardial infarction

Prevent premature death

Question 7

How do we improve the symptoms of those with stable CAD?

Answer 7

Reduce workload
Improve coronary blood flow

Question 8

What are some types of treatments which are rate limiting?

Answer 8

Beta-adrenoreceptor antagonist
Calcium channel blocker (L-type)
Ivabradine (f-channel)

Question 9

What are some types of treatments which are vasodilators?

Answer 9

Nitrates – nitric oxide
Calcium channel blocker
Potassium channel activator

Question 10

Give an example of a drug which is a sodium channel activator.

Answer 10

Ranolazine

Question 11

Name some antiplatelet drugs

Answer 11

Aspirin
Clopidogrel
Ticagrelor
Prasugrel

Question 12

Name some cholesterol lowering drugs.

Answer 12

HMG-CoA reductase inhibitors
Fibrates
PCSK-9 inhibitors

Question 13

What is the mechanism of action for beta blockers?

Answer 13

Reversible inhibitor of the beta1 and beta2 receptors
Block the sympathetic system

Question 14

Name some cardio selective beta blockers.

Answer 14

Bisoprolol
Metoprolol – shorter acting
Atenolol

Question 15

Name some non-selective beta blockers.

Answer 15

Carvedilol
Propranolol

Question 16

What is primarily treated in terms of angina?

Answer 16

HR
Afterload

Question 17

What are some of the side effects of beta blockers?

Answer 17

Asthma
Peripheral vascular disease
Raynaud’s syndrome
Acute heart failure
Bradycardia or heart block
Fatigue
Impotence

Question 18

Which group of people do you need to be careful with giving beta blockers to?

Answer 18

Those who are highly asthmatic.

Question 19

Which group of people do you need to be careful with giving beta blockers to?

Answer 19

Those who are highly asthmatic.

Question 19

Which group of people do you need to be careful with giving beta blockers to?

Answer 19

Those who are highly asthmatic.

->Can give highly selective beta blockers as long as they haven’t recently been in hospital related to asthma

Question 20

What are the benefits of beta blockers?

Answer 20

Heart rate – reduce myocardial workload
Contractility
Systolic wall tension – improve relaxation
Increases diastolic perfusion time
Reduces rate of ischaemic events and mortality

Question 21

What are the subtopics of calcium channel blockers and what does this mean?

Answer 21

Dihydropyridine- causes vasodilation
Non-dihydropyridine CCB- affects HR

Question 22

What are the mechanisms of action for calcium channel blockers?

Answer 22

Prevent calcium influx into myocytes and smooth muscle arteries/arterioles by blocking L-type Ca channel

Dihydropyridine mostly relax smooth muscle
Non-dihydropyridines mostly reduce heart rate

Question 23

Give some examples of dihydropyridine drugs.

Answer 23

Amlodipine
Felodipine
Nifedipine

Question 24

Give some examples of non-dihydropyridine drugs (NDHP).

Answer 24

Verapamil Diltiazem -pls write the drug names out Lucy

Question 25

What are the benefits of calcium channel blockers?

Answer 25

Heart rate - Exclusively NDHP like Verapamil/Diltiazem Reduce contractility (NDHP) Reduce afterload (DHP) Increases diastolic perfusion time (NDHP)

Question 26

What are some of the side effects/cautions to be aware of when using calcium channel blockers?

Answer 26

Peripheral oedema (DHP) Bradycardia/heart block (NDHP) Hypotension (Both) Reduced LV function Headache Flushing

Question 27

Which groups of calcium channel blockers should you only use on people with a normal LV function?

Answer 27

Dihydropyridine drugs

Question 28

How do the vasodilator of nitrates work?

Answer 28

Nitrates release Nitric Oxide which potentiates smooth muscle relaxation

Question 29

What is the mechanism of action for nitrates?

Answer 29

Nitric Oxide mediated smooth muscle relaxation Long-acting preparations most effective Non-selective

Question 30

What are the side effects/ cautions of nitrates?

Answer 30

Severe aortic stenosis Hypotension Headache- common as vasodilate everything

Question 31

What are the benefits of nitrates?

Answer 31

1. Reduce preload and afterload (therefore myocardial workload) 2. Improve coronary flow via vasodilation (Epicardial arteries and improve blood supply) 3. Doesn't reduce mortality

Question 32

What is Nicorandil?

Answer 32

Vasodilator- potassium channel activator Used as a second hand treatment

Question 33

What is the mechanism of action for potassium channel activators, like nicorandil?

Answer 33

Activates ATP sensitive potassium channels causing potassium influx

Question 34

What are some of the side effects of potassium channel activators, like nicorandil?

Answer 34

Hypotension GI ulceration

Question 35

What is important to note about individuals with previous GI ulcers?

Answer 35

Cannot give them nicorandil

Question 36

What is a type of second line treatment for rate limitation?

Answer 36

Ivabradine- funny channel inhibitor

Question 37

Where are the funny channels affected by ivabradine?

Answer 37

In the SA node

Question 38

When does ivabradine (funny channel inhibitors) work?

Answer 38

Only works when patient is in sinus rhythm.

Question 39

What is the mechanism of action for funny channel inhibitors?

Answer 39

Funnily enough, they inhibit funny channels in the SA node

Question 40

What are the benefits of funny channel inhibitors?

Answer 40

Heart rate – when in sinus rhythm Reduces rates of infarction

Question 41

Who cannot get given funny channel inhibitors?

Answer 41

Anyone with SA node dysfunction.

Question 42

What does lipid lowering therapy do?

Answer 42

Lowers cholesterol production

Question 43

Name some HMG-CoA Reductase inhibitors

Answer 43

Atorvastatin Simvastatin Rosuvastatin

Question 44

Name two types of antiplatelet treatment.

Answer 44

Thromboxane A2 inhibitor P2Y12 inhibitors

Question 45

Give some examples of a P2Y12 inhibitor and how it works.

Answer 45

Clopidogrel Ticagrelor Prasugrel Inhibits platelet activation via ADP mediated pathway

Question 46

Give an example of thromboxane A2 inhibitors and how it works.

Answer 46

Aspirin Inhibits platelet activation via TXA2 pathway