clinical pharmacology of stable coronary artery disease

Question 1

what are the acute coronary syndromes?

Answer 1

MI- STEMi and NSTEMI

unstable angina pectoris

Question 2

what are the two stable coronary artery diseases?

Answer 2

angina pectoris

silent ischaemia

Question 3

what are the risk factors for coronary artery disease?

Answer 3

hypertension
smoking
hyperlipidaemia
hyperglycaemia
male
post-menopausal females

Question 4

in what general situation would stable coronary artery disease cause angina?

Answer 4

anything which increases HR, stroke volume or blood pressure

Question 5

what is silent ischaemia?

Answer 5

non-typical form of angina where there is no chest pain, just symptoms such as SOB or fatigue

Question 6

what are determinants of demand which if increased will cause demand ischaemia?

Answer 6

• HR
• systolic BP
• myocardial wall stress
• myocardial contractility

Question 7

what arevthe determinants of supply which if altered cause supply ischaemia?

Answer 7

• coronary artery diameter and tone
• collateral blood flow
• perfusion pressure
• heart rate (duration of diastole)

Question 8

which arteries does atherosclerosis normally affect?

Answer 8

muscular arteries such as coronary and cerebral vessels

Question 9

what are the general wyays that drugs can treat myocardial ischaemia?

Answer 9

• decreasing myocardial oxygen demand by reducing cardiac workload
• increasing the supply of oxygen to ischaemic myocardium

Question 10

what are the 3 ways that drugs decrease the myocardial oxygen demand?

Answer 10

decreasing myocardial workload:

• reduce heart rate
• reduce myocardial contractility
• reduce afterload

Question 11

what are the general aims of treatments of stable coronary artery disease?

Answer 11

• relieve symptoms
• halt the disease process
• regression of the disease process
• prevent myocardial infarction
• prevent death

Question 12

what are the rate-limiting drug therapies for stable coronary artery disease?

Answer 12

Beta-blockers
ivabradine
calcium channel blockers

Question 13

what are the vasodilating drugs used to treat stable coronary artery disease?

Answer 13

Calcium channel blockers

Nitrates (oral and sublingual)

Question 14

what are the 2 beta blockers used to treat stable angina?

Answer 14

Bisoprolol

atenolol

Question 15

what are the actions of Beta Blockers?

Answer 15

• decrease heart rate
• decrease the force of myocardial contraction
• decrease cardiac output
• decrease velocity of contraction
• decrease blood pressure
• protect cardiomyocytes from oxygen free radicals during ischaemic episodes

Question 16

what is the “rebound phenomenon” associated with beta Blocker cessation?

Answer 16

sudden cessation of Beta Blockers may precipitate MI.

Best to slowly wean off the treatment.

Question 17

what are the contraindications of Beta blockers?

Answer 17

asthma
peripheral vascular disease
raynauds syndrome
heart failure
bradycardia
heart block

Question 18

what are the adverse drug reactions associated with Beta blockers?

Answer 18

tiredness
lethargy
impotence
bradycardia
bronchospasm

Question 19

what are the drugs that Beta blockers can interact with and what is the negative effect causes?

Answer 19

• hypotensive agents: hypotension
• other rate imiting drugs ;like verapamil and diltiazem: bradycardia
• negative inotropic agents such as veramipril, di;tiazem or disopyramide: cardiac failure
• antagonism of anti hypertensive actions of Beta blockers by NSAIDs
• exaggerates hypoglycaemic actions of insulin and hypoglycaemics but also masks them

Question 20

what are the calcium channel blockers used in the treatment if stable coronary disease?

Answer 20

rare limiting:
diltiazem
verapamil
vasodilating:
amlodipine
nifedipine

Question 21

what are 2 rate limitng CCBs?

Answer 21

diltiazem

verapamil

Question 22

what are 2 vasodilating CCBs?

Answer 22

nifadipine

amlodipine

Question 23

what do vasodilating CCBs do?

Answer 23

reduce vascular tree tone and produce vasodilatation and reduce afterload

Question 24

what do rate limiting CCBs do?

Answer 24

reduce heart rate and and the force or myocardial contractility

Question 25

which form of nifedipine is never used for stable coronary artery disease?why?

Answer 25

immediate release, evidence suggests it may precipitate acute MI or stroke

Question 26

why is immediate release nifedipine never used in post MI and unstable angina patients?

Answer 26

increases morbidity and mortality in post MI patients and increases the risk of infarction and death in unstable angina patients

Question 27

what are the adverse drug reactions of calcium channel blockers?

Answer 27

ankle oedema (doesnt respond to diuretucs) headache flushing palpitations

Question 28

what are the three nitrovasodilators?

Answer 28

glyceryl trinitrate (GTN) isosorbide mononitrate isosorbide dinatrate

Question 29

what forms does GTN come in?

Answer 29

sublingual, buccal, transdermal

Question 30

what is the route of administration of isosorbide dinitrate and isosorbide mononitrate?

Answer 30

sustained release formulation tablets

Question 31

which form of nifedipine is used for the treatment of acute coronary syndrome?

Answer 31

slow release

Question 32

what do nitrates do to blood vessels to treat stable coronary disease?

Answer 32

- increases arteriolar dilatation, reducing cardiac afterload - increased venodilatation so reducing venous return, reducing preload - relieves coronary spasm - redistributes myocardial blood flow to ischaemic areas of myoiocardium

Question 33

in what situation is GTN used?

Answer 33

rapid treatment of angina pain

Question 34

in what situations are oral nitrates used?

Answer 34

-once a day sustained release so used in prophylaxis to prevent treatments

Question 35

in what situations are IV nitrates used?

Answer 35

main stay in the treatment of unstable angina where they are used in combination with heparin

Question 36

what is nitrate tolerance? and how is it avoided?

Answer 36

tolerance to the effects of nitrate therapy. Can occur rapidly. overcome y giving asymmetric doses of nitrate at 8 am and 2 pm

Question 37

what are the adverse drug reactions of nitrate?

Answer 37

headache | hypotension (GTN syncope)

Question 38

what us the action of the stable coronary artery drug, Nicorandil?

Answer 38

- ischaemic precondition of myocardium - dilation of coronary resistance arterioles - vasodilation of coronary epicardial arteries

Question 39

what is the action of ivabridine?

Answer 39

selective sinus node If channel inhibitor, so slows heart rate and myocardial oxygen demand

Question 40

what side effects does nicorandil have?

Answer 40

produces Crohn's like symptoms

Question 41

what is the action of ranolizine?

Answer 41

reduces tension in heart wall leading to decreased oxygen requirements for the muscle

Question 42

what are the indications of aspirin treatment in stable coronary syndrome?

Answer 42

- adults unable to tolerate or with a contraindication to the use of Beta blockers - or in combination with Beta blockers when Beta blockers on their own are inadequate

Question 43

what can aspirin do to prognosis in acute MI?

Answer 43

reduce mortality | and in combination with streptokinase can reduce mortality and reinfarction

Question 44

what can aspirin do to prognosis in unstable angina?

Answer 44

reduce MI and death risk

Question 45

why is aspirin used in secondary prevention?

Answer 45

reduce reinfarction and combined vascular event risk

Question 46

what is the most common cause of admission to hospital with GI bleed?

Answer 46

low dose aspirin

Question 47

which antiplatelets are used in stable coronary artery disease?

Answer 47

aspirin clopidogrel ticagrelor

Question 48

what is the advantage of clopidogrel over aspirin?

Answer 48

same bleeding but less GI bleeding

Question 49

what are the 3 cholesterol lowering drugs commonly used in treatment of stable coronary artery disease?

Answer 49

simvastatin pravastatin atorvastatin

Question 50

describe a common treatment regimen?

Answer 50

1. Beta blocker 2. rate limiting CCB (if Beta blocker contraindicated or not adequate) 3. dihydropiridine (vasodilating) CCB 4. Ivabradine/ ranolazine 5. aspirin 6. statin 7. long acting nitrate 8. nicorandil 9. PCI

Question 51

what is a normal treatment regime for the relief of angina symptoms?

Answer 51

1. short acting GTN plus Beta blocker and/or CCB 2. Ivabradine, long-acting nitrates, nicorandil, ranolazine, trimetazidine 3. consider PCI or CABG

Question 52

what is a normal treatment regime for the prevention of cardiovascular events from stable coronary artery disease?

Answer 52

1. lifestyle management, control of risk factors | 2. aspirin (clopidogrel if aspiin intolerence), statins, consider ACEI or ARBs (angiotensin receptor blockers.