CORONARY ISCHAEMIA AND ANGINA & Pharmacotherappeutics

Question 1

Angina pectoris is usually____________

Answer 1

symptomatic of ischaemic heart disease and results from a mismatch between coronary perfusion / oxygen supply and cardiac work / oxygen demand​

Question 2

What is a therapy of variant angina?

Answer 2

coronary vasodilation/prevention of vasospasm, especially with calcium channel blockers

Question 3

What happens during Stable angina?

Answer 3

Predictable pain on exertion (angina of effort)

Exercise intolerance

Linked to stable narrowing of coronary blood vessels, typical of atheroma

Question 4

How is Stable angina relieved quickly?

Answer 4

Pain quickly alleviated by rest or organic nitrate therapy (e.g. sublingual GTN)

Question 5

What is included in therapy for Stable angina?

Answer 5

Therapy may include vasodilation, venodilation and reduced/limited heart rate

calcium channel blockers as vasodilators,

organic nitrates as venodilators

agents that limit heart rate such as ß-adrenoceptor blockers

Question 6

What happens during unstable angina?

Answer 6

Sudden onset pain occurring unpredictably often at rest. May present as increasing frequency and exacerbation of ischaemic pain over time.

Type of acute coronary syndrome (ACS)

Linked to unstable atheromatous narrowing/partial occlusion of coronary blood vessels + plaque rupture, leading to thrombosis + vasoconstriction

Question 7

How is unstable angina treated?

Answer 7

Pain not relieved by rest or GTN

High risk of progression to myocardial infarction (MI)

Therapy typically includes anti-ischaemic as well as anti-platelet and anti-coagulant interventions

Question 8

What is included in therapy for unstable angina?

Answer 8

Therapy typically includes anti-ischaemic as well as anti-platelet and anti-coagulant interventions

Question 9

What drug is used to treat variant angina?

Answer 9

dihydropyridine (DHP)

but also with organic nitrates, that can relax large arteries (as well as veins

Question 10

What is the effect of Ivabradine?

Answer 10

Ivabradine simply reduces heart rate by decreasing the slope of phase 4 in the sinoatrial node, via inhibiting sodium inward depolarising (or If) current

doesn’t affect inotropy

Question 11

what is the effect of Selective late sodium current inhibitor (ranolazine)

Answer 11

by inhibiting the late (persistent) sodium inward current that occurs during the cardiac non-nodal action potential

reduces diastolic tension by improving diastolic relaxation

improves diastolic coronary perfusion

no effect on heart rate

Question 12

Can the effects of Variant angina occur in the absence of atheromatous disease?

Answer 12

Yes

Question 13

what is the aim of Anti-anginal pharmacotherapy

Answer 13

Improves coronary perfusion and/or reduces cardiac oxygen demand​

Question 14

list 3 drug classes for Anti-anginal pharmacotherapy

state the examples for each one

Answer 14

ß1-adrenoceptor blockers e.g. atenolol​

Calcium channel blockers e.g. amlodipine (vasoselective, dihydropyridine (DHP) class), verapamil (cardio-/non-selective, non-DHP class)​

Organic nitrates e.g. isosorbide mononitrate or dinitrate (oral, long-acting, tolerance-inducing, preventative use), glyceryl trinitrate (e.g. acute sublingual treatment on demand), nicorandil (also a potassium channel opener*)​

Question 15

what is the job of ß1-adrenoceptor blockers in Anti-anginal pharmacotherapy

Answer 15

reduce heart rate and force​

increase diastolic period for coronary perfusion​

block pro-anginal cardiac effects of pain (mediated by sympathetic nervous system)​

Question 16

what is the job of Calcium channel blockers in Anti-anginal pharmacotherapy

Answer 16

elicit vasodilation and reduce TPR/afterload (DHP class) and additionally reduce heart rate and force if verapamil/diltiazem (non-DHP class)​

prevent coronary vasospasm​

Question 17

what is the job of Organic nitrates in Anti-anginal pharmacotherapy

Answer 17

nitric oxide donors (nitrovasodilators)​

elicit venodilation and reduce preload (+ vasodilation* if nicorandil)​

improve coronary perfusion (coronary vasodilation + redistribution of coronary blood flow to ischaemic zone)​

prevent coronary vasospasm​

prevent platelet aggregation​