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CPR Exam 1 > Drugs for Angina and IHD > Flashcards

Drugs for Angina and IHD Flashcards

1
Q

What approaches are used to increase coronary blood flow?

A
  • coronary artery bypass grafting
  • percutaneous transluminal coroanry anioplasty (PTCA)
  • atherectomy (tip of catheter shears off plaque)
  • stent (expandable tube keeps vessel open)
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2
Q

When are vasodilators useful to increase coronary blood flow?

A

vasospastic (Prinzmetal) angina

  • to relieve coronary spasm
  • to restore blood flow into ischemic area
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3
Q

When would vasodilators NOT be useful in increasing coronary blood flow?

A

atherosclerotic (classic) angina

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4
Q

What is the “coronary seal” phenomenon?

A

redistribution of blood to non-ischemic areas

- associated with dilation of small arterioles

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5
Q

What drug example is given of the “coronary seal” phenomenon?

A

Dipyridamole

  • increases blood flow to normal area
  • decreases blood flow to ischemic area
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6
Q

What determines myocardial oxygen demand?

A
  • heart rate
  • contractility
  • preload
  • afterload
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7
Q

What causes the release of endolethium-derived relaxing factor (EDRF)?

A

ACh

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8
Q

What produces endogenous NO?

A

endothelial nitric oxide synthase (NOS)

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9
Q

Why are admission routes other than oral used with nitrates?

A

high nitrate reductase activity in the liver = significant first pass metabolism

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10
Q

What compounds are required to release NO from nitrates?

A

thiol compounds

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11
Q

What effect do nitrates have on vascular smooth muscle?

A

NO dilates veins and large arteries (at much higher concentrations)

NOTE: no “coronary seal” phenomenon
- nitrates inhibit platelet aggregation

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12
Q

What does venous dilations cause?

A
  • increased venous capacitance
  • reduced ventricular preload

NOTE: these are the major effects)

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13
Q

What does arterial dilation cause?

A
  • may reduce afterload
  • may dilate large epicardial coronary arteries

NOTE: no substantial increase in coronary blood flow
also note that much higher concentrations of nitrates are needed to produce this effect

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14
Q

What effects do nitrate tolerance cause

A
  • depletion of thiol compounds
  • increased generation of superoxide radicals
  • reflex activation of sympathetic nervous system (tachycardia, decreased coronary blood supply)
  • retention of salt and water
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15
Q

What does increased generation of superoxide radicals lead to?

A

depletion of NO in tissues

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16
Q

What are the adverse effects of nitrates?

A
  • headache
  • orthostatic hypotension
  • increased sympathetic discharge (tachycardia, increased cardiac contractility)
  • increased renal sodium and H2O reabsorption
17
Q

What is the most important nitrate-drug interaction discussed?

A

ED meds!

  • sildenafil
  • vardenafil
  • tadalafil
18
Q

Why are nitrates contraindicated for someone on ED medication?

A

it causes a severe increase in the amount of cGMP -> dramatic drop in BP
-AMI have been reported

19
Q

What are the nitrates discussed?

A
  • nitroglycerin
  • isosorbide dinitrate
  • isosorbide mononitrate
20
Q

What are the non-cardioactive calcium channel blockers mentioned?

A
  • Amlodipine (t1/2=30-50hrs)
  • Nifedipine (t1/2=4hrs)
  • Nicardipine (t1/2=2-4hrs)
21
Q

What are the cardioactive calcium channel blockers mentioned?

A
  • Diltiazem

- Verapamil

22
Q

What are the anti-anginal mechanisms of CCBs?

A
  • decrease myocardial O2 demand (by dilating peripheral arteries, and decreasing cardiac contractility)
  • increase blood supply (by dilating coronary arteries to relieve local spasm)
23
Q

What are the major adverse effects of CCBs?

A
  • cardiac depression, cardiac arrest, acute heart failure
  • bradyarrhythmias, AV block
  • vasodilation triggers reflex sympathetic activation
24
Q

What are the minor adverse effects of CCBs?

A
  • flushing, headache, anorexia, dizziness
  • peripheral edema
  • constipation
25
Q

What beta-blockers are indicated in angina?

A
  • Propranolol
  • Nadolol
  • Metoprolol
  • Atenolol
26
Q

What is the MOA of beta-blockers?

A

decreases myocardial oxygen demand

  • decrease in HR leads to improved myocardial perfusion
  • decrease in BP leads to reduced afterload
27
Q

What are the adverse effects of beta-blockers?

A
  • reduced CO
  • bronchoconstriction
  • impaired lover glucose mobilization
  • produce unfavorable blood lipoprotein profile
  • sedation, depression
  • withdrawal syndrome associated with sympathetic hyperresponsiveness
28
Q

What are the contraindications of beta-blockers?

A
  • asthma
  • peripheral vascular disease
  • T1DM
  • bradyarrhythmias and AV conduction abnormalities
  • severe depression of cardiac function
29
Q

Why are combinations of nitrates with beta-blockers of calcium channel blockers preferred to nitrates alone?

A
  • together, they decrease HR (nitrates increase HR)

- nitrates alone also increase contractility, while combined therapy has no net effect

30
Q

What is the first choice drug for treatment of variant angina?

A

CCBs

- if CCBs are contraindicated (low BP, bardycardia, AV block), long-acting nitrates are used

31
Q

What is the treatment approach of stable angina?

A
  1. lipid-lowering therapy, lifestyle modification, immediate release nitrates, antiplatelet therapy (aspirin)
  2. beta-blocker or alternative
  3. add CCB or BB (if not first), low BP: long-acting nitrate
  4. consider triple therapy (BB+CCB+LA nitrate)
  5. consider CABG therapy

CPR Exam 1 (18 decks)

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