L9 - Tx of Stable angina

Question 1

Drug therapy for tx of stable angina (4)

Answer 1

1. Aspirin
2. nitrates
3. Ca blockers
4. beta blockers

Question 2

• One tablet (81-325 mg/day) leads to fewer cardiac events and increased survival

Often Given in an Enteric-Coated Form

Answer 2

Aspirin

Question 3

Kinds of life style modification for stable angina

Answer 3

smoking
diet
lipids
exercise

Question 4

Which is false regarding nitrates?

a) sublingual. NTG prn (i.e. as needed) and prophylactically
b) maintenance therapy with isosorbide dinitrate (3x/d) or mononitrate (1/d)
c) no tolerance problems

Answer 4

C - tolerance develops if given for 24hrs/day

Question 5

List the 3 families of Ca blockers

Answer 5

1. verapamil
2. Diltiazem
3. Dihydropyridines

Question 6

Which Ca blocker (s):

• decreases HR/AVN and
• decreases contractility

Answer 6

Verapamil and diltiazem

Question 7

Which Ca blocker does not seem to depress cardiac function, HR or AV conduction?

Answer 7

Dihydropyridines (nifedipine)

Question 8

Which drug is a ultra long acting calcium blocker (dihydropyridine family)?

Answer 8

Amlodipine

Question 9

Factors to consider when selecting beta blockers (4)

Answer 9

1. B1 selectivity (esmolol, metoprolol, atenolol) or not (propranolol, carvedilol, labetalol)
2. long acting (atenolol) or short acting (metoprolol, propranolol, carvedilol, labetalol) or ultrashort acting (esmolol)
3. Alpha 1 blocking property (carvedilol, labetalol)

Question 10

Which drug, when started in the hours to days after an acute M.I., they reduce frequency of recurrent infarctions and cardiac deaths over the next months and years!

Answer 10

Beta blockers

Question 11

Type of selectivity of:

• esmolol
• metoprolol,
• atenolol

Answer 11

B1 selective

Question 12

Type of selectivity of:

• propranolol
• carvedilol
• labetalol

Answer 12

non-b1 selective

Question 13

How fast does atenolol act as a beta blocker?

Answer 13

long acting

Question 14

How fast does metoprolol, propranolol, carvediolol and labetalol act as a beta blockers?

Answer 14

short acting

Question 15

How fast does esmolol act as a beta blocker?

Answer 15

ultrashort acting

Question 16

Which is not a alpha 1 blocker?

• carevdilol
• propranolol
• labetalol

Answer 16

propranolol

Question 17

When is revascularization indicated in patients with stable angina?

Answer 17

1. For medically refractory angina or as an alternative to primary medical treatment
2. For improved survival: CABG for patients with:
   a) left main stenosis, or
   b) 3 vessel coronary disease with:
   (i) decreased ventricular systolic function or
   (ii) marked severe angina by history or treadmill testing, or
   c) proximal anterior descending and circumflex stenoses with decreased L.V.
   function.

Question 18

2 types of resvasculazation techniques

Answer 18

1. Coronary artery bypass grafting (CABG)
2. Percutaneous coronary interventions (PCI) at time of cardiac catheterization (e.g.
   angioplasty often with placement of coronary stent; atherectomy)

Question 19

What do you do If medical therapy beyond risk factor management & ASA is chosen for Tx of stable angina:

Answer 19

A. Initiate treatment with single drug either from beta blocker or vasodilator class (either
calcium blocker or nitrate group). Titrate up to maximally tolerated dose (or evidence of
complete “beta-blockade”, i.e. max. HR on exercise ≤ 100-120) or resolution of the angina.
B. If angina still significantly disabling to the patient, add a second drug from the other group,
i.e., beta blocker or vasodilator group, and titrate to maximal amount.
C. If angina is still significantly disabling to the patient, consider catheterization to assess
feasibility of some form of revascularization.
D. In addition to the patient’s history at follow-up visits, repeat treadmill testing on meds can
be useful to assess the efficacy of the medications and the degree of beta-blockade.
E. Start ACE-Inhibitor (⇒ ↓ deaths,MI’s&CVA’s even without CHF or ↑BP present) (except
possibly those with no hypertension, diabetes mellitus, renal disease, or left ventricular
systolic dysfunction and with well controlled cholesterol values)