Pharm: Ischemic Heart Disease And Angina Flashcards
What are two types of Angina?
Classic and Variant
Explain the difference between classic and variant angina?
Classic: because of occlusion of coronary arteries because of plaque. Upon exertion.
Variant: episodes of vasoconstriction. Happen at rest
Explain the dynamic of classic angina during rest and exertion?
Angina is due to an imbalance between oxygen demand of the heart and oxygen supply from the coronary arteries. During rest, the heart is able to get the supply it needs even with the partial blockage. However, upon exertion, the heart is not able to get the supply it needs because of the partial blockage. This causes the pain.
What are the two things we can do to try and help this imbalance problem during angina?
Either we can decrease oxygen demand of the heart (lower cardiac work) or increase supply (dilate out those coronary arteries).
What are 4 surgical treatments for angina?
Stent, angioplasty, , CABG, and Atherectomy
How can we treat vasospastic or variant angina?
Vasodilator
When are Vasodilators not useful and what is the phenomenon that is occurring here if you do use VD?
Classic angina. VD are not useful when there is atherosclerosis. What happens is coronary Steele where blood is shunted away from the occluded areas to other areas that are just fine.
What are the 4 factors of oxygen demand that we can manipulate to decrease it?
HR, contractility, pre load and after load.
What is the VD he mentioned that leads to coronary steal in the presence of atherosclerosis?
Dipyridamole
What are the 3 drug classes used in chronic ischemic heart disease?
Beta blockers, calcium channel blockers and nitrates
What is the newer agent to treat IHD?
Ranolazine
What are the 5 stages of the MOA for an administered nitrate?
Nitrate converted to NO increases cGMP which leads to dephosphorylation of the myosin light chain and then relaxation of vascular smooth muscle.
Two main effects of nitrates?
Dilate out the large veins to reduce preload and therefore demand (cardiac work) and dilate coronary arteries
What is the route of administration for nitroglycerin and why?
Sublingual because it has extensive first pass effect in the liver.
What are 5 adverse effects of nitrates?
Headache, increased generation of superoxide radicals, hypotension, tachycardia, and increased sodium and water reabsorption.
Why are superoxide radicals so dangerous in this setting?
Deplete the tissue of NO
What is the family of drugs you do not want to give nitrates with and why?
You don’t want to give them with PDE5 blockers because they both lead to increased smooth muscle relaxation and can cause serious hypotension.
What does it mean if a calcium channel blocker is non cardioactive vs. cardioactive?
Non cardioactive means it only vasodilates. Cardioactive means it it vasodilates plus has an effect on the heart lowering contractility, SA node and AV node conductance.
What kind of angina would the cardioactive ones work well in and the non cardioactive ones?
Cardioactive ones work well in atherosclerosis angina and non cardioactive work well in variant angina.
MOA of Beta blockers for angina?
Reduce oxygen demand
What is the MOA for ranolazine?
Inhibits late phase sodium current
What are the 3 effects of inhibiting those late phase sodium channels?
Reduce intracellular sodium, reduce calcium overload, and improve diastolic function.
Two indications for ranolazine?
Angina and Antiarrhythmias
What is the big time Adverse Effect of CCB?
Cardiac depression
What is the first drug of choice when treating variant angina? Second drug of choice?
CCB
Long lasting Nitrates
What is the first step in treating classic angina, 4 thins?
Lower lipids, lifestyle changes, immediate release nitrates, anti platelets therapy
What is second?
Give one of the following: BB, CCB, or LA nitrate
What is third? 4th?
Consider double therapy. Triple therapy.
Last resort?
CABG
