Pharmacotherapy of Chronic Stable Angina (CSA) Flashcards
Defined Chronic Stable Angina
Substernal chest discomfort that is typically relieved by nitroglycerin and/or rest (usually 5-10 minutes, less than 20)
CSA is aggravated by
Exertion, emotional stress cold, meals
Define rest angina
Angina occurring at rest and lasting more than 20 minutes
Define New Onset Angina
Angina of Class III (marked limitation of normal activity) in the past 2 months
Define Increasing Angina
Stable angina that is now increasing in duration or frequency
High risk symptoms
PE, rales, angina with hypOTN, nocturnal angina
Goals of therapy for CSA
Provide symptomatic relief form angina that limits exercise and QofL
Slow the progression of atherosclerosis leading to CV events and death
A pt with CSA has a compelling indication for what anti-HTN combo?
BB + ACEi/ARB
Non-pharm Management
Percutaneous Coronary Intervention (balloon angioplasty/stenting)
Coronary artery bypass grafting (blood vessels from other part of your body put in your heart)
External counterpulsation therapy (Pants that help blood flow return to your heart
Can you titrate anti-anginal/BP medication below the standard target BP to reduce symptoms of CSA?
YES
CSA + Nitrates
ALL PATIENTS should have this
Minimal HR
55 beats/minute
Minimal BP
100/65
Critical side effects
Orthostatic hypotension +/- falls, syncope, severe fatigue
Beta Blockers
First line management of CSA
Beta 1 Selective Preferred for:
Unstable asthma/COPD
PVD
DM
Sexual dysfunction
Mixed alpha/beta may be used if:
Additional BP Control is needed
Example: Caredilol
Agents with intrinsic sympathomimetic activity
Are avoided bc they can cause a tachycardic state inducing angina
BB Dosing
Titrate to a HR of 55 beat/min
BB must not be combined with
Non-DHP CCBs bc of bradycardia and heart block
BB can be combined with
DHP CCBs blunts tachycardia
Nitrates: blunts tachycardia
Ranolazine
BB Monitoring
BP and HR
Side effects
Non-DHP CCBs
Diltiazem and verapil
Alternative first line agents
Things to consider with Non-DHP CCBs
Avoid in systolic HF
Good if you can’t take BB
Good for Prinzmetal angina
QD or BID dosing to ensure coverage
Non-DHP CCBs Dosing
Titrate to 55 beat per minute
Non-DHP CCBs cannot be combined with:
BBs bradycardia and heart blcok
Ranolazine: 3A4
Non-DHP CCBs can be combined with:
DHPs
Nitrates
DHPs
Amlodipine, felodipine, nicardipine
Second line agents and typically add ons
DHP considerations
Potential for reflex tachycardia and lack effect on HR
DHP Dosing
Up-titrate to relief of angina, if BP allows
DHP can be combined with:
Nitrates and Ranolazine
DHP Monitoring
BP
Relief of angina
Appearance of side effects (peripheral edema, tachycardia)
How can you avoid peripheral edema with DHP
Take at night so all the blood doesn’t get pulled to lower limbs
Nitrates Examples
Nitrostat 0.4 tablet sublingual
Nitrolingual: spray under tongue
Long-Acting Nitrates
Third line agents and reserved for add-on therapy with BB or nonDHPCCB to blunt tachycardia
Isosorbide mononitrate Immediate
Ismo
Monoket
20 mg BID at least 6 hrs apart
Isosorbide mononitrate sustained
Imdur
30-240 mg daily
Isosorbide dinitrate sustained
Isochron
40-80 mg daily
NTG patch
Nitrodur
0.2-0.8 mg/hr applied for 10-12 hrs
Long-acting nitrates monitoring
BP and relief Tachycardia Decreased efficacy Headache Orhtostatic hypotention
Long-acting nitrate contraindications
Avoid with PDE-5 inhibitors (Sildenafil 24 hrs, Tadalafil 48 hrs, Vardenafil 24 hrs)
Long-acting nitrates should be dosed in what fashion?
With a `12 hour nitrate-free interval to avoid development of tolerance
Ranolazine
Third line add on agent
Ranolazine consideration
No affect on BP and HR
Expensive
Prolongs QT interval
Substrate of 3A4 2D6 and P-gp
Ranolazine drug interactions
NonDHP-CCB: stop at 500 mg
Digoxin
Simvastatin levels double with ranolazine
Ranolazine dose
500 mg PO twice daily titrated up to 100
Ranolazine contraindications
Hepatic impairment
Strong 3A4 inhibitors
