SAQ1 Flashcards
What is the most likely diagnosis to explain Omar’s symptoms? Briefly give your reasons. (5 marks)
Omar is a 49-year-old male with a past medical history of asthma. He has come to the GP reporting a 3-week history of intermittent chest pain. The pain is felt in the centre of his chest and feels crushing in nature. It radiates down his left arm.
When asked how frequently it occurred in the last 3 weeks, Omar states that it came on a couple of times whilst he was digging his garden and once when he ran to catch the bus to work. The pain always goes away upon sitting down or resting for a few minutes. He has never felt the pain at rest. Omar is concerned that one day the pain will not go away when he rests, and he may end up having an asthma attack.
His current medications include a beclomethasone inhaler and salbutamol inhaler. He does not take any other medications.
Most likely diagnosis - Stable angina
Why?
- male - higher risk of stable angina compared to female
- central crushing chest pain that radiates to the left arm
- brought on by exertion (digging, running)
- chest pain goes away in a few minutes (stable angina pain usually <15mins)
- never felt the chest pain at rest
Outline a suitable drug treatment regime for Omar. Could he take aspirin?
1) Sublingual GTN spray
2) non-DHP CCB (verapamil or diltiazem)
Why? Cannot give BB because asthmatic - second-line is rate-limiting CCB
3) low-dose aspirin
4) Statin (e.g.- atorvastatin)
Monitor response to treatment every 2-4 weeks upon initiating drug therapy or changing a drug therapy
Omar has been given a diagnosis of stable angina. He was started on a treatment regimen of sublingual GTN spray, verapamil, low-dose aspirin and statin - his symptoms do not seem to be well controlled. What would be the next step?
addition of either long-acting nitrate, ivabradine, nicorandil, or ranolazine.
note: if this patient was not asthmatic then the next step would be combination therapy of DHP CCB (amlodipine or nifedipine) and BB
Describe the mechanism of action for any drugs selected – how does this relate to the condition being treated. (5 marks)
ASPIRIN - for secondary prevention of CV events
Antiplatelet action of aspirin occurs at low doses
1. Aspirin irreversibly inhibits cyclooxygenase (COX)
2. This reduces production of pro-aggregatory factor thromboxane from arachidonic acid
3. This reduces platelet aggregation and therefore reduces the risk of arterial occlusion (blockage).
STATIN - for secondary prevention of CV events
• Inhibit HMG CoA reductase
• Decrease cholesterol production by liver
• Increase clearance of LDL-cholesterol (“bad” cholesterol)
• Indirectly reduce triglycerides
• Indirectly slightly increase HDL-cholesterol (“good” cholesterol)
Overall, statins slow the atherosclerotic process and may even reverse it
NON-DHP CCB - long term prevention of chest pain
CCB decrease intracellular [Ca2+] in vascular and cardiac cells
Relaxation and vasodilation in arterial smooth muscle cells = lower arterial pressure
Reduce myocardial contractility
GTN - manage acute attacks of stable angina
Nitrates are converted to NO
NO= ↑cGMP and ↓Ca2+ in VSMC
- relaxation of venous vessels which ↓ cardiac preload and LV filling
- reduces cardiac work and myocardial oxygen demand
These relieve angina and cardiac failure
Side effects of the drugs selected in the regimen
ASPIRIN
- GI irritation
- Peptic ulcer + haemorrhage
- Bronchospasms
STATIN
- Headaches
- GI disturbances
GTN
- Headaches
- Flushing
- Light-headed
non-DHP CCB
- Headache
- Constipation
What non-pharmacological management advice would you give to Omar?
Balanced diet
Regular exercise
No smoking
No alcohol
Stable angina patient has been given the following:
- GTN spray
- statin
- CCB
- aspirin
What additional medication would you give the patient if they have diabetes w/stable angina?
ACE inhibitor
Non-dihydropyridine (diltiazem/verapamil) should never be used with B-blockers - Why?
Taken together may cause HF, bradycardia and even systole
