Stable Angina ~ ✔ Flashcards
Stable angina
~ predictable chest pain or pressure (via physical exertion or emotional stress = increase in myocardial oxygen demand)
~ pain radiate to neck, shoulders, jaw or arms; pain relieved with rest
~ usually results from atherosclerotic plaques in coronary arteries that restrict blood flow & oxygen supply to heart;
~ can lead to CV complications i.e. stroke, unstable angina, myocardial infarction, & sudden cardiac death
Acute attacks of stable angina management
GTN sublingual
long-term prevention of chest pain in patients with stable angina
~ beta-blocker (atenolol, bisoprolol, metoprolol or propranolol) = 1st line therapy
~ rate-limiting CCB (verapamil or diltiazem) = alternative if BB contra-indicated, (Prinzmetal’s angina / decompensated heart failure)
~ Dihydropyridine derivative CCB (amlodipine) effective in patients with Prinzmetal’s angina.
If BB alone fails to control symptoms adequately, COMBO of BB & CCB. If this combination not appropriate due to intolerance of, or contra-indication to, either beta-blockers or CCB, consider addition of either long-acting nitrate, ivabradine, nicorandil, or ranolazine.
~ long-acting nitrate, considered as monotherapy in if cannot tolerate BB & CCB, if both contraindicated, or when they both fail to adequately control angina symptoms.
Response to treatment assessed every 2–4 weeks following initiation or change of drug therapy; drug doses titrated to maximum tolerated effective dose.
If combination of 2 drugs at maximum therapeutic dose fails to control angina symptoms, patients = referral to a specialist.
Secondary prevention of cardiovascular events
in stable angina
All patients with angina assumed at high-risk for CV events
~ occurrence of CV events prevented by management of CV risk factors through lifestyle changes (smoking cessation, weight, physical activity), psychological support, & drug tx.
All patients with stable angina due to atherosclerotic disease given long-term tx with low-dose aspirin & statin. TX with ACE inhibitor considered, particularly if diabetes
Non drug tx in stable angina
Revascularisation by coronary artery bypass graft or percutaneous coronary intervention
Acute stable angina attacks tx steps
Short acting nitrates
1. GTN
2. Isosorbide dinitrate (SL)
Long term prophylaxis of stable angina tx steps
~ long acting nitrates
1. MR isosorbide dinitrate
2. Isosorbide mononitrate
~ Beta blockers
~ CCBs
~ Ivabradine
~ Ranolazine
~ Nicorandil
Acute stable angina attack
- GTN (SL or spray)
lasts 20-30 mins
if using twice a week = long term prophylaxis
GTN SL expiry
8 weeks after opening
foil-lined no cotton wadding
GTN administration in stable angina
PRN or before angina-inducing activity e.g. exercise
- take sitting down
1st dose under tongue & wait 5 mins
2nd dose & wait 5 mins
3rd dose & wait 5 mins
(1 dose = 1 tab or 1-2 sprays)
if pains persists = 999
Stable angina prophylaxis after GTN
- Beta blocker OR CCB (diltiazem)
- Beta blocker + dihydropyridine CCB (Amlodipine, MR nifedipine, felodipine) = max 2 drugs
—– if one or both contraindicated = add/use vasodilator (long acting nitrate) !
Vasodilator in stable angina
long acting nitrates
Ivabradine (only in sinus rhythm)
Ranolazine
Nicorandil
Nicorandil MHRA alert
now given as 2nd line
- ulcer complications: mouth skin, eye, GI
- do not drive until established performed is not impaired
Nitrates MOA
potent coronary vasodilators
reduce venous return and cardiac output
short acting nitrates e.g.
GTN
Long acting nitrates e.g.
Isosorbide mononitrate - BD (MR prep taken OD)
MR isosorbide dinitrate BD (SL, alternative to GTN)
Nitrate and tolerance & how
with long-acting prep / transdermal patches
===> maintain effectiveness by reducing blood nitrate Cp to low levels for 4-12 hours a day by
- Leave patch off for 8-12 hours - overnight
- Take 2nd dose after 8 hours not 12h for MR isosorbide dinitrate (BD) and Isosorbide mononitrate (BD
- MR isosorbide mononitrate taken OD so no tolerance !
Nitrates SIDE EFFECTS
- vasodilation
- flushing
- throbbing headache
- dizziness
- postural hypotension
- tachycardia
- dyspepsia
- heartburn
Nitrates injections (GTN/ isosorbide dinitrate in MI) side effects
- severe hypotension
- sweating
- apprehension
- restlessness
- muscle twitching
- retrosternal discomfort
- palpitations
Nitrates and stopping
avoid abrupt withdrawal of nitrates (and CCbs) = worsen angina
