Stable Ischaemic Heart Disease and Angina Therapy

Question 1

what are the risk factors for SIHD and angina?

Answer 1

> hypertension
> smoking
> hyperlipidaemia
> hyperglyaemia
> male
> post-menopausal females

Question 2

what is the purpose of drug treatment?

Answer 2

> relieve symptoms
> halt disease process
> regress the disease process
> prevent myocardial infarction
> prevent death

Question 3

in an atheroma plaque what layer of artery is affected the most?

Answer 3

the intimal area

Question 4

how does stable angina arise?

Answer 4

a mismatch between myocardial blood/oxygen supply and demand

Question 5

how do drugs correct the supply and demand imbalance of oxygen in the myocardium?

Answer 5

Decrease myocardial oxygen demand:
> reduction of the heart rate
> reduction of the myocardial contractility
> reduction of afterload
Increase supply of oxygen to myocardium

Question 6

name 2 beta blocker used

Answer 6

> bisprolol

> atenolol

Question 7

what are beta blockers?

Answer 7

reversible antagonists for beta1 and 2 receptors

Question 8

what three things do beta blockers decrease?

Answer 8

> heart rate
contractility
systolic wall tension

Question 9

how do beta blockers improve perfusion of the sub-endocardium

Answer 9

by increasing diastolic perfusion time

Question 10

what do beta blockers protect cardiomyocytes from during ischemic episodes?

Answer 10

oxygen free radicals

Question 11

how do beta blocker increase the threshold at which angina occurs?

Answer 11

they reduce the heart rate, force of contraction and blood pressure so the balance point at which demand for oxygen outstrips the supply.

Question 12

what is rebound phenomena?

Answer 12

sudden cessation of beta blocker therapy may precipitate myocardial infarction

Question 13

what are the contraindications for beta blockers?

Answer 13

> asthma
> peripheral vascular disease
> raynauds syndrome
> heart failure (dependant on sympathetic system)
> bradycardia/heart block

Question 14

what adverse drug reaction can occur due to beta blockers?

Answer 14

> tiredness
> lethargy
> impotence
> bradycardia
> bronchospasm

Question 15

what drug-drug interactions with beta blockers can cause hypotension?

Answer 15

other hypotensive agents

Question 16

what drug-drug interactions with beta blockers cause bradycardia?

Answer 16

other rate limiting drugs such as verapamil or diltiazem

Question 17

what drug-drug interactions with beta-blocker cause cardiac failure?

Answer 17

negatively inotropic agents such as verapamil, diltiazem or disopyramide

Question 18

what drug-drug interactions with beta blockers agonise antihypertensive actions?

Answer 18

NSAIDs

Question 19

what are the drug drug interaction of beta-blockers and insulin/oral hypoglycaemics?

Answer 19

they exaggerate and mask hypoglycaemic actions of insulin or oral hypoglycaemics

Question 20

name three calcium channel blocker

Answer 20

> diltiazem
verapamil
amlodipine

Question 21

what is the action of calcium channel blockers?

Answer 21

they prevent calcium influx into myocytes and smooth muscle lining the arteries and arterioles by blocking the l-type calcium channels. this reduces vascular tone, afterload, heart rate and myocardial oxygen requirements.

Question 22

what are the effects of rate limiting calcium channel blocker?

Answer 22

they reduce heart rate and force of contraction

Question 23

what are the effects of vasodilating calcium channel blockers

Answer 23

they produce a reflex tachycardia

Question 24

why should you never use nifedipine immediate release?

Answer 24

there is evidence that the use of rapidly acting vasodilatory CCBs may precipitate and MI or stroke

Question 25

what are the contraindications of calcium channel blockers?

Answer 25

post MI (may increase morbidity and mortality) and unstable angina (increase infarction rate and death).

Question 26

name some adverse drug reaction from calcium channel blockers

Answer 26

> ankle oedema > headache > flushing > palpitations

Question 27

name three nitrovasodilators and their administration methods

Answer 27

> glyceryl trinitrate (sublingual, buccal, transdermal) > isosorbide mononitrate (sustained release formulation, tablets) > isosorbide dinitrate (sustained release formulation, tablets)

Question 28

describe the pharmacology of nitrovasodilators

Answer 28

they relax almost all smooth muscle by releasing NO which then stimulates the release of cGMP which produces smooth muscle relaxation.

Question 29

what is the effect of nitrovasodilators on preload and afterload?

Answer 29

they reduce preload and afterload

Question 30

how do nitrates relieve angina?

Answer 30

> arteriolar dilation (reduce cardiac afterload) > peripheral veno-dilation (reducing venous return, afterload) > relieves coronary vasospasm > redistributes myocardial blood flow to ischaemic areas

Question 31

what nitrate is used for prophylaxis?

Answer 31

oral nitrates given as a once a day sustained release

Question 32

what is used to rapidly treat angina pain?

Answer 32

GTN

Question 33

what is the main treatment of unstable angina?

Answer 33

intravenous nitrates used in combination with heparin

Question 34

how can tolerance to nitrates be overcome?

Answer 34

> giving asymmetric doses of nitrate 8am and 2pm | > using a sustained release preparation which incorporates a nitrate free period

Question 35

what adverse drug reactions can occur with nitrates?

Answer 35

> headache | > hypotension: GTN syncope

Question 36

what does nicorandil activate?

Answer 36

silent potassium channels

Question 37

what is the affect of nicorandil?

Answer 37

it allows entry of potassium into cardiac myocytes inhibiting the calcium influx, having a negative inotropic action.

Question 38

what problems arise due to nicorandil?

Answer 38

bowel ulceration

Question 39

what channel does ivabradine inhibit?

Answer 39

sinus node If channel

Question 40

what is the affect of ivabradine?

Answer 40

it slows diastolic depolarisation slope of the SA-node resulting in a reduction in heart rate and myocardial oxygen demand

Question 41

what does aspirin inhibit?

Answer 41

platelet thromboxane production

Question 42

what are the indications for aspirin?

Answer 42

> adults who are unable to tolerate/with a contraindication for the use of beta blockers > in combination wit beta blockers in patients inadequately controlled with an optimal beta-blocker dose

Question 43

what does clopidogrel inhibit?

Answer 43

ADP receptor activated platelet aggregation

Question 44

name three HMG CoA reductase inhibitors

Answer 44

> simvastatin > pravastatin > atorvastatin