Treatment of Angina

Question 1

Angina is a problem of?

Answer 1

Demand > supply

Question 2

This angina presents with prolonged and frequent pain and is associated with MI

Answer 2

Unstable angina

Question 3

This angina is from a reduction in coronary blood flow due to vasospasm

Answer 3

Variant angina

Question 4

This angina is exercise induced

Answer 4

Exertional angina

Question 5

What are the 3 approaches for treating angina?

Answer 5

1. Increase coronary BF
2. Decrease myocardial O2 consumption (by decreasing HR and contractility)
3. Prevent platelet aggregation (aspirin)

Question 6

Prototype nitrate?

Answer 6

Nitroglycerin

Question 7

Nitrates give off NO which vasodilates. Describe the mech of action of how it does this

Answer 7

NO activates guanylyl cylcase which increases cGMP which activates protein kinase G which induces smooth muscle relaxation which causes vasodilation

Question 8

Does NO act on arteries, veins, or both?

Answer 8

BOTH!!

Question 9

The venodilatory effect of NO causes?

Answer 9

Decreased preload

Question 10

Adverse effects of nitrates (4)

Answer 10

1. Hypotension
2. Reflex tachycardia
3. Headache
4. Rash

Question 11

Bigtime contraindication for nitrates?

Answer 11

Boner pills- type 5 PDE inhibitors

Question 12

How are nitrates metabolized?

Answer 12

In the liver by glutathione-organic nitrate reductase. Dont give nitrates po. Give them IV, transdermal, sublingual

Question 13

Pts can eventually tolerate nitrates. How do you prevent this?

Answer 13

Have nitrate free intervals every day. Usually best to do at night when you are not exerting yourself anyway

Question 14

Why are the Ca2+ channel blockers verapamil and diltiazem cardiac specific?

Answer 14

They are use-dependent. The Ca2+ channels in the SA and AV nodes in the heart are used all the dang time!

Question 15

Why are the Ca2+ channel blockers DHPs vasculature specific?

Answer 15

They are voltage dependent. Vessels have a more constant voltage and are not used as much as the Ca2+ channels in the SA or AV node

Question 16

What are the effects of verapamil and diltiazem on the heart?

Answer 16

Slows HR, decreases contractility, and slows AV conduction. Prevents or reverses vasospasm

Question 17

What are the DHP’s antianginal effects?

Answer 17

Vasodilates so increases coronary BF and decreases afterload

Question 18

Which Ca2+ channel blocker would it make sense to combine with a beta blocker?

Answer 18

The DHPs. Beta blockers would prevent the reflex tachycardia brought on by DHPs

Question 19

What is the best drug class to use for treating angina?

Answer 19

beta blockers

Question 20

What are the beta blocker’s antianginal effects?

Answer 20

1. Blunts HR and inotropic response to exercise
2. Reduce afterload (via CNS effect)
3. Do NOT prevent coronary vasospasm

Question 21

Ca2+ channel blockers are good for pts in which beta blockers are contraindicated. What pts would this include?

Answer 21

Pts with asthma, COPD

Question 22

Best treatment for angina is beta blocker. What drug classes could you add to the beta blocker for better effects?

Answer 22

Nitrates or DPH (Ca2+ channel blockers)

Never combine beta blockers and verapamil/diltiazem!!!

Question 23

A sinus bradycardia, AV block, or valvular deficiency would favor which type of Ca2+ channel blocker?

Answer 23

DHP- the “pines”

Question 24

Indications for verapamil/diltiazem for angina?

Answer 24

asthma, COPD, severe peripheral vascular disease

Question 25

This is a new, expensive drug that has indications to treat angina in combo with beta blockers, amlodapine, or nitrates

Answer 25

Ranolazine