Treatment of Angina

Question 1

what shrinks the window between systole

Answer 1

• Shorteningdiastole
– e.g. increased heart rate
• Increased ventricular end diastolic pressure
– e.g. aortic valve stenosis
• Reduced diastolic arterial pressure
– e.g. mitral or aortic valve incompetence, heart failure

Question 2

Coronary ischaemia

Answer 2

usually the result of atherosclerosis

– Causes angina

Question 3

Sudden ischaemia

Answer 3

usually caused by thrombosis

- may result in cardiac infarction

Question 4

Coronary spasms

Answer 4

sometimes causes angina

– “variant” angina

Question 5

Cellular calcium over load results from ischaemia

Answer 5

– may cause cell death and dysrhythmias

Question 6

Angina Pectoris

Answer 6

• Chest pain due to inadequate supply of oxygen to the heart – Typicallysevereandcrushing
– “Tight, constricting, dull or heavy”–SIGN Guidelines

Question 7

Characteristic distribution of pain

Answer 7

– Often retrosternal, or left side of chest and can radiate to left arm,
neck, jaw and back
– Brought on by exertion, cold or excitement
– Thought chemical factors that cause pain in skeletal muscle (i.eK+,H+ and adenosine) are responsible

Question 8

stable angina

Answer 8

– Predictable chest pain on exertion

– Caused by a fixed narrowing of the coronary arteries

Question 9

• Unstable Angina

Answer 9

– Occurs at rest and with less exertion than stable angina
– Associated with a thrombus around a ruptured atheromatous plaque
but without complete occlusion of the vessel (similar to MI)

Question 10

• Variant (Prinzmetal) Angina

Answer 10

– Uncommon
– Caused by coronary artery spasm
– Not completely understood, but sometimes associated with atherosclerosis

Question 11

Treatments to reduce chest pain symptoms

Answer 11

– Beta-blockers
– Nitrates
–Calcium channel antagonists
– Nirocandil 
– Ivabradine 
– Ranolazine

Question 12

Treatments to prolong survival

Answer 12

– Beta-blockers
– Aspirin
– Statins
- (Angiotensin Converting Enzyme Inhibitors) 
– (Angiotensin II Receptor Blockers)

Question 13

Treatment of symptoms

Answer 13

Offer short-acting nitrate for preventing/treating episodes of angina.

Question 14

Offer first-line treatment:

Answer 14

– Usually a β-blocker, but a calcium channel blocker (CCB)
can be considered if not optimal

If bode ineffective the other option is contraindicated, nicornadil or ivabradine

Question 15

Antianginal drugs

Answer 15

• Mainly work by ↓ the metabolic demand of the muscle
• Organic nitrates, nicorandil and calcium antagonists are vasodilators
– ↓ preload or afterload
• b-blockers and ivabradine slow down the heart – ↓ the metabolic demand of the muscle

Question 16

Glyceryl trinitrate and isosorbide mononitrate

Answer 16

– Powerful vasodilators
– Work by being metabolised to nitric oxide (NO) and relax smooth muscle (particular vascular smooth muscle)
– Act on veins to ↓ cardiac preload
• Higher concentrations can affect arteries,↓a Herload
– ↓ cardiac workload is helped by dilaIon of collateral coronary vessels

Question 17

– ↓ cardiac workload is helped by dilaIon of collateral coronary vessels

Answer 17

• Improves distribution of coronary blood flow towards ischaemic areas
• Dilation of constricted coronary vessels is particularly beneficial in variant angina

Question 18

Clinical Uses of Organic Nitrates in Angina - stable angina

Answer 18

– Prevention by sublingual glyceryl trinitrate shortly before
exertion or isosorbide mononitrate long before

Question 19

Clinical Uses of Organic Nitrates in Angina - unstable angina

Answer 19

– intravenous glyceryl trinitrate (GTN)

Question 20

Clinical Uses of Organic Nitrates in acute heart failure

Answer 20

– intravenous GTN

Question 21

Clinical Uses of Organic Nitrates in Chronic Heart Failure(CHF)

Answer 21

– isosorbide mononitrate with hydralazine in patients of African American origin especially, (or patient cannot tolerate more commonly used CHF drugs)

Question 22

b-blockers

Answer 22

• Important (first line treatment) in the prophylaxis and
treatment of stable and unstable angina
• ↓cardiac oxygen consumption by slowing the heart
• Also have an antidysrhythmic action
– reduce death after MI
• Bisoprolol,Atenolol

Question 23

Calcium Channel Blockers (CCBs)

Answer 23

• Two main types:
– Dihydropyridine derivatives, e.g.amlodipine and lercanidipine
– Rate-limiting, e.g.verapamil and diltiazem

Question 24

Action of Calcium Channel Blockers (CCBs)

Answer 24

• Preventing opening of voltage-gated L-type Ca2+ channels
– blockCa2+entry
– Mainly affect the heart and smooth muscle to inhibit calcium entry upon muscle cell depolarisation

• Vasodilator effect mainly on resistance vessels
– reducesafterload
– also dilate coronary vessels (important in variant angina)

Question 25

• Verapamil and diltiazem

Answer 25

can reduce and impair AV conduction and myocardial contractility

Question 26

– Amlodipine or lercanidipine

Answer 26

safe in patients with heart failure, used instead of a Beta-Blocker in Prinzmetal angina or alongside beta-blockers in most angina

Question 27

– Diltiazem or verapamil

Answer 27

used but contraindicated in heart failure, bradycardia, AV block or in presence of Beta-Blocker

Question 28

side effects of CCBs

Answer 28

– headache, constipation, ankle oedema

Question 29

• Antidysrhythmics

Answer 29

– Mainly verapamil
• Slows ventricular rate in rapid atrial fibrillation
• Prevents recurrence of supraventricular tachycardia(SVT)
• No effect on ventricular arrhythmias

Question 30

• Hypertension

Answer 30

– Mainly amlodipine or lercanidpine

Question 31

Potassium Channel Activators

Answer 31

• Nicorandil
– combines activation of potassium K+ATP channels
with nitrovasodilator actions
• Causes hyperpolarisation of vascular smooth muscle
– both an arterial and venous dilator
– causes headaches, flushing and dizziness
– used for patients who remain symptomatic despite optimal management with other drugs

Question 32

• Ivabradine

Answer 32

– Inhibits funny “f”-type channels in heart

– Reduces cardiac pacemaker activity •  inhibits heart rate

Question 33

• Ranolazine

Answer 33

– Unique anti-anginal used as a last resort