Vasodilators and the Angina pectoris

Question 1

What are the 3 drug classes mainly used for angina

Answer 1

nitrates
CCBs
Beta blockers

Question 2

How does medication help with angina

Answer 2

decreases how much oxygen the heart needs by decreasing one or more of these things: heart size, heart rate, blood pressure, and contractility

Question 3

Nitrates and calcium channel blockers may help by angina by___ and help variant angina by ____

Answer 3

causing a redistribution of coronary flow and increase oxygen delivery to ischemic tissue
In variant angina, they help by reversing coronary artery spasm.

Question 4

Nitro: What are the 3 considerations

Answer 4

store in an air tight container due to loss of potency
may develop tolerance
due to low bioavailability, sublingual route is preferred to achieve rapid response; sustained effect is limited to 15-30 minutes

Question 5

Nitro: must be stored in

Answer 5

air tight container due to loss of potency

Question 6

Nitro: patient may develop

Answer 6

tolerance

Question 7

Nitro: due to low bioavailability,

Answer 7

sublingual route is preferred to achieve rapid response; sustained effect is limited to 15-30 minutes

Question 8

Isosorbide: 2 considerations

Answer 8

you might develop tolerance

isosorbide mononitrate is the active metabolite of isosorbide dinitrate and has 100% bioavailability.

Question 9

Whats the main target of nitrates

Answer 9

vascular smooth muscle

Question 10

All 7 Effects of Nitrates:

Answer 10

1. Veins relax so you have less ventricular preload
2. Pulmonary vascular pressures decrease
3. Heart size is reduced.
4. In the absence of heart failure, cardiac output is reduced.
5. In heart failure, preload is often abnormally high; the nitrates and other vasodilators, by reducing preload, may have a beneficial effect on cardiac output in this condition
6. The indirect effects of nitroglycerin are tachycardia and increased cardiac contractility.
7. Retention of salt and water, especially with intermediate- and long-acting nitrates. These compensatory responses contribute to the development of tolerance.

Question 11

Effects of Nitrates: Veins relax so you have

Answer 11

less ventricular preload

Question 12

Effects of Nitrates: Pulmonary vascular pressures

Answer 12

decrease

Question 13

Effects of Nitrates: Heart size is

Answer 13

reduced

Question 14

Effects of Nitrates: In the absence of heart failure,

Answer 14

cardiac output is reduced.

Question 15

Effects of Nitrates: In heart failure,

Answer 15

preload is often abnormally high; the nitrates and other vasodilators, by reducing preload, may have a beneficial effect on cardiac output in this condition

Question 16

Effects of Nitrates: The indirect effects of nitroglycerin are

Answer 16

tachycardia and increased cardiac contractility.

Question 17

Effects of Nitrates: Retention of

Answer 17

salt and water, especially with intermediate- and long-acting nitrates. These compensatory responses contribute to the development of tolerance.

Question 18

4 Adverse effects of Nitrates

Answer 18

orthostatic hypotension
tachycardia
headache
tolerance

Question 19

Angina of effort

Answer 19

myocardial oxygen requirement increases, especially during exercise, and coronary blood flow does not increase proportionately
Not enough blood flow in the presence of CAD, also known as classic angina

Question 20

Nitrates can be used for 3 types of Angina

Answer 20

Angina of effort
Variant angina
Unstable angina

Question 21

Variant angina

Answer 21

sometimes you have blood vessel spasms, usually associated with underlying atheromas, can also cause significant myocardial ischemia and pain (vasospastic or variant angina). Vasospastic angina is also called Prinzmetal angina.

Question 22

Unstable angina

Answer 22

acute coronary syndrome, is said to be present when episodes of angina occur at rest and there is an increase in the severity, frequency, and duration of chest pain in patients with previously stable angina. Increased coronary artery resistance or small platelet clots occurring in the vicinity of an atherosclerotic plaque. Associated with increased risk of MI

Question 23

All of the ways that CCBs help with angina:

Answer 23

• Decreasing myocardial contractile force, which reduces myocardial oxygen requirements
• They decreases arterial and intraventricular pressure by blocking arterial smooth muscle
• Stress on the left ventricular wall decreases
• They stop coronary artery spasm
• The sinus node rate is decreased
• AV node conduction slows down
• Verapamil and diltiazem also have their own special way, which is that they have an antiadrenergic effect

Question 24

CCBs help with angina by decreasing ___ ___ ___, which reduces myocardial oxygen requirements

Answer 24

myocardial contractile force

Question 25

CCBs help with angina by decreasing ___ and ___ ___ by blocking arterial smooth muscle

Answer 25

arterial and intraventricular pressure

Question 26

CCBs help with angina by decreasing stress on the ___ wall

Answer 26

ventricular wall

Question 27

CCBs help with angina by stopping ___ ___ spasm

Answer 27

coronary artery spasm

Question 28

CCBs help with angina by the ___ node rate is ____

Answer 28

sinus node rate is decreased, and so is the AV node

Question 29

CCBs help with angina, verapamil and diltiazem spefically help because

Answer 29

they have an antiadrenergic effect

Question 30

Is it possible to have so much calcium that the CCBs don't work?

Answer 30

It's possible, but it's unlikely because the levels of calcium would have to be super high. Sympathomimetics can increase calcium getting into the cells, which obviously isn't good for CCBs

Question 31

calcium channel blockers are ___ active agents

Answer 31

orally

Question 32

CCBs have ___ ___-pass effect

Answer 32

high first-pass effect

Question 33

CCBs have ____ ____ ____ binding

Answer 33

high plasma protein binding

Question 34

CCBs have ____ metabolism

Answer 34

extensive metabolism

Question 35

What are the three things that characterize CCBs

Answer 35

high first-pass effect high plasma protein binding extensive metabolism

Question 36

Verapamil and diltiazem routes

Answer 36

oral and IV

Question 37

3 Clinical Uses of Verapamil and diltiazem

Answer 37

arrhythmias (AF and atrial flutter) Unstable angina Postinfarction angina

Question 38

Clinical Uses of Verapamil and diltiazem: arrhythmias such as

Answer 38

AF and atrial flutter

Question 39

What should you know about CCBs for treating unstable angina

Answer 39

immediate-release short-acting calcium channel blockers can increase the risk of adverse cardiac events and therefore are contraindicated

Question 40

Clinical Uses of diltiazem: Postinfarction angina

Answer 40

Diltiazem can decrease the frequency of and may be used for patients with non–Q-wave myocardial infarction

Question 41

What in general should you know about Adverse Effects of CCBs

Answer 41

Adverse effects are rare, but can include really bad things: serious cardiac depression, including bradycardia, atrioventricular block, cardiac arrest, and heart failure They can also cause less serious stuff like edema and constipation with verapamil

Question 42

Clinical use for beta blockers

Answer 42

Stable angina

Question 43

How do beta blockers help with stable angina

Answer 43

decreased heart rate, blood pressure, and contractility, which means there's less oxygen demand. Also, since the heart is going slower there is more time for perfusion.

Question 44

5 beta blocker Contraindications

Answer 44

``` asthma severe bradycardia AV block bradycardia-tachycardia syndrome Severe unstable left ventricular failure ```

Question 45

Adverse effects of Beta blockers

Answer 45

``` impaired exercise tolerance insomnia, unpleasant dreams, worsening of claudication, and erectile dysfunction. ```

Question 46

Summary: Stable angina can be treated with

Answer 46

Nitrates CCBs BBs

Question 47

Summary: Vasospastic angina can be treated with

Answer 47

Nitrates | CCBs

Question 48

Summary: Unstable angina and acute coronary syndrome

Answer 48

Nitrogylcerine BBs and for refractory cases CCBs