Anti Anginals

Question 1

three types of angina

Answer 1

chronic stable
unstable
prinzmetal (variant)

Question 2

what is chronic stable angina caused by and what does it lead to

Answer 2

chronic narrowing of coronary arteries due to atherosclerosis leading to increased oxygen demand –> pain with a predictable threshold of physical activity

Question 3

what is unstable angina caused by and what does it lead to

Answer 3

transient formation and dissolution of a blood clot within a coronary artery due to an atherosclerotic plaque rupture –> reduction in oxygen supply

Question 4

what is prinzmetal variant angina caused by

Answer 4

coronary spasm which temporarily reduces coronary blood flow

Question 5

short term and long term goals of antianginal therapy

Answer 5

short term: reduce or prevent anginal symptoms that limit exercise capability and quality of life

long term: prevent MI, arrhythmias, heart failure, and extend pt’s life

Question 6

what does angina result from

Answer 6

reduction in oxygen supply/demand ratio hence anti anginals improve this ratio

Question 7

drugs used to treat angina

Answer 7

• vasodilators (increase oxygen supply and decrease oxygen demand): calcium channel blockers and nitrates
• cardioinhibitory drugs (decrease oxygen demand): beta blockers and calcium channel blockers
• ranolazine: sodium channel blocker
• anti thrombotic drugs: anti coagulants and anti platelet drugs

Question 8

what are the calcium channel blockers

Answer 8

VAND
verapamil
amlodipine
nifedipine
diltiazem

Question 9

what are calcium channel blockers used to treat

Answer 9

• hypertension, angina, and arrythmias

- treats all three types of angina: chronic stable, unstable angina, prinzmetal angina

Question 10

what are used in combination with dihydropyridines and why

Answer 10

beta blockers are used with amlodipine and nifedipine because of reflex tachycardia

also used if beta blockers are contraindicated

Question 11

what are the anti-anginal effects of CCBs

Answer 11

increased vasodilation –> increased oxygen supply

cardiodepressant –> reduce oxygen demand

Question 12

importance of CCB dilating the coronary arteries other than increasing oxygen supply

Answer 12

reverse coronary vasospasm that occurs in prinzmetal variant angina

Question 13

adverse effects of calcium channel blockers

Answer 13

• dihydropyridines: reflex tachycardia, dizziness, flushing, headache, hypotension, constipation, and peripheral edema
• non-dihydropyridines: cardiac conduction abnormalities (bradycardia, AV block and heart failure), anorexia, nausea, hypotension, peripheral edema

Question 14

contraindications for CCBs

Answer 14

bradycardia, conduction defects, heart failure

Question 15

nitrates used to treat angina

Answer 15

isosorbide dinitrate
isosorbide mononitrate
nitroglycerin
sodium nitroprusside

Question 16

clinical application of nitrates (name them again)

Answer 16

isosorbide dinitrate, isosorbide mononitrate, nitroglycerin, sodium nitroprusside

for stable, unstable, and variant

nitrogylcerin: first line for acute anginal symptx
nitroprusside: emergency and ICU settings
isosorbide mononitrate and dinitrate: prophylaxis

Question 17

mechanism of nitrates

Answer 17

they work via NO

• relax vascular smooth muscle (vasodilation)
• inhibit platelet aggregation (anti-thrombotic)
• inhibiting leukocyte endothelial interactions (anti-inflammatory)

Question 18

why does tolerance develop rapidly with nitrates and how is it overcome?

Answer 18

vessels become desensitized to the vasodilatory effects of nitrates

overcome by infrequent dosing with smallest amount possible

Question 19

of all the nitrates which has longest half life and importance

Answer 19

isosorbide dinitrate and mononitrate

impo because it can be used for long term therapy

Question 20

adverse effects of nitrates

Answer 20

hypotension
reflex tachycardia
headache (cerebral vasodilation)
facial flushing
nitroprusside - cyanide toxicity

Question 21

contraindication of nitrates and why

Answer 21

sildenafil (cGMP dependent phosphodiesterase) used to tx erectile dysfunction –> inhibits breakdown of cGMP –> increase in plasma cGMP –> hypotension and impaired coronary perfusion

Question 22

beta blockers used for anginas

Answer 22

MAP
metoprolol
atenolol
propanolol

Question 23

clinical use of beta blockers in angina

Answer 23

pts with stable angina who have had ACS (acute coronary syndrome - STEMI, nonSTEMI) or who have left ventricular dysfunction

Question 24

what are the anti anginal effects attributed to beta blockers

Answer 24

they reduce workload of the heart hence decreasing oxygen demand

Question 25

adverse effects of beta blockers

Answer 25

- hypoglycemia - bronchoconstriction - CNS effects - disturbed lipid metabolism - CV effects: bradycardia, heart failure, hypotension, heart failure, reduced exercise capacity - drug withdrawal: abrupt cessation can cause unstable angina, MI, or death due to upregulation of beta receptors during blockade

Question 26

contraindications for beta blockers

Answer 26

- restrictive airway disease (COPD, asthma) - sinus bradycardia and partial AV block - heart failure - variant angina: beta blockers reduce oxygen demand which cannot treat problem here which is reduced oxygen supply

Question 27

what is ranolazine used

Answer 27

alternative option for pts with chronic angina that have failed all other therapies

Question 28

mechanism of action for ranolazine

Answer 28

blocks sodium current which prevent calcium overload within the cell leading to improved coronary flow typically Na late inward current lead to Ca inward current via the Na/Ca exchanger --> Ca leads to contraction of myocytes and impaired relaxation hence worsening the ischemia

Question 29

adverse effects of ranozaline

Answer 29

``` QT prolongation (increases ventricular depolarization) nausea, vomiting, dizziness, constipation ```

Question 30

contraindication of ranozaline

Answer 30

pts with QT prolongation --> risk of torsades de pointes and ventricular arrhythmias

Question 31

treatment of acute attack of stable angina

Answer 31

nitroglycerin or rest

Question 32

maintenance therapy for stable angina

Answer 32

- long acting nitrates plus beta blockers are preferred - CCBs when beta blocker not successful or contraindicated - ranozaline when nitrates, beta blocker, and CCBs not successful -aspirin and aggressive cardiovascular risk reduction should be part of maintenance therapy

Question 33

tx for acute attack of unstable angina (usually occurs between stable angina and MI)

Answer 33

nitroglycerin or rest

Question 34

long term maintenance of unstable angina

Answer 34

nitroglycerin and beta blockers

Question 35

drug used for symptomatic treatment of variant prinzmetal angina

Answer 35

nitroglycerin and calcium channel blockers