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Flashcards in Anti-Anginals - Duan Deck (33):

What is Angina pectoris?

Chest pain due to temporary ischemia WITHOUT necrosis of heart tissue.


What causes pain in Angina pectoris?

Heart tissue is not getting enough oxygen and nutrients to meet metabolic demand and you have reversible damage to myocytes.


What are the clinical symptoms of Angina pectoris?

1. chest pain or discomfort that may radiate to arms, neck, jaw, shoulders or back
2. nausea
3. fatigue
4. dyspnea
5. diaphoresis
6. dizziness


Typically Angina pectoris is associated with what?



What are the types of Angina pectoris?

1. unstable
2. stable
3. Prinzmetal


Describe stable angina.

1. typically occurs with atherosclerosis
2. occurs with exertion or exerise and stress, NOT at rest
3. atherosclerosis has caused stenosis of the coronary arteries and there is a reduction in blood flow
4. this blood flow is adequate at rest but is insufficient during exertion or stress
5. symptoms last less than 20 minutes so injury is reversible
6. can be relieved by rest or nitroglycerin
7. shows ST depression on EKG


Describe unstable angina.

1. typically occurs with atherosclerosis
2. if a plaque ruptures then thrombotic constituents are exposed and a thrombus forms that partially occludes the vessel so that not enough blood can flow through to meet metabolic demands even at rest
3. often occurs at rest, while sleeping or with very little physical exertion
4. may last up to 20-30 minutes but does not cause necrosis
5. is not relieved by rest but is relieved by nitroglycerin
6. shows ST depression on EKG


What is a variant type of Angina that does not involve atherosclerosis?

Prinzmetal Angina. This is caused by vasospasm that transiently blocks a coronary artery.


Describe Prinzmetal angina.

1. angina due to transient coronary vasospasm
2. usually lasts for less than 20 minutes so injury is reversible but can cause MI if it lasts for longer than 20-30 minutes
3. caused by exposure to cold, emotional stress, certain meds, smoking, cocaine use
4. can occur at rest or during sleep
5. is relieved by nitro or calcium channel blockers
6. shows ST elevation on EKG because it is transmural injury


An MI may occur when?

When there is acute and complete coronary artery occlusion that lasts longer than 20 minutes. The hallmark is necrosis of myocardium.


What are the 2 general goals of anti- anginals?

1. increase oxygen supply
2. decrease oxygen demand


What types of therapies can increase coronary blood flow?

1. nitrates
2. calcium channel blockers
3. stents
4. angioplasty
5. bypass surgery


What types of therapies increase regional myocardial blood flow?

1. nitrates
2. calcium channel blockers
3. B-blockers
4. chronic use of statins
5. chronic use of aspirin


What types of therapies work on heart rate to decrease oxygen demand?

1. calcium channel blockers
2. B-blockers


What types of therapies work on contractile force to decrease oxygen demand?

1. calcium channel blockers
2. B-blockers


What type of therapy decreases preload of the heart to reduce oxygen demand?



What type of therapies decrease afterload on the heart to decrease oxygen demand?

1. nitrates
2. calcium channel blockers


What is the mechanism of action (MOA) of organic nitrates such as nitroglycerin?

1. Dilation of veins - this causes decreased venous return and decreased preload on the heart so this will help to decrease the work of the heart and will decrease oxygen demand
2. dilation of arteries - this decreases peripheral resistance and decreases afterload on the heart so it will help to get more blood to heart and increase oxygen supply while also decreasing the work of the heart and decreasing oxygen demand
3. dilation occurs because nitrates cause increased NO which causes increased cGMP which causes relaxation of the vessels.


Describe the pharmacokinetics of nitrates.

1. high lipid solubility
2. metabolized by nitrate reductase in the liver
3. given sublingually to avoid the liver and first pass effect - this results in rapid onset of action of about 30 seconds to 3 minutes
4. duration of action is about 30-60 minutes of the sublingual tablet


What are the adverse effects of nitrates?

1. headache
2. postural hypotension
3. methemoglobinemia
4. nitrates can cause reflex tachycardia but will not if given with beta blockers or calcium channel blockers


What are two things that may happen with use of nitrates that should be avoided?

1. tolerance - repeated exposure may cause
2. dependence


What is the main nitrate in use?

Nitroglycerin - also called Nitroprin.


What are some other nitrates that can be used?

1. Amyl nitrate - dilates arteries, does not last as long as nitroglycerin
2. Isosorbide dinitrate - is long acting
3. Erythrityl tetranitrate - used to treat chronic, stable angina and can be used prophylactically
4. Pentaerythritol tetranitrate - very similar structurally to nitroglycerin but with longer onset and longer duration


How are B-blockers used to treat Angina?

1. can be used prophylatically
2. block beta adrenergic receptors of the heart so that heart rate and contractile force is decreased leading to decreased oxygen demand
3. decreased heart rate and contractility lead to a decrease in blood pressure which leads to decreased afterload and decreased oxygen demand


Name the main Beta blocker used.

1. Propranolol - also called Inderal


Name the calcium channel blockers used?

1. Nifedipine or Procardia
2. Verapamil or Isopin
3. Diltiazem or Cardizem


How do calcium channel blockers work?

1. they are vasodilators
2. vasodilators lead to decreased blood pressure, decreased after load and decreased oxygen demand
3. they are also extremely potent coronary vasodilators which increases coronary and regional blood flow which increases oxygen demand - so they are very good at treating vasospasm


What is a new drug that is used to treat chronic angina?

Ranolazine. This drug reduces calcium levels in cardiac myocytes.


What drugs are used to treat stable angina?

1. nitrates
2. calcium channel blockers
3. B-blockers
4. aspirin


What drugs are used to treat unstable angina?

1. nitrates
2. calcium channel blockers
3. B-blockers
4. aspirin


What drugs are used to treat variant or Prinzmetal angina?

1. nitrates
2. calcium channel blockers


What drugs are used to treat MI?

1. nitrates
2. B-blockers
3. aspirin
4. fibrinolytic drugs


What are some other therapies used in conjunction with anti-anginals to treat angina?

1. other meds such as ACE inhibitors, oral anti-platelet drugs, statins and anticoagulants. These help to lower BP and cholesterol, slow heart rate, prevent blood clots and dilate vessels
2. lifestyle changes to prevent episodes of angina
3. medical procedures can be used if meds and lifestyle changes don't work - examples include angioplasty, CABG