antianginal drugs

Question 1

angina def

Answer 1

episodes of reversible myocardial ischemia,

inducible by exercise, emotion or other stress;

It is reproducible and are commonly associated with transient chest discomfort.

Question 2

Classification according to the new york heart association

Answer 2

Class I : No limitation of physical activity (Ordinary physical activity does not cause symptoms).
Class II : Slight limitation of physical activity (Ordinary physical activity does cause symptoms).
Class III : Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms).
Class IV : Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest).

Question 3

3 groups of drugs according to their effect in angin a

Answer 3

1. symptomatic relievers
2. prognosis improvers
3. metabolic agents

Question 4

list the symptomatic releiver drugs

Answer 4

bb
ccb
organic nitrates
selective if inhibitors

Question 5

list the prognostic improving drugs

Answer 5

antiplatelets
statins
ace inhibitors
arbs

Question 6

list the metabolic agents

Answer 6

trmetazidine

ranolazine

Question 7

effects of bb on the heart in angina

Answer 7

Prolong diastole(-ve dromotropy)> Increase perfusion of ischemic areas 
 -ve chromotropy 
Reduce 02 demand
-ve inotropism 
-ve chromotropism 
These 2 effects reduce blood pressure

Question 8

indications of bb in angina

Answer 8

Post MI
Stable angina w/o CI
Silent ischemia
Cold induced angina ( just as effective as CCB)

Question 9

drug combo of bb in angina

Answer 9

COMBO w/ dihydropyridines
Combo w/ nitrates
Never w/ non dihydro’s- same action => HF and Hypotension.
Not w/ neuroleptics-> hypotension

Question 10

bb used in angina w/ co-existing systolic heart failure

Answer 10

β1-selective blockers BISOPROLOL and METROPOLOL, or a

beta-blocker with additional vasodilating effects (CARVEDILOL and NEVIBILOL) in gradually increasing doses

Question 11

bb used in angina w/ thyrotoxicosis

Answer 11

beta-blockers W/O intrinsic sympathomimetic activity e.g.

PROPANOLOL
(blocks the conversion of T4 to T3).

Question 12

bb used in angina w/ liver failure

Answer 12

hydrophilic beta-blockers (atenolol) due to renal excretion,

beta-blockers with dual route of elimination – urine and bile (bisoprolol).

Question 13

bb used in angina w/ renal insufficiency

Answer 13

FAT SOL beta-blockers because they undergo extensive first-pass metabolism in the liver.

propanolol & metropolol

Question 14

dosing principles of bb in angina

Answer 14

HR at rest should be: 55-60bpm
HR at exertion: max 75% of resting HR / 100BPM
Severe stable: <50bpm w/o CM’s of bradycardia heart block
ECG stress test is reduced while using BB

Question 15

dihidropyridine classification

Answer 15

1st gen: nifedipine: 10 mg. short acting. 3x/24hr. Blocks Ca2+ in vascular smooth muscle->VD->increased myocardial bf and O2 supply
2nd gen: felodioine: 10mg. Imdt acting. 2x/day
3rd gen: amlodipine: 10mg. Long acting

Question 16

non dihydriopryidine classification

Answer 16

Inferior to BB post MI, and in CHF
Used when BB

verapamil
diltiazem

Question 17

when are CCB used

Answer 17

when BB are contraindicated

Ideal for prinzmetal angina as they prevent spazm. BB favour spasm in prinzemetal due to unopposed alpha receptor action

Question 18

which class of ccb is preferred in systolic heart failure

Answer 18

DHP> non DHP

non DHP reduce CO

Question 19

which class of ccb is preferred in renal failuire

Answer 19

non DHP> DHP

because DHP strongly bind to pp but hypoproteinemia occurs in renal failure -> increased level of free drugs-> increased toxic

Question 20

drug combo of CCB

Answer 20

DHP combo w/ bb not non DHP-same effect

Non DHP comb w/ nitrates, not DHP-same vasodilating effect -> hypotensh

Question 21

classification of organic nitrates

Answer 21

Glyceryl trinitrate
Nitroglycerin – sublingual tab. 0,5 mg;

Nitroglycerine – lingual aerosol (each dose contains 0,4 mg).

Isosorbide mononitrate - tab. 20 mg

Isosorbide dinitrate - tab. 10 mg, slow release tab. 40 mg; spray (each dose contains 1,25 mg) 15 ml.

Question 22

effects of organic nitrates on the heart in angina

Answer 22

• dilate venous capacitance vessels and lower left ventricular filling pressure (“preload”).
• dilate arterial resistance vessels and reduce ventricular emptying (“afterload”).
• Reduce myocardial oxygen demand
• have little effect on the total coronary flow but improve the blood flow through collateral vessels.

-relieve coronary artery spasm.
Increase myocardial oxygen supply

-Don’t actually reduce mortality of angina only symptoms

Question 23

when are nitrates prescribed over CCB

Answer 23

if the dual therapy of BB and CCB is ineffective

Question 24

short acting nitrates

Answer 24

Nitroglycerin spray: faster acting
Nitroglycerin sublingual
standard initial therapy for effort angina.

• (0.3–0.6 mg) every 5 min until the pain goes/
• a maximum of 1.2 mg has been taken within 15 min.
• patient should rest sitting (standing promotes syncope,
• lying down enhances venous return and heart work)

Isosorbide sublingual

-slower onset of anti-anginal action than nitroglycerin
because the dinitrate requires hepatic conversion to the mononitrate.
Effect lasts for about 1 h.

Question 25

Long acting nitrates (for angina prophylaxis).

Answer 25

Continuous admin causes tolerance and loss of effect

12 hour nitrate free interval req to prevent tolerance

Question 26

Transdermal nitroglycerin patches

Answer 26

Severe angina at nighy/rest

Req 12 hour nitrate free interval

Question 27

Drug interxns

Answer 27

No Combo w/ PDE5 inhibiters =
causes hypotension

No Combo w/ DHP = increases vasodilation

Can combo w/ beta blockers and nonDHP

Question 28

name a Selective If inhibitor

Answer 28

Ivabradine :7.5mg 2x/24hr

Question 29

how does ivabradine work

Answer 29

reduction of HR by affecting the sinus node

Decreaed HR decreases myocardial O2 demand

Question 30

when is ivabradine used

Answer 30

Chronic stable angina w/ intolerance to BB

Heart rate 60bpm<

Effective combo w/BB

Question 31

ivabradine contraindications

Answer 31

Sick sinus syndrome 
AV block 3rd.4th degree
HF class 3-4
Acute coronary syndrome 
Severe liver failure

Question 32

ivabradine adr’s

Answer 32

viual disturbances d/2 phosphenes
Bradycardia and AV block
Headache and dizzyness

Question 33

list antiplatelets used in angina

Answer 33

Aspirin low dose (150 MG/DAY)

thienopyridines antagonise P2Y12

receptor meant for platelet AD

Question 34

list the Thienopyridines

Answer 34

Clopidogrel: second line treatment for aspirin intolerance

Prasugrel: used in acute coronary syndrome

Ticagrelor: acute coronary syndrome

Question 35

how do statins improve prognosis

Answer 35

Reduce LDL chol by inhibiting HMG-CoA-reductase
LDL 1.8mmol/L is aim
Has long term benefits in reducing CVS diseases

Question 36

adr’s of statins

Answer 36

gi: nause, vom, anorexia, constipation, diarrhea
Liver dysfunc- AST, ALT, GGT, CK monitoring req
myopathy

Question 37

when are Ace inhibitors & ARBS used

Answer 37

in concomitant 
HTN,
HF, 
LVD, 
DB- nephroprotective

Question 38

how does trimetazidine improve prognosis

Answer 38

anti-ischemic
Increases ATP synth
Decreases acidosis in ischemic tissues (mi)
Is an adjuvant drug to BB in effort induced myocardial ischemia

Question 39

trimetazidine adr’s

Answer 39

Allergy
Nausea
Parkinsonism = contraindicated in parkinson’s

Question 40

how does Ranolazine improve prognosis

Answer 40

Selective late sodium current inhibitor
Anti ischemic and anti metabolic effects
Used as an adjuvant in intolerance to BB/CCB