Cardiovascular Therapeutics

Question 1

IHD

Answer 1

Ischaemic Heart Disease

Angina or MI

Question 2

Greatest risk factor for chronic heart failure

Answer 2

IHD as the cardiomyocytes become dysfunctional

Question 3

Risk factors for developing heart disease

Answer 3

Male Gender
Family History
Ethinicity
Smoking - Most important
Diabetes
Hypercholesterolaemia
Hypertension
Sedentary Lifestyle
Obesity

Question 4

Stable Angina

Answer 4

Atherosclerosis in coronary artery, limiting heart’s ability to respond to increased demand

Symptoms on exertion but relieved by rest

Question 5

Unstable Angina

Answer 5

Plaque rupture and formation of a non-occlusive thromboembolism or vasospasm

Symptoms at rest

Question 6

ECG Diagnosis of Angina

Answer 6

ST-Depression

Question 7

Angiography

Answer 7

Needed for definitive diagnosis of angina

Insert catheter into radial artery and advance it up into coronary circulation
Insert radio-opaque dye and X-ray heart

This would show the narrowing seen in IHD

Question 8

Management of Angina

Answer 8

Lifestyle

• Stop smoking
• Exercise
• Diet
• Weight

Coronary artery bypass grafting

Angioplasty & Stenting

Question 9

PTCA

Answer 9

Percutaneous Transluminal Coronary Angioplasty

Angioplasty with a stent

Primary treatment of heart attack in the UK

Question 10

STEMI

Answer 10

ST Elevation Myocardial Infarction

Question 11

GTN

Answer 11

Glyceryl Trinitrate (Drug to treat angina)

Releases NO in blood, leading to vasodilation as it activates guanylyl cyclase and releases cGMP

Major effect is venodilation that reduces pre-load, reducing work on heart and thus angina symptoms

Question 12

Delivery of GTNs

Answer 12

As a spray under the tonguethat either prevents attacks or can relieve one

Question 13

Risk of oral Nitrates

Answer 13

Prolonged exposure can reduce effectiveness; tolerance is developed

Question 14

How to clinically overcome nitrate tolerance

Answer 14

Aim for a nitrate free period; 2 doses rather than 3 per day

Question 15

Beta-blockers

Answer 15

Selective B1 Adrenoceptor blockers

First choice drugs for prevention of IHD

Negative Inotropic and chronotropic effects reducing cardiac work and preventing symptoms

Question 16

When does coronary flow occur and how do beta-blockers affect this

Answer 16

Coronary flow only occurs during diastole

By slowing the heart, the diastolic period will be increased, as will the time for coronary blood flow

Question 17

General effects of Beta-Blockers

Answer 17

Anti-arrhythmic effects and reduce the risk of myocardial infarction.

Question 18

Calcium channel blockers

Answer 18

Vasodilators and improve coronary blood flow, so prevent symptoms of IHD

Question 19

Types of Calcium Channel Blockers with example

Answer 19

Rate-limiting Agents (e.g. Verapamil)

Dihydropyridines (e.g. Amlodipine)

Question 20

Rate Limiting Agents Ca2+ Channel Blockers

Answer 20

Act on the heart and have myocardial depressant actions

- Used as a substitute for beta-blockers in AFib as they have a similar effect

Question 21

Dihydropyridines

Answer 21

Selective Ca2+ channel blockers that are selective for vascular smooth muscle and lead to vasodilatation

Question 22

ACE Inhibitors

Answer 22

Reduces mortality of patients with IHD

Question 23

Potassium Channel Activators

Answer 23

Nicorandil - combined NO donor and activator of ATP sensitive K-Channels

Opens K+ channels, letting K+ leave cells leading to hyperpolarisation and making them less excitable - Vasodilation

Target is ATP-sensitive K+ channel

Question 24

Ivabradine

Answer 24

Inhibits If channels (Pacemaker Na/K currents in the SAN)

Reduces heart rate

(Might be potassium channel activators)

Question 25

Antiplatelet Drugs

Answer 25

To prevent thromboembolism

• -> Low dose aspirin
• -> Clopidogrel is good but has issues over resistance

Question 26

What is the biological mechanism behind statins (simply)

Answer 26

HMG-CoA reductase inhibitors which inhibit the synthesis of cholesterol by the body

Question 27

Effect of statins on the liver

Answer 27

Statins inhibit cholesterol synthesis, so body compensates by expressing more LDL receptors, leading to an increased uptake of LDL from plasma by the liver

This is a more significant effect of statins

Question 28

Atorvastatin

Answer 28

The go-to statin

Reduces LDL synthesis and increases LDL uptake in liver

Question 29

Rhabdomyolysis

Answer 29

The muscle itself breaks down, leading to release of muscle fibre content into blood

Question 30

Side effects of statins

Answer 30

Muscle damage

• Myopathy
• Rhabdomyolysis

Increased diabetes risk
Monitor liver functions

Question 31

What might statins interact with

Answer 31

Macrolides
Grapefruit juice
Calcium Channel Blockers

Question 32

NICE guidance of statins

Answer 32

Primary Prevention: Treat patient with >10% risk of CV disease over next 10 years

20mg atorvastatin (low intensity)

Secondary Prevention: 80mg Atorvastatin (high intensity)

Question 33

Process of angina treatment

Answer 33

Question 34

Which calcium channel blockers can be used alongside beta blockers

Answer 34

Dihydropyridines can be used alongside beta blockers, but rate-liming Ca blockers are fatal with beta blockers

Question 35

Post-myocardial infarction prescriptions to prevent secondary MI

Answer 35

Beta-blockers
ACE inhibitor
Statins
Antiplatelet drugs