Clinical Pharmacology of Stable Coronary Artery Disease

Question 1

Acute Coronary Syndromes

Answer 1

MI (STEMI, NSTEMI)

Unstable Angina

Question 2

Stable Coronary Artery Disease

Answer 2

Angina pectoris

Silent Ischaemia

Question 3

Risk Factors (6)

Answer 3

• Hypertension
• Smoking
• Hyperlipidaemia
• Hyperglycaemia
• Male
• Post-menopausal females

Question 4

• In the atherosclerosis what are most of the changes in the intimal layer a result of?

Answer 4

Accumulation of monocytes, lymphocytes, foam cells and connective tissue

Question 5

What is the origin of foam cells

Answer 5

Smooth muscle

Question 6

What do these accumulations in the arteries contain

Answer 6

Necrotic core

Fibrous cap

Question 7

How cab drugs correct the imbalance of supply and demand (2)

Answer 7

Decrease myocardial oxygen demand

Increasing the supply of oxygen to ischaemic myocardium

Question 8

How can drugs reduce the myocardial oxygen supply (3)

Answer 8

Reduce heart rate
Reduce contractility
Reduce afterload

Question 9

The purpose of the drug treatment (5)

Answer 9

• Relieve symptoms
• Halt the disease process
• Regression of the disease process
• Prevent MI
• Prevent death

Question 10

Demand Ischaemia is determined by (4)

Answer 10

HR
Systolic blood pressure
Myocardial wall stress
Myocardial contractility

Question 11

Supply Ischaemia is determined by (4)

Answer 11

Coronary artery diameter and tone
Collateral blood flow
Perfusion pressure
Heart rate (duration of diastole)

Question 12

What is the action of beta blockers

Answer 12

Rate limiting

Question 13

What is the use of beta blockers

Answer 13

Decrease the determinants of myocardial oxygen demand: HR, Contractility, systolic wall tension

Question 14

What is the mechanism of beta blockers

Answer 14

Reversible antagonists of the B1 and B2 receptors

Block the sympathetic system

Question 15

What are the contraindication for beta blockers (5)

Answer 15

Asthma
Peripheral vascular disease
Raynauds Syndrome
Heart Failure
Bradycardia/Heart block

Question 16

Beta Blocker adverse drug reactions (5)

Answer 16

Tiredness/fatigue
Lethargy
Impotence
Bradycardia
Bronchospasm

Question 17

What is the rebound phenomena

Answer 17

Sudden cessation of beta blocker therapy may precipitate myocardial infarction

Question 18

Who is at risk of experiencing rebound phenomena

Answer 18

• Those at risk include patients with angina and men over 50 years receiving beta blockers for other reasons

Question 19

Beta blocker + Hypotensive drugs

Answer 19

Hypotension

Question 20

Beta Blocker + Rate limiting drug (verapamil or Diltiazem)

Answer 20

Bradycardia

Question 21

Beta blocker + inotropic drugs (Verapamil, Diltiazem and Disopyramide)

Answer 21

Cardiac failure

Question 22

Beta blocker + NSAIDs

Answer 22

Antagonise antihypersensitive actions

Question 23

Beta blocker + Insulin or Oral Hypoglycaemics

Answer 23

exaggerate or mask hypoglycaemic actions

Question 24

Calcium channel action can be

Answer 24

Rate limiting

Vasodilation

Question 25

Rate limiting Calcium channel blockers use

Answer 25

Diltiazem and Verapamil reduce HR and force of contraction

Question 26

Rate limiting calcium channel blockers mechnaism

Answer 26

Prevent calcium influx into myocyte and smooth muscle lining by blocking L-type calcium channels

Question 27

Contraindications of Rate limiting calcium channel blockers

Answer 27

Post MI | Unstable angina

Question 28

How does rate limiting calcium channel blockers Dihydropyridine work

Answer 28

inhibition of the smooth muscle L-type calcium current, thus decreasing intracellular calcium concentration and inducing smooth muscular relaxation

Question 29

Adverse reactions of rate limiting calcium channel blockers (4)

Answer 29

Ankle oedema Headache Flushing Palpitation

Question 30

Action of non-rate limiting calcium channel blockers

Answer 30

Nifedipine or amlodipine produce reflex tachycardia

Question 31

Mechanism of non rate limiting calcium channel blockers

Answer 31

Vasodilation | reduce vascular tone and reduce afterload

Question 32

Contraindication of non rate limiting calcium channel blockers (2)

Answer 32

Never use Nifedipine immediate release can cause MI or stroke Don't use post MI in patients with impaired LV function

Question 33

Action of Ivabradine

Answer 33

Rate limiting

Question 34

Action of Ivabradine

Answer 34

Reduces heart rate and myocardial oxygen demand

Question 35

Mechanism of Ivabradine

Answer 35

Selective sinus node channel inhibitor | Slows the diastolic depolarisation slope of SA node

Question 36

Contraindications of Ivabradine (3)

Answer 36

Low heart rate Allergy Severe Hepatic disease

Question 37

Adverse reaction of Ivabradine (5)

Answer 37

``` Visual disturbances Headache, dizziness Bradycardia Atrial fibrillation Heart block ```

Question 38

Nitrates action

Answer 38

Vasodilators

Question 39

Examples of nitrates

Answer 39

GTN Isosorbide Mononitrate Isosorbide Dinitrate

Question 40

Action of Nitrates

Answer 40

Reduce preload and afterload to reduce myocardial oxygen consumption

Question 41

Mechanism of Nitrates

Answer 41

Relax almost all smooth muscle by releasing NO which then stimulates the release of cGMP which produces smooth muscle relaxation

Question 42

Complications of Nitrates

Answer 42

Tolerance | Requires nitrate free period

Question 43

Adverse reactions of Nitrates

Answer 43

Headache (increase dose slowly) | Hypotension (GTN syncope)

Question 44

Use of Clopidogrel

Answer 44

Prevents atherosclerotic events in PVD

Question 45

Mechanism of Clopidogrel

Answer 45

Inhibits ADP receptor activated platelet aggregation

Question 46

Nicorandil (4)

Answer 46

* Activate ATP sensitive potassium channels * Entry of potassium into cardia myocytes inhibits calcium influx and so has a negative inotropic action * Ischaemic pre-conditioning (cardioprotective) * Vasodilation of coronary epicardial arteries

Question 47

Ranolazine

Answer 47

* Inhibits persistent or late inward sodium current in heart muscle in a variety of voltage gated sodium channels * Inhibition of current leads to reductions in calcium levels * Reduction in calcium levels leads to reduced tension in the heart all and a reduced oxygen requirement for muscles

Question 48

When would you use antiplatelet agents

Answer 48

* Adults unable to tolerate or have a contraindication to the use of beta-blockers * Used in combination with beta blockers in patients that cannot be controlled with an optimal bet-blocker dose

Question 49

Examples of Cholesterol Lowering Agents

Answer 49

• Simvastatin, Pravastatin, Atorvastatin

Question 50

Action of • Simvastatin, Pravastatin, Atorvastatin

Answer 50

• HMG CoA Reductase Inhibitors

Question 51

NICE Guiidelines for tretament

Answer 51

* Beta blocker first line for stable angina * Inadequate control- calcium channel blockers are used * Combination of the 2 can be used if symptoms are not controlled

Question 52

Patients with stable angina due to atherosclerotic disease should be on

Answer 52

Long term aspirin and statin

Question 53

Why should they be on statin even if blood cholesterol is good

Answer 53

Stabilise plaques

Question 54

All patients with angina should be considered for treatment with

Answer 54

ACEi

Question 55

Drugs for secondary prevention

Answer 55

* Aspirin 75mg daily (low dose to take into account risk of bleeding and comorbidities) * ACEI for people with stable angina and diabetes * Statin treatment * Treatment for high blood pressure

Question 56

1st line treatment

Answer 56

fast acting nitrates Beta blocker/CCB

Question 57

2nd line (5)

Answer 57

``` Ivabradine Long acting nitrates Nocorandil Ranolazine Trimetazadine ```