CVS part 2 ischemic heart disease (angina)

Question 1

Where is the pain felt in angina?

Answer 1

Severe pressing pain- substernal, neck, shoulders, epigastric due to metabolites that accumulate when there is myocardial ischemia.

Question 2

What is the cause of angina?

Answer 2

Decreased blood flow and therefore decreased Oxygen to the heart. This can be due to atherosclerosis of the coronary arteries. Often there is endothelial dysfunction & impaired vasodilation meaning even small increases in oxygen demand can induce an attack.

Question 3

What is the main form of treatment?

Answer 3

Organic nitrates

Question 4

What are the 2 main types of medications used as prophylaxis of angina?

Answer 4

Calcium channel blockers (cause vasodilation) & beta blockers (decrease HR & contractile force thereby decreasing O2 demand of heart)

Question 5

Angina is not a disease itself, but usually a symptom of what underlying condition?

Answer 5

Coronary artery disease (CAD)

Question 6

What is exercise-induced angina (aka Classical/atherosclerotic) angina?

Answer 6

Atheromatous obstruction of large coronary vessels cause inadequate blood flow. Effort increases the heart’s workload which increases O2 demand leading to ischemia and pain.

Question 7

What is Vasospastic angina (aka Prinzmetal’s Angina/Variant Angina/ Rest Angina)?

Answer 7

A reversible coronary spasm (usually in the vicinity of an atherosclerotic plaque) Pain can occur at anytime.

Question 8

What is unstable angina (aka acute coronary syndrome)?

Answer 8

Episode of angina occurring at rest. Reoccurring & unpredictable.
Associated with thrombi & platelet aggregation in the vicinity of atherosclerotic plaque & therefore surrounding vasospasm. It is the precursor of a possible MI- emergency.

Question 9

Who is most likely to develop silent ischemia?

Answer 9

People with diabetes/ who have had a heart attack previously

Question 10

What is the difference between angina & MI?

Answer 10

With angina: damage to cardiomyocytes is temporary

Question 11

How can drugs relax vascular smooth muscle?

Answer 11

1. Increase cGMP (NO increases cGMP)
2. Decreasing intracellular calcium levels (intracellular calcium is needed from vasoconstriction) (beta blockers & calcium channel blockers decrease calcium influx)
3. Preventing depolarization of vascular smooth muscle cell membrane
4. Increase cAMP in vascular smooth muscle cells

Question 12

What 3 nitrates are used to treat angina?

Answer 12

Glyceryl Trinitrate, Isosorbide Dinitrate & Isosorbide Mononitrate.

Question 13

In what 2 ways is Glyceryl Trinitrate administered?

Answer 13

Sublingual (tablet/spray), IV

Question 14

What brand names are Glyceryl Trinitrate?

Answer 14

Angised, Nitrolingual & Nitrocine

Question 15

What are the indications for Glyceryl Trinitrate?

Answer 15

Acute angina, hypertensive emergencies & heart failure

Question 16

What is the MOA of Glyceryl Trinitrate?

Answer 16

Causes release of NO, causing vasodilation & decreasing O2 demand of heart

Question 17

Key notes of Glyceryl Trinitrate?

Answer 17

Rapid onset; sublingual used for acute relief & IV used for emergencies (acute MI)

Question 18

How is Isosorbide Dinitrate administered?

Answer 18

Orally, IV, Sublingual

Question 19

What is sublingual Isosorbide dinitrate used for?

Answer 19

acute relief

Question 20

What is PO administration of Isosorbide Dinitrate used for?

Answer 20

Prophylaxis

Question 21

What brand name does Isosorbide Dinitrate fall under?

Answer 21

Isordil

Question 22

What is Isosorbide Dinitrate used for?

Answer 22

Angina prophylaxis & heart failure

Question 23

What is the MOI of Isosorbide Dinitrate?

Answer 23

Longer-acting nitrate that dilates veins & arteries, reducing cardiac workload.

Question 24

Key notes of Isosorbide Dinitrate?

Answer 24

Used for treatment of chronic angina; can develop tolerance

Question 25

How is Isosorbide Mononitrate administered?

Answer 25

Orally

Question 26

What brand name does Isosorbide Mononitrate fall under?

Answer 26

Ismo

Question 27

What is Isosorbide used for?

Answer 27

Angina prophylaxis

Question 28

What is the MOI of Isosorbide Mononitrate?

Answer 28

It's an active metabolite of Isosorbide Dinitrate & provides sustained vasodilation

Question 29

Key notes of Isosorbide Mononitrate?

Answer 29

Longer duration of action than Isosorbide Dinitrate. Used as prophylaxis, not for acute relief.

Question 30

Which nitrate is short acting?

Answer 30

Glyceryl Trinitrate

Question 31

What 2 nitrates are longer acting?

Answer 31

Isosorbide dinitrate & Isosorbide mononitrate.

Question 32

What do nitrates at lower doses cause?

Answer 32

venoselective & vasodilation

Question 33

What causes nitrate tolerance?

Answer 33

Long-acting nitrates Chronic use Compensatory salt & water retention

Question 33

What do nitrates at higher does do?

Answer 33

Arterial & venous dilation Sympathetic reflex

Question 33

What is an NB interaction with nitrates?

Answer 33

Phosphodiesterase inhibitors (PDE5 inhibitors) eg. Sildenafil (viagra)- causes synergistic smooth muscle relation which cause hypoperfusion of organs & MI

Question 34

What are side effects of calcium-channel blockers?

Answer 34

1. Vasodilation related: headache, flushing, palpitations, oedema 2. Muscle cramps 3. Constipation 4. Cardiac suppression 5. increased digoxin levels

Question 35

What 2 CCB drugs are used to treat angina?

Answer 35

Diltiazem & Verapamil (non-dihydropyridines)

Question 36

How are Diltiazem & Verapamil administered?

Answer 36

Orally

Question 37

What is Diltiazem used to treat?

Answer 37

Stable & variant angina, hypertension & arrythmias

Question 38

What is Verapamil used to treat?

Answer 38

Stable angina, hypertension & arrythmias

Question 39

What is the MOI of Diltiazem?

Answer 39

Inhibits calcium influx in cardiac & vascular smooth muscle, reducing myocardial oxygen demand & causing vasodilation

Question 40

Key notes of Diltiazem ?

Answer 40

Avoid in heart failure with reduced ejection fraction (HFrEF); caution with beat-blockers

Question 41

What is the MOI of verapamil?

Answer 41

Similar to Diltiazem but with stronger negative chronotropic & ionotropic effects

Question 42

Key notes of Verapamil?

Answer 42

Avoid use in severe LV dysfunction; strong CYP3A4 inhibitor

Question 43

Why should the use of CCB & beta blockers together be done with caution?

Answer 43

Diltiazem & Verapamil suppress pace maker activity & so do beta-blockers. Therefore when used together can lead to extreme bradycardia; severe suppression of AV-node conduction & potent reduction in contractility.

Question 44

Beta-blockers cause a decreased HR, how is this beneficial in angina?

Answer 44

It increases diastolic perfusion time which may increase coronary perfusion.

Question 45

Which type of medication is useful in silent angina?

Answer 45

Beta-blockers as they reduce total amount of ischemic time per day

Question 46

How can the unwanted effects of betablockers (increased ejection time & increased end-diastolic volume) be rectified?

Answer 46

They can be used with nitrates

Question 47

What 3 types of medications can be used for angina of effort?

Answer 47

Betablockers, long-acting nitrates & CCB

Question 48

What 2 types of medications can be used to treat vasospastic angina?

Answer 48

CCB & nitrates

Question 49

What types of drugs can be used to treat unstable angina?

Answer 49

Anticoagulants & anti-platelet drugs (eg. aspirin & clopidogrel); nitrates & beta blockers & CCBs in resistant cases

Question 50

What type of med can be used to treat silent angina?

Answer 50

Beta blockers that may be combined with other medications