Ischemic Heart Disease Pharmaceutical Approach

Question 1

What are possible treatments for typical angina?

Answer 1

beta blocker + aspirin
- Clopidogrel can replace aspirin

beta-blocker + aspirin + long-acting nitrate

Question 2

What is a treatment regimen for typical angina in a patient with left ventricular dysfunction or diabetes mellitus?

Answer 2

ACEIs

Question 3

What is a treatment regimen for typical angina when therapy with a beta-blocker is compromised (contraindicated, adverse effects, or unsuccessful)?

Answer 3

Calcium-channel blockers (DHPs) or long-acting nitrates

Question 4

What are the therapeutic objectives for unstable angina?

Answer 4

The first things given are MONA. Morphine, oxygen, nitroglycerin, and aspirin.

Note: A beta-blocker would also be given. If this is contraindicated a Non-DHP calcium channel blocker is given.

Question 5

After pharmaceutical management of an unstable angina what are the procedural treatments?

Answer 5

PCI, CABG, and thrombolytics

Question 6

What are organic nitrates?

Answer 6

prodrugs which increase the source of NO

Question 7

What are the effects of organic nitrates?

Answer 7

The organic nitrates cause relaxation of vascular smooth muscle. This greatly decreases venous return decreasing preload and afterload. Also dilate the coronary arteries.

Question 8

Describe the mechanism of organic nitrates?

Answer 8

Organic nitrates are metabolized –> increase in available NO. NO will increase cGMP which causes smooth muscle relaxation.

Question 9

What is nitroglycerin (NTG)?

Answer 9

An organic nitrate. Commonly available in sublingual tablet.

Short duration of action.

Question 10

What is isosorbide dinitrate?

Answer 10

This is a long-acting sublnigual drug.

Question 11

What are the adverse effects of organic nitrates?

Answer 11

Headaches, dizziness, orthostatic hypotension, and tolerance

Note: can be limited by 8 hour drug free period per day.

Question 12

What are the contraindications for organic nitrates?

Answer 12

Avoid in acute MI with right ventricular infarction and patients on erectile dysfunction drugs.

Question 13

What are verapamil and diltiazem?

Answer 13

These drugs are non-DHP calcium channel blockers which have prominent cardiac effects.

Question 14

What are nifedipine, amlodipine, and felodipine?

Answer 14

These are DHP calcium channel blockers with prominent ateriolar vasodilatory effects.

Note: Capable of inducing reflex tachycardia. Preferred because they have a longer duration of action.

Question 15

Why do the non-DHPs have cardiac effects?

Answer 15

They delay the recovery of the L-type calcium channels decreasing rate of SA node depolarization and slow AV nodal conduction.

Note: all CCBs decrease coronary resistance and increase coronary blood flow.

Question 16

Which calcium channel blocker causes constipation?

Answer 16

Verapamil

Question 17

What are the toxic effects of CCB?

Answer 17

Hypotension, headache, coronary steal, constipation, edema, coughing

Question 18

What is a contraindication of Non-DHPs?

Answer 18

Beta-blocker treatment or SA/AV nodal conduction defects.

Question 19

What does clopidogrel do?

Answer 19

Irreversible inhibitor of ADP receptor on platelets. Indicated for unstable angina, prophylaxis of TIA. Standard treatment for stent placement.

Question 20

What is abciximab?

Answer 20

monoclonal antibody against GpIIb/IIIa receptor. Indicated for unstable angina and atherectomy.