Stable Angina and Anti-Angina Drug Pharmacology Flashcards by Zain Aslam

What is angina and what is it caused by?

Chest pain due to reduced coronary artery blood flow

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Describe the feeling and location of angina pain.

Tight-band/crushing pain
Retrosternal
Radiates to jaw or left arm

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Lying down eases angina pain - true or false?

False - makes it worse, eases upon sitting forward

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When does angina normally happen?

When myocardial O2 demand increases - exertion, cold weather, large meal etc

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What three things regarding coronary arteries can cause angina? - place in order of how common.

Coronary atheroma

Coronary artery spasms

Coronary inflammation

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What else causes angina which is uncommon?

Reduced O2 transport - anemia

Increased O2 demand - LVH or thyrotoxicosis

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What are the non-modifiable risk factors for angina?

Gender - Males and post-menopausal females

Age
Genetics/Family history

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What are the modifiable risk factors?

Hypertension
Hyperlipidaemia
Hyperglycaemia
Smoking

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What symptoms do you look for in a history of a patient with suspected angina?

Dyspnoea and fatigue on exertion
Syncope on exertion
Chest pain -restrosternal radiating to left arm/jaw

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What signs might be present?

Tar stains - smoker
Obesity 
xanthalasma and corneal arcus 
Hypertension
Bruits
Abdmonial aortic aneurysm
Absent or reduced peripheral pulses 
Retinopathy

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What’s retinopathy?

Damage to retina

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Name the investigations?

Blood checks
CxR
ECG
ETT
Myocardial perfusion imaging
Invasive angiography

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What to look for in bloods?

FBC
Lipid profile
Fasting glucose
Us and Es

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What to look for in a CxR?

Can exclude other causes of chest pain such as pulmonary oedema

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What to look for in ECG?

Pathological Q-waves

LVH - ST depression

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What makes an ETT positive?

Angina symptoms with St-segment depression on exertion relatively quickly

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Does a negative ETT mean that angina is excluded?

No - but if there was a high workload prognosis is good

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Myocardial perfusion imagine - better or worse at detecting CAD?

Better as it shows localisation of ischemia and size of area affected

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What are some negatives of myocardial perfusion imaging?

Expensive

Uses radiation

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How is myocardial perfusion imaging carried out?

Stress applied to patient via exercise or pharamlogically

Tracer injected via IV twice - at rest and at peak stress

Two reading compared

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When does myocardial perfusion imaging show ishchaemia?

If tracer seen at rest but not at peak stress

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When does myocardial perfusion imaging show infarction?

If tracer is not seen at all in both readings

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When would invasive angiography be used?

If there is a strongly positive ETT suggesting multivessel disease

If angina won’t clear with meds

If diagnosis still not clear

If patients are young

If there is a high occupational risk with patients - like a driver having an angina attack and crashing

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How is invasive angiography carried out?

Cannula inserted into radial or femoral arteries, passed to aortic root and into ostium of coronary arteries

Contrast is injected and an image of vessel lumen is viewed on an x-ray

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Severity: Stage 1?

Symptoms only on significant exertion - none on rest

Severity: Stage 2?

Slight limitation of daily activities - symptoms on walking more than 1 flight of stairs

Severity: Stage 3?

Marked limitation of daily activities - symptoms on only one flight of stairs

Severity: Stage 4?

Symptoms on the most basic activities such as washing or getting dressed

What are the steps in a medical treatment regime?

1 - Prescribe a short acting nitrate - GTN spray 2 - Beta blockers or CCBs 3 - Swap between beta blockers and CCBs or use both together 4 - revascularisation

How do nitrates work?

Vasodilators - relax smooth muscle by releasing cAMP Venodilatiors - reduces venous return This reduces preload and afterload which reduces myocardial O2 demand

Do nitrates relieve coronary vasospasm?

Yes

Adverse drug reactions of nitrates ?

Headache | Hypotension - GTN syncopes

What is step 2 in a treatment regime?

Prescribe either B.blockers or CCBs

Name some beta blockers?

Bisoprolol | Atenolol

How do beta blockers work?

They are rate limiting drugs Block B1 and B2 receptors which blocks noradrenaline or adrenaline binding to it. There for it blocks the sympathetic response

What do beta blockers reduce?

``` HR Force of contraction Velocity of contraction CO BP ```

What do beta blockers protect myocytes from?

O2 free radicals during ischaemic period

Beta blockers increase exercise threshold - T or F

True

Contraindictions of beta blockers?

Asthma - (Blocks B2 agonist response) Peripheral vascular disease Heart failure - these patients depend on sympathetic drive Bradycardic patients - causes heart block

Adverse drug reactions of beta blockers?

Tiredness Bradycardia Rebound - if taken off suddenly can induce a MI

Drug - Drug interactions of beta blockers?

Anti-hypertensive agents - hypotension Rate limiting drugs - bradycardia/heart failure NSAIDS - blocks anti-hypertensive actions Insulin - masks effects

How do CCBs work?

Block L-type channels

What are the 2 types of CCBs - name some drugs for each

Rate limiting - verapamil and diltiazem Vasodilating - amlodipine felodipine

What is the purpose of using CCBs?

Both types work to reduce myocardial O2 demand (rate limiting) and workload (vasodilating)

Contraindictions of CCBs?

Don't use nifedipine as its a rapid vasodilator and can cause a stroke/MI Post MI patients as can increase morality/morbitiy Unstable angina

Adverse drug reactions for CCBs?

Ankle oedema which doesn't respond to diuretics Headache Flushing Palpitations

Adverse drug reactions of just rate limiting CCBs?

Bradycardia | Constipation

What is step 3 in treating angina?

Swap between B.Blocker or CCB or Use both together

What is step 4?

Consider revascularisation

In patients with atherosclerotic plaques - what other drugs should we give as a routine?

Aspirin/Clopidogrel | Statins

How does aspirin work?

Anti-platelet aggravater Inhibits platelet thromboxane production which makes platelets

Whats a bad side effect of aspirin?

Causes bleeds - especially GI - be wary when giving to elderly

How does clopidogrel work?

Also stops platelet aggregation Inhibits ADP platelet activation

Side effects of clopidogrel?

Also causes bleeds - not as much in GI though

How do statins work?

HMG Co-A reductase inhibitors | Reduce cholesterol

If a patient cannot take b.blockers or CCBs - what is some alternative treatment?

Long acting nitrates Ivabradine Nicorandil Ranolazine

Desribe long acting nitrates

Isosorbide mono/di nitrate Sustained release via tablets

Whats a problem with long acting nitrates and how is it overcome?

Tolerance quickly develops Give doses at 8am and 2pm for a sustained release period followed by a nitrate free period

How does ivabradine work?

Sinus node inhibitor Rate limiting Slows the diastolic depolarization of sinus node

How does nicorandil work?

K+ channel opener Also known as a preconditioner The influx of k+ stops the influx of Ca2+ into cells giving a negative inotropic response, vasodilation and venodilation

What does inotropic mean?

Force of contraction

Surgical treatment - how does PCI work?

Same as invasive angiography - but a balloon and stent are placed in the vessel to "widen" it and squash the plaque

What drugs must be given if a stent is placed in the artery?

Aspirin and clopidogrel to stop platelet activation until the body no longer regards the stent as a foreign opject This stops thrombosis

Does stenting cure the disease?

No - it only really deals with symptoms

Risks of PCI and stenting?

Re-stenosis Emergency CABG MI Death

When is a CABG used?

When there is a mutlivessel disease or the anatomy is unsuitable for PCI

Does CABG have a longer lasting benefit?

Yes - but graft can begin to deteriorate after 10 years

What subgroups benefit more from a CABG?

If there is a 70% stenosis of the left main stem artery If there is a 3 vessel CAD A 2 vessel CAD with either significant stenosis of left main stem artery or less than 50% ejection fraction

Describe the CABG procedure.

Long saphenous vein (commonly used) or mammary artery taken If a vein needs to be reversed so valves face the right way Attached to aorta distal to site of blockage to BYPASS it

IS CABG safer than PCI?

Yes - fewer risks BUT these risks are higher

What are the risks of CABG?

Death | Q-wave MI

Stable Angina and Anti-Angina Drug Pharmacology Flashcards

(71 cards)