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38 Cards in this Set

  • Front
  • Back
“chest pain” or discomfort
Aggrevated by exertion or emotional stress and relieved by nitroglycerin.
Ischemia- Demand for oxygen exceeds the supply of adequate blood flow to the myocardium.
Unstable Angina Symptoms:
rest angina
severe new onset angina
increasing angina
pathophysiology of angina
Coronary atherosclerotic disease (Atherosclerosis)
Characterized by deposits which thicken and harden blood vessel walls.
A clinical diagnosis of angina has a 90 percent predictive accuracy for the presence of coronary heart disease (CHD).
Coronary artery spasm (Vasospasm)
Imbalance of myocardial oxygen supply and demand
Chronic stable angina (exertional)
Reversible ischemia resulting from increased myocardial oxygen demand with fixed obstruction
Distinguishing characteristics
Precipitating factors
Relieved by rest and/or SL NTG
relief for Angina
Nitroglycerin relief
Relief of pain occurring within 45 seconds to 5 minutes of taking SL NTG
Characteristics of Chronic Stable Angina
Sensation of extreme pressure or heavy weight on chest, alone or with pain
Burning sensation
Feeling of tightness
Shortness of breath
Choking or squeezing sensation
Over or near sternum
Anywhere between epigastrium and pharynx
Occasionally limited to left shoulder and left arm
Rarely limited to right arm
0.5 to 30 minutes
Variant Angina (Prinzmetal’s or Vasopastic Angina)
Reversible ischemia resulting from focal coronary artery spasm
Usually in patients with underlying atherosclerosis)
Can occur at rest
Often occurs at night
Unstable angina
Reversible ischemia from interaction among unstable atherosclerotic lesion, coronary vascular spasm, and platelet aggregation
Distinguishing characteristics
Increased frequency, duration, or severity
New onset angina with minimal exertion
Pain lasting > 30 minutes and not relieved by SL NTG
Angina occurring within 4 weeks after an acute MI
Prevent MI and death
Prevent atherosclerotic progression (irreversible ischemia) – cholesterol lowering agents
Antiplatelet agents
Prevent myocardial ischemia and anginal pain
Relief of symptoms
Decrease frequency, duration, and intensity of anginal episodes
Modify risk factors
Modify risk factors
Percutaneous coronary intervention (PCI)
Coronary artery bypass graft (CABG)
Increase myocardial oxygen supply
Decrease myocardial oxygen demand (consumption)
Drug therapy used:
Beta blockers
Calcium channel blockers
New agent ranolazine
First-line therapy for the treatment of acute anginal symptoms.
In exertional stable angina
Improve exercise tolerance
Lengthens time to onset of angina
Mechanism of Action
Cause vasodilation
Stimulate the production of cyclic guanosine monophoshate (cGMP),
Relaxation of vascular smooth muscle and a vasodilation
Stable angina:
Decrease in cardiac oxygen demand
Variant angina:
Increase in oxygen supply
Nitrate Side Effects
Postural Hypotension
Reflex tachycardia
GI upset
Allergic contact dermatitis from topical ointment or patch
Nitrate Drug Interactions
Phosphodiesterase type 5 inhibitors (PDE5)
Nitrate Dosing Information
Nitrates should be taken on an empty stomach for faster absorption
Patients on long-term or high dose nitrate therapy should avoid abrupt withdrawal
Possibility of inducing an anginal episode
Nitrate Tolerance
Need for higher dosages to sustain efficacy
All intermediate and long-acting nitrate dosage forms can cause nitrate tolerance
Nitrate-free periods (mini drug holidays) can partially or completely reverse the effects of nitrate tolerance
If possible patch removal at night
Nitrate Dosing Forms Available
sublingual (SL) tablet (Nitrostat®, NitroQuick®, Nitrotab®)
lingual spray (Nitrolingual®)
sustained release oral tablet or capsule
transmucosal or buccal tablet (Nitrogard®)
topical ointment (Nitro-Bid®)
transdermal patch (Minitran®, Nitro-Dur®)
Isosorbide dinitrate
sublingual tablet (Isordil®)
oral tablet or capsule (Isordil Titradose®)
sustained release oral tablet or capsule (Dilatrate-SR®)
chewable tablet
Isosorbide Mononitrate
Oral tablet (ISMO®, Monoket®)
Sustained release oral tablet (Imdur®)
Choosing a Nitrate
The choice depends on the onset and duration of action required
Immediate relief
Relief of an anticipated anginal attack:
SL NTG, SL ISDN, transmucosal NTG
Long-term (chronic) prophylaxis:
oral ISDN, isosorbide mononitrate, or NTG; NTG ointment or patch
NTG Sublingual (SL) Tablets
SL nitroglycerin remains the therapy of choice
Acute anginal episodes
Prophylactically for activities known to elicit angina.
Onset of action
Several minutes
Duration is 30 to 40 minutes.
Initial dose dose is 0.2 to 0.6 mg
Can give one-half the dose if patient becomes hypotensive.
Proper Use of SL NTG
Use one tablet under the tongue at a time
After 1st tablet call 911 or report to an ER
Wait 5 minutes before using a second tablet
Do not take more than 3 tablets within 15 minutes
Do not chew or swallow the SL tablets
Use of NTG lingual spray
Dosing is similar to that of SL NTG
Can be sprayed onto or under the tongue
Drug should not be inhaled
Use of Topical NTG
Remove the patch for 10-12 hours.
Dose of 0.1 mg/hour increasing to 0.8 mg per hour as needed
Apply to any “non-hairy” area and rotate site
Replace with a new patch if it comes off
Measure dose of ointment with the “dose-measuring application papers” provided
Wipe off old ointment before applying new
Do not massage into skin
Use of Transmucosal (Buccal) NTG
Place tablet in buccal cavity between the upper lip and gum, or between the cheek and gum
Tablet remains intact for about 4 to 5 hrs.
May dissolve when hot liquids consumed
Remove undissolved
medication at bedtime
Isosorbide Dinitrate/Mononitrate
Isosorbide dinitrate:
Dosing schedule of 10 mg at 8 AM, 1 PM, and 6 PM results in a 14 hour nitrate dose-free interval.
Can be taken twice daily at 8 AM and 4 PM.

Extended release isosorbide mononitrate:
Administered once per day
Starting dose is 30 mg once daily up to 120 mg
Useful in patients who have effort-induced angina.
Beta Adrenergic Blocking Agents
Beta blockers reduce :
Heart rate and blood pressure during exercise
Ischemic threshold during exercise is delayed or avoided
Mechanism of Action
Decrease myocardial oxygen demand
Increase myocardial oxygen supply by increasing diastolic filling time
Dosing of Beta Adrenergic Blocking Agent
Initial doses should be low and gradually titrated. Examples:
Atenolol (Tenormin) 25 mg once daily, increased to a maximum of 200 mg once daily
Metoprolol 25 mg BID, increased to 200 mg BID
Beta Blockers Side Effects
Worsening of symptoms of peripheral vascular disease
Fatigue, central nervous system side effects
Cautions with Beta Blockers
Use with caution in patients with:
Obstructive airways disease
Peripheral vascular disease
Vasospastic or variant (Prinzmetal) angina
Do not discontinue abruptly
Calcium Channel Blocking Agents
Mechanism of Action
Prevent calcium entry into vascular smooth muscle cells
Decrease myocardial oxygen demand
Decrease afterload, contractility and heart rate
Generally decrease HR
Increase myocardial oxygen supply
Increase diastolic filling time
Coronary artery dilation
Types of Calcium Channel Blockers
Diltiazem (Cardizem®)
Verapamil (Calan®, Covera®)
Long Acting second generation dihydropyridines
Amlodipine (Norvasc®)
Felodipine (Plendil®)
Short-acting dihydropyridines
Nifedipine (Procardia®) should be avoided
Place in Therapy
Ca Channel Blockers
Use in combination with beta blockers
Add to unsuccessful treatment with beta blockers
Can substitute for a beta blocker when contraindicated or cause side effects
Effective in vasospastic or variant (Prinzmetal) angina
Ca Channel Blockers Side effects
Reflex tachycardia
Heart block
Worsening heart failure
Pedal edema
Ranolazine (Ranexa®)
New class of drugs: partial fatty acid oxidation (pFOX) inhibitors
Indicated for patients who have failed prior angina therapy
Decrease oxygen demand by:
Reducing fatty acid oxidation
Stimulating glucose oxidation with cardiac myocytes
No decrease in heart rate or blood pressure
Ranolazine (Ranexa®)
Most common side effects in trials:
Potential for QTc prolongation
Aspirin with Angina
Works by inhibiting thromboxane A2, a prostaglandin
Prostaglandin stimulates platelet aggregation and induces vasoconstriction
Unless contraindicated, all patients should receive aspirin to reduce risk of MI
If contraindicated, use ticlopidine (Ticlid) or clopidogrel (Plavix)
Initial Monotherapy
The only antianginals proven to prevent reinfarction and to improve survival in patients who have had an MI
Calcium channel blocker or long-acting nitrate
If initial treatment with a beta-blocker is unsuccessful,
Add a calcium channel blocker or a long-acting nitrate
If beta-blocker not tolerated, use a calcium channel blocker or a long-acting nitrate
Nitroglycerin sublingual or spray for all patients
Treatment of Unstable Angina
Beta blocker
GIIb/IIIa Inhibitor