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34 Cards in this Set
- Front
- Back
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What kind of angina do you get with chronic coronary artery disease?
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stable angina
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Acute Coronary Syndromes
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1. Unstable Angina
2. Non-Q wave (non-ST elevation): MI 3. Q Wave (ST elevation): MI |
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Risk Factors for Coronary Artery Disease
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Age
Genetic predisposition Hypertension Cigarrete smoke Diabetes Mellitus Dyslipidemia Chlamydia infection ? Risk factors are additive |
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Stable angina
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lumen narrowed by plaque
inappropriate vasoconstriction |
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Unstable Angina
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plaque ruptured
platelet aggregation thrombus formation unoppossed vasoconstriction |
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Variant Angina
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no overt plaque
intense vasospasm |
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When do you start seeing symptoms when an artery is occluded?
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anything between 40% and 80% occlusion angina while exercisiing
occlusion greater than 80% symptoms at rest |
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What are the determinants of Myocardial Ischaemia
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imbalance of supply and demand of oxygen
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Drugs used for Angina Pectoris
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1. Nitrates
2. B-blockers 3. Calcium Channel Blockers others not covered in this lecture: antiplatelet agents, antilipid drugs) Combination: nitrate + B-blocker: vasodilator and reflex tachycardia inhibition |
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Myocardial Ischemia during Exercise and effect of Nitrates:
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1. Very Effective: takes 2 minutes
2. Does not do much at rest 3. Stress test: oxygen demand greater than supply: give nitrate |
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Nitrates
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Nitroglycerine (glyceryl trinitrate)
Isosorbide Dinitrate Isosorbide Mononitrate |
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Nitrates PD
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relaxation of all smooth muscle, including vascular smooth muscle
1. prompt relaxation of venous tone -enhancement of venous capacitance -reduction of cardiac preload 2. gradual decrease in arteriolar resistance: decrease afterlaod and deccrease peripheral resistance: leads to decrease in myocardial oxygen demand use spray: bucally absorbed |
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Nitrates PK
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Nitroglycerine:sublingual, buccal, transdermal, i.v.
NOT P.O.: high first pass metabolism |
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Nitrates USE
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Acute attacks of angina pectoris
Anticipated Attacks Prolonged preventive therapy (ISMN, ISDN: long acting) Paroxysmal nocturnal dyspnea in CHF As spasmolytic in colic pain (biliary, renal, intestinal) |
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Nitrate Tolerance
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1. need to use glutathione system---> used up
2. Nitrates: will not be able to use if glutathione is all used up |
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Sodium Nitroprusside
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strongest vasodilator
does not need any activation limitelss not dependent on glutathione |
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Factors that induce Nitrate Tolerance
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continous or prolonged nitrate exposure
Large doses frequent dosing |
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Prevent Tolerance
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intermittent dosing
small doses infrequent dosing provide nitrate-free interval |
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Typical Nitrate Regimen
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NTG patch, remove patch for 10-12 h/day
ISMN (t1/2= 4-5 hrs) two daily doses 7 hours apart glutathine system recharges in between dosages: nitrous free interval |
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ISDN vs. ISMN
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pg. 5 go over it.
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Sodium Nitroprusside
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Ferrocyanide Compound
direct NO-donator---> very effective, immediate acting vasodilator i.v. infusion, t1/2<3 min, protect from light, converted to cyanide and thiocyanide |
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Sodium Nitroprusside
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1. in ICU and emergency setting may be used in certain hypertensive emergencies
2. controlled hypotension during surgery 3. Special forms of severest cardiac failure: Grade IV or when waiting for transplant |
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Sodium Nitroprusside: AE and Precautions
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Extreme Caution:
borderline systolic blood pressure myocardial ischemia in absence heart failure hepatic or renal insufficiency AE: severe nausea, vomiting headache, other CNS disturbances TOX: cyanide intoxication may be used for some hours only, then discontinue |
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Coronary Steal Syndrome
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Hydralazine
Dypyridamole caused when there is narrowing of the coronary arteries and an arteriolar vasodilator is used - "stealing" blood away from those parts of the heart. This happens as a result of the narrowed coronary arteries being always maximally dilated to compensate for the decreased upstream blood supply. Dilating the other arterioles causes blood to be shunted away from the coronary vessels |
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Calcium Channel Blockers
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Verapamil
Diltiazem Nifedipine (and dihydropyridines) PK: p.o., iv highly bound by serum proteins, hepatic metabolism, renal excretion PD: block L-type calcium channels -cardiodepressant effects -arteriolar vasodilation |
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Calcium Channel Blockers AE
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dihydropyridines (due to excessive vasodilation)
dizziness, headache, flushing, digital dyasthesia, nausea, peripheral edema constipation, reflex tachycardia verapamil, diltiazem bradycardia, slow SA and AV conduction Some substances increase digoxin plasma levels |
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Verapamil Indications
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Angina
Hypertension Arrhythmia |
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Nifedipine and other Dihydropyridines
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angina
hypertension NOT FOR ARRHYTHMIA |
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Diltiazem
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Angina
Hypertension Arrhythmia |
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B-blocker in Angina Pectoris
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Propanolol
Atenolol Metoprolol reduce the severityand frequency in exertional angina, somewhat effective in unstable angina negative inotropic, negative chrontropic, reduced systolic blood pressure during exercise Net Effect= reduced myocardial O2 demand |
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When do you use B-blockers in Angina Pectoris?
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cardioprotective in post MI-patients, given early, continued for 2-3 yrs (b1-selective blocker)
Ineffective in vasospastic angina, may worsen condition B-blockers has somewhat vasoconstriction properties: worsen symptoms |
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Beta Blocker vs. Ca-channel Blocker
Type of Angina |
Exertional: B-blocker
Vasospastic: Ca channel blocker |
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Beta Blocker vs. Ca-channel Blocker
Concomitant Disease |
COPD, Asthma: Ca Channel Blocker
Ventricular Arryhtmia: B-blocker |
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Beta Blocker vs. Ca-channel Blocker
Age of Patient |
< 40: B-blocker
>60: Ca-channel blocker |
