Cad/angina

Front 1

Stable/Exertional Angina

Back 1

Only occurs when there is exertion

Front 2

Variant/Vasospastic Angina

Back 2

Occurs at rest

Front 3

2 ways to treat coronary ischemia

Back 3

Reduce oxygen demand and workload on heart, or increase oxygen supply to heart through vasodilation (minimal)

Front 4

CAD

Back 4

Coronary artery disease - cardiac ischemia due to narrowing of the coronary arteries

Front 5

CAD pathogenesis

Back 5

Atherosclerosis, thromoembolism, hypertension, diabetes, sudden coronary vasospasm

Front 6

Which drug classes reduce oxygen demand and workload of heart?

Back 6

Nitrates, B blockers, and CCBs

Front 7

Which drug classes increase oxygen supply to the heart?

Back 7

Nitrates and CCBs

Front 8

Nitrates mechanism of action

Back 8

Prodrugs that release NO, which increases cGMP to relax smooth muscle cells - main action is venodilation (capacitance) to reduce preload - also dilate arterioles (resistance) at higher doses

Front 9

Nitrates best used for

Back 9

Acute angina - tolerance develops

Front 10

Nitrates typical route of administration

Back 10

Sublingually, transdermally, or huge oral dose - first pass metabolism

Front 11

Inhaled NO

Back 11

For pulmonary hypertension

Front 12

Nitroglycerin metabolite activity

Back 12

Not very active

Front 13

Isosorbite dinitrate metabolite activity

Back 13

Isosorbide mononitrates are active

Front 14

Isosorbide 5-mononitrate

Back 14

Excellent bioavailability (no significant first-pass) - can be given orally

Front 15

Nitrate tolerance causes

Back 15

True vascular tolerance (reduced capacity to convert to NO) or pseudotolerance (mechanisms extraneous to vessel wall)

Front 16

Isosorbide clinical uses

Back 16

Acute symptomatic relief of angina, prophylactic management, long-term prophylactic management of stable angina, and perioperative hypertension

Front 17

Sodium nitroprusside

Back 17

Nitrovasodilator - unlike nitroglycerin, no tolerance - dilates both arterioles and venules

Front 18

Sodium nitroprusside therapeutic uses

Back 18

Primarily for hypertensive emergencies (short-term preload and afterload reduction) - also lower BP during acute aortic dissection, improve CO in CHF with pulmonary edema not responding to other treatments, decrease O2 demand after acute MI

Front 19

Is sodium nitroprusside used for long-term hypertension management?

Back 19

No - can cause cyanide poisoning when used continuously

Front 20

Drug Holiday

Back 20

Used for nitrates - Nitrate Free Interval to overcome tolerance

Front 21

Nitrate tolerance

Back 21

Highest in nitroglycerine, less with isosorbide dinitrate. None in sodium nitroprusside

Front 22

Beta antagonists effects

Back 22

Reduced HR, contractility, renin release, afterload, workload on heart

Front 23

Metoprolol

Back 23

B1 blocker

Front 24

Atenolol

Back 24

B1 blocker

Front 25

Beta antagonist adverse effects

Back 25

Reduced exercise tolerance, asthma, PAD worsens, cold hands and feet, bad dreams, depression, ED, altered plasma lipids

Front 26

CCBs

Back 26

Calcium channel blockers - block L-type Ca2+ channels - reduce HR, afterload - negative inotropic effect

Front 27

DHP affinity

Back 27

Higher for smooth muscle than cardiac muscle, so useful for hypertension

Front 28

CCBs adverse effects

Back 28

Flushing, bradycardia (with verapamil or diltiazem), tachycardia (nifedipine), ankle edema, cardiac depression, other smooth muscle - constipation, urinary retention, headache

Front 29

DHP effect on heart rate

Back 29

Increase through reflexive tachycardia

Front 30

CCBs vs nitrates

Back 30

CCBs act on vasculature and heart while nitrates act mostly on vasculature. CCBs are predominantly arteriolar dilators, while nitrates are predominantly venodilators

Front 31

Is skeletal muscle effects by CCBs?

Back 31

No - relies on intracellular Ca2+ from sarcoplasmic reticulum

Front 32

Do nitrates or CCBs dilate coronary arteries?

Back 32

CCBs

Front 33

Dihydropyridines (DHPs)

Back 33

CCB class - more arterial dilation and little cardiac effect - used as antihypertensive agents - slow

Front 34

Benzothiazepines

Back 34

CCB class - used for angina - cardiac effect

Front 35

Phenylalkylamines

Back 35

CCB class - greater suppressive cardiac effect than benzothiazepines

Front 36

Nifedipine

Back 36

Dihydropyridine CCB

Front 37

Amlodipine

Back 37

Dihydropyridine CCB

Front 38

Diltiazem

Back 38

Benzothiazepine CCB

Front 39

Verapamil

Back 39

Phenylalkylamine CCB

Front 40

Different CCB classes have different

Back 40

Binding sites on L-type channel

Front 41

Nifedipine and diltiazem bind

Back 41

Synergistically

Front 42

Nifedipine and verapamil bind

Back 42

Inhibit each other's binding

Front 43

Nifedipine vs amlodipine

Back 43

Amlodipine has higher bioavailability, longer half-life, OD dosing, slow onset, less intense effect, significantly less tachycardia (which can worsen ischemia in nifedipine use)

Front 44

CCB contraindication

Back 44

Heart failure (especially verapamil and diltiazem)

Front 45

Diltiazem and verapamil are not to be used with

Back 45

B blockers (cardio-depression

Front 46

Nifedipine can increase risk of

Back 46

Myocardia ischemia (due to tachycardia)

Front 47

Which CCB to use in hypertension?

Back 47

Amlodipine

Front 48

Which CCB to use in angina?

Back 48

Diltiazem (but verapamil as well according to later slide) (and can be either stable or variant angina)

Front 49

Which CCB to use in some types of arrhythmias?

Back 49

Verapamil

Front 50

Major side effects of CCBs

Back 50

Constipation and flushing, especially in dihydropyridines

Front 51

Why not use DHPs for angina?

Back 51

Reflex tachycardia

Front 52

B blockers used for

Back 52

Stable angina

Front 53

B blocker caution

Back 53

Unopposed a1 coronary vasoconstrction

Front 54

B blockers vs nitroglycerin

Back 54

B-blockers have longer duration of action and tolerance is less problematic, so more suited for chronic prophylaxis of stable angina

Front 55

Diltiazem and verapamil key mechanism of angina relief

Back 55

Coronary vasodilation

Front 56

Can B1 blockers be used in mixed angina?

Back 56

Yes

Front 57

B1 blockers are not to be used in which kind of angina?

Back 57

Vasospastic/variant/Prinzmetal angina

Front 58

Pentoxifylline

Back 58

Used for PVD symptoms of vasospasm causing lower body pain and inability to walk - PDE inhibitor, TNFa inhibitor, adenosine antagonist - reduces blood viscosity, promotes red cell deformability, helpful in vascular dementia - effect in intermittent claudication (pain in leg from exercise) - can walk further in a set period of time