Cv- Drugs For Ischemic Heart Disease

Front 1

What are the 2 types of ischemic heart disease?

Back 1

1. atherosclerosis (coronary thrombosis/plaque formation)->unstable angina, MI
2. transient coronary ischemia->angina pectoris

Front 2

What is the goal in ischemic heart disease?

Back 2

1. increase oxygen supply
2. decrease oxygen demand

Front 3

What are the 2 types of angina pectoris?

Back 3

1. atherosclerosis and exertion->stable angina
2. acute vasospasm->variant or prinzmetal's angina

Front 4

What is meant by stable vs. unstable angina?

Back 4

stable goes away with rest, unstable keeps getting worse

Front 5

How does variant or prinzmetal's angina occur?

Back 5

decreased blood flow due to vasospasm of coronary arteries->usually during rest or sleep

Front 6

What is going to help alleviate pain from prinzmetal's angina?

Back 6

increase oxygen supply by dilating the coronary aa.

Front 7

Why does stable angina occur?

Back 7

exertion causes increased oxygen demand, but this demand is not met due to atherosclerosis

Front 8

Why is there no increase in O2 supply with exercise in a person with stable angina?

Back 8

resistant arterioles are already fully dilated at rest due to atherosclerotic plaque

Front 9

What do you think will help to
alleviate the pain from an
attack of stable angina?

Back 9

reduce oxygen demand because coronary aa. can not be further dilated due to plaque

Front 10

What are 3 things that affect myocardial oxygen demand?

Back 10

1. HR
2. contractility
3. ventricular wall tension

Front 11

Does ventricular wall tension increase or decrease oxygen demand?

Back 11

increase

Front 12

What effects will increased preload or afterload have on ventricular wall tension?

Back 12

increase

Front 13

How can you reduce oxygen demand in stable angina?

Back 13

1. decrease HR and contractility
2. dilate arteries and veins

Front 14

What are the goals of treating stable angina?

Back 14

1. prevent MI and death
2. reduce sx of angina and occurence of ischemia

Front 15

What are the 4 classes of anti-anginal drugs?

Back 15

1. beta blockers
2. nitrates
3. calcium channel blockers
4. ranolazine

Front 16

T or F: all beta blockers are equally effective in treating stable angina.

Back 16

true

Front 17

What are the major and minor effects of beta blockers that reduce angina?

Back 17

1. reduce HR and contractility
2. reduce BP

Front 18

What are the first line drugs to treat stable angina?

Back 18

beta blockers

Front 19

What are the 3 main organs involved with BP reduction in the beta blockers?

Back 19

1. heart
2. brain (reduced SNS)
3. kidneys

Front 20

What does propranolol do to improve chronic stable exertional angina?

Back 20

delay or prevent the onset of angina during exercise

Front 21

Are beta blockers used to treat vasospastic angina? Why or why not?

Back 21

1. no
2. beta blockers will block beta-2 receptors, which will cause coronary vasoconstriction

Front 22

If a patient has HTN and stable angina, what class of drugs should be used?

Back 22

beta blockers

Front 23

What would be some contraindications for beta blocker use in stable angina?

Back 23

1. asthma
2. bradycardia
3. AV block

Front 24

What are the 4 organic nitrates and nitrites?

Back 24

1. amyl nitrite
2. nitroglycerin
3. isosorbide dinitrate
4. isosorbide mononitrate

Front 25

Aside from NO, what other signaling molecule will result in smooth muscle relaxation?

Back 25

acetylcholine

Front 26

What is the MOA for organic nitrates and nitrites?

Back 26

1. each will break down into NO in endothelial cells
2. NO diffuses over to smooth muscle->guanylyl cyclase->increases cGMP->relaxation

Front 27

Arteries or veins: which will demonstrate increased affect by NO?

Back 27

veins-more enzymes that release NO from nitrates are present in the veins->results in greater venous (instead of arterial) dilation

Front 28

How does dilating veins result in decreased oxygen demand?

Back 28

veins will hold more blood for storage->decreases preload->reduced ventricular wall tension->reduced oxygen demand

Front 29

What will giving higher doses of nitrates do?

Back 29

dilate arteries->decreases PVR->decreases afterload->decreases ventricular wall tension->decreases oxygen demand

Front 30

Dilating veins would be beneficial in what type of angina?

Back 30

stable angina-this is because variant or prinzmetal's must dilate coronary aa.

Front 31

Are beta blockers good for treating prinzmetal's angina?

Back 31

no

Front 32

What effect will nitrates have on coronary blood flow?

Back 32

dilates large epicardial coronary arteries->may redistribute blood to ischemic areas

Front 33

Can nitroglycerin effectively dilate an atherosclerotic epicardial coronary artery?

Back 33

no-these arteries are already dilated out of necessity due to plaque formation

Front 34

How does nitroglycerine relieve pain in stable angina?

Back 34

decreases oxygen demand

Front 35

What is the MOA of nitroglycerine in treating vasospastic angina?

Back 35

dilates large epicardial coronary aa.->relieves vasospasm->oxygen supply

Front 36

Summarize the effects of nitrates on stabile and vasospastic angina.

Back 36

1. nitrates decrease oxygen demand
2. nitrates increase oxygen supply

Front 37

Why are hydralazine and nitroprusside not used to treat stable angina? How?

Back 37

1. they can cause increased ischemia and angina
2. reflex tachycardia->increased oxygen demand
3. dilating coronary resistance arterioles->coronary steal

Front 38

Explain coronary steal.

Back 38

1. if you have an atherosclerosed coronary a. and a normal coronary a., and you give a vasodilator, the side that is atherosclerosed will provide more resistance to blood flow
2. this will leave the less affected side with the majority of the blood, thus "stealing" it from the ischemic area

Front 39

Describe the 1/2 life of the nitrates and nitrites.

Back 39

1. nitroglycerin-1-4 minutes
2. isosorbide dinitrate-1 hr
3. isosorbide mononitrate-5 hrs

Front 40

How is isosorbide dinitrate given?

Back 40

orally or sublingually

Front 41

What is the difference between the oral, IV, and sublingual doses of the nitrates?

Back 41

1. oral-takes longer to have effect, but lasts longer
2. sublingual-acts more quickly, but is gone sooner
3. IV-super fast

Front 42

What are the organic nitrates and nitrites used for?

Back 42

1. stable angina
2. vasospastic angina
(both can be given acutely or prophylactically)

Front 43

What form of nitroglycerine is best for unstable angina or acute MI?

Back 43

IV

Front 44

Should nitroglycerine be used with or without beta blockers?

Back 44

either way, depending on whether or not the patient has problems with beta blockers

Front 45

What is a major problem with nitroglycerine? How can this be fixed?

Back 45

1. tolerance occurs rapidly and can occur with other nitrates
2. must have nitrate free period (i.e. during sleep)

Front 46

What are the major adverse effects of using nitrates?

Back 46

vasodilatory effects

Front 47

What drug can be used to treat the reflex tachycardia that can come with nitrates?

Back 47

beta blockers

Front 48

Why are other nitrates like sildenafil (viagra) a problem with nitroglycerine?

Back 48

1. sildenafil works by blocking PDE-5, which breaks down cGMP
2. sexual stimulation causes corpus cavernosum to release NO->cGMP->vasodilation
3. if cGMP is not broken down due to sildenafil, the vasodilation will be unopposed->severe hypotension

Front 49

What is the MOA for DHP's?

Back 49

inhibits Ca++ uptake by smooth muscle cells->relaxation->vasodilation->decreased PVR->reduces afterload->decreases ventricular wall tension->decreases oxygen demand

Front 50

What happens to HR with the DHP's? Why is this a problem?

Back 50

1. decreased PVR->decreased BP->reflex tachycardia
2. reflex tachycardia increases oxygen demand->not good when treating stable angina

Front 51

Why are non-DHP's better at treating stable angina?

Back 51

1. decrease afterload->decrease wall stress->decrease O2 demand
2. decrease HR and contractility->decrease O2 demand

Front 52

What is the MOA of non-DHP CCB's in treatment of vasospastic angina?

Back 52

dilation of epicardial coronary aa.->decreased vasospasm

Front 53

How are CCB's used to treat vasospastic and stable angina? What is given for acute stable angina?

Back 53

1. prophylactically
2. beta blockers (first line)

Front 54

What is the MOA for ranolazine?

Back 54

blocks late cardiac Na+ current

Front 55

In non-ischemia, does the late cardiac Na+ current play a large or small role?

Back 55

small

Front 56

Explain the late cardiac Na+ current.

Back 56

1. during phase 2 of AP-influx of Na+ via slowly inactivating Na+ channel creates late Na+ current
2. during ischemia, this current is increased->enhances reverse mode of Na+-Ca++ exchange->Ca++ overload

Front 57

How does Ca++ overload lead to ischemia?

Back 57

1. increased wall tension->increased O2 demand and compression of the coronary aa (which causes decreased oxygen supply)
2. this causes left ventricular dysfunction

Front 58

What are the end results of ranolazine?

Back 58

1. by reducing late Na+ current, reduces Ca++ overload
2. decrease myocardial O2 consumption because you are not getting wall tension
3. improve myocardial oxygen perfusion
4. improve myocardial function
5. decreases frequency of anginal attacks
6. increases exercise duration

Front 59

What effect will ranolazine have on HR and BP?

Back 59

no significant effects-good for treating people with stable angina with low BP

Front 60

How is ranolazine used?

Back 60

for stable angina with or without other drugs

Front 61

What is the major adverse effect of ranolazine?

Back 61

prolongs QT interval-not usually problematic though

Front 62

What are the contraindications of using ranolazine?

Back 62

1. prolonged QT interval
2. hepatic dysfunction and use of another CYP3A inhibitor (grapefruit or non-DHP CCB); this would increase risk of prolonged QT interval

Front 63

Are beta blockers used in heart failure patients?

Back 63

no

Front 64

Would beta blockers and nitrates be a good combination to use in treating stable angina?

Back 64

yes-nitrates can cause reflex tachycardia, beta blockers can stop this from occuring

Front 65

What would you give a patient with stable angina and HTN?

Back 65

beta blockers or CCB's

Front 66

Would beta blockers and DHP's be a good combination to use in treating stable angina?

Back 66

yes

Front 67

What could be used to treat stable angina and bradycardia or AV block?

Back 67

nitrates, DHP’s, and ranolazine