Cv Pharm Ischemic Heart Disease

Front 1

what is ischemia

Back 1

when oxygen supply does not meet oxygen demand

Front 2

what is stable angine and variant angina (what is other name for this)

Back 2

stable angina - atherosclerosis and exertion

prinzmetal's angina - acute vasospasm

Front 3

factors that affect myocardia O2 demand - and how can we decrease demand specificaly

Back 3

heart rate - slow it down
contractility - less force
ventricular wall tension - want to decrease afterload and preload
preload - dilate veins
afterload - dilater arteries

Front 4

main drug classes used for treating ischemic heart disease

Back 4

beta blockers
nitrates
CCBs
Ranolazine

Front 5

organs of body that beta blockers affect

Back 5

heart, vessels, brain and kindey

Front 6

goal of BBs in chronic stable angina

Back 6

to prevent or delay the onset of angina during exercise

Front 7

what is first line therapy for stable angina
why?

Back 7

BBs
BB improve survival in patients with recent MI
improve survival and prevent sroke and HF in px's with HTN

Front 8

Review BB side effects

Back 8

bronchospasm, sexual dysfunction
increase TGs and decrease HDL
CNS effects - depression, nightmares, insomnia
unopposed vasoconstriction in peripheral vascular disease
Rebound htn
GLUCOSE INTOLERANCE

Front 9

contraindications of BB for stable angina

Back 9

asthma, brochospastic
maybe diabetes, but not that significant

Front 10

what do we use to treat vasospastic angina

Back 10

CCBs or organic nitrates

NOT BB - they do not work.

Front 11

list nitrates - 4

Back 11

amyl nitrite
nitroglycerin
isosorbide dinitrate
isosorbide mononitrate

Front 12

MOA of nitrate

what specifically does it work on? why???
and what if we up the dose

Back 12

nitrates are metabolized into NO
increase cGMP and relax smooth muscle cell

dilates more VEINS --> decrease preload***************!$%^&
b/c veins are rich in enzyme that release NO from nitrates


at very high doses ARTERIES --> decrease afterload

Front 13

what aspect of blood supply or oxygen demand do we want to change for stable angina vs. variant angina

Back 13

stable angina - we want to decrease o2 demand because there is blockage that will not allow more blood - slow heart rate, less contraction. we dilate veins and decrease preload also

variant angina - dilate arteries to increase o2 supply

Front 14

why is hydralazine not used for stable angina?

Back 14

aggravates angina and ischemia because of reflex tachycardia

if we dilate coronary resistant arteries (unblocked), we steal blood from ischemic areas

Front 15

half lives of the nitrates

Back 15

nitroglycerin - 1-4 min
isosorbide dinitrate ~1hr
isosorbide mononitrate ~5 hrs

Front 16

pharmacokinetics of isosorbide dinitrate

Back 16

if absorbed sunlingual - works in 3-5 min and lasts ~2hrs

if absorbed in gut, works in ~60min and lasts much longer (up to 8hrs for extended release ORAL form)

Front 17

pharmacokinetics of nitroglycerin

Back 17

if absorbed in mouth - works in 1-5min and lasts only ~30min

if absorbed in gut, works in about 30~60 min and lasts longer PATCH form may last up to 12 hrs)
Injected IV works immediately

Front 18

main clinical uses of nitrates

know the specifics of each

Back 18

vasospastic angina - acutely and prophylactically

Stable angina - acutely and prophylactically

Front 19

How to treat acute stable angina

Back 19

isosorbide dinitrate - sublingual

nitroglycerin - sublingual, lingual spray

IV nitroglycerin FOR UNSTABLE ANGINA or acute MI!!!!

Front 20

how to phrophylactically treat stable angina with nitrates?

Back 20

isosorbide dinitrate or mononitrate - oral

nitroglycerin - oral or patch
USED for initial therapy when BBs are contraindicated
OR IN COMBINATION WITH BBs

Front 21

when are beta blockers contraindicated?

Back 21

sinus bradycardia, AV block


nonspecific BBs -bronchospastic

Use cautiously in diabetics
asthma
severe COPD

Front 22

what is the problem with organic nitrates?

and how can we counteract this problem?

Back 22

tolerance occurs rapidly and cross tolerance with other nitrates

Nitrate free interval each day - NOT used for essential HTN

Front 23

organic nitrate side effects

Back 23

all those involved with vasodilation - flushing, headache, ORTHOSTATIC HTN, dizziness
reflex tachycardia

Front 24

what can we use to prevent the reflex tachycardia?

Back 24

BBs

Front 25

what are the major drug interactions we need to watch out for when we give Organic nitrates?

why?

Back 25

sildenafil, ardenafil, tadalafil
--afils!!!!

B/c these drugs inhibit the breakdown of cGMP. cGMP concentration is increase by NO with nitrates and cause vasodilation. If we inhibit, we may get SEVERE HYPOTENSION********

Front 26

which CCBs do we use in treating angina

when are they contraindicated?

Back 26

we can use all of them...

CONTRAINDICATED IN HEART FAILURE

Front 27

MOA of CCBs in stable angina

mianly DHPs

Back 27

relax smooth muscle cells, decrease PVR in ARTERIES

Front 28

what do DHP CCBs work on??

Back 28

ARTERIES ONLY

little or no effect on veins

Front 29

what vasodilators have effects on veins too? unrelated to this lecture....

Back 29

alpha blockers
ace inhibitors
nitroprusside

Front 30

problem with giving nifedipine for stable angina?

so how do we counter act?

Back 30

reflex tachycardia -
detremental to stable angina

use NON DHPs to counteract reflex tachycardia

BUT nifedipine is a drug choice for prinzmetals

Front 31

MOA of CCBs in variant/vasospastic angina

Back 31

blocking calcium channels on SMCs will allow coronary vessels to relax and increase o2 supply

Front 32

main clinical use of CCBs for angina and which types

Back 32

preferred tx - prophylactic treatment of variant angina

prophylactic treatment of stable angina when BBs are contraindicated.
or use in combo with BBs

Front 33

MOA: blocks late cardia Na Currect

Back 33

Ranolazine

Front 34

what happens to cardiac mycocytes during ischemia, regarding ions.

Back 34

late Na channel usually is very small portion of depolarizing current (Ca++ is main). but in ischemia, Na current increases of late Na+ channel.
increasae in intracellular Na, which causes increase activity of Na-Ca exchanger brining in Ca++
Causes Ca++ overload in myocyte
LASTLY, Ca Overload - increases wall tension --> increase O2 load and compresses coronary arteries --> decreased supply

Front 35

MOA of ranolazine
explain

Back 35

blocks the late Na inward channel on myocytes

may decrease the amount of calcium overload
decrease myocardial oxygen consumtion
improve myocardial oxygen perfusion

Front 36

main clinical use of ranolazine

Back 36

decrease frequency of anginal attacks
increase exercise duration

Front 37

affect of ranolazine on HR and BP

Back 37

no significant effect on HR or BP

Front 38

when can we use ranolazine

Back 38

alone, or in combo with BBs, CCBs, or nitrates

Front 39

Side effects of ranolazine?

why is one of these a big problem?

Back 39

LONG QT intervals*******

may also block K+ channels, longer QT=longer repolarization, potential for arrythmias - torades de pointes

dizziness, headache, constipation, nausea

Front 40

Contraindications of Ranolazine

Back 40

Long QT interval
don't use with a cytochrome p450 3A inhibitors - verapamil, diltiazem, grapefruit ***********

Front 41

metabolism of Ranolazine

Back 41

via Cytochrome P450 3A -
contraindicated with cyp3A inhibitors - grapefruit juice, verapamil, diltiezem

Front 42

what drug would u give for prophylactic therapy if px has stable angina and heart failure

Back 42

BB, nitrates,

*******NOT CCBs***even DHPs, they still affect the heart***
NO ALPHA BLOCKERS
NO THIAZIDES

Front 43

what do we use to treat stable angina and HTN

Back 43

BBs
alternative CCBs

Front 44

would you use BBs and CCBs to treat stable angina?

Back 44

no, they may cause bradycardia.
be careful, how you go about it.