Cv System -Ischemic Heart Disease

Front 1

What is stable angina?

Back 1

chest pain do to atherosclerosis or exertion.there is an increase of o2 demand but there's no increase of blood flow. alleviate by decreasing demand.

Front 2

What is Prinzmetal's Angina?

Back 2

Angina caused by decrease in coronary blood flow due to vasospasm. Often occurs at rest or during sleep. Can be alleviated by increasing oxygen supply.

Front 3

Why do you get ischemia.

Back 3

Supply is not balanced with demand. There's an increase of demand in the face of a fixed o2 supply.

Front 4

How do you decrease O2 demand?

Back 4

decrease HR, decrease contractility, decrease ventricular wall tension. dilate peripheral arteries and veins.

Front 5

What classes of drugs are used for the tx of angina?

Back 5

beta blockers
nitrates
calcium channel blockers
ranolazine

Front 6

MoA of beta blockers

Back 6

prevent b1 receptors, decrease HR, decrease contractility, decrease BP, all to decrease o2 demand.

Front 7

What other organs besides the heart are involved in the reduction of BP with beta blockers?

Back 7

CNS and kidney.

beta blockers stop sympathetic outflow.

Front 8

Propranolol is good for what type of angina?

Back 8

chronic stable exertional angina. it will delay or prevent the onset of angina during exercise. this will decrease the o2 demand, and should be taken prophylactically.

Front 9

What type of angina isnt beta blockers good for?

Back 9

vasospastic angina!

Front 10

first line against stable angina...

Back 10

beta blockers

Front 11

contraindications for beta blockers use in angina

Back 11

asthma
bradycardia
AV block

Front 12

What are the names of organic nitrates?

Back 12

nitro-
____nitrate.

Front 13

MoA of nitrates

Back 13

organic nitrates and nitrites are converted to nitric oxide in the endothelial cells of blood vessels. The NO diffuses over to the smooth muscle where it stimulates guanylyl cyclase to increase cGMP production. the cGMP causes smooth muscle relaxation.

Front 14

Which dilates more with nitrates, arteries or veins?

Back 14

nitros are more of a venous dilator. there are more enzymes that release NO in the veins. you need a higher dose of nitrate to work on the arteries to decrease o2 demand.

Front 15

how does dilating in veins decrease o2 demand?

Back 15

dilate veins -> increase venous capacitance -> decrease preload -> dec. ventricular end diastolic vol. -> dec wall tension -> dec o2 demand

Front 16

what do nitates do for stable and vasospastic angina?

Back 16

Stable -> decrease o2 demand
Vasospastic -> increase o2 supply

Front 17

Why dont you use hydralazine or nitroprusside for stable angina?

Back 17

-aggravates angina and ischemia
-too much reflex tachy
-dilate coronary resistance arterioles
->steals blood from ischemia area (coronary steal)

Front 18

Pharmacokinetics of isosorbide dinitrate and nitroglycerin

Back 18

iso- sublingual, oral. works quickly and lasts about 2 hours. when absorbed in intestinal tract, works slower but lasts longer.

nitro- subling, ling,ointment, patch, iv. qorks very quickly PO, but doesnt last long. through skin or GI, works slower but lasts longer. IV is almost immediate.

Front 19

What's the problem with using nitrates?

Back 19

tolerance occurs rapidly, and there is cross tolerance with other nitrates. To prevent tolerance with chronic use, you should have a nitrate-free interval each day.

Front 20

Adverse reactions to nitrates

Back 20

Vasodilation induced problems
Dizziness
Reflex tachy
Headache
Orthostatic Hypotension
Flushing

Front 21

Nitrates drug interaction with Sildenafil

Back 21

Sildenafil is a drug that inhibits cGMP specific PDE5 enzyme. When nitrates stimutate NO which increases cGMP, PDE5 will break it down into metabolites. Sildenafil will inhibit this breakdown, thus allowing the cGMP to cause severe hypotension.

Front 22

Which calcium channel blockers are used for angina?

Back 22

the non-DHPs, verapamil and diltiazem. and the DHPs "dipines"

Front 23

how well do they compare to eachother?

Back 23

on heart:
verapamil>diltiazem>>>nifedipine

on vascular smooth muscle:
nifedipine>verapamil>diltiazem

Front 24

Does the use of CCBs reduce afterload or preload?

Back 24

when you dilate arteries (dec PVR) that decreases AFTERLOAD.

Front 25

What happens to HR with nifedipine?

Back 25

reflex tachy. this may make the angina worse because your'e increasing O2 demand. The non-DHP tend to work better for those with stable angina.

Front 26

CCB MoA for vasospastic angina

Back 26

ccbs dilate the epicardial coronary arteries which decreases the vasospasm

Front 27

Clinical use of CCBs and angina

Back 27

prophylactic for vasospastic angina, and prophylactic for stable angina (although Bblockers are still first line for stable, so use in combo or if you cant use a bblocker)

Front 28

Ranolazine MoA

Back 28

blocks the late cardiac Na current, second phase of the action potential. during this phase, there is influx of Na via a slowly inactivating Na channel reating the late channel. with ischemia, there is an increase of late Ina, causing an increase in intracellular Na, which causes more activity of the Na-Ca exchanger in reverse (Na out and Ca in). This causes a Ca overload.

Front 29

What does Ca overload do in ischemic myocardium.

Back 29

increased diastolic wall tension, increased O2 demand, compression of coronary arteries, reduced O2 supply.

Front 30

What is the end result of renolazine?

Back 30

by reducing the late Ina, it mar reduce Ca overload,decrease myocardial o2 consumption, improve myocardial o2 perfusion, and improve myocardial function. this may decrease the amnt of anginal attacks and increase exercise duration.

Front 31

What effet does ranolazine have on HR and Bp?

Back 31

no significant effects.

Front 32

What type of angina is ranolazine good for?

Back 32

stable angina. alone or in combo with bblockers, nitrates, or ccbs.

Front 33

adverse effects of ranolazine

Back 33

dizzy, headache, constipation, nausea, prolongation of QT interval, which effects repolarization by blocking K channels, allowing arrhythmias, specifically Torsades

Front 34

so what are the contraindications of ranolazine?

Back 34

-prolonged QT interval
-metabolized by cytochrome p450 in the liver, causing hepatic dysfunction, concurrent use with CYP3A inhibitor (includes verapamil, diltiazem, grapefruit)

Front 35

Which drug could you give if a pt has stable angina and heart failure?

Back 35

Bblockers, then nitrates, then ranolazine.

not ccb bc they're negative iontotropic drugs, and not used for tx of heart failure due to systolic dysfunction

Front 36

Would bblockers and nitrates be a good combo to use in tx stable angina?

Back 36

yes. the bblockers stop the reflex tachy that can be caused by the nitrates.

Front 37

Stable angina and HTN?

Back 37

BBLOCKERS!

not thiazides. we have compelling reason not to use the first line.

second should be CCB.

not nitrates bc not HTN drugs.

Front 38

Would bblockers and CCBs be a good combo to use in treating stable angina?

Back 38

BB with DHP, but not non-dhp because that would be too much effect on the heart.

Front 39

Stable angina and sinus bradycardia or AV block

Back 39

Nitrates!
then DHP, and ranolazine. don't use bblockers bc it can decrease HR even more and same with nondhps.

Front 40

stable angina and a-fib?

Back 40

one way to tx afib is slow ventricular rate, targeting the AV node.

use bblockers then nondhps.

Front 41

What effet does ranolazine have on HR and Bp?

Back 41

no significant effects.

Front 42

What type of angina is ranolazine good for?

Back 42

stable angina. alone or in combo with bblockers, nitrates, or ccbs.

Front 43

adverse effects of ranolazine

Back 43

dizzy, headache, constipation, nausea, prolongation of QT interval, which effects repolarization by blocking K channels, allowing arrhythmias, specifically Torsades

Front 44

so what are the contraindications of ranolazine?

Back 44

-prolonged QT interval
-metabolized by cytochrome p450 in the liver, causing hepatic dysfunction, concurrent use with CYP3A inhibitor (includes verapamil, diltiazem, grapefruit)

Front 45

Which drug could you give if a pt has stable angina and heart failure?

Back 45

Bblockers, then nitrates, then ranolazine.

not ccb bc they're negative iontotropic drugs, and not used for tx of heart failure due to systolic dysfunction

Front 46

Would bblockers and nitrates be a good combo to use in tx stable angina?

Back 46

yes. the bblockers stop the reflex tachy that can be caused by the nitrates.

Front 47

Stable angina and HTN?

Back 47

BBLOCKERS!

not thiazides. we have compelling reason not to use the first line.

second should be CCB.

not nitrates bc not HTN drugs.

Front 48

Would bblockers and CCBs be a good combo to use in treating stable angina?

Back 48

BB with DHP, but not non-dhp because that would be too much effect on the heart.

Front 49

Stable angina and sinus bradycardia or AV block

Back 49

Nitrates!
then DHP, and ranolazine. don't use bblockers bc it can decrease HR even more and same with nondhps.

Front 50

stable angina and a-fib?

Back 50

one way to tx afib is slow ventricular rate, targeting the AV node.

use bblockers then nondhps.