F. Anti-Anginal Drugs

Front 1

How many Anti-anginal drugs?

Back 1

8

Front 2

How do you remember the Anti-anginal drugs?

Back 2

Nitro and ice
In Ne Va Da
Poke Rattlesnakes

Front 3

What is Nitro and Ice?

Back 3

The acute angina drugs
-Nitroglycerin
-Isosorbide dinitrate

Front 4

What is In Ne Va Da?

Back 4

The prophylactic drugs
-Isosorbide mononitrate
-Nifedipine
-Verapamil
-Diltiazem

Front 5

What is Poke Rattlesnakes?

Back 5

The chronic angina drugs
-Propanolol
-Ranolazine

Front 6

What is Angina caused by?

Back 6

Coronary ischemia/insufficiency due to an imbalance between myocardial O2 supply and demand

Front 7

What do the drugs that treat angina mainly do?

Back 7

-Reduce oxygen demand
(increasing oxygen supply is a minor mechanism)

Front 8

What are the 3 direct determinants of myocardial oxygen demand?

Back 8

1. Contractility
2. Heartrate
3. Wall tension (LaPlace)

Front 9

What are the 3 determinants of Wall tension?

Back 9

-LV pressure
-Ventricular volume
-Wall thickness

Front 10

What happens to heart size during acute angina attacks?

Back 10

The heart increases in size which increases wall tension and causes oxygen demand to go up

Front 11

What do the Beta blockers tend to affect regarding oxygen demand?

Back 11

Contractility and HR (not wall tension)

Front 12

What else reduces contractility and heartrate?

Back 12

Diltiazam and Verapamil (CCB's)

Front 13

What are the 2 main determinants of Oxygen supply to the heart?

Back 13

-AV oxygen difference (how much is extracted from hemoglobin)
-Myocardial distribution between Endo/Epicardial coronary vessels

Front 14

Can much more oxygen be extracted from Hb in coronary circulation?

Back 14

No

Front 15

What are 3 ways you can increase oxygen supply to the heart?

Back 15

1. Increase collateral bloodflow
2. Relieve coronary spasms
3. Reduce stenosis in stenotic vessels

Front 16

What are the 2 main types of Angina?

Back 16

1. Primary (Atypical)
2. Secondary (Typical)

Front 17

What is Primary Atypical angina also called?

Back 17

Prinzmetal's

Front 18

What is Primary Prinzmetal's angina caused by?

Back 18

Vasospasm of the large coronary artery

Front 19

What are the symptoms of Prinzmetal's angina?

Back 19

-Angina at rest
-Arrythmia

Front 20

What are patients with Prinzmetal's angina at risk for?

Back 20

Precipitation of acute MI

Front 21

How is Prinzmetal's angina treated acutely and chronically?

Back 21

Acutely - nitroglycerin
Chronic - CCB

Front 22

What don't you want to give patients with Prinzmetal's? Why?

Back 22

Beta blockers - because if you block the B2 receptors, you're blocking vasodilation and making the situation worse.

Front 23

What is Secondary/Typical Angina caused by?

Back 23

Oxygen demand in excess of the supply.

Front 24

What are 2 conditions in which Oxygen demand of the heart will be in excess of the supply?

Back 24

1. Large vessel stenosis or occlusion (ie CAD)
2. Subendocardial ischemia (diastolic crunch)

Front 25

When is subendocardial bloodflow maximum?

Back 25

During diastole

Front 26

What is the main way to reduce diastolic crunch?

Back 26

Slow heartrate w/ B-blockers to prolong diastole

Front 27

What drugs will help situations in which plaques are partially occluding coronary vessels?

Back 27

Calcium channel blockers - by vasodilating the vessel, the angina will be reduced.

Front 28

If the plaque is concentric and covering the whole wall, will CCB's still be effective?

Back 28

No

Front 29

What happens to cardiac vessels over time as vessels are occluded?

Back 29

Angiogenesis occurs resulting in development of collateral vessels.

Front 30

What is Stable angina?

Back 30

When pain is only felt with exercise.

Front 31

What is unstable angina?

Back 31

Angina at rest.

Front 32

When is Prinzmetal's angina typically felt?

Back 32

In the morning

Front 33

What happens to coronary perfusion when a coronary artery undergoes spasm in Prinzmetal's angina?

Back 33

The whole wall becomes ischemic - transmural ischemia

Front 34

And what are the 3 adverse effects of transmural ischemia in Prinzmetal's?

Back 34

-Anginal pain at rest
-Arrythmias
-Impaired mechanical function

Front 35

What does the EKG show in patients with Prinzmetal's angina?

Back 35

A huge rise in the ST segment.

Front 36

And how is Prinzmetal's treated acutely? Chronicly?

Back 36

-Nitrates acutely
-CCBs chronicly to prevent the vasospasm

Front 37

What is used to diagnose Prinzmetal's angina?

Back 37

Ergonovine - an inducer of coronary artery spasm.

Front 38

What determines the bloodflow from Epicardial large coronary vessels, down into the smaller endocardial branches?

Back 38

Pressure gradients

Front 39

What is the normal pressure gradient between Epicardial and subendocardial coronary vessels?

Back 39

80:5 - 75 mm Hg

Front 40

What happens when an epicardial vessel is occluded?

Back 40

After the occlusion, the pressure will be much lower - like 40 mm Hg; so now the gradient for subendocardial flow is only 35 mm Hg.

Front 41

What happens as the tissue beyond the occlusion becomes ischemic?

Back 41

Preload rises as cardiac function is falling, so that perfusion pressure is even worse, resulting in a classic Angina attack.

Front 42

What will be the better treatment for classic angina?

Back 42

An agent that reduces preload.

Front 43

What change will be seen on the EKG in
-Prinzmetal's angina
-Classic Angina

Back 43

Prinz: Elevated ST segment
Classic: Depressed ST segment

Front 44

What is Stable angina predominantly due to?

Back 44

A Fixed OBSTRUCTION - 95% obstruction, maybe 5% spasm

Front 45

What is Prinzmetal's angina predominantly due to?

Back 45

SPASM - 95%, and maybe 5% obstruction

Front 46

What is the best acute treatment for vasospasm in Prinzmetal's?

Back 46

Nitroglycerin

Front 47

What is the best treatment for prophylactic prevention of spasm in Prinzmetal's?

Back 47

Calcium antagonists - Diltiazem, Verapamil, Nifedipine, etc.

Front 48

What 3 drugs are useful for treating classic stable angina?

Back 48

-Nitrates
-B-blockers
-Calcium antagonists

Front 49

What are 2 procedures to use if the spasm/occlusion in Classic angina doesn't respond to drugs?

Back 49

-Dilation via PTCA (stent)
-Bypass operation

Front 50

What is used to treat all unstable angina and acute attacks?

Back 50

Nitrates - nitroglycerin

Front 51

So to review; what are the 2 factors that are altered by the drugs that treat Angina?

Back 51

1. Increase Oxygen supply to myocardium
2. Decrease Oxygen demand of Myocardium

Front 52

How do the drugs increase O2 supply? (4 ways)

Back 52

1. Increase subendocardial flow to the ischemic area
2. Increase collateral bflow
3. Decrease coronary spasm
4. Dilate eccentric stenosis

Front 53

What are 3 ways that drugs decrease the O2 demand of the myocardium?

Back 53

1. Decrease HR
2. Decrease Contractility
3. Decrease wall tension

Front 54

And 2 ways the drugs decrease wall tension?

Back 54

-Decrease afterload (systolic)
-Decrease preload (diastolic)