F. Anti-Anginal Drugs - Drugs

Front 1

What is the prototypic nitrate used for treating Angina? In what situations?

Back 1

Nitroglyceirn - for acute anginal attacks

Front 2

What is the major effect of nitrates?

Back 2

Reduced preload by specific venodilation

Front 3

In what 3 other ways to nitrates affect cardiac bloodflow?

Back 3

1. Increased stenotic vessel diameter
2. Increase collateral vessel diameter
3. Increase transmural bloodflow to increase endocardial perfusion

Front 4

How do nitrates affect HR, contractility, and wall tension?

Back 4

-No effect on HR/contractility
-Marked reduction in wall tension dt the decreased preload

Front 5

Does nitroglycerin only dilate cardiac tissue?

Back 5

No - it is a very nonselective dilating agent - can act on smooth muscles in blood vessels and GI tract.

Front 6

How does Nitroglycerin cause vasodilation?

Back 6

By forming a nitrosothiol which activates guanylyl cyclase and increases cyclic GMP.

Front 7

What is the effect of increased cGMP in smooth muscle?

Back 7

Reduces cytosolic free calcium hence relaxes the smooth muscle.

Front 8

How do Nitrates increase subendocardial bloodflow so well?

Back 8

By reducing wall tension due to the marked reduction in venous blood returning to the heart (LVEDP).

Front 9

So what specifically is reduced by nitrates to allow for better subendocardial perfusion?

Back 9

Diastolic crunch is reduced!

Front 10

Even though he said Nitroglycern was a specific veinodilator, does it not affect arteries?

Back 10

Yes, nitrates also cause arteriolar dilation and decrease systemic blood pressure (afterload) to some extent

Front 11

What parameter is reduced by reducing afterload by the Nitrates?

Back 11

MVO2

Front 12

How do nitrates achieve longterm cardiac protection?

Back 12

By producing delayed preconditioning

Front 13

What happens to these preconditioning effects when patients develop tolerance to the vasodilator effects of nitrates?

Back 13

They persist

Front 14

What is nitrates tolerance? With what nitrates does this develop?

Back 14

A decrease in the effect of the drugs when administered in a long acting form - develops with all nitrates

Front 15

What determines how tolerant a patient will become?

Back 15

The dose

Front 16

How soon after stopping the drug will nitrate tolerance disappear?

Back 16

24 hrs

Front 17

How can nitrate tolerance be avoided?

Back 17

By using the least effective dose and creating discontinuous plasma levels.

Front 18

What are 4 major contraindications to Nitrate therapy?

Back 18

-Previous hypersensitivity
-Hypotension
-Acute MI with low VFP
-First trimester pregnancy

Front 19

What are 3 conditions in which you should use Nitrates with caution?

Back 19

1. Constrictive pericarditis
2. Intracranial hypertension
3. Hypertrophic cardiomyopathy

Front 20

How is Nitroglyceride administered?

Back 20

-Buccally or Sublingually

Front 21

What is the onset/duration of action of nitroglyceride?

Back 21

Both are fast and short.

Front 22

What other administration method is available for short acting nitroglycerin action?

Back 22

Spray - aerosol for under tongue

Front 23

What other nitrate is available for buccal administration?

Back 23

Isosorbide dinatrate

Front 24

What are the major long-acting nitrates available orally for longterm prophylaxis of angina?

Back 24

-Isosorbide dinitrate
-Isosorbide mononitrate

Front 25

What are the 2 major effects of B-blockers by which they treat angina?

Back 25

1. Reduce contractility
2. Reduce heartrate
(by blocking the effects of the symp nervous system)

Front 26

What effect do the B-blockers have on the oxygen supply/demand balance?

Back 26

They reduce oxygen demand.

Front 27

What is the only effect B-blockers have on coronary bloodflow?

Back 27

Improvement in subendocardial bloodflow by the reduction in HR which allows more time in diastole.

Front 28

What are the 4 major contraindications to B-blockers?

Back 28

-Hypotension
-Bradycardia
-Chronic bronchitis/ASTHMA
-Severe chronic renal insufficiency

Front 29

And what shouldn't you do when discontinuing B-blocker therapy?

Back 29

Withdraw too rapidly - could cause a rebound sympathetic increase.

Front 30

Which CCB's are effective in reducing HR to decrease oxygen consumption?

Back 30

-Diltiazem
-Verapamil

Front 31

Which CCB's are effective in reducing cardiac contractility to decrease oxygen consumption?

Back 31

-Verapamil (mostly)
-Diltiazem

Front 32

Which CCB's are effective in coronary vasodilation?

Back 32

All of them - so they increase O2 delivery

Front 33

Which CCB's are most effective in reducing afterload by vasodilating, to decrease oxygen consumption?

Back 33

Dihydropyradines

Front 34

What are 4 other drugs used for treating Angina?

Back 34

-Aspirin
-Warfarin
-Antiplatelet drugs
-Statins

Front 35

What antiplatelet drug is used for treating Angina and in what cases?

Back 35

Clopidogrel - when stents have been put in.

Front 36

What is a novel drug for tretment of Chronic angina?

Back 36

Ranolazine

Front 37

When is Ranolazine used?

Back 37

Only in Stable angina patients unresponsive to standard therapy, and in combination with other antianginal drugs.

Front 38

How are drugs for treating Angina often given?

Back 38

In combinations

Front 39

Which 2 drugs are often given in combo?

Back 39

-Nitrates
-Beta blockers