Pharm Exam 4 (Tx Of Angina)

Front 1

1) What are the 2 methods utilized to improve the imbalance between O2 delivery and O2 demand in angina

Back 1

a) Increase delivery by increasing coronary flow
b) Decrease myocardial demand (decrease cardiac work)

Front 2

1) Pharmacologic intervention for tx of Angina

Back 2

a) Organic Nitrates,
b) CCB,
c) BB
d) Antithrombotic drugs (aspirin)
e) Cholesterol lowering drugs
f) Trimetazidine
g) Ranolzaine

Front 3

1) Types of angina

Back 3

a) Stable angina and angina of effort
• Most common type
• The MCC of angina is an atherosclerotic obstruction of the Lg coronary vessels
b) Variant Angina
• Transient
• Reversible spams of localized portions of the coronary blood vessels
• Not predictable
c) Unstable Angina
• Acute episodes
• Occurs even at rest
• May have been previously stable
• High incidence of MI and sudden death
• This is the worst kind of angina

Front 4

1) O2 requirements for the heart increase when there is an increase in

Back 4

a) HR
b) Contractility
c) Arterial pressure
d) Ventricular volume

Front 5

1) Physiologically, what do CCB do to tx angina?

Back 5

a) Increases flow to ischemic subendocardial tissue leads to an increase in regional blood flow distribution which leads to an increase in O2 supply
b) Increased coronary blood flow
• Increasing O2 supply
c) Some decrease HR
• Decreasing O2 demand
d) Some decrease cardiac contractility
• Decreasing O2 demand
e) Decreases afterload
• Decreasing myocardial wall tension which leads to a decreasing O2 demand

Front 6

1) Cardiac Clinical uses of CCB

Back 6

a) Angina
b) Recent clinical trials indicate that long acting CCBs are as effective as BB for the prevention of death and MI in angina pts
• Moreover CCB’s may be more effective in preventing a stroke than BB

Front 7

1) CCB are used to tx what types of angina?

Back 7

a) CCB can be used for stable angina and variant angina
• CCB are the DOC for variant angina
• Some are effective in unstable angina\
• No efficacy in AMI

Front 8

1) CCB effects in stable angina

Back 8

a) Decreases arteriolar tone and systemic vascular resistance
b) Leads to a decreased arterial and intraventricular pressure
c) Which leads to a decrease in wall tension
d) Which leads to a decrease in O2 demand
• The non-dihydropyridines also decrease HR and contractility which cause a further decrease in myocardial O2 demand

Front 9

1) CCB effects in variant angina

Back 9

a) Relieve and prevent coronary artery spasms which increases coronary blood flow
b) DOC for variant angina

Front 10

1) Physiologically how are BB helpful in tx angina

Back 10

a) These drugs are not vasodilators
b) The beneficial effects of the BB are related to their hemodynamic effects (all of which decrease O2 demand)
c) Decrease HR
• Decreasing cardiac demand
d) Decrease cardiac contractility
• Decreasing cardiac demand
e) Can be used for stable and unstable angina
• No efficacy in variant angina
------No effect on artery spasms
------Not for tx of acute event
f) Used in management of angina of effort
• Not used in variant angina or acute angina attacks
g) BB can also be used in MI
• Increases flow to ischemic subendocardial tissue which increases regional blood flow distribution which increases O2 supply

Front 11

1) Which BB are approved for tx of angina

Back 11

a) Atenolol
b) Metoprolol
c) Nadolol
d) Propranolol

Front 12

1) When and how are BB used to tx reflex tachacardia?

Back 12

a) by moving the threshold) induced by
• organic nitrates and
• dihydropyridine CCB

Front 13

1) How are organic nitrates useful in tx of angina

Back 13

a) Increases flow to ischemic subendocardial tissue which increases regional blood flow distribution which increases O2 supply
b) Increased coronary blood flow
• Increasing O2 supply
c) Decrease preload
• Decreasing myocardial wall tension which decreases O2 demand
d) Can be used for all forms of angina
• Has a little effect on MI

Front 14

1) Clinical use of organic nitrates

Back 14

a) Sublingual nitro is the most frequently used agent for the immediate tx of angina because of its rapid onset of action (1-3 min)
• Not a good choice for maintenance therapy because its short duration of action
b) Slowly absorbed preparations include buccal, oral, and transdermal forms. These formulations provide blood concentrations for long periods, but this leads to the development of tolerance.
• These formulations can be used for maintenance therapy
• To reduce or prevent tolerance in maintenance therapy, it is suggested to have a nitrate-free period for 8-10 hours

Front 15

1) Effects of organic nitrates on stable angina

Back 15

a) These drugs relax most smooth muscle
• Low concentration of organic nitrates produce dilation of veins that predominates over that of the arterioles
b) Venodilation leads to an increased venous capacitance which decreases ventricular end diastolic pressure (decreased preload)
• Decreasing preload reduces work and favors subendocardial perfusion
c) Arteriodilation causes a decrease in afterload
• Does some of this but remember venodilation >>arteriodilation with nitrates
d) Decrease in preload and afterload leads to a decrease in myocardial wall tension which leads to a decrease in myocardial O2 demand

Front 16

1) Effects of organic nitrates in variant angina

Back 16

a) Benefits pt by relaxing smooth muscle of the epicardial coronary arteries and relieving coronary artery spasm

Front 17

1) Effects of organic nitrates in unstable angina

Back 17

a) Both increase coronary vascular tone and increased myocardial O2 demand may precipitate unstable angina. Consequently, nitrates may exert their beneficial effects by causing dilation of epicardial coronary arteries and by reducing myocardial O2 demand

Front 18

1) Adverse effects and tolerance of organic Nitrates

Back 18

a. The major adverse effects are a direct extension of their action (vasodilation)
i. Orthostatic hypotension
ii. Tachycardia
iii. Throbbing headache
b. These drugs are contraindicated if the intracranial pressure is elevated
c. With continuous exposure to nitrates, tachyphylaxis develops (reduced pharmacological effects)(tolerance)

Front 19

1) How is Antithrombotic drugs (aspirin) used in the tx of angina?

Back 19

a) Has some efficacy in stable angina, unstable angina, and MI
• No efficacy in variant angina
b) Aspirin can prevent the formation of platelet thrombi and reduce the risk of MI and death in persons with angina

Front 20

1) How are Cholesterol lowering drugs used in the tx of angina

Back 20

a) Has some efficacy in stable angina, unstable angina, and MI
• No efficacy in variant angina
b) Pts with CHD should be evaluated for hyperlipidemia and treated appropriately with dietary restrictions and drug therapy to retard the progress of atherosclerosis

Front 21

1) MOA of Trimetazidine

Back 21

a) Blocks Fatty acid metabolism
b) Increases glucose metabolism

Front 22

1) How is Trimetazidine used in the tx of angina

Back 22

a) Leads to a decrease in effective metabolism per molecule of fuel consumed but less O2 is consumed

Front 23

1) MOA of Ranolzaine

Back 23

a) Inhibits Na influx into the heart

Front 24

1) How is Ranolzaine used in the Tx of angina

Back 24

a) Inhibits Na influx into the heart  reduced Na/Ca exchange
Slight reduction in O2 demand