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49 Cards in this Set
- Front
- Back
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What is angina pectoris?
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A sudden onset of chest pain related to insufficient oxygenation of the muscle of the heart.
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Where may the chest pain radiate?
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Characteristically to the neck, left arm, jaw and back.
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What are the causes of insufficient oxygenation of the heart?
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An imbalance between the oxygen demand and oxygen delivery to the heart. This may be caused by excessive exercise, during coronary artery spasm or from obstruction to flow in the coronary arteries.
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What is the duration of an anginal attack?
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15seconds to 15 minutes.
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Does cellular death occur during angina?
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No it does not. Cellular death occurs only during an infarction which is a more severe result of insufficient oxygen delivery.
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What are the three classes of drugs used to treat angina pectoris?
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Beta blockers, calcium channel blockers and Nitrates.
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Which are the organic nitrates used in the treatment of angina?
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Nitroglycerin
Isosorbide dinitrate Isosorbide mononitrate and more which are not mentioned in Lippincott |
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Which are the beta blockers used in angina?
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Acebutolol, Atenolol, Metoprolol and Propranolol
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Which are the calcium channel blockers used in the treatment of angina?
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Amlodipine, Diltiazem, Felodipine, Nicardipine, Nifedipine and Verapamil
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What are other options for treatment besides pharmacological intervention?
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Lifestyle and risk factor modifications, especially cessation of smoking, are also important in the treatment of angina.
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What are other medical procedures to treat angina?
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Bypass surgery and angioplasty.
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What are the different types of angina?
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1. Stable angina
2. Unstable angina 3. Prinzmetals angina (variant angina) |
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Which is the most common form of angina?
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Stable angina
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What is usually the reason for stable angina?
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atherosclerotic plaques obstructing the blood flow in the coronary arteries.
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When does stable angina occur?
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Only during exertion, if it occurs during rest it has progressed to unstable angina.
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What is unstable angina in relation to stable angina and myocardial infarction?
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Unstable angina is a progression of stable angina but still has not evolved to a myocardial infarction.
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What is characteristic for unstable angina?
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The anginal attacks occur with higher frequency, are more severe, and may occur at rest.
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What is another way of confirming unstable angina?
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That the symptoms are not relieved by nitroglycerin. Stable angina is relieved by nitroglycerin.
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What differs in the treatment of stable and unstable angina?
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Unstable angina, unlike the stable angina, requires hospital admission and more aggressive therapy to prevent MI.
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What is Prinzmetal's angina?
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An uncommon pattern of episodic angina due to coronary artery vasospasm.
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To what agents does Prinzmetals angina usually respond promptly?
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To the coronary artery vasodilators such as nitroglycerin or calcium channel blockers.
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What are the organic nitrates structurally?
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They are simple nitric and nitrous acid esters of glycerol.
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What differs between the different nitrates?
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Their volatility (the propensity for nitrous oxide to dissociate)
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What is the mechanism of action of the nitrates?
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They enter the endothelial cells, where their nitric oxide dissociates and causes increased levels of cGMP which leads to dephosphorylation of the myosin light chains and thus to relaxation.
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Which is the agent of choice for prompt relief of anginal attacks?
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Nitroglycerin sublingually
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Why is nitroglycerin administered sublingually?
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For rapid absorption and because extensive first pass metabolism would occur with oral absorption, about 90%.
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What are the effects of administartion of nitroglycerin?
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First, there is dilation of the veins, causing a pooling of blood in the veins, which diminishes the workload of the heart. Then the coronary arteries are dilated which increases the delivery of blood to the heart muscle.
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What is the difference between the different nitric derivatives?
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They differ in their onset of action and rate of elimination.
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What is the time for onset of action for nitroglycerin?
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1 minute
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What is the time of onset for action of isosorbide mononitrate?
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Over 1 hour.
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What is the reason for a rather long half life of isosorbide mononitrate?
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It is resistant to breakdown in the liver.
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What is the most common side effect of the nitrates?
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Headache because of vasodilation of meningeal arteries.
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How many patients undergoing nitrate therapy develop headaches?
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From 30 to 60% that receive long acting agents develop headaches, facial flushing and tachycardia.
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What are other side effects of the nitrates?
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They may cause postural hypotension, especially in combination with other vasodilators such as sildenafil, and tadafil.
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What is a special aspect about nitrates that leads to the requirement of taking breaks of nitroglycerin administration?
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Tolerance develops rather quickly.
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How is tolerance to nitrates overcome?
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By having daily nitrate-free intervals to restore sensitivity to the drug.
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How long is this nitrate-free interval?
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Typically 10 to 12 hours.
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When do we incorporate these nitrate-free intervals?
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During night, when need for nitrates are at its lowest.
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So how do we use nitroglycerin patches?
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We apply the patches for 12 hours and then they are removed for the subsequent 12 hours, restoring sensitivity.
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When during the day is variant angina at its worst?
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During morning
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So for the variant angina patients the nitrate-free interval should not occur during night but during...
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the afternooon.
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What do we do with patients who do not derive sufficient benefit from the nitrates?
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We add another agent.
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What is the reasoning for using beta blockers in the treatment of angina?
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They reduce the workload and oxygen demand of the heart.
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Which type of beta blockers should be avoided in angina?
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The ones with ISA.
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Which type of beta blockers are preferred in the treatment of angina?
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The cardioselective ones without ISA.
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What is the reasoning behind using calcium channel blockers in the treatment of angina?
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Because they reduce the workload of the heart and dilate the coronary arteries.
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Why is calcium influx into the myocardial cells increased during ischemia?
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Because ischemia produces a proportional degree of depolarization.
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So what effect does calcium channel blockers have in addition to vasodilation?
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They protect the myocardium by inhibiting the entrance of calcium into cardiac and smooth muscle cells of the coronary and systemic arterial beds.
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When should we be careful about the calcium channel blockers?
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In patients with HF because the calcium channel blockers have negative inotropic effects.
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