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85 Cards in this Set
- Front
- Back
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define angina pectoris
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uncomfortable sensation in the chest and adjacent anatomic structures produced by myocardial ischemia
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what is ischemic heart disease?
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its a condition in which imbalance between the myocardial oxygen supply and demand results in myocardial hypoxia and accumulation of waste metabolites
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what is the most common cause of ischemic heart disease?
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atherosclerotic disease of the coronary arteries : (Coronary artery disease)
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_____ _____ area contributes to arrhythmias
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electrical neutral
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when does the majority of the coronary perfusion take place?
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diastole
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hypoxia leads to the formation of _______
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vasodilators
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what happens to wall stress in conditions such as HTN?
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increases therefore causing an increase in oxygen consumption
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what is the cause of an angina?
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oxygen supply to the myocardium is reduced due to an increase in oxygen demand that is not being met.
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what are osme of the underlying patholoies associated with angina?
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coronary arteriosclerosis, transient platelet aggregation and formation of a thrombus in the coronary arteries, coronary vasoconstriction due to accumulation of potent vasoconstrictors at sites of endothelial injury, coronary artery spasm of unknown causes, and excess sympathetic activity.
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what are the 3 major types of angina?
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stable, variant, unstable
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define stable angina
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chronic pattern of transient angina pectoris precipitated by physical activity of emotional agitation.
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which angina goes away with rest ?
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stable angina
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what would you see on an ECG of stable angina?
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temporary depression of the ST segment
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what is the cause of stable angina?
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fixed narrowing of the coronary vessels by an atheroma
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define variant angina
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typical anginal pain that occurs at rest.
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pt comes into the ER describing sharp chest pains that occur first thing in the morning. What type of angina is it?
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Variant angina
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which type of angina occurs in a cyclical manner?
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variant angina
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what would a ECG show for a variant angina?
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transient shift in ST segments (usually ST elevation)
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what is the most serious angina?
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unstable angina
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pt comes into the ER describing chest pains that have been progressively stronger and longer. Pt says that they started after he walked from the bathroom to the couch (less than 10 ft). What type of angina is this?
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unstable angina
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what is the cause of unstable angina?
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reduced coronary perfusion due to thrombus or plaque obstructing coronary blood flow
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what is the cause of variant angina?
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coronary spasms rather than an increase in myocardial oxygen demand.
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how do you treat stable angina?
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with long acting nitrates, B-blockers (non-selective and B1 selective) and calcium channel blockers. ALso must treat the underlying atherosclerosis (ie statins) and prophylaxis against thrombosis (ie aspirin or clopidogrel)
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what is the sequence of events that occur after the administration of nitrates?
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increase in nitrites --> increase in NO --> increase cGMP --> increase dephosphorylation of myosin light chain --> resulting in vascular smooth muscle relaxation
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what type of drug will cause prolonged vasodilation is paired with nitrates?
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PDE 5 inhibitor- VIAGRA
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a pt comes into the ER complaining of chest pain that is currently still occuring, what drug class should you be giving him a drug from to end the attack?
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organic nitrates
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what drug class can be used a prophylaxis against recurrent attacks?
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Organic nitrates
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pt presents will all the signs of an unstable angina attack. He is a diabetes and had an MI two days ago, what do you give him?
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Organic nitrates
-why?: B-blockers are contraindicated for asthmatics and Diabetics. Ca Channel blockers are contraindicated for people who recently had an MI. |
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besides anginas, what else can organic nitrates be used for?
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tx of cyanide poisoning
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what is the MOA of organic nitrates?
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1) reduce myocardial O2 consumption by:
a) peripherally venodilating- decreased preload b) dilating arteries- decreasing afterload (lowered arterial resistance) 2) increase O2 supply to ischemic area= dilate coronary arteries 3) use collaterals to peruse blood vessels |
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why do we administer nitrates instead of dipyridamole which have the same end goal?
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dipyriadamole does not utilize collaterals and because of it causing blood flow to normal areas to be increased and bloodflow to ischemic areas to be reduced.
Nitrates, on the other hand, use collaterals and causes an even distribution to normal tissue and an increased flow to ischemic areas. |
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what the side effects caused by organic nitrates?
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headache, orthostatic hypotension, syncope, dizziness, flushing, nausea, reflex tachycardia,
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what is the side effect of organic nitrates that is caused by a large IV dose of nitroglycerine?
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it can cause methemoglobinemia
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what drug is contraindicated with organic nitrates? what will result if they are administered together?
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PDE inhibitors; hypotensive shock
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what drug should you be cautious about administering with organic nitrates?
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migrane medication because it can increase BP and decrease the effects.
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what patient category should organic nitrates be hesitant to be administered to?
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pts with liver problems.
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T/F
Tolerance develops slowly to organic nitrates. |
FALSE
rapidly! |
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what must you allow your pt to have when prescribing them organic nitrates?
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a nitrate free interval 10-12 hours to not develop tolerance to the drug.
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where should organic nitrate tables be stored?
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somewhere cool, dry and dark and in a container. They lose potency when exposed to air and light
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how long should you keep organic nitrate tablets?
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6 months max.
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what are the four drugs in the organic nitrate family?
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amyl nitrite, glyceryl trinitrate (nitroglycerine), isosorbide dinitrate, isosorbide mononitrate
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what additional MOA might nitroglycerin provide?
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relaxation of vascular smooth muscle by intracellular conversion to nitrite ions, propelling the cascade.
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which drug of the organic nitrates is highly volatile? how is it administered and how long does it last?
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amyl nitrate; inhaled; ultra short duration of action
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which drug of the organic nitrates is moderately volatile? how is it administered and how long does it last?
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Nitroglycerin (Glyceryl trinitrate); sublingual and patch; quick and short (sublingual) and long acting (patch)
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which drug of the organic nitrates is the least potent, but longest lasting?
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isosorbide mononitrate
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what are the two drugs of the organic nitrates that are long acting?
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isosorbide dinitrate, isosorbide mononitrate
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what is the only drug class proven to reduce mortality in reference to anti-anginals?
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B-blockers
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what are the B-blockers usually paired with?
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nitrates
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what is the 1st choice of tx drug to prevent recurrence of sx in stable angina?
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B-blockers
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which drug class slows progression of MI and therefore decreases mortality in unstable angina pts?
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B-blockers
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B-blockers are not useful in what type of angina?
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Variant angina
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what is the MOA of B-blockers?
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-B1 antagonism
-Prevents exertion induced increase in HR and cardiac contractility --> reduces myocardial work and oxygen demand |
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what are the two b-blockers that are preferred because of their cardioselectiveness?
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metropolol and atenolol
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what are the side effects of B-blockers?
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bradycardia, bronchospasms, fatigue, depression, and rebound HTN if stopped suddenly
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what are the contraindicated factors of B-blockers?
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asthma and Diabetes Mellitus
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what is DM a contraindication?
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it masks hypoglycemia
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pt is brought to the ER complaining of SOB and chest pain. What do you give him?
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IV B-blocker
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when would you prescribe chronic use B-blockers for your pt?
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to reduce recurrence of angina and arrhythmias
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what drug class would you prescribe from as a prophylactic tx in stable and variant angina?
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L-type Ca 2+ channel blockers
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which drug class is particularly useful in athero-sclerotic angina with nitrates?
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L-Type Ca 2+ channel blockers
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what other medical issues can be treated with L-type Ca 2+ channel blockers?
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Paroxysmal supraventircular tachycardia (PSVT), migraines, reynaud's dz, and stroke
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what is the MOA of L-type Ca 2+ channel blockers with stable and variant angina?
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blocks Ca 2+ entry via the L-type channels during membrane depolarization in Cardiac and vascular smooth muscle.
This results in a decrease in myocardial workload, HR and contractility.--> this will lead to a dilation of peripheral vasculature, dilating the coronary artery relieving coronary vasospasm. |
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what are the side effects associated with L-type Ca 2+ channel blockers?
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constipation, sinus brady, gingival hyperplasia
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what will a high dose of L-type Ca 2+ channel blockers cause?
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heart failure, AV block, depressed myocardial contraction, nausea, edema, flushing, dizziness and reflex tach
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what are the subcategories of L-type Ca 2+ channel blockers and their associated drugs?
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Dihydropyradines (Nifedipine, Bepiridil)
Phenylalkylamines (verapamil) Benzothiazapines (dilitiazem) |
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what type of L-type channels do dihydropyradines block?
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Vascular L-type channels
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what are the side effects associated with dihydropyradines?
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constipation and bradycardia
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what type of angina is indicated for nifedipine?
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variant
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what is the MOA of nifedipine?
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causes both veno and coronary vasodilation reducing the pre and afterload
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what are the side effects associated with nifedipine?
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headache, flushing, ankle edema, reflex tach (less than nitrates), constipation, gingival hyperplasia
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is it a good idea to give a L-type Ca 2+ channel blocker and B-blocker in a post MI pt?
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no, because you will precipitate AV effects making things worse
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what is the MOA of bepiridil?
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blocks both Na+ and Ca 2+ channels
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what type of angina is indicated for bepiridil?
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chronic stable angina
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what are some side effects associated with bepiridil?
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Heart failure (if combined with B-blockers), torsades (other arrhythmias), agranulocytosis (this is specific to bepiridil)
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what type of angina is indicated for verapamil usage?
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stable, variant angina
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what is the MOA of verapamil?
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decrease workload and O2 demand which slows HR and conduction through AV resulting in decreased contractility
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what are the side effects associated with verapamil?
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constipation, gingival hyperplasia, sinus bradycardia
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what are the side effects associated with a HIGH dose of verapamil?
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myocardial depression, HF, edema, headache, hypotension, reflex tach
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this drug + b-blocker = av block
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verapamil
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what type of L-type channel is preferentially blocked by phenylalkylamines?
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Cardiac L-type channels
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what type of L-type channel is blocked by benzothiazapines?
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both cardiac and vascular
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what type of angina is indicated for dilitiazem treatment?
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stable, variant angina
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what is the tx strategy for variant angina?
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nitrates, calcium channel blockers (esp nifedipine)
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how do you manage acute coronary syndrome?
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B-blockers (always given post-mi), opioids, anticoagulants and antiplatelet drugs
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post-acs, how do you manage it? (short term and long term)
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short: antiplatelet agents and antiarrythmic agents
long: life style modification, ace inhibitors, b-blockers, antiplatelet agents and statins |
