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Therapeutics
Angina and Myocardial Ischemia
32
Dance
Undergraduate 2
08/23/2009

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Cards

Term
Coronary Arteries
Definition
  1. Left Main Coronary
  2. Right Coronary
  3. Circumflex
  4. Left Anterior Descending
Term
Ischemic Heart Disease is divided into two broad categories:
Definition
  1. Chronic Coronary Artery Disease

-Stable Angina

 

2.  Acute Coronary Syndromes

 

-Unstable Angina

-Non-ST Elevation Myocardial Infarction

-ST Elevation Myocardial Infarction

Term
Pathophysiology of Unstable Angina
Definition
  • Plaque that has formed ruptures
  • Platelet aggregation
  • Thrombus formation
  • Unopposed vasoconstriction
Term
Pathophysiology of Stable Angina
Definition
  • Lumen narrowed by atherosclerotic plaque
  • Inappropriate vasoconstriction (caused by endothelial damage)
Term
Pathophysiology of Variant Angina
Definition
  • No overt plaques
  • Intense vasospasm --> results in ischemia
Term
Depending on the anatomic site of the plaque rupture (in Unstable Angina), this process can lead to:
Definition
  1. Non-Q wave (non-ST elevation) Myocardial Infarction

OR

 

2.  Q wave (ST elevation) Myocardial Infarction

Term

Chronic Coronary Artery Disease (Stable Angina)

Treatment Goal:

Definition
Restore the balance between myocardial oxygen supply and myocardial oxygen demand
Term
If myocardial O2 demand exceeds O2 supply:
Definition
an ischemic episode results
Term
Amyl Nitrite: Classification
Definition
Vasodilator (organic nitrite)
Term
Isosorbide Nitrate: Classification
Definition
Vasodilator (organic nitrate)
Term
Nitroglycerin: Classification
Definition
Vasodilator (organic nitrate)
Term
Atenolol: Classification
Definition
Beta1 Blocker
Term
Metoprolol: Classification
Definition
Beta1 Blocker
Term
Nadolol: Classification
Definition
Non-Selective Beta Blocker
Term
Propranolol: Classification
Definition
Non-Selective Beta Blocker
Term
Amlodipine: Classification
Definition
DHP Ca2+ Channel Blocker
Term
Nifedipine: Classification
Definition
Rapid Release DHP Ca2+ Channel Blocker
Term
Diltiazem: Classification
Definition
Non-DHP Ca2+ Channel Blocker
Term
Verapamil: Classification
Definition
Non-DHP Ca2+ Channel Blocker
Term
Ranolazine: Classification
Definition
Fatty Acid Oxidation Inhibitor
Term
Organic Nitrites and Nitrates: MOA
Definition
  1. Dilation of venous capacitance vessels: results in reduced venous return, lower ventricular filling pressure (preload), decreases ventricular wall tension, reduces myocardial O2 demand
  2. Aterial dilation: results in reduced resistance to ventricular emptying (afterload), decrease cardiac work, reduced myocardial O2 demand
  3. Blood flow through collateral vessels improved: results in increased blood supply to ischemic areas of myocardium
Term
Organic Nitrites and Nitrates: Adverse Effects
Definition

Due to excessive vasodilation:

  1. headache
  2. hypotension
  3. dizziness
  4. reflex tachycardia
Term
Organic Nitrites and Nitrates: Drug Interactions
Definition
  1. PDE 5 Inhibitors: sildenafil (viagra)

-in the presence of PDE5 inhibitor, nitrates cause profound increases in cGMP and can cause dramatic reduction in blood pressure

Term
Organic Nitrites and Nitrates: Other Considerations
Definition
  1. Tolerance can develop if there is a sustained high plasma nitrate concentration

To prevent nitrate tolerance, skin patch should be removed for at least 12-14hrs each day

Term
Organic Nitrites and Nitrates: Indications
Definition
  1. Angina (all)
  2. Congestive Heart Failure (nitroglycerin, isosorbide dinitrate)
  3. Non-ST-Segment-Elevation Myocardial Infarction
  4. Acute Myocardial Infarction
Term
Ca2+ Channel Blockers: MOA
Definition
  1. Artery dilation: results in reduced resistance to ventricular emptying (afterload), decreased cardiac work, reduced myocardial O2 demand (requires higher concentrations), little effect on most venous beds
  2. Actions in cardiac cells: verapamil and diltiazem depress the rate of SA node pacemaker and slow AV conduction
  3. Increase coronary blood flow: nifedipine, verapamil, diltiazem
Term
Ca2+ Channel Blockers: Adverse Effects
Definition
  1. DHP: dizziness, hypotension, headache, flushing, nausea
  2. Nifedipine (immediate-releasing formula): worsening of angina due to coronary steal and/or reflex tachycardia
  3. Verapamil and Diltiazem: bradycardia, transient asystole
Term
Ca2+ Channel Blockers: Drug Interactions
Definition
  1. Verapamil and a Beta Blocker can cause AV block and/or severe depression of ventricular function
  2. The use of verapamil to treat digitalis toxicity is contraindicated; AV nodal conduction disturbances may be exacerbated
Term
Fatty Acid Oxidation Inhibitor: MOA
Definition
  1. Thought to block the trans-cellular late Na+ current --> by altering [Na+]i level, ranolazine blocks Na+ dependent Ca2+ channels, thus preventing Ca2+ overload
  2. Does not significantly alter HR or BP
  3. Used in combination with other antianginal drugs
  4. Decrease angina episodes and increase exercise tolerance 
Term
Fatty Acid Oxidation Inhibitor: Adverse Effects
Definition
  1. Known to increase the QT interval on the EKG
  2. Dizziness
  3. Headache
  4. Constipation
  5. Nausea/vomiting
Term
Fatty Acid Oxidation Inhibitor: Drug Interactions
Definition
  1. CYP3A Inhibitors: diltiazem, verapamil, grapefuit juice
  2. Inhibitors of P-glycoprotein: amiodarone, clarithromycin, cyclosporin
  3. Risk of additive QT prolongation: quinidine (class Ia), dofetilide, sotalol, amiodarone (class III)
Term
Fatty Acid Oxidation Inhibitor: Indications
Definition
  1. Chronic Stable Angina refractory to other antianginal drugs
  2. Acute coronary syndrome: Unstable Angina, NSTEMI
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