angina

Question 1

how do you treat variant/angiospastic/prinztmetals angina

Answer 1

nitrates, CCB

Question 2

O2 demand depends on —— which is determine by —–?

Answer 2

cardiac workload
which is determined by:
1. HR
2. contractility
3. Ventricular wall tension

Question 3

What does wall tension represent and how is it increased

Answer 3

wall tension = force developed during contraction

*increase wall tension by increasing pressure and/or increasing volume

Question 4

any increase in HR or contractility will cause what

Answer 4

increase the need for O2

Question 5

O2 supply depends on

Answer 5

myocardial delivery and extraction

Question 6

heart normally extracts 75% of O2 in blood so how can you increase O2 available to tissues

Answer 6

only way is to increase O2 delivery through coronary blood flow

Question 7

Coronary blood flow is directly proportional to

Answer 7

perfusion pressure

duration of diastole

Question 8

Coronary flow may be decreased by

Answer 8

1. shortening diastole (due to ^HR) (this decreases filling time)
2. Increased vendtricular end diastolic pressure
3. reduced diastolic arterial pressure
   * prevents pressure gradiant that is conducive to blood flow

Question 9

MOA of nitrates/nitrite

Answer 9

vasodilation via NO that stimulates cGMP (dephos Myosin LC) = relax

Question 10

describe the vasodilation that occurs with nitrates/nitrites

Answer 10

UNEVEN: veins more dilated = increase venous capacitance = decreased preload

*arterioles dilated less but still decrease afterload

Question 11

Nitrates are DOC for

Answer 11

acute angina attack

Question 12

What makes nitrates good/bad

Answer 12

good: decrease cardiac workload bc decrease preload and afterload

BAD: increase cardiac workload: bc the dec BP stimulates baroreflex to increase HR an contractility thus decreasing diastolic perfusion time

Question 13

what makes for anginal relief

Answer 13

Predominant: decrease myocardial O2 requirement
Secondary: redistribution of coronary blood flor to ischemic areas
*also relax SM in bronchi, GI and GU

Question 14

pharmacokinetics of oral organic nitrates

Answer 14

rapid hepatic metab with high first pass

Question 15

what are the fastest acting nitrites

Answer 15

inhaled: amyl nitrite
IV: nitroprusside

Question 16

benefits to SL nitrite

Answer 16

avoids hepatic damage!
rapid absorption
immediate anginal relief (1-3 min onset, lasts 10-30min)

Question 17

amyl nitrite form

Answer 17

volatile liquids, inhaled

Question 18

Isosorbide dinitrate form

Answer 18

solid, SL or oral tab

Question 19

Adverse effects of nitrates

Answer 19

acute toxicity, pronounced vasodilation causes:
orthostatic hypotension, tachycardia, HA
*not suitable for long term

Question 20

what is mondays disease

Answer 20

explosive manufacturers w/ chronic exposure
friday sx disappear bc tolerance
monday: HA/dizzy

Question 21

How do CCB work

Answer 21

relax all SM dependent on Ca

*differences in tissue selectivity can result in opposite effects on HR (dipines increase HR, verapamil decreases HR)

Question 22

when is slow release nifedipine indicated

Answer 22

ONLY in HTN

*may provoke angina (bc increase HR)

Question 23

what type of tx are CCB good for (re angina)

Answer 23

chronic angina, not for immediate angina relief

Question 24

Nifedipine benefits

Answer 24

coronary vasodilation increases myocardial O2 supply, decreases afterload

Question 25

Nifedipine harmful effect

Answer 25

enhanced development of MI | *rapid hypotension --> baroreflex --> increase cardiac workload

Question 26

Verapamil/diltiazem benefit

Answer 26

decreased cardiac workload: decrease myocardial contractility, bradycardia (bc dec SA and AV node)

Question 27

harmful effect of Verapamil/diltiazem

Answer 27

potential to cause serious cardiac depression --> cardiac arrest, AV block, CHF

Question 28

BB major effects are..

Answer 28

both cardiac and vascular

Question 29

3 organs BB has CV effect on

Answer 29

heart: decrease CO Kidney: decrease renin CNS: decrease SNS

Question 30

how do BB cause anginal relief

Answer 30

decrease SNS = dec cardiac activity and dec vasoconstriciton = hypotension, dec HR = decreased cardiac workload = decreased myocardial O2 demand *also, dec HR increases myocardial perfusion time

Question 31

can BB produce coronary vasodilation?

Answer 31

NO NO NO... BB do not cause direct vasodilation thus are NOT indicated for variant angina

Question 32

what type of angina should we use BB for

Answer 32

CLASSICAL - not variant bc BB do not cause direct vasodilation

Question 33

adverse effects of BB include

Answer 33

bronchoconstriciton (bad for asthma) ^ TAG: bad for hyperlipidemics ^ Glu intolerance: bad for DM CNS SE: fatigue/depression/sleep disturbances *potentially harmful if used in variant angina bc slows HR, prolongs ejection time = increase LV end diastolic volume = increase myocardial O2 requirement

Question 34

MOA of Fanolazine and indication

Answer 34

``` PFox inhibitor (decrease O2 consumption in ischemic tissue, decrease contractility) *use only when others don't work ```

Question 35

why are BB potentially harmful in variant angina

Answer 35

*potentially harmful if used in variant angina bc slows HR, prolongs ejection time = increase LV end diastolic volume = increase myocardial O2 requirement

Question 36

effective tx of angina will..

Answer 36

increase exercise tolerance | decrease freq and duration of myocardial ischemia

Question 37

tx for variant

Answer 37

nitrates and CCB *but slow release nifedipine may worsen angina, better for nitrate + cardio CCB ie verapamil *BB will not cause vasodilation of spastic coronary vessels

Question 38

Most effect drug combo for classic angina

Answer 38

BB and vasodilator

Question 39

how can you minimize the harmful effects of CCB or BB

Answer 39

by combing with nitrates and vice versa

Question 40

how can you minimize reflex tachy

Answer 40

combine nitrates with CCB or BB

Question 41

preferred for asthma angina pt

Answer 41

CCB (verapamil) and nitrate least: BB

Question 42

DM angina pt tx

Answer 42

CCB (verapamil) and nitrate least: BB

Question 43

CHF angina pt tx

Answer 43

nitrate least: BB, CCB (verapamil, diltiazem)

Question 44

HTN angina pt tx

Answer 44

BB, CCB least: nitrate

Question 45

PUD angina pt tx

Answer 45

BB, nitrate least: CCB

Question 46

Sildenafil MOA and use

Answer 46

selective inhibitor of cGMP PDE5 | *intended for angina but found to be better for ED

Question 47

indication for sildenafil

Answer 47

ED, pulm HTN

Question 48

PK of sildenafil

Answer 48

oral, rapid absorption, 40% bioavailable | Max concentration: 30-120 min, t1/2 4 hr

Question 49

how is sildenafil metab

Answer 49

CYP3A4 major | CYP2C9 minor

Question 50

Adverse effects of Sildenafil

Answer 50

mild/mod: HA, flushing, dyspepsia, nasal congestion, UTI, blue color tinge to vision/ blurred vision

Question 51

When should you not rx sildenafil

Answer 51

pregnant/lactating, pt currently on nitrates, pt on alpha blockers (double hypotension effect)

Question 52

other contraindication for sildenafil

Answer 52

inhibitors of CYP3A4 and 2CP: increase sildenafil *ketoconazole, erythromycin, quinidine, Cimetidine/omeprazole *note omeprazole also increases toxicity of quinidine and warfarin and clopidogrel

Question 53

other PDE5 inhibitors and MOA

Answer 53

Vardenafil and Tadalafil | *more selective for PDE5 than PDE6, less visual blue tinge

Question 54

Vardenafil benefits

Answer 54

faster onset than sildenafil or tadalafil

Question 55

Tadalafil benefits

Answer 55

longer duration (24-36 hours) = spontaneity