Angina Pectoris

sudden pain beneath the sternum, often radiating to left arm and shoulder; oxygen supply to the heart is insufficient to meet demand 3 main objextives of therapy: minimized frequency, intensity and duration of attacks; improve pts functional capacity with as few AEs as possible; prevent or delay the worst possible outcome: MI Stable Angina: AKA: classic, effort, exertional patho: large meals, emotional excitement, cold exposure, CAD, nicotine, alcohol, caffeine intense pain that subsides w/in 15 min w/rest or rx therapy

vOrganic Nitrates
dilate all blood vessels including coronary arteries
long acting - prophylaxis, short acting - acute attacks

nitroglycerine (Nitro-Bid, Nitrostat, Nitrol, etc)

indications: acute, unstable or unctrolled exacerbations of angina, sustained anginal therapy, IV periop control of BP, tx of HF with MI may be used prophylactically before exercise to reduce preload AEs: HEADACHE, orthostatic HypoTN, reflex tachy; cyanide poisoning can occur in pts receiving prolonged IV nitro prusside interactions: HypoTN rxs, ETOH, beta blockers, CCBs, phenothiazines, verapamil, diltiazem, PHOSPHODIESTERASE TYPE 5 INHIBITORS (erectile dysfunction drugs - MUST ASK ABOUT THESE D/T POSSIBILITY OF DEATH ) Tolerance with patches or paste can develop quickly (w/cross-tolerance): prevent with a nitrate freeperiod; pt may have angina when during nitratefree period. SL tablets are light sensitive and should be stored in a cool, dark place; 6mo shelf life; max dose 1 tab q5min x3 tabs... call 911 if no relief after 1st tab Other Rx: isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate-SR); isosorbide mononitrate (Imdur, Monoket, Ismo)

Tx: organic nitrates, beta blockers, calcium channel blockers, ranolazine

Vasospastic Angina: AKA: prinzmetal's, variant patho: coronary artery spasm Tx: organic nitrates, calcium channel blockers Unstable Angina:

AKA: preinfarction, crescendo

MEDICAL EMERGENCY patho: sxs at rest, new-onset exertional, intensification of existing Tx: anti-ischemic, anti-platelet, anti-coagulant therapy Anti-Platelet Therapy aspirin (ASA) - indefinitely clopidogrel (Plavix) abciximab (ReoPro) eptifibatide (Integrilin) Anti-Coagulant Therapy subQ LMW heparin IV unfractioned heparin

Anti-Ischemic Therapy MONA + B: MORPHINE , OXYGEN, NITROGLYCERINE, ACE-I, BETA BLOCKER

Beta Blockers

decrease O2 demand by slowing conduction, reducing contractility and slowing the HR; opposes reninl
propranolol metoprolol atenolol nadol AEs: brady, HypoTN, decreased AV conduction, reduction of contractility, asthmatic effects (wheezing, dyspnea), insomnia, depression, lethargy, drowsiness, bizarre dreams, sexual dysfunction/impotence use w/caution in pts with diabetes

ranolazine Calcium Channel Blockers block Ca channels in VSM verapamil new class of anti-anginals not 1st line therapy - combine with 1st line agents if inadequate response to other 1st line meds does not reduce HR, BP, or vascular resistance known to prolong QT interval Contraindications: pts w/pre-existing QT prolongation, hepatic impairment, taking other QT prolonging drugs, taking other moderately potent CYP450 inhibitors interactions: QT drugs, CYP450 drugs, dig (increase dig levels), ketoconazole & verapamil (raise ranolazine levels)

diltiazem
nifedipine AEs: dry cough, dilation of periheral arterioles, reflex tachy, HypoTN, brady, HF, AV block, GI: constipaiton, nausea, etc; dermatitis, dyspnea, rash, flushing, peripheral edema, wheezing

Risk Factors: Rx prevention of MI and death: smoking high cholesterol hypertension Revascularization Therapy coronary artery bypass graft (CABG) percutaneous transluminal coronary anginoplasty (PTCA)

antiplatelet drugs
cholesterol lowering drugs ACE inhibitors anti-anginal agents

diabetes
obesity physical inativity