C

A
R
D
I
O
V
A
S
C
U
L
A
R
D
R
U
G
S

DRUGS USED IN
THE TREATMENT
OF
ANGINA PECTORIS

ANGINA PECTORIS
CORONARY
HEART
DISEASE

MYOCARD
INFARCTION

SUDDEN DEATH

ANGINA PECTORIS
STABLE ANGINA
ATHEROSCLEROTIC ANGINA
ANGINA OF EFFORT

VARIANT ANGINA
VASOSPASTIC ANGINA
REST ANGINA
PRINZMETALS ANGINA

UNSTABLE ANGINA

MYOCARDIAL
O2 REQUIREMENT > DELIVERY

MYOCARDIAL
ISCHEMIA

RETROSTERNAL
PAIN/
DISCOMFORT

THERAPEUTIC
STRATEGIES

D
O2

O2

NT
E
M
E
IR
U
Q
RE

RY
E
IV
L
E

TREATMENT

Pharmacologic
NITRATES
BETA BLOCKERS
CALCIUM CHANNEL BLOCKERS
NICORANDIL
RANOLAZINES
ANTIPLATELET DRUGS (low dose aspirin / clopidogrel)
STATINS

Nonpharmacologic
MYOCARDIAL REVASCULARIZATION
- Coronary Angioplasty
- Coronary artery by pass grafting (CABG)

CARDIAC
CONTRACTILITY

PRELOAD

MYOCARDIAL
OXYGEN REQUIREMENT

HEART RATE

AFTERLOAD

EJECTION TIME

VENOUS
TONE

BLOOD
VOLUME

ARTERIOLAR
TONE

VENOUS
RETURN

PERIPHERAL
RESISTANCE

PRELOAD

AFTERLOAD

Drugs and their clinical uses

DRUGS

STABLE
ANGINA

VARIANT
ANGINA

NITRATES

BETA BLOCKERS

CALCIUM CHANNEL
BLOCKERS

NICORANDIL

RANOLAZINE

A = ACUTE

A,P

A,P

P
P
P
P

P = PROPHYLACTIC

v
v
v

P
P
P

CARDIAC
CONTRACTILITY
Beta Blockers
CCBs

PRELOAD
Nitrates

MYOCARDIAL
OXYGEN REQUIREMENT

HEART RATE
Beta Blockers
CCBs

AFTERLOAD
CCBs

NITRATES

Venodilatation > arterial dilatation >>> arteriolar dilatation

ANGINA OF EFFORT
Venodilation
preload
oxygen
requirement
Dilatation epicardial
coronary artery
coronary flow

VARIANT ANGINA
Reversal of coronary
spasm and increased flow

NITRATES

NITRATES
Short acting agents
Sublingual TNG
Sublingual ISDN
Long acting agents
ISDN oral, sustained action
TNG ointment, skin patch
ISMO oral, sustained action
TNG : trinitroglycerine, ISDN : isosorbide finitrate, ISMO :isosorbide mononitrate

(Nicotinamide moiety)

(NO2 group)

RANOLAZINE

Inhibitor of late sodium current

Antianginal effect ?

Imbalance of O2 supply and demand

Late INa
Na entry [Na+]i
Cytosolic Ca2+

Electrical instability
afterpotentials
arrhythmia (VT)

Mechanical dysfunction
Abnormal contraction and
relaxation
Diastolic tension