Angina Pectoris

sudden pain beneath the sternum, often radiating to left arm and shoulder; oxygen supply to the heart is
insufficient to meet demand
vOrganic Nitrates
3 main objextives of therapy: minimized frequency, intensity and duration
dilate of
allattacks; improve
blood vessels pts functional
including coronary
capacity with as few AEs as possible; prevent or delay the worst possible outcome:
arteries MI
long acting - prophylaxis, short acting - acute
Stable Angina: attacks
AKA: classic, effort, exertional nitroglycerine (Nitro-
patho: large meals, emotional excitement, cold exposure, CAD,
nicotine, alcohol, caffeine Bid, Nitrostat, Nitrol,
intense pain that subsides w/in 15 min w/rest or rx therapy etc)
indications: acute, unstable or unctrolled
Tx: organic nitrates, beta blockers, calcium channel
exacerbations of angina, sustained
blockers, ranolazine
anginal therapy, IV periop control of BP,
tx of HF with MI
Vasospastic Angina: may be used prophylactically before
AKA: prinzmetal's, variant exercise to reduce preload
patho: coronary artery spasm AEs: HEADACHE, orthostatic HypoTN,
reflex tachy; cyanide poisoning can occur
Tx: organic nitrates, calcium channel blockers in pts receiving prolonged IV nitro
prusside
interactions: HypoTN rxs, ETOH, beta
Unstable Angina: blockers, CCBs, phenothiazines,
AKA: preinfarction, crescendo verapamil, diltiazem,
PHOSPHODIESTERASE TYPE 5
MEDICAL EMERGENCY INHIBITORS (erectile dysfunction
patho: sxs at rest, new-onset exertional, intensification of existing drugs - MUST ASK ABOUT THESE D/T
Tx: anti-ischemic, anti-platelet, anti-coagulant therapy POSSIBILITY OF DEATH )
Tolerance with patches or paste can
Anti-Platelet develop quickly (w/cross-tolerance):
Anti-Ischemic
Therapy prevent with a nitrate free-period; pt may
Therapy Anti-Coagulant
aspirin (ASA) - have angina when during nitrate-free
MONA + B: Therapy period.
indefinitely
MORPHINE , subQ LMW heparin
OXYGEN, clopidogrel (Plavix) SL tablets are light sensitive and should
NITROGLYCERINE, IV unfractioned be stored in a cool, dark place; 6mo shelf
abciximab (ReoPro) life; max dose 1 tab q5min x3 tabs... call
ACE-I, BETA heparin
eptifibatide 911 if no relief after 1st tab
BLOCKER
(Integrilin) Other Rx: isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate-SR);
isosorbide mononitrate (Imdur,
Monoket, Ismo)
 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
Calcium Channel Blockers
block Ca channels in VSM
verapamil
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
ranolazine
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)

Risk Factors:
Rx prevention of MI and
death: smoking Revascularization Therapy
antiplatelet drugs high cholesterol coronary artery bypass graft
cholesterol lowering drugs hypertension (CABG)
ACE inhibitors diabetes percutaneous transluminal
obesity coronary anginoplasty (PTCA)
anti-anginal agents
physical inativity