Angina Medical Management

angina

deep, poorly localized chest or arm
discomfort reproducibly associated with physical
exertion or emotional stress and is relieved promptly (i.e., less than 5 min) with rest and/or the use of sublingual
nitroglycerin

chronic stable angina

chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms

variant angina

pain at rest, thought to be caused by coronary artery vasospasm

ACS (acute coronary syndrome)

symptoms can include unstable angina, non-ST elevation MI, acute MI (ST elevation)

drugs used for stable angina

Nitrates (short & long acting)
Beta Antagonists (beta blockers)
Calcium channel blockers (use in variant angina)

nitrates

this class of drugs works by increasing vasodilation esp. venodilation, dilation of coronary arteries
prevent acute angina attacks, prevention of attacks (prophylactic therapy) in conjunction w/ Beta
blockers or CCBs

beta blockers

this class of drugs treats angina by reducing O2 demand by reducing contractility, HR and blood pressure; often preferred agent for chronic prophylactic therapy

calcium channel blockers

this class of drugs causes vasodilation of systemic arterioles and coronary arteries, decrease in myocardial contractility, decrease in conduction velocity of SA and AV nodes
VARIANT or Prinzmetal's angina, good for pts with contraindications, intolerance of B-blockers, effective for chronic prophylaxis

nitrates

can be administered by IV, SL, buccal, spray are rapid acting, with short duration for acute
attacks
ointment (20-60 min onset and lasts 2-8hours)
patch (onset 40-60min and lasts > 8 hrs)
Isosorbide dinitrate (acute attack and prophlaxis)
Isosorbide mononitrate (for prophylaxis)

beta blockers

these drugs can be started in pts with ACS, MI and left vent; dysfunction and continue indefinitely

nitrates

adverse effects of these drugs includes flushing, HA, postural hypotension, tolerance (nitrate free 8-12hrs/day) store in tightly closed glass container in cool place away from light

beta blockers

adverse effects include bradycardia, heart failure, bronchospasm, vasoconstriction, heart block

nitrates

do not take with Viagra, PD5 inhibitors, Levitra, Cialis or other phosphodiesterase inhibitors- can cause severe hypotension
CI: patients with large RV infarct, hypertrophic cardiomyopathy

calcium channel blockers

verapamil and diltiazem less peripheral
vasodilation, greater cardiac effects including reduced heart rate
dihydropyridines - peripheral vasodilation

calcium channel blockers

adverse effects include HR elevation with nifedipine and dihydropyridines, DO NOT USE short acting nifedipine as it may precipitate myocardial ischemia

Ranolizine (Ranexa)

add on therapy for chronic angina; a unique modulator of metabolic pathways in myocardial
tissues
AE: dizzy, HA, N, watch EKG (QT interval prolongation)

SL or lingual nitroglycerin spray

treat acute angina attacks with ...

beta blockers

>1 episode a day & chronic angina can be treated with ...

CCBs/ long acting nitrate therapy

treat variant angina with ...