Ch 29: Stable Angina

what is angina

chest pain, pressure, tightness usually caused by ischemia of the heart muscle or spasm of the coronary arteries

stable angina

predictable chest pain brought on by exertion or stress and relieved within minutes by rest or short acting nitroglycerin

unstable angina

type of acute coronary syndrome; medical emergency where chest pain increases and is not relieved with nitroglycerin or rest

pathophysiology of angina

imbalance of myocardial oxygen demand (workload) and supply (blood flow)

non-drug considerations for stable angina treatment

• heart healthy diet

• moderate intensity of aerobic activity

• limit alcohol intake

• quit smoking

• avoid chronic NSAIDs

treatment approach for stable angina

A = antiplatelet and antianginal drugs

B = blood pressure

C = cholesterol (statins) and cigarettes (cessation)

D = diet and diabetes

E = exercise and education

purpose of antiplatelet drugs

secondary prevention

purpose of antianginal drugs

reduce chest pain by decreasing myocardial oxygen demand or increase oxygen supply

recommended antiplatelet for stable angina

aspirin

when to use clopidogrel in stable angina

allergy or other contraindication to aspirin

dual antiplatelet therapy (DAPT) place in stable angina

not recommended for secondary prevention — only recommended after recent ACS or PCI

what drug classes can be used to prevent symptoms of stable angina

• beta blockers

• DHP/non-DHP CCBs

• long-acting nitrates

if patient is still symptomatic with initial monotherapy…

adding a second antianginal drug from a different class is recommended

recommended drug class for immediate relief

sublingual tab or translingual spray nitroglycerin

MOA of aspirin

irreversible inhibition of COX-1 and 2 enzymes = decreased prostaglandin and thromboxane A2 production

MOA of clopidogrel

prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

typical dosing of aspirin for stable angina

75 - 100mg daily

typical dosing of clopidogrel

75mg daily

drug interactions associated with antiplatelet drugs

additive effects with drugs that increase bleeding risk (anticoagulants, NSAIDs, SSRIs, SNRIs, some dietary supplements)

drug interaction associated with aspirin

caution in combo with other otoxicic drugs

drug interaction associated with clopidogrel

avoid moderate or strong 2C19 inhibitors (omeprazole, esomeprazole)

clinical benefit of BB in stable angina

reduce myocardial oxygen demand (decrease: HR, contractility, and left ventricular wall tension)

clinical benefit of non-DHP CCBs

decrease HR and contractility

clinical benefit of DHP CCB

decrease SVR (afterload)

all CCBs ___ blood flow through coronary arteries

increase

clinical benefit of nitrates

reduces myocardial oxygen demand (decreasing preload) and increases myocardial oxygen supply (increase blood flow thru collateral arteries)

contraindications for ranolazine

• liver cirrhosis

• concurrent use of strong 3A4 inhibitors or inducers

ranolazine has this specific warning associated with it

QT prolongation

typical doses of nitroglycerin SL tab

0.3mg, 0.4mg, and 0.6mg

typical dose of nitroglycerin TL spray

0.4mg

contraindications of nitrates

• hypersensitivity

• concurrent use of PDE-5 inhibitors or soluble guanylate stimulators

warnings associated with nitrates

• hypotension

• tachyphylaxis (tolerance)

store nitroglycerin SL tabs in ___

original amber glass bottle

how long of a nitrate free period is necessary to prevent tolerance

10-12 hrs

application frequency of nitrate patches

wear for 12-14 hours (rotate sites)

off for 10-12 hours

dosing of nitrate ointment

BID 6 hours apart

how is isosorbide mononitrate dosed

BID 7 hours apart

what is the preferred combination in patients that have stable angina and HFrEF

isosorbide dinitrate + hydralazine

ranolazine is an inhibitor of the following:

3A4

2D6

Pgp

priming directions for nitroglycerin TL spray

before use and if not used within 6 weeks