ANGINA PECTORIS

TYPES OF ANGINA
STABLE ANGINA UNSTABLE ANGINA PRINZMETALS ANGINA NOCTURNAL ANGINA ANGINA DECUBITUS

Etiology
*CAD
*VESSEL CONSTRICTION *HYPER METABOLIC CONDITIONS:
EXERCISE
THYROTOXICOSIS STIMULANT ABUSE HYPER THYROIDISM EMOTIONAL STRESS

*ANEMIA *HEART FAILURE *PULMONARY DISEASE

Pathophysiology

Signs & Symptom

Medical Therapy--aspirin
enteric-coated aspirin, 75 to 325 mg per day
produces a sustained functional defect in the platelet associated with prolongation of the bleeding time

arachidonic acid
cyclo-oxygenase inhibition (aspirin)

thromboxane A2(TXA2) (the key modulator of irreversible platelet aggregation)

Medical Therapy:Nitrates
Reduce preload

Reduce afterload
Dilate epicardial coronary Nitric oxide (NO)

Frishman WH: Pharmacology of the nitrates in angina pectoris. Am J Cardiol 56:8I, 1985.

Medical Therapy :Nitrates

Nitrate dosing*

Formulation?
Sublingual tablet GTN
Sublingual tablet ISDN Oral spray GTN Oral GTN SR Buccal tablet GTN Oral ISDN Oral ISDN SR Oral IS-5-MN Oral IS-5-MN SR GTN ointment 2% Transdermal GTN patch

Dose
0.3~.6 mg
2.5~10 mg 0.4-mg metered dose 2.6 mg 2.6.5.2 1, 2, 3, and 5 mg 10~30mg 80~120 mg 20 mg 60~240 mg 0.5~2 0.2~.8 mg/h*

Frequency
As required
As required As required Three times a day Two or three times a day Two or three times a day Daily Twice a day Daily Twice a day Daily

Onset/duration action
2 min/20~30 min
5~10 min/1?~2h 2 min/20~30 min 2~5 min/3~5h 2~5 h/3~5 h 15 min/4~6h 60 min/10~12 h 30 min/5~7h 60 min/10~14 h 15 min/8 h 30 min/12~24h

* Adapted from Abrams J. Therapy of angina pectoris with long acting nitrates: Which agent and when. Can J Cardiol 1996; 12C:9C-16C. GTN indicates nitroglycerin; ISDN, isosorbide Dinitrate; IS-5-MN, isosorbide-5-mononitrate; and SR, sustained release.

* A nitrate-free interval of at least 8 h per 24-h period should be provided to avoid tolerance.

Medical Therapy :Nitrates

Principle side effects headache flushing lightheadness Occasionally side effects nitrates syncope
Because: a rapid decline in systolic blood pressure in the
upright position, associated with arterial dilatation and venous pooling.

Medical Therapy :-blocker

Mechanism

Medical Therapy:
classes of -receptors : -1 and -2

-blocker Pharmacology

Cardioslectivity:

nonselective: affect the heart, peripheral vasculature, bronchial tree, and modulation of hepatic and skeletal muscle glyconeogenesis -1 selective: (metoprolol and atenolol) tends to circumvent the undesirable consequences (constriction of the bronchial tree and arterial smooth muscle ) of nonselective b-blockade
Selective b-1 blocker effects, however, are only relatively selective, and at increased doses these agents produce -2 blockade

Medical Therapy :-blocker

Name (proprietary)
Propranolol (Inderal) (Inderal LA) Nadolol (Corgard) Nonselective

Property
Nonselective

Frequency
Twice a day Daily Daily

Daily dose, mg
80-320 60-320 80-240

Timolol (Blocadren)
Metoprolol (Lopresor) (Lopresor SR) Atenolol (Tenormin) Acebutolol (Sectral) Pindolol (Visken)

Nonselective
B1 selective

Twice a day
Twice a day Daily

15-45
100-400 100-400 50-200 200-600 15-45

B1 selective

Daily

B1 selective partial ISA Twice a day Nonselective ISA Twice a day

Three times a day (>30 mg total) Sotalol (Sotacor)* Nonselective with type 3 Twice a day antiarrhythmic effect
* Sotalol is not approved for angina pectoris use. ISA indicates intrinsic sympathomimetic activity.

160-480

Medical Therapy :-blocker

Untoward effects of nonselective -blockade
Coronary vasoconstriction : Prinzmetal variant angina Peripheral circulatory vasoconstriction : Raynauds disease Bronchial constriction: Asthma, COPD Response to hypoglycemia Impaired hepatic gluconeogenesis Impaired general awareness Triglycerides/high-density lipoprotein cholesterol

Medical Therapy :Calcium-blocker

When symptoms persist or side effects limit treatment with -blockers and/or nitrates, the use of calcium antagonists may provide significant additional relief. It has been suggested that a special niche for calcium antagonists resides with Prinzmetals variant angina patients .

Medical Therapy :Calcium-blocker

Classification of calcium-blocker
*Dihydropyridines
nifedipine SR nifedipine longer-acting: felodipine amlodipine

*Diltilzem *Verapamil

Medical Therapy: Calcium-blocker

provoking factors mental stress preload alleviating factors

physical stress
cold air lying down supply demand

constriction periferal artery relax

myocardium contractivity heart rate

BP
supply

angina

angina relief

demand