C
HAPTER
49 D
RUGS
FOR
A
NGINA
P
ECTORIS
angina pectoris
– sudden pain beneath the sternum, often radiating to the leftshoulder and arm- precipitated when the oxygen supply to the heart is insufficient to meet oxygendemand- secondary to atherosclerosis of the coronary arteriesDrug Therapy Goals:prevention of myocardial infarction (MI) and death- drugs used are cholesterol-lowering drugs- antiplatelet drugsprevention of myocardial ischemia and anginal pain
I. A
NGINA
P
ECTORIS
: P
ATHOPHYSIOLOGY
AND
T
REATMENT
S
TRATEGY
A. F
ORMS
OF
A
NGINA
P
ECTORIS
1. Chronic Stable Angina (Exertional Angina or Angina of Effort)
- triggered most often by an increase in physical activity- emotional excitement, large meals, and cold exposure may alsoprecipitate an attack- occurs in response to strain- underlying cause is coronary artery disease (CAD), characterizedby deposition of fatty plaqueon the arterial wall- if artery is only partially occluded by plaque, blood flow willbe reduced and anginapectoris will result- if complete vessel blockage occurs, blood flow will stop andMI (heart attack) willoccur- goal of antianginal therapy is to reduce the intensity and frequencyof anginal attacks- tactics = increase cardiac oxygen supply, which there is littlewe can do aboutor decrease oxygen demand with drugs that decreaseheart rate, contractilityafterload, and preload- can be treated with organic nitrates, beta blockers, and calciumchannels blockers- all three relieve the pain of stable angina primarily bydecreasing cardiac oxygendemand- drugs only provide symptomatic relief, they do not affect theunderlying pathology(CAD)- to reduce MI, all patients should receive an antiplatelet drug(aspirin)
- patients should attempt to avoid factors that lead to chest pain,such as overexertion, heavymeals, emotional stress, and exposure to cold- should be encouraged to quit smoking and to establish aregular program of aerobicexercise- overweight patients should be given a restricted calorie diet
2. Variant Angina (Prinzmetals’ Angina, Vasospastic Angina)
- caused by coronary artery spasm, which restricts blood flow to themyocardium- secondary to insufficient oxygenation of the heart- pain is produced at any time, even during rest and sleep- goal of therapy is to reduce the incidence and severity of attacks- treated primarily by reducing oxygen demand, variant angina istreated by increasing cardiacoxygen supply- increased with vasodilators, which prevent or relievecoronary artery spasm- calcium channel blockers and organic nitrates- treatment is symptomatic only, drugs do not alter theunderlying pathology
3. Unstable Angina
- medical emergency- results from severe CAD complicated by vasospasm, plateletaggregation, and transientcoronary thrombi or emboli- patients may present with either symptoms of angina at rest, newonset exertional angina orintensification of existing angina- treatment strategy is to maintain oxygen supply and decreaseoxygen demand- goal is to reduce pain and prevent progression of MI or death- all patients should be hospitalized- acute management consists of anti-ischemic therapycombined with antiplatelet andanticoagulation therapyAnti-ischemic Therapy: * nitroglycerin – sublingually (tablet or spray)followed by IV therapy* beta blocker – if contraindicated, substitute withnondihydropryridinecalcium channel blocker (verapamil ordiltiazem)* supplemental oxygen* IV morphine sulfate* angiotensin-converting enzyme inhibitor
Antiplatelet Therapy:* aspirin* clopidogrel (plavix)* abciximab (reopro)* eptifibatide (intefrilin) or tirofiban (aggrastat)Anticoagulant Therapy:* subcutaneous low-molecular weightheparin
II. O
RGANIC
N
ITRATES
- relieve angina by causing vasodilation
A. N
ITROGLYCERIN
- effective, fast acting, and inexpensive- remains the drug of choice for relieving acute anginal attacks- applications of specific preparations are based on their time course:
•
rapid onset are employed to terminate an ongoing anginal attack –applications are administered as soon as pain begins
•
rapid acting preparations can also be used for acute prophylaxis of angina – preparations are taken just prior to anticipated exertion
•
long acting preparations are used to provide sustained protectionagainst anginal attacksSpecific Preparations:Sublingual Tablets (beneath the tongue) & Translingual Spray (oral mucosa)- absorbed directly through the oral mucosa andinto the bloodstream- bypasses the liver, temporarily avoidingmetabolism- effects begin rapidly (1 – 3 minutes) and persistup to 1 hour- ideal for termination of ongoing anginal attackand short termprophylaxis when exertion is anticipated- if 1 tablet is insufficient, 1 or 2 additional tabletsshould be taken at 5minute intervals- patient should be instructed to place the tabletunder the tongue andleave it there while it dissolves – ineffectiveif swallowed- shelf life can be prolonged by storing tablets in atightly closed, darkcontainer- patients should be instructed to write the date of opening on thecontainer and to discard unused tablets 6months later
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Chapter 49 Drugs for Angina Pectoris
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