CV Pharmacology

Anti-Anginal Agents
Reading:
Antianginal Drugs
Formative Assessment
Practice question
Clinical:
e-Medicine articles
Coronary Artery Disease
Risk Factors for CAD
Angina Pectoris

Prepared and presented:

Marc Imhotep Cray, M.D.
BMS and CK-CS Teacher

Coronary heart disease (CHD)

Defined (Etiologic Dx)

Coronary heart disease (CHD) is a

condition in which proper circulation of blood
and oxygen are not provided to heart and
surrounding tissue.
Result is due to a narrowing of small blood
vessels, which normally supply heart with
blood and oxygen.
Coronary heart disease, a type of
cardiovascular disease, is the leading
cause of death for both men and women
in the United States.
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Causes (Anatomic Dx)

The typical cause of

coronary heart
disease is
atherosclerosis,
which takes place
with plaque and fatty
build up on the
artery walls,
narrowing the
vessels.
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CAD Risk Factors

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Certain conditions are considered to put an individual at greater

risk for coronary heart disease. The following are some risk
factors:
Age (particularly 40+)
Diabetes
Genetics (heredity)
High blood pressure
High bad cholesterol (LDL)
Increased levels of C-reactive protein, fibrinogen, or homocysteine
Lack of sufficient physical activity
Low good cholesterol (HDL)
Menopause
Obesity
Smoking
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Symptoms

1.
2.
3.

Some more frequent

symptoms of coronary
heart disease include:
Angina (ischemic pain)
Myocardial Infarction
Shortness of breath

Diagnosis

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Diagnosis of coronary heart disease may be

accomplished by a variety of means:
Coronary angiography
Coronary arteriography
Coronary CT angiography
Echocardiogram
Electrocardiogram (ECG)
Electron-beam CT (EBCT)
Exercise stress test
Magnetic resonance angiography
Nuclear scan
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Treatment

1.
2.
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6.

Coronary heart disease treatment methods

may include: (depends on the presenting
Physiologic Dx)
Angioplasty with stenting
Coronary artery bypass surgery
Medication
Minimally invasive heart surgery
Proper diet and exercise
Quitting smoking
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Coronary Artery O2 Supply

and Demand

Angina Pectoris (Chest Pain)

When the supply of

oxygen and nutrients in
the blood is insufficient
to meet the demands of
the heart, the heart
muscle aches
The heart demands a
large supply of oxygen
to meet the demands
placed on it

The myocardial supply:demand ratio--a critical

review. [Am J Cardiol. 1978]
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R/O MI Algorithm

Contemporary Diagnosis and Management of Unstable Angina

GUYS R. http://www.mayoclinicproceedings.com/inside.asp?AID=1529&UID=
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Antianginal Pharmacologic
Agents

Nitrates
Beta blockers
Calcium channel blockers

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Types of Angina

Chronic stable angina

(also called classic or effort angina)

Unstable angina

(also called preinfarction or crescendo angina)

Vasospastic angina

(also called Prinzmetals or variant angina)

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Antianginal Agents:
Therapeutic Objectives

Increase blood flow to ischemic heart muscle

and/or
Decrease myocardial oxygen demand

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Antianginal Agents:
Therapeutic Objectives

Minimize the frequency of attacks and

decrease the duration and intensity of anginal
pain
Improve the patients functional capacity with
as few side effects as possible
Prevent or delay the worst possible outcome,
MI

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Antianginal Agents:
1)Nitrates
Available forms:
Sublingual
Buccal
Chewable tablets
Capsules

Ointments
Transdermal patches
Inhalable sprays
Intravenous solutions

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Antianginal Agents: Nitrates(2)

Cause vasodilation due to relaxation of

smooth muscles
Potent dilating effect on coronary
arteries

Used for prophylaxis and treatment

of angina

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Antianginal Agents: Nitrates(3)

Nitroglycerin

Prototypical nitrate
Large first-pass effect with PO forms
Used for symptomatic treatment of ischemic
heart conditions (angina)
IV form used for BP control in perioperative
hypertension, treatment of CHF, ischemic pain,
and pulmonary edema associated with acute MI

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Antianginal Agents: Nitrates(4)

isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate SR)
isosorbide mononitrate
(Imdur, Monoket, ISMO)

Used for:

Acute relief of angina

Prophylaxis in situations that may provoke
angina
Long-term prophylaxis of angina
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Antianginal Agents: Nitrates(5)

Side Effects

Headache
Usually diminish in intensity and frequency
with continued use
Tachycardia, postural hypotension
Tolerance may develop

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Antianginal Agents:
2)Beta Blockers

atenolol (Tenormin)
metoprolol (Lopressor)
propranolol (Inderal)
nadolol (Corgard)

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Antianginal Agents:
Beta Blockers(2)
Mechanism of Action

Decrease the HR, resulting in decreased

myocardial oxygen demand and increased
oxygen delivery to the heart
Decrease myocardial contractility, helping to
conserve energy or decrease demand

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Antianginal Agents:
Beta Blockers(3)
Therapeutic Uses

Antianginal
Antihypertensive
Cardioprotective effects, especially after MI

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Antianginal Agents: Beta

Blockers(4)
Side Effects
Body System Effects
Cardiovascular

Metabolic

bradycardia, hypotension
second- or third-degree heart block
heart failure
Altered glucose and lipid
metabolism

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Antianginal Agents:
Beta Blockers(5)
Side Effects
Body System Effects
CNS

Other

dizziness, fatigue,
mental depression, lethargy,
drowsiness, unusual dreams
impotence
wheezing, dyspnea

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Antianginal Agents:
3) Calcium Channel Blockers
Medicinal Chemistry Classes
Prototypical Agents
Verapamil (Calan)
Dihydropyridines
Non-Dihydropyridines
diltiazem (Cardizem)
Amlodipine
Bepridil (Vascor)
(Norvasc),
Diltiazem
nifedipine (Procardia)
Felodipine
(Plendil)
Nimodipine
Isradipine
Nicardipine
Nifedipine

(Cardiazem)
Verapamil (Isoptin,
Calan)

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Antianginal Agents:
Calcium Channel Blockers(2)
Mechanism of Action

Cause peripheral arterial vasodilation

Reduce myocardial contractility
(negative inotropic action)
Result: decreased myocardial oxygen demand

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Antianginal Agents:
Calcium Channel Blockers(2)
Therapeutic Uses

First-line agents for treatment of angina,

hypertension, and supraventricular
tachycardia
Short-term management of atrial fibrillation
and flutter
Several other uses

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Antianginal Agents:
Calcium Channel Blockers(3)
Side Effects

Very acceptable side effect and safety profile

May cause hypotension, palpitations, tachycardia
or bradycardia, constipation, nausea, dyspnea

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THE END

THANK YOU FOR YOUR ATTENTION

Reference Resource
(Online Textbooks)

Principles of Pharmacology: The Pathophysiologic Basis of

Drug Therapy Cairo CW, Simon JB, Golan DE. (Eds.); LLW
2012 (Google Books Online).
Goodman and Gilmans The Pharmacological Basis of
Therapeutics. Brunton LL, Chabner BA , Knollmann BC (Eds.);
M-H 12th ed. 2011.
Basic and Clinical Pharmacology, Katzung, Masters, Trevor; M-

H 12th ed.

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