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ANGINA

Angina treatments

If a part of the heart muscle does not get enough blood, it doesn't get enough oxygen to work properly
this is called ischaemia. Ischaemia can cause chest pain or discomfort (angina).

Angina occurs when the oxygen demand of your heart muscle exceeds that which is supplied by the
coronary arteries (the blood vessels which supply your heart muscle with oxygen so that it can pump
blood around the body).

Angina arises when the coronary arteries become narrowed and partially blocked, which significantly
limits the blood supply to an area of heart muscle, especially during times of increased need, such as
during exercise or in particularly stressful situations.

Why should angina be treated?If the blood supply to the heart muscle is blocked or severely restricted,
it may begin to die. This is called a heart attack. Doctors refer to it as myocardial infarction.

Angina does not permanently damage the heart muscle, unless it progresses to a heart attack. The
extent to which the coronary arteries are blocked will affect how much oxygen-rich blood can reach the
heart muscle.

If you have angina, your doctor will want to treat it to:

provide you with relief from symptoms such as chest pain;

prevent further attacks from happening; and

avoid the risk of you having a heart attack.

Types of anginaAngina pain is usually brought on by exercise, stress, emotion or cold.


1. Stable angina

This is the most common type of angina, and pain is usually brought about by physical exertion that
results in the heart rate increasing. This type of angina is defined as stable because there is a regular
pattern for the pain and similar triggers exist for each attack of angina. Sufferers of stable angina can
usually predict how an attack can happen, and these attacks usually only last for a couple of minutes.
The pain is usually relieved by rest or by taking angina medication.1

2. Unstable angina

Unstable angina does not follow a regular pattern. A small amount of physical effort such as walking, or
even just resting, can result in an attack. In many cases, stable angina can progress to unstable angina,
which may be an indication of worsening of coronary heart disease.1 In these cases, you should see a
doctor urgently.

Generally, pain from unstable angina is worse than with stable angina. The pain also tends to happen
more often, and each episode may last as long as half an hour.1

3. Variant angina

Variant angina is the least common of the three types of angina and is also called Prinzmetals angina.
This type usually occurs without warning while resting, or at night, and affects women more than men.

Its important to note that angina is not a heart attack, but is rather a temporary reduction in adequate
flow of blood to the heart. With a heart attack (or myocardial infarction) blood supply is completely cut
off to part of the heart leaving behind permanent damage to the heart muscle. However if you develop
angina it indicates that you may be at an increased risk of eventually having a heart attack.1

Aspirin

Taking aspirin has been shown to reduce the risk of heart attack and death in people with angina when
taken correctly. This is because it can prevent blood clots from forming, which may block the coronary
arteries, causing a heart attack. However, aspirin can cause stomach upset and gut disorders so ask your
doctor whether aspirin is suitable for you. If it isn't, you may be able to take a different medicine called
clopidogrel (brands include Plavix and Iscover).
(Note: These clot-preventing medicines can make you more likely to bleed during surgery. If you need to
have an operation, check with your doctor whether and when these medicines should be stopped
beforehand.)

Nitrates

Nitrates have been used to treat angina for more than 100 years and are available as patches, spray and
tablets.

One of the mechanisms that helps nitrates to relieve angina is their ability to open up the coronary
arteries and so increase blood flow to the heart muscle. They work very quickly to make it easier for the
heart to pump.

Nitrates are used in 2 ways:

to relieve angina pain when it comes on; and

as maintenance medication to stop episodes of angina from happening in the first place.

Beta-blockers

Beta-blockers slow the heart and lower the pressure in the arteries so the heart does not need as much
oxygen as normal to pump. This makes it less likely that angina will occur, as the heart muscle should
have enough oxygen to work effectively. Beta-blockers have also been shown to reduce the risk of death
and heart attack in people who have had a previous heart attack.

Some beta-blockers appear to be more effective in angina than others.

Beta-blockers which are used for angina include atenolol (brands include Tenormin and Tensig) and
metoprolol (brands include Betaloc and Lopresor).

Like many medicines, beta-blockers can have side effects. These may include: bad dreams, fatigue,
dizziness, upset stomach and depression. Beta-blockers may not be suitable for people with asthma.
Your doctor will be able to advise if beta-blockers are appropriate for you.
Calcium channel blockers or calcium antagonists

These medicines reduce the heart rate and slightly enlarge the coronary blood vessels by slowing down
the rate at which calcium enters the heart muscle and blood vessel walls. This has the end result of
improving the blood flow to the heart muscle and reducing the workload on the heart.

Your doctor may prescribe certain classes of calcium channel blockers in conjunction with a beta-
blocker, or may prescribe a calcium channel blocker alone if you are unable to take a beta-blocker.
Among the most common side effects of the calcium channel blockers are headaches and dizziness.

Some of the calcium channel blockers available are: amlodipine (e.g. Norvasc); nifedipine (e.g. Adalat
and Adalat Oros); diltiazem (e.g. Cardizem, Cardizem CD); and verapamil (e.g. Cordilox and Isoptin).

Side-effects of calcium-channel blockers

Side-effects are the unwanted effects of taking a medicine. This section doesnt include every possible
side-effect of calcium-channel blockers. Please read the patient information leaflet that comes with your
medicine for more information.

Calcium-channel blockers can cause a drop in your blood pressure. This can make you feel dizzy when
you stand up. To help prevent this, make sure you get up slowly when you stand up from lying or sitting
down, and stay next to your bed or chair until you're sure that you arent feeling dizzy. Dont drive or do
anything else that needs you to be alert until you know how you react to your medicine.

Calcium-channel blockers slow down your heart (especially the medicines verapamil and diltiazem) and
can cause headaches, constipation, flushing of your face and fluid retention, especially around your
ankles.

Drug treatment for angina

Long-term prevention of symptoms

Several medicines can be used to prevent pain from angina. These medicines can be taken on their
own or in combination with each other, depending on your doctors prescription:

Beta-blockers

Calcium antagonists

Nitrates

Other therapies also exist

Prevention of worsening coronary heart disease

Several drugs can be used to help prevent coronary heart disease and associated angina symptoms
from worsening:
ACE inhibitors

Anticoagulants

Aspirin

Statins

Surgery

In severe cases of angina where medication doesnt control its symptoms, or where there are multiple
narrowed arteries, surgery may be recommended. 1 Surgery recommendations depend on the location
of the coronary artery blockage and therefore may not be suitable in all cases. The two most common
surgeries for angina are:

Angioplasty

Coronary artery bypass graft (CABG)

SIDE EFFECTS OF NITRATES

Call911or other emergency services right away if you have:

Trouble breathing.

Hives.

Swelling of your face, lips, tongue, or throat.

Call your doctor right away if you have:

Blurred vision.

Severe headache that does not go away.

Skin rash.

Common side effects of this medicine include:

Dizziness or lightheadedness.

Headache.

Flushing, or feeling warm, in the face and neck.

Nausea.
DOSE FOR NITRATES

Onset of action: Sublingual tablet: 1-3 minutes; Translingual spray: 2 minutes; Buccal tablet: 2-5
minutes; Sustained release: 20-45 minutes; Topical: 15-60 minutes; Transdermal: 40-60 minutes; I.V.
drip: Immediate

Peak effect: Sublingual tablet: 4-8 minutes; Translingual spray: 4-10 minutes; Buccal tablet: 4-10
minutes; Sustained release: 45-120 minutes; Topical: 30-120 minutes; Transdermal: 60-180 minutes;
I.V. drip: Immediate

Duration: Sublingual tablet: 30-60 minutes; Translingual spray: 30-60 minutes; Buccal tablet: 2 hours;
Sustained release: 4-8 hours; Topical: 2-12 hours; Transdermal: 18-24 hours; I.V. drip: 3-5 minutes

Half-life elimination: 1-4 minutes

Indications

Dinitrate: Treatment and prevention of angina pectoris

Mononitrate: Prevention of angina pectoris

Contraindications and cautions

Contraindicated with allergy to nitrates, severe anemia, head trauma, cerebral hemorrhage,
hypertrophic cardiomyopathy, narrow-angle glaucoma, postdural hypotension

Use cautiously with pregnancy, lactation, acute MI, CHF.

Dosages

-ADULTS

To avoid tolerance to drug, take short-acting products bid or tid with last dose no later than 7 PM and
SR products once daily or bid at 8 PM and 2 PM. This creates a nitrate-free period.

Isosorbide dinitrate

Angina pectoris: Starting dose, 2.55 mg sublingual, 5-mg chewable tablets, 5- to 20-mg oral
tablets. For maintenance, 1040 mg q 6 hr oral tablets or capsules; SR, initially 40 mg, then 4080 mg
PO q 812 hr.

Acute prophylaxis: Initial dosage, 510 mg sublingual or chewable tablets q 23 hr.

Isosorbide mononitrate
Prevention of angina: 20 mg PO bid given at least 7 hr apart; ER tablets3060 mg/day PO may
be increased to 120 mg/day if needed. In smaller patients, start with 5 mg (one-half of 10-mg tablet)
but then increase to at least 10 mg by day 2 or 3 of therapy. Give first dose when waking and second
dose 7 hr later. This creates a nitrate-free period and minimizes tolerance to drug.

SIDE EFFECTS: Headache, dizziness, flushing, rapid heartbeat or restlessness may occur as your body
adjusts to the medication. If they persist or become bothersome, inform your doctor. To prevent
dizziness and lightheadedness when rising from a seated or lying position, get up slowly. Notify your
doctor if you experience: blurred vision, dry mouth, skin rash, nausea. Headache is often a sign the
medication is working. Treat headaches with an aspirin or non-aspirin pain reliever as recommended
by your doctor. If the headaches continue or become severe, notify your doctor. In the unlikely event
you have an allergic reaction to this drug, seek medical attention immediately. Symptoms of an
allergic reaction include: rash, itching, swelling, dizziness, trouble breathing. If you notice other effects
not listed above, contact your doctor or pharmacist.

ASPIRIN CONTRA-INDICATIONS

Contraindicated in patients with blood disorder, liver or kidney impairment and hypersensitivity.

If you are taking this medicine to prevent heart attack or stroke, avoid also taking ibuprofen (Advil,
Motrin). Ibuprofen may make aspirin less effective. If you must use both medications, take the ibuprofen
at least 8 hours before or 30 minutes after you take the aspirin (non-enteric coated form).

Aspirin indications

(Indications) : This medication is an analgesic and antipyretic, prescribed for pain, heart attack and fever.
The drug decreases the substances that cause pain and inflammation.

ASPIRIN DOSE

Usual Adult Dose for Angina Pectoris

75 mg to 325 mg orally once a day beginning as soon as unstable angina is diagnosed and continuing
indefinitely.

Usual Adult Dose for Angina Pectoris Prophylaxis

75 mg to 325 mg orally once a day, continued indefinitely.

Usual Adult Dose for Thromboembolic Stroke Prophylaxis

75 mg to 325 mg orally once a day, continued indefinitely.

Usual Adult Dose for Myocardial Infarction - Prophylaxis

75 mg to 325 mg orally once a day, continued indefinitely.


Usual Adult Dose for Ischemic Stroke - Prophylaxis

75 mg to 325 mg orally once a day, continued indefinitely.

Usual Adult Dose for Revascularization Procedures - Prophylaxis

For coronary artery bypass graft (CABG):

325 mg orally once a day beginning 6 hours after the procedure and continuing for 1 year or
indefinitely as needed.

For percutaneous transluminal coronary angiography (PTCA):

325 mg orally once 2 hours prior to procedure, then 160 to 325 mg orally once a day indefinitely.

For carotid endarterectomy:

80 mg orally once a day up to 650 mg orally twice a day beginning prior to surgery and continuing
indefinitely.

ASPIRIN SIDE EFFECTS

What are the possible side effects of Aspirin?

Aspirin (Oral)

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficult
breathing; swelling of your face, lips, tongue, or throat.

Stop using aspirin and call your doctor at once if you have:

ringing in your ears, confusion, hallucinations, rapid breathing, seizure (convulsions) severe nausea,
vomiting, or stomach pain bloody or tarry stools, coughing up blood or vomit that looks like coffee
grounds fever lasting longer than 3 days; or swelling, or pain lasting longer than 10 days Common side
effects may include:

upset stomach, heartburn drowsiness; or mild headache

Contact your doctor if you experience these side effects and they are severe or bothersome. Your
pharmacist may be able to advise you on managing side effects.

heartburn or indigestion

mild-to-moderate abdominal or stomach cramps, pain, or discomfort

Although most of the side effects listed below don't happen very often, they could lead to serious
problems if you do not seek medical attention.
Check with your doctor as soon as possible if any of the following side effects occur:

bruising more easily

confusion

dizziness

fainting

nausea or vomiting

pain, buzzing or ringing in ears

severe or continuing abdominal or stomach pain, cramping, or burning

unusual tiredness or weakness

Stop taking the medication and seek immediate medical attention if any of the following occur:

any loss of hearing

bleeding

signs of stomach bleeding, such as bloody or black, tarry stools

swelling of the mouth and throat

symptoms of an allergic reaction, e.g.:

difficulty breathing

hives

itchy skin rash

Aspirin should not be taken by people who are allergic to ibuprofen or naproxen,[70][71] or who have
salicylate intolerance[72][73] or a more generalized drug intolerance to NSAIDs, and caution should be
exercised in those with asthma or NSAID-precipitated bronchospasm. Owing to its effect on the
stomach lining, manufacturers recommend people with peptic ulcers, mild diabetes, or gastritis seek
medical advice before using aspirin.[70][74] Even if none of these conditions is present, the risk of
stomach bleeding is still increased when aspirin is taken with alcohol or warfarin.[70][71] Patients
with hemophilia or other bleeding tendencies should not take aspirin or other salicylates.[70][74]
Aspirin is known to cause hemolytic anemia in people who have the genetic disease glucose-6-
phosphate dehydrogenase deficiency, particularly in large doses and depending on the severity of the
disease.[75] Use of aspirin during dengue fever is not recommended owing to increased bleeding
tendency.[76] People with kidney disease, hyperuricemia, or gout should not take aspirin because it
inhibits the kidneys' ability to excrete uric acid, and thus may exacerbate these conditions. Aspirin
should not be given to children or adolescents to control cold or influenza symptoms, as this has been
linked with Reye's syndrome

BETA BLOCKERS DEFINITION

Drugs which block the action of adrenaline. Beta blockers are commonly used to reduce stress on the
heart and to lower blood pressure, due to the fact that they slow the heart beat, lower the force with
which the heart contracts and reduce blood vessel contraction throughout the body.

In addition to their applications in treating heart conditions and high blood pressure, beta blockers
have also been found useful in conditions such as glaucoma, migraine, anxiety disorders, tremors
secondary to lithium and movement disorders caused by antipsychotic medications.

Also Known As: beta antagonists

BETA-BLOCKERS SIDE EFFECTS

What are the known side-effects?

Most people who take beta-blockers have no side-effects, or only minor ones. However, because of
their action in various parts of the body, some people have unwanted side-effects. For example:

Sometimes the heart rate can go too slowly. This can make you dizzy or feel faint.

If you have diabetes you need to be aware that beta-blockers may dull the warning signs of a low
blood sugar level (hypoglycaemia - often called a hypo). For example, you may not develop
palpitations (the sensation of rapid, irregular, or forceful heartbeats) or tremor, which tend to occur as
the blood sugar is going too low.

Some people develop cool hands and feet when taking beta-blockers. This is because they can
constrict (narrow) small blood vessels and reduce the circulation to the skin of the hands and feet.

Tiredness, depression, impotence (you cannot get a proper erection), vivid dreams, nightmares and
other sleeping problems occur in some people.

There is some evidence to suggest that beta-blockers may provoke type 2 diabetes to develop in some
people.
Some people with asthma are advised not to take a beta-blocker. If you have asthma or something
similar, discuss this with your GP.

The above is not a full list of possible side-effects, but mentions the main ones that may occur. Read
the information leaflet that comes with your particular brand for a full list of possible side-effects and
cautions.

BETA-BLOCKERS DOSE

Angina: Oral: 50 mg once daily; may increase to 100 mg/day. Some patients may require 200 mg/day.

BETA-BLOCKERS INDICATIONS

hypertensive emergency

hypotension induction

peri-operative hypertension

BETA BLOCKERS CONTRA-INDICATIONS

ISOSORBIDE

Usual Adult Dose for Angina Pectoris

Initial: 2.5 mg (SL) or 5 mg (Chew) once and repeat as needed as soon as the tablet has dissolved or
chewed.

The dose may be doubled and titrated upwards as tolerated. The onset of action is within 3 minutes.

Usual Adult Dose for Angina Pectoris Prophylaxis

Initial SR: 40 mg orally every 8 to 12 hours.

Maintenance SR: 10 to 40 mg every 8 to 12 hours.

Initial tab: 5 mg orally every 6 hours.

Maintenance tab: 10 to 40 mg every 6 hours.

Initial SL: 5 mg every 2 to 3 hours.

Maintenance SL: Not recommended for prophylaxis.

Initial Chew: 5 mg every 2 to 3 hours.


Maintenance Chew: not recommended for prophylaxis

Isosorbide Dinitrate: Indications

Isosorbide dinitrate has documented advantages for angina pectoris: buccal applications (chewing
capsules, spray, tablets) can stop seizures almost as dependently as glyceryl trinitrate. For the
prevention of chronic seizures oral sustained release preparations are best suited; they are generally
equally as or more efficacious than calcium-channel blocking agents. A combination with the latter is
possible. For unstable angina pectoris, ISDN can be administered intravenously (as an alternative to
glyceryl trinitrate).

Isosorbide dinitrate is also suitable for the treatment of heart failure. In combination with the
vasodilator hydralazine, it has proven to be life-prolonging in a large study involving men with chronic
heart failure.

Even though ISDN's most important metabolite isosorbide-5-mononitrate is now available as a drug,
many specialists still prefer the dinitrate. The mononitrate may produce the same effects, but all the
important studies have so far been carried out with ISDN.

The relaxation of the smooth muscle produced by the nitrates may also be useful for esophageal spasm
and achalasia.

Pharmacokinetics

Bioavailability Peak plasma level Plasma half-life Active metabolites Elimination

variable 20%* 45 minutes 1 hour important* partially renal

*Already in the first liver passage, ISDN is metabolized almost entirely into active metabolites
(isosorbide-5-mononitrate and isosorbide-2-mononitrate). The effect is based largely on isosorbide-5-
mononitrate which does not have any active metabolites and which has a half-life of 4 to 5 hours.

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