1 ANGINA ANGINA MYOCARDIAL OXY. DEMAND >. OXY. SUPPLY. OXY. SUPPLY < SYMPTOMS – chest pain mostly relieved by taking rest, dyspnea, sweating, nausea.. SYMPTOMS – chest pain mostly relieved by taking rest, dyspnea, sweating, nausea.. TYPES - STABLE TYPES - STABLE UNSTABLE UNSTABLE VARIANT/ PRINZMETAL VARIANT/ PRINZMETAL

2 Spasm of vascular smooth muscle Spasm of vascular smooth muscle Or due to Or due to Obstruction of blood vessels caused by atherosclerotic lesions Obstruction of blood vessels caused by atherosclerotic lesions

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Stable vs Unstable Angina pains normally occur during periods of physical exertion. ‘unstable angina’ is used to describe pains which occur at rest Severe coronary disease

5 Exertion is the most common cause of pain and discomfort from stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low (such as when you are sitting). But with exertion, like walking up a hill or climbing stairs, the heart works harder and needs more oxygen. Other causes include: Exertion is the most common cause of pain and discomfort from stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low (such as when you are sitting). But with exertion, like walking up a hill or climbing stairs, the heart works harder and needs more oxygen. Other causes include: Emotional stress Emotional stress Exposure to very hot or cold temperature Exposure to very hot or cold temperature Heavy meals Heavy meals Smoking Smoking

6 Unstable Angina Unstable Angina Unstable angina is caused by blood clots that partially or totally block an artery. If plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. The clot may grow large enough to completely block the artery and cause a heart attack. Blood clots may form, partly dissolve, and later form again. Chest pain can occur each time a clot blocks an artery. Unstable angina is caused by blood clots that partially or totally block an artery. If plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. The clot may grow large enough to completely block the artery and cause a heart attack. Blood clots may form, partly dissolve, and later form again. Chest pain can occur each time a clot blocks an artery.

7 Variant Angina Variant Angina Variant angina is caused by a spasm in a coronary artery. The spasm causes the walls of the artery to tighten. This narrows the artery, causing the blood flow to the heart to slow or stop. Variant angina may occur in people with and without CAD. Other causes of spasms in the arteries that supply the heart with blood are: Variant angina is caused by a spasm in a coronary artery. The spasm causes the walls of the artery to tighten. This narrows the artery, causing the blood flow to the heart to slow or stop. Variant angina may occur in people with and without CAD. Other causes of spasms in the arteries that supply the heart with blood are:spasm in a coronary arteryspasm in a coronary artery Exposure to cold Exposure to cold Emotional stress Emotional stress Medications (vasoconstricting) that constrict or narrow blood vessels Medications (vasoconstricting) that constrict or narrow blood vessels Medications (vasoconstricting) that constrict or narrow blood vessels Medications (vasoconstricting) that constrict or narrow blood vessels Cigarette smoking Cigarette smoking Cocaine use Cocaine use

8 DRUGS ORGANIC NITRATES ORGANIC NITRATES BETA BLOCKERS BETA BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

9 ORGANIC NITRATES Sublingual Nitroglycerin Sublingual Nitroglycerin Transdermal Nitroglycerin Transdermal Nitroglycerin Isosorbide dinitrate, isosorbide-5- mononitrate Isosorbide dinitrate, isosorbide-5- mononitrate Amyl nitrite, Erythrityl tetra nitrate and Pentaerythritol tetra nitrate Amyl nitrite, Erythrityl tetra nitrate and Pentaerythritol tetra nitrate

10 ACTIONS RELEASES NO, which in turn activates guanylate cyclase and increase cyclic GMP levels RELEASES NO, which in turn activates guanylate cyclase and increase cyclic GMP levels Cyclic GMP causes dephosphorylation of myosin light chains resulting in vascular smooth muscle relaxation Cyclic GMP causes dephosphorylation of myosin light chains resulting in vascular smooth muscle relaxation

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12 VASO DILATION, MORE VENODILATION VASO DILATION, MORE VENODILATION DECREASES PRELOAD DECREASES PRELOAD DECREASES OXY. DEMAND DECREASES OXY. DEMAND

13 KINETICS ONSET OF ACTION ONSET OF ACTION NITROGLYCERIN < 1 MIN NITROGLYCERIN < 1 MIN FIRST PASS METABOLISM : SIGNIFICANT FIRST PASS METABOLISM : SIGNIFICANT ROUTES OF ADMIN. SUBLINGUAL ROUTES OF ADMIN. SUBLINGUAL –TRANS DERMAL –ORAL : ISOSORBIDE DINITRATE

14 Continuous administration of nitrates may lead to tolerance of their clinical efficacy. Continuous administration of nitrates may lead to tolerance of their clinical efficacy.

15 SIDE EFFECTS MC: Headache The most common side effect of nitrates is headache. For most people, headaches subside after a few days MC: Headache The most common side effect of nitrates is headache. For most people, headaches subside after a few days Dizziness, weakness due to postural hypotension. Dizziness, weakness due to postural hypotension. Drug rash, especially with Pentaerythritol tetra nitrate. Drug rash, especially with Pentaerythritol tetra nitrate.

16 BETA BLOCKERS MECH _____________________? MECH _____________________? RECEPTORS ____________? RECEPTORS ____________? DRUGS _______________? DRUGS _______________? CI ___________________? CI ___________________? USES : REDUCE FREQUENCY AND SEVERITY OF ANGINAL ATTACKS USES : REDUCE FREQUENCY AND SEVERITY OF ANGINAL ATTACKS POST MI POST MI

17 Beta blockers are used for long term treatment of CAD. Beta blockers are used for long term treatment of CAD. They prevent angina by decreasing the workload on the heart. They prevent angina by decreasing the workload on the heart.

18 CALCIUM CHANNEL BLOCKERS MECH –Inhibit the entrance of Ca into cardiac & smooth muscle cells of the coronary and systemic arterial beds. MECH –Inhibit the entrance of Ca into cardiac & smooth muscle cells of the coronary and systemic arterial beds. GREATER EFFECT ON ARTERIOLES GREATER EFFECT ON ARTERIOLES DECREASES AFTER LOAD DECREASES AFTER LOAD DECRASES OXY. DEMAND DECRASES OXY. DEMAND

19 NIFEDIPINE NIFEDIPINE VERAPAMIL VERAPAMIL DILTIAZEM DILTIAZEM ON ARTERIES ON HEART CONDUCTION CI : AV BLOCK  CARDIAC CONDUCTION SIMILAR TO VERAPAMIL

20 USES VARIANT ANGINA – DUE TO VASOSPASM VARIANT ANGINA – DUE TO VASOSPASM EXERTIONAL ANGINA EXERTIONAL ANGINA RAYNAUDS DISEASE RAYNAUDS DISEASE

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22 SIDE EFFECTS HEADACHE HEADACHE FLUSHING FLUSHING HYPOTENSION HYPOTENSION NAUSEA NAUSEA REFLEX TACHYCARDIA REFLEX TACHYCARDIA

23 Aspirin, an antiplatelet drug, reduces the risk of heart attacks and death. Antiplatelet drugs make blood clots less likely to form by preventing platelets from sticking together. Aspirin, an antiplatelet drug, reduces the risk of heart attacks and death. Antiplatelet drugs make blood clots less likely to form by preventing platelets from sticking together.