1. CLINICAL PHARMACY IN CARDIOLOGY

2. ISCHEMIC HEART DISEASE
There are 35 risk factors for development of IHD –
The most important risk factors for coronary artery disease
Smoking
Hypertension
Hyperlipidaemia
Diabetes mellitus
95 % of patients with IHD are observed to have aterosclerotic changes in coronary arteries

3. Angina pectoris is a clinical syndrome characterized by episodes of chest pain. It occurs when there is a deficit in myocardial oxygen supply (myocardial ischemia) in relation to myocardial oxygen demand. It is most often caused by atherosclerotic plaque in the coronary arteries but may also be caused by coronary vasospasm. The development and progression of atherosclerotic plaque is called coronary artery disease.
When physical exertion, strong emotions, extreme temperatures, or eating increase the demand on the heart, a person with angina feels temporary pain, pressure, fullness, or squeezing in the center of the chest or in the neck, shoulder, jaw, upper arm, or upper back. This is angina, especially if the discomfort is relieved by removing the stressor and/or taking sublingual (under the tongue) nitroglycerin.
The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day.

4. Life-threatning symptoms: chest pain +
sweating,
weakness,
faintness,
numbness or tingling,
nausea
Pain that does not go away after a few minutes
Pain that is of concern in any way

5. Most cases of coronary heart disease are caused by atherosclerosis (hardening of the arteries).
Atherosclerosis is a condition in which a fatty substance/cholesterol builds up inside the blood vessels. These buildups are called plaques, and they can block blood flow through the vessels partially or completely.
Multiple risk factors:
diabetes,
high blood pressure,
smoking,
high cholesterol, and
genetic predisposition may accelerate this build up.

6. Angina Pectoris Symptoms
Angina itself is a symptom (or set of symptoms), not a disease. Any of the following may signal angina:
An uncomfortable pressure, fullness, squeezing, or pain in the center of the chest
It may also feel like tightness, burning, or a heavy weight.
The pain may spread to the shoulders, neck, or arms.
It may be located in the upper abdomen, back, or jaw.
The pain may be of any intensity from mild to severe.

8. ANTIANGINAL (CORONARY ACTIVE) DRUGS
І. Nitrates and sidnonims
ІІ. Beta-adrenoblockers
ІІІ. Calcium channel blockers
ІУ. Activators of potassium channels

9. isosorbid-5-mononitrate
NITRATES
Glyceryl trinitrate
isosorbid dinitrate
isosorbid-5-mononitrate
INDICATIONS
Treatment and prevention of angina.
Treatment of acute left ventricular failure.

10. NITRATES
Nitrates are first-line treatments for the symptoms of angina but do not affect the course of the underlying disease.
They cause vasodilatation; this can be hazardous in some patients:
Patients who are hypovolaemic (severe hypotension).
Patients with cardiac disease such as hypertrophic cardiomyopathy or mitral stenosis.
Patients with bleeding (e.g. following head trauma or cerebral haemorrhage).
No dosage adjustment is usually required in renal or hepatic insufficiency.
Avoid these drugs during pregnancy; the effects on blood pressure can affect placental blood flow.

11. Nitroglycerine Unique transdermal system in a form of plaster

12. Contraindications for nitroglycerine use
Close-angled form of glaucoma
Increasing of intracranial pressure, insult
Acute myocardium infarction (in case of presence of hypotension and collapse)

13. Iso Mak Retard 20mg Iso Mak Retard 40mg Isomak Retard 60mg (isosorbid dinitrate)

14. Molsidomine – corvaton - sydnopharm
SYDNONIMINS
Molsidomine – corvaton - sydnopharm
is metabolized in liver forming a substance – SIN-1a which contains free NО group (doesn’t need previous interaction with SH-groups)
nitrogen oxide stimulates guanilatecyclase that activates synthesis of cGMP
cGMP causes dilation of vessels
2 mg of molsidomine= 0,5 mg of nitroglycerine

15. Beta-adrenoceptor antagonists
Coronary artery disease.
Prophylaxis against angina.
Adjunct to the treatment of, and following myocardial infarction.
There are many beta-blockers and the choice can seem daunting. The main choice is between those that are relatively selective for beta1 adrenoceptors (sometimes called cardioselective) and those that are not.
Do not stop treatment with a beta-blocker suddenly. Rebound symptoms can be severe, including precipitation of an acute coronary syndrome.

16. Nebivolol beta-blocker that also causes vasodilation by stimulating the release of nitric oxide

17. Treatment of arrhythmias
Beta-blockers can be useful in the treatment of (tachy)arrhythmias in the peri-infarction period.
A short-acting beta-blocker such as esmolol can be used for the treatment of acute SVT.
Longer-acting drugs have a role in prophylaxis against SVT.

18. Treatment of arrhythmias
Beta-blockers will reduce the heart rate in patients with AF.
Always consider whether cardioversion would be more appropriate. This can be electrical or chemical(options include flecainide, verapamil, amiodarone).
Sotalol also has class III antiarrhythmic actions, it is only used for treating arrhythmias.
It is more effective than lidocaine for the treatment of sustained ventricular tachycardia.
It will prolong the QT interval, and so carries a risk of inducing the arrhythmia torsade de pointes

19. Calcium channel blockers classification

20. Calcium channel blockers
1. Phenyalkylamines(verapamil)
2. Benzthiazepines(dilthiazem)
3. Derivatives of Dihydropyridine (nifedipine, amlodipine, nimodipine)
Drugs of 1 and 2 groups dominantly influence on heart (depress automatism of sinus node, conductivity through conductive heart system), show antiarrhythmic, antianginal and hypotensive action.
Derivatives of dihydropyridine (nifedipine group) – decrease blood pressure and cause dilation of coronary vessels, cause reflective tachycardia

21. Indications

22. Common side effects of calcium channel blockers include:
headache,
constipation,
rash,
nausea,
flushing,
edema (fluid accumulation in tissues),
drowsiness,
low blood pressure, and
dizziness.
Sexual dysfunction, overgrowth of gums, and liver dysfunction also have been associated with calcium channel blockers. Verapamil (Covera-HS, Verelan PM, Calan) and diltiazem (Cardizem LA, Tiazac) worsen heart failure because they reduce the ability of the heart to contract and pump blood.

23. Usage of calcium channel antagonists
Disease
Drugs
Hypertension
Verapamil
Dylthiazem
Nifedipin
Felodipin
Amlodipin
Stenocardia
Verapamil
Dylthiazem
Nifedipin
Amlodipin
Supraventricular tachy-arrhythmia
Verapamil
Dylthiazem
Possible combination with β-blockers
Dylthiazem
Nifedipin
Felodipin
Amlodipin
-recommended drug
--should be used carefully

24. Nifedipin (Са2+ ions antagonist of dyhydropyrydine series)

25. Nicorandil Potassium channel activator
Nicorandil is not a treatment for acute angina or acute coronary syndromes.
Avoid nicorandil in patients with acute myocardial infarction or acute heart failure.
Avoid nicorandil in patients with hypotension; it can lower the blood pressure.
No dosage adjustment is usually required in renal or hepatic insufficiency.
There is no information as to the safety of nicorandil during pregnancy; avoid it unless absolutely essential.

26. Adjunctive Antianginal Drugs Acetylsalicylic acid
mg per day – as antiplatelet drug, decreases risk of development of acute myocardium infarction and decreases mortality of patients with IHD
Primary and secondary prevention of complications of atherosclerotic disease.
Angina.
Myocardial infarction.
Stroke.
Peripheral vascular disease.

27. Adjunctive Antianginal Drugs
Antihypertensives. These drugs needed for clients with hypertension. Because beta-blockers and calcium channel blockers are used to manage hypertension as well as angina, one of these drugs may be effective for both disorders.

28. Amiodarone Antiarrhythmic drug acting on atrial and ventricular tissues
Amiodarone has a complex mechanism of action that is incompletely understood, but is probably mediated through effects on cardiac potassium channels.
Amiodarone prolongs the action potential and refractory period homogeneously throughout the heart.
The principal ECG change is a prolongation of the QT interval.
Amiodarone is a class III antiarrhythmic drug in the Vaughanв-Williams classification.

29. Amiodarone Treatment by mouth Treatment by intravenous infusion
200 mg 3 times daily for 1 week reduced to 200 mg twice daily for a further week.
Maintenance dose, usually 200 mg daily or the minimum required to control the arrhythmia.
Treatment by intravenous infusion
Via a central line, 5 mg/kg over minutes with ECG monitoring; maximum 1.2 g in 24 hours.
Emergency treatment during cardiopulmonary resuscitation
VF or pulseless VT, 300 mg by intravenous injection over at least 3 minutes (pre-filled syringe).

30. Common types of cholesterol-lowering drugs include:
statins
resins
nicotinic acid (niacin)
gemfibrozil
clofibrate
Various medications can lower blood cholesterol levels. They may be prescribed individually or in combination with other drugs. They work in the body in different ways. Some affect the liver, some work in the intestines and some interrupt the formation of cholesterol from circulating in the blood.  
Reason for Medication
Used to lower LDL ("bad") cholesterol, raise HDL ("good") cholesterol and lower triglyceride levels

31. Choose good nutrition Reduce blood cholesterol Lower high blood pressure Be physically active every day Aim for a healthy weight Manage diabetes Reduce stress Limit alcohol Stop smoking