FEBRUARY 10,2110

A 47 yr old man reports a 6 month Hx of chest pressure while playing handball.He
describes substernal tightness and left arm numbness only while exerting.The total cholesterol and LDL are elevated. The exercise test is positive.How should the patient’s case be managed?

Typical Progression of Coronary Atherosclerosis
Abrams, J. N Engl J Med 2005;352:2524-2533

Symptoms of Angina
Abrams J. N Engl J Med 2005;352:2524-2533

Classification and Severity of Angina
Abrams J. N Engl J Med 2005;352:2524-2533

• Wall stress = Pr/w where: P = pressure r = radius w = wall thickness

Marked venodilation with sublingual use
Decreased ventricular preload
Decreased ventricular size
Decreased end-diastolic pressure
NET EFFECT: Decreased oxygen demand
Slight arteriolar dilation with higher doses

Regulation of the Relaxation of Vascular Smooth Muscle by Nitric Oxide
NITROGLYCERIN
Griffiths, M. J.D. et al. N Engl J Med 2005;353:2683-2695

USES:
Angina pectoris-prophylaxis and treatment
Heart failure
SIDE EFFECTS:
Tolerance
Headache
Syncope
Interaction with sildenafil(Viagra &others)

Direct relaxation of all vascular smooth muscle
Venous relaxation with oral or topical use
Arteriolar and venous relaxation with IV use

ACTION
Venous relaxation – Long acting
USES Oral
Angina pectoris – prophylaxis
Heart failure-when ACE inhibitors/ARBs contraindicated
ADR
Headache, Nitrate tolerance
Interaction wiih sildenafil

Regulation of the Relaxation of Vascular Smooth Muscle by Nitric Oxide
NITROGLYCERIN
Griffiths, M. J.D. et al. N Engl J Med 2005;353:2683-2695

Equally Effective for:
Hypertension
Angina
Arrhythmias

METOPROLOL
PROPRANOLOL

•
•
•
Limit heart rate
Decrease myocardial contractility
Decrease oxygen demand

BETA BOCKERS – ADVERSE EFFECTS
CNS
Bad dreams
Depression
Cardiovascular
Aggravation of severe CHF
Aggravation of occlusive arterial disease
Slow A-V conduction
Pulmonary
Bronchospasm in Asthmatics
Drug interactions
With drugs that impair A-V conduction (digoxin and some calcium channel blockers)

CALCIUM CHANNEL ANTAGONISTS
FOR ANGINA PECTORIS
Others Verapamil
Diltiazem
Nifedipine

EFFECT VERAPAMIL DILTIAZEM
VASODILATION MODERATE
DECREASED
CONTRACTILITY
MILD
DECREASED A-V
CONDUCTION
MILD
MODERATED
NONE
MILD
NIFEDIPINE/AM-
LODOPINE
MARKED
NONE OF
REFLEX
INCREASE
NONE

CALCIUM CHANNEL ANTAGONISTS
MECHANISM OF ACTION IN ANGINA PECTORIS
Decreased in myocardial oxygen demand
Decrease in afterload
Decrease in cardiac contractility ( V & D)*
Increase in myocardial oxygen supply
Increase in coronary blood flow
* Verapamil & Diltiazem

CALCIUM CHANNEL ANTAGONISTS
ADVERSE EFFECTS
Hypotension
Headache
Constipation
Heart failure
AV Block
Peripheral edema

ANTIANGINAL DRUGS
COMPARATIVE PHARMACOLOGIC EFFECTS
Nitrates Calcium Beta
Channel Blockers
Blockers
Increase in O
2
Supply
Decrease in O
2
Demand o
+
+ o
+ +

ANTIANGINAL DRUGS
COMPARATIVE ADVERSE EFFECTS
Nitrates Calcium Beta
Channel Blockers
Blockers
AV Block 
LV Dysfunction 
Bronchoconstriction 
+
+

+
-/+
+