Angina pectoris

.Angina = pain or discomfort=choke, pectoris=chest

.Angina: - is a symptom of myocardial ischemia
Angina occurs in person with impaired or decrease
.coronary blood flow

-:Types of angina
Angina due to atherosclerosis due to deposition of-1
fats in inner walls of coronary artery and loss of its
.elasticity
Variant angina due to coronary spasm and this -2
.called vasospastic angina
Vincent angina due to infection with spirochetes -3
.infection in mouth and throat

;Symptoms
Feeling of pressure in the region of sternum and
arm especially left arm, breathlessness,
.suffocation, anxiety

-: Angina attack increases in case of

Increase O2 demand (needed for FOC and HR) and -1
decrease in oxygen supply (decrease in blood flow in
coronary artery)
Severe exercise, stress, heavy metals, fatty meals -2
.and severe cold atmosphere

-:In angina
O2 demand > O2 supply
Increase in FOC
Increase in heart rate and effort of heart
So in TTT of angina we aim to increase o2 supply
through coronary arteries and decrease o2
.demand

-:Angina treatment

Nitrates and nitrites-1

C a channel blocker-2
B blocker-3
Surgical procedure -4

General measures-5

Nitrites and Nitrates -1

:MOA
A-Reduction of nitrites and nitrates to nitric oxide
-:(NO) by
organic nitrates reductase enzyme-1
.SH group in nitrate receptor -2
B-The NO is vasodilator due ta activation of guanyl
cyclase enzyme which convert GTP into CGMP which
. is vasodilator
C-NO is vasodilator to all smooth blood vessels
.especially veins and venules more than arteries
D-No is a vasodilator to capillaries although the
capillaries are not smooth blood vessels due to
.relaxation of capillary sphincter
.E-NO causes V.D to the vena cava and aorta
F-Vasodilatation in vena cava leads to decrease the
.blood in the heart and decreasing preload
G-Vasodilatation in aorta leads to decrease the after
load and decrease the peripheral vascular resistance
.(PVR)

H-Generalized vasodilatation leads to pooling of blood

in dilated blood vessels in abdomen and lower limb
and decrease the COP, BP , decreasing the O2
. demand
I- NO decreases the amount of the blood in
ventricles lead to decrease the ventricle dilation
and increases the dilation of coronary artery so
.increases the blood flow to heart
J-Nitrates or nitrites have no direct effect on
coronary artery of ischemic heart as vasodilator
because the coronary blood vessels are maximum
dilated and fat deposits will prevent
vasodilatation due to loss of elasticity so the
.nitrites do not work trough this mechanism
The nitrites or nitrates decrease O2 demand and
.increase O2 supply
NB Nitrates relax all smooth muscles ex: - GIT ,
.uterus , bronchi

-:Side effects of nitrates of nitrites

GIT upset (nausea-vomiting)-1
Due to vasodilatation-2
V.D of retinal and intraocular vessels
lead to increase in IOP, So C.I. in
glaucoma

Flushing of face
and neck

V.D of cranial blood vessels lead

to headache mainly in workers

Reflex tachycardia and

vasoconstriction and this
called sympathetic response

If we do not adjust the dose of nitrates leads to -3

serious hypotension and more vasodilatation effect
and pooling of blood in large arteries lead to heart
.ischemia
Impaired sympathetic response to hypotension lead -4
.to nitrite syncope (fainting coma)
Administration of nitrate in large doses in young -5
.children cause methemoglobinemia
Because nitrate is converted to nitrite by
bacterial enzymes, nitrite is oxidizing agent
converted hemoglobin(ferrous) into methemoglobin

(ferric) which has no ability to carry oxygen lead to

. cyanosis

Pharmaceutical preparation of nitrite or nitrate

Sublingual tablet or chewable tablet used as -1
.prophylactic or to cut short attack
Ointment-2
Oral tablets-3
Patches (transdermal patches )-4
Ex: nitroglycerine or glyceryl trinitrite - amyl
nitrite- mannitol hexanitrate- isosorbide dinitarte
.octyl nitrite erythritol tetranitrate

-:Pharmacokinetics
Short T 1/2 (5 minutes)-1
Rapid onset of action (30 sec)-2
Oral tablet used as prophylactic for long term of -3
.action

B blocker ex propranolo- atenolol

-:MOA
Decrease the HR COP- O2 demand, but not
causing vasodilatation of coronary blood vessels but
cause vasoconstriction. So the B blocker decreases
O2 demand only not increasing O2 supply. B blocker
is contraindicated in variant angina

Ca channel blocker ex:- verapamilamlodipine-nefidipine-dilitiazemcinnarzine

-: MOA
Blocking C a channel in blood vessels lead to
vasodilatation lead to increase the O2 supply by
vasodilatation of coronary blood vessels. Blocking Ca
channel in heart lead to decrease HR FOC lead to
.decrease the oxygen demand

-;Surgical procedures -4
.Ex; heart stent by pass effect

General measures -5
-:To decrease cardiac work
Correct obesity-1
Avoid heavy meals-2
Avoid stress condition by using anxiolytics -3
-: To prevent arterial degeneration
.Avoid consumption of animal fat-1
Using antihyperlipidemia
fenofibrate
Stop smoking -3

ex: cholestyramine- -2