Angina pectoris

Sudden,severe,pressing chest pain

starting substernal &radiate to left
arm.
Due to imbalance between myocardium
oxygen requirement and oxygen supply.
Risk factors :
Age,sex,obesity.smoking,diabetes.

Classification of angina
1. Exertional angina,
Stable,Atherosclerotic,Classic,
Due to obstruction of coronaries by
atheroma.
2. Variant, Vasospastic angina
due to Spasm of coronaries.
3- Unstable angina.
Due to spasm and partial obstruction of
coronaries.

Determinants of Oxygen Demand

Need to improve ratio
Coronary blood flow / cardiac work
or
Cardiac O2 Supply / Cardiac O2Requirement

Angina Risk Factors

Obesity
Na+ intake
Physical inactivity
Smoking
Hypertension
Stress
High blood cholesterol

Age
Gender
Family history

Cholesterol Levels
Total cholesterol less than 200 mg/dl desirable
200 239 mg/dl borderline high
240 mg/dl and over high
HDL cholesterol greater than 35 mg/dl -desirable, the higher the better
LDL cholesterol less than 130 mg/dl desirable
130-159 mg/dl borderline
160mg/dl or higher high
Ratio LDL:HDL < 3 is desirable

Improving supply/demand ratio

Relaxation of resistance vessels (small arteries and arterioles)
BP Afterload
(Nitrates, calcium channel blockers and beta-blockers)
Relaxation of capacitance vessels (veins and venules)
Venous return, heart size, Preload
(Nitrates and calcium channel blockers)
Blockade of sympathetic influence on the heart
Contactility, HR, O2 demand
(Beta-blockers)
Coronary Dilation
- Important mechanism for relieving vasospastic angina
- O2 supply
(Nitrates)

Nitrates & Nitrites

Formation of Nitric oxide (NO)
activation of guanylate cyclase
Ca++ uptake SR
Toxicity: headache, flushing,
hypotension, possible circulatory
collapse

Nitrates & Nitrites

Preparations :
1- Short acting:
Start within few minutes and total duration of
action 15-30 minutes.
A) Nitroglycerine (Glyceryl trinitrate)
Used as sublingual tablets.
B) Isosorbide dinitrate
As sublingual spray.
C) Amyl nitrite

Inhalation

2- Long acting
Nitroglycerine, Isosorbide dinitrate,
Isosorbide mononitrate,Erythrityl
Tetranitrate.
Action of all start within hours and
continue for hours .

They are given :

Orally,Ointment,Buccal,Transdermal
patch,Parenteral.

Absorption
Well absorbed according to the route:
GIT : long acting
Sublingual : short acting
Transdermal , inhaLation: long acting

Pharmacological actions
Nitrates relax all types of smooth muscles
vascular or non vascular .
Relax both arteries and veins but more
effective on veins.
They have no direct effect on cardiac or
skeletal muscles.
NO released stimulate guanylyl cyclase
In platelets causing increase cGMP that
decrease platelet aggregation.

Clinical uses
Short acting for acute attacks
Long acting for prophylactic

All type of angina

Adverse effects

Orthostatic hypotension
headache
Tachycardia
Facial or cutaneous flushing
Tolerance (Tachyphylaxis)
Salt and water retention
Carcinogenicity
Methaemoglobinemia only with nitrities

Contraindication
Nitrates are contraindicated in
increase intracranial pressure.
Nitrates can be used safely in increase
of intraocular pressure (Glucoma).

Calcium channel blockers

1- They block calcium entry in
myocardium causing
A) decrease myocardium contractility &
myocardium oxygen requirement.
B) decrease heart rate causing decrease in
myocardium oxygen requirement.

2-Block calcium entry in vascular

smooth muscles (arterioles) causing
a)decrease in peripheral resistance( after
load)------ decrease in oxygen
requirement.
b)Relief of coronary spasm.

 Main: Verapamil, Diltiazem, Nifedipine

Others: Nicardipine, Bepridil
Toxicity
a. Hypotension
b. Effects related to vasodilation (dizziness, flushing,
headache)
c. Gingival hyperplasia
d. Constipation, especially with verapamil
e. Cardiac depression with verapamil and diltiazem
f. Tachycardia with nifedipine and nicardipine
g. Arrhythmias and agranulocytosis with bepridil

Clinical uses
In all types of angina but very effective
in variant angina .
Used mainly in prophylactic therapy.

-Adrenoceptor blocking
drugs
They are not vasodilators
They are used in treatment of angina :
They decrease both heart rate &
myocardial contractility that decrease in
myocardial oxygen requirement at rest &
in exercise so improve exercise
tolerance.
Propranolol, Atenolol, Nadolol

Clinical uses
They are effective in the prophylactic
treatment of classic & unstable angina.
They are not used in variant angina.
They are effective in treatment of silent or
ambulatory angina (no pain ).
Decrease mortality of patients with recent
myocardial infarction.

Drug treatment of angina

1- Acute attack :
Short acting nitrates or nitritis.
2- Prophylactic therapy ;
Long acting nitrates.
Calcium channel blockers.
- adrenoceptors blockers.

Surgical therapy
Ballon
Coronary by pass.

Angina Surgical Treatment

(Coronary bypass, angioplasty, stents