antihypertensive drugs drugs for congestive heart failure major cause : atherosclerosis coronary artery spasm decreased blood

flow traumatic injury embolic events coronary bloodflow AV oxygen difference regional myocardial distribution can cause Prinzmetal angina (Variant angina) and MI

often with restricted oxygen supply etiology+therapy affected by cold,smoking,exercise, nitroglycerin, b-blockers preload - diastolic filling pressure increased oxygen demand decreases by nitrates decreases by nitrates and calcium blockers

afterload - peripheral vascular resistance decrease cardiac oxygen demand heart rate

decreased by beta-blockers and some calcium blockers

most effective ::: wall tension contractility others reduced blood oxygenation tachycardia, hyperthyroidism, hypotension decreased by beta -blockers and calcium blockers

e.g. anemia, hypoxia Stable or classic angina is due to fixed stenosis of the coronary arteries, and is brought on by exercise and stress. acute coronary disease Unstable angina (crescendo angina) can occur suddenly at rest, and becomes progressively worse, with an increase in the number and severity of attacks.

stable angina 90%

unstable angina (10-20% of these patients progress to MI) general ischemic heart disease types

Prinzmetal (variant) angina

Variant angina (Prinzmetals angina) occurs at rest, at the same time each day and is usually due to coronary artery spasm.

glyceryltrinitrate acute attack isosorbidmono /dinitrate hospital:angina pain treated with opioids smoking most common: anigina pectoris blood pressure blood lipids reduce risk factors BMI less than 140/90 or 130/90 (kidney disease or diabetes) less than 100 for LDL if triglycerides > 200, then total cholesterol-HDL< 130

18.5 to 24.9 waist circumferences !!

HbA1c < 7% MOST COMMON CAUSE atherosclerosis ECG diagnostic often normal exercise ECG Stress testing preferred dipyridamol, adenosine, dobutamine

pharmacological stress testing stress perfusion imaging

99m Tc

synonyme coronary artery disease formation of NO, which is identical to EDRF and activates guanylyl cyclase to increase cGMP MOA reduces preload and afterload reduce oxygen demand improve perfusion of myocardium venous vasodilation primarily reduces preload

nitroglycerin 90% first pass, therefore sublingual (akut) or transdermal (preventive) glyceryltrinitrate sublingual fast relief 1-2m, last for about 20-30 minutes Nitroglycerin increases cardiac force because the decrease in blood pressure evokes a compensatory increase in sympathetic discharge. nitrates isosorbidmono / dinitrate long-acting mononitrates are preferred dinitrate is converted to mononitrate more stable than nitroglycerin nitrate tolerance side-effects reflex tachycardia most common: headache postural hypotension, dizziness, throbbing, hot flushes, rash, methemoglobinemia esters are volatile and explosive, moisture will lead to hydrolysis of esters and lead to less effect more effective when used together with b-blockers decrease heart rate, contractility and blood pressure MOA decrease sympathetic mediated myocardial stiumlation decrease pre-and afterload ??? contraindication b-blockers preferred not in asthma, diabetes,bradycardia,heart failure and peripheral vascular disease avoid in Prinzmetal angina (may induce vasospasm) atenolol, metoprolol, bisoprolol, nebivolol atenolol, nadolol, sotalol less sleep disturbances may precipitate angina decrease oxygen demand - inotrop and - chronotrop nitrate-free period of 4-8 hours a day

cardioselective water-soluble

but all can be given CAVE: abrupt withdrawal causes rebound receptor sensitivity OTHERWISE look under REVISION Hypertonie look under REVISIONHypertonie use Prinzmetal angina, stable angina, migraine, hypertension, SV arrhythmia, Raynaud's syndrome reduce afterload dilating increases oxygen delivery MOA block Ca entry of coronary and peripheral vascular smooth muscle prevent and reverse coronary spasm reduced preload due to the reduced venous pressure; reduced afterload due to the reduced arteriolar pressure; increased coronary blood flow; reduced cardiac contractility and thus reduced myocardial oxygen consumption; and a decreased heart rate???? cardiovascular pharmacology antianginal drugs prevention / treatment of (un)stable angina nifedipine mostly acts on arterioles, greatest decrease in BP and greatest - inotrop effect short-acting side-effect: can produce tachycardia (would increase oxygen demand (therefore with b-blocker)) 30-90 d longer-acting amlodipine dihydropyridine felodipine calcium channel blocker types isradipine nimodipine side-effects lower extremity edema dizziness most inhibitory effect on ventricle phenylalkylamine non-dihydropyridine benzothiazepine diltiazem verapamil used when b-blockers are contraindicated, not together with b-blockers:bradycardia less negative in HF than other members 5-10mg od longer-acting 5-10mg od DOC angina at rest, Prinzmetal angina

antiarrhythmic drugs diuretics anticoagulant, fibrinolytic and antiplatelet drugs

side-effect: constipation, may also cause sleeplessness,muscle fatique, nystagmus increases serum digitalis concentrations during the first week 80-160mg tds, SR 120-480mg od between nifedipine and verapamil 30-80mg qds, SR 120-320mg od

- inotrop and - chronotrop side-effects bradycardia, CHF, hypotension. dizziness, constipation headache, flushing, reflex tachycardia, ankle swelling

highly protein-bound and metabolized completely in liver look under REVISIONHypertonie antiplatelet agents nicorandil other aspirin clopidogrel 75mg-162mg if aspirin is contraindicated

K channel activator+NO3 component

perhexilin maleate peripheral vasodilators dipyridamole dipiperidino-dipyrimidine now primarily used as a platelet aggregation inhibitor

renin-angiotensin

ACE inhibitors might be beneficial, esp. Perindopril ! as well as Angiotensin Receptor Blockers beta-blocker DOC, unless contraindicated, then Ca blocker in heart failure only Ca-dihydropyridine type only

good combination: beta blocker + nifedipin/amlodipin + nicorandil antihyperlidimic drugs unstable angina NSTEMI (non- ST.....) indicated an impending AMI monitor monitor

requires immediate reperfusion therapy /necrosis additional fibrinolytics types STEMI (ST-segment elevated myocardial infarction) influenca vaccination therapy antianginal drugs antiplatelets Anterior infarcts tend to be larger and result in a worse prognosis than inferoposterior infarcts. They are usually due to left coronary artery obstruction, especially in the anterior descending artery; inferoposterior infarcts reflect right coronary or dominant left circumflex artery obstruction. Transmural infarcts involve the whole thickness of myocardium from epicardium to endocardium and are usually characterized by abnormal Q waves on ECG. diagnosis ECG cardiac enzymes: CK-MB Troponin I and T nitrates other antianginal drugs morphine oxygen aspirin therapy clopidogrel warfarin after stent 162-325mg d for 1-6months especially when post-STEMI added to aspirine in STEMI patients with 75mg bd post-STEMI INR=2-3 maybe in conjunction with aspirin and clopidogrel INR02-2.5 heparin parenteral enoxaparin etc others see under anticoagulants myocardial infarction (MI) synonymes short-acting nifedipine sumatriptane drugs not to be used sildenafil thyroxine sympathomimetics antihyperlidimic drugs general acute myocardial infarction (AMI) heart attack long term therapy 75mg od causes venous pooling and reduces preload,cardiac workload and oxygen consumption anginal pain LDH b-blockers ACE-inhibitors, Angiotensin receptor blockers

acute ischemic (coronary) syndromes

antiplatelets