Angina

Question 1

3 types of angin

Answer 1

STABLE: angina come on with activity or emotional stress and resolves with NTG

UNSTABLE: chest pain even at rest or not resolving with rest or NTG

VASOPASTIC (PRINZMETAL OR VARIANT ANGINA)
- due to coronary artery spasm. occurs when pt is at rest usually between midnight or early morning

Question 2

angina treatment for chronic stable angina

Answer 2

• Nitrates sublingual NtG is DOC for acute managment
• BB1ST LINE FOR CHRONIC ANGINA
• add on CCB (verapmil diltiazem, amlodipine, nifedipine, nicardipine)
• Ranolazine (Ranex) Qt, 3a4 substrate

Question 3

TX FOR UNSTABLE ANGINA

Answer 3

-MED EMERGENCY –MONA
NTG followe by IV NTG
BB IV mostly Metoprolol

Question 4

Vasopastic angina tx

Answer 4

aka. Prinzmetal or Variant angina
- CCB 1stline (verapmil, diltiazem, Nicardipine)
- Nitrate subling NTG prn

Question 5

Nitrates MOA, AE, Monitor

Answer 5

• dec myocardial o2 demand by vasodilation of peripheral veins and arteries
• SE: flushing, hypotension, HA
• NEEDS 12-18 HR NITRATE FREE INTERVAL EACH DAY TO AVOID TOLERANCE
• MONITOR: BP, HR

Question 6

Nitrates DUR

Answer 6

• Avoid nitrates if (SBP <90)
• PDE-5 INHIBITORS
• Sildenafil (viagra, Revation- PHT)
• Tadalfil (cialis for BPH, ED & Adcicra for PHT)
• Vardenafil ( Levitra) for ED
• Avanafil (Stendra)

Question 7

Nitroglycerin IV

Answer 7

• indication for acute angina
• D5w
• start at 5-10mcg/min
• NTG iV must be made in glass or Non Pvc bag

Question 8

ISosorbide dinitrate

Answer 8

Oral tab (Isodril titradose)
- 7am,noon, 5pm

Oral SR( Dilatrate SR caps)
- take 8am and 2pm
- may be cut in half, but not chewed or crushed (swallow whole)

allow nitrate free period to help minimize tolerance

Question 9

Isosorbide mononitrate

Answer 9

XR (Imdur)
- QD
- may be cut in half
- do not use for acute angina

Question 10

NTG sublingual tab

Answer 10

• Take sL tabe Q5 min prn chest pain. if pain presist after one dose call 911
• Max 3 tabs in 15 min

SL tab can also be use propylactically 5-10 min prior to activities

Question 11

NTG counseling

Answer 11

keep SL tab in orginal bottle
IF SL not available use Amyl Nitrate(2-6 Inh)

Question 12

Nitroglycerin spray

Answer 12

• Nitrolingual, NitroMIst solution: 0.4mg/spray
• spray under or onto tounge at onset of attack.
• Max 3 sprays
• do not shake the container
• Prime
• Nitrolingual: Prime 5 X
• NitroMist: Prim 10X
• Bottle primed for 6 weeks
• Do not risne mout alteast for 5-10 min

Question 13

Nitroglycerin SL Powder (GoNitro)

Answer 13

-** sublingual powder 0.4 mg / packet**
- max of 3 pack in 15 min
- may use ppx 5-10 min prior to activites that may provoke angina attack

Question 14

NTG ointment 2% ( NItro BID)

Answer 14

apply 1/2 inch upon rising and 1/2 inch 6 hour later
- Max 2 dose/day
- 1inch ointment : 15mg
- apply for nitrate free period of 10-12 hrs each day

Question 16

NTG transdermal Patch

Answer 16

Mintran, Nitro-Dur

for anginal ppx

do not use for acute attack

Question 17

BB blocker inchronic angina treatment

Answer 17

BB 1st line (should not be use in pt with vasopastic angina- may ind coronary vasospasm)

BB effect:
- dec HR, myocardial contractilty, afterload

• dec o2 demand of heart

Question 18

chronic angina treatment

Answer 18

** BB 1st line**
-** CCB (either added to BB or substitued for BB)
- Recommend swithcing to verapmil, diltiazem or adding Long acting dhp - amlodipine
- Long Acting Nitrates ( isosorbide mononitrate XR, Nitro-Dur patch)
** - Ranolazine (Ranexa)

Question 19

Vasospastic angina tx

Answer 19

- CCB: verapmil or Diltazem (non-dhp)
-** Long acting nitrates**
- all pt should have rapid acting nitrate for acute angina

non dhp: verampil neg ionotrope and chronotrope

Question 20

Ranolazine

Answer 20

• Qt prolongatin
• Cyp3a4 substrate