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New Paradigm of Anti Anginal Therapy
dr.Yerizal Karani SpPD,SpJP(K)
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Angina Pectoris• Angina pectoris sudden severe pressing
chest pain or heaviness radiating to the neck, jaw, back and arms associated with diaphoresis, tachypnea and nausea.
• Angina insufficient coronary flow to meet oxygen demands of the myocardium precipitated by any activity/process that creates an imbalance in O2 supply and demand
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Types of Angina
• Angina occurs in three overlapping patterns:– Stable angina– Unstable angina– Prinzmetal (variant)
angina
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Nitrat
• Nitrogliserin (gliseril trinitrat) very fast onset sublingually acute condition
• Isosorbide dinitrate fast onset sublingually (substitute of gliseril trinitrat)
• Isosorbide mononitrate slow onset used in preventing angina
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" Decrease in the effect of a drugwhen administered in a long-acting form"
Nitrates Tolerance
• Develops with all nitrates
• Is dose-dependent
• Disappears in 24 h. after stopping the drug
• Tolerance can be avoided– Using the least effective dose
– Creating discontinuous plasma levels
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WITH CAUTION:� Constrictive pericarditis� Intracranial hypertension� Hypertrophic cardiomyopathy
Nitrates Contraindications• Previous hypersensitivity• Hypotension ( < 80 mmHg)• AMI with low ventricular filling pressure • 1st trimester of pregnancy
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Contraindication B-Blocker
• Hypotension: BP < 100 mmHg
• Bradycardia: HR < 50 bpm
• Chronic bronchitis, ASTHMA
• Severe chronic renal insufficiency
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Reasons for Using Nitrates and Beta Blockers in Combination in Angina
• Beta Blockers prevent reflex tachycardia and contractility produced by nitrate-induced hypotension.
• Nitrates prevent any coronary vasospasm produced by Beta Blockers.
• Nitrates prevent increases in left ventricular filling pressure or preload resulting from the negative inotropic effects produced by Beta Blockers.
• Nitrates and Beta Blockers both reduce myocardial oxygen consumption by different mechanisms.
• Nitrates and Beta Blockers both increase subendocardial blood flow by different mechanisms
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Anti Anginal EffectNitrate B-Blocker CCB
Endocardial blood flow ↑↑ ↑ ↑
Collateral ↑↑ → ↑↑
Wall tension ↓ →↑ ↓
Heart rate ↑ (reflex) ↓↓ ↑↓
Contractility ↑ (reflex) ↓↓ ↓→↑
Cardiac work ↓↓ ↓↓ ↓↓
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Take Home Messages
• Angina pectoris imbalance of O2 in supply & demand of the myocardium
• Nitrogliserin: very fast onset of nitrate in angina pectoris
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THANK YOU...