3. A type of chest pain caused by reduced
blood flow to the heart.
4. • Angina pectoris is a clinical syndrome of IHD resulting from
transient myocardial ischemia.
• It is characterized by paroxysmal pain in the substernal or
precordial region of the chest which is aggravated by an increase in
the demand of the heart and relieved by a decrease in the work of
the heart.
• Often, the pain radiates to the left arm, neck, jaw or right arm.
• It is more common in men past 5th decade of life.
ANGINA
5.
6.
7. • Stable angina is the most common type of angina.
• It occurs when the heart is working harder than usual.
• Stable angina has a regular pattern. (“Pattern” refers to how
often the angina occurs, how severe it is, and what factors
trigger it.)
• The pain usually goes away a few minutes after you rest or take
your angina medicine.
• Stable angina isn't a heart attack, but it suggests that a heart
attack is more likely to happen in the future.
Stable angina
8. • Unstable angina doesn't follow a pattern.
• It may occur more often and be more severe than stable angina.
• Unstable angina also can occur with or without physical exertion, and
rest or medicine may not relieve the pain.
• Unstable angina is very dangerous and requires emergency
treatment.
• This type of angina is a sign that a heart attack may happen soon.
Unstable Angina
9. • Variant angina is rare.
• A spasm in a coronary artery causes this type of angina.
• Variant angina usually occurs while you're at rest, and the pain
can be severe.
• It usually happens between midnight and early morning.
• Medicine can relieve this type of angina.
Variant (Prinzmetal's) Angina
10. • Chest discomfort rather than actual pain:
• The discomfort is usually described as a
– pressure,
– heaviness,
– tightness,
– squeezing,
– burning,
– choking sensation.
SIGNS AND SYMPTOMS
11. • Apart from chest discomfort, anginal pains
may also be experienced in
the epigastrium (upper central abdomen),
back, neck area, jaw, or shoulders.
• It is exacerbated by having a full stomach
and by cold temperatures.
• Pain may be accompanied by
breathlessness, sweating, and nausea in
some cases.
13. 2) Other medical problems
• Hyperthyroidism
• Hypoxemia
• Profound anemia
• Uncontrolled hypertension
3) Other cardiac problems
• Tachyarrhythmia
• Bradyarrhythmia
• Valvular heart disease
• Hypertrophic cardiomyopathy
14. • Angina results when there is an imbalance between the heart's
oxygen demand and supply.
• This imbalance can result from an increase in demand (e.g.,
during exercise) without a proportional increase in supply (e.g.,
due to obstruction or atherosclerosis of the coronary arteries).
• However, the pathophysiology of angina in females varies
significantly as compared to males Non-obstructive coronary
disease is more common in females
Pathophysiology
20. • Organic nitrates are prodrugs and they release nitric oxide.
• Nitrates are mainly venodilators also cause arteriolar dilation
and as a result reduces both preload and afterload.
• These compounds cause a rapid reduction in myocardial oxygen
demand, followed by rapid relief of symptoms.
Organic nitrates
21. Administered nitrates
Increased nitrates in the blood
Increased formation of nitric oxide
Increased cGMP formation
increased dephosphorylation of myosin
Vascular smooth muscle relaxation
• vasodilation
22. • The nitrates are inactivated in liver by
glutathione or ganic nitrate reductase.
• Therefore their oral bioavailability is
considerably less due to their first-pass
metabolism.
• The sublingual route, which avoids first pass
effect, is therefore preferred.
• Duration of action lasts for about 25-30min
pharmacokinetics
23. On other smooth muscles:
• Smooth muscles of bronchi, oesophagus, biliary tract, etc are
relaxed by nitrates.
Pharmacological actions of nitrates:
24. Venodilation arterial dilatation
Peripheral pooling of blood PVR
Venous return to the heart Afterload
Preload
Left and right end-diastolic
volume and pressure
Cardiac work
O2 requirement of myocardium RELIEF OF PAIN
Pharmacological
action on vascular
smooth muscles
25. • The most common adverse effect of nitroglycerin, as well as of
the other nitrates, is headache.
• High doses of organic nitrates can also cause postural
hypotension, facial flushing, and tachycardia. Sildenafil
potentiates the action of the nitrates.
• Over doses may cause methaemoglobinaemia.
Adverse drug reactions
26. • Continuous exposure to nitrates in the chemical industry results
in development of tolerance.
• Workers may experience headache and dizziness on starting
work during first few days.
• As there is no exposure to chemicals over the weekend ,
tolerance disappears.
• Symptoms disappear when they start work on Monday– “
Monday disease”.
Tolerance
33. Nifedipine
• Functions mainly as an arteriolar vasodilator.
• This drug has minimal effect on cardiac conduction or heart rate.
• Nifedipine is administered orally, usually as extended-release tablets.
It undergoes hepatic metabolism to products that are eliminated in
both urine and the feces.
34. • The vasodilation effect of nifedipine is useful in the treatment of
variant angina caused by spontaneous coronary spasm.
• Nifedipine can cause flushing, headache, hypotension, and
peripheral edema
35. • The diphenylalkylamine verapamil slows cardiac atrioventricular (AV)
conduction directly, and decreases heart rate, contractility, blood pressure,
and oxygen demand.
• Verapamil causes greater negative inotropic effects than nifedipine, but it
is a weaker vasodilator.
• The drug is extensively metabolized by the liver; therefore, care must be
taken to adjust the dose in patients with liver dysfunction.
Verapamil
36. • Verapamil is contraindicated in patients with preexisting depressed
cardiac function or AV conduction abnormalities.
• It also causes constipation.
• Verapamil should be used with caution in patients taking digoxin,
because verapamil increases digoxin levels.
37. • It dilates peripheral and coronary arteries but its dilating
property is less marked than DHPs.
• It also causes negative inotropic, chronotropic and dromotropic
effects.
• It is used in the treatment of angina, hypertension and
supraventricular arrhythmias.
Diltiazem
38. • Verapamil or diltiazem should not be given with beta blockers as
SA nodal depression, conduction defects or asystole may occur
or be aggravated.
• These should not be used with other cardiac depressants drugs
like quinidine or disopyramide.
• These drugs increase plasma digoxin levels by decreasing its
excretion.
DRUG INTERACTIONS
39. • All CCBs are well absorbed through GI tract but they undergo
varying degree of first pass metabolism.
• All are highly bound to plasma proteins, metabolized in the liver
and excreted in urine.
Pharmacokinetics
46. • Voltage gated K channels: These channels open when the cell is
depolarized and therefore help in the process of repolarization. These are
present mainly in vascular and other smooth muscles
• Calcium activated K channels: An increase in intracellular ca+2
concentration causes opening of these channels, causes repolarization.
• ATP sensitive K channels: These are present in cardiac muscle and beta
cells of islets of Langerhans of pancreas
Potassium channels
