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1. CV Pharmacology
Anti-Anginal Agents
Prepared and presented:
Marc Imhotep Cray, M.D.
BMS and CK-CS Teacher
Reading:
Antianginal Drugs
Formative Assessment
Practice question
Clinical:
e-Medicine articles
Coronary Artery Disease
Risk Factors for CAD
Angina Pectoris

2. 2
Coronary heart disease (CHD)
Defined (Etiologic Dx)
 Coronary heart disease (CHD) is a
condition in which proper circulation of blood
and oxygen are not provided to heart and
surrounding tissue.
 Result is due to a narrowing of small blood
vessels, which normally supply heart with
blood and oxygen.
 Coronary heart disease, a type of
cardiovascular disease, is the leading
cause of death for both men and women
in the United States.

3. 3
Causes (Anatomic Dx)
 The typical cause of
coronary heart
disease is
atherosclerosis,
which takes place
with plaque and fatty
build up on the
artery walls,
narrowing the
vessels.

4. 4

5. 5
CAD Risk Factors
 Certain conditions are considered to put an individual at greater
risk for coronary heart disease. The following are some risk
factors:
1. Age (particularly 40+)
2. Diabetes
3. Genetics (heredity)
4. High blood pressure
5. High bad cholesterol (LDL)
6. Increased levels of C-reactive protein, fibrinogen, or homocysteine
7. Lack of sufficient physical activity
8. Low good cholesterol (HDL)
9. Menopause
10. Obesity
11. Smoking

6. 6
Symptoms
 Some more frequent
symptoms of coronary
heart disease include:
1. Angina (ischemic pain)
2. Myocardial Infarction
3. Shortness of breath

7. 7
Diagnosis
 Diagnosis of coronary heart disease may be
accomplished by a variety of means:
1. Coronary angiography
2. Coronary arteriography
3. Coronary CT angiography
4. Echocardiogram
5. Electrocardiogram (ECG)
6. Electron-beam CT (EBCT)
7. Exercise stress test
8. Magnetic resonance angiography
9. Nuclear scan

8. 8
Treatment
 Coronary heart disease treatment methods
may include: (depends on the presenting
Physiologic Dx)
1. Angioplasty with stenting
2. Coronary artery bypass surgery
3. Medication
4. Minimally invasive heart surgery
5. Proper diet and exercise
6. Quitting smoking

9. 9
Coronary Artery O2 Supply
and Demand

10. 10
Angina Pectoris (Chest Pain)
 When the supply of
oxygen and nutrients in
the blood is insufficient
to meet the demands of
the heart, the heart
muscle aches
 The heart demands a
large supply of oxygen
to meet the demands
placed on it The myocardial supply:demand ratio--a critical
review. [Am J Cardiol. 1978]

11. 11
R/O MI Algorithm
Contemporary Diagnosis and Management of Unstable Angina
GUYS R. http://www.mayoclinicproceedings.com/inside.asp?AID=1529&UID=

12. 12
Antianginal Pharmacologic
Agents
 Nitrates
 Beta blockers
 Calcium channel blockers

13. 13
Types of Angina
 Chronic stable angina
(also called classic or effort angina)
 Unstable angina
(also called preinfarction or crescendo angina)
 Vasospastic angina
(also called Prinzmetal’s or variant angina)

14. 14
Antianginal Agents:
Therapeutic Objectives
 Increase blood flow to ischemic heart muscle
and/or
 Decrease myocardial oxygen demand

15. 15
Antianginal Agents:
Therapeutic Objectives
 Minimize the frequency of attacks and
decrease the duration and intensity of anginal
pain
 Improve the patient’s functional capacity with
as few side effects as possible
 Prevent or delay the worst possible outcome,
MI

16. 16
Antianginal Agents:
1)Nitrates
Available forms:
Sublingual Ointments
Buccal Transdermal patches
Chewable tablets Inhalable sprays
Capsules Intravenous solutions

17. 17
Antianginal Agents: Nitrates(2)
 Cause vasodilation due to relaxation of
smooth muscles
 Potent dilating effect on coronary
arteries
 Used for prophylaxis and treatment
of angina

18. 18
Antianginal Agents: Nitrates(3)
Nitroglycerin
 Prototypical nitrate
 Large first-pass effect with PO forms
 Used for symptomatic treatment of ischemic
heart conditions (angina)
 IV form used for BP control in perioperative
hypertension, treatment of CHF, ischemic pain,
and pulmonary edema associated with acute MI

19. 19
Antianginal Agents: Nitrates(4)
 isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate SR)
 isosorbide mononitrate
(Imdur, Monoket, ISMO)
Used for:
 Acute relief of angina
 Prophylaxis in situations that may provoke
angina
 Long-term prophylaxis of angina

20. 20
Antianginal Agents: Nitrates(5)
Side Effects
 Headache
 Usually diminish in intensity and frequency
with continued use
 Tachycardia, postural hypotension
 Tolerance may develop

21. 21
Antianginal Agents:
2)Beta Blockers
 atenolol (Tenormin)
 metoprolol (Lopressor)
 propranolol (Inderal)
 nadolol (Corgard)

22. 22
Antianginal Agents:
Beta Blockers(2)
Mechanism of Action
 Decrease the HR, resulting in decreased
myocardial oxygen demand and increased
oxygen delivery to the heart
 Decrease myocardial contractility, helping to
conserve energy or decrease demand

23. 23
Antianginal Agents:
Beta Blockers(3)
Therapeutic Uses
 Antianginal
 Antihypertensive
 Cardioprotective effects, especially after MI

24. 24
Antianginal Agents: Beta
Blockers(4)
Side Effects
Body System Effects
Cardiovascular bradycardia, hypotension
second- or third-degree heart block
heart failure
Metabolic Altered glucose and lipid
metabolism

25. 25
Antianginal Agents:
Beta Blockers(5)
Side Effects
Body System Effects
CNS dizziness, fatigue,
mental depression, lethargy,
drowsiness, unusual dreams
Other impotence
wheezing, dyspnea

26. 26
Antianginal Agents:
3) Calcium Channel Blockers
Prototypical Agents
 Verapamil (Calan)
 diltiazem (Cardizem)
 nifedipine (Procardia)
•Dihydropyridines
•Amlodipine
(Norvasc),
Felodipine
(Plendil)
•Nimodipine
•Isradipine
•Nicardipine
•Nifedipine
•Non-Dihydropyridines
•Bepridil (Vascor)
•Diltiazem
(Cardiazem)
•Verapamil (Isoptin,
Calan)
Medicinal Chemistry Classes

27. 27
Antianginal Agents:
Calcium Channel Blockers(2)
Mechanism of Action
 Cause peripheral arterial vasodilation
 Reduce myocardial contractility
(negative inotropic action)
 Result: decreased myocardial oxygen demand

28. 28
Antianginal Agents:
Calcium Channel Blockers(2)
Therapeutic Uses
 First-line agents for treatment of angina,
hypertension, and supraventricular
tachycardia
 Short-term management of atrial fibrillation
and flutter
 Several other uses

29. 29
Antianginal Agents:
Calcium Channel Blockers(3)
Side Effects
 Very acceptable side effect and safety profile
 May cause hypotension, palpitations, tachycardia
or bradycardia, constipation, nausea, dyspnea

30. 30
Reference Resource
(Online Textbooks)
Principles of Pharmacology: The Pathophysiologic Basis of
Drug Therapy Cairo CW, Simon JB, Golan DE. (Eds.); LLW
2012 (Google Books Online).
Goodman and Gilman’s The Pharmacological Basis of
Therapeutics. Brunton LL, Chabner BA , Knollmann BC (Eds.);
M-H 12th ed. 2011.
Basic and Clinical Pharmacology, Katzung, Masters, Trevor; M-
H 12th ed.
THE END
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