Transcript Calcium channel blockers

Done by:
3rd
jan 2009
Ahmed M. Aljabri
Pharm.D
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Angina
 Overview
 Pathophysiology
 Types of angina
 Diagnosis
 Management
 Key points
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
Angina pectoris is a medical term for chest pain
or discomfort due to coronary heart disease

Angina is a symptom of a condition called
myocardial ischemia

It occurs when the heart doesn't get as much
blood (hence as much oxygen) as it needs

This usually happens because
one or more of the heart's
arteries is narrowed or blocked
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Epidemiology :

Is the single most common cause of premature
death in Europe and in 2020 will be the major cause
of death in the world

About 1.3 million person with new cases of angina
and 330,000 complicated to myocardial infarction
every year

Angina occurs in 1:3 men and 1:4 women

It can be a sign of heart disease, even when initial
tests don't show evidence of CAD

Risk factors may include :age, male sex, family history,
smoking, alcohol, heavy meals, sedentary life stile,
hypertension, obesity, lipid disorders, diabetes mellitus,
haemostatic factors and physical inactivity
Symptom :

Typical angina is a pain in
the centre of the chest

The discomfort also may be
felt in the neck, jaw,
shoulder, back or arm

Angina often occurs when the heart needs more blood
 For example, running to catch a bus could trigger an attack of
angina while walking might not

Angina may happen during exercise, strong emotions or
extreme temperatures
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1.
Stable angina
2.
Unstable angina
3.
Variant (Prinzmetal's) angina

Knowing how the types are different is important
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
People with stable angina have episodes of chest pain
that are
 Usually predictable
 Has a regular pattern
 Lasting from 0.5 to 30 minutes

It occurs when the heart is working harder than usual
 On exertion
 Under mental or emotional stress

Normally the chest discomfort is relieved with
rest, nitroglycerin or both
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
In people with unstable angina,
 Unexpected chest pain
 Doesn't follow a pattern
 More severe and prolonged than typical angina
 It can occur with physical exertion or at rest and may relieved by
medicine
People with new, worsening or persistent chest discomfort
should be evaluated in a hospital emergency department and
monitored carefully

Unstable angina is an acute coronary syndrome and
should be treated as an emergency
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
Chest pain usually
 Occurs spontaneously
 Occurs when a person is at rest
 Very painful and usually occur between midnight and 8 a.m.

It doesn't follow physical exertion or emotional stress

Variant angina is due to transient coronary artery spasm
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Differential Diagnosis of Episodic Chest Pain
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
Person's medical history and risk factors

Chest X-ray

Electrocardiogram (ECG)

Echocardiography
Cardiac enzymes to role out
myocardial infarction

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
The accuracy of
exercise stress
tests in the
diagnosis of
significant
coronary artery
disease is 60% to
70%

It’s the most accurate test to detect
arterial coronary narrowing

Acute myocardial infarction (heart attack)

Severe cardiac arrhythmias

Cardiac arrest leading to sudden death
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DESIRED OUTCOME(Goals)

The short-term goals of therapy are
 To reduce or prevent the symptoms of angina that limit exercise
capability and impair quality of life

Long-term goals of therapy are
 To prevent CHD events such as MI, arrhythmias, and heart failure
and to extend the patient’s life
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
Lifestyle changes

Medicines

Medical procedures
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






Stop smoking and alcohol
intake
Physical activities within limits
Avoid large meals and rich
foods that leave you feeling
stuffed
Control the body weight
Control the blood sugar if the
patient is diabetic
Control the blood cholesterol if
the patient has a lipid disorder
Avoid stressed

You also can make lifestyle
changes that help lower
your risk of heart disease

medications used to
treat angina address
the myocardial
oxygen
demand/supply
imbalance from a
hemodynamic
perceptively
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Treat with drugs
Blood supply to the heart
Coronary vasodilators
1.Nitroglycerin
Heart's demand for oxygen
Drugs that reduce blood pressure
&
Drugs that slow the heart rate
2.Beta-blockers
and
3.calcium antagonists
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 1.Short-acting

nitroglycerin tab (0.3-0.6 up to 1.5 mg)
• Can be repeated at five minute intervals .used in acute attach
• Can also be used prior to exertion to prevent angina
• Short term effect;1-7 min
spray preparation where each “puff” is 0.4 mg
Nitroglycerin intravenous infusion5-200 micro gm/min;
short action require continuous infusion
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2.Longer-acting nitroglycerin preparations such as;
• Isordil tablets 5-80mg,
2-3times daily
•(Nitro-Dur )transdermal systems (patch form)0.2-0.8mg/hrs
every 12 hr.
•Nitro ointment
All relieves spasm of the coronary arteries and can redistribute
coronary artery blood flow to areas that need it most
Side effect :
Headache
Flushing
Hypotension

Beta blockers relieve angina by inhibiting the effect of
adrenaline on the heart
 Decreases the heart rate
 Lowers the blood pressure
 Reduces the pumping force of the heart muscle
All of which reduce the heart muscle's demand for oxygen
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Beta-blockers are the preferred initial choice, often used in
conjunction with an organic nitrate to more positively address
the hemodynamic imbalances causing the angina
Cardio selective beta blocker
 Acebutolol : 200-600mg twice daily
 Atenolol :
50-200mg/day
 Bisoprolol: 10mg/day
 Metoprolol: 50-200mg
 Nadolol:
40-80mg/day
 Propranolol :20-80mg twice daily

Side effects :
 Worsening of asthma
 Excess lowering of the heart rate and blood pressure
 Depression
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

If the patient cannot tolerate the beta-blocker or betablocker therapy is contraindicated, a calcium channel
blocker with or without an organic nitrate can be
considered
Calcium channel blockers relieve angina by lowering blood
pressure, and reducing the pumping force of the heart muscle
Reducing muscle oxygen demand

Calcium channel blockers is the drug of choice in variant
angina
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
Calcium channel blockers:
 Amlodipine :5-10mg OD
long duration of action
 Felodipine :5-10mg OD
long duration of action
 Nicardipine : 20-40 mg three times short duration
 Nifedipine : immediate release 30-90mg daily short duration
Miscellaneous;
 Verapamil.: Immediate release 80-160mg (TDS) short duration
{Hypotension,bradycardia, edema, myocardial depression}
 Diltiazem :immediate release,30-80mg (QID)
{Hypotension,bradycardia, edema }
Side effects :
 Swelling of the legs
 Excess lowering of the heart rate and blood pressure
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
Treatment of choice ; is sublingual
nitroglycerin. This therapy is effective for
stable, unstable, or variant angina
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
Beta-blockers alone or in conjunction with an organic nitrate

If the beta-blocker therapy is contraindicated or ineffective in
preventing angina a calcium channel blocker may be used



Since the combination of a beta-blocker and either verapamil or
diltiazem frequently induces undesirable bradycardia
a dihydropyridine is often selected in combination with a betablocker
Since stable and unstable angina are nearly always related to
coronary artery disease, in addition to anti anginal therapy,
patients should be placed on aspirin and, especially if the patient
has heart failure or diabetes mellitus


Calcium channel blockers are the preventive
treatment of choice for variant angina
Organic nitrates may be added, if needed
Beta-blockers are to be avoided since they
induce coronary vasospasm
Procedures are used to treat angina

Percutaneous transluminal coronary angioplasty

Laser angioplasty and atherectomy

Coronary artery bypass graft surgery
Before performing any of these procedures, a doctor must
find the blocked part(s) of the coronary arteries
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

A newly developed computerized x-ray scan
(ultrafast CT scan) is highly accurate in
detecting small amounts of calcium in the
plaque of coronary arteries
If an ultrafast CT scan shows no calcium in
the arteries, atherosclerotic coronary artery
disease is unlikely especially in younger age
Coronary arteries can close after angioplasty,
causing recurrent angina or even heart attacks
 One way to decrease the risk of coronary artery
closure is by deploying stents to keep the
arteries open



Newer drug-coated stents are being improved to
significantly reduce the rate of artery closure.
Early studies in Europe with Rapamycin-coated
stents have resulted in near-zero restenosis
rates, which have previously been
unprecedented. These stents are now widely
available

Angina is one of many causes of chest pain

Angina is chest pain that is a result of inadequate oxygen
supply to the heart muscle

Angina can be caused by coronary artery disease or
spasm of the coronary arteries
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
ECG, exercise stress test, stress echocardiography, and
cardiac catheterization are important in the diagnosis of
angina

Treatment of angina includes lifestyle modification,
medications, angioplasty, and/or coronary artery bypass
surgery
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•
http://www.americanheart.org/presenter.jhtml?i
dentifier=4472
•
Joseph T. et-al, PHARMACOTHERAPY, McGrawHill Inc., 6th Edition, 2005, Chapter 15, pg.297320
Leon S.et al, comprehensive pharmacy review,
the point inc, 6th Edition,2007,chapter 39,page
786-812.
www.uptodate.com.uptodate 16.3
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Thank
you