Angina pectoris

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Angina pectoris

  1. 1. DRUGS USED IN ANGINAPECTORIS & MYOCARDIAL INFARCTION WIWIK RAHAYU, dr., M.Kes Depart.of.Pharmacology & Therapy Faculty Of Medicine – Riau University
  2. 2. ANGINA PECTORISA syndrome of inadequate oxygen delivery tothe myocardium relative to the oxygenrequirement of this tissue• Symptom Severe, transient retrosternal pain radiated to the left arm, back or jaw• Duration: 0,5 – 30 minute• ECG:
  3. 3. ANGINA PECTORIS↓ O2 Supply Ischemic PAIN
  4. 4. TYPE OF ANGINA PECTORIS1. CLASSIC ANGINA – Atherosklerosis – Precipitating factor (+)2. PRINZMETALS – Vasospasm – Precipitating factor (-)3. UNSTABLE A rapid increase in frequency and intensity of anginal pain occurs, which is thought to herald imminent myocardial infection.
  5. 5. Angina Pectoris PATHOPHYSIOLOGY (I) RISK FACTOR • Age • Hypertension • Smoking • Hypercholesterolemia • DM • Oral contraception • Genetic ? atherosklerosi s OBSTRUCTION (a.coronary) Decreased 02 supply
  6. 6. Angina Pectoris PATHOPHYSIOLOGY II O2 supply & O2 demand Precipitating factors ISCHEMIA PAIN
  7. 7. PRINCIPLES IN THE TREATMENT OF ANGINA PECTORIS• O2 supply to the tissue• O2 demand of the tissue3. Risk Factor
  8. 8. ANTI ANGINAL DRUGS1. ORGANIC NITRATES – AMIL NITRIT – NITROGLYCERIN – ISOSORBIDE DINITRATE• Ca ++ CHANNEL BLOCKERS (CCB) – NIFEDIPINE, AMILODIPINE – DILTIAZEM – VERAPAMIL• β ADRENERGIC BLOCKERS – PROPANOLOL cs
  9. 9. NITROGLYCERINENitroglycerine – the prototype nitrate drug.All nitrates have the same mechanism of Action.MECHANISM OF ACTION Administrated nitrates ↑ Nitrites ↑ Nitric oxide (NO) ↑ cGMP ↑ Dephosphorylation of myosin light chain Vascular smooth muscle relaxation
  10. 10. Nitroglycerin EFFECT Venodilatation Relief of Preload coronary a spasm Collateral flow O2 demand O2 supply O2 supply Inotropic ? Chronotropic ?
  11. 11. Nitroglycerin EFFECT High Dose Vasodilatation BP tachycardia Paradoxal effect O2 demand
  12. 12. Nitroglycerin EFFECT • Increased O2 supply • Decreased O2 demand Preload Afterload • Contractility (N) • Heart rate • Decreased in platelet aggregation (?)
  13. 13. Dosage
  14. 14. Nitroglycerin INDICATION • ANGINA PECTORIS • Acute • Prophylaxis • ACUTE MYOCARDIAL INFARCTION • CONGESTIVE HEART FAILURE
  15. 15. Nitroglycerin ADVERSE DRUG REACTIONS • Common side – effects Headaches • Serious SE – Hypotension – Syncope ( cause cerebral ischemia) tachycardia • Others Edema Methemoglobinemia SL: Burning sensation • Withdrawal symptoms • Tolerance
  16. 16. Nitroglycerin ADVERSE DRUG REACTIONS Tolerance • Appears within 12 hours • Long acting preparation Continuous infusion Caused: - BM depletion • Avoid by a nitrate free interval • Cross tolerance
  17. 17. Nitroglycerin CONTRAINDICATION • Hypotension • Severe anemia • Brain injury • Tachyaritmia
  18. 18. CALCIUM CHANNEL BLOCKERS (CALCIUM ANTAGONIST)I. NIFEDIPINE AMLODIPINE, FELODIPINE, NICARDIPINE, NIMODIPINE, ETCII. DILTIAZEMIII. VERAPAMIL
  19. 19. CCB MECHANISM OF ACTION • Inhibit the influx of Calcium into CARDIAC & VASCULAR cells MUSCLE TONE
  20. 20. CCB EFFECTS (I) Vascular Effects Cardiac Effects Vasodilatation Heart Rate ↓ Conduction↑ O2 supply After load↓ BP ↓ Contraction ↓ O2 demand ↓ O2 demand
  21. 21. CCB EFFECTS (II) Phenylalkylamines Dihydropyridines Benzothiazepines A (Verapamil) D (Diltiazem) B(Nifedipine) C(Nimodipine)Vasodilatation Peripheral ++ +++ + + Coronary ++ +++ + +++ Cerebral + + +++ +Heart Rate ↓ ↑ - ↓SA Node ↓ - - ↓↓AV Node ↓↓ - - ↓Contractility ↓↓ ↑ - ↓
  22. 22. PharmacokineticsDrug Absorption Bioavailability Active Half Onset Peak Metabolites Life of Effect (hr) Action after after oral Oral Dosing DosingVerapamil >90% 10%-35% + 5 <1hr 1-2hrNifedipine >90% 60%-70% - 2 <20min 30min (2-3 min)* <1hrDiltiazem >80% 40% + 3,5 2-3hr
  23. 23. CLINICAL PROBLEMS AND SIDE EFFECTSVERAPAMIL Problems in 8% to 10% of patients Major Cardiodepression Moderate Hypotension AV node block Peripheral edema Minor Headache ConstipationNIFEDIPINE Problems in 17% to 20% of patients Major Hypotension Headache Peripheral edemaDILTIAZEM Problems in 2% to 5% of patients Minor Hypotension -AV Node Block Peripheral edema -Cardiodepression
  24. 24. NIFEDIPINE• Effects (?)• SE: VD flushing, dizziness, headache, palpitation, peripheral edema rare myalgia, hypokalemia, gingival swelling• Drug Interaction Cimetidine Prazosin
  25. 25. Nifedipine • Indication 1.PRINZMETAL,S (VASOSPASTIC) ANGINA Monotherapy, 40-80 mg More effective when combined with Isosorbid 4.CHRONIC STABLE ANGINA Combined with Beta Blocker 6.UNSTABLE ANGINA Monotherapy is contraindication Combined with Beta Blocker
  26. 26. Nifedipine SECOND GENERATION DHP AMLODIPIN: Dosage: 5-10 mg, once daily NICARDIPINE: Dosage: 20-40 mg, every 8 hours NIMODIPINE : Subarachnoid Hemorrhage Migraine
  27. 27. BETA BLOCKER• CARDIOSELECTIVE – Acebutolol – Atenolol * – Metoprolol *• NON CARDIOSELECTIVE – Propanolol * – Nadolol * – Carteolol – Sotalol• VASODILATOR NONSELECTIVE – Labetolol – Pindolol – Carvedilol
  28. 28. PROPANOLOL Is the prototype β adrenergic blocker ↓Inotropic chronotropic ↓ O2 demandβ Adrenergic domotropicblocker ↓Renin → Ag → peripheral →BP ↓ resistance aldosteron ↓ Sodium, water BP ↓ retention
  29. 29. INDICATIONI. ANGINA PECTORIS For Chronic management of stable anginaIII. MYOCARDIAL INFARCTION Reduces infarct size and has tens recovery Reduce the incidence f sudden arrhythmic death after myocardial infarctVI. HYPERTENSIONVII. ARRYTHMIAVIII.MIGRAINEIX. GLAUCOMAX. HYPERTHYROIDISM
  30. 30. PropanololSIDE EFFECTS
  31. 31. SELECTION OF DRUGS Drugs ESR Liposoluble FPE Elimination T 1/2Propanolol +++ ++ L 1-6 Nadolol 0 0 0 K 20-24 Atenolol + 0 0 K 6-7Metoprolol + + ++ L 3-7
  32. 32. CONTRAINDICATION• Severe bradycardia, heart block• Asthma or bronchospasm• Severe depression• Peripheral vascular (gangrene, skin, necrosis, Raynaud’s phenomenon)• DM• Renal failure
  33. 33. ACUTE MYOCARD INFARCT↓ O2 Supply Infarct PAIN
  34. 34. THERAPY1. Oksigen2. Morfin3. Metaklopramide4. Nitrogliserin5. Aspirin6. Streptokinase7. Heparin8. Laksativ (bila perlu)
  35. 35. Other DrugsACE INHIBITORReduce: 1. Remodeling ventricle 2. Haemodinamic 3. Reduce heart failureBETA BLOCKER – Reduce O2 myocard demand – Reduce size of infarct
  36. 36. Kasus:Seorang laki-laki 56 tahun, datang dengankeluhan sering nyeri dada (khas)PD: TD= 200/100 mmHgDiagnosis: Angina Pectoris KlasikPertanyaan:- Bagaimana terapi akut, kronis, lainnya
  37. 37. Seorang wanita 62 tahun, datang dengankeluhan nyeri dada terutama pagi hari.PD: TD=180/90, Riwayat DM (+)Diagnosis: Angina Pectoris VasospastikPertanyaan:- Bagaimana terapi akut, kronis, lainnya ?
  38. 38. Seorang laki-laki, 60 tahun datang ke UGDdengan keluhan nyeri dada hebat, muntah,keringat dinginPD: TD= 180/100Diagnosis: Acute Myocard InfarctPertanyaan:- Bagaimana penanganan pasien tersebut?
  39. 39. Wassalam,

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