Angina pectoris
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to like this
No Downloads

Views

Total Views
2,160
On Slideshare
2,076
From Embeds
84
Number of Embeds
1

Actions

Shares
Downloads
130
Comments
1
Likes
0

Embeds 84

http://firdath-rubenzani-1305.blogspot.com 84

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. DRUGS USED IN ANGINAPECTORIS & MYOCARDIAL INFARCTION WIWIK RAHAYU, dr., M.Kes Depart.of.Pharmacology & Therapy Faculty Of Medicine – Riau University
  • 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. ANGINA PECTORIS↓ O2 Supply Ischemic PAIN
  • 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. Angina Pectoris PATHOPHYSIOLOGY (I) RISK FACTOR • Age • Hypertension • Smoking • Hypercholesterolemia • DM • Oral contraception • Genetic ? atherosklerosi s OBSTRUCTION (a.coronary) Decreased 02 supply
  • 6. Angina Pectoris PATHOPHYSIOLOGY II O2 supply & O2 demand Precipitating factors ISCHEMIA PAIN
  • 7. PRINCIPLES IN THE TREATMENT OF ANGINA PECTORIS• O2 supply to the tissue• O2 demand of the tissue3. Risk Factor
  • 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. 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. Nitroglycerin EFFECT Venodilatation Relief of Preload coronary a spasm Collateral flow O2 demand O2 supply O2 supply Inotropic ? Chronotropic ?
  • 11. Nitroglycerin EFFECT High Dose Vasodilatation BP tachycardia Paradoxal effect O2 demand
  • 12. Nitroglycerin EFFECT • Increased O2 supply • Decreased O2 demand Preload Afterload • Contractility (N) • Heart rate • Decreased in platelet aggregation (?)
  • 13. Dosage
  • 14. Nitroglycerin INDICATION • ANGINA PECTORIS • Acute • Prophylaxis • ACUTE MYOCARDIAL INFARCTION • CONGESTIVE HEART FAILURE
  • 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. 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. Nitroglycerin CONTRAINDICATION • Hypotension • Severe anemia • Brain injury • Tachyaritmia
  • 18. CALCIUM CHANNEL BLOCKERS (CALCIUM ANTAGONIST)I. NIFEDIPINE AMLODIPINE, FELODIPINE, NICARDIPINE, NIMODIPINE, ETCII. DILTIAZEMIII. VERAPAMIL
  • 19. CCB MECHANISM OF ACTION • Inhibit the influx of Calcium into CARDIAC & VASCULAR cells MUSCLE TONE
  • 20. CCB EFFECTS (I) Vascular Effects Cardiac Effects Vasodilatation Heart Rate ↓ Conduction↑ O2 supply After load↓ BP ↓ Contraction ↓ O2 demand ↓ O2 demand
  • 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. 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. 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. NIFEDIPINE• Effects (?)• SE: VD flushing, dizziness, headache, palpitation, peripheral edema rare myalgia, hypokalemia, gingival swelling• Drug Interaction Cimetidine Prazosin
  • 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. Nifedipine SECOND GENERATION DHP AMLODIPIN: Dosage: 5-10 mg, once daily NICARDIPINE: Dosage: 20-40 mg, every 8 hours NIMODIPINE : Subarachnoid Hemorrhage Migraine
  • 27. BETA BLOCKER• CARDIOSELECTIVE – Acebutolol – Atenolol * – Metoprolol *• NON CARDIOSELECTIVE – Propanolol * – Nadolol * – Carteolol – Sotalol• VASODILATOR NONSELECTIVE – Labetolol – Pindolol – Carvedilol
  • 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. 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. PropanololSIDE EFFECTS
  • 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. CONTRAINDICATION• Severe bradycardia, heart block• Asthma or bronchospasm• Severe depression• Peripheral vascular (gangrene, skin, necrosis, Raynaud’s phenomenon)• DM• Renal failure
  • 33. ACUTE MYOCARD INFARCT↓ O2 Supply Infarct PAIN
  • 34. THERAPY1. Oksigen2. Morfin3. Metaklopramide4. Nitrogliserin5. Aspirin6. Streptokinase7. Heparin8. Laksativ (bila perlu)
  • 35. Other DrugsACE INHIBITORReduce: 1. Remodeling ventricle 2. Haemodinamic 3. Reduce heart failureBETA BLOCKER – Reduce O2 myocard demand – Reduce size of infarct
  • 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. 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. 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. Wassalam,