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Angina pectoris

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  • 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,