angina & antianginal drugs

1. ANGINA
“It is a type of chest pain caused by reduced blood flow to the heart”
Angina is a symptom of coronary artery disease (CAD) or ischemic heart
disease and it is the most common cause of death worldwide.
Angina which is also called as angina Pectoris is oftenly described as follow,
Typical angina pectoris is a characteristic of
• Sudden
• Severe
• Crushing chest pain
That may radiate to the neck, jaw, back and
arms.

2. ANGINA
• Symptoms of Angina
• Squeezing
• Pressure
• Heaviness
• Tightness or pain in your chest
• Causes:
Angina is Usually due to
• The obstruction or spasm of the coronary arteries
• Anemia
• Abnormal heart rhythm
• Heart failure

3. • The Major mechanism of the coronary artery obstruction is an
“Atherosclerosis” as part of CAD.
“Angina is a strangling feeling in the chest “
Classification of Angina Pectoris :
1. Stable Angina
2. Unstable Angina
3. Variant Angina

4. 1. Stable Angina
1. Stable Angina :
It also called as effort angina related to the myocardial ischemia.
Typical Presentation is chest discomfort, associated with some activity for
example,
• Running
• Walking
• Exercise
Minimal or no symptoms at rest or after administration of sublingual
nitroglycerin tablet.

5. 2- Unstable Angina
It is a type of acute “Coronary syndrome”.
It is defined as “angina pectoris”.
It has one of three features,
1. It occurs at rest , usually lasting >10 minutes
2. It is severe and of new onset
3. It occurs with crescendo Pattern ( more severe, prolonged ,frequent than
before)

6. 3-Prinzmetal Variant or Rest Angina
It Occurs at rest due to coronary artery spasm.
It Responds promptly to nitroglycerin.

7. Risk factors of Angina
• Hypertension
• Diabetes
• smoking
• Obesity
• Anemia
• Arterial disease
• Hyperlipidemia and
• Thyrotoxicosis

8. Diagnosis Of Angina
Investigations
• ECG changes
“Usually normal during rest but during pain, elevation of ST segment with or
without T- wave inversion”.
• Blood test:
 increase cardiac Enzyme like ‘Troponins’
 CKMB

9. Treatment strategies
Four types of drugs used for Angina alone or in combination.
1. Beta blockers
2. Calcium channel blockers
3. Organic nitrates
4. Sodium channel blocking drug (Ranolazine)

10. stable ischemic heart disease
angina symptoms present
sublingual nitroglycerine for immediate relief
BETA-BLOCKERS
add (if inadequate relief after titration)
Ca++ channel blocker OR long acting nitrate
(inadequate relief) add
RANOLAZINE

11. 1. BETA BLOCKERS
Decrease oxygen demand for the myocardium by inhibiting B1 receptor.
Decrease heart rate
Decrease contractility
Decrease cardiac output
Decrease BP

12. BETA BLOCKERS
• Beta-blockers reduces both frequency and severity of disease angina.
Drugs name :
1. Metoprolol
2. Nebivolol
3. Atenolol
• Dose should be gradually taper off (2-3 weeks ).

13. 2. Calcium Channel Blockers
Calcium is essential for muscular contraction.
Calcium influx Increases in ischemia.
“ Calcium channel blockers protect the tissue by inhibiting the entrance of
Calcium into heart ”.
All Calcium channel blockers are arteriolar vasodilator and reduces
myocardial oxygen consumption, which will give relief to angina pain.

14. 2. Calcium Channel Blockers
Drugs name :
1. Diltiazem
2. Verapamil
3. Amlodipine
4. Nifedipine

15. 3. ORGANIC NITRATES
• These compounds cause a reduction in myocardial oxygen demand followed
by relief of symptoms.
• They are effective in stable, unstable, and variant angina.
• M.O.A : Organic nitrates relax vascular smooth muscles
• Administered nitrates nitrites nitric oxide
• cGMP Dephosphorylation of myosin light chain
vascular smooth muscles relaxation
note : cGMP ( cyclic guanosine 3,5 monophosphate)

16. 3. ORGANIC NITRATES
Drug Names :
1. Nitroglycerine
2. Isosorbide dinitrate
3. Isosorbide mono nitrate
Sublingual Nitroglycerin : Available in tablet or spray formula.
Drug of choice for prompt relief of an angina attack.
All patients should have nitroglycerine on hand to treat acute angina attacks.
It is commonly administered via sublingual because first pass metabolism
occurs in liver, or transdermal route.
Side effects : headache, tachycardia and high dose can cause postural
hypotension .

17. 4. SODIUM CHANNEL BLOCKER
• Drug name : Ranolazine
• It has anti angina and anti arrhythmic properties.
• Ranolazine inhibits the late phase of the sodium current,
improving the oxygen supply & demand equation.
• It is most often used by patients who have failed to response other
anti Anginal therapies.
• metabolized in liver.
• Side effect : QT prolongation