Pharmacotherapeutical Approach towards angina pectoris

1. Preparedby
MD SULTANAHMAD
SecondYear D Pharm
ALLAMA TR COLLEGE OF PHARMACY
Presented to-
Mr. Azad Moidul Islam
Asst. Professor,
Allama TR College of Pharmacy

2.  A disease marked by brief sudden attacks of chest
pain or discomfort caused by deficient oxygenation
of the heart muscles usually due to impaired blood
flow to the heart.
 Angina is the result of myocardial ischemia caused
by an imbalance between myocardial blood supply
and oxygen demand.
 It is a common presenting symptom (typically, chest
pain) among patients with coronary artery disease.

3. There are 4 types of angina:
Stable angina:
Pain lasting 5-15 minutes that is relieved by angina
medication. It usually has a trigger, such as physical exercise
or exertion, anxiety or emotional stress, cold temperatures.
Unstable angina:
Pain lasting longer than 15 minutes that may not be fully
relieved by angina medication. It may indicate that you are
having a heart attack. Unstable angina often occurs without a
specific trigger.

4. Microvascular Angina:
 Also called Syndrome X.
 Cause unknown.
 Probably due to poor functioning of the small
blood vessels of the heart, arms and legs
 No arterial blockage.
 Difficult to diagnose because it does not have
arterial blockage.

5. Prinzmetal’s angina:
 Prinzmetal’s angina is a variant form of
angina with normal coronary vessels or
minimal Atherosclerosis.
 It is probably caused by spasm of coronary
artery.
 Also known as Vasospastic or Variant Angina.

7. Patient Name - XYZ
Patient Age – 67 Years
Sex – Male
Unit – Medicine D
Date of Admission – 27/11/2022
Date of Discharge – 01/12/2022
Family History – Father died due to heart attack at the age
of 45
Social History – Mixed diet, non alcoholic and non smoker

8. Medical History
K/C/O hypertension
Chief Complaints
 Chest Pain
 Pain in the Shoulder
 Weakness
 Breathlessness
Medication History
Under the treatment of Tab. Telmisartan since 10 years.

9. PHYSICAL EXAMINATION
General
 BP - 150/90 mmHg
 PR - 90 bpm
CVS - S1, S2 +ve; murmurs heard
RS - B/L Normal Vesicular Breath Sounds present
CNS – Consciousness and oriented
FINAL DIAGNOSIS
Angina Pectoris

10. PARAMETERS OBSERVED VALUE NORMAL VALUE
Hb 11.6g/dl 14-18g/dl
RBC 3.5 x 10⁶ cells/mm³ 4.3-5.9x10⁶
cells/mm³
PCV 42% 39-49%
MCV 88 μm³ 76-100μm³
MCH 21pg/cell 27-33pg/cell
MCHC 25g/dl 33-37g/dl
PLATELET 2.4L/mm³ 1.4-4.4 L/mm3
TROPONIN LEVEL 0.2 ng/ml 0.1ng/ml
ESR 18mm in 1st hour 0-20mm in 1st hour
CRP 2.9mg/dl <3.0mg/dl
MYOGLOBIN LEVEL 78 ng/ml 10-65 ng/ml
CPK 110mcg/dl 10-120mcg/dl

11. PARAMETERS OBSERVED VALUES NORMAL VALUES
Cholesterol 250mg/dl <200mg/dl
Triglycerides 178mg/dl <160mg/dl
LDL 140mg/dl <130mg/dl
HDL 55mg/dl >45mg/dl

12. SUBJECTIVE EVIDENCE
 C/o chest tightness, anxiety, left shoulder and hand
pain, weakness. One day before admission he was
severely dyspnic & distressed.

13. OBJECTIVE EVIDENCE
 ECG: ST- Elevation
 BP: 150/90 mm Hg
 Total Cholesterol: 250mg/dl
 Triglycerides: 178mg/dl
 LDL: 140mg/dl

14. ASSESSMENT
 From subjective and objective evidence, it is
diagnosed as the patient was suffering from Angina
Pectoris.

15. THERAPEUTIC GOALS
Patient specific
 To relieve the radiating pain as well as the dyspnic condition
of patient.
 To prevent hospitalization
 To improve the quality of life of patient.
Disease specific
 To relieve signs and symptoms of Angina.
 To prevent further complication of CAD.

16. ASSESSMENT OF PREVIOUS THERAPY
 Tab. Telmisartan 20 mg
ASSESSMENT OF CURRENT THERAPY
 IV Fluid NS
 Tab. Carvedilol 12.5mg TID
 Tab. Aspirin 80mg BID
 Tab. Capoten 12.5 mg TID
 Tab. Atorva 20mg OD
 Tab. Omeprazole 20mg OD
 Tab. FEOSOL (ferrous sulphate) 300mg BID
 Tab. Nitroglycerin 10 mg TID

17. Drugs Frequency D-1 D-2 D-3 D-4 D-5
IV Fluid NS Q6h + + + - -
Tab Carvedilol 12.5mg
1-1-1 + + - - -
Tab Aspirin 80mg
1-0-1 - - + + +
Tab Captopril 12.5mg 1-1-1 + + + + +
Tab Atorva 20mg
1-0-0
+ + - - -
Tab Omeprazole 20mg 1-0-0
- - + + +
Tab Feosol 300mg 1-0-1 - + + + +
Tab Nitroglycerin
1-1-1 + + + + +

18. PROGRESS CHART
DAY INVESTIGATIONS
Day-1 Patient felt Mild pain on the chest, BP: 150/85mm Hg
PR : 90 bpm, LDL: 140mg/dl
pO2: 70mm Hg
Day-2 Patient felt Reduced pain, BP-130/90mm Hg
PR-88 bpm, LDL: 135mg/dl
pO2: 75mmHg
Day-3 Reduced pain, BP-130/85 mm Hg,
PR-84 bpm, LDL: 135mg/dl
pO2: 90 mmHg
Day-4 Patient was comfortable, BP: 125/80 mmHg
PR-80 bpm, LDL: 135 mg/dl
pO2: 90 mmHg
Day-5 Patient was comfortable, BP-120/85 mmHg,
PR-80 bpm, LDL: 135mg/dl
pO2: 95mmHg

19. PLANNING
Discharge Medication:
 NIFEREX 150-Forte (Vit B12, Vit C, iron supplement)
5ml OD for 15days
 Tab ATAST(Atorvastatin) 10mg 0-0-1 for 5 days
 Tab TELMISARTAN 20mg 1-0-0 Continue

20.  THERAPEUTIC PARAMETERS
 TOXICITY PARAMETERS

21. THERAPEUTIC PARAMETERS :
 Aspirin- It prevents heart attack in people with CAD.
 Nitroglycerin- It is a vasodilator. It dilates the blood vessels.
 Atorvastatin- It reduces the cholesterol and triglycerides level in
the blood.
 Tab. Ferrous Sulphate – It is an iron supplement used for the
treatment of low blood iron level.

22. TOXICITY PARAMETERS:
 Aspirin – angioedema, bronchospasm, CNS Alterations,
dermatological problems, Gl pain, ulceration, bleeding.
 Atorvastatin- It may result in nausea, diarrhoea and constipation.
 Verapamil- It may cause dizziness and headache (sometimes).
 Ferrous Sulphate Tab (FEOSOL) – It may cause Vomiting and
itching.

23. DRUG INTERACTIONS
 No major interactions were found.
 Moderate interactions include:
Captopril<> Aspirin
Dose adjustment should be done as it decreases kidney
function.
Omeprazole <> Fe multivitamin
Omeprazole may reduce the absorption of iron
multivitamin
Atorvastatin <> Omeprazole
Combining these medications may increase the risks of
side effects like liver damage.

24. CLINICAL PHARMACIST INTERVENTION
All the drugs prescribed were screened for drug interactions.
 Omeprazole may reduce the absorption of iron multivitamin
 Combining the medications like Atorvastatin along with
Omeprazole may increase the risks of side effects like liver
damage.
All the drugs prescribed were screened for adverse drug
reactions, no adverse drug reactions were found

25. PATIENT COUNSELING:
 ABOUT MEIDICATIONS
 Take medicines prescribed properly, don’t refill prescription unless advised.
 Inform physician for any side effects.
 Don’t double the dose if missed.
 ABOUT DISEASE
 Periodic screening for hypertension and other cardiac risks.
 Educating patient about the risks leading after an attack of angina.
 ABOUT LIFESTYLE MODIFICATION
 Drink lots of water.
 Low physical activity.
 Take iron rich balanced diet.
 Adequate fluid intake.
 Avoid excess salt & FATTY intake.

26.  Q1) Why Myoglobin level increases in Angina Pectoris?
 Ans: Myoglobin is an oxygen-binding protein found in cardiac and
skeletal muscle. Measurement of myoglobin provides an early index of
damage to the myocardium.
 Q2) Which type of Angina is most dangerous?
 Ans: Unstable angina is the most dangerous. It does not follow a
pattern and can happen without physical exertion (they may not have a
trigger).
 Q3) Can someone live a normal life with angina?
 Ans: Many people can lead a normal life if they take their medication
and address their risk factors.
 Q4) What are the causes of high Troponin level?
 Ans: High troponin level may be due to blockage of a arteries by a
blood clot, fat, or tumor cells (pulmonary embolus) or due to
abnormally fast heartbeat.