This presentation was used for lecture class of BSN

1. Anti-anginal drugs
and
Drugs used in Heart failure
Dr. Pravin Prasad
M.B.B.S., MD Clinical Pharmacology
Lecturer, Lumbini Medical College
6 March, 2019 (22 Falgun 2075), Wednesday

2. By the end of the class BSN 1st year
students will be able to:
➢Classify drugs used in the treatment of:
✓Angina pectoris
✓Heart failure
✓Hyperlipidaemia
➢Explain the mechanism of action, indications and
adverse effects of:
✓Nitrates
✓Digoxin

3. Angina Pectoris: Introduction
➢Condition in which there is an inadequate supply of
blood and oxygen to a portion of the myocardium
➢Spectrum of diseases that includes:
✓Angina Pectoris
✓Myocardial Infarction
✓Chronic ischaemic heart disease with heart
failure
✓Sudden cardiac death

4. Anti-anginal Drugs: Classification
➢Nitrates:
✓Short acting: Glyceryl trinitrate (GTN, Nitroglycerin)
✓Long acting: Isosorbide dinitrate, Isosorbide
mononitrate
➢Beta (β) blockers: Metoprolol, Atenolol
➢Calcium Channel Blockers(CCBs): Nifedipine,
Amlodipine
➢Potassium channel openers: Nicorandil
➢Others: Dipyridamol, Trimetazidine, Ranolazine,
Ivabradine, Oxyphedrine

5. Nitrates
➢Includes Nitroglycerine, Isosorbide mononitrate/
dinitrate
➢Acts by:
✓Decreasing cardiac work in stable angina
•Dilatation of veins → peripheral pooling of
blood → decreased preload
•Dilatation of arteries → decreased afterload
✓Increasing blood supply in variant angina
•Dilates larger coronary arteries

6. Nitrates: Indications
➢Angina Pectoris:
✓Classical as well as variant
✓Terminating an attack as well as prophylaxis
➢ Acute Coronary Syndrome
➢ Congestive Heart Failure and acute Left
Ventricular Failure
➢ Biliary colic, Esophageal spasm
➢ Cyanide poisoning: sodium nitrate

7. Nitrates: Adverse effects
➢Due to vasodilatation:
✓ Fullness of head, throbbing headache
✓ Flushing, weakness, sweating, palpitation,
dizziness, fainting
➢Tolerance, cross tolerance
➢Dependence
➢Methemoglobinemia
➢Rashes (pentaerythritol nitrate)

8. Drugs used in Heart
failure

9. Heart Failure: Introduction
➢Heart cannot pump blood adequate for body
demand
➢Leads to a continuous loop of:
✓Reduced cardiac output
✓Ventricular remodelling
➢Drugs needed to help heart pump blood better

10. Drugs for Heart Failure:
Classification
➢Inotropic drugs: Digoxin, Dobutamine, Dopamine,
Amrinone/Milrinone
➢Diuretics: Furosemide, Thiazides
➢RAS inhibitors: ACE inhibitors, ARBs
➢Aldosterone Antagonists: Spironolactone,
Eplerenone
➢Vasodilators: Hydralazine, Nitrate, Nitroprusside
➢β- blockers: Metoprolol, Bisoprolol, Carvedilol,
Nebivolol

11. Digoxin
➢Includes: digoxin, digitalis
➢Also known as cardiac glycosides
✓Extracted from plants
➢Acts by:
✓Increasing force of contraction
✓Decreasing heart rate
•Better emptying of heart (Cardiac output
increased)

12. Digoxin: Mechanism of Action

13. Digoxin: Mechanism of Action
➢Binds to and inhibits Na+ K+ ATPase of myocardial
fibres
✓Progressive accumulation of Na+ and Ca2+
intracellularly
✓Extra Ca2+ loaded into sarcoplasmic reticulum
✓Increased release of Ca2+ subsequently
✓Increased force of contraction

14. Digoxin: Indications
➢Congestive Heart Failure
✓ Most effective in patients with dilated heart and
low ejection fraction
✓ CHF with AF in need of ventricular rate control:
continuous digoxin
➢Cardiac arrhythmias
✓Atrial Fibrillation, Flutter
✓Paroxysmal Supraventricular Tachycardia (PSVT)

15. Digoxin: Adverse effects
➢Cardiac:
✓Arrhythmias: all types
✓Partial to complete A-V block
➢Extra-cardiac:
✓Endocrine: gynaecomastia
✓GIT: nausea, vomiting, abdominal pain
✓CNS: headache, mental confusion, restlessness,
disorientation, psychosis

16. Drugs used in Dyslipidaemia
➢Also known as hypolipidaemic drugs
✓Decreases the blood lipids (bad cholesterol) level
➢Commonly prescribed in patients with:
✓Dyslipidaemia
✓Hypertension
✓Diabetes mellitus
✓Ischaemic heart disease

17. Hypolipidaemic drugs: Classification
➢ HMG-CoA reductase inhibitors (Statins)
✓Simvastatin, Atorvastatin, Rosuvastatin
➢ Bile acid sequestrants (Resins)
✓Cholestyramine, Colestipol
➢Lipoprotein lipase activators (PPARα activators, Fibrates)
✓Clofibrate, Gemfibrozil, Fenofibrate
➢ Lipolysis and triglyceride synthesis inhibitor
✓Nicotinic acid
➢ Sterol absorption inhibitor
✓Ezetimibe

18. Conclusion
➢Nitrates are used for the termination of attack of
angina pectoris
✓Acts by decreasing preload and afterload in
stable angina
✓Acts by dilating coronary vessels in variant
angina
➢Digoxin is used for the treatment of heart failure
✓Acts by increasing the cardiac output

19. Any queries?
➢Next class:
✓Drugs used in Bronchial asthma
✓Drugs used in cough
✓Antihistamines
➢Thank you.