1. Dr. RAGHU PRASADA M S
MBBS,MD
ASSISTANT PROFESSOR
DEPT. OF PHARMACOLOGY
SSIMS & RC.
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2. 2

3.  Angina occurs in three overlapping patterns:
 Stable angina
 Unstable angina
 Prinzmetal
(variant) angina
3

4.  “Stable” indicates the reproducible nature of the
angina; the same activity at the same intensity
faithfully produces symptoms.
 Typically this type of angina
is relieved by rest or acute
use of nitroglycerin.
4

5.  Unstable angina occurs when anginal symptoms
occur with
 less cardiac demand; previously tolerated activities
elicit symptoms,
 of great concern is angina at rest.
 These episodes are less or un-responsive to
nitroglycerine or rest.
 Crescendo angina describes a rapid progression of
myocardial ischemia often heralding infarction.
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6. 1. uncommon pattern of myocardial ischemia usually occurring
at rest and often in young individuals (particularly women)
lacking classic risk factors or significant demonstrable
coronary disease.
2. The anginal attacks in PVA tend to have a circadian rhythm
and generally occur in the early morning hours.
3. These attacks can be triggered by alcohol, rapid eye
movement sleep, atrial pacing, cocaine, nicotine,
acetylcholine, and hyperventilation.
4. It is induced by coronary artery vasospasm it generally
responds promptly to vasodilators. PVA has been associated
with other vasospastic disorders such as migraine headaches
and Raynaud’s phenomena.
6

7. I ORGANIC NITRATES
 a) Rapid onset slow acting-AMYL NITRATE,
NITROGLYCERINE
 b) Slow onset, long acting- ISOSORBIDE DINITRATE,
ISOSORBIDE MONONITRATE, ERYTHRITYL
TETRANITRATE, PENTAERYTHRITOL TETRANITRATE
II. CALCIUM CHANNEL BLOCKERS
 VERAPAMIL, DILTIAZEM, NIFEDIPINE,
NICARDIPINE, NITRENDIPINE, ISARDIPINE,
AMLODIPINE, BENIDIPINE
7

8. III BETA BLOCKERS
PROPRANOLOL, ATENOLOL, METAPROLOL, NADOLOL,
BISOPROLOL AND CELIPROLOL
MISCELLANEOUS
1. Potassium Channel Openers: NICORANDIL
2. Cytoprotective Drugs: TRIMETAZIDINE, RANOLAZINE
3. Antiplatelet Drugs: ASPIRIN, TICLOPIDINE,
CLOPIDOGREL, DIPYRIDAMOLE, CILASTAZOL
4. Bradycardic Drugs: IVABRADINE
5. HMG-Co A Reductase Inhibitors: STATINS
6. PVD: NAFTIDOFURYL AND PENTOXIPHYLLINE
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9. ORGANIC NITRATES
 a) Rapid onset slow acting-AMYL NITRATE,
NITROGLYCERINE(GTN)-t1/2-2min
 b) Slow onset, long acting-
 ISOSORBIDE DINITRATE-s/l and oral, t1/2-
40min,
 , ISOSORBIDE MONONITRATE t1/2-4-6hrs,
ERYTHRITYL TETRANITRATE,
PENTAERYTHRITOL TETRANITRATE--chronic
prophylaxis
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11. 11

12. The difference between nitrate preparations is
mainly in time of onset of action.
1. Nitroglycerin suffers marked 1st pass
metabolism so administration is sublingual
(rapid absorption and onset (<1 minute), t1/2
~10 minutes. As nitroglycerin is metabolized
anginal symptoms will return. Transdermal
administration either as patch or paste
provides a depot of agent for a steady
availability.
2. Isosorbide mononitrate & isosorbide dinitrate
are long acting nitrates that are relatively
resistant to hepatic catabolism t1/2 ~ 1 hour.
12

13.  Angina pectoris
 Acute coronary symptoms
 Biliary colic
 Cyanide poisoning
 CHF and acute LVF
 Myocardial infarction(MI)
 Esophagial spasm
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14.  Orthostatic hypotension
 Tachycardia
 Severe throbing headache
 Flushing
 syncope
14

15. decrease in the effect of drug when
administered in long acting form.
 develops with all nitrates
 is dose dependent
 disappears in 24hrs after stopping the drug
 Tolerance can be avoided
-Using the least effective dose
-Creating discontinuous plasma levels
D/I: Sildenafil
15

16.  Previous hypersensitivity
 Hypotension ( < 80 mmHg)
 AMI with low ventricular filling pressure
 1st trimester of pregnancy
Constrictive pericarditis
Intracranial hypertension
Hypertrophic cardiomyopathy
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17.  PROPRANOLOL,
 ATENOLOL,
 METAPROLOL,
 NADOLOL,
 BISOPROLOL AND CELIPROLOL
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18. 18

19.  Hypotension: bp < 100 mmhg
 Bradycardia: hr < 50 bpm
 Chronic bronchitis, asthma
 Severe chronic renal insufficiency
19

20. Dihydropyridines:
NIFEDIPINE, NICARDIPINE,
 NITRENDIPINE, ISARDIPINE,
 AMLODIPINE, BENIDIPINE
Non-Dihydropyridines:
 VERAPAMIL, DILTIAZEM,
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21. 21

22.  Immediate release capsules- headache, ankle
oedema
 Headache
 Tachycardia and gingival hyperplasia
 Negetive ionotropic effect
 C/I- unstable angina, LV failure, aortic stenosis,
obstuctive cardiomyopathy
 D/I-enzyme inhibitors
22

23. Beta Blockers prevent reflex tachycardia and contractility
produced by nitrate-induced hypotension.
Nitrates prevent any coronary vasospasm produced by
Beta Blockers.
Nitrates prevent increases in left ventricular filling
pressure or preload resulting from the negative inotropic
effects produced by Beta Blockers.
Nitrates and Beta Blockers both reduce myocardial
oxygen consumption by different mechanisms.
Nitrates and Beta Blockers both increase subendocardial
blood flow by different mechanisms
23

24. Preload-----------------
After load--------------
Myocardial wall size--
Coronary blood flow---------
Collateral blood flow---------
Blood flow to ischemic area-
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25. 25

26. POTASSIUM CHANNEL OPENERS-Nicorandil
Dual mechanism antianginal drug activates ATP
sensitive K+ channels  membrane hyperpolarisation
Also act as NO donors- relaxes blood vessels by
increasing cGMP  arterial dilatation is coupled with
venodilatation fall in BP
Cardioprotective action stimulating ischaemic
preconditioning activation of mitochondrial KATP
channels
ADR-flushing, palpitation, headache, dizziness
26

27. TRIMETAZIDINE-non-haemodynamic mechanism
Cytoprotective effect on myocardial o2 demand
Inhibits (LC3-KAT)-3 Ketoacyl-CoA-thiolase- a key
enzyme in fatty acid oxidation shifts heart from
utilizing fatty acid to glucose decreases myocardial
oxygen demand
Inhibits superoxide cytotoxicity
maintains LV function
Stable angina
Frequency of angina is decreased
S/E-fatigue, muscle cramps, gastritis
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28. PFOI-partial fatty Acid Oxidation Inhibitor
Inhibits inward sodium current (INa+) during ischemia
facilitates calcium entry Na+/Ca+ exchanger reduction
in ca overload cardioprotective effect
Prolongs exercise tolerance to angina but has no action on
HR and BP
500mg BD orally
Safe in combination with Ca channel blockers,
Beta-blockers and nitrates
S/E –QT prolongation, constipation, postural hypotension
D/I-class I and III antiarrhythmic drugs
28

29. Blockade of cardiac pacemaker(sino-atrial)cell f
channels active in phase 4 depolarisation
Decreases the myocardial oxygen demand
No effect negetive ionotropic effect, negetive
lucitropic, electrophysiological
Heart rate reduction decreases oxygen demand and
prolongation of diastole
Prolongs exercise tolerance to angina
29

30. Aspirin, Ticlopidine and Clopidogrel
Inhibits binding of ADP to its receptors
Reduce platelet aggregation
Cilastozole
Phosphodiesterase III inhibitor
Vasodilatation and inhibits platelet aggregation
Metabolised by cyp3A4
100mg bd
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31. Powerful coronary dialator
Inhibits adenosine deaminase adenosinelocal
mediator in autoregulation of coronary flow
inhibits phosphodiesterase potentiates PGI2
Inhibit platelet aggregation
For prophylaxis of coronary and cerebral thrombosis
S/E-
exacerbation of anginacoronary steal phenomenon,
GIT distress
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Dipyridamol
Hydralazine
Nitroprusside
Isoflurane

33. Statins
They regression of atheromatous plaque
Improvement of endothelial function
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34. Pentoxiphylline (oxypentifylline)
Is a theobromine analogue and inhibits
phosphodiesterase enzyme
Reduces blood viscosity
Improves the blood flow in ischemic area
No coronary steal phenomenon
Used in non-haemorrhagic stroke, chronic
cerebrovascular insufficiency
400mg bd
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35. CILOSTOZOL-antiplatelet drug-PDE3 inhibitor
NAFTIDOFURYL(-5HT2A) receptor antagonist-drug for
PVD
LEVOCARNITINE-improves the metabolic status of
skeletal muscle
CYCLANDELATE –cerebrovascular and peripheral
vascular disorders
400mg TDS
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36. 1. Pain and anxiety-- -GTN, morphine
2. Opioid analgesics and Antianxiety agents
3. Pethidine, Diazepam, alprazolam
4. General measures-O2 therapy, dopamine,
5. atropine, diltiazem,
6. Maintainance of blood volume-Saline , dextran
7. Correction of acidosis- sod. Bicarbonate infusion
8. Prevention of treatment of arrhythmias
9. -beta blocker
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37. 7. Pump failure-furosemide, vasodilators, ionotropic
drugs
8. Prevention of thrombus extension, venous
thrombosis- aspirin, heparin, anticoagulants-
dalteparin, Enoxaparin
9. Thrombolysis and reperfusion-fibrinolytic agents-
streptokinase, urokinase
10. Prevention of remodeling and CHF-ACE inhibitors,
ARBs- lisinopril, ramipril
11. Prevention of future attacks-platelet inhibitors-
clopidogrel, β blockers, statins
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