This document discusses various classes of drugs used in the treatment of angina pectoris and myocardial infarction. It describes the mechanisms of action, effects, uses, and adverse effects of nitrates, beta-blockers, and calcium channel blockers. Specifically, it notes that nitrates reduce preload and oxygen demand, beta-blockers decrease contractility and heart rate to lower oxygen demand, and calcium channel blockers decrease afterload and coronary spasm to increase oxygen delivery.

2.  Amyl
Nitrite
 Nitroglycerin (duration depends on
administration)
 Isosorbide mononitrate (long duration, great
bioavailability)

3.  MoA:
denitrated by glutathione releasing free
nitrites which are converted to NO which
increase cGMP  dephosphorylation of MLCK
and decrease in [Ca] in cell
 Actions


Decrease O2 demand by decreasing preload
(relaxation of large veins - VENODILATOR)
Increase O2 delivery by relieving coronary spasm
 Tolerance
appears rapidly but disappears
rapidly too
 DO NOT WITHDRAW FROM PTS WHO ARE ON
THEM FOR YEARS

4.  Adverse






Reflex tachycardia and postural hypotension with
high doses
Increased cGMP = decreased platelet aggregation
Nitrites = methemoglobin formation
Throbbing HA, dizziness, flushing (prevent with
NSAIDS)
Hypotension w/ sildenafil (viagara)
Contraindicated in hypertrophic
cardiomyopathy (preload is already reduced)

5.  Tx
and prevention of acute attack
(sublingual)
 Chronic prophylaxis
 Relieve pulmonary congestion
 Cyanide poisoning (amyl nitrite produces
methemoglobin which complexes with
cyanide)

6.  Propranolol;
Metoprolol
 MoA: decrease O2 demand by decreasing
contractility and heart rate
 Actions


Decrease cardiac O2 demand
Increase myocardial perfusion because of
increased diastolic perfusion time

7.  Adverse



Increased EDV  increased Ejection time
Withdrawal effects
Interact with calcium channel blockers which act
on the heart or P450 inducers/inhibitors
 Uses


Myocardial Infarction
Chronic prophylaxis of exertional angina (not
effective in variant angina)

8.  Nifedipine

selectivity for vessels only
 Diltiazem

& Nimodipine
& Verapamil
selectivity for heart and vessels
 MoA:




Decrease O2 demand by decreasing afterload,
contractility, and heart rate
Increase O2 delivery by relieving coronary spasm
Diltiazem and verapamil: decrease automaticity
vasodilation

9. 
Adverse






HA and dizziness
Flushing and peripheral edema
Profound hypotension (coronary steal phenomenon
with nifidepine!), tachycardia
Verapamil = constipation & gingival hyperplasia
Adverse effects with B-blockers
Uses
Good for exertional angina by decreasing O2 demand
 Variant angina because they increase myocardial O2
supply
 Hypertension
 DOC for Raynaud’s Phenomenon


10.  Aka
prinzmetal or vasospastic angina is due
to large vessel spasm

Occurs regularly or certain times of the day and
there is pain at rest

11.  B-blockers
and nitrates work because Bblockers can prevent reflex tachycardia and
increased tachycardia while the nitrates
prevent increased EDV and ejection time
 Nitrates and Ca-channel blockers work
because of similar reasoning

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