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Cardiology - Angina Pectoris + PAD (3 Types of Angina Stable Angina …
Cardiology - Angina Pectoris + PAD
3 Types of Angina
Stable Angina
Unstable Angina
Prinzemental;s Angina
Vasospastic / *Prinzemental's Angina
very rare
occurs at REST, usually when highest vagal activity
--> sleeping or laying down
spontaneous and resolves on its own after 15 minutes
tx
--> acute = sublingual GTN
--> chronic / preventative = CCBs (diltiazam, verapamil)
Clinical Cases
Vasospasm angina case
Clinical Case
Notes
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note that
Clinical Case
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Clinical Case
Notes:
classic presentation is young SMOKER with spontaneous angina in SLEEP
--> smoking is the largest risk factor especially for Spastic angina
Drug induced *Prinzemental's Angina
"
Pretzal's are a SCAM
--> since they have holes in them**"
smoking, cocaine, amphetamines, migraine meds (triptans + dihydroergotamine)
Pretzal's are a SCAM
"
Pretzal's
" = Prinzemental's Angina / vasospasm
"
S
" = smoking
"
C
" = cocaine
"
A
" = amphetamines
"
M
" = migraine meds (triptan triggers and double ego)
--> triptans
--> dihydroergotamine
Unstable Angina
ONLY occurs during REST
relieved by rest and GTN
Stble Angina
ONLY occurs on exertion
relieved by rest and GTN
*Treatment of Angina
see pharmacology
*Acute Tx for Angina
sublingual / buccal GTN
fast acting within 2-5 min
fast since no first-pass metabolism from liver
main action of GTN and vasodilators to help angina is to vasodilate = decrease preload to the heart
this decreases the stretch and O2 need of the heart
secondary is the small vasodilation of the coronary arteries
Cases
Angina Treatment
Case Presentation:
Notes
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Solution = HR increased and End diastolic volume decreased
GTN = glycerol trinitrate or nitroglycerine is 1st line treatment for angina
it causes systemic venodilation, which lowers the venous return to the heart
--> this lowers the end-diastolic ventricular volume
--> the heart thus has to work less harder and requires less O2
--> this gives relief from the pain and ischemia
peripheral resistance also decreases due to venous dilation from GTN
--> the afterload also decreases and there is also a drop in BP
drop in BP from GTN causes reflex tachycardia
Tetralogy case
Clinical Case
Notes
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note that
*Chronic Tx for Angina
oral nitrates = most common isosorbide dinitrate
higher doses than sublingal GTN since has first pass metabolism
Oral Isosorbide dinitrate case
Notes
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note that
Clinical Case
*Drugs for Angina
Vasodilators / *Nitrates
NO releasing drugs
NO --> cGMP --> myosin light chain dephosphorylation
--> inactivates them --> vasodilation of SM
Nitrates
also Nitrate pathway drugs
increased cGMP / PDE5 inhibitors
NO your ABCs ... easy as cGMP .. and PDE
Guanylate Cyclase activators
increase cGMP --> protein Kinase G
ANP... easy as cGMP... BNP easy as cGMP... Viagra... easy as cGMP ... and PDE
NO, ANP, BNP, sildenafil (PDE5),
--> all act on the same cGMP pathway fro vasodilation
PDE non-specific --> both PDE3 cAMP platelets / PDE 5 endothelial SM
Cilostazole, dipyridimole
In PAD, you want "
CILO STAYZ oPenDE"
1 more item...
MOA
note that vasodilators like GTN or Isosorbide dinitrate cause vasodilation mainly on LARGER VEINS
1 more item...
ANP and BNP relation to Viagra = sildenafil MOA
Guanylate Cyclase activators
increase cGMP --> protein Kinase G
ANP... easy as cGMP... BNP easy as cGMP... Viagra... easy as cGMP ... and PDE
sildenafil inhibits PDE5, which breaks down cGMP
--> thus same pathway as ANP and BNP to cause vasodilation
Nitrates Side Effects
flushing
--> from too much vasodilation of the peripheries
Headaches are common
--> not due to the vasodilation (as previously thought, makes sense conceptually)
--> more to do with inflammation from NO
--> from increased CGRP
Clinical Case
4 more items...
Nitrate Tolerance
note that people build tolerance to nitrates very easily
they need a nitrate free time every night
--> when CO is the lowest
tolerance builds to NO and more responsive to vasoconstrictive agents
*Arteriole Specific VAsodilators
"MINOR HYDRO effects"
Minoxidil and Hydralazine
they ONLY dilate arterioles and NOT the veins
MOA
note that vasodilators like Minoxidil and Hydralazine ONLY dilate arterioles and NOT the veins
--> thus the Baroreceptors and Renal perfusion juxta cells notice pressure drop
activation response of RAAAS system and increase sympathetic to to the heart replace alot of the effects of these drugs
NOT effective long term,
ONLY used as add on for other anti-hypertensives in resistant HTN or in HTN emergencies
Clinical Cases
Clinical Case
Clinical Case
Notes
:
note that
*CCBs
non-dihydropyridines
--> ONLY act peripherally through vasodilation
--> don't effect central HR or contractility
decreased the arteriole resistance
--> lower the afterload on the heart
*PAD = Peripheral Artery Disease
Angina of the legs
Intermittent Claudication
worse on exertion and relieved by rest
PathoPhys
atherosclerolitc plaques like in angina are the main cause
smoking is main risk factor
Clinical Cases
Clinical Case
Notes
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note that
Clinical Case
Notes
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note that smoking is the biggest factor for developing PAD and intermittent claudication
Clinical Cases
PAD = Peripheral Artery Disease
Angina of the legs
Notes
:
note a key to clinical presentation of PAD is that they present as if angina, but of the lower extremities, =/- bilateral
key symptom is pain sleeping in the bed at night
--> relieved by sleeping in a chair or
with foot hanging off the side of the bed
--> classic sign
--> elevating the foot reduces circulation to the foot
--> having it elevated increase the BP and allows the blood to push past the arteriosclerosis
as for angina, PAD you need to screen for the major CVS risk factors, including diabetes
Case Presentation:
Clinical Case
Notes
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note that
Clinical Case
PAD in specific organs
renal artery stenosis
*Renal Artery Stenosis
seen in Arteropaths with systemic atherosclerosis
present with refractory HTN since kidney has no blood flow
--> out of control RAAS system
Clinical Cases
Clinical Case
Notes
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note that
Clinical Case
