Download Angina medications

Angina Pectoris (Weeping of Heart)
A very detrimental coronary artery disease (CAD)
Jony Mallik
M.Pharm; MS
Coronary Arteries
The heart receives its own supply of blood from the coronary arteries. Two major coronary
arteries branch off from the aorta near the point where the aorta and the left ventricle meet.
These arteries and their branches supply all parts of the heart muscle with blood.
Right Coronary Artery (RCA)
The right coronary artery branches into:
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Right marginal artery
Posterior descending artery
The right coronary artery supplies:
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right atrium
right ventricle
bottom portion of both ventricles and back of the septum
The main portion of the right coronary artery provides blood to the right side of the heart, which
pumps blood to the lungs. The rest of the right coronary artery and its main branch, the posterior
descending artery, together with the branches of the circumflex artery, run across the surface of
the heart's underside, supplying the bottom portion of the left ventricle and back of the septum.
Left Main Coronary Artery (also called the left main trunk)
The left main coronary artery branches into:
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Circumflex artery
Left Anterior Descending artery (LAD)
The left coronary arteries supply:
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Circumflex artery - supplies blood to the left atrium, side and back of the left ventricle
Left Anterior Descending artery (LAD) - supplies the front and bottom of the left ventricle
and the front of the septum
Angina Pectoris
Angina is one of the serious causes of chest pain. "Angina" is an abbreviation of angina
pectoris, a Latin term for "squeezing of the chest." Chest pain is a common symptom caused by
many different conditions. Some causes require prompt medical attention, such as angina, heart
attack, blood clots in the lungs, or tearing of the aorta. Other causes of chest pain that may not
require immediate medical intervention include spasm of the esophagus, gallbladder attack, or
inflammation of the chest wall. An accurate diagnosis is important in providing proper treatment
to patients with chest pain or acute coronary syndrome.
Simply “ANGINA PECTORIS” is the severe, very constricting pain on the chest due to the
imbalance of the oxygen supply & demand of the cardiac muscle (myocardium).
Symptoms of ANGINA
Angina is chest discomfort that occurs when there is decreased blood oxygen supply to an area
of the heart muscle. In most cases, the lack of blood supply is due to a narrowing of the
coronary arteries as a result of arteriosclerosis.
Angina is usually felt as:
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pressure,
heaviness,
tightening,
squeezing, or
aching across the chest, particularly behind the breastbone.
This pain often radiates to the neck, jaw, arms, back, or even the teeth.
Patients may also suffer:
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indigestion,
heartburn,
weakness,
sweating,
nausea,
cramping, and
shortness of breath.
Angina usually occurs during exertion, severe emotional stress, or after a heavy meal, when the
heart muscle demands more blood oxygen than the narrowed coronary arteries can deliver.
Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing a nitroglycerin
tablet under the tongue, which relaxes the blood vessels and lowers blood pressure. Both rest
and nitroglycerin decrease the heart muscles demand for oxygen, relieving angina.
Classes of ANGINA
Angina is classified in one of three types: 1) stable angina 2) unstable angina 3) Prinzmetal
angina
Stable angina
Stable angina is the most common type of angina, and what most people mean when they refer
to angina. People with stable angina have angina symptoms on a regular basis and the
symptoms are somewhat predictable (for example, walking up a flight of steps causes chest
pain). For most patients, symptoms occur during exertion and commonly last less than five
minutes. They are relieved by rest or medication, such as nitroglycerin under the tongue. Stable
angina is one of many causes of chronic chest pain.
Unstable angina
Unstable angina is less common but more serious. The symptoms are more severe and less
predictable than the pattern of stable angina. Pain is more frequent, lasts longer, occurs at rest,
and is not relieved by nitroglycerin under the tongue (or the patient needs to use more
nitroglycerin than usual). Unstable angina is not the same as a heart attack, but warrants an
immediate visit to your physician or hospital emergency department as further cardiac testing is
urgently needed. Unstable angina is often a precursor to a heart attack.
Prinzmetal's / Variant angina
This is when angina occurs at rest, when sleeping, or when exposed to cold temperatures. In
these cases, the symptoms are caused by decreased blood flow to the heart muscle from a
spasm of the coronary artery. The majority of people with this type of angina also have coronary
artery disease. These spasms occur close to the blockage. It is also known as Variant angina.
Treatment of ANGINA
Treatment options include:
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rest,
medications (nitroglycerin, beta blockers, or calcium channel blockers),
percutaneous coronary intervention (stenting or transluminal coronary angioplasty
(PTCA), or
 coronary artery bypass graft surgery (CABG).
Angina medications
Nitroglycerin
Resting, nitroglycerin tablets (placed under the tongue), and nitroglycerin sprays all relieve
angina by reducing the heart muscle's demand for oxygen. Nitroglycerin also relieves spasm of
the coronary arteries and can redistribute coronary artery blood flow to areas that need it most.
Short-acting nitroglycerin can be repeated at five minute intervals. When three doses of
nitroglycerin fail to relieve the angina, further medical attention is recommended. Short-acting
nitroglycerin can also be used prior to exertion to prevent angina.
Longer-acting nitroglycerin preparations are useful in preventing and reducing the frequency
and intensity of episodes in patients with chronic angina. The use of nitroglycerin preparations
may cause headaches and lightheadedness due to an excess lowering of blood pressure. Also
these agents may be of danger when used with certain medications for erectile dysfunction.
Other organic nitrates like isosorbide mononitrate & isosorbide dinitrate also effective in angina
condition.
Beta Blockers
Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart. Inhibiting
adrenaline decreases the heart rate, lowers the blood pressure, and reduces the pumping force
of the heart muscle, all of which reduce the heart muscle's demand for oxygen. Beta blockers
include:
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acebutolol
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atenolol
bisoprolol
metoprolol
nadolol
propranolol
timolol
carvedilol
Side effects include of beta blockers include:
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worsening of asthma,
excess lowering of the heart rate and blood pressure,
depression,
fatigue,
impotence,
increased cholesterol levels, and
shortness of breath due to diminished heart muscle function (congestive heart failure).
Calcium Channel Blockers (CCBs)
Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping
force of the heart muscle, thereby reducing muscle oxygen demand. Calcium channel blockers
also relieve coronary artery spasm. Calcium channel blockers include:
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amlodipine
bepridil
diltiazem
felodipine
isradipine
nicardipine,
nifedipine
nimodipine
nisoldipine
verapamil
Side effects of calcium channel blockers include:
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swelling of the legs,
excess lowering of the heart rate and blood pressure, and
depression of heart muscle function.
Now a days calcium channel blockers may used in combination with nitroglycerine for the
special treatment of unstable angina. Actually in angina condition the preload & afterload
become rise & it is extreme in unstable angina. Nitroglycerine helps to reduce preload & calcium
channel blockers can reduce afterload extensively. So a combination form of both of them is
very helpful tools to reduce workload of the heart. Before going to take any medication(s) don’t
hesitate to go to your doctor/pharmacist.
Other antianginal drugs
Ranolazine is indicated for the treatment of chronic angina. Ranexa may be used with beta
blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE
inhibitors, and angiotensin receptor blockers (ARBs).
Angioplasty and coronary artery bypass surgery
When patients continue to have angina despite maximally tolerated combinations of
nitroglycerin medications, beta blockers, and calcium channel blockers, cardiac catheterization
with coronary arteriography is indicated. Depending on the location and severity of the disease
in the coronary arteries, patients can be referred for balloon angioplasty (percutaneous
transluminal coronary angioplasty or PTCA with or without stents) or coronary artery bypass
graft surgery (CABG) to increase coronary artery blood flow.
Author:
Jony Mallik
B.Pharm(Hons.); M.Pharm (Thesis); MS
Email: [email protected]