Pharmocotherapy of ischaemic heart disease
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Pharmocotherapy of Ischaemic Heart Disease. Ischaemic Heart Disease. Causes of IHD aren´t totally clear No satisfactory causal treatment, we eliminate only symptoms and treat complications. IHD.

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Ischaemic heart disease
Ischaemic Heart Disease

Causes of IHD aren´t totally clear

No satisfactory causal treatment, we eliminate only symptoms and treat complications


IHD

Is condition/disease, at which requirements of myocardium exceed possibilities of its supply with oxydized blood. The cause of this imbalance is wide spectrum of patophysiologic mechanisms and reasons.

  • cardiac: coronary, extracoronary

  • extracardiac


Clinical forms of ihd
Clinical Forms of IHD

Acute – unstable angina pectoris

acute myocardial infarction

sudden heart death

Chronic – asymptomatic IHD

angina pectoris - after excercise

- combined

- variant

- Prinzmetal´s

state after MI

dysrythmic IHD

chronic heart failure


Types of ap
Types of AP

  • Stable – occurence of problems at standard situations and their frequency, intensity and duration not changed

  • Unstable – sudden beginning, longer duration of pain

  • Prinzmetal´s – caused by spasmus, elevation of ST segment on ECG


Deffects of blood perfusion can develop slowly and progressively (chronic) or can develop abruptly (acute form; even MI).

Changes caused by ischaemia can be temporary or permanent (irreparable damage of myocard). Conditions are usually interconnected, without sharp limits and IHD needs to be understood dynamically and individually.

AP was the first time described in the second half of 18th century by Wiliam Heberden and treated with nitroglycerin in the year 1879.


Angina pectoris
Angina pectoris progressively (chronic) or can develop abruptly (acute form; even MI).

  • Anginous pains is symptom of IHD

  • Not every ischaemia is accompanied with pain – silent ischaemia (only at ECG – depression of ST segment)


Patologically anatomical ground
Patologically-anatomical ground progressively (chronic) or can develop abruptly (acute form; even MI).

Coronary atherosclerosis

Organ damage – embolia, vasculitis

Function impairment – spasms, defects in relaxation of arteriolas


Non pharmacologic approach
Non-pharmacologic approach progressively (chronic) or can develop abruptly (acute form; even MI).

Changes of lifestyle (nicotine, food) → lowering lipids

Psychosocial factors (excercise, taking care of oneself) → primary and secondary prevention


Risk factors
Risk factors progressively (chronic) or can develop abruptly (acute form; even MI).

  • Hyperlipoproteinaemia

  • Hypertension

  • Diabetes mellitus

  • Smoking

  • Obesity

  • Family disposition

  • Male gender

  • Age

CAN BE INFLUENCED

CAN´T BE

INFLUENCED


Primary prevention
Primary prevention progressively (chronic) or can develop abruptly (acute form; even MI).

Active monitoring and searching for persons having risk factors with the goal to prevent formation of atherosclerosis

!! Low doses of acetylsalicylic acid!!

Males – accorcing to clinical studies taking aspirin din´t decrease mortlity, decreased occurrence of MI, increased cerebral bleeding (US Physician´s Health Study)


females progressively (chronic) or can develop abruptly (acute form; even MI). even more unclear – prospective study 1991 showed that occurrence of the first MI decreased, but overall or cardiovascular mortality didn´t decrease

HST – postmenopausal women

Women´s Health Initiative Study proved, that among women in the first year of using HST significantly increases risk of coronary event occurrence


Secondary prevention
Secondary prevention progressively (chronic) or can develop abruptly (acute form; even MI).

Consistent pharmacologic intervention to influence all risk factors among persons with clinically manifested IHD, among persons after MI, with the goal to prevent or at least slower disease progression


Stabilised ihd
Stabilised IHD progressively (chronic) or can develop abruptly (acute form; even MI).

  • We make better prognosis through prevention of occurrence of MI and cardiovascular death

  • We eliminate and decrease symptoms of patient – medications, catetrisation, aortocoronary bypass


Therapy of stable ap
Therapy of stable AP progressively (chronic) or can develop abruptly (acute form; even MI).

  • Antiaggregatory drugs

  • Nitrates – EBM didn´t prove benefit

  • Calcium channel blockers

  • Betablockers

  • Others (molsidomin, trimetasidin, ivabradin)


Drugs inhibiting platelet aggregation
Drugs Inhibiting Platelet Aggregation progressively (chronic) or can develop abruptly (acute form; even MI).

Antiaggregatory therapy decreases among patients with AP risk of complications (MI, sudden heart death) by 23 %.


Drugs inhibiting platelet aggregation devided according to mechanism of action
Drugs inhibiting platelet aggregation devided according to mechanism of action

  • Inhibition of TXA A2 formation through prostaglandin pathway – inhibition of COX-1 (ASA, indobufen)

  • Inhibition of TXA A2 formation through increasing level of cAMP in thorbocyte – inhibition of fosfodiesterase (dipyridamole)

    - stimulation of adenylatcyclase (prostacyclin)

  • Inhibition of fibrinogen bridges formation between thrombocytes

    - inhibition of receptor for ADP on thrombocyte membrane (thienopyridines – ticlopidine, clopidogrel)

    - inhibition of receptor for fibrinogen on thrombocyte membrane – glykoprotein IIb/IIIa (fibans, abciximab)


Examples of drugs inhibiting platelet aggregation
Examples of Drugs Inhibiting Platelet Aggregation mechanism of action

  • Aspirin

  • Ticlopidine

  • Clopidogrel

  • Indobufen

  • Dipyridamole


Aspirin
Aspirin mechanism of action

  • Antiaggregatory effect is given by irreversible blockade of COX-1 (thromboxane A2 is missing)

  • Optimal dose is between 1 mg/1kg daily

  • IND.- manifested IHD, AP, silent ischaemia

  • KI – allergy, ulcer, GIT bleeding


Ticlopidine
Ticlopidine mechanism of action

  • Inhibition of platelet activation, mediated with adenosindiphosphate, starting after several days

  • 2 times per day 250 mg

  • Risk of leukopenia occurance


Clopidogrel
Clopidogrel mechanism of action

  • Tienopyridine

  • 1 times per day 75 mg

  • Good tollerance

  • According to CAPRIE lowers atherotrombotic complication occurance regardless of its localisation by 9% more than ASA


Indobufen
Indobufen mechanism of action

  • Dose 2 times per day 200 mg effective in already 2 hours

  • Effect is reversible, vanishes till 24 hours

  • 10 days before planned surgery we administer instead of ASA


Dipyridamole
Dipyridamole mechanism of action

  • Alone not recommended because of low antiaggregatory effect and making worse IHD „steal phenomenon“

  • Combination of dipyridamole with retarded release 200 mg and 30 mg ASA (Aggrenox) is used in neurology in prevention of stroke


Nitrates
Nitrates mechanism of action

Lower intensity and also frequency of episodes, but according to EBM doesn´t influence morbidity and mortality


Nitrates mechanism of action
Nitrates Mechanism of Action mechanism of action

  • Nitrates are changed by sulfhydrylic groups of gluthation to nitrosotiol, from which in endothelium is released NO (equivalent of EDRF)

  • Vasodilation of epicardial coronary arteries

  • In system venodilation, lower blood return and lower metabolic requirements of myocardium

  • In higher doses occurs vasodilation also in arterial portion with subsequent BP reduction, which is compensated by reflex tachycardia


Tollerance
Tollerance mechanism of action

  • Maintaining of high plasmatic levels of nitrates leads to their antianginal effect decrease

  • Reason is depletion of free sulfhydrylic groups in vessel wall

  • We avoid tollerance by skipping one dose (10-12 hours without nitrates)


Nitroglycerin
Nitroglycerin mechanism of action

  • Different application forms

  • At sublingual administration pain subsides in 1-5 minutes

  • At peroral administration effect starts in 20-40 minutes and lasts 2-6 hours

  • Used mainly at acute episodes


Ca2 channel blockers
Ca2+ Channel Blockers mechanism of action

  • Different chemical structures, with different haemodynamic and clinic effects

  • According to chemical structure divided to:

    - dihydropyridins (amlodipine, felodipine, lacidipine, nifedipine, isradipine)

    - phenylalkylamins (verapamil, gallopamil)

    - benzothiazepins (diltiazem)


Ca2 cb mechanism of action
Ca2+CB – Mechanism of Action mechanism of action

Block influx of calcium to cell through slow L-type channels, lower its intracellular concentration what causes relaxation of smooth muscle in vessel wall, decrease of contractility, decrease of electrical irritability and conductivity


Antianginal effect of ca2 cb
Antianginal effect of Ca2+CB mechanism of action

Direct dilation of coronary arteries and so increased oxygen supply

Decreased demand of myocardium to oxygen with systemic arterial dilation, with subsequent decrease of peripheral vascular resistance, decrease of

contractility and decrease of frequency


Selectivity of ca2 cb
Selectivity of Ca2+CB mechanism of action


Nifedipine
Nifedipine mechanism of action

  • The oldest Ca2+CB

  • If nowadays administered, only as retarded form!

  • Otherwise occurs fast vasodilation with subsequent reflex activation of sympathicus – tachycardia

  • 2nd and 3rd generation of DHP are much more convenient


More convenient dhp
More Convenient DHP mechanism of action

  • Amlodipine – 1 times per day 5-10 mg, possible combination with BB

  • Felodipine – 1 times per day 5-10 mg

  • Isradipine – 2 times per day 2,5 mg

  • Lacidipine – 4-8 mg daily

  • Nitrendipine – 1 times per day 10-40 mg


Verapamil
Verapamil mechanism of action

  • Only phenylalkylamine in practice

  • Administered to patients, which can´t take BB

  • KI – combination with BB

    AV blocks II., III. degree

    Lowers renal excretion of digoxin


Diltiazem
Diltiazem mechanism of action

  • Suitable for monotherapy

  • KI combination with BB, AV block

  • Retard form 2 times per day


Beta blockers
Beta Blockers mechanism of action

  • Decrease oxygen consumption

  • Increase fibrilation base

  • Antiarrhytmic effect

  • Stopping of administration can´t be abrupt


Ki bb
KI BB mechanism of action

  • Atrial bradycardia

  • Bradycardia below 50 per min

  • Ischaemic disease of lower extremities, worsening claudication


BB mechanism of action

  • We try to chose cardioselective drugs

  • Importance of ISA is still questionable – not recommended after overcomed MI


Representatives
Representatives mechanism of action

  • Metipranol – nonselective

  • Pindolol – nonselective with ISA

  • Metoprolol – cardioselective

  • Atenolol – cardioselective

  • Carvedilol – hybrid (alfa1 also beta)


Molsidomin
Molsidomin mechanism of action

  • At its administration no tollerance

  • Not suitable for acute episode of AP

  • Effective in long-term prevention


Trimetazidin
Trimetazidin mechanism of action

  • Metabolic modulator

  • Influence metabolism of cardiomyocytes

  • At ischaemia transfers ATP production from to oxygen more demanding b-oxidation of fatty acids to glykolysis, which demands less oxygen

  • Has no haemodynamic effects


Ivabradin
Ivabradin mechanism of action

  • Is blocker of sinus node, in which blocks flow If

  • Causes atrial bradycardia


Hyperhomocysteinaemia
Hyperhomocysteinaemia mechanism of action

Marker of increased cardiovaskular risk, no its reason

Preventive taking of niacin has no proven benefit

No pharmacologic proofs, that lowering of homocysteinaemia is connected with lower risk of CVD occurance


Dyslipidemia
Dyslipidemia mechanism of action

Is disorder of plasmatic protein metabolism, can have different manifestation. Disorder can have genetic or dietetic reason, or connected disease.


Classification of lipids
Classification of Lipids mechanism of action


Pharmacotherapy of dyslipoprotinemias
Pharmacotherapy of dyslipoprotinemias mechanism of action

  • Affecting mainly cholesterol

    • Statins – atorvastatin

    • Bile acid sequestrants – cholestyramine

    • Ezetimibe – selective inhibitor of CH resorbtion

  • Affecting cholesterol and TAG

    - fibrates – fenofibrate

    - derivates of nicotinic acid – lower synthesis of VLDL in liver and so also formation of LDL


  • Statins
    Statins mechanism of action

    Inhibit enzyme HMGCoA reductase, and so decreases intracellular synthesis of new cholesterol a decreases concentration of LDL


    Fibrates
    Fibrates mechanism of action

    Bind as ligand for PPAR α – receptor activated with peroxisome proliferator

    Increase lipolysis of lipoprotein lipases


    State after mi
    State after MI mechanism of action

    • Modification of life-style

    • Antiagreggatory therapy

    • Anticoagulant therapy

    • Betablockers

    • iACE

    • Ca2+CB

    • Coronary angioplastic


    Unstable ap
    Unstable AP mechanism of action

    • Anticoagulant therapy

    • Antiaggregatory therapy

    • Nitrates

    • BB

    • Urgent angiography


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