new paradigm of anti anginal therapy dr yerizal karani sppd spjp k n.
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New Paradigm of Anti Anginal Therapy dr.Yerizal Karani SpPD,SpJP(K). Angina Pectoris. Angina pectoris  sudden severe pressing chest pain or heaviness radiating to the neck, jaw, back and arms  associated with diaphoresis, tachypnea and nausea.

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angina pectoris
Angina Pectoris
  • Angina pectoris  sudden severe pressing chest pain or heaviness radiating to the neck, jaw, back and arms  associated with diaphoresis, tachypnea and nausea.
  • Angina  insufficient coronary flow to meet oxygen demands of the myocardium  precipitated by any activity/process that creates an imbalance in O2 supply and demand
types of angina
Types of Angina
  • Angina occurs in three overlapping patterns:
    • Stable angina
    • Unstable angina
    • Prinzmetal (variant) angina
nitrat
Nitrat
  • Nitrogliserin (gliseril trinitrat)  very fast onset sublingually  acute condition
  • Isosorbide dinitrate  fast onset sublingually (substitute of gliseril trinitrat)
  • Isosorbide mononitrate  slow onset  used in preventing angina
nitrates tolerance
Nitrates Tolerance

" Decrease in the effect of a drug

when administered in a long-acting form"

  • Develops with all nitrates
  • Is dose-dependent
  • Disappears in 24 h. after stopping the drug
  • Tolerance can be avoided
    • Using the least effective dose
    • Creating discontinuous plasma levels
nitrates contraindications
Nitrates Contraindications
  • Previous hypersensitivity
  • Hypotension ( < 80 mmHg)
  • AMI with low ventricular filling pressure
  • 1st trimester of pregnancy

WITH CAUTION:

  • Constrictive pericarditis
  • Intracranial hypertension
  • Hypertrophic cardiomyopathy
contraindication b blocker
Contraindication B-Blocker
  • Hypotension: BP < 100 mmHg
  • Bradycardia: HR < 50 bpm
  • Chronic bronchitis, ASTHMA
  • Severe chronic renal insufficiency
reasons for using nitrates and beta blockers in combination in angina
Reasons for Using Nitrates and Beta Blockers in Combination in Angina

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

take home messages
Take Home Messages
  • Angina pectoris  imbalance of O2 in supply & demand of the myocardium
  • Nitrogliserin: very fast onset of nitrate in angina pectoris