Anti-anginal drugs
| Drug
|
Features
|
| Nitrates: nitroglycerine (acts within minutes when given sublingually); isosorbide mono- and dinitrate are longer acting
|
Anti-anginal effect is due to decreased preload, which reduces myocardial oxygen demand; decreases coronary vasospasm in Prinzmetal’s angina; dilates epicardial coronary arteries
|
| Calcium channel blockers
|
Non-dihydropyridines are preferred, such as diltiazem and verapamil
|
| Beta blockers
|
Anti-anginal effect is due to beta 1 blockade: decreases heart rate and contractility, which decreases myocardial oxygen requirements; atenolol, metoprolol, carvedilol preferred
|
| Ranolazine
|
Reduces sodium influx during ventricular depolarization by blocking Na channels; may prolong QTc; adverse effects include dizziness, edema, tinnitus, vertigo, constipation, dry mouth, asthenia, palpitations, hypotension
|
| Dipyridamole (persantine)
|
Acts as a vasodilator and platelet inhibitor; inhibits the enzyme phosphodiesterase, increasing cAMP; adverse effects include dizziness, diarrhea, headache, flushing, arthralgia, bleeding tendencies
|
| Ivabradine
|
Inhibits funny currents in the SA node, decreasing heart rate; levels are affected by drugs acting on Cyt P450 enzymes; adverse effects include blurred vision, gastrointestinal upset, AF, prolongation of QTc, bradycardia
|
| Trimetazidine
|
Increases myocardial resistance to ischemia by decreasing beta oxidation of fatty acids, thereby decreasing oxygen demand; cytoprotective effect; adverse effects include nausea, vomiting, thrombocytopenia, agranulocytosis, hepatic dysfunction, and may worsen Parkinson syndrome
|
Nitrates
- Decrease preload → lower myocardial oxygen demand
- Relieve coronary vasospasm (Prinzmetal’s angina)
- Dilate epicardial coronary arteries
Calcium channel blockers
- Non-dihydropyridines (diltiazem, verapamil) preferred for angina
Beta blockers
- Block beta 1 receptors → decrease HR and contractility
- Lower myocardial oxygen requirements
- Preferred: atenolol, metoprolol, carvedilol
Ranolazine
- Blocks Na channels → reduces sodium influx during depolarization
- May prolong QTc interval
- Adverse effects: dizziness, edema, tinnitus, constipation, hypotension
Dipyridamole
- Vasodilator and platelet inhibitor
- Inhibits phosphodiesterase → increases cAMP
- Adverse effects: dizziness, headache, bleeding tendencies
Ivabradine
- Inhibits funny currents in SA node → decreases heart rate
- Levels influenced by CYP450 drugs
- Adverse effects: blurred vision, GI upset, AF, bradycardia, QTc prolongation
Trimetazidine
- Decreases beta oxidation of fatty acids → lowers myocardial oxygen demand
- Cytoprotective against ischemia
- Adverse effects: nausea, thrombocytopenia, agranulocytosis, hepatic dysfunction, worsens Parkinsonism
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