ANGINA PECTORIS By:- Sayantan Chatterjee*, Subhajit Hazra** Pharmaceutical Engineering (Bachelor of Pharmacy) *Presenter ; ** Co-Editer

ANGINA PECTORISA Chronic disease of CVS

Occurs with Interminent chest pain spread along the Chest, Shoulders and Arms.

•Angina pectoris, or angina, as it is commonly referred to, and coronary artery disease or arteriosclerosis are closely related.

•Angina occurs in people who have some form of blockage in the coronary arteries. In other words, it occurs in people with coronary heart disease.

•Angina pectoris: a heart condition marked by paroxysms of chest pain due to reduced oxygen to the heart

• It occurs when the Oxygen Supply to the Myocardium is insufficient for its needs.

Factors affecting Oxygen Demand Supply Ratio

ANGINA-CORONARY OCCLUSION

CORONARY OCCLUSION

Types Of Angina Pectoris

1. Stable Angina

2. Unstable Angina

3. Variant Angina (Prinzmetal’s Angina)

STABLE ANGINAPredictableOccurs on exercise, emotion or eating.Caused by increase demand of the heart and

by a fixed narrowing of coronary vessels, almost always by atheroma.

Coronary obstruction is ‘fixed’Blood flow fails to increase during increased

demand despite the local factors mediated ‘vasodilation’ and so ischeamic pain is felt.

So, the diastolic pressure increases and this causes a endocrinal ‘crunch’ and thus causing Ischeamatic pain in this region.

Thus, a form of acutely developing and rapidly reversible left ventricular failure results which is relieved by taking rest and reducing the myocardial workload.

UNSTABLE ANGINAThis is characterized by Pain that occurs with

less excertion , cumulating pain at rest.The pathology is similar to that involved in

Myocardial Infraction, namely platelet-fibrin thrombus associated with a ruptured atheromatous plaque, but without complete occulation of the vessels.

The risk of infraction is subtanial, and the main aim of therapy is to reduce this.

VARIANT ANGINA (PRINZMETAL’S ANGINA)UncommonOccurs at rest generally during sleepCaused by Large Coronary Artery SpasmUsually associated with atheromatous

diseaseAbnormally reactive and

hypertrophied segments in the Coronary Artery

Drugs aimed at preventing & relieving Coronary Spasm.

DIAGNOSIS1. STRESS (EXERCISE) TEST.2. ECG (ELECTROCARDIOGRAPHY)3. CHEST X-RAY4. CARDIAC ANGIOGRAPHY/ CARDIAC

CATHETERIZATION5. ERGONOVINE TEST6. BLOOD TEST (BIO-MARKERS)

1. EXERCISE TEST/STRESS TESTUsed to measure heart’s response to exercisePatient asked to walk on a treadmill while the

physician takes the ECG So any changes in heart function can be

determinedAlternatively the patient recieves an injection

of a radioisotope (generally Thallium) which makes the heart visible to a special-linked camera

90% accurateBut doesn’t identify the exactly where and

how the coronary arteries are blocked.

2. ELECTROCARDIOGRAM (ECG)Measures electrical activity of the heartProvides info about the changes or damages

to the heart muscleDoesn’t detect the narrowing of the coronary

arteriesDuring an Anginal attack the ECG may show 1. S-T phase depression.2. T- phase inversion and/or3. Ventricular arrythmia ECG- more abnormal with Unstable Angina

where the elevation in S-T segment is found.

STABLE ANGINA

At Rest

After Excercise

3. CHEST X-RAYPerformed to rule out any lung disease or

heart damage that may be causing the pain.Also may reveal enlargement of heart

4. CARDIAC ANGIOGRAPHY/ CARDIAC CATHETERIZATIONShows the precise size and location of

blockages within the Coronary arteriesA cathereter is inserted through the blood

vessels from the forearm or groinIt is snaked through arteries till it reaches

the heartA fluid is pumpedSo the arteries and the heart are clearly

visible

5. ERGONOVINE TESTGenerally done if the person is assumed to

suffer from Coronary SpasmDone along with angiographyThe artery-narrowing drug—Ergonovine or

Ach is given to cause Coronary SpasmThe persons response to ergonovanine is

measured

6. BLOOD TEST/BIOMARKERSBlood test for amount of Lipids within the

bloodBecause lipids major cause of anginal attackLipid profile for :- 1. HDL 2. LDL 3.

TRIGLYCERIDES Recently the newer biomarkers like the C-

reactive protein and B-type natriuretic protein have been found out and the tests for each of them is done

These tests are predictive of the moratality of heart disease

TREATMENT3 Classes of drugs used according their mode

of action

1. NITRATES

2. - ADRENOCEPTOR ANTAGONISTS

3. CALCIUM CHANNEL BLOCKERS

4. K+ CHANNEL OPENERS.

Improving Oxygen Demand:Supply Ratio

a. Relaxation of resistance vessels (small arteries and arterioles) ↓TPR → ↓BP → ↓Afterload (Nitrates, calcium channel blockers and beta-blockers)

b. Relaxation of capacitance vessels (veins and venules) ↓Venous return, ↓heart size, ↓Preload (Nitrates and calcium channel blockers)

c. Blockade or attenuation of sympathetic influence on the heart ↓Contactility, ↓HR, ↓O2 demand (Beta-blockers)

d. Coronary Dilation, Important mechanism for relieving vasospastic angina, ↑O2 supply (Nitrates)

NITRATESProdrugsSources of Nitric OxideEg:- Nitroglycerin, Isosorbide Dinitrate Isosorbide-5-Mononitrate

Mechanism Of Action

PHARMACO-LOGICAL ACTIONS OF NITRATES

TOXICITY OF NITRATESHeadacheIncreased mortalityRecurrence of Myocardial InfractionDizzinessFlushingRapid heart beatRestlessnessDry mouthSkin rashNausea

MARKETED FORMULATIONSGTN Sorbitrate (PIRAMAL)Vasovin (TORRENT)

ISMO retard (PIRAMAL)Angicor (NOVARTIS)

Nitroglyceride

Isosorbide-5-monophosphate

CALCIUM CHANNEL BLOCKERSDisrupt Ca++ through Ca++ channels-ve ionotrpic effect2 types:-1. Dihydropyridine (amlodipine, nifedipine,

nicardipine)2. Non-Dihydropyridine

1. Phenylalkylamine (verapamil, gallopamil)2. Benzodiazapenes (diltiazem)3. Non-selective (bepridil, mibefradil)

MECHANISM OF ACTION

Pharmaclogical Actions

TOXIC EFFECTS

MARKETED PREPARATIONSCalaptin (PIRAMAL)Vasopten (TORRENT)Coriem XL (RANBAXY)Dicard (INTAS)Amtas (INTAS)Cadeut (PFIZER)

Verapamil

Diltiazem

Amplodipine

-ADRENOCEPTOR ANTAGONOSTSImportant in prophylaxis of angina and

treating unstable anginaDecrease O2 consumption by the heartEffects on coronary vessels-not importantAvoided in variant anginaAs they increase the chances of spasmEg:-

Atenolol Propranolol

PHARMACOLOGICAL ACTIONS

MECHANISM OF ACTION

MARKETED PREPARATIONSBetacard ( TORRENT)

Aten (ZYDUS CADILA)

Betacap (SUN PHARMA)

Cardilax (INTAS)

COMBINATION THERAPY1. Nitrates + -blockers :- in stable angina2. Ca++ channel blockers + -blockers :-in

stable angina when the treatment with nitrates and -blockers has failed.

3. Ca++ channel blockers + Nitrates :- in unstable angina

4. All 3 together:- when the combinations of 2 drugs has failed, where:-

1. Nitrates:- decrease Preload2. Ca++ channel Blockers:- decrease Afterload3. -blockers:- decrease heart rate and

myocardial contractions

Recommended Drug therapy for Angina with other medications

NEWER DRUGSRANOLAZINE (Ranexa™; CV Therapeutics,

Inc.), a drug that has been in development for 20 years. It is a Sodium Channel Blocker.

NICORANDIL, a potassium channel activator, and also has a Nitrogen Donating Moeity.

References Basic and Clinical Pharmacology 12/E

(LANGE Basic Science) (Page no. – 191 – 207).

Essentials of Medical Pharmacology (English) 7th Edition (Page no. – 539 – 559).

THANK YOU!!!!