Updated: 12/21/2019

Antianginal Drugs

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Snapshot
  • A 54-year-old man presents to the emergency department after experiencing pressure-like sternal chest pain that radiates down the left arm. Medical history is significant for hypertension, hypercholesterolemia, and type II diabetes. He smokes 2 packs of cigarettes per day for the past 25 years. On physical exam, the patient appears anxious and diaphoretic. An electrocardiogram demonstrates an ST-segment elevation in leads V1-V4. Cardiac troponins are sent. He is given aspirin, nitroglycerin, metoprolol, clopidogrel, and unfractionated heparin. The cardiac catheterization lab is activated .
Introduction
  • Appropriate treatment for acute coronary syndrome must be instituted immediately in order to
    • limit myocardial damage
    • decrease the risk of complications
    • restore the balance between myocardial oxygen supply and demand
NSTEMI and Unstable Angina (UA)
  • Introduction
    • NSTEMI and UA are managed in the same manner
    • the goal is to to provide 
      • anti-ischemic therapy
        • restores the myocardial oxygen supply and demand
      • anti-thrombotic therapy
        • prevents further growth of the partial thrombotic occlusion
  • Medications
    • anti-ischemic therapy
      • β-blockers (e.g., metoprolol)
        • mechanism
          • decreased sympathetic drive to the heart
            • promotes myocardial electrical stability
            • decreases myocardial demand
            • ↓ cAMP
          • improves mortality in patients with an MI
        • contraindications
          • bronchospasm
          • decompensated heart failure
          • hypotension
      • nitrates (e.g., nitroglycerin, isosorbide mononitrate, and dinitrate)
        • mechanism 
          • venodilation reduces preload to the heart, which reduces myocardial demand
            • recall that a reduction in preload reduces ventricular wall stress
          • afterload reduction and decreased SVR
          • coronary artery dilation improves blood flow to the myocardium
            • recall that venodilation >> arterial dilation
            • this can steal blood from already maximally dilated ischemic myocardium 
          • ↑ cGMP 
        • adverse events
          • nitroprusside causes cyanide toxicity
          • development of tolerance for the vasodilating action during the work week
          • a headache may result from vasodilation of cerebral arteries
          • can results in hypotension when combined with other blood pressure lowering medications
      • calcium channel blockers (e.g., verapamil and diltiazem)
        • mechanism
          • reduces heart rate and cardiac contractility
          • this medication is reserved for patients unresponsive to β-blockers and nitrates or have contraindications to β-blockers
            • this is because calcium channel blockers do not provide a mortality benefit
    • anti-thrombotic therapy
      • aspirin
        • mechanism
          • an inhibitor of thromboxane A2 synthesis 
            • thromboxane A2 is a prominent promoter of platelet activation
          • improves mortality and should be continued indefinitely
      •  P2Y12 ADP receptor inhibitor (e.g., clopidogrel and ticagrelor)
        • mechanism
          • prevents ADP from binding to the P2Y12 receptor, which would normally further activate platelets
    • anti-coagulation therapy
      • unfractionated heparin
        • mechanism
          • binds to antithrombin to enhance its effects
          • inhibits factor Xa
ST-Segment Elevation Myocardial Infarction (STEMI)
  • Introduction
    • STEMI suggest that there is a total occlusion of the vessel
      • thus the main goal is to induce rapid reperfusion via
        • percutaneous coronary intervention (PCI) OR
        • fibrinolytic therapy
      • patients are also given medications such as those used in NSTEMI and UA
        • aspirin
        • unfractionated heparin
        • β-blockers
        • nitrates
        • P2Y12 ADP receptor inhibitor 
  • Reperfusion therapy
    • primary PCI
      • the preferred method for reperfusion
      • must be performed within 90 minutes of first medical contact
        • aspirin and a P2Y12 receptor inhibitor is given prior to the procedure
    • fibrinolytic therapy (e.g., alteplase)
      • performed if PCI cannot be performed within 90 minutes or is unavailable
      • fibrinolytics convert plasminogen to plasmin, which degrades newly formed clots
Adjunctive Therapy
  • Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril)
    • provides a mortality benefit
    • prevents ventricular cardiac remodeling and reduces the rate of heart failure
  • Statins (e.g., atorvastatin) 
    • an HMG-CoA reductase inhibitor that lowers cholesterol levels
Therapy And Their Effect On Mortality
 
Effect on Mortality of Therapy Used in Acute Coronary Syndromes
Mortality Benefit
No Mortality Benefit
  • Aspirin
  • β-blockers
  • PCI
  • Statins
  • P2Y12 ADP receptor inhibitor 
  • Thrombolytics
  • Oxygen
  • Morphine
  • Nitrates
  • Calcium channel blockers
  • Lidocaine
  • Amiodarone
 
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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