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CASE 21

CASE 21. Michelle Legaspi.

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CASE 21

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  1. CASE 21 Michelle Legaspi

  2. 65 y/o male retired teacher sought consult because of occasional chest heaviness non-radiating occuring during a moderate physical exertion (e.g. climbing up the stairs, or carrying a heavy object), or after an emotional outburst. He noticed that this was often relieved by rest or relaxation with duration 5-10 minutes. He also claims to have a positive family history of heart disease

  3. Angina Pectoris • Pain in the chest • Characteristic: heaviness • Relieved by rest • Male: 50-60 years old • Usually due to atherosclerotic heart disease • Classic Angina or “angina of effort” • Impaired oxygen delivery as a result of abnormalities of the coronary arteries

  4. Laboratory Examinations • vital signs • patient history • physical exam • ECG • ST depression during treadmill test

  5. Plan of Management • Pharmacologic • Beta blockers • Nitrates • Calcium channels blockers • Non-Pharmacologic a. Stop smoking b. Decrease alcohol consumption c. Stress management d. Decrease fat and cholesterol in diet e. Lose weight f.  Decease salt intake

  6. Pharmacokinetics • Nitrates • First past effect (liver-nitrate reductase) • Bioavailability: low 10-20% • Route: • Sublingual: avoids the 1st past effect • Oral: longer duration of action • Buccal • Spray • IV • Transdermal • Ointment • Metabolites • 2 dinitroglycerin: significant vasodilator efficacy; most therapeutic effect of oral route • 2 mononitro • Excretion: kidney in the form of glucuronide derivative

  7. Pharmocodynamics • Dilates all the smooth muscles, biliary systems, ureters and bronchioles • Relaxing action is most active in the blood vessels • Anti-angina effect is due to a reduction on peripheral arterial resistance and thus decrease in after load • Dilate veins: reduce venous return • Results in decrease in left ventricular volume makes the heart move efficiently • Decrease in both the preload and afterload as a result of respective dilation of venous capacitance and arteriolar resistance vessel

  8. Side effects • Throbbing headache • Flushing of the face • Dizziness especially in the beginning of treatment • Postural hypotension due to the pooling of blood in the dependent portions of the body

  9. Contraindication • Renal ischemia • Acute myocardial infarction • Patients receiving other anti-hypertensive agents

  10. Beta Adrenergic Blocking Drugs • Beneficial • Hemodynamic effect • Decrease heart rate, blood pressure, contractility • Decrease myocardial oxygen requirements at rest and during exercise • Increase in diastolic perfusion time • Reduce heart rate and blood pressure • Reduce myocardial oxygen consumption

  11. Side effects • Increase end-diastolic volume • Increase in ejection time • Increase myocardial oxygen associated with increased diastolic volume • Can be balanced by the use of nitrates

  12. Contraindication • Congestive heart failure • decrease in cardiac output; heart compensate by increasing heart rate • Asthma • block beta 1 and beta 2 receptor • Complete heart block • heart rate is slow • DM • inhibit insulin and stimulate glucagon

  13. Calcium channel blockers • Pharmacokinetics • Inhibits calcium transport, excitation-contraction and cardiac work are depressed. • Peripheral vasodilation which further reduces cardiac work load • Pharmacodynamics • Relaxes and reduces the tone of all smooth muscles • Relaxing action is marked on vascular smooth muscle • Arterioles are much more affected than veins • Lower blood pressure and reduce afterload without appreciable effect on the preload

  14. Side effects • Nausea and vomiting • Dizziness • Flushing • Tachycardia: due to hypotension

  15. Contraindication • Cardiogenic shock • Recent myocardial infarction • Heart failure • Atrio-ventricular block

  16. Combination therapy • Nitrate and Beta blockers • beta blockers block reflex tachycardia • Calcium channel blockers and beta blockers • exertional angina that is not controlled • Calcium channel blocker and nitrates • severe vasopastic or exertional angina w/ CHF and sick sinus syndrome • Calcium channel blocker, Beta blockers and Nitrate • exertional angia not controlled by administration of two types of anti-anginal agent

  17. Nitrates • Short acting • Nitroglycerin, sublingual • Isosorbide dinitrate, sublingual • Amyl nitrite, inhalant • Long acting • Nitroglycerin, oral sustained-action • Nitroglycerin, 2% ointment, transdermal • Nitroglycerin, slow-release, buccal • Nitroglycerin, slow-release patch, transdermal • Isosorbide dinitrate, sublingual • Isosorbide dinitrate, oral • Isosorbide dinitrate, chewable oral • Isosobide monoitrate oral

  18. Beta Adrenergic Blocking Drugs • Popranolol • absorbed well in the GIT, • t1/2 = 3-5 hours • Nadolol • Calcium Channel Blockers • Nifedipine • Verafamil • Diltiazem

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