Treatment of Angina Pectoris

The basic problem in angina pectoris is that the supply of oxygen to the heart is insufficient to meet myocardial demands at a given point in time, which results in an imbalance between myocardial oxygen supply and demand (Fig. 22—l).6 34 This imbalance leads to myocardial ischemia, which results in several 

Although angina pectoris is believed to be caused by the buildup of lactic acid and other metabolites, the exact mechanisms responsible for mediating anginal pain remain unknown. Also, the emotional state of the patient and other factors that influence central pain perception play an obvious role in angina pectoris.20,34 In fact, the majority of anginal attacks may be silent in many patients, and myocardial ischemia may ffe- 

FIGURE 22-1 T Myocardial ischemia equation. (Adapted from Miller AB. Mixed ischemic subsets. Comparison of the mechanism of silent ischemia and mixed angina. Am J Med 1985 79 [suppl 3a] 25, with permission.] 

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Nitroglycerin remains the dmg of choice for treatment of angina pectoris. It has also been found useful for the treatment of congestive heart failure, myocardial infarction, peripheral vascular disease, such as Raynaud s disease, and mitral insufficiency, although the benefits of nitroglycerin in mitral insufficiency have been questioned. 

Prenyl amine (66) was long used in the treatment of angina pectoris, in which condition it was believed to act by inhibiting the uptake and storage of catecholamines in heart tissue. Droprenilamine (69), an analogue in which the phenyl ring is reduced, acts as a coronary vasodilator. One of several syntheses involves simple reductive alkylation of 1,1-diphenyl-propylamine (67) with cyclohexyl acetone (68)... 

DHPs are potent arterial vasodilators. They act on resistance vessels and therefore reduce peripheral vascular resistance, lower arterial blood pressure, and antagonize vasospasms in coronary or peripheral arteries. By reducing afterload, DHPs also reduce cardiac oxygen demand. Together with their vascular spasmolytic effect, this explains most of the beneficial actions of DHPs in angina pectoris. Most DHPs are only licensed for the therapy of hypertension, some of them also for the treatment of angina pectoris and vasospastic (Prinzmetal) angina. 

Katzung, B.G. and Chatterjee, K., Vasodilators and the treatment of angina pectoris, in Basic and Clinical Pharmacology, 8th ed., Katzung, B.G., Ed., Lange Medical Books/McGraw-Hill, New York, 2001, chap. 12. 

The drug nitroglycerin (glyceryl trinitrate), which is used in the treatment of angina pectoris, releases NO in the bloodstream and thereby leads to better perfusion of cardiac muscle. 

CHF associated with acute Ml treatment of angina pectoris unresponsive to organic nitrates or -blockers production of controlled hypotension during surgical procedures. 

Papaverine is an opium alkaloid initially isolated in the mid-1800s. It relaxes smooth muscle and is a potent vasodilator. As such it is used to dilate pulmonary and other arteries. It is therefore sometimes of use in the treatment of angina pectoris (usually caused by partial blockage of the coronary artery), heart attacks and bronchial spasms. 

While Lind described the method of the comparative trial, he was not concerned with issues that we now call the placebo effect. The first placebo controlled trial was published by Evans and Hoyle in 1933. They evaluated drugs used in the treatment of angina pectoris. Their comments almost 75 years ago are appropriate today. 

Evans W, Hoyle C. The comparative value of drugs used in the continuons treatment of angina pectoris. Q J Med 1933 28 311-38. 

There is little doubt concerning the effectiveness of nitroglycerin in the treatment of angina pectoris. 

Adrenoceptor blockade is a rational approach to the treatment of angina pectoris, since an increase in sympathetic nervous system activity is a common feature in acute anginal attacks. Based on their ability to reduce oxygen demand, all (3-blockers tested so far have also been shown to be effective in the treatment of second-... 

Because of these interindividual variations in the kinetics of propranolol, the therapeutic dose of this drug is best determined by titration. End points of titration include relief of anginal symptoms, increases in exercise tolerance, and plasma concentration of propranolol between 15 and 100 ng/mL. For additional details on the pharmacokinetics of propranolol and other (3-receptor antagonists approved for clinical use in the treatment of angina pectoris, see Table 17.3 and Chapter 11. 

Table 17.3 and Chapter 11 provide additional details concerning the most commonly used p-blockers (i.e., propranolol, nadolol, atenolol, and metoprolol) in the treatment of angina pectoris. 

Unlabeled Uses Treatment of angina pectoris, idiopathic cardiomyopathy... 

Calcium channel blockers depress the contractility of the myocardium and decrease the cardiac work and the requirement of oxygen. This effect proves to be beneficial in the treatment of angina pectoris. 

Uses of NG. Aside from die expl uses discussed under Dynamite and Smokeless Powder (NG gelled with NC), the only extensive use for NG is as a decrease of blood pressure in the treatment of angina pectoris where It is in competition with other polyol nitrates. There is voluminous literature on the pros, aons, and wherefores of this subject... 

Although its pharmacological effects are similar to those of verapamil, diltiazem is almost exclusively used in the treatment of angina pectoris. It has a short elimination half-life that requires thrice-daily oral dosing. Diltiazem is well tolerated especially by elderly patients. 

Chapter 12 Vasodilators the Treatment of Angina Pectoris Chapter 13 Drugs Used in Heart Failure Chapter 14 Agents Used in Cardiac Arrhythmias Chapter 15 Diuretic Agents... 

AccessMedicine Print Chapter 12. Vasodilators the Treatment of Angina Pectoris... 

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