AcuteAnginalAttack.docVIP

Acute Anginal Attack ~ Nitrates – nitroglycerine or isosorbide dinitrate, given sublingually, or oral spray. Side effects: headache, orthostatic hypotension, reflex tachycardia If no relief – give another dose after 5 mins After 20 mins, 3 doses and still no relief – consider MI or bad nitrates. Use prophylactically Contras: Hypotension, hypovolemia, PDE5 inhibitor Chronic Stable Angina ~ Aspirin – 74 mg daily in all patients, unless allergic, as anti-platelet therapy, to prevent acute vascular events. Side effect: dyspepsia. Treat with antacids, H2 agonists, proton pump inhibitors. Best treatment = misoprostil, a synthetic prostaglandin If allergic – use clopidogrel (=plavix) instead. ~ Beta Blockers – preferred in initial therapy unless specifically contraindicated b/c reduce mortality in prior MI patients don’t stop intake suddenly dosing – 55 to 60 bpm. Can go below 50 if severe angina side effects: asthma, impotence, depression, hypoglycemia, unfavorable lipid profile, Raynaud phenomenon, worsening of variant angina Contras: variant angina Caution in: asthmatics, diabetics, peripheral artery disease. ~ Calcium channel blockers – use if beta blockers are contraindicated Indicated for variant angina short acting dihydros cause adverse events, so avoid long acting dihydros and rate limiting agents are recommended no diff in major cardiac events in beta blockers vs. calcium blockers vs. ACEI vs. diuretics Contraindications: rate limiting agents + beta blockers. LV dysfunction (*exception = amlodipine) ~ Nitrates – Often used as combo therapy with beta blockers Given orally or transdermal pathes – importance of nitrate free period!! Remove gradually to avoid cardiac ischemia caused by dependence Alone, cause reflex tachycardia (and increased cardiac oxygen demand), therefore used with beta blockers or calcium agents. Side effects: headache (tends to go away with continuation of treatment), orthostatic hypotension, reflex tachycardia, methemoglobinemia, cyanosi