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Antianginals

Nitrates

  • General
  • Used to relieve chest pain in patients with stable angina pectoris and acute coronary syndrome
  • Primarily vasodilators and dilate, veins, arterioles, and coronary arteries by relaxing vascular smooth muscle cells, venodilators
  • Angina improved due to systemic vasodilation (decreased preload)
    • Their primary anti-ischemic effects are due to systemic vasodilation and decrease in cardiac preload rather than coronary vasodilation
    • Systemic venodilation lowers preload and left ventricular end-diastolic and end-systolic volume
    • This causes reduced LV wall stress reducing myocardial oxygen demand, and relieving anginal symptoms
    • Arterial and arteriolar vasodilation can decrease systemic vascular resistance and blood pressure, but to a lesser degree
  • They do act as coronary vasodilators, but benefit is uncertain
  • No direct effect on cardiac chronotropy or inotropy (contractility) and left ventricular ejection fraction
  • SE: Reflex Tachycardia
    • Concomitant use of beta blockers to prevent
  • Isosorbide Dinitrate
  • Isosorbide Mononitrate
  • Sodium Nitroprusside
  • Parenteral vasodilator with quick onset and offset of action and is commonly used for rapid BP control in patients with hypertensive emergency
    • Its metabolism releases NO and Cyanide
    • Induces arteriolar and venous vasodilation
    • May cause reflex tachycardia and enhance ventricular contraction increasing aortic wall stress (give BB first)
  • SE: Irreversible Cyanide toxicity (Thiocyanate, most common in renal insufficiency), disorientation, Headache, tinnitus, Tachyphylaxis
  • Nitroglycerin
  • IV: Use only for patients with ACS or Acute pulmonary edema
  • Avoid in patients with RV infarction and those on PDE-5 inhibitors

Non-Nitrates

  • Ranolazine
  • Partially inhibits fatty acid oxidation and increases glucose oxidation
  • No HR or BP reduction