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Pharmacology notes

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MANAGEMENT OF CORONARY ARTERY DISEASE AND
COMPLICATIONS;
Angina pectoris, myocardial infarction and acute coronary syndromes;
Angina is a symptom experienced when myocardial oxygen delivery is
insufficient to meet myocardial energy requirements.
Myocardial infarction is defined as death of myocardium due to severe ischaemia.
In recent years, unstable angina and non-ST segment elevation myocardial
infarction (non-STEMI) and ST segment elevation myocardial infarction
(STEMI) have collectively been known as acute coronary syndromes (ACS).
An acute coronary syndrome (ACS) is a set of signs and symptoms related to the
heart.
Classical symptoms of acute coronary syndrome (ACS) include; chest pain
typically radiating to the left arm or left side of the neck), Dyspnoea, Nausea,
Vomiting, Palpitation, Sweating and anxiety (often described as a sense of
impending doom).
Acute coronary syndrome are of two types;
1) Unstable angina: Not associated with heart muscle damage
2) Myocardial infarction: Heart muscle is damaged.
There are two types of myocardial infarction. These types are named according to
the appearance of the electrocardiogram (ECG/EKG) as;
Non-ST segment elevation myocardial infarction (NSTEMI)
ST segment elevation myocardial infarction (STEMI).
Angina occurs in two forms;
Stable angina
Unstable angina
Stable angina;
Attacks are predictable, provoked by exertion or excitement and recedes when the
increased energy demand is withdrawn.
The underlying pathology is usually chronic coronary artery disease with
moderate to severe fixed stenosis of the coronary arteries with super-added
variation in coronary tone.
Anaemia and thyrotoxicosis can precipitate or aggravate angina by reducing
oxygen delivery and increasing energy requirements respectively.
Treatment can be directed at increasing myocardial oxygen supply (coronary
vasodilatation) or reducing myocardial oxygen consumption (reduce heart rate,
contractility, preload and afterload.
Drugs that reduce heart rate also increase duration of diastole ( the time when
most myocardial blood flow occurs).

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Unstable angina;
This occurs with increasing frequency and severity and on a lesser exertion or at
rest and is unpredictable.
The underlying pathology is usually rupture or dissection of an atheromatous
plaque with thrombus formation or extension in the coronary arteries. Spasm may
be an additional mechanism.
Acute changes in coronary arteries pathology are presumed and therapeutic
intervention directed to halting, reversing or bypassing the coronary artery
occlusive process in the hope of avoiding myocardial infarction.
Given the nature of the pathophysiological process, an antithrombotic therapy is
the key.
At the same time, treatment is aimed at reducing myocardial energy requirements.
Severe unstable angina can progress to myocardial infarction or even death.
This categorization reflects how the treatment of ACS is determined by the way in
which the patient presents. Unstable angina and non-STEMI may be
indistinguishable at presentation (with confirmation of infarction dependent upon
increase in cardiac biochemical markers e.g. troponin). Their management is
similar and include;
1) Anti-platelet therapy
2) Antithrombotic drugs
3) Anti-ischaemic drugs
4) Percutaneous coronary intervention (PCI)
5) Coronary artery bypass surgery
There is evidence that revascularization reduces recurrent angina and myocardial
infarction.
Drugs used in angina;
1) Glyceryl trinitrate;
Mechanism;
A potent, direct, short-acting, smooth muscle relaxant with widespread vasodilator
activity.
Whether the predominant effect is a direct action on the coronary arteries to
increase flow or a peripheral reduction in preload and afterload is disputed.
Pharmacokinetics;
Virtually 100% first-pass metabolism and it is therefore given sublingually,
bucally, transdermally, as a patch or paste or intravenously.
It is very rapidly cleared by liver metabolism; half-life of about 2-minutes.
Adverse effect;
These are dose related and result from vasodilatation and hypotension.
2

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MANAGEMENT OF CORONARY ARTERY DISEASE AND COMPLICATIONS; Angina pectoris, myocardial infarction and acute coronary syndromes; Angina is a symptom experienced when myocardial oxygen delivery is insufficient to meet myocardial energy requirements. Myocardial infarction is defined as death of myocardium due to severe ischaemia. In recent years, unstable angina and non-ST segment elevation myocardial infarction (non-STEMI) and ST segment elevation myocardial infarction (STEMI) have collectively been known as acute coronary syndromes (ACS). An acute coronary syndrome (ACS) is a set of signs and symptoms related to the heart. Classical symptoms of acute coronary syndrome (ACS) include; chest pain typically radiating to the left arm or left side of the neck), Dyspnoea, Nausea, Vomiting, Palpitation, Sweating and anxiety (often described as a sense of impending doom). Acute coronary syndrome are of two types; 1) Unstable angina: Not associated with heart muscle damage 2) Myocardial infarction: Heart muscle is damaged. There are two types of myocardial infarction. These types are named according to the appearance of the electrocardiogram (ECG/EKG) as; Non-ST segment elevation myocardial infarction (NSTEMI) ST segment elevation myocardial infarction (STEMI). Angina occurs in two forms; Stable angina Unstable angina Stable angina; Attacks are predictable, provoked by exertion or excitement and recedes when the increased energy demand is withdrawn. The underlying pathology is usually ...
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