ANTI-ANGINAL DRUGS

ANTI-ANGINAL DRUGS

Q. 1 Which of the following agent decreases cardiac afterload?

 A Nicorandil

 B

Glyceryl trinitrate

 C

Isosorbide dinitrate

 D

None

Q. 1

Which of the following agent decreases cardiac afterload?

 A

Nicorandil

 B

Glyceryl trinitrate

 C

Isosorbide dinitrate

 D

None

Ans. A

Explanation:

Nicorandil reduces afterload and preload, while in the coronary circulation it dilates both the large epicardial and smaller resistance vessels. Because Nicorandil is an anteriolar dilator and hence primarily decrease after load.

Hydralazine and minoxidil reduce afterload by relaxing arteriolar smooth muscle. The venodilators and diuretics are used to decrease preload. The venodilators include nitroglycerine and isosorbide dinitrite. Drugs that reduce both prelod and afterload include nitroprusside, prazosin, ACE inhibitors and angiotensin II receptor blockers.


Q. 2

β -blockers are used in all except‑

 A

Hypertension

 B

Thyrotoxicosis

 C

Variant angina

 D

All of the above

Ans. C

Explanation:

Ans. is ‘c’ i.e., Variant angina

We all know that attacks of variant angina occur due to coronary vasospasm.

So, the drugs which relieve coronary vasospasms will be used in variant angina (C.C.B.’s, Nitrates)

β blockers are contraindicated in these patients because 13 blockers, instead of dilating the coronary arteries constrict the coronary arteries (due to unopposed a mediated constriction).

Remember,

blockers are useful in classical angina. (They cause favourable redistribution of blood)


Q. 3 Verapamil is contraindicated in all, except

 A

PSVT with AV Block

 B

Variant angina

 C

Beta adrenergic toxicity

 D

Digitalis toxicity

Ans. B

Explanation:

Ans. is ‘b’ i.e., Variant angina

“All CCBs are effective in reducing frequency and severity of classical as well as variant angina”.

Due to these cardiodepressant effects, it is C/I in the following conditions.

           Sick sinus syndrome (causes cardiac arrest)

           A- V block (Accentuate conduction defects)

           Congestive heart failure

           Hypotensive states

           Ventricular tachycardias

           AF with accessory pathway or WPW syndrome.

o Other conditions in which Verapamil is C/I.

           Digoxin toxicity —> Increases plasma digoxin level by decreasing its excretion, toxicity can develop.

           Quinidine and disopyramide —> Both these drugs have cardiac depressant action.

Verapamil is not used with β blockers because their depressant effect on SA and AV node may add up.

β


Q. 4 Treatment of stable angina include –

 A

Nitrates

 B

CCBs

 C

Streptokinase

 D

a and b

Ans. D

Explanation:

Ans. is ‘a’ i.e., Nitrates & ‘b’ i.e., CCBs


Q. 5

Agent of first choice in an acute attack of Prinzmetal’s angina is –

 A

Diltiazem

 B

Nitrates

 C

Propranolol

 D

Verapamile

Ans. B

Explanation:

Ans. is ‘b’ i.e., Nitrates

Treatment of variant angina

Drugs are :

1.       Nitrates

2.       Calcium channel blockers (verapamil, diltiazem)

o Nitroglycerin is considered the drug of choice for the patient with variant angina.

o Prazosin a selective a-blocker may also be used because it prevents a mediated vasospasm.

o β-blocker’s are contraindicated because they cause constriction of coronary artery due to unopposed a mediated vasoconstriction.

Prevention of variant angina

o In contrast Nitrates are not used for the prevention of variant angina because of delevelopment of tolerance.

o CCBs are the DOC for prevention.


Q. 6 Drug not used in prinzmetal angina is‑

 A Propranolol

 B

Propranolol

 C

Nitritesrites

 D

Isosorbide dinitrate

Ans. A

Explanation:

Ans. is ‘a’ i.e., Propranolol

o P-blocker’s are contraindicated because they cause constriction of coronary artery due to unopposed a mediated vasoconstriction.


Q. 7

Drugs used in unstable angina are all except

 A

Intravenous heparin

 B

Aspirin

 C

Intravenous nitroglycerin

 D

Lidocaine by bolus infusion

Ans. D

Explanation:

Ans. is ‘d’ i.e., Lidocaine by bolus infusion


Q. 8

Trimetazine is used for –

 A

Hypertension

 B

Angina

 C

CHF

 D

Arrhythmia

Ans. B

Explanation:

Ans. is ‘b’ i.e, Angina

o The drug that inhibit fatty acid oxidation is Trimetazine.

o These drugs are partial  inhibitors of FA oxidation

o These drugs also inhibit lipid peroxidation —> Reduce the generation of free radicals

o These drugs are indicated for the treatment of chronic angina pectoris who failed to respond to standard antianginal therapy.


Q. 9 All of the folloiwng statements about Ranolazine are true, except;

 A Piperazine derived antianginal agent

 B

May be used as first line agent in chronic angina

 C

May improve glycemic control

 D

Hypotension is an established adverse effect

Ans. D

Explanation:

Ans. is ‘d’ i.e., Hypotension is an established adverse effect

  • Ranolazine is an effective newer anti-anginal drug but unlike CCBs and beta-blockers it does not significantly alter the heart rate or blood pressure.
  • It is a piperazine derivative.
  • Ranolazine appears to have other promising non-anginal effects, including glycemic control, improvement in endothelial function and decreases the incidence of atrial fibrillation and other arrhythmias.
  • Ranolazine has been generally well tolerated in clinical trials its most common adverse effects are nausea, constipation and dizziness.
  • About option b
  • Most of the text books have mentioned that ranolazine can be used as add-on therapy in chronic stable angina. o However, it has recently been approved as first line agent:
  • ” Previously limited by its FDA indication to use in angina in combination with a calcium channel blocker, beta blocker or nitrate; ranolazine is now approved for use as a first line agent in chronic angina”. .. The Heart. org.

Q. 10 Which of the following doesn’t worsen angina?

 A

Sumatriptan

 B

Oxyfedrine

 C

Dipyridamole

 D

Thyroxine

Ans. B

Explanation:

Ans. is ‘b’ i.e., Oxyfedrine

Drugs that exacerbate Angina

o Amphetamines                      o Alpha blocker                    o Beta agonists                     o Beta blockers withdrawal

o Dipyridamol                           o Vasopressin                       o Ergotamine                        o Decongestants

o Excessive thyroxine                 o Hydralazine                       o Methysergide                     o Minoxidil

o Nifedipine                            o Nicotine and cocaine            o Oxytocin                           o Sumatriptan

o Theophylline


Q. 11 First line drug choice for management of hypertension in patients with angina:

 A Beta Blockers

 B

ACE Inhibitors

 C

Calcium Channel Blockers

 D

Hydralazine

Ans. A

Explanation:

Answer is A (Beta Blockers)

‘Hypertension: A companion to Braunwald’s Heart Disease (Elsevier) 2007/335

Beta-blockers are the first line drugs of choice for treatment of hypertension in patients with coronary artery disease & stable angina

`Beta blockers are the first line choice when treating hypertension in a patient with coronary artery disease’ — Evidence Based Medicine Guidelines (John Wiley & Sons)

‘Beta blockers reduce angina symptoms, improve mortality and lower BP, and they should be the drugs offirst choice in hypertensive patients with CAD and stable angina’ — ‘Hypertension: A companion to Braunwald’s Heart Disease’


Q. 12 Acute anginal attack can be terminated by:

September 2007

 A Nitroglycerin

 B

Digoxin

 C

Lignocaine

 D

Verapamil

Ans. A

Explanation:

Ans. A: Nitroglycerin

Absorption of Nitrates is most rapid and complete through the mucous membrane.For this reason, nitroglycerin is the most commonly administered sublingually.

Their mechanism of action is systemic venodilation with concomitant reduction in LV end diastolic volume and pressure, thereby reducing myocardial wall tension and oxygen requirements.

Complications are a pulsating feeling in the head, postural dizziness.


Q. 13 Best time to administer long term nitrates for nocturnal angina:

September 2011

 A Early morning

 B

Noon

 C

Evening

 D

Late night

Ans. C

Explanation:

Ans. C: Evening

If nocturnal angina is a predominant symptom, long term nitrates can be given at the end of the day

Nitrates:

  • They cause vasodilation, flushing, headache, dizziness, met-hemoglobinemia
  • Decreases preload and afterload
  • Decreases myocardial oxygen consumption
  • Causes reflex tachycardia, hypotension
  • Long acting nitrates are not used chronically as tolerance develops
  • *Shortest acting NITRITE: Amyl nitrite
  • Shortest acting nitrate: Nitroglycerine
  • Longest acting nitrate: Penta-erythritol-nitrate

Q. 14 Which of the following is a  Rho kinase inhibitor?

 A Fasudil

 B

Ranolazine

 C

Amiloride

 D

Nicorandil

Ans. A

Explanation:

Ans. a. Fasudil


Q. 15

Tachycardia due to nitrates in a patient with angina pectoris is blocked by‑

 A

Digoxin

 B

Dobutamine

 C

Beta-blocker

 D

Calcium channel blocker

Ans. C

Explanation:

Ans. is ‘c’ i.e., Beta-blocker

Use of beta-blocker and long-acting nitrate combination is rational in classical angina because :

  1. Tachycardia due to nitrate is blocked by beta-blocker
  2. The tendency of beta-blocker to cause ventricular dilatation is countered by nitrate
  3. The tendency of beta-blocker to reduce the total coronary flow is opposed by nitrate

Q. 16 All of the following statements about antianginal action of nitrates are true except‑

 A Myocardial O2 consumption

 B

Both pre and after load

 C

Total coronary flow

 D

Cause favourable redistribution of coronary flow

Ans. C

Explanation:

Ans. is ‘c’ i.e., Total coronary flow 

Mechanism of action of nitrates in Prinzmetal’s angina is endothelium independent coronary vasodilation. When metabolized, organic nitrates release nitric oxide (NO) that binds to guanylyl cyclase in vascular smooth muscle cells, leading to an increase in cyclic guanosine monophosphate, which causes relaxation of vascular smooth muscle.

“Nitrates benefit patients with variant (also known as Prinzmetal) angina by relaxing the smooth muscle of the epicardial coronary arteries and relieving coronary artery spasm.”

Pharmacological actions of nitrates

  • The only major action is direct nonspecific smooth muscle relaxation. Preload reduction – Nitrates dilate veins more than arteries decreased venous return (preload) → decreased end diastolic size and pressure → decreased O2 consumption.
  • The most prominant action is exerted on vascular smooth muscles.
  • Afterload reduction – Nitrates also produce some arteriolar dilatation → slightly decreased total peripheral resistance (afterload).
  • Redistribution of coronary flow.
  • Other smooth muscles – Nitrates cause relaxation of bronchi, biliary tract, esophagus → can be used in biliary colic and esophageal spasm.

Q. 17 Mil) kinase inhibitor

 A Fasudil

 B

Ranolazine

 C

Amiloride

 D

Nicorandil

Ans. A

Explanation:

Ans. a. Fasudil


Q. 18

Drug causing decrease in late sodium current ‑

 A

Nicorandil

 B

Ranolazine

 C

Trimetazidine

 D

Molsidomine

Ans. B

Explanation:

Ans. is ‘B’ i.e., Ranolazine

Ranolazine

  • Ranolazine is an effective newer anti-anginal drug but unlike CCBs and beta-blockers it does not significantly alter the heart rate or blood pressure.
    • Ranolazine alters the trans-cellular late sodium current and affects the sodium-dependent calcium channels during myocardial ischemia thus prevents calcium overload, resulting in reduced oxygen demand, and prevent angina.
    • Ranolazine is useful as add-on therapy in chronic stable angina which is refractory to more standard anti-anginal medication. However, it is not found to be useful in acute coronary syndrome.

Q. 19 Drug of choice for classical angina attack ‑

 A CCBs

 B

β-blocker

 C

GTN

 D

Prazocin

Ans. C

Explanation:

Ans. is ‘c’ i.e., GTN 

PHARMACOLOGICALTREATMENT OF STABLE (CLASSICALANGINA)

  • For immediate pre-exertional prophylaxis and acute attack
  • Sublingual glyceral trinitrate (Drug of choice)
  • Acts by decreasing preload (LV filling pressure → myocardial oxygen demand).
  • Also cause redistribution of blood flow to the ischemic zone by dilating conducting coronary vessels.
  • Nifedipine by bite capsule
  • Decrease myocardial oxygen demand by decreasing contractility and arterial pressure.
  • Also dilates coronary artery.

For long term prophylaxis

  • fl-blockers (DOC)
  • They reduces the myocardial oxygen demand by inhibiting the increase in heart rate, arterial pressure and myocardial contractility caused by adrenergic stimulation.
  • CCBs 
  • Are used if coronary spasm is suspected or P-blockers are contraindicated.
  • Long acting nitrates o Usually avoided because of development of tolerance.
  • Nicorandil (Potassium-channel opener)
  • Decreases preload (venodilatation) and L.V. filling pressure –> myocardial oxygen demand.
  • ACE inhibitors
  • Particularly useful in patient at increased risk, especially if DM or LV dysfunction is present, and in those who have not achieved adequate control of blood pressure by 13-blockers.

Q. 20 Treatment of choice for prinzmetal’s angina 

 A Nitroglycerine

 B

CCBs

 C

P-blockers

 D

Prazosin

Ans. A

Explanation:

Ans. is ‘a’ i.e., Nitroglycerine 

Treatment of variant angina

  • Prinzmetal’s variant angina is due to spasm of coronary vessels.
  • The drugs which dilate the coronary vessels, are the main treatment of Prinzmental’s angina.
  • Drugs are :
  1. Nitrates
  2. Calcium channel blockers (verapamil, diltiazem)
  • Nitroglycerin is considered the drug of choice for the patient with variant angina.
  • Prazosin a selective a-blocker may also be used because it prevents a mediated vasospasm.
  • ii-blocker’s are contraindicated because they cause constriction of coronary artery due to unopposed a mediated vasoconstriction.

Prevention of variant angina

  • In contrast Nitrates are not used for the prevention of variant angina because of delevelopment of tolerance.
  • CCBs are the DOC for prevention.


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