Pharmacological management of Ischaemic heart disease and acute myocardial infarction - PowerPoint PPT Presentation

1 / 50
About This Presentation
Title:

Pharmacological management of Ischaemic heart disease and acute myocardial infarction

Description:

Pharmacological management of Ischaemic heart disease and acute myocardial infarction Hamid Shamsolkottabi MD Cardiologist Sina Heart Center, Esfahan, IRAN – PowerPoint PPT presentation

Number of Views:365
Avg rating:3.0/5.0
Slides: 51
Provided by: Noelk150
Category:

less

Transcript and Presenter's Notes

Title: Pharmacological management of Ischaemic heart disease and acute myocardial infarction


1
Pharmacological management of Ischaemic heart
disease and acute myocardial infarction
  • Hamid Shamsolkottabi MD
  • Cardiologist
  • Sina Heart Center, Esfahan, IRAN

2
Atherosclerosis
  • The complications of atherosclerosis constitute
    the greatest cause of morbidity and mortality in
    the Western World accounting for 40 of all deaths

3
Atherosclerosis
  • Progressive luminal narrowing
  • - angina pectoris
  • - intermittent claudication
  • Plaque rupture and thrombosis
  • - acute coronary syndromes
  • - transient ischaemic attack
  • Aneurysm formation

4
Aims of treatment
  • Relieve symptoms
  • Slow disease progression
  • Reduce risk of acute event
  • Improve survival

5
Management overview
  • Pharmacological treatment
  • Managing risk factors
  • Interventional procedures

6
Angina pectoris
  • Myocardial oxygen demand
  • exceeds supply ? chest pain
  • Stable angina
  • - transient myocardial ischaemia
  • - predictable, reproducible
  • - relieved by rest or GTN

7
Principles of treatment
  • Increase oxygen supply or reduce oxygen demands
    of myocardium
  • Reduce heart rate
  • Reduce preload
  • Reduce afterload
  • Improve coronary blood flow

8
Symptomatic treatment
  1. Nitrates
  2. Beta blockers
  3. Calcium channel blockers
  4. Potassium channel activators
  5. Selective pacemaker If current inhibitorIvabradine
    (Procolalan)

9
Describing any drug
  • MOA and pharmacological properties
  • Indications
  • Cautions/Contraindications
  • Side effects
  • Important interactions
  • Dose/overdose

10
Nitrates - Mode of action
  • Metabolised to release Nitric oxide (NO)
  • ? cGMP
  • Dephosphorylation of myosin light chains
  • Increased intracellular calcium
  • Muscle relaxation

11
Nitrates - Mode of action
  • Venodilation - ? preload
  • Coronary artery vasodilation - ? supply
  • Moderate arteriolar dilation - ? afterload

12
Pharmacological properties
  • Glyceryl trinitrate (GTN)
  • short acting, first pass metabolism
  • sublingual/intravenous/patch administration
  • Isosorbide dinitrate
  • intermediate acting
  • sublingual/intravenous/oral administration
  • Isosorbide mononitrate
  • long acting
  • oral administration

13
Alfred Nobel
14
Pharmacological properties
  • Tolerance (tachyphylaxis)
  • - reduced therapeutic effects
  • Monday morning sickness
  • ? due to depletion of free tissue SH
  • Long-acting preparations /infusions/transdermal
    patches
  • Nitrate free period

15
Indications
  • Relief of acute angina attack
  • Prophylaxis of stable angina
  • (prior to exercise GTN or long-acting)
  • Left ventricular failure

16
Cautions/Contraindications
  • Hypotension
  • Aortic stenosis
  • HOCM
  • Constrictive pericarditis

17
Side effects
  • Headache
  • Flushing
  • Dizziness
  • Postural hypotension
  • Tachycardia
  • Overdose rarely precipitates methaemoglobinaemia

18
Important interaction
  • Phosphodiesterase inhibitors eg sildenafil
  • Inhibits cGMP breakdown
  • severe hypotension
  • nitrates contraindicated if taken within the
    previous 24 hours
  • Infusion reduces anticoagulant effect of heparin

19
Beta blockers
20
Mode of action
  • Competitive inhibitors of catecholamine at
    beta-adrenoceptor sites
  • Inhibit sympathetic stimulation of heart and
    smooth muscle
  • ? HR ? contractility ß1
  • Vasoconstriction bronchoconstriction ß2

21
Pharmacological properties
  • Cardioselective eg atenolol metoprolol
  • Non selective eg propranolol
  • Intrinsic sympathomimetic (partial agonist)
    activity eg celiprolol pindolol
  • Alpha-blocking activity eg carvedilol
  • Lipid soluble (eg propranolol) versus water
    soluble (eg atenolol)
  • Up-regulation of receptors withdrawal syndrome

22
Indications
  • Symptomatic angina
  • Hypertension
  • Acute coronary syndromes
  • Post myocardial infarction
  • Stable heart failure
  • Arrhythmias
  • Thyrotoxicosis/Benign essential tremor

23
Cautions/Contraindications
  • C/I in asthma
  • Uncontrolled heart failure
  • Bradycardia
  • Heart block
  • Phaeochromocytoma without prior alpha blockade
  • Caution coronary spasm/COPD/PVD
  • Avoid abrupt withdrawal

24
Important Interaction
  • Verapamil and beta blockers ? precipitate heart
    block - asystole
  • Must NOT give IV verapamil to beta blocked
    patients
  • Extreme caution combined orally

25
Side effects
  • Beta-1 effects Bradycardia, heart block, heart
    failure
  • Beta-2 effects bronchospasm, worsening PVD,
    Raynauds phenomenon
  • Fatigue, depression, nightmares, impotence
  • May mask hypoglycaemia and worsen glycaemic
    control in IDDM

26
Dose
  • Rational choice - long-acting cardioselective
    beta blocker od or bd
  • Anti-anginal effects are dose related
  • Titrate to resting heart rate 50-60 bpm

27
Calcium antagonists
28
Mode of action
  • Prevent opening of voltage-gated calcium channels
  • Bind to ?-1 subunit of cardiac and smooth muscle
    L-type calcium channels
  • Vasodilator effect on resistance vessels ?
    afterload
  • Coronary artery dilation
  • Negative chronotropic
  • Negative inotropic effects

29
Pharmacological properties
  • 3 classes
  • Phenylalkylamines eg verapamil
  • - relatively cardioselective
  • - -ve chronotropic and inotropic
  • Dihydropyridines eg nifedipine amlodipine
  • - relatively smooth muscle selective
  • - potent vasodilator
  • Benzothiazepines eg diltiazem
  • - intermediate

30
Indications
  • Symptomatic control of angina
  • Coronary spasm
  • Hypertension
  • Arrhythmias
  • Subarachnoid haemorrhage (nimodipine)

31
Side effects
  • Peripheral vasodilation
  • - flushing, headache, ankle oedema
  • Cardiac effects
  • - AV block, heart failure
  • Constipation
  • Short-acting dihydropyridines a/w ? mortality and
    MI

32
Potassium channel activators
33
Potassium channel activators - nicorandil
  • Activates K ATP channel
  • NO donor effects
  • Arterial and venodilator
  • S/E Flushing, dizziness, headache
  • Usually 3rd or 4th line agent

34
Selective pacemaker If current inhibitor
  • Ivabradine (Procolalan)
  • reduces spontaneous beating rate of the sinus
    node by slowing the diastolic depolarization
    slope of the action potential
  • selective and prolonged reduction in heart rate,
    both at rest and during exercise
  • Indicated for angina where cannot give a beta
    blocker
  • Ongoing trials (Beautiful trial)

35
Additional therapy in stable angina
  • Low-dose aspirin
  • Lipid lowering therapy
  • ACE inhibitors
  • Treat ?BP and diabetes
  • Smoking cessation
  • Weight reduction
  • Intervention

36
Antiplatelet agents
  • Aspirin inhibits cyclo-oxygenase and
    thromboxane A2 synthesis
  • Theinopyridines clopidogrel block binding of
    ADP to platelet receptor
  • Glycoprotein IIb/IIIa inhibitors (abciximab)
    inhibit cross-bridging of platelets by fibrinogen

37
Acute coronary syndrome
  • Angina at rest gt20mins
  • New onset angina severely affecting exercise
    tolerance
  • Increasing frequency or duration or occurring
    with lesser exertion

38
Acute coronary syndromes
  • Plaque rupture and coronary thrombosis
  • Unstable angina
  • Non-ST elevation MI (subendocardial infarction)
  • Acute transmural myocardial infarction

39
Goals of treatment
  • Relief of ischaemic pain
  • Assess haemodynamic state
  • Anti-platelet therapy to prevent further
    thrombosis
  • Initiate reperfusion therapy with percutaneous
    angioplasty or thrombolysis if appropriate
  • Secondary prevention

40
Initial Management
  • Oxygen
  • Aspirin 150-300mg chewed/dispersible
  • Nitrates GTN 0.4mg sublingual - IV
  • Intravenous morphine 2.5-10mg antiemetic
    cyclizine 50mg
  • Decide on definitive treatment
  • Beta-blocker atenolol 5mg over 5 mins repeated
    after 10-15 mins
  • Clopidogrel 300mg if undergoing PCI
  • Glycoprotein IIb/IIIa inhibitors (abciximab) if
    undergoing PCI
  • ACE inhibitor within 24 hours
  • Tight glycaemic control
  • Optimise potassium and magnesium

41
Definitive treatment-ST elevation Myocardial
infarction
  • Primary coronary angioplasty
  • 90 recanalisation
  • Door to balloon time lt90mins ? up to 3hrs
  • Ideal where cardiogenic shock and when
    thrombolytics contraindicated
  • clopidogrel 300mg loading dose then 75mg
    od
  • Glycoprotein IIb/IIIa inhibitors
    (abciximab)

42
Definitive treatment-ST elevation Myocardial
infarction
  • Primary PCI not available
  • Thrombolysis
  • 50-60 recanalisation
  • Door to needle time lt30mins
  • Effective up to 12 hours

43
Fibrinolytic agents
44
Mode of action
  • Activate plasminogen to form plasmin which
    degrades fibrin breaking up thrombi
  • Streptokinase, alteplase, reteplase, tenecteplase
  • Streptokinase antibodies within 4 days
  • Alteplase, reteplase followed by heparin for 48
    hours

45
Indications
  • Acute ST elevation myocardial infarction
  • Acute pulmonary embolism
  • Acute ischaemic stroke within 3 hours

46
Contraindications
  • Recent haemorrhage trauma or surgery
  • Recent dental extraction
  • Coagulation defectsbleeding disorders
  • Aortic dissection
  • History of cerebrovascular disease
  • Active peptic ulceration
  • Severe menorrhagia
  • Severe hypertension
  • Active cavitating lung disease
  • Acute pancreatitis
  • Severe liver disease
  • Oesophageal varices
  • Previous reaction to streptokinase (Streptokinase)

47
Relative contraindications
  • Venepuncture (non-compressible site)
  • Recent invasive procedure
  • External chest compressions
  • Pregnancy
  • Abdominal aortic aneurysm
  • Diabetic retinopathy
  • Anticoagulant therapy

48
Side effects
  • Nausea and vomiting
  • Bleeding
  • Reperfusion arrhythmias
  • Hypotension
  • Back pain
  • Allergic reactions (esp streptokinase)

49
Unstable angina/NSTEMI
  • MONA morphine O2 nitrate aspirin
  • Heparin eg enoxaparin 1mg/kg 12 hourly
  • Beta-blocker atenolol 5mg over 5 mins repeated
    after 10-15 mins
  • Clopidogrel
  • Glycoprotein IIb/IIIa inhibitors (abciximab) if
    undergoing PCI
  • ACE inhibitor if indicated
  • Tight glycaemic control
  • Optimise potassium and magnesium

50
Reading/Website list
  • British national formulary BNF
  • www.uptodate.com
  • American heart association guidelines
Write a Comment
User Comments (0)
About PowerShow.com