Quiz on Treatment of Angina Pectoris

A 63-year-old male professor suffering from chest pain upon exertion is diagnosed with classical angina. A drug formulation that you should prescribe for rapid relief of symptoms, taken as needed is:
  1. Metoprolol
  2. Nitroglycerin patch
  3. Oral nitroglycerin
  4. Sublingual nitroglycerin formulation is rapidly absorbed (& avoids the first-pass metabolism), producing rapid relief of anginal pain in most patients. Remember: NITRATES are the NUMBER ONE CHOICE for the ACUTE TREATMENT of ANGINA!
  5. Verapamil

A 60-year-old Caucasian woman experiences progressive dyspnea while traveling from New Orleans to Washington, DC by airplane (nonstop). You are asked to examine her, and you make the diagnosis of acute pulmonary edema. The flight attendant brings an oxygen tank and a nasal cannula to provide supportive therapy, and you take off your tie and summon other passengers to do the same to apply rotating tourniquets to the patient’s extremities. You then ask the other passengers if they carry which of the following drugs with them, with the hope of inducing peripheral venous pooling and reducing cardiac preload in this patient?
  1. Digoxin
  2. Hydralazine
  3. Nitroglycerin
  4. Propranolol
  5. Verapamil

A drug prescribed for prophylaxis for the exertional (classical) form of angina, but NOT for variant (vasospastic) angina is:
  1. Clopidogrel
  2. Nifedipine
  3. Nitroglycerin
  4. Propranolol: Beta-blockers can block beta-2 receptors and result in "unopposed" alpha-mediated vasoconstriction in patients with vasospastic angina.
  5. Verapamil

A 59-year-old man with a history of angina is given a prescription for an oral nitrate formulation (isosorbide dinitrate) 20 mg bid. A second agent that this patient should be warned "NOT" to take while on this oral nitrate formulation is:
  1. Aspirin (low dose)
  2. Grapefruit juice
  3. Metoprolol
  4. Sildenafil Viagra & similar PDE5 inhibitors including tadalafil (Cialis) and vardenafil (Levitra) can produce potentially life-threatening hypotension if taken within 24 hrs of a nitrate. There is enough PDE5 expressed in arterial smooth muscle to produce this drug interaction. Since isosorbide dinitrte is taken daily (typically with a 14 hr dose-free interval to minimize the development of tolerance), these drugs are contraindicated.
  5. St. John's wort

A 56-year-old man with a history of exertional angina presents to the Emergency Department with blurred vision, low blood pressure, bradycardia & confusion. During his history taking, you learn that he took three tablets of his "heart medicine" (metoprolol) after forgetting to take them for 3 days. Which drug of choice should be given to reverse his cardiovascular symptoms by increasing heart rate & myocardial contractility, and thereby blood pressure as well?
  1. Atropine
  2. Glucagon: Glucagon has its own cardiac receptors that stimulate adenylate cyclase (as do beta-1 receptors). Hence it can produce similar effects as beta-1 agonists, but via an independent group of receptors that are not effected by beta-blockers. There is also less guesswork involved in picking the right dose needed to correct the patient's condition since there is no competition between the agonist (glucagon) & thge antagonist (metoprolol) involved.
  3. Insulin
  4. Isoproterenol
  5. Norepinephrine

A 63-year-old woman with exertional angina is taking atenolol 100 mg QD for the management of her angina. While the drug appears to be effective in reducing her heart rate, it has not provided an adequate change in her double product (heart rate x systolic blood pressure) at the time of onset of anginal pain during a treadmill test. A second drug that could be added to her drug regimen that could improve her treadmill performance would be:
  1. Aspirin
  2. Atropine
  3. Clopidogrel
  4. Glucagon
  5. Isosorbide dinitrate Beta-blockers increase the ejection time as well as increase the end diastolic volume, two effects that increase oxygen demand by the heart. Nitrates can reduce oxygen demand by increasing venous capacitance, thereby reducing end diastolic volume. In addition, beta-blockers reduce the reflex tachycardia that nitrates can produce (which increases oxygen demand) - so the combination of a nitrate & a beta-blocker is ideal in that they reduce each other's unwanted side effects, while producing different effects, by different mechanisms, that reduce angina.

A 57-year-old man with a history of atrial fibrillation is diagnosed with classic angina. Which of the following would be contraindicated in this patient?
  1. Diltiazem
  2. Metoprolol
  3. Nifedipine: Nifedipine is a "dihydropyridine" type L-type calcium channel blocker. These drugs are vascular-selective and will produce a fall in mean arterial blood pressure. This effect will reduce the AVN ERP by baroreceptor reflex. This is not an effect you want to produce in a patient with both AFib & angina of effort, because it will increase ventricular rate - and increase the likelihood of both an anginal attack, or a myocardial infarction.
  4. Verapamil
  5. Warfarin

A 60-year-old woman with a history of smoking presents with the chief complaint of chest pain that occurs at night while at rest. A treadmill test is negative. A 24 hr holter recording reveals transient ST elevation and AV block (suggestive of occlusion of her right coronary artery) that are temporarily associated with anginal attacks. Coronary angiography with provocative testing with acetylcholine injection reproduces her chest pain & ECG changes. Which drug will be contraindicated in her treatment?
  1. Diltiazem
  2. Isosorbide dinitrate
  3. Metoprolol: Beta blockers (both beta-1 selective and nonselective types) are contraindicated in vasospastic angina because of the concern about blocking beta-2 receptors in coronary arteries, and leaving "alpha receptors unopposed"...resulting in an enhanced likelihood of vasospasm. Beta-1 selective blockers are only selective and are not specific for only blocking beta-1 vs beta-2 receptors.
  4. Nitroglycerin sublingually
  5. Verapamil

A 73-year-old woman with a history of diabetes & angina of effort presents to the emergency department with the chief complaint of prolonged chest pain of 40 mins duration that developed while she was watching TV. She is given oxygen by nasal cannula, a chewable aspirin & a sublingual nitroglycerin tablet while her ABCs are assessed. She is placed on a heart monitor, blood pressure cuff, and pulse oximeter, and given 4 mg of morphine by i.v. push. Her ECG indicates an elevated heart rate with normal (non-elevated) ST segments and the absence of enhanced Q waves in each lead; a blood sample is taken. Both metoprolol & enoxaparin are administered. After 30 minutes her lab report indicates that her cardiac enzymes (troponin I & CK-MB) are within the normal range. The next best course of action would be to give:
  1. Lovastatin
  2. Clopidogrel this patient has the signs & symptoms of unstable angina. Clopidogrel has been proven to be beneficial in improving morbidity and mortality in a patient with unstable angina. Your score is 11%.
  3. Alteplase
  4. Warfarin

A class of antianginal medications with multiple mechanisms of action that include: decreased preload, decreased oxygen demand, decreased afterload (at high doses), and increased myocardial oxygen delivery by dilating large epicardial arteries.
  1. Beta-blockers
  2. Dihydropyridine calcium channel blockers
  3. Non-dihydropyridine calcium channel blockers

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