ANTI-ANGINAL DRUGS TUTORIAL

1. All of the following medications can be useful for managing stable angina in a patient
with coronary artery disease except:
Amlodipine.
Atenolol.
Immediate-release nifedipine.
Isosorbide dinitrate.

2. Which side effect is associated with amlodipine?

A. Bradycardia.
B. Cough.
C. Edema.
D. QT prolongation.

3. Which medication should be prescribed to all angina patients to treat an acute

attack?
A. Isosorbidedinitrate.
B. Nitroglycerin patch.
C. Nitroglycerin sublingual tablet or spray.
D. Ranolazine.

4. A 68-year-old male with a history of angina had a MI last month, and an

echocardiogram reveals heart failure with reduced ejection fraction. He was
continued on his previous home medications (diltiazem, enalapril, and nitroglycerin),
and atenolol was added at discharge. He has only had a few sporadic episodes of
stable angina that are relieved with nitroglycerin or rest. What are eventual goals for
optimizing this medication regimen?

A. Add isosorbide mononitrate.

B. Increase atenolol.
C. Stop atenolol and increase diltiazem.
D. Stop diltiazem and change atenolol to bisoprolol.

5. A patient whose angina was previously well controlled with once-daily isosorbide
mononitrate states that recently he has been taking isosorbide mononitrate twice a
day to control angina symptoms that are occurring more frequently during early
morning hours. Which of the following is the best option for this patient?
A. Continue once-daily administration of isosorbide mononitrate but advise the
patient to take this medication in the evening.
B. Advise continuation of isosorbide mononitrate twice daily for full 24-hour
coverage of angina symptoms.
C. Switch to isosorbide dinitrate, as this has a longer duration of action than the
mononitrate.
D. Switch to nitroglycerin patch for consistent drug delivery and advise him to
wear the patch around the clock.
 6. What do the terms ‘high first-pass metabolism’ and ‘low bioavailability' mean and
why do you think GTN is not taken orally?

7. List all the adverse effects of Nitrates and Beta blockers.

8. Refer to AMH and write down counseling points on the use of the nitrate patch,
sublingual tablets and spray.

CASE
A 55-year-old man presented with complaints of tightness and discomfort over middle
part of chest felt episodically, particularly after walking briskly or climbing stairs or during
sex. This is relieved within 5–10 minutes of rest. One or two episodes occur practically every
day. He is a past smoker who quit smoking 5 years back when he was diagnosed to have
chronic obstructive pulmonary disease (COPD), for which he regularly takes 2 inhalations of
Ipratropium Br. 3 times a day and 2 puffs of salbutamol inhalation whenever he feels out of
breath. The pulse was 90/min and BP 124/82 mm Hg. The resting ECG was normal, but
stress test was positive. A diagnosis of exertional angina was made and he was prescribed—
Tab glyceryl trinitrate 0.5 mg to be put under the tongue as soon as he begins to feel the
chest discomfort, as well as before undertaking any physical exertion.
(a) Should he be prescribed another drug to be taken on a regular basis to prevent episodes
of angina? If so, which drugs can be given to him and which cannot be given?
(b) Should additional medication be given to prevent long-term complications and improve
survival?