![Page 1: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/1.jpg)
1
APPROACH TO A PATIENTWITH
CHEST PAINMPPRC CONFERENCE
Group 3 MED 2C
![Page 2: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/2.jpg)
2
GENERAL INFORMATION
Name: B.C.Age: 60 years oldGender: MaleCitizenship: Filipino Religion: Roman CatholicOccupation: FarmerAddress: BulacanSource: PatientCHIEF COMPLAINT: CHEST PAIN
![Page 3: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/3.jpg)
3
2 years
1 month
Chest pain- grade 3/10- substernal- heaviness- effort related (3km walk)- relieved after 4 minutes of rest- recurs once a month
Chest pain- grade 6/10- 10- 20 meters walk- radiation to the left arm
Consult and admission
![Page 4: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/4.jpg)
4
PAIN ASSESSMENT AND ALGORITHM
P - precipitating, aggravating, relief
Q - quality
R - radiation, location
S - severity (1-10)
T - timing
![Page 5: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/5.jpg)
5
PAST MEDICAL HISTORY
• (+) Hypertension for 10 years– Highest BP 200/100 – Usual BP 140-150/90 – On irregular intake of metoprolol 50mg
• No previous surgical illness requiring hospitalization
![Page 6: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/6.jpg)
6
FAMILY HISTORY
• Father: (+) HPN, (+) DM, sudden death at 55y/o
• Mother: (+) HPN, stroke at 60y/o
• Brother: (+) HPN, (+) DM
• Sister: (+) HPN, (+) DM
![Page 7: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/7.jpg)
7
PERSONAL AND SOCIAL HISTORY
• Patient is a rice farmer in Bulacan• Fond of eating tuyo, bagoong, alamang• 50-pack year smoking history• Drinks 1-2 bottles of gin 3x a week• No illicit drug use
![Page 8: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/8.jpg)
8
REVIEW OF SYSTEMS
• General Survey– No significant weight loss– No loss of consciousness and headache
• HEENT– No blurring of vision– No ear discharge or tinnitus
• Respiratory– No cough – No colds – No dyspnea
![Page 9: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/9.jpg)
9
REVIEW OF SYSTEMS
• Gastro-intestinal– No epigastric pain – No diarrhea– No constipation – No melena– No hematochezia
• Genitourinary– No dysuria – No frequency – No urgency – No pollakiuria
![Page 10: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/10.jpg)
10
REVIEW OF SYSTEMS
• Musculo-skeletal– No joint pains
• Endocrine/Metabolism– No polyuria – No polydypsia – No polyphagia– No heat or cold intolerance
![Page 11: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/11.jpg)
11
PHYSICAL EXAMINATION
• General Survey– Conscious– Coherent – Normosthenic – Not in Cardiopulmonary distress
• Vital Signs– BP 160/90– PR 100/min regular– RR 19/min – T 37oc
![Page 12: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/12.jpg)
12
PHYSICAL EXAMINATION
• Anthropometric Measurements– Height: 1.5 m– Weight: 52.6 kg– BMI: 23
• HEENT– Pink palpebral conjunctiva – Anicteric sclera – No nasal nor aural discharge – Moist buccal mucosa– No neck mass
![Page 13: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/13.jpg)
13
PHYSICAL EXAMINATION• Respiratory
– Symmetrical chest expansion – No retraction – Resonant, unimpaired transmission of vocal and tactile fremiti– Clear breath sounds
• Gastrointestinal– Abdomen flabby – Normoactive bowel sounds – Tympanitic, nontender – Liver dullness 10cm – Traube’s space not obliterated
• Extremities– Pulses ++ on all extremities– No pedal edema
![Page 14: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/14.jpg)
14MV
TV
PVAV
S1 S2 S1 S2
CAP
JVP 4.5cm at 45 deg
Adynamic precordium, apex beat 6th LICS AAL,
(-) heaves
![Page 15: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/15.jpg)
15
CHIEF COMPLAINT:
Chest Pain“An unpleasant sensation in the anterior wall of the thorax associated with actual or potential tissue damage and mediated by specific nerve fiber to the brain where conscious appreciation may be modified by various factors. “
Stedmans Medical Dictionary, 27th edition
![Page 16: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/16.jpg)
16
![Page 17: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/17.jpg)
17
ORGAN SYSTEMS THAT COULD BE INVOLVED
Reference: Mosby’s Guide to Physical Examination, 6th edition
![Page 18: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/18.jpg)
18
ORGAN SYSTEMS THAT COULD BE INVOLVED
Reference: Mosby’s Guide to Physical Examination, 6th edition
![Page 19: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/19.jpg)
19
![Page 20: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/20.jpg)
20
SALIENT FEATURES (SUBJECTIVE)Pertinent Positive (+)- 60 y/o male- Farmer- Chest pain- Hypertension- Preference for salty foods- 50 pack year smoking history- Alcohol drinkerFamily History- Hypertension- Diabetes mellitus- stroke
Pertinent Negative (-)- Fatigue- Dyspnea- Palpitations- Weight loss- Cough- Epigastric pain- Joint pain- Polyuria, polydypsia, polyphagia- Heat and cold intolerance
![Page 21: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/21.jpg)
21
SALIENT FEATURES
Objective
- BP 160/90- Apex beat 6th LICS AAL
![Page 22: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/22.jpg)
22
PATHOPHYSIOLOGY
![Page 23: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/23.jpg)
23
![Page 24: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/24.jpg)
24
MYOCARDIAL ISCHEMIA
• occurs when myocardial oxygen demand exceeds oxygen supply
![Page 25: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/25.jpg)
25
PATHOGENESIS OF ATHEROSCLEROSIS
![Page 26: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/26.jpg)
26
GeneticGeneticHyperlipidemiaHyperlipidemiaEndocrine (DM)Endocrine (DM)
Functional Impairment of EndotheliumFunctional Impairment of Endothelium
Increased LDL or other lipid influxIncreased LDL or other lipid influx
Initiation of InflammationInitiation of InflammationMonocyte InfluxMonocyte Influx
Initiation of InflammationInitiation of InflammationMonocyte InfluxMonocyte Influx
Inadequate Wound HealingSmooth muscle cell proliferation
Matrix DepositionAtheroma FormationThrombus Formation
Inadequate Wound HealingSmooth muscle cell proliferation
Matrix DepositionAtheroma FormationThrombus Formation
Occlusion of arteryOcclusion of artery
MECHANISM OF OCCLUSION
![Page 27: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/27.jpg)
27
![Page 28: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/28.jpg)
28Development of atherosclerotic plaque
![Page 29: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/29.jpg)
29
MAJOR RISK FACTORS•Age: male > 45 y/o female > 55 y/o•Family history in a first degree relative of premature CAD (acute MI) male relative < 55 y/o female relative < 65 y/o•Diabetes mellitus•Chronic smoking•Hypertension•Obesity•Dyslipidemia
MINOR RISK FACTORS•Sedentary lifestyle•Chronic infection/ inflammation•hyperhomocysteinemia
Reference: ATP III
![Page 30: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/30.jpg)
30
PATHOLOGY
![Page 31: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/31.jpg)
31
Showing yellowish atherosclerotic plaques
GROSS SPECIMEN OF THE HEART
Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html
![Page 32: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/32.jpg)
32
HYPERTROPHIED HEART
Image retrieved: http://www.studentconsult.com/common/cfm
![Page 33: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/33.jpg)
33
![Page 34: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/34.jpg)
34
NORMAL CORONARY ARTERY
Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html
![Page 35: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/35.jpg)
35
Abn. >75% narrowing, assoc. w/ angina
Image retrieved from: http://library.med.utah.edu/WebPath/CVHTML/CV005.html
narrowing of the lumen due to build up of atherosclerotic plaque
CORONARY ARTERY WITH ATHEROSCLEROSIS
![Page 36: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/36.jpg)
36
Normal myocardium Cardiac muscle w/ ischemia
Image retrieved: http://www.studentconsult.com/common/cfm and http://library.med.utah.edu/WebPath/TUTORIAL/MYOCARD/MI031.html
•central nuclei •syncytial arrangement of the fibers•pale pink intercalated disks
•myocytes hypertrophied•large, dark nuclei
![Page 37: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/37.jpg)
37
PLAQUE STABILIZATIONUnstable plaque
Thinner vs thickerfibrous cap
Lipid core
•Greater lipid content and loose necrotic tissue create less echo on an ultrasound (hypoechogenicity), while dense fibrous tissue in more stable plaque creates more echo
(hyperechogenicity)
Stable plaque
More vs fewerinflammatory cells
Toschi V et al. Circulation. 1997;95:594-599; Libby P. Circulation. 1995;91:2844-2850; Schartl M et al. Circulation. 2001;104:387-392.
![Page 38: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/38.jpg)
38
LV hypertrohy
Increase myocardial
oxygen demand
Necrosis
Hypoxia
Ischemia
CHEST PAINIncrease Lactic Acid
Increase anaerobic
respicration
![Page 39: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/39.jpg)
39
REFERRED PAIN
![Page 40: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/40.jpg)
40
![Page 41: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/41.jpg)
41
• Stimulus PGE2, H+ ions, bradykinin, K+ ischemia• Primary viscerosensory fibers terminate in Lamina I
& V• Spinal segments also receive cutaneous
somatosensory input from dermatomes of the chest wall and arm
• Tract cells in the posterior horn that receive somatosensory input may also be activated
• Response Cerebral cortex interprets the pain as originating from the surface of the body
![Page 42: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/42.jpg)
42
RADIOLOGIC AND ANCILLARY TESTS
![Page 43: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/43.jpg)
43
DIAGNOSTIC TESTS
• Chest X ray• ECG• Ancillary test
- Lipid profile- fasting blood sugar
Reference: Harrison’s Principles of Internal Medicine 17 th Edition
![Page 44: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/44.jpg)
44
X-RAYImportant in the diagnosis of the following:• cardiac enlargement• ventricular aneurysm• signs of heart failure
Important in assessing the degree of cardiac damage
Reference: Harrison’s Principles of Internal Medicine 17 th EditionReference: Harrison’s Principles of Internal Medicine 17 th Edition
![Page 45: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/45.jpg)
45
X-RAY
![Page 46: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/46.jpg)
46
NORMAL ECG ACTIVATIONNORMAL ECG ACTIVATION
![Page 47: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/47.jpg)
47
S-T SEGMENT ELEVATIONS-T SEGMENT ELEVATION
![Page 48: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/48.jpg)
48
S-T SEGMENT DEPRESSIONS-T SEGMENT DEPRESSION
![Page 49: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/49.jpg)
49
T-WAVE INVERSIONT-WAVE INVERSION
![Page 50: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/50.jpg)
50
ANCILLARY TESTS
• Lipid Profileo TC: < 200 mg/dLo LDL: < 130 mg/dLo HDL: > 60 mg/dL
• Fasting Blood Sugaro 70-99 mg/dL
Reference: Harrison’s Principles of Internal Medicine 17 th Edition
![Page 51: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/51.jpg)
5151
PHARMACOLOGY
![Page 52: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/52.jpg)
5252
TREATMENT GOALS
• Relieve symptoms of angina pectoris
– Correction of O2 delivery and demand imbalance for myocardial cells
– Increasing delivery– Decreasing O2 demand
• Treat any modifiable risk factors
![Page 53: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/53.jpg)
5353
BASIC PHARMACOLOGY
• Four approved drug groups:
1. Organic Nitrates2. Ca2+ Channel Blockers3. ß-Blockers4. pFOX inhibitors
![Page 54: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/54.jpg)
5454
NITROGLYCERINNO
cGMP
VASODILATION
GUANYLYL CYCLASE
NITRITES & NITRATES
• NITROGLYCERIN• MOA:
• Direct results:relaxation of veins preload, CO
• Indirect results: stimulation of guanylyl cyclase in platelets to platelet aggregation
• Increase myocardial O2 delivery
Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition
![Page 55: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/55.jpg)
5555
Ca2+ CHANNEL BLOCKERS
• MOA:
– Inhibition of Ca2+ entry
– Ca2+ transmembrane current
– Vasodilation, vascular resistance
– myocardial contractile force
• Relieves and prevents focal coronary artery spasms
• LV wall stress declines
• cardiac contractility O2 requirement
Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition
![Page 56: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/56.jpg)
5656
ß-BLOCKERS
• Management of angina with effort
• Not used for vasodilation
• O2 requirement
• MOA:
ß1 ANTAGONIST
HR, BPCONTRACTILITY
DIASTOLIC PERFUSION TIME
CORONARY PERFUSION
Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th editionReference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition
![Page 57: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/57.jpg)
5757
OTHER ANTIANGINAL DRUGS
• pFOX inhibitors: partially inhibit FA oxidation pathway
• Shift myocardial metabolism toward use of glucose instead of FA
• O2 requirement
• RANOLAZINE
Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition.Reference: Bertram Katzung, MD. Basic and Clinical Pharmacology. 10th edition.
![Page 58: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/58.jpg)
58
CLINICAL PHARMACOLOGYDRUG INDICATION NORMAL DOSE CONTRAINDICATIONS
Nitrates
Sublingual NTG Angina 0.3-0.6 mgintolerance of side effects: flushing, headache, ishchemia on withdrawal
Oral NTG Angina 2.5-5 mg q4-6h as aboveCa2+ Channel Blockers
AmlodepineAngina, Hypertension
5-10 mg once daily
intolerance to side effects: edema, constipation, hypotension
Nifedipine Angina, Hypertension 30-90 mg daily hypotension, constipation
Beta-Blockers
PropranololAngina, Hypertension 20-80 mg qid
Asthma, AV conduction block, heart failure
Clopidogrel Anti-Platelet 75 mg daily GI bleeding
Statins Hyperlipidemia 10-80 mg Liver disease
Platelet Aggregation Inhibitors
Anti-Hyperlipidemic Drugs
Reference: Harrison’s Principles of Internal Medicine, 17th EditionReference: Harrison’s Principles of Internal Medicine, 17th Edition
![Page 59: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/59.jpg)
5959
NON-PHARMACOLOGICAL APPROACH
• risk for myocardial ischemia associated with in age• Risk: Men > Women (pre-menopausal)
• Cease smoking• Maintenance of a proper diet• Exercise regularly• Decrease alcohol consumption
![Page 60: APPROACH TO A PATIENT WITH CHEST PAIN MPPRC CONFERENCE Group 3 MED 2C](https://reader033.vdocuments.us/reader033/viewer/2022052603/568146bc550346895db3edf5/html5/thumbnails/60.jpg)
60
THANK YOUTHANK YOU
MACALMA, GLENNMACAPAGAL, JUSTIN ROMEOMADRID, BIANCAMALABANAN, MICHELLEMALACA, JOSEPH CHESTERMALLARI, ROMINA GRIZELDAMALVAR, ALFREDMAMAUAG, MARY JOYMANAHAN, JOYCEMANALO, VICTORIA CAMILLEMANANSALA, PRINCESSMANCOL, MATILDE CLAIREMANDAPAT, JANICEMARANAN, REAGAN
MACALMA, GLENNMACAPAGAL, JUSTIN ROMEOMADRID, BIANCAMALABANAN, MICHELLEMALACA, JOSEPH CHESTERMALLARI, ROMINA GRIZELDAMALVAR, ALFREDMAMAUAG, MARY JOYMANAHAN, JOYCEMANALO, VICTORIA CAMILLEMANANSALA, PRINCESSMANCOL, MATILDE CLAIREMANDAPAT, JANICEMARANAN, REAGAN