Mr Z is a 48-year-old man who presents to the general medicine clinic complaining of recent onset of chest pain (CP) on exertion. He says that he was feeling fine until about a week ago when he started experiencing intermittent CP while mowing the lawn. He also states that the CP subsides after sitting down in the shade and resting for about 5 minutes.
FamilyHistory: Father who died at age 46 secondary to coronary artery disease (CAD).
Smoking History: One pack of cigarettes per week for 20 years.
Conclusion
After the cardiac work-up for Mr Z, it was concluded that he had a diagnosis of unstable angina. He was prescribed nitroglycerin sublingual tablets for chest pain and a beta-blocker to help decrease the workload of the heart and decrease myocardial oxygen demand. His lipid panel revealed elevated cholesterol (250 mg/dL with lowdensity lipoprotein [LDL] 140 mg/dL and high--density lipoprotein [HDL] 40 mg/dL) and triglycerides (296 mg/dL). He was started on atorvastatin to help lower his cholesterol because it is a component of atherosclerotic plaques. Smoking cessation counseling was given, and the patient was advised to start on nicotine patches.
Angina pectoris is a symptom of ischemic heart disease that is frequently characterized by chest pain. There are three basic categories of angina: stable (exertional) angina, unstable angina. and vasospastic angina. Both stable and unstable angina reflect underlying atherosclerotic narrowing of coronary arteries. Vasospastic angina, or Prinzmetal's variant angina, is usually not associated with CAD and is due to coronary spasms that result in decreased myocardial blood flow.
Nitrates are the drugs of choice for relieving angina because they decrease preload and myocardial oxygen demand by venous dilatation. In addition, nitrates dilate coronary arteries even in the setting of atherosclerosis. The two proposed mechanisms by which nitrates promote venodilatation are stimulation of cyclic guanosine monophosphate (GMP) production and inhibition of thromboxane synthetase.
Adverse effects
Headache
Postural hypotension
Syncope
After several days of therapy, tolerance develops and headache and hypotension should resolve.Patients with nitrate induced syncope should have their dose reduced.
Drug interactions
Sildenafil is contraindicated because of potentiation of hypotensive effects of Nitrates.
