Coronary Artery Vasospasm Medication
- Author: Stanley S Wang, MD, JD, MPH; Chief Editor: Eric H Yang, MD more...
Nitrates and calcium channel blockers are the mainstays of medical therapy for vasospastic angina. Other agents have been tried with variable success, including endothelin antagonists such as bosentan.
Nitrates produce a direct, endothelium-independent vasodilatation of the large coronary arteries. In addition, they reduce preload by dilating venous capacitance vessels, which results in decreased myocardial oxygen consumption. Nitrates act as an exogenous source of nitric oxide, which causes vascular smooth muscle relaxation and may have a modest effect on platelet aggregation and thrombosis.
Nitroglycerin causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate (GMP). The result is a decrease in blood pressure. Dosage forms include sublingual, transdermal, and intravenous (IV) preparations. The distinction between short-acting preparations for treatment of acute attacks and long-acting preparations for prevention of recurrent episodes is important.
Isosorbide dinitrate relaxes vascular smooth muscle by stimulating intracellular cyclic GMP. It decreases preload and afterload, causing decreased myocardial oxygen demand. Isosorbide dinitrate is used for the treatment and prevention (sustained-release preparations) of variant angina. The onset of action is approximately 3.5 minutes, and the antianginal effect lasts about 2 hours.
Isosorbide mononitrate is used for the prevention of variant angina. The onset of action of oral isosorbide mononitrate is not sufficiently quick to permit its use as an acute antianginal agent. The half-life is approximately 5 hours.
Calcium Channel Blockers
Calcium antagonists relax coronary smooth muscle and produce coronary vasodilation, which in turn improves myocardial oxygen delivery. Dihydropyridines (eg, amlodipine and felodipine) exhibit greater vascular selectivity than nondihydropyridines (eg, verapamil and diltiazem), which also inhibit impulse conduction within the sinoatrial and atrioventricular nodes.
Nifedipine is the prototypical dihydropyridine, indicated for treatment of acute attacks and prevention of recurrent attacks. Sublingual administration is generally safe, despite theoretical concerns.
Amlodipine is generally regarded as a dihydropyridine, though experimental evidence suggests that it may also bind to nondihydropyridine binding sites. It has a substantially longer half-life than nifedipine and is administered daily. It is appropriate for prophylaxis of variant angina.
Verapamil is a nondihydropyridine that is appropriate for prophylaxis of variant angina. It is recommended for rate control in atrial fibrillation or flutter. During depolarization, verapamil inhibits the entry of calcium ions into slow channels or voltage-sensitive areas of the vascular smooth muscle and myocardium.
Diltiazem is a nondihydropyridine that is appropriate for prophylaxis of variant angina. During depolarization, it inhibits the entry of calcium ions into slow channels or voltage-sensitive areas of the vascular smooth muscle and myocardium.
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