Antianginal drugs – classification, mechanism, uses MCQs With Answer

Antianginal drugs – classification, mechanism, uses

Antianginal drugs reduce myocardial ischemia by improving oxygen supply or decreasing demand. This concise review for B.Pharm students covers classification, mechanisms and clinical uses of major antianginal classes: nitrates, beta‑blockers, calcium‑channel blockers, late sodium current inhibitors (ranolazine), If‑current inhibitors (ivabradine), and potassium channel openers (nicorandil). Emphasis is on pharmacodynamics, pharmacokinetics, adverse effects, drug interactions (e.g., nitrates with PDE‑5 inhibitors), and practical considerations such as tolerance, dosing and combination therapy. Understanding mechanisms — decreased preload/afterload, coronary vasodilation, reduced heart rate/contractility — is essential for rational therapy. This resource prepares you for exams and clinical practice. Now let’s test your knowledge with 30 MCQs on this topic.

Q1. Which class of antianginal drugs primarily reduces myocardial oxygen demand by decreasing heart rate and contractility?

• Nitrates
• Beta‑blockers
• Calcium‑channel blockers (dihydropyridine)
• Ranolazine

Correct Answer: Beta‑blockers

Q2. Sublingual nitroglycerin relieves acute angina mainly by which mechanism?

• Blocking L‑type calcium channels in myocardium
• Inhibiting the late sodium current
• Releasing nitric oxide to increase cGMP and cause venodilation
• Opening If channels in the SA node

Correct Answer: Releasing nitric oxide to increase cGMP and cause venodilation

Q3. Which antianginal drug class is most effective for vasospastic (Prinzmetal) angina?

• Beta‑blockers (nonselective)
• Long‑acting nitrates and calcium‑channel blockers
• Ivabradine
• Ranolazine

Correct Answer: Long‑acting nitrates and calcium‑channel blockers

Q4. Ranolazine exerts its antianginal effect primarily by:

• Inhibiting PDE‑5 and increasing cGMP
• Blocking late inward sodium current (INaL) to reduce intracellular Ca2+
• Blocking beta‑1 adrenergic receptors
• Opening ATP‑sensitive K+ channels

Correct Answer: Blocking late inward sodium current (INaL) to reduce intracellular Ca2+

Q5. Ivabradine reduces anginal episodes by selectively inhibiting which ionic current?

• Rapid delayed rectifier potassium current (IKr)
• L‑type calcium current
• Funny current (If) in the SA node
• Late sodium current (INaL)

Correct Answer: Funny current (If) in the SA node

Q6. A major clinical limitation of long‑term nitrate therapy is:

• Development of tolerance with continuous exposure
• Severe bradycardia as the most common adverse effect
• Accumulation in renal failure leading to toxicity
• Direct myocardial depression causing heart failure

Correct Answer: Development of tolerance with continuous exposure

Q7. Which drug interaction is dangerous and contraindicated with organic nitrates?

• Concurrent ACE inhibitor therapy
• Concurrent PDE‑5 inhibitor (e.g., sildenafil)
• Concurrent aspirin therapy
• Concurrent atorvastatin therapy

Correct Answer: Concurrent PDE‑5 inhibitor (e.g., sildenafil)

Q8. Which calcium‑channel blocker is most likely to decrease heart rate and AV conduction?

• Amlodipine
• Nifedipine (short‑acting)
• Verapamil
• Nitroglycerin

Correct Answer: Verapamil

Q9. Nicorandil’s antianginal action combines nitrate‑like effects with:

• Beta‑adrenergic blockade
• ATP‑sensitive K+ channel opening
• Inhibition of late sodium current
• CYP3A4 induction

Correct Answer: ATP‑sensitive K+ channel opening

Q10. Which antianginal is preferred for immediate relief of an acute anginal attack?

• Sublingual nitroglycerin
• Oral amlodipine
• Oral isosorbide mononitrate once daily
• Ivabradine oral tablets

Correct Answer: Sublingual nitroglycerin

Q11. A B.Pharm student should note that isosorbide mononitrate differs from isosorbide dinitrate mainly because it:

• Is less potent as a nitrate
• Has significant first‑pass hepatic metabolism producing active metabolites
• Has better oral bioavailability and longer duration of action
• Is used only intravenously

Correct Answer: Has better oral bioavailability and longer duration of action

Q12. Which adverse effect is most characteristic of nitrates?

• Constipation
• Headache and facial flushing
• Gingival hyperplasia
• Bronchospasm

Correct Answer: Headache and facial flushing

Q13. In a patient with stable angina and asthma, which beta‑blocker property is preferred?

• Nonselective beta blockade
• High intrinsic sympathomimetic activity
• Cardioselective beta‑1 blockade
• Potent vasodilatory alpha‑blockade

Correct Answer: Cardioselective beta‑1 blockade

Q14. Combining a beta‑blocker with a dihydropyridine CCB (e.g., amlodipine) is commonly used because:

• The combination increases preload dramatically
• They act synergistically to reduce heart rate
• DHP CCBs reduce afterload while beta‑blockers reduce heart rate and contractility
• They both inhibit late sodium current

Correct Answer: DHP CCBs reduce afterload while beta‑blockers reduce heart rate and contractility

Q15. Which antianginal is associated with QT interval prolongation and requires ECG monitoring in some patients?

• Verapamil
• Ranolazine
• Nitroglycerin
• Atenolol

Correct Answer: Ranolazine

Q16. Trimetazidine, used as a metabolic modulator in angina, primarily shifts myocardial metabolism toward:

• Fatty acid oxidation
• Glucose oxidation to improve ATP efficiency
• Anaerobic glycolysis exclusively
• Ketone body utilization

Correct Answer: Glucose oxidation to improve ATP efficiency

Q17. Which statement about dosing regimens to avoid nitrate tolerance is correct?

• Continuous 24‑hour transdermal nitrate is recommended
• Use a daily nitrate‑free interval (e.g., overnight) to prevent tolerance
• Tolerance cannot be prevented, so nitrates should be avoided
• Doubling the dose daily prevents tolerance

Correct Answer: Use a daily nitrate‑free interval (e.g., overnight) to prevent tolerance

Q18. Which antianginal is contraindicated in patients with severe hepatic impairment due to extensive hepatic metabolism and CYP3A4 interactions?

• Nitroglycerin sublingual
• Ranolazine
• Isosorbide mononitrate
• Hydralazine

Correct Answer: Ranolazine

Q19. Which mechanism increases myocardial oxygen supply rather than decreasing demand?

• Venodilation reducing preload
• Coronary artery vasodilation improving coronary blood flow
• Negative inotropy lowering oxygen consumption
• Bradycardia lowering heart rate

Correct Answer: Coronary artery vasodilation improving coronary blood flow

Q20. Which class of calcium‑channel blockers is preferred when significant hypertension accompanies angina and a decrease in heart rate is not desirable?

• Dihydropyridines (e.g., amlodipine)
• Non‑dihydropyridines (verapamil, diltiazem)
• Cardioselective beta‑blockers
• Late sodium current inhibitors

Correct Answer: Dihydropyridines (e.g., amlodipine)

Q21. Which antianginal medication is useful to reduce heart rate in patients intolerant of beta‑blockers?

• Ivabradine
• Isosorbide dinitrate
• Nicorandil
• Nifedipine

Correct Answer: Ivabradine

Q22. Verapamil combined with a beta‑blocker may precipitate which adverse event due to additive effects?

• Severe hypotension with reflex tachycardia
• Severe bradycardia and AV block
• Seizures due to CNS toxicity
• Renal failure from reduced renal perfusion

Correct Answer: Severe bradycardia and AV block

Q23. Which pharmacokinetic feature is true for glyceryl trinitrate (nitroglycerin) when given orally?

• High oral bioavailability due to no first‑pass effect
• Extensive first‑pass hepatic metabolism resulting in poor oral bioavailability
• Elimination primarily unchanged in urine
• Not metabolized and excreted in bile

Correct Answer: Extensive first‑pass hepatic metabolism resulting in poor oral bioavailability

Q24. A patient on ranolazine should be monitored for which laboratory/ECG change?

• Hyperkalemia
• Prolongation of QT interval
• Marked elevation of liver enzymes in all patients
• Shortened PR interval

Correct Answer: Prolongation of QT interval

Q25. Which of the following is a reasonable first‑line strategy for chronic stable angina management?

• Immediate IV nitrates only
• Lifestyle modification, antianginal pharmacotherapy (beta‑blocker or CCB or nitrates) and secondary prevention
• Sole use of ranolazine without addressing risk factors
• Discontinue all anti‑ischemic therapy and observe

Correct Answer: Lifestyle modification, antianginal pharmacotherapy (beta‑blocker or CCB or nitrates) and secondary prevention

Q26. Which adverse effect is commonly associated with dihydropyridine calcium‑channel blockers?

• Bradycardia and AV block
• Peripheral edema due to precapillary arteriolar dilation
• Excessive salivation
• Hyperglycemia

Correct Answer: Peripheral edema due to precapillary arteriolar dilation

Q27. In acute pulmonary edema with severe hypertension, which antianginal/vasodilator may be used intravenously for rapid preload and afterload reduction?

• Oral isosorbide mononitrate
• Intravenous nitroglycerin
• Amlodipine oral
• Ivabradine oral

Correct Answer: Intravenous nitroglycerin

Q28. Which statement about beta‑blocker selection in ischemic heart disease is correct?

• Nonselective beta‑blockers are preferred in asthmatic patients
• Beta‑1 selective agents (e.g., metoprolol) are often preferred to minimize bronchospasm
• All beta‑blockers increase myocardial oxygen demand
• Beta‑blockers are contraindicated after myocardial infarction

Correct Answer: Beta‑1 selective agents (e.g., metoprolol) are often preferred to minimize bronchospasm

Q29. Which antianginal drug’s effectiveness can be reduced by concurrent therapy with strong CYP3A4 inhibitors?

• Sublingual nitroglycerin
• Ranolazine
• Isosorbide mononitrate
• Nitroprusside

Correct Answer: Ranolazine

Q30. For a patient with stable angina and resting bradycardia, which agent would be least appropriate because it further lowers heart rate?

• Ivabradine
• Atenolol
• Verapamil
• Nifedipine

Correct Answer: Nifedipine

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com