¿Cuál es la causa principal de la angina variante (Prinzmetal)?

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Su causa fundamental es un **desequilibrio** entre el **requerimiento de oxígeno del miocardio** y el **oxígeno que se le suministra** a través de los vasos coronarios. Este desequilibrio lleva a una acumulación de metabolitos ácidos que provocan el dolor. ### Determinantes del Consumo de Oxígeno del Miocardio El corazón tiene una demanda de oxígeno alta y continua. Los principales factores que la aumentan son: - **Estrés en la pared ventricular:** Determinado por la presión intraventricular y el radio del ventrículo (volumen). - **Frecuencia cardiaca.** - **Contractilidad miocárdica.** Cualquier fármaco que reduzca el tamaño, la frecuencia o la fuerza de contracción del corazón disminuirá su necesidad de oxígeno. ### Determinantes del Suministro de Oxígeno al Miocardio El flujo sanguíneo coronario es inversamente proporcional a la **resistencia vascular coronaria**. - **Factores intrínsecos:** Productos metabólicos y actividad del sistema nervioso autónomo. - **Daño endotelial:** La aterosclerosis altera la capacidad de dilatación de los vasos, aumentando la resistencia. - **Presión diastólica aórtica y duración de la diástole:** El flujo coronario ocurre principalmente durante la diástole, por lo que la taquicardia reduce el tiempo de perfusión. ### Mecanismos Farmacológicos de Relajación del Músculo Liso Vascular 1. **Incremento de cGMP:** Facilita la defosforilación de la miosina, evitando su interacción con la actina. Ej: Óxido nítrico (NO) y nitratos orgánicos. 2. **Disminución del Ca2+ intracelular:** Reduce la activación de la cinasa de cadena ligera de miosina (MLCK). Ej: Bloqueadores de los canales de calcio. 3. **Estabilización de la membrana (Hiperpolarización):** Aumento de la permeabilidad al K+. Ej: Abridores de canales de K+ (Nicorandil). 4. **Incremento del cAMP:** Acelera la inactivación de la MLCK. Ej: Agonistas β2 (no usados en angina). ### Clasificación de la Angina de Pecho Tipo de Angina | Sinónimo | Mecanismo Principal | Desencadenante | Urgencia Angina de Esfuerzo | Clásica | Obstrucción ateromatosa fija (límite estructural) | Aumento de la demanda (ejercicio) | Crónico / Manejable Angina Variante | Prinzmetal | Espasmo transitorio del músculo liso coronario | Caída del aporte (independiente del esfuerzo) | Crónico / Manejable Angina Inestable | SCA sin elevación del ST | Placa fisurada con trombo lábil | Caída del aporte severa (en reposo) | Urgencia médica inminente #### Angina de Esfuerzo (Clásica) - **Fisiopatología:** Una obstrucción fija impide que el flujo coronario aumente proporcionalmente a la demanda durante el ejercicio. - **Tratamiento:** Reducir la demanda de O2 (nitratos, β-bloqueadores, bloqueadores de Ca2+). #### Angina Variante (Prinzmetal) - **Fisiopatología:** Vasoespasmo coronario reversible, con o sin ateroma subyacente. - **Diagnóstico:** Interrogatorio o pruebas de provocación en hemodinamia. - **Tratamiento:** Nitratos y bloqueadores de los canales de calcio. Los β-bloqueadores NO son eficaces. #### Angina Inestable (Síndrome Coronario Agudo) - **Fisiopatología:** Fisuramiento de una placa vulnerable con formación de un trombo lábil que causa oclusión subtotal. - **Riesgo:** Alto riesgo de infarto de miocardio fulminante. - **Tratamiento:** Medidas enérgicas para aumentar el aporte y disminuir la demanda de O2. ¿Cuál es la causa principal de la angina variante (Prinzmetal)? La angina variante es causada por un espasmo coronario que reduce el aporte de oxígeno, a diferencia de la angina de esfuerzo, que es por un aumento de la demanda. ------ ## Nitratos y Nitritos Los nitratos orgánicos son la base del tratamiento para el alivio inmediato de la angina. Su prototipo es la **Nitroglicerina**. ### Química y Almacenamiento - **Naturaleza:** Ésteres orgánicos simples del ácido nítrico. - **Prototipo:** Nitroglicerina (trinitrato de glicerilo). - **Regla de Oro:** Las tabletas sublinguales pierden potencia por volatilización y adsorción en plásticos. **Conservar siempre en frascos de vidrio bien cerrados.** No es sensible a la luz. ### Farmacocinética - **Obstáculo del primer paso hepático:** El hígado inactiva rápidamente los nitratos, dando una baja biodisponibilidad oral. - **Vías de administración para esquivar el hígado:** - **Sublingual (Rescate):** Absorción rápida en minutos. Efecto de 15-30 minutos. Ej: Nitroglicerina sublingual. - **Oral (Mantenimiento):** Requiere dosis altas para alcanzar niveles sistémicos o usar metabolitos activos. Ej: Mononitrato de isosorbida (100% biodisponibilidad). - **Transdérmica (Mantenimiento):** Parches o ungüentos para efecto prolongado. - **Inhalatoria (Obsoleta):** Nitrito de amilo, de absorción ultra-rápida pero duración muy corta y olor desagradable. ### Farmacodinamia (Mecanismo de Acción) La cascada del óxido nítrico (NO) es clave: 1. **Bioactivación:** La nitroglicerina es desnitrada por enzimas (ej. ALDH2) para liberar **ión nitrito**, que se convierte en **Óxido Nítrico (NO)**. 2. **Activación de Guanilil Ciclasa:** El NO activa la guanilil ciclasa soluble, aumentando el **cGMP**. 3. **Relajación del Músculo Liso:** El cGMP aumenta, lo que lleva a la defosforilación de la miosina y a la relajación del músculo liso vascular. ### Gradiente de Respuesta Vascular - **Venoso > Arterial:** Las venas responden a concentraciones más bajas de nitratos que las arterias. - **Efecto Principal:** Relajación venosa marcada que disminuye el **retorno venoso** y la **precarga**, reduciendo el trabajo y el tamaño del corazón. ### Efectos Clínicos en la Angina Tipo de Angina | Beneficio y Mecanismo Angina de Esfuerzo | **Beneficio:** Reducción de la demanda de O2. **Mecanismo:** Disminución del retorno venoso, volumen intracardiaco y tensión de la pared ventricular. Angina Variante (Prinzmetal) | **Beneficio:** Alivio del vasoespasmo. **Mecanismo:** Relajación directa del músculo liso en las arterias coronarias epicárdicas. Angina Inestable | **Beneficio:** Protección múltiple. **Mecanismo:** Dilata arterias epicárdicas, reduce la demanda de O2 y disminuye la agregación plaquetaria (vía IV). ### Toxicidad y Efectos Adversos - **Adversos frecuentes:** Hipotensión ortostática severa (riesgo de síncope), taquicardia refleja y cefalea intensa (por dilatación meníngea). - **Contraindicación absoluta:** **Presión intracraneal elevada** (la dilatación meníngea la exacerba). - **Peligro físico:** Retirar los parches transdérmicos antes de una desfibrilación externa para evitar arcos eléctricos y quemaduras. ### Taquifilaxia (Tolerancia) - **Definición:** Pérdida del efecto terapéutico con la exposición continua a nitratos (infusiones IV, parches sin descanso, VO frecuente). - **Mecanismos:** Agotamiento de grupos sulfhidrilos, inactivación de ALDH2 por radicales libres y activación simpático-hormonal (retención hidrosalina). - **Prevención:** Establecer **periodos libres de nitratos** (al menos 8 horas) entre dosis de formas de acción prolongada. - **Dato histórico:** "Enfermedad del lunes" en trabajadores de fábricas de explosivos, que desarrollaban tolerancia durante la semana y la perdían el fin de semana. ### Toxicidad Especial: Metahemoglobinemia - **Mecanismo:** El ion nitrito oxida el hierro ferroso de la hemoglobina a hierro férrico, formando metahemoglobina, que no transporta O2. - **Riesgo:** Dosis altas de nitritos. Especialmente en lactantes por microbiota intestinal. - **Uso histórico:** Inducir metahemoglobinemia para tratar intoxicación por cianuro. **Esquema obsoleto, hoy se usa hidroxocobalamina.** ### Otros Nitrovasodilatadores - **Nicorandil:** Mecanismo dual (liberador de NO + activador de canales KATP cardiacos). Genera preacondicionamiento miocárdico y reduce sobrecarga de Ca2+. Aprobado en Europa y Japón. - **Molsidomina:** Profármaco liberador de NO. Eficacia similar a nitratos **SIN desarrollar tolerancia**. No disponible en EE.UU. ### Preparaciones de Nitratos (Cuadro Resumen) Medicamento | Dosis | Duración de la acción **De acción corta** | | Nitroglicerina, sublingual | 0.15-1.2 mg | 10-30 minutos Dinitrato de isosorbida, sublingual | 2.5-5 mg | 10-60 minutos Nitrito de amilo, inhalante (obsoleto) | 0.18-0.3 mL | 3-5 minutos **De acción larga** | | Nitroglicerina, acción oral sostenida | 6.5-13 mg c/6-8h | 6-8 horas Nitroglicerina, ungüento 2%, transdérmico | 1-1.5 pulgadas c/4h | 3-6 horas Nitroglicerina, parche transdérmico | 10-25 mg/24h | 8-10 horas Dinitrato de isosorbida, oral | 10-60 mg c/4-6h | 4-6 horas Mononitrato de isosorbida, oral | 20 mg c/12h | 6-10 horas Tetranitrato de pentaeritritol (PETN) | 50 mg c/12h | 10-12 horas **No combinar nitratos con inhibidores de la PDE-5 (Sildenafil, Vardenafil, Tadalafil).** La combinación produce una hipotensión sinérgica severa y potencialmente mortal. Deben pasar al menos 6 horas entre la toma de un nitrato y un inhibidor de PDE-5. ¿Cuál es el mecanismo principal por el cual la nitroglicerina alivia la angina de esfuerzo? El efecto principal de la nitroglicerina es venodilatador, lo que reduce el retorno venoso (precarga), el volumen ventricular y, por tanto, el consumo de oxígeno del miocardio. ------ ## Bloqueadores de los Canales de Calcio (BCC) Son agentes de primera línea para la profilaxis de la angina y el tratamiento de la hipertensión. Actúan bloqueando los canales de calcio tipo L, principalmente en el músculo liso vascular y el cardíaco. ### Propiedades Farmacocinéticas Generales - **Vía de administración:** Activos por vía oral. Verapamilo y Diltiazem también tienen formulaciones IV. - **Metabolismo:** Alto efecto de primer paso hepático, alta unión a proteínas plasmáticas y amplio metabolismo tisular. ### Farmacodinamia - **Mecanismo Celular:** Bloquean el influjo de Ca2+ a través de los canales de tipo L, reduciendo el Ca2+ intracelular disponible para la contracción. - **Efectos Vasculares:** Producen una relajación selectiva predominante en el lecho **arterial/arteriolar** (mínimo efecto venoso). Disminuyen la resistencia vascular periférica y la presión arterial. - **Efectos Cardíacos:** Reducen la contractilidad (inotropismo negativo) y, en el caso de Verapamilo y Diltiazem, la frecuencia cardíaca (cronotropismo negativo) y la conducción AV (dromotropismo negativo). ### Espectro de Selectividad (Clave) Fármaco | Efecto Primario | Uso Clave Dihidropiridinas (Nifedipino, Amlodipino) | Vasodilatación periférica | Hipertensión Verapamilo | Depresión inotrópica, cronotrópica y dromotrópica | Arritmias y control de frecuencia Diltiazem | Equilibrio entre vasodilatación y depresión cardíaca | Angina, hipertensión ### Usos Clínicos Principales - **Cardiopatía Isquémica:** Profilaxis de angina estable y **tratamiento de elección para la angina vasoespástica (de Prinzmetal)**. - **Hipertensión Arterial:** Por su potente efecto vasodilatador. - **Arritmias Cardíacas:** Verapamilo y Diltiazem para taquicardias supraventriculares y control de frecuencia en fibrilación/aleteo auricular. - **Otras:** Profilaxis de migraña, fenómeno de Raynaud y vasoespasmo cerebral post-hemorrágico (Nimodipino, Nicardipino). ### Farmacología Clínica de los BCC más Usados Fármaco | Biodisponibilidad (%) | Vida media (t1/2) | Dosificación habitual | Indicaciones principales **Dihidropiridinas** | | | | Amlodipino | 65-90 | 30-50 h | 5-10 mg/día VO | Angina, hipertensión Nifedipino | 45-70 | 4 h | 20-40 mg c/8h VO | Angina, hipertensión, Raynaud Felodipino | 15-20 | 11-16 h | 5-10 mg/día VO | Hipertensión, Raynaud **No dihidropiridinas** | | | | Diltiazem | 40-65 | 3-4 h | 30-80 mg c/6h VO | Angina, hipertensión, arritmias Verapamilo | 20-35 | 6 h | 80-160 mg c/8h VO | Angina, hipertensión, arritmias, migraña ### Toxicidad y Efectos Adversos - **Cardiovasculares (Severos):** Depresión cardíaca excesiva, bradicardia, bloqueo AV, paro cardíaco, exacerbación de insuficiencia cardíaca. - **Leves:** Cefalea, rubor, mareos, náuseas, estreñimiento (marcado con Verapamilo) y edema periférico. ### Alerta Clínica - **Peligro de la acción corta:** Los BCC de acción corta e inmediata (como Nifedipino de liberación rápida) aumentan el riesgo de eventos cardíacos adversos y están contraindicados en angina inestable. Se deben usar formulaciones de **acción prolongada** (Amlodipino, Felodipino). **Precaución al combinar BCC y β-bloqueadores.** La combinación de Verapamilo o Diltiazem con β-bloqueadores puede producir bloqueo AV severo y depresión de la función ventricular. La Amlodipina, sin embargo, puede usarse de forma segura en pacientes con insuficiencia cardíaca. ------ ## Bloqueadores β y Nuevos Fármacos Antianginosos ### Bloqueadores β - **Mecanismo:** Antagonismo competitivo de los receptores β-adrenérgicos, reduciendo la frecuencia cardíaca, la contractilidad y la presión arterial. - **Beneficio Clínico:** Disminuyen la demanda de oxígeno. Son el pilar profiláctico de elección en angina de esfuerzo, superiores a los BCC en ensayos clínicos. - **Efectos Adicionales:** Reducen la isquemia silenciosa y la mortalidad en insuficiencia cardíaca y post-infarto. ### La Paradoja Hemodinámica - **Efecto Beneficioso:** Reducción de la demanda de O2. - **Efecto Nocivo:** Aumento del volumen telediastólico y del tiempo de eyección (aumentan la demanda de O2). - **Solución:** El uso concomitante con **nitratos** contrarresta estos efectos deletéreos. ### Perfil de Seguridad (Contraindicaciones) - **Cardiovasculares:** Bradicardia severa, bloqueo AV, síndrome taquicardia-bradicardia, insuficiencia ventricular izquierda grave e inestable. - **Respiratorias:** **Asma** y otras afecciones broncoespásticas (contraindicación absoluta para β-bloqueadores no selectivos). ### Nuevos Fármacos Antianginosos El horizonte terapéutico evoluciona hacia dianas moleculares, iónicas y metabólicas. #### Ranolazina - **Mecanismo:** Inhibe la **corriente de sodio tardía** (INa tardía). Esto reduce la entrada de sodio, disminuye la actividad del intercambiador Na+/Ca2+, baja el calcio intracelular y, por tanto, la tensión diastólica y el trabajo miocárdico. - **Efecto:** Disminuye la demanda de O2 sin afectar la FC o la PA. - **Estado Clínico:** Aprobada en EE.UU. para angina estable. Prolonga el intervalo QT pero no se asocia a torsade de pointes. - **Interacciones:** Inhibe el metabolismo de digoxina y simvastatina. #### Moduladores Metabólicos (pFOX) - **Concepto:** Cambian el sustrato energético del miocardio de ácidos grasos a glucosa, que requiere menos oxígeno por unidad de ATP producido. Optimizan el metabolismo del miocardio isquémico. - **Trimetazidina:** Inhibe la enzima 3-cetoacil-tiolasa (LC-3KAT). Eficaz en angina estable, pero **no aprobada en EE.UU.** - **Perexilina:** Mismo mecanismo que la trimetazidina, pero con riesgo de hepatotoxicidad y neuropatía periférica. Requiere monitoreo plasmático. No aprobada en EE.UU. #### Ivabradina - **Mecanismo:** Bloqueador selectivo de los canales de sodio activados por hiperpolarización en el **nodo sinusal**. - **Efecto:** Reduce la frecuencia cardíaca **sin afectar** la contractilidad, la presión arterial ni el músculo liso bronquial o gastrointestinal. - **Ventaja:** Útil cuando los β-bloqueadores están contraindicados o no son tolerados. Aprobada en Europa para angina; en EE.UU. para insuficiencia cardíaca. #### Fasudil - **Mecanismo:** Inhibidor de la **Rho cinasa (ROCK)** , una enzima que inhibe la relajación vascular. - **Efecto:** Reduce el vasoespasmo coronario. En investigación para angina. #### Alopurinol - **Mecanismo:** Inhibidor de xantina oxidasa. Reduce el estrés oxidativo endotelial. - **Efecto:** Prolonga el tiempo de ejercicio en pacientes con angina. No aprobado para esta indicación. ### Matriz de Decisión Clínica Fármaco | Mecanismo Principal | Ventaja Principal | Aprobación (EE.UU.) **Bloqueadores β** | Disminución FC, Contractilidad, PA | Pilar profiláctico. Aumenta perfusión diastólica | Sí **Ranolazina** | Inhibe INa tardía (Disminuye Ca2+) | Disminuye tensión diastólica sin afectar FC/PA | Sí **Trimetazidina** | Inhibe LC-3KAT (pFOX) | Optimiza uso de O2 (glucosa vs grasas) | No **Ivabradina** | Bloquea canales nodo SA | Disminución FC directa sin efecto inotrópico | Off-label (Angina) ¿Cuál es el mecanismo de acción de la Ranolazina en el tratamiento de la angina? Inhibe la corriente de sodio tardía (INa tardía), lo que reduce el calcio intracelular y la tensión diastólica, disminuyendo el trabajo miocárdico sin afectar la frecuencia cardíaca ni la presión arterial. ------ ## Farmacoterapia y Estrategias Clínicas La terapia de la enfermedad arterial coronaria (CAD) se divide en dos grandes estrategias: el **Escudo** y la **Espada**. ### El Escudo Basal: Prevención y Modificación de Riesgos - **Objetivo:** Tratar la enfermedad subyacente (aterosclerosis) para prevenir futuros eventos. - **Condiciones a modificar:** Hipertensión, hiperlipidemia, obesidad, tabaquismo y depresión. - **Fármacos Clave:** - **Estatinas:** Pilar para detener y revertir la enfermedad aterosclerótica. - **Antiplaquetarios:** Ácido acetilsalicílico (AAS) y Clopidogrel para prevenir trombosis. - **IECA:** Reducen el riesgo de eventos adversos en pacientes de alto riesgo. ### Angina de Esfuerzo: La Balanza de la Demanda y el Suministro - **Objetivo:** Restablecer el equilibrio reduciendo la demanda o aumentando el aporte. - **Fármacos:** Nitratos, BCC y β-bloqueadores aumentan el tiempo hasta el inicio de la angina en pruebas de esfuerzo. - **Nota:** Generalmente no cambian el umbral de la angina (la FC y PA a la que ocurre el dolor). ### Matriz de Decisión en Angina Estable Presentación del Paciente | Terapia de Elección Paciente Hipertenso | Monoterapia con BCC (acción prolongada) o β-bloqueador. Paciente Normotenso | Nitratos de acción prolongada. Terapia Combinada (Mayor Eficacia) | Propranolol + Nifedipino o Nifedipino + Verapamilo. Si falla la terapia triple | Angiografía y Revascularización (PCI o CABG). ### La Espada: Revascularización - **Objetivo:** Tratar síndromes agudos y fallas del escudo. - **Métodos:** - **Intervención Coronaria Percutánea (PCI):** Colocación de stents farmacológicos. - **Injerto de Revascularización Coronaria (CABG):** Cirugía de bypass. - **Indicación:** Angina refractaria a tres medicamentos o isquemia crítica que amenaza la vida. ### Angina Variante (Prinzmetal) - **Terapia de Elección: Nitratos y BCC.** Los BCC extinguen los ataques en ~70% de los pacientes. - **Contraindicación Crítica: Los β-bloqueadores NO son eficaces.** La revascularización quirúrgica y la angioplastia NO están indicadas. ### Síndrome Coronario Agudo (SCA) y Angina Inestable - **Urgencia:** Tratamiento agresivo e inmediato. - **Estrategia:** Aumentar el suministro y reducir la demanda de forma simultánea. - **Fármacos:** - Nitroglicerina IV. - β-bloqueadores. - BCC en casos resistentes. - Antiagregantes plaquetarios potentes (AAS + Clopidogrel). - Inhibidores de la glicoproteína IIb/IIIa (Abciximab) si se requiere PCI. ### Vía Clínica de Urgencia ```mermaid flowchart TD A["Paciente con dolor torácico en reposo"] --> B["Evaluación y ECG"] B --> C["Diagnóstico de Angina Inestable / SCA"] C --> D["Tratamiento de Urgencia"] D --> E["Nitroglicerina IV y β-bloqueadores"] E --> F["Antiplaquetarios (AAS + Clopidogrel)"] F --> G["Inhibidores de IIb/IIIa si se requiere PCI"] G --> H["Estatinas e IECA"] ``` ### Fármacos de Elección y sus ADME (Resumen) Fármaco (Prototipo) | Vía de Adm. | Característica ADME Clave | Indicación Principal Nitroglicerina | Sublingual | Alto primer paso hepático. Se usa SL para evitarlo. | Alivio agudo de angina. Mononitrato de Isosorbida | Oral | 100% de biodisponibilidad. | Profilaxis de angina. Amlodipino | Oral | Larga vida media (30-50h), una vez al día. | Profilaxis de angina e HTA. Verapamilo | Oral/IV | Alto primer paso, baja biodisponibilidad (20-35%). | Arritmias, angina, HTA. Metoprolol | Oral/IV | β-bloqueante cardioselectivo. | Profilaxis de angina, post-IAM. **Para el examen:** Recuerda siempre diferenciar el tratamiento de la **Angina de Esfuerzo** (β-bloqueadores son la primera línea) de la **Angina Variante** (BCC y nitratos son los únicos eficaces; los β-bloqueadores están contraindicados). Esta es una pregunta clásica. ------ ## Tratamiento de la Enfermedad Arterial Periférica (EAP) y Claudicación Intermitente La aterosclerosis también puede afectar las arterias de las extremidades, causando isquemia muscular durante el ejercicio, que se manifiesta como dolor (claudicación). ### La "Paradoja del Vasodilatador" - **Falla Terapéutica:** Los vasodilatadores convencionales NO son beneficiosos en la claudicación. - **Razón Fisiológica:** Los vasos distales a la obstrucción ya están dilatados al máximo en reposo como mecanismo compensatorio. Administrar vasodilatadores sistémicos no mejora el flujo en la zona isquémica. ### Arsenal Farmacológico Periférico Fármaco | Mecanismo | Efecto en PAD **Antiplaquetarios** (AAS, Clopidogrel) | Prevenir coagulación en placas sistémicas. | Reduce riesgo de IM y ACV. **Poco o ningún efecto sobre la claudicación.** **Cilostazol** | Inhibidor de PDE3 (antiagregante + vasodilatador selectivo). | **Recomendado.** Aumenta la tolerancia al ejercicio en claudicación grave. **Pentoxifilina** | Derivado de xantina. Reduce viscosidad sanguínea. | **NO se recomienda actualmente.** Eficacia dudosa. ### Intervenciones Físicas y Quirúrgicas - **Ejercicio supervisado:** Beneficio comprobado para aumentar la distancia de marcha. - **Revascularización:** Angioplastia con stent o cirugía de bypass en pacientes con isquemia grave o refractaria a tratamiento. **Resumen de Fármacos para Cardiopatía Isquémica y PAD** - **Nitratos:** Alivio agudo (SL) y profilaxis (oral, transdérmico). Mecanismo: NO → cGMP → relajación del músculo liso. Efecto principal: venodilatación (↓ precarga). Tolerancia con uso continuo. - **BCC:** Profilaxis. Dihidropiridinas (ej. Amlodipino) para HTA; Verapamilo/Diltiazem para arritmias. Mecanismo: ↓ Ca2+ intracelular. - **β-bloqueadores:** Profilaxis en angina de esfuerzo. Mecanismo: ↓ FC, contractilidad y PA. Contraindicados en asma. - **Nuevos fármacos:** Ranolazina (↓ corriente de Na+ tardía), Ivabradina (↓ FC, sin efecto inotrópico). - **PAD:** Cilostazol y ejercicio. Evitar vasodilatadores convencionales. 3d:T153b,¡Perfecto! Aquí tienes un resumen enfocado para tu examen de farmacología, con los conceptos clave y las diferencias que casi siempre caen. Vamos a ello. --- ## 🎯 Resumen de Farmacología: Cardiopatía Isquémica y Vasodilatadores ### 1. La Base: El Desequilibrio de Oxígeno La angina ocurre por un **desequilibrio** entre el oxígeno que el corazón necesita (demanda) y el que recibe (suministro). - **Aumentan la DEMANDA:** Frecuencia cardíaca, contractilidad y estrés en la pared ventricular (presión y volumen). - **Disminuyen el SUMINISTRO:** Aterosclerosis (vasos rígidos), espasmo coronario y taquicardia (reduce el tiempo de diástole, cuando el corazón se perfunde). **Regla de oro:** Cualquier fármaco que reduzca el tamaño, la frecuencia o la fuerza de contracción del corazón disminuye su necesidad de oxígeno. --- ### 2. Los Tres Pilares Clásicos: Un Resumen Comparativo Esta tabla es esencial para el examen. Grábatela. - **Prototipo:** Nitroglicerina (SL). - **Mecanismo:** Liberan NO → aumentan cGMP → relajan el músculo liso. - **Efecto principal:** Venodilatación → **↓ Precarga**. - **Uso clave:** Alivio agudo (SL) y profilaxis. - **Efectos adversos:** Cefalea, hipotensión. - **Ojo:** Tolerancia y contraindicación con sildenafil. - **Prototipos:** Amlodipino (DHP), Verapamilo/Diltiazem (no DHP). - **Mecanismo:** Bloquean canales de Ca²⁺ tipo L → ↓ Ca²⁺ intracelular. - **Efecto principal:** Vasodilatación arterial → **↓ Poscarga** (y ↓ contractilidad). - **Uso clave:** Profilaxis; **tratamiento de elección en angina de Prinzmetal**. - **Efectos adversos:** Estreñimiento (Verapamilo), edema. - **Ojo:** Evitar acción corta (Nifedipino rápido). - **Prototipo:** Propranolol, Metoprolol. - **Mecanismo:** Bloquean receptores β → ↓ FC, contractilidad y PA. - **Efecto principal:** ↓ Demanda de O₂. - **Uso clave:** **Primera línea en angina de esfuerzo**. - **Efectos adversos:** Bradicardia, broncoespasmo. - **Ojo:** **Contraindicados en asma y angina de Prinzmetal.** --- ### 3. Mecanismo de Acción Detallado: Las 4 Vías de Relajación ```mermaid flowchart TD A["Relajación del músculo liso vascular"] --> B["↑ cGMP"] A --> C["↓ Ca2+ intracelular"] A --> D["Hiperpolarización (↑ K+)"] A --> E["↑ cAMP"] B --> B1["Nitratos y NO"] C --> C1["Bloqueadores de Ca2+"] D --> D1["Nicorandil"] E --> E1["Agonistas β2 (no usados en angina)"] ``` --- ### 4. Tipos de Angina y su Tratamiento (¡Pregunta Clásica!) | Tipo de Angina | Mecanismo | Tratamiento de Elección | |---|---|---| | **Angina de Esfuerzo** | Obstrucción fija → ↑ demanda | **β-bloqueadores** (1ª línea), nitratos, BCC | | **Angina Variante (Prinzmetal)** | Espasmo coronario → ↓ aporte | **Nitratos y BCC** 🏆 | | **Angina Inestable (SCA)** | Placa fisurada + trombo | **Urgencia:** Nitroglicerina IV, β-bloqueadores, antiplaquetarios | > ⚠️ **Atención:** La angina de Prinzmetal NO se trata con β-bloqueadores, ya que pueden empeorar el espasmo. Es una pregunta de examen muy repetida. --- ### 5. Farmacocinética Clave de los Nitratos - **Problema:** El hígado los inactiva (efecto de primer paso). - **Solución:** - **Sublingual (SL):** Alivio inmediato de la angina (15-30 min de efecto). - **Oral/Transdérmico:** Para mantenimiento y profilaxis. - **Mononitrato de isosorbida:** 100% de biodisponibilidad oral. **Tolerancia (Taquifilaxia):** Se pierde el efecto con el uso continuo. - **Solución:** Periodos libres de nitratos de al menos **8 horas** (por ejemplo, no usar el parche por la noche). --- ### 6. Nuevos Fármacos Antianginosos (Resumen Rápido) | Fármaco | Mecanismo | Dato Clave | |---|---|---| | **Ranolazina** | Inhibe la corriente de sodio tardía → ↓ Ca²⁺ | No afecta FC ni PA. Prolonga QT. | | **Ivabradina** | Bloquea canales del nodo sinusal | ↓ FC sin afectar contractilidad. | | **Trimetazidina** | Inhibe la 3-cetoacil-tiolasa (pFOX) | Cambia metabolismo a glucosa (mejor eficiencia de O₂). No aprobada en EE.UU. | | **Nicorandil** | ↑ NO + activa canales K⁺ | Mecanismo dual, preacondicionamiento. | | **Cilostazol** | Inhibidor de PDE3 | Para claudicación intermitente (PAD). Aumenta distancia de marcha. | --- ### 7. Datos de Examen: Toxicidades y Contraindicaciones - **Nitratos + Sildenafil:** Hipotensión severa y **mortal**. 🚫 - **Nitratos en presión intracraneal elevada:** Contraindicados (dilatan meninges). - **Β-bloqueadores + Verapamilo/Diltiazem:** Riesgo de bloqueo AV severo. 🚫 - **Metahemoglobinemia:** Por dosis altas de nitritos (oxidan el hierro de la hemoglobina). Hoy se trata con **hidroxocobalamina** (no más nitritos). --- ### 📌 Resumen Final (Para Repasar Rápido) 1. **Angina de esfuerzo:** Disminuir demanda → β-bloqueadores, nitratos, BCC. 2. **Angina de Prinzmetal:** Aliviar espasmo → Nitratos y BCC. 3. **Angina inestable:** Urgencia → Nitroglicerina IV + antiplaquetarios + β-bloqueadores. 4. **PAD:** No uses vasodilatadores convencionales (paradoja). Usa **Cilostazol** o ejercicio. --- ¿Quieres que profundicemos en algún tema en particular, como las diferencias entre los BCC (dihidropiridinas vs no dihidropiridinas) o el mecanismo exacto de los nitratos?5:["$","$L29",null,{"value":{"GET /exams/6a8a12c01f025ad31ff5b927":{"user":null,"exam":{"questions":[{"id":"c9896967-bed6-449e-98dd-3f71f1f237c2","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se administra una tableta sublingual para el alivio inmediato de un episodio anginoso.","questionContent":"Dosis de nitroglicerina sublingual para alivio agudo","questionImage":null,"type":"single","options":[{"id":"A","text":"0.15–1.2 mg"},{"id":"B","text":"0.5–2.0 mg"},{"id":"C","text":"1.0–3.0 mg"},{"id":"D","text":"2.5–5.0 mg"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"La dosis habitual de nitroglicerina sublingual es de **0.15 a 1.2 mg**. Esta vía evita el primer paso hepático y proporciona alivio en 1–3 minutos. Las dosis más altas no son típicas para esta presentación.","helpful_links":[],"tags":[]},{"id":"2f0136cf-192e-4ada-8347-ba85018b7875","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se utiliza para el alivio o profilaxis de la angina.","questionContent":"Dosis de dinitrato de isosorbida sublingual","questionImage":null,"type":"single","options":[{"id":"A","text":"0.5–1.0 mg"},{"id":"B","text":"2.5–5 mg"},{"id":"C","text":"5–10 mg"},{"id":"D","text":"10–20 mg"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis sublingual de dinitrato de isosorbida es de **2.5 a 5 mg**, con una duración de acción de 10 a 60 minutos. Es una opción de acción intermedia.","helpful_links":[],"tags":[]},{"id":"c84a82d9-99f2-4765-95a1-77edc2dc5b95","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Esta vía se utilizaba antiguamente para el alivio rápido de la angina.","questionContent":"Dosis de nitrito de amilo inhalante (obsoleto)","questionImage":null,"type":"single","options":[{"id":"A","text":"0.1–0.2 mL"},{"id":"B","text":"0.18–0.3 mL"},{"id":"C","text":"0.3–0.5 mL"},{"id":"D","text":"0.5–1.0 mL"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis del nitrito de amilo inhalante es de **0.18 a 0.3 mL**. Su uso actualmente es obsoleto por su olor desagradable y duración extremadamente corta (3–5 minutos).","helpful_links":[],"tags":[]},{"id":"6cda160b-0369-4ec1-b455-29a02777e176","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se emplea para la profilaxis de la angina.","questionContent":"Dosis de nitroglicerina de acción oral sostenida","questionImage":null,"type":"single","options":[{"id":"A","text":"3–6 mg cada 6–8 h"},{"id":"B","text":"6.5–13 mg cada 6–8 h"},{"id":"C","text":"10–20 mg cada 12 h"},{"id":"D","text":"20–40 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La presentación oral sostenida de nitroglicerina se dosifica a **6.5–13 mg cada 6–8 horas**, con una duración de acción de 6 a 8 horas.","helpful_links":[],"tags":[]},{"id":"42ca759b-deef-4c17-ac8d-467370d8397f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se aplica sobre la piel para un efecto prolongado.","questionContent":"Dosis de nitroglicerina en ungüento al 2% transdérmico","questionImage":null,"type":"single","options":[{"id":"A","text":"0.5–1 pulgada cada 4 h"},{"id":"B","text":"1–1.5 pulgadas cada 4 h"},{"id":"C","text":"2–3 pulgadas cada 6 h"},{"id":"D","text":"1–2 pulgadas cada 12 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis del ungüento al 2% es de **1 a 1.5 pulgadas cada 4 horas**, proporcionando 3–6 horas de acción.","helpful_links":[],"tags":[]},{"id":"23ca1548-08b7-4c42-be57-58c3108a2cbd","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se coloca un parche al día para profilaxis.","questionContent":"Dosis de parche transdérmico de nitroglicerina de liberación lenta","questionImage":null,"type":"single","options":[{"id":"A","text":"5–10 mg/24 h"},{"id":"B","text":"10–25 mg/24 h"},{"id":"C","text":"25–50 mg/24 h"},{"id":"D","text":"50–100 mg/24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El parche transdérmico proporciona **10–25 mg en 24 horas** (un parche por día), con una duración efectiva de 8–10 horas antes de desarrollar tolerancia.","helpful_links":[],"tags":[]},{"id":"e9eac66d-31f8-408c-b3c6-6ebad0e42bef","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Otra formulación sublingual con duración ligeramente mayor.","questionContent":"Dosis de dinitrato de isosorbida sublingual (segunda presentación)","questionImage":null,"type":"single","options":[{"id":"A","text":"1.25–2.5 mg por 2 h"},{"id":"B","text":"2.5–10 mg por 2 h"},{"id":"C","text":"5–15 mg por 4 h"},{"id":"D","text":"10–20 mg por 6 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El dinitrato de isosorbida sublingual se dosifica a **2.5–10 mg por 2 horas**, con una duración de acción de 1.5 a 2 horas.","helpful_links":[],"tags":[]},{"id":"52753659-47a5-4f94-85de-f41d9f95b312","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Para profilaxis de angina a largo plazo.","questionContent":"Dosis de dinitrato de isosorbida oral","questionImage":null,"type":"single","options":[{"id":"A","text":"5–20 mg cada 4–6 h"},{"id":"B","text":"10–60 mg cada 4–6 h"},{"id":"C","text":"20–80 mg cada 8 h"},{"id":"D","text":"40–120 mg cada 12 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis oral es de **10 a 60 mg cada 4–6 horas**, con una duración de 4–6 horas. Es una de las formulaciones orales más usadas.","helpful_links":[],"tags":[]},{"id":"1ed7caa8-4ff3-4e40-aaa3-b584f6b86fd7","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Metabolito activo con biodisponibilidad del 100%.","questionContent":"Dosis de mononitrato de isosorbida oral","questionImage":null,"type":"single","options":[{"id":"A","text":"10 mg cada 8 h"},{"id":"B","text":"20 mg cada 12 h"},{"id":"C","text":"30 mg cada 24 h"},{"id":"D","text":"40 mg cada 6 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El mononitrato de isosorbida se administra a **20 mg cada 12 horas**, con una duración de 6 a 10 horas. Su biodisponibilidad oral es completa.","helpful_links":[],"tags":[]},{"id":"2de7b02e-b2f2-4f21-ad6e-4d56fb09e8ed","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Nitrato de acción prolongada.","questionContent":"Dosis de tetranitrato de pentaeritritol (PETN) oral","questionImage":null,"type":"single","options":[{"id":"A","text":"25 mg cada 8 h"},{"id":"B","text":"50 mg cada 12 h"},{"id":"C","text":"75 mg cada 24 h"},{"id":"D","text":"100 mg cada 6 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis de PETN es **50 mg cada 12 horas**, con una duración de 10–12 horas. Se promociona para acción prolongada.","helpful_links":[],"tags":[]},{"id":"d9056fde-8d5e-4dd3-9718-90439ac157a8","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC dihidropiridínico de acción prolongada.","questionContent":"Dosis de amlodipino en angina e hipertensión","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5 mg una vez al día"},{"id":"B","text":"5–10 mg una vez al día"},{"id":"C","text":"10–20 mg una vez al día"},{"id":"D","text":"20–40 mg una vez al día"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis habitual de amlodipino es **5 a 10 mg una vez al día**, con una vida media de 30–50 horas, permitiendo una sola toma diaria.","helpful_links":[],"tags":[]},{"id":"eada3d11-285e-4dfa-b57e-abe971a8a938","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC dihidropiridínico.","questionContent":"Dosis de nifedipino en angina (liberación prolongada)","questionImage":null,"type":"single","options":[{"id":"A","text":"10–20 mg cada 8 h"},{"id":"B","text":"20–40 mg cada 8 h"},{"id":"C","text":"30–60 mg cada 12 h"},{"id":"D","text":"40–80 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Para angina, nifedipino de liberación prolongada se dosifica a **20–40 mg cada 8 horas**. Las formulaciones de liberación inmediata están contraindicadas en angina inestable.","helpful_links":[],"tags":[]},{"id":"6bf033de-9475-4e99-a6f6-dd8f58a18e20","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC dihidropiridínico con efecto cerebral.","questionContent":"Dosis de nicardipino en angina","questionImage":null,"type":"single","options":[{"id":"A","text":"10–20 mg cada 8 h"},{"id":"B","text":"20–40 mg cada 8 h"},{"id":"C","text":"30–50 mg cada 12 h"},{"id":"D","text":"40–80 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Nicardipino se administra a **20–40 mg cada 8 horas** por vía oral, con una vida media de 2–4 horas.","helpful_links":[],"tags":[]},{"id":"7e4f9487-63ed-4a19-a269-bfb62e27a5e2","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC dihidropiridínico de acción prolongada.","questionContent":"Dosis de felodipino en hipertensión","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5 mg una vez al día"},{"id":"B","text":"5–10 mg una vez al día"},{"id":"C","text":"10–20 mg una vez al día"},{"id":"D","text":"20–40 mg una vez al día"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Felodipino se usa a **5–10 mg una vez al día**, con una biodisponibilidad de 15–20% y vida media de 11–16 horas.","helpful_links":[],"tags":[]},{"id":"9b205819-a8c7-425a-a97e-8fcad8d60a2e","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC no dihidropiridínico.","questionContent":"Dosis de diltiazem en angina","questionImage":null,"type":"single","options":[{"id":"A","text":"15–30 mg cada 6 h"},{"id":"B","text":"30–80 mg cada 6 h"},{"id":"C","text":"60–120 mg cada 8 h"},{"id":"D","text":"120–240 mg cada 12 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Diltiazem se dosifica a **30–80 mg cada 6 horas** por vía oral, con una vida media de 3–4 horas. También disponible en formulaciones de liberación prolongada.","helpful_links":[],"tags":[]},{"id":"a53e77c0-6c0b-462f-9c00-b33d4646d5f4","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"BCC no dihidropiridínico.","questionContent":"Dosis de verapamilo en angina","questionImage":null,"type":"single","options":[{"id":"A","text":"40–80 mg cada 6 h"},{"id":"B","text":"80–160 mg cada 8 h"},{"id":"C","text":"120–240 mg cada 12 h"},{"id":"D","text":"240–480 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis oral de verapamilo en angina es **80–160 mg cada 8 horas**, con una biodisponibilidad del 20–35% y vida media de 6 horas.","helpful_links":[],"tags":[]},{"id":"a349b80e-1cc4-4ea4-91a5-d4958da7a3ec","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se usa por vía IV para taquicardias supraventriculares.","questionContent":"Dosis intravenosa de verapamilo en arritmias","questionImage":null,"type":"single","options":[{"id":"A","text":"25–50 µg/kg"},{"id":"B","text":"75–150 µg/kg"},{"id":"C","text":"150–300 µg/kg"},{"id":"D","text":"1–2 mg/kg"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis IV de verapamilo es **75–150 µg/kg**, administrada en bolo. También se usa en control de frecuencia en fibrilación auricular.","helpful_links":[],"tags":[]},{"id":"e718de12-64eb-4467-9b32-f1060e45bf7f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Formulación IV para uso agudo.","questionContent":"Dosis intravenosa de diltiazem","questionImage":null,"type":"single","options":[{"id":"A","text":"25–50 µg/kg"},{"id":"B","text":"75–150 µg/kg"},{"id":"C","text":"150–300 µg/kg"},{"id":"D","text":"1–2 mg/kg"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Diltiazem IV se dosifica igualmente a **75–150 µg/kg**, similar al verapamilo, para control de arritmias o hipertensión urgente.","helpful_links":[],"tags":[]},{"id":"c1f88d8d-0202-4dcd-b4cb-ad498a1bef99","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se investiga su efecto sobre el estrés oxidativo.","questionContent":"Dosis de alopurinol en estudio para angina","questionImage":null,"type":"single","options":[{"id":"A","text":"100 mg/día"},{"id":"B","text":"300 mg/día"},{"id":"C","text":"600 mg/día"},{"id":"D","text":"900 mg/día"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"En estudios, la dosis alta de **600 mg/día** de alopurinol prolongó el tiempo de ejercicio en pacientes con angina aterosclerótica. No está aprobado para esta indicación.","helpful_links":[],"tags":[]},{"id":"8b122324-32fc-4037-8e77-5d59de6dd27c","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"A pesar de la liberación en 24 h, la eficacia hemodinámica es menor.","questionContent":"Dosis de nitroglicerina en parche (duración efectiva)","questionImage":null,"type":"single","options":[{"id":"A","text":"4–6 horas"},{"id":"B","text":"8–10 horas"},{"id":"C","text":"12–14 horas"},{"id":"D","text":"24 horas completas"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Aunque el parche libera durante 24 h, los efectos hemodinámicos completos no persisten más de **8 a 10 horas** debido al desarrollo de tolerancia.","helpful_links":[],"tags":[]},{"id":"28a280fa-00fe-4e73-bb4c-be1e82fd586f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Con biodisponibilidad completa.","questionContent":"Dosis de mononitrato de isosorbida (vida media)","questionImage":null,"type":"single","options":[{"id":"A","text":"2–4 horas"},{"id":"B","text":"6–10 horas"},{"id":"C","text":"10–12 horas"},{"id":"D","text":"12–24 horas"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La duración de acción del mononitrato de isosorbida oral es de **6 a 10 horas**, lo que permite una dosificación dos veces al día.","helpful_links":[],"tags":[]},{"id":"b982d0c5-40c6-44a9-bd6d-8b08f29fe6d7","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Forma de administración rápida.","questionContent":"Dosis de dinitrato de isosorbida oral masticable","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5–5 mg"},{"id":"B","text":"5–10 mg"},{"id":"C","text":"10–20 mg"},{"id":"D","text":"20–40 mg"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El dinitrato de isosorbida masticable se administra a **5–10 mg**, con una duración de 2–3 horas.","helpful_links":[],"tags":[]},{"id":"19d9e316-ada6-4e49-aa8b-94a809afde19","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Tabletas que se colocan entre la encía y la mejilla.","questionContent":"Dosis de nitroglicerina bucal de liberación lenta","questionImage":null,"type":"single","options":[{"id":"A","text":"0.5–1 mg cada 4 h"},{"id":"B","text":"1–2 mg cada 4 h"},{"id":"C","text":"2–4 mg cada 6 h"},{"id":"D","text":"5–10 mg cada 8 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La forma bucal de nitroglicerina se dosifica a **1–2 mg cada 4 horas**, con una duración de 3–6 horas.","helpful_links":[],"tags":[]},{"id":"7f129732-d67f-48a7-9b32-59c616be164f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Otra presentación de liberación prolongada.","questionContent":"Dosis de nitroglicerina acción oral sostenida (segundo rango)","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5–5 mg cada 6 h"},{"id":"B","text":"6.5–13 mg cada 6 h"},{"id":"C","text":"10–20 mg cada 12 h"},{"id":"D","text":"20–40 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis de acción oral sostenida es consistentemente **6.5–13 mg cada 6–8 horas**, como se indica en las tablas.","helpful_links":[],"tags":[]},{"id":"750b63c6-8b36-44cb-a6eb-de47ebbcc34f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Con duración de 10–12 h.","questionContent":"Dosis de PETN (vida media)","questionImage":null,"type":"single","options":[{"id":"A","text":"25 mg cada 8 h"},{"id":"B","text":"50 mg cada 12 h"},{"id":"C","text":"75 mg cada 24 h"},{"id":"D","text":"100 mg cada 6 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El tetranitrato de pentaeritritol se dosifica a **50 mg cada 12 horas**, siendo una de las opciones de acción más prolongada.","helpful_links":[],"tags":[]},{"id":"4c5390d7-1aa6-42ee-b78e-aa3da9ca188d","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Alternativa a las tabletas.","questionContent":"Dosis de nitroglicerina en aerosol sublingual","questionImage":null,"type":"single","options":[{"id":"A","text":"0.2 mg por pulverización"},{"id":"B","text":"0.4 mg por pulverización"},{"id":"C","text":"0.8 mg por pulverización"},{"id":"D","text":"1.2 mg por pulverización"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El aerosol sublingual de nitroglicerina suele administrar **0.4 mg por pulverización**, con efectos similares a la tableta.","helpful_links":[],"tags":[]},{"id":"ed51de44-bfd9-4151-b0c8-b7b1329e0971","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"No se especifica en el material, pero se puede inferir que no es una presentación común. (Pregunta de control)","questionContent":"Dosis de dinitrato de isosorbida en parche (no mencionado)","questionImage":null,"type":"single","options":[{"id":"A","text":"5 mg/24 h"},{"id":"B","text":"10 mg/24 h"},{"id":"C","text":"25 mg/24 h"},{"id":"D","text":"No está disponible en parche"}],"correctOptions":["D"],"matches":[],"match_pairs":[],"explanation":"El dinitrato de isosorbida no tiene presentación en parche transdérmico; esa forma es exclusiva de la nitroglicerina.","helpful_links":[],"tags":[]},{"id":"66253294-2c50-40d8-984a-6372d8ee775c","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Indicación adicional.","questionContent":"Dosis de verapamilo en migraña","questionImage":null,"type":"single","options":[{"id":"A","text":"40–80 mg cada 8 h"},{"id":"B","text":"80–160 mg cada 8 h"},{"id":"C","text":"120–240 mg cada 12 h"},{"id":"D","text":"240 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Para migraña, verapamilo se usa a la misma dosis que en angina: **80–160 mg cada 8 horas**, aunque no es una indicación de primera línea.","helpful_links":[],"tags":[]},{"id":"2ab4e8fd-31a5-490a-9ed0-53a4da987a27","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Forma de liberación sostenida para una toma diaria.","questionContent":"Dosis de diltiazem en hipertensión (liberación prolongada)","questionImage":null,"type":"single","options":[{"id":"A","text":"120–240 mg una vez al día"},{"id":"B","text":"180–360 mg una vez al día"},{"id":"C","text":"240–480 mg una vez al día"},{"id":"D","text":"30–80 mg cada 6 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"En liberación prolongada, diltiazem se dosifica a **180–360 mg una vez al día**. La forma convencional es 30–80 mg cada 6 h.","helpful_links":[],"tags":[]},{"id":"d466b9d0-72d2-4c91-9981-a61ee0f068e8","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Permite dosificación una vez al día.","questionContent":"Dosis de amlodipino (vida media)","questionImage":null,"type":"single","options":[{"id":"A","text":"24 horas"},{"id":"B","text":"30–50 horas"},{"id":"C","text":"60–90 horas"},{"id":"D","text":"más de 100 horas"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La vida media de amlodipino es de **30 a 50 horas**, lo que justifica su administración diaria.","helpful_links":[],"tags":[]},{"id":"e621ea74-4c0b-439f-a8c4-bf10a0e19194","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Indicación adicional.","questionContent":"Dosis de nifedipino en fenómeno de Raynaud","questionImage":null,"type":"single","options":[{"id":"A","text":"10–20 mg cada 8 h"},{"id":"B","text":"20–40 mg cada 8 h"},{"id":"C","text":"30–60 mg cada 12 h"},{"id":"D","text":"40–80 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Para Raynaud, la dosis de nifedipino de liberación prolongada es la misma que para angina: **20–40 mg cada 8 horas**.","helpful_links":[],"tags":[]},{"id":"b20a910a-a29d-4e69-aa5c-b7ba1fe0dfec","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Otra dihidropiridina útil.","questionContent":"Dosis de felodipino en Raynaud","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5 mg una vez al día"},{"id":"B","text":"5–10 mg una vez al día"},{"id":"C","text":"10–20 mg una vez al día"},{"id":"D","text":"20–40 mg una vez al día"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Felodipino se dosifica a **5–10 mg una vez al día** para hipertensión y Raynaud.","helpful_links":[],"tags":[]},{"id":"0175ae1e-b7ed-4ab6-b997-b12e42d0c19e","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se usa por vía intravenosa o intracerebral.","questionContent":"Dosis de nicardipino en vasoespasmo cerebral","questionImage":null,"type":"single","options":[{"id":"A","text":"1–2 mg/h IV"},{"id":"B","text":"3–5 mg/h IV"},{"id":"C","text":"5–15 mg/h IV"},{"id":"D","text":"20–30 mg/h IV"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"Nicardipino se infunde a **5–15 mg/h IV** para prevenir el vasoespasmo cerebral post-hemorrágico, aunque la dosis exacta puede variar.","helpful_links":[],"tags":[]},{"id":"7c547b1a-5030-4e5d-bd7c-dd0413318f3b","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Históricamente usado por su alta afinidad cerebral.","questionContent":"Dosis de nimodipino (retirado) en vasoespasmo cerebral","questionImage":null,"type":"single","options":[{"id":"A","text":"60 mg cada 4 h"},{"id":"B","text":"60 mg cada 6 h"},{"id":"C","text":"120 mg cada 8 h"},{"id":"D","text":"30 mg cada 12 h"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"Nimodipino se administraba a **60 mg cada 4 horas** para reducir la morbilidad tras hemorragia subaracnoidea, aunque ya está retirado en algunos países.","helpful_links":[],"tags":[]},{"id":"291b132a-b609-4045-b586-2402067a0855","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se usa en situaciones agudas.","questionContent":"Dosis de nitroglicerina intravenosa en angina inestable","questionImage":null,"type":"single","options":[{"id":"A","text":"1–5 µg/min"},{"id":"B","text":"5–20 µg/min"},{"id":"C","text":"20–50 µg/min"},{"id":"D","text":"50–100 µg/min"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La infusión IV de nitroglicerina suele iniciarse a **5–20 µg/min** y titularse según respuesta, aunque el texto no especifica una dosis exacta, es un rango clínico común.","helpful_links":[],"tags":[]},{"id":"1d5a2da5-0246-49fc-842b-3498222fdc37","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Se absorbe completamente por vía oral.","questionContent":"Dosis de isosorbida mononitrato (biodisponibilidad 100%)","questionImage":null,"type":"single","options":[{"id":"A","text":"5 mg cada 12 h"},{"id":"B","text":"10 mg cada 12 h"},{"id":"C","text":"20 mg cada 12 h"},{"id":"D","text":"40 mg cada 12 h"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La dosis estándar de mononitrato de isosorbida es **20 mg cada 12 horas**, aprovechando su biodisponibilidad total.","helpful_links":[],"tags":[]},{"id":"db2717bd-44b8-493b-83c3-63494a196fe6","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Modulador metabólico.","questionContent":"Dosis de trimetazidina (no aprobada en EE.UU.)","questionImage":null,"type":"single","options":[{"id":"A","text":"20 mg cada 8 h"},{"id":"B","text":"35 mg cada 12 h"},{"id":"C","text":"70 mg al día"},{"id":"D","text":"100 mg al día"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Trimetazidina se usa a **35 mg cada 12 horas** en países donde está aprobada, aunque no en EE.UU.","helpful_links":[],"tags":[]},{"id":"ab86f891-48ed-4bbb-8ef8-0bb48eeae798","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Requiere monitoreo por toxicidad.","questionContent":"Dosis de perexilina (control plasmático)","questionImage":null,"type":"single","options":[{"id":"A","text":"100 mg al día"},{"id":"B","text":"200 mg al día"},{"id":"C","text":"400 mg al día"},{"id":"D","text":"600 mg al día"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La perexilina se dosifica típicamente a **200 mg al día** pero requiere ajuste según niveles plasmáticos debido a riesgo de hepatotoxicidad y neuropatía.","helpful_links":[],"tags":[]},{"id":"877a06be-259e-451f-b43a-d38ef01fea65","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Reduce la frecuencia cardíaca.","questionContent":"Dosis de ivabradina (para angina, off-label en EE.UU.)","questionImage":null,"type":"single","options":[{"id":"A","text":"2.5 mg cada 12 h"},{"id":"B","text":"5 mg cada 12 h"},{"id":"C","text":"7.5 mg cada 12 h"},{"id":"D","text":"10 mg cada 12 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Ivabradina se inicia a **5 mg cada 12 horas**, ajustable a 7.5 mg si es necesario. Está aprobada para insuficiencia cardíaca en EE.UU. y para angina en Europa.","helpful_links":[],"tags":[]},{"id":"b478b820-5813-489f-abef-3bb56449162d","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Aprobada en EE.UU. para angina estable.","questionContent":"Dosis de ranolazina","questionImage":null,"type":"single","options":[{"id":"A","text":"250 mg cada 12 h"},{"id":"B","text":"500 mg cada 12 h"},{"id":"C","text":"750 mg cada 12 h"},{"id":"D","text":"1000 mg cada 12 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Ranolazina se inicia a **500 mg cada 12 horas**, pudiendo aumentarse a 1000 mg cada 12 h. No se especifica en el texto, pero es un dato clínico común.","helpful_links":[],"tags":[]},{"id":"7d2e29e3-005b-4cd5-a96b-477ba406475e","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Inhibidor de PDE3.","questionContent":"Dosis de cilostazol en claudicación","questionImage":null,"type":"single","options":[{"id":"A","text":"50 mg cada 12 h"},{"id":"B","text":"100 mg cada 12 h"},{"id":"C","text":"150 mg cada 12 h"},{"id":"D","text":"200 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Cilostazol se administra a **100 mg cada 12 horas** para mejorar la tolerancia al ejercicio en claudicación grave.","helpful_links":[],"tags":[]},{"id":"9bcfd957-5a38-45c5-8483-b0002ed30fa3","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Derivado de xantina.","questionContent":"Dosis de pentoxifilina (no recomendada)","questionImage":null,"type":"single","options":[{"id":"A","text":"400 mg cada 8 h"},{"id":"B","text":"400 mg cada 12 h"},{"id":"C","text":"600 mg cada 24 h"},{"id":"D","text":"800 mg cada 8 h"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"Pentoxifilina se dosifica a **400 mg cada 8 horas**, pero actualmente no se recomienda para claudicación por su escasa eficacia.","helpful_links":[],"tags":[]},{"id":"fbdc608e-f212-4864-8b80-9c23d911dd99","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Antagonista 5-HT2.","questionContent":"Dosis de naftidrofurilo (no disponible en EE.UU.)","questionImage":null,"type":"single","options":[{"id":"A","text":"100 mg cada 8 h"},{"id":"B","text":"200 mg cada 12 h"},{"id":"C","text":"300 mg cada 24 h"},{"id":"D","text":"400 mg cada 8 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Naftidrofurilo se usa a **200 mg cada 12 horas** en países donde está aprobado, con efectos similares al cilostazol.","helpful_links":[],"tags":[]},{"id":"cc756a4b-e169-48a2-8469-c84db7e272ca","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Para evitar sobredosis.","questionContent":"Dosis de nitroglicerina en ungüento (máximo por aplicación)","questionImage":null,"type":"single","options":[{"id":"A","text":"1 pulgada"},{"id":"B","text":"2 pulgadas"},{"id":"C","text":"3 pulgadas"},{"id":"D","text":"4 pulgadas"}],"correctOptions":[],"matches":[],"match_pairs":[],"explanation":"La dosis recomendada es **1 a 1.5 pulgadas** de ungüento al 2% cada 4 horas. Aplicar más no aumenta el beneficio y eleva el riesgo de hipotensión.","helpful_links":[],"tags":[]},{"id":"2820bbc4-5908-4bb0-8a3b-4b38ae6abdbe","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Para evitar tolerancia se usan periodos libres.","questionContent":"Dosis de parche de nitroglicerina (mínimo efectivo)","questionImage":null,"type":"single","options":[{"id":"A","text":"5 mg/24 h"},{"id":"B","text":"10 mg/24 h"},{"id":"C","text":"15 mg/24 h"},{"id":"D","text":"25 mg/24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El parche de **10 mg/24 h** es la dosis inicial habitual, aunque se puede escalar hasta 25 mg.","helpful_links":[],"tags":[]},{"id":"6d3fde5f-6d90-4967-b4ed-82f0d52316a6","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"No se especifica en la tabla, pero se puede deducir.","questionContent":"Dosis de dinitrato de isosorbida (liberación sostenida oral)","questionImage":null,"type":"single","options":[{"id":"A","text":"10–20 mg cada 12 h"},{"id":"B","text":"20–40 mg cada 12 h"},{"id":"C","text":"40–80 mg cada 24 h"},{"id":"D","text":"60–120 mg cada 24 h"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Las formas de liberación sostenida de dinitrato suelen dosificarse a **20–40 mg cada 12 horas**, aunque el texto no lo detalla, es una práctica común.","helpful_links":[],"tags":[]},{"id":"df0f76eb-bf4c-47f2-8d27-3416b04d911f","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Para evitar efectos adversos.","questionContent":"Dosis de verapamilo (máxima diaria)","questionImage":null,"type":"single","options":[{"id":"A","text":"240 mg"},{"id":"B","text":"360 mg"},{"id":"C","text":"480 mg"},{"id":"D","text":"600 mg"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La dosis máxima diaria de verapamilo en angina suele ser **480 mg** (dividida en 3 tomas). 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Por encima de esta dosis se incrementa la depresión cardíaca.","helpful_links":[],"tags":[]},{"id":"96e2304c-7375-45c0-be4e-0ad772188579","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Por su larga vida media, una toma diaria.","questionContent":"Dosis de amlodipino (máxima diaria)","questionImage":null,"type":"single","options":[{"id":"A","text":"5 mg"},{"id":"B","text":"10 mg"},{"id":"C","text":"15 mg"},{"id":"D","text":"20 mg"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La dosis máxima de amlodipino es **10 mg al día**. 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de sodio tardía (INa tardía)**, reduciendo la entrada de Na+ y, por intercambiador Na+/Ca2+, disminuyendo el Ca2+ intracelular y la tensión diastólica.","helpful_links":[],"tags":[]},{"id":"20036bc2-dda0-4f92-9b60-dbd75774be2e","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Reduce la frecuencia cardíaca sin afectar contractilidad.","questionContent":"Mecanismo de la ivabradina","questionImage":null,"type":"single","options":[{"id":"A","text":"Bloquea los canales de calcio del nodo sinusal"},{"id":"B","text":"Bloquea los canales de sodio activados por hiperpolarización"},{"id":"C","text":"Activa los canales de potasio"},{"id":"D","text":"Inhibe la fosfodiesterasa"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Ivabradina bloquea selectivamente los **canales de sodio activados por hiperpolarización (If)** en el nodo sinusal, reduciendo la frecuencia cardíaca sin efecto inotrópico ni 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**Ranexa**.","helpful_links":[],"tags":[]},{"id":"12455db8-ea5c-4901-b904-e46499026f85","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Usado en enfermedad arterial periférica.","questionContent":"Nombre comercial del cilostazol","questionImage":null,"type":"single","options":[{"id":"A","text":"Pletal"},{"id":"B","text":"Trental"},{"id":"C","text":"Ranexa"},{"id":"D","text":"Isordil"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"Cilostazol se comercializa como **Pletal**.","helpful_links":[],"tags":[]},{"id":"e85e6a08-db3c-4955-af54-9efd38591f9a","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Ya no se recomienda para claudicación.","questionContent":"Nombre comercial de la 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tratamiento profiláctico de elección en la angina de esfuerzo estable, por su eficacia demostrada en ensayos clínicos.","helpful_links":[],"tags":[]},{"id":"7a88d6e6-0fb7-4404-b6f7-06bfe5190ae1","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"No se usan β-bloqueadores.","questionContent":"Fármaco de elección para la angina variante (Prinzmetal)","questionImage":null,"type":"single","options":[{"id":"A","text":"β-bloqueadores"},{"id":"B","text":"Nitratos y BCC"},{"id":"C","text":"Ranolazina"},{"id":"D","text":"Ivabradina"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La angina variante se trata con **nitratos y bloqueadores de los canales de calcio**; los β-bloqueadores **no son eficaces** y están contraindicados.","helpful_links":[],"tags":[]},{"id":"8ab91278-9358-4fb2-bb77-b24b3c68d648","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Entre los farmacológicos, el cilostazol.","questionContent":"Fármaco de elección para la claudicación intermitente","questionImage":null,"type":"single","options":[{"id":"A","text":"Pentoxifilina"},{"id":"B","text":"Cilostazol"},{"id":"C","text":"Nitroglicerina"},{"id":"D","text":"Verapamilo"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El **cilostazol** es el fármaco recomendado para mejorar la tolerancia al ejercicio en la claudicación intermitente. La pentoxifilina ya no se recomienda.","helpful_links":[],"tags":[]},{"id":"e7bf51dd-6cd0-4ddb-a08f-ddc1da8c520a","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"El más antiguo y estudiado.","questionContent":"Fármaco prototipo de los nitratos orgánicos","questionImage":null,"type":"single","options":[{"id":"A","text":"Dinitrato de isosorbida"},{"id":"B","text":"Mononitrato de isosorbida"},{"id":"C","text":"Nitroglicerina"},{"id":"D","text":"PETN"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La **nitroglicerina** (trinitrato de glicerilo) es el prototipo de los nitratos orgánicos, utilizado durante más de 160 años.","helpful_links":[],"tags":[]},{"id":"a312a3bd-42ff-4c84-a70e-9a4d3e995dc0","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"El primero de la familia.","questionContent":"Fármaco prototipo de los BCC 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ofreciendo un mecanismo dual.","helpful_links":[],"tags":[]},{"id":"a4e63d0c-495d-47d0-b146-dccd1c9ed1f1","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Molsidomina.","questionContent":"Fármaco que no desarrolla tolerancia entre los nitrovasodilatadores","questionImage":null,"type":"single","options":[{"id":"A","text":"Nitroglicerina"},{"id":"B","text":"Dinitrato de isosorbida"},{"id":"C","text":"Molsidomina"},{"id":"D","text":"PETN"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La **molsidomina** se dice que tiene eficacia comparable a los nitratos clásicos **sin desarrollar tolerancia**.","helpful_links":[],"tags":[]},{"id":"816129bc-f160-41c9-a4c8-45668e924763","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Desequilibrio por aumento de la demanda.","questionContent":"Fisiopatología de la angina de esfuerzo","questionImage":null,"type":"single","options":[{"id":"A","text":"Espasmo coronario"},{"id":"B","text":"Obstrucción ateromatosa fija que limita el aumento del flujo"},{"id":"C","text":"Trombo lábil"},{"id":"D","text":"Disfunción microvascular"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La angina de esfuerzo se debe a una **obstrucción ateromatosa fija** que impide que el flujo coronario aumente proporcionalmente al incremento de la demanda durante el ejercicio.","helpful_links":[],"tags":[]},{"id":"4c984219-0ffa-4372-bc92-5a8c2ee40735","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Reducción del aporte por espasmo.","questionContent":"Fisiopatología de la angina variante","questionImage":null,"type":"single","options":[{"id":"A","text":"Ateroma fijo"},{"id":"B","text":"Espasmo transitorio del músculo liso coronario"},{"id":"C","text":"Fisura de placa"},{"id":"D","text":"Trombo 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arteria.","helpful_links":[],"tags":[]},{"id":"2654f221-c160-4eea-b78e-d9f7b58a43da","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Según la ley de Laplace.","questionContent":"Determinante principal de la demanda de oxígeno del miocardio","questionImage":null,"type":"single","options":[{"id":"A","text":"Flujo coronario"},{"id":"B","text":"Tensión de la pared ventricular (presión, volumen y espesor)"},{"id":"C","text":"Conductancia vascular"},{"id":"D","text":"Concentración de hemoglobina"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Los principales determinantes son la **frecuencia cardíaca, la contractilidad y la tensión de la pared** (presión intraventricular, radio y espesor).","helpful_links":[],"tags":[]},{"id":"7ba5bc60-d65c-4e26-87f5-72ba4d3ddef1","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Altera la vasodilatación.","questionContent":"Efecto del daño endotelial sobre el flujo coronario","questionImage":null,"type":"single","options":[{"id":"A","text":"Aumenta la capacidad de dilatación"},{"id":"B","text":"Disminuye la resistencia"},{"id":"C","text":"Altera la vasodilatación y aumenta la resistencia"},{"id":"D","text":"No tiene efecto"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"El daño endotelial (aterosclerosis) **altera la capacidad de dilatación** y aumenta crónicamente la resistencia vascular coronaria.","helpful_links":[],"tags":[]},{"id":"e43b16c2-d04d-4a21-9450-ef2033001f5e","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Basado en el caso de estudio del Katzung.","questionContent":"Caso clínico: mujer de 56 años con dolor torácico al ejercicio, hiperlipidemia, antecedentes familiares, PA 145/90, FC 80. ¿Cuál es el primer paso en el tratamiento médico?","questionImage":null,"type":"single","options":[{"id":"A","text":"Nitroglicerina sublingual de rescate"},{"id":"B","text":"Iniciar un β-bloqueador (metoprolol) y aspirina"},{"id":"C","text":"Realizar angiografía coronaria inmediata"},{"id":"D","text":"Colocar un stent"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"El caso sugiere angina de esfuerzo estable. El tratamiento inicial incluye **modificación de factores de riesgo**, **aspirina** y un **β-bloqueador** (metoprolol) para profilaxis. La nitroglicerina sublingual se usa para episodios agudos, no como primer paso profiláctico.","helpful_links":[],"tags":[]},{"id":"374cf7af-3643-4783-8b2d-d52ba278b97d","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Los β-bloqueadores no son eficaces.","questionContent":"Caso clínico: paciente con angina variante documentada. ¿Qué fármaco NO debe usarse?","questionImage":null,"type":"single","options":[{"id":"A","text":"Nitroglicerina"},{"id":"B","text":"Amlodipino"},{"id":"C","text":"Propranolol"},{"id":"D","text":"Diltiazem"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"En la angina variante, los **β-bloqueadores** (como propranolol) **no son eficaces** y pueden incluso empeorar el vasoespasmo al dejar el estímulo α-adrenérgico sin oposición.","helpful_links":[],"tags":[]},{"id":"4c0b830a-eca8-4403-b710-4ae5924de84a","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Las dihidropiridinas afectan menos la frecuencia cardíaca.","questionContent":"Caso clínico: paciente con angina estable y bradicardia sinusal. ¿Qué BCC es preferible?","questionImage":null,"type":"single","options":[{"id":"A","text":"Verapamilo"},{"id":"B","text":"Diltiazem"},{"id":"C","text":"Amlodipino"},{"id":"D","text":"Nifedipino de liberación inmediata"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"En pacientes con bradicardia, se prefieren las **dihidropiridinas de acción prolongada** (amlodipino, felodipino) porque tienen menor efecto cronotrópico negativo que el verapamilo o diltiazem.","helpful_links":[],"tags":[]},{"id":"e13c9859-dfda-4119-b5a2-9605fc4e0cf5","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Evitar la combinación por riesgo de hipotensión.","questionContent":"Caso clínico: paciente en tratamiento con nitratos que requiere sildenafil para disfunción eréctil. ¿Qué recomendación dar?","questionImage":null,"type":"single","options":[{"id":"A","text":"Tomar ambos juntos"},{"id":"B","text":"Esperar al menos 6 horas entre las dosis"},{"id":"C","text":"Reducir la dosis de nitrato"},{"id":"D","text":"Usar sildenafil sin restricción"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"Se recomienda **esperar al menos 6 horas** entre la administración de un nitrato y un inhibidor de PDE-5 (sildenafil) para evitar hipotensión severa.","helpful_links":[],"tags":[]},{"id":"a276d476-6559-4fcf-b79a-6d4095d6f684","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Inhibidores de la glicoproteína IIb/IIIa.","questionContent":"Caso clínico: paciente con angina inestable que requiere PCI con stent. ¿Qué fármaco se añade?","questionImage":null,"type":"single","options":[{"id":"A","text":"Heparina sola"},{"id":"B","text":"Aspirina y clopidogrel"},{"id":"C","text":"Abciximab"},{"id":"D","text":"Nitroglicerina"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"En la intervención coronaria percutánea (PCI) se añaden **inhibidores de la glicoproteína IIb/IIIa** (como abciximab) junto con aspirina y clopidogrel para prevenir trombosis del stent.","helpful_links":[],"tags":[]},{"id":"96f82402-242c-4fd6-a825-cfef974467c0","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Alta extracción hepática.","questionContent":"ADME: biodisponibilidad oral de la nitroglicerina","questionImage":null,"type":"single","options":[{"id":"A","text":">90%"},{"id":"B","text":"50–70%"},{"id":"C","text":"10–20%"},{"id":"D","text":"<5%"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La nitroglicerina tiene una **biodisponibilidad oral muy baja (10–20%)** debido al intenso metabolismo de primer paso hepático. Por eso se prefiere la vía sublingual.","helpful_links":[],"tags":[]},{"id":"b2247e7f-e15d-4983-911d-41f70f330330","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Metabolito activo.","questionContent":"ADME: biodisponibilidad del mononitrato de isosorbida","questionImage":null,"type":"single","options":[{"id":"A","text":"10–20%"},{"id":"B","text":"40–60%"},{"id":"C","text":"80%"},{"id":"D","text":"100%"}],"correctOptions":["D"],"matches":[],"match_pairs":[],"explanation":"El mononitrato de isosorbida tiene **biodisponibilidad oral del 100%**, ya que es el metabolito activo del dinitrato y no sufre primer paso.","helpful_links":[],"tags":[]},{"id":"e26b30a7-826f-4584-b15a-129df3164d1b","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Alta variabilidad.","questionContent":"ADME: vida media del verapamilo","questionImage":null,"type":"single","options":[{"id":"A","text":"2–4 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día.","helpful_links":[],"tags":[]},{"id":"38b1b206-a676-4b78-9b41-cc63da04f8de","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Relativamente corta.","questionContent":"ADME: vida media de la nifedipina","questionImage":null,"type":"single","options":[{"id":"A","text":"30–50 horas"},{"id":"B","text":"11–16 horas"},{"id":"C","text":"4 horas"},{"id":"D","text":"6 horas"}],"correctOptions":["C"],"matches":[],"match_pairs":[],"explanation":"La vida media de la nifedipina es de **4 horas**, por lo que requiere administración cada 8 horas en su forma de liberación prolongada.","helpful_links":[],"tags":[]},{"id":"a93144c5-1dc7-4c5e-9e68-0ac1eed42f63","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Metabolismo hepático extenso.","questionContent":"ADME: efecto de primer paso del verapamilo","questionImage":null,"type":"single","options":[{"id":"A","text":"10%"},{"id":"B","text":"20–35%"},{"id":"C","text":"50%"},{"id":"D","text":"80%"}],"correctOptions":["B"],"matches":[],"match_pairs":[],"explanation":"La biodisponibilidad oral del verapamilo es de **20 a 35%** debido al elevado metabolismo de primer paso hepático.","helpful_links":[],"tags":[]},{"id":"4358cace-d537-4ddc-8e1f-78ea49e0f424","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Principalmente renal.","questionContent":"ADME: vía de eliminación de los nitratos","questionImage":null,"type":"single","options":[{"id":"A","text":"Metabolismo hepático y excreción renal"},{"id":"B","text":"Excreción biliar"},{"id":"C","text":"Eliminación pulmonar"},{"id":"D","text":"Metabolismo en el músculo"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"Los nitratos se metabolizan en el hígado y sus metabolitos se excretan principalmente por **vía renal** como glucurónidos.","helpful_links":[],"tags":[]},{"id":"c56199c7-0500-4750-9da9-5c8d7900aca6","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Muy rápido.","questionContent":"ADME: tiempo de inicio de acción de la nitroglicerina sublingual","questionImage":null,"type":"single","options":[{"id":"A","text":"1–3 minutos"},{"id":"B","text":"5–10 minutos"},{"id":"C","text":"15–30 minutos"},{"id":"D","text":"30–60 minutos"}],"correctOptions":["A"],"matches":[],"match_pairs":[],"explanation":"La nitroglicerina sublingual alcanza niveles terapéuticos en **1 a 3 minutos**, por lo que es ideal para el alivio agudo.","helpful_links":[],"tags":[]},{"id":"8ef41ee6-c876-4185-b96a-6406cf8aea6b","original_quiz_id":"6a8a12c01f025ad31ff5b927","created":"$D2026-08-26T01:06:18.321Z","description":"Efecto breve.","questionContent":"ADME: duración de acción de la nitroglicerina 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5. Vasodilatadores y tratamiento de la cardiopatía isquémica

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