13.下列那些藥品對缺血性心臟病（ischemic heart disease）是有害的？①progesterone ②prednisolone ③pravastatin ④cyclosporine
(A)①②③
(B)①②④
(C)②③④
(D)①③④

Progesterone, Prednisolone會體液滯留，增加心臟負擔

Cyclosporine會造成三高也不太好

lipid lowering agent(-statin)對於ischemic heart disease 有益

請問~progesterone、prednisolone、cyclosporine對缺血性心臟病有害的原因、機轉是什麼？

ANTIANGINAL THERAPY
There are three classes of antiischemic drugs commonly used in the management of angina pectoris: beta blockers, calcium channel blockers, and nitrates. Ranolazine is a newer addition. Often, a combination of these agents is used for control of symptoms. These agents are also used for patients who have anginal-equivalent symptoms, such as dyspnea on exertion.

Treatments to prevent angina
Initial beta-blocker monotherapy — We recommend beta blockers as first-line therapy to reduce anginal episodes and improve exercise tolerance.

Alternative monotherapy — In patients who cannot tolerate a beta blocker, alternative initial therapies include calcium channel blockers or long-acting nitrates. Calcium channel blockers are more convenient and better tolerated but should not be used in patients with significant left ventricular dysfunction.

Calcium channel blockers — Calcium channel blockers can be used as monotherapy as an alternative to beta blockers or in combination therapy.

Long-acting diltiazem or verapamil or a second-generation dihydropyridine (amlodipine or felodipine) are preferred. Short-acting dihydropyridines, especially nifedipine, should be avoided unless used in conjunction with a beta blocker in the management of SIHD because of evidence of an increase in mortality after a myocardial infarction and an increase in acute myocardial infarction in hypertensive patients.

Long-acting nitrates — Long-acting nitrates can be used as monotherapy as an alternative to beta blockers or in combination therapy.

In patients with exertional stable angina, chronic nitrate therapy using oral or dermal preparations improves exercise tolerance, time to onset of angina, and ST-segment depression during exercise testing. However, the long-term utility of nitrates can be limited by the induction of nitrate tolerance.
Combination therapy for persistent symptoms — Combination therapy is commonly used in the treatment of SIHD for patients who have continued symptoms on monotherapy. In general, any combination of a beta blocker, calcium channel blocker, and long-acting nitrate can be appropriate. However, some patients may not tolerate the combination of a beta blocker and calcium channel blocker due to hypotension or bradycardia. Ranolazine, a late sodium channel blocker can be added as a third medication, if needed.

Acute symptom management
Short-acting nitrates — Nitrates, usually in the form of a sublingual preparation, are the first-line therapy for the treatment of acute anginal symptoms. Patients should be instructed to use them at the onset of angina or for prophylaxis of anginal episodes.
Reducing exacerbating factors — Treatment of any underlying medical conditions that might aggravate myocardial ischemia, such as hypertension, fever, tachyarrhythmias (eg, atrial fibrillation), thyrotoxicosis, anemia or polycythemia, hypoxemia, or valvular heart disease, should be undertaken. Asymptomatic low-grade arrhythmias are not treated routinely but may require therapy under certain circumstances, such as left ventricular dysfunction.

PREVENTING DISEASE PROGRESSION
The optimal management of patients with stable angina requires more than antianginal therapy. Therapies aimed at preventing cardiovascular events are central to long-term care.

We recommend that all patients with stable ischemic heart disease (SIHD) receive education and counseling about issues such as medication compliance, control of risk factors, and regular exercise [1,2]. In addition, there are several medical therapies which can reduce the risk of cardiovascular events and disease progression.

Antiplatelet therapy — In the absence of a contraindication, all patients should be treated with aspirin. We believe that doses of aspirin from 75 to 325 mg daily are associated with the best risk/benefit ratio. Some experts prefer to stay within the 75 to 162 mg per day range. Clopidogrel is an alternative in patients who are allergic to aspirin.

Lipid-lowering therapy — We recommend that all patients with SIHD be treated with evidence-based doses of a high-intensity statin regardless of the baseline low-density lipoprotein (LDL) cholesterol.

Other risk factor reduction — Risk factor reduction should be a central component of the management of patients with stable angina. Elements include treatment of hypertension, cessation of smoking, weight reduction, and glycemic control in diabetics. In addition to contributing to chronic progression of atherosclerosis, smoking and hypertension can precipitate acute coronary ischemia by increasing oxygen demands and reducing oxygen supply. The specific goals are described elsewhere.

For patients with diabetes mellitus and cardiovascular disease, certain medications (eg, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists) may decrease adverse cardiovascular outcomes and are favored as adjunctive therapy to be used along with first-line treatment in such patients.

Participation in regular exercise is likely beneficial, although patients may want to avoid more strenuous exercise in cold weather or after a meal. Recommendations for referral to cardiac rehabilitation programs and routine physical activity for patients with stable angina pectoris are discussed separately.

ACE inhibitors or ARBs in select patients — Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have known benefits for a subset of patients with SIHD, such as those with hypertension, diabetes mellitus, decreased left ventricular ejection fraction (less than 40 percent), or chronic kidney disease. However, in the absence of these indications, whether ACE inhibitors or ARBs have a cardioprotective effect is uncertain. This is discussed in detail elsewhere.