Drugs Used to Treat Angina Pectoris Chapter 25 Drugs Used to Treat Angina Pectoris Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 25 Lesson 25.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Define angina pectoris Define ischemic heart disease Identify assessment data needed to evaluate an anginal attack Implement medication therapy health teaching for an anginal patient in the clinical setting Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont’d) Explain the rationale for the use of HMG-CoA reductase inhibitors (statins) in the treatment of cardiovascular disease Describe the actions of nitrates, beta-adrenergic blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors on the myocardial tissue of the heart Slide 4 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Angina Pectoris Chest discomfort arising from the heart due to lack of oxygen to the heart muscle Variable presentations Squeezing in the chest, pressure, tightness, choking, burning, heaviness, may radiate to neck, shoulder, jaw Precipitating factors Physical activity, exposure to cold, drinking caffeine-containing beverages, smoking, emotional stress, sexual intercourse, eating large meals Symptom of coronary artery disease (CAD) caused by plaque buildup in blood vessels (atherosclerosis) or a spasm of the artery. Attacks may last from 30 seconds to 30 minutes and are often described as feeling like someone or something is sitting on the chest. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Types of Angina Pectoris Chronic stable angina Precipitated by stress or exertion, short duration Relieved by rest or nitroglycerin Probable cause: fixed atherosclerotic obstruction Unstable angina Unpredictable; changes in frequency, duration, and onset Probable cause: atherosclerosis and thrombus formation Variant angina Occurs at rest, characteristic ECG changes Probable cause: vasospasm of the coronary artery Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Treatment of Angina Pectoris Goals Prevent myocardial infarction and death Pain relief Alternatives to drug therapy Coronary angioplasty Coronary artery bypass surgery Patient education Avoid precipitating factors Reduce risk factors Exercise Symptoms must be caught early so quality of life can be improved and life can be prolonged. Risk factors include diabetes mellitus, hypertension, and dyslipidemia. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Classes that Treat Angina Nitrates Beta-adrenergic blocking agents ACE inhibitors Calcium channel blockers Fatty oxidase enzyme inhibitors Statins Platelet-active agents Nitrates are the oldest of all the drugs and are very effective. Combination therapy is beneficial for many patients. Statins have become a standard in drug therapy. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Process for Anginal Therapy Obtain history of attacks Precipitating factors Characterize attacks CNS involvement Cardiovascular signs Obtain medication history Prescription and nonprescription Effect of agents used on attacks Obtain nutritional history History of high cholesterol CNS involvement may be in the form of confusion, restlessness, or irritability, as well as syncope and anxiety. Cardiovascular signs include palpitations, peripheral pulses, and vital signs. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education Correct use of prescription medications Common adverse effects from prescription medication Avoid fatigue and cold weather Lifestyle modifications Smoking cessation referral, if necessary Always stop activity or exercise when chest pain is present Patient self-assessment form It often helps patients to use a pill organizer. Rapid lifestyle adjustments can lead to feelings of depression. Allow patients and families to verbalize feelings. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Nitrates Nitroglycerin – most common drug Actions Uses Decreases oxygen demand on heart; dilates arteries and veins; reduces blood volume; decreases preload on heart Uses Drug of choice to treat angina pectoris Common adverse effects Excessive hypotension, prolonged headache, tolerance For specific drugs, see Table 25-1. Patients can develop tolerance, especially when large doses are administered frequently. Nitrate-free periods are necessary. As patients become adjusted to therapy, headaches usually diminish. Drugs used for erectile dysfunction, such as sildenafil (Viagra), are contraindicated because a fatal drop in blood pressure may occur. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Nitrates (cont’d) Administration forms Sublingual tablets – dissolve rapidly, primarily for acute attacks Sustained-release capsules, tablets, ointment, transmucosal tablets, and transdermal patches – used prophylactically to prevent anginal attacks Translingual spray – for acute and prophylaxis of attacks Amyl nitrite for inhalation (glass vials) Inform the patient of medication deterioration; every 3 months, nitroglycerin prescriptions should be refilled and a dark-colored glass container should be used for storage. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Beta-Adrenergic Blocking Agents Actions Block beta adrenergic receptors in heart Reduce myocardial oxygen demand Reduce blood pressure Uses Reduce the number of anginal attacks Reduce nitroglycerin use See Chapter 23 for further discussion For specific drugs, see Table 13-3. Therapy should start at low doses and work upward for patient tolerance. Combination therapy with nitrates is more effective than using either drug alone. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Calcium Channel Blockers Actions Inhibit flow of calcium ions across cell membrane Reduce peripheral vascular resistance Improve coronary blood flow Uses Reduce incidence of MI, secondary prevention for patients with known coronary artery disease See Chapter 23 for further discussion For specific drugs, see Table 25-2. Potent vasodilators; have an overall effect on myocardial activity. Should be used with caution in patients who may be developing heart failure. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: ACE Inhibitors Actions Promote vasodilation, minimize cellular aggregation, prevent thrombus formation Uses Reduce incidence of MI; secondary prevention for patients with known coronary artery disease (CAD) See Chapter 23 for further discussion For specific drugs, see Table 23-5. Also recommended for patients with acute MI or heart failure with left systolic dysfunction. Adverse effects such as dizziness, tachycardia, and fainting may occur within 3 hours after the first several doses. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Fatty Oxidase Enzyme Inhibitor Drug: ranolazine (Ranexa) Actions Enzyme modulator that affects the metabolism within myocardial cells to reduce oxygen demand Uses Treat chronic stable angina Common adverse effects Dizziness, headache, constipation, nausea Used in combination with calcium channel blockers, beta-blockers, or nitrates. Does not affect blood pressure or heart rate. Prolongs Q-T interval; does not reduce symptoms of an acute attack. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.