1. 21
Drugs For Angina Pectoris, Myocardial Infarction, And Cerebrovascular Accident

2. Directory
Classroom Response System
Lecture Note Presentation

3. Question 1
The patient should remove the transdermal nitroglycerin patch at night to:

4. Question 1 Choices Prevent overdose Prevent adverse reactions
Ensure the dosage is appropriate
Delay development of tolerance

5. Question 1 Answer Prevent overdose Prevent adverse reactions
Ensure the dosage is appropriate
Delay development of tolerance

6. Question 2
When treating angina, the nurse knows that the mechanism of action of a beta-adrenergic blocker is:

7. Question 2 Choices
Slowed heart rate and decreased contractility of the heart
Relaxation of arterial and venous smooth muscle
Increased contractility and heart rate
Decreased peripheral resistance

8. Question 2 Answer
Slowed heart rate and decreased contractility of the heart
Relaxation of arterial and venous smooth muscle
Increased contractility and heart rate
Decreased peripheral resistance

9. Question 3
The patient taking calcium channel blockers should use extreme caution when taking which of the following medications?

10. Question 3 Choices Acetaminophen (Tylenol) Ibuprofen (Motrin)
Digoxin (Lanoxin)
Ranitidine (Zantac)

11. Question 3 Answer Acetaminophen (Tylenol) Ibuprofen (Motrin)
Digoxin (Lanoxin)
Ranitidine (Zantac)

12. Question 4
The patient is complaining of a viselike pain in his chest that subsides with rest. The patient is likely experiencing:

13. Question 4 Choices A stroke A myocardial infarction Angina
A cerebral vascular accident

14. Question 4 Answer A stroke A myocardial infarction Angina
A cerebral vascular accident

15. Learning Outcomes
Describe how the myocardium receives its oxygen and nutrient supply.
Explain the pathophysiology of angina pectoris.
Identify lifestyle changes that may be implemented to manage symptoms of angina.

16. Learning Outcomes
Explain the pathophysiology of myocardial infarction.
Describe the pharmacologic treatment of CVA.

17. Learning Outcomes
For each of drug classes listed in the Drug Snapshot, identify representative drugs, explain the mechanisms of drug action, primary actions, and important adverse effects as they relate to the treatment of angina, myocardial infarction or CVA.

18. Learning Outcomes
Categorize drugs used to treat angina, myocardial infarction, and CVA based on their classification and mechanisms of action.

19. Core Concept 21.1
Coronary heart disease is caused by a restriction in blood flow to the myocardium.

20. Heart Facts Heart is the hardest working organ in the body
Heart muscle or myocardium must receive a continuous supply of oxygen and nutrients

21. Heart Facts
Receives essentially no nutrients from the blood traveling through the heart’s chambers
Heart muscle receives its nutrients from the first two arteries branching off the aorta, the right and left Coronary Arteries

22. Core Concept 21.2
Angina pectoris is characterized by severe chest pain caused by lack of sufficient oxygen flow to heart muscle.

23. Angina Pectoris Most common cause is atherosclerosis
A buildup of fatty, fibrous material called plaque in the walls of arteries
Reduced blood supply to cardiac muscle cells is called myocardial ischemia

24. Angina Pectoris Classic presentation Intense pain in the chest
Often moving to the left side of the neck and lower jaw and down the left arm

25. Figure Plaque and thrombus formation in the coronary artery Source: Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ

26. Types of Angina Stable Angina
Predictable in its frequency, intensity, and duration

27. Types of Angina Unstable Angina
More frequent or severe, occurs during periods of rest
Requires more aggressive medical intervention.
Sometimes considered a medical emergency because it is associated with an increased risk of MI.

28. Types of Angina Vasospastic or Prinzmetal’s angina
Caused by spasms of the coronary arteries
Pain occurs most often during periods of rest

30. Core Concept 21.3
Anginal pain can often be controlled through positive lifestyle changes and surgical procedures.

31. Life Style Changes Limit alcohol consumption to small amounts.
Eliminate foods high in cholesterol or saturated fats.
Keep blood cholesterol and other lipid indicators within the normal ranges.
Do not use tobacco.

32. Life Style Changes Keep blood pressure within the normal range.
Exercise regularly and maintain optimum weight.
Keep blood glucose levels within normal range.
Limit salt (sodium) intake.
Reduce stress levels as much as possible.

33. Surgical Intervention
Coronary arteries are significantly obstructed
Percutaneous transluminal coronary angioplasty (PTCA), with stent insertion
Coronary artery bypass graft (CABG)

34. Concept Review 21.1
How can a health care provider distinguish between stable angina and unstable angina?

35. Core Concept 21.4
The pharmacological management of angina is achieved by reducing cardiac workload.

36. Pharmacologic Treatment
Goals
Reduce the frequency of anginal episodes
Terminate acute anginal pain in progress

37. Pharmacologic Treatment
This can be accomplished by
Slowing the heart rat
Dilating veins so the heart receives less blood (reduced preload)
Causing the heart to contract with less force (reduced contractility)
Lowering blood pressure, thus offering the heart less resistance when ejecting blood from the ventricles (reduced afterload)

38. Three Classes of Drugs
Organic nitrates drugs of choice for terminating acute angina pain
Beta-adrenergic blockers drugs of choice for preventing angina pain
Calcium channel blockers are used when beta blockers are not tolerated well

39. Figure 21.2 Mechanisms of action of drugs used to treat angina pectoris

40. Core Concept 21.5
The organic nitrates relieve anginal pain by dilating veins and the coronary arteries.

41. Two Types of Nitrates Short acting Long acting
Example: Nitroglycerin
Taken sublingually
Quickly stop an acute anginal attack in progress
Long acting
Example: isosorbide dinitrate

42. Two Types of Nitrates
Taken orally or delivered through a transdermal patch
Decrease the frequency and severity of anginal episodes.
Side Effects: orthostatic hypotension,reflex tachycardia, headache,flushing of the skin

44. Table 21.2 (continued) Selected Drugs for Angina and Myocardial Infarction

45. Table 21.2 (continued) Selected Drugs for Angina and Myocardial Infarction

46. Core Concept 21.6
Beta-adrenergic blockers are often drugs of choice for reducing the frequency of angina attacks.

47. Beta-adrenergic Blockers
Reduce the workload on the heart
used for angina prophylaxis
Side Effects:fatigue, lethargy and depression occur
Slow the heart rate, contraindicated in patients with bradycardia and heart block

48. Beta-adrenergic Blockers
Heart rate should be closely monitored so that it does not fall below beats/min at rest or 100 beats/min during exercise.

49. Core Concept 21.7
Calcium channel blockers relieve anginal pain by reducing the cardiac workload.

50. Calcium Channel Blockers
Decreases the myocardial oxygen demand
Reduce myocardial oxygen demand by lowering blood pressure and slowing the heart rate
Cause arteriolar smooth muscle to relax

51. Calcium Channel Blockers
Lower peripheral resistance and reducing blood pressure
Dilate the coronary arteries, bringing more oxygen to the myocardium
Drug of choice for vasospastic angina

52. Concept Review 21.2
How does decreasing the workload on the heart result in reduction in anginal pain?

53. Core Concept 21.8
The early diagnosis and treatment of myocardial infarction increases chances of survival.

54. Figure Blockade and reperfusion following myocardial infarction (MI): (a) blockage of left coronary artery causing myocardial ischemia; (b) infusion of thrombolytics; (c) blood supply returning to myocardium; (d) thrombus dissolving and ischemia clearing Source: (a) and (c) Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ

55. Figure 21.3 (continued) Blockade and reperfusion following myocardial infarction (MI): (a) blockage of left coronary artery causing myocardial ischemia; (b) infusion of thrombolytics; (c) blood supply returning to myocardium; (d) thrombus dissolving and ischemia clearing Source: (a) and (c) Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ

56. Figure 21.3 (continued) Blockade and reperfusion following myocardial infarction (MI): (a) blockage of left coronary artery causing myocardial ischemia; (b) infusion of thrombolytics; (c) blood supply returning to myocardium; (d) thrombus dissolving and ischemia clearing Source: (a) and (c) Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ

57. Figure 21.3 (continued) Blockade and reperfusion following myocardial infarction (MI): (a) blockage of left coronary artery causing myocardial ischemia; (b) infusion of thrombolytics; (c) blood supply returning to myocardium; (d) thrombus dissolving and ischemia clearing Source: (a) and (c) Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ

58. Goals of the Pharmacologic Treatment of MI
Restore blood supply (perfusion) to the damaged myocardium as quickly as possible through the use of thrombolytics
Reduce myocardial oxygen demand with organic nitrates, beta blockers or CCBs to prevent another MI

59. Goals of the Pharmacologic Treatment of MI
Control or prevent MI-associated dysrhythmias with beta blockers or other antidysrhythmics
Reduce post-MI mortality with aspirin, beta blockers and ACE inhibitors
Manage severe chest pain and associated anxiety with analgesics

60. Thrombolytics dissolve clots blocking the coronary arteries.
Core Concept 21.9
Thrombolytics dissolve clots blocking the coronary arteries.

61. The Goals Thrombolytic Therapy
Dissolve clots that are obstructing the coronary arteries
Restore circulation to the myocardium
Thrombolytics are most effective when administered from 20 minutes to 12 hours after the onset of MI symptoms

62. Core Concept 21.10
Drugs are used to treat the symptoms and complications of acute myocardial infarction (MI).

63. Treatment of MI Immediate Need
Ensure that the heart continues functioning
Permanent damage from the infarction is minimized

64. Treatment of MI Drugs Used Beta-adrenergic blockers
Antiplatelets and anticoagulants
Angiotensin-converting Enzyme (ACE) inhibitors
Pain management

65. Concept Review 21.3
Why is it important to treat an MI within the first 24 hours after symptoms have begun? What classes of drugs are used for this purpose?

66. Aggressive treatment of CVA can increase survival
Core Concept 21.11
Aggressive treatment of CVA can increase survival

67. Treatment of CVA Two main goals
Prevention of strokes through the use of anticoagulants and antihypertensive agents
Restoration of blood supply to the affected portion of the brain as quickly as possible.
Thrombolytics as soon as the patient arrives at the hospital
These agents are most effective if administered within 3 hours of the attack.