2. Coronary vasodilators Antianginal drugs  Angina pectoris: is a clinical syndrome characterized by paroxysm of pain in the anterior chest caused by insufficient coronary blood flow and/or inadequate oxygen supply to the myocardial muscle.  Causes: (1) Atherosclerosis.(2) Vasospasim.  There are three groups of drugs used for treatment of angina:  Nitrates/nitrites.  Beta-adrenergic blocking agents.  Calcium channel blocking agents.

3. Nitrates/nitrites:  - Nitrates/nitrites - Action: direct relaxation of blood vessels and smooth muscles vasodilatation O 2 requirements.  - Relaxation of smooth muscles of coronary arteries coronary vasodilatation blood supply to the myocardium.  - Relaxation of arteries and veins BP workload in the heart.

4. Objectives of treatment:  Treatment of anginal attack and thus relief pain.  Prophylactic treatment to prevent or delay the occurrence of MI.  Prolongs intervals between attacks.  Indications:  Prophylaxis and treatment of acute angina pectoris.  Treatment of chronic angina pectoris.  Treatment of hypertension associated with MI or CHF.  Nitroglycerin ointment for treatment of Raynaud’s disease.

5. Contraindications:  Sensitivity to nitrates  Hypotension.  Severe anemia.  Hypotension.  Head trauma.  Cerebral hemorrhage.

6. Side effects:  Headache, syncope, dizziness.  Postural hypotension, transient flushing, and palpitation.  Topical application may lead to dermatitis.  Drug interaction : Antihypertensive agents, Beta-adrenergic blocking agents, and calcium-channel blocking agents (they may lead to additive hypotension).

7. Dosage:  there are several forms available:  Sublingual: Cordil 5 mg PRN.  PO: Isotard 20 – 40 mg twice a day.  Topical: available as patches or ointment.  Parental (IV infusion).

8. Nursing considerations: 1. Medications should be taken on an empty stomach. 2. Carry sublingual tablets in a glass bottle, tightly capped. 3. If anginal pain is not relieved in 5 minutes by first sublingual tablet, to take up to 2 more tablets at 5 minutes interval. If pain has not subsided 5 minutes after the 3 rd tablet, client should be taken to the emergency room as this case could be an infarction (MI) and not angina. 4. Take sublingual tablets 5-15 minutes prior to any situation likely to cause anginal pain such as climbing stairs. 5. Take sublingual tablets while sitting to avoid postural hypotension.

9. Isosorbide dinitrate:  Present in the forms of capsules; chewable, sublingual, tablets.  Trade names: Isoral, Cordil, Isotard.  Class: coronary vasodilator.  Dosage forms: caps 20-40 mg, tabs 20-40 mg.  Uses:  Tabs for only prophylaxis of anginal pain.  Chewable, sublingual to terminate acute attack and relieve acute pain.  Esophageal spasm.  Side effects: Headache, hypotension.

10. Dosage:  Sublingual: acute attack 2.5-5 mg Q 2-3 hrs.  Oral caps/tabs: 5-20 mg Q 6 hrs.  Extended release tabs: 20 –80 mg Q 8-12 hrs.  Note : Isosorbide mononitrate given for patients with liver impairments.