1. Antianginal Drugs Lilley Reading and Workbook – Chap 23

2.  Supply and Demand: ◦ When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart  The heart requires a large supply of oxygen to meet the demands placed on it  Ischemia ◦ Poor blood supply to an organ - myocardium  Ischemic heart disease ◦ Poor blood supply to the heart muscle ◦ Atherosclerosis or Coronary artery disease  Myocardial infarction (MI) ◦ Necrosis, or death, of cardiac tissue ◦ Disabling or fatal

3.  Chronic stable angina (also called classic or effort angina)  Unstable angina (also called preinfarction or crescendo angina)  Vasospastic angina (also called Prinzmetal’s or variant angina)

4.  Increase blood flow to ischemic heart muscle and/or  Decrease myocardial oxygen demand  Minimize the frequency of attacks and decrease the duration and intensity of angina pain  Improve the patient’s functional capacity with as few adverse effects as possible  Prevent or delay the worst possible outcome, M I

5.  Nitrates/nitrites   (beta)-blockers  Calcium channel blockers

6. Available forms  Sublingual* Buccal*  Chewable tablets Oral capsules/tablets  Intravenous solutions  Ointments* Transdermal patches*  Translingual sprays* * Bypass the liver and the first-pass effect

7.  Vasodilation due to relaxation of smooth muscles  Potent dilating effect on coronary arteries  Used for prevention and treatment of angina  Vasodilation results in reduced myocardial oxygen demand  Nitrates cause dilation of both large and small coronary vessels  Nitrates alleviate coronary artery spasms  Result: oxygen to ischemic myocardial tissue

8.  Rapid-acting forms ◦ Used to treat acute anginal attacks ◦ Sublingual tablets; intravenous infusion  Long-acting forms ◦ Used to PREVENT anginal episodes

9. Nitroglycerin  Prototypical nitrate  Large first-pass effect with oral forms  Used for symptomatic treatment of ischemic heart conditions (angina)  IV form used for BP control in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies

10.  isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate SR)  isosorbide mononitrate (Imdur, Monoket, ISMO) Uses:  Acute relief of angina  Prophylaxis in situations that may provoke angina  Long-term prophylaxis of angina

11. Adverse effects  Headaches ◦ Usually diminish in intensity and frequency with continued use ◦ Treated with acetaminophen  Tachycardia, postural hypotension  Tolerance may develop

12. Tolerance  Occurs in patients taking nitrates around the clock or with long-acting forms  Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish ◦ Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning

13. Nursing implications  I V forms of NTG must be given with special non-PVC tubing and bags  Discard parenteral solution that is blue, green, or dark red  Follow specific manufacturer’s instructions for IV administration

14.  Instruct patients in proper technique and guidelines for taking sublingual NTG for anginal pain  Instruct patients never to chew or swallow the SL form  Instruct patients that a burning sensation felt with SL forms indicates that the drug is still potent  Instruct patients to keep a fresh supply of NTG on hand; potency is lost in about 3 months after the bottle has been opened

15.  Medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler to preserve potency  Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication  To reduce tolerance, the patient may be instructed to remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period

16.  Instruct patients to take prn nitrates at the first hint of anginal pain  Monitor VS frequently during acute exacerbations of angina and during IV administration  If experiencing chest pain, the patient taking SL NTG should be lying down to prevent or decrease dizziness and fainting that may occur due to hypotension

17. If anginal pain occurs:  Stop activity and sit or lie down  Take a SL tablet (as prescribed),  If no relief of chest pain, call Emergency Services/911 immediately  Do not try to drive to the hospital

18.  atenolol (Tenormin)  metoprolol (Lopressor)  propranolol (Inderal)  nadolol (Corgard)

19. Mechanism of action   1 -receptors on the heart are blocked  Decrease the HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart  Decrease myocardial contractility, helping to conserve energy or decrease demand  After an MI, a high level of circulating catecholamines irritate the heart, causing an imbalance in supply and demand ratio and even leading to life-threatening dysrhythmias.  -blockers block the harmful effects of catecholamines, thus improving survival

20. Indications  Angina  Antihypertensive  Cardiac dysrhythmias  Cardioprotective effects, especially after MI  Some used for migraine headaches, essential tremors, and stage fright

21. Adverse effects Body SystemAdverse Effects CardiovascularBradycardia, hypotension, second- or third-degree heart block; heart failure MetabolicAltered glucose and lipid metabolism CNSDizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams OtherImpotence, wheezing, dyspnea

22. Nursing implications  Patients taking  -blockers should monitor pulse rate daily and report any rate lower than 60 beats per minute  Dizziness or fainting should also be reported  Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods  These medications should never be abruptly discontinued due to risk of rebound hypertensive crisis  Inform patients that these medications are for long-term prevention of angina, not for immediate relief

23. Mechanism of action  Cause coronary artery vasodilation  Cause peripheral arterial vasodilation, decreasing systemic vascular resistance  Reduce the workload of the heart  Result: decreased myocardial oxygen demand

24. Indications  First-line drugs for treatment of angina, hypertension, and supraventricular tachycardia  Coronary artery spasms (Prinzmetal’s angina)  Short-term management of atrial fibrillation and flutter  Raynaud’s Phenomenon Adverse effects  Very acceptable adverse effect and safety profile  May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea (other adverse effects possible

25. Constipation is a common problem Patients should:  take in adequate fluids  Eat high-fiber foods

26.  Before administering, perform a complete health history to determine presence of conditions that may be contraindications for use or call for cautious use  Obtain baseline VS, including respiratory patterns and rate  Assess for drug interactions  Patients should not take any medications, including OTC medications, without checking with the physician  Patients – encourage to limit caffeine intake

27.  Patients should report blurred vision, persistent headache, dry mouth, dizziness, edema, fainting episodes, weight gain of 2 pounds in 1 day or 5 or more pounds in 1 week, pulse rates less than 60, and any dyspnea  Alcohol consumption and hot baths or spending time in whirlpools, hot tubs, or saunas will result in vasodilation, hypotension, and the possibility of fainting  Teach patients to change positions slowly to avoid postural BP changes  Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of pills taken, and therapeutic effects

28.  Monitor for adverse reactions ◦ Allergic reactions, headache, lightheadedness, hypotension, dizziness  Monitor for therapeutic effects ◦ Relief of angina, decreased BP, or both

29. A 62-year-old patient is having an anginal attack but avoids taking his prescribed PRN dosage of nitroglycerin. Appropriate nursing actions would include: (Select all that apply.) 1. having him take the prescribed dose immediately. 2. asking him why he avoids taking the dose as soon as the pain starts. 3. giving him a thorough explanation of the purpose(s) or value of taking the medication. 4. reprimanding him severely for his hesitancy in self-administering the nitroglycerin

30.  Instruct the patient on the proper storage  of nitroglycerin to keep the medicine in:  1. a chest pocket for easy access.  2. its container for 6 months.  3. the original, dark-colored glass container.  4. its container in the refrigerator to reduce  deterioration.

31. Calcium channel blockers reduce anginal pain by: 1. promoting vasodilatation and minimizing cellular aggregation. 2. increasing the heart rate and blood pressure. 3. stimulating peripheral vasoconstriction. 4. increasing peripheral resistance