1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 23 Antianginal Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Angina Pectoris (Chest Pain)  When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart, the heart muscle “aches”  The heart requires a large supply of oxygen to meet the demands placed on it

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ischemia  Ischemia  Poor blood supply to an organ  Ischemic heart disease  Poor blood supply to the heart muscle  Atherosclerosis  Coronary artery disease  Myocardial infarction (MI)  Necrosis, or death, of cardiac tissue  Disabling or fatal

4. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Types of Angina  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)

5. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Drugs for Angina  Nitrates/nitrites   (beta)-blockers  Calcium channel blockers

7. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Therapeutic Objectives  Increase blood flow to ischemic heart muscle and/or  Decrease myocardial oxygen demand

8. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Therapeutic Objectives (cont’d)  Minimize the frequency of attacks and decrease the duration and intensity of anginal pain  Improve the patient’s functional capacity with as few adverse effects as possible  Prevent or delay the worst possible outcome, MI

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates/Nitrites Available forms  Sublingual*  Buccal*  Chewable tablets  Oral capsules/tablets  Intravenous solutions* * Bypass the liver and the first-pass effect  Ointments*  Transdermal patches*  Translingual sprays*

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates/Nitrites (cont’d)  Cause vasodilation due to relaxation of smooth muscles  Potent dilating effect on coronary arteries  Used for prevention and treatment of angina

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates/Nitrites (cont’d)  Vasodilation results in reduced myocardial oxygen demand  Nitrates cause dilation of both large and small coronary vessels  Result: oxygen to ischemic myocardial tissue  Nitrates alleviate coronary artery spasms

12. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates/Nitrites (cont’d)  Rapid-acting forms  Used to treat acute anginal attacks  Sublingual tablets; intravenous infusion  Long-acting forms  Used to PREVENT anginal episodes

13. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates/Nitrites (cont’d) 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

14. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates  isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate SR)  isosorbide mononitrate (Imdur, Monoket, ISMO) Used for:  Acute relief of angina  Prophylaxis in situations that may provoke angina  Long-term prophylaxis of angina

15. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitrates (cont’d) Adverse effects  Headaches  Usually diminish in intensity and frequency with continued use  Tachycardia, postural hypotension  Tolerance may develop

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 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

17. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers  atenolol (Tenormin)  metoprolol (Lopressor)  propranolol (Inderal)  nadolol (Corgard)

18. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) 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

19. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) Mechanism of action  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 after an MI

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) Indications  Angina  Antihypertensive  Cardiac dysrhythmias  Cardioprotective effects, especially after MI  Some used for migraine headaches, essential tremors, and stage fright

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) Adverse effects Body SystemAdverse Effects CardiovascularBradycardia, hypotension, second- or third-degree heart block; heart failure MetabolicAltered glucose and lipid metabolism

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) Adverse effects (cont'd) Body SystemAdverse Effects CNSDizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams OtherImpotence, wheezing, dyspnea

23. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Calcium Channel Blockers  verapamil (Calan, Isoptin)  diltiazem (Cardizem)  nifedipine (Procardia)  amlodipine (Norvasc) Many others

24. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Calcium Channel Blockers (cont’d) 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

25. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Calcium Channel Blockers (cont’d) 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  Several other uses

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Calcium Channel Blockers (cont’d) Adverse effects  Very acceptable adverse effect and safety profile  May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea (other adverse effects possible)

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  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

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Patients should not take any medications, including OTC medications, without checking with the physician  Patients should be encouraged to limit caffeine intake

29. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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

30. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  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

31. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin Nursing implications  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

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin (cont’d) Nursing Implications (cont'd)  Instruct patients to keep a fresh supply of NTG on hand; potency is lost in about 3 months after the bottle has been opened  Medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler to preserve potency

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin (cont’d) Nursing implications (cont'd)  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

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin (cont’d) Nursing implications (cont'd)  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

35. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin (cont’d) If anginal pain occurs:  Stop activity and sit or lie down  Take a SL tablet, and wait 5 minutes  If no relief in 5 minutes, take a second SL tablet  If no relief in 5 minutes, take a third SL tablet  After three tablets/15 minutes, if no relief of chest pain, call Emergency Services/911 immediately  Do not try to drive to the hospital

36. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nitroglycerin (cont’d) Nursing implications (cont'd)  IV 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

37. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Calcium Channel Blockers Nursing implications  Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods

38. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers 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

39. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.  -Blockers (cont’d) Nursing implications (cont’d)  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

40. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antianginal Drugs: Nursing Implications  Monitor for adverse reactions  Allergic reactions, headache, lightheadedness, hypotension, dizziness  Monitor for therapeutic effects  Relief of angina, decreased BP, or both