ANTIANGINAL AGENTS
•Nitrates
•Beta blockers
•Calcium channel blockers
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 demands a large supply of oxygen to meet the demands placed on it.
•The heart demands a large supply of oxygen to meet the demands placed on it.
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)
•Unstable angina(also called preinfarction or crescendo angina)
•Vasospastic angina(also called Prinzmetal’s or variant angina)
Therapeutic Objectives
•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 anginal pain
•Improve the patient’s functional capacity with as few side effects as possible
•Prevent or delay the worst possible outcome, MI
•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 anginal pain
•Improve the patient’s functional capacity with as few side effects as possible
•Prevent or delay the worst possible outcome, MI
NITRATES
Available forms:
Sublingual Ointments
Buccal Transdermal patches
Chewable tablets Inhalable sprays
Capsules Intravenous solutions
•Cause vasodilation due to relaxation of smooth muscles
•Potent dilating effect on coronary arteries
•Used for prophylaxis and treatment of angina
Nitroglycerin
•Prototypical nitrate
•Large first-pass effect with PO forms
•Used for symptomatic treatment of ischemic heart conditions (angina)
•IV form used for BP control in perioperative hypertension, treatment of CHF, ischemic pain, and pulmonary edema associated with acute MI
•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
Sublingual Ointments
Buccal Transdermal patches
Chewable tablets Inhalable sprays
Capsules Intravenous solutions
•Cause vasodilation due to relaxation of smooth muscles
•Potent dilating effect on coronary arteries
•Used for prophylaxis and treatment of angina
Nitroglycerin
•Prototypical nitrate
•Large first-pass effect with PO forms
•Used for symptomatic treatment of ischemic heart conditions (angina)
•IV form used for BP control in perioperative hypertension, treatment of CHF, ischemic pain, and pulmonary edema associated with acute MI
•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
Side Effects
•Headache
–Usually diminish in intensity and frequency with continued use
•Tachycardia, postural hypotension
•Tolerance may develop
–Usually diminish in intensity and frequency with continued use
•Tachycardia, postural hypotension
•Tolerance may develop
BETA BLOCKERS
•atenolol (Tenormin)
•metoprolol (Lopressor)
•propranolol (Inderal)
•nadolol (Corgard)
Mechanism of Action
•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
Therapeutic Uses
•Antianginal
•Antihypertensive
•Cardioprotective effects, especially after MI
Side Effects
Body System Effects
Cardiovascular bradycardia, hypotension second- or third-degree heart block heart failure
Metabolic Altered glucose and lipid metabolism
CNS dizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams
Other impotence wheezing, dyspnea
•metoprolol (Lopressor)
•propranolol (Inderal)
•nadolol (Corgard)
Mechanism of Action
•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
Therapeutic Uses
•Antianginal
•Antihypertensive
•Cardioprotective effects, especially after MI
Side Effects
Body System Effects
Cardiovascular bradycardia, hypotension second- or third-degree heart block heart failure
Metabolic Altered glucose and lipid metabolism
CNS dizziness, fatigue, mental depression, lethargy, drowsiness, unusual dreams
Other impotence wheezing, dyspnea
CALCIUM CHANNEL BLOCKERS
•verapamil (Calan)
•diltiazem (Cardizem)
•nifedipine (Procardia)
Mechanism of Action
•Cause peripheral arterial vasodilation
•Reduce myocardial contractility (negative inotropic action)
•Result: decreased myocardial oxygen demand
Therapeutic Uses
•First-line agents for treatment of angina, hypertension, and supraventricular tachycardia
•Short-term management of atrial fibrillation and flutter
•Several other uses
Side Effects
•Very acceptable side effect and safety profile
•May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea
•diltiazem (Cardizem)
•nifedipine (Procardia)
Mechanism of Action
•Cause peripheral arterial vasodilation
•Reduce myocardial contractility (negative inotropic action)
•Result: decreased myocardial oxygen demand
Therapeutic Uses
•First-line agents for treatment of angina, hypertension, and supraventricular tachycardia
•Short-term management of atrial fibrillation and flutter
•Several other uses
Side Effects
•Very acceptable side effect and safety profile
•May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea
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.
•Patients should not take any medications, including OTC medications, without checking with the physician.
•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 under 60, and any dyspnea.
•Alcohol consumption and hot baths or spending time in jacuzzis, 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.
Nitroglycerin
•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. •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.
•Instruct patients to take prn nitrates at the first hint
of anginal pain.
•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.
•Monitor VS frequently during acute exacerbations of angina and during IV administration.
•IV forms of NTG must be contained in glass IV bottles and must be given with infusion pumps.
•Discard parenteral solution that is blue, green, or dark red.
•Follow specific manufacturer’s instructions for IV administration. Use special IV tubing provided or non-PVC tubing.
Calcium Channel Blockers
•Blood levels should be monitored to ensure they are therapeutic.
•Oral CCBs should be taken before meals and as ordered.
•Patients should be encouraged to limit caffeine intake.
Beta Blockers
•Patients taking beta 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.
•Monitor for adverse reactions –Allergic reactions, headache, light-headedness, hypotension, dizziness
•Monitor for therapeutic effects –Relief of angina, decreased BP, or both
•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 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 under 60, and any dyspnea.
•Alcohol consumption and hot baths or spending time in jacuzzis, 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.
Nitroglycerin
•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. •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.
•Instruct patients to take prn nitrates at the first hint
of anginal pain.
•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.
•Monitor VS frequently during acute exacerbations of angina and during IV administration.
•IV forms of NTG must be contained in glass IV bottles and must be given with infusion pumps.
•Discard parenteral solution that is blue, green, or dark red.
•Follow specific manufacturer’s instructions for IV administration. Use special IV tubing provided or non-PVC tubing.
Calcium Channel Blockers
•Blood levels should be monitored to ensure they are therapeutic.
•Oral CCBs should be taken before meals and as ordered.
•Patients should be encouraged to limit caffeine intake.
Beta Blockers
•Patients taking beta 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.
•Monitor for adverse reactions –Allergic reactions, headache, light-headedness, hypotension, dizziness
•Monitor for therapeutic effects –Relief of angina, decreased BP, or both