1. Antianginal Agents. Antidysrythmic Agents

2. Coronary Ischemia: Supply and Demand Economics

3. Coronary Ischemia: Supply and Demand Economics

4. The Grip of Angina

5. Supply-Demand Mismatch

6. Myocardial Oxygen Demand
Heart Rate
Wall Stress
Contractility
Adapted from Runge et al, Netter’s Cardiology

7. Determinants of Myocardial Oxygen Supply

8. Determinants of Myocardial Oxygen Supply

9. Coronary Flow Reserve
Adapted from Maseri A, Ischemic Heart Disease, Churchill Livingstone, 1995

10. 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.

11. Antianginal Agents
Nitrates
Beta blockers
Calcium channel blockers

12. Antianginal Agents: Therapeutic Objectives
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

13. Nitric Oxide
Opie LH: Heart Physiology Lippincot Williams & Wilkins, 2004

14. Antianginal Agents: Nitrates
Available forms:
Sublingual Ointments
Buccal Transdermal patches
Chewable tablets Inhalable sprays
Capsules Intravenous solutions

16. Antianginal Agents: Nitrates
Side Effects
Headache
Usually diminish in intensity and frequency with continued use
Tachycardia, postural hypotension
Tolerance may develop

17. Nitrate Tolerance
Occurs with chronic administration of long acting nitrates.
Efficacy of drug diminishes with chronic exposure (tachyphylaxis).
Tolerance readily reverses with nitrate free interval.

18. Adrenergic Receptors Beta1 Beta2 Alpha
SA node, AV node, His-Purkinje system
Myocardium
Juxtaglomerular apparatus
Adipocytes
Beta2
Peripheral and coronary vasculature
Bronchi
Peripheral Muscle
Uterine Muscle
Alpha
Peripheral circulation
Beta-1
Beta-2
Alpha
Adapted from Runge et al, Netter’s Cardiology

19. Antianginal Agents: Beta Blockers
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

21. Antianginal Agents: Beta Blockers
Therapeutic Uses
Antianginal
Antihypertensive
Cardioprotective effects, especially after MI

22. Antianginal Agents: Calcium Channel Blockers
verapamil (Calan)
diltiazem (Cardizem)
nifedipine (Procardia)

23. Role of Calcium Channels in Myocardial Contraction
Opie LH, Heart Physiology, Williams Lippincott and Williams 2004

24. Role of Calcium Channel in Vascular Smooth Muscle Function
Opie LH, Heart Physiology, Williams Lippincott and Williams 2004

25. Antianginal Agents: Calcium Channel Blockers
Mechanism of Action
Cause peripheral arterial vasodilation
Reduce myocardial contractility (negative inotropic action)
Result: decreased myocardial oxygen demand

26. Antianginal Agents: Calcium Channel Blockers
Therapeutic Uses
First-line agents for treatment of angina, hypertension, and supraventricular tachycardia
Short-term management of atrial fibrillation and flutter
Several other uses

28. Antianginal Agents: Calcium Channel Blockers
Side Effects
Very acceptable side effect and safety profile
May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea

29. Treatment of Ischemic Heart Disease

30. Antianginal Agents: Nursing Implications
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.

31. Antianginal Agents: Nursing Implications
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.

32. Antianginal Agents: 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.

33. Antianginal Agents: Nitroglycerin
Nursing Implications
Patients are taught to take up to three tablets every 5 minutes. If no relief from chest pain is obtained after three tablets, they should seek medical assistance.
Absorption nitroglycerin ointments best over a nonfatty and nonhairy portion of skin. The upper torso is the preferred site of application. The nurse should wear gloves when applying to prevent transdermal absorption by the applier. The ointment is measured as one straight line on the nitroglycerin patch and is gently spread over paper and applied, but not rubbed, into the skin.

34. Antianginal Agents: Nitroglycerin
Nursing Implications
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.

35. Antianginal Agents: Nitroglycerin
Nursing Implications
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.

36. Antianginal Agents: Nitroglycerin
Nursing Implications
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.

37. Antianginal Agents: Nitroglycerin
Nursing Implications
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.

38. Antianginal Agents: Calcium Channel Blockers
Nursing Implications
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.

39. Antianginal Agents: Beta Blockers
Nursing Implications
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.

40. Antianginal Agents: Beta Blockers
Nursing Implications
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.

41. Antidysrhythmics Dysrhythmia Antidysrhythmics
Any deviation from the normal rhythm of the heart
Antidysrhythmics
Drugs used for the treatment and prevention of disturbances in cardiac rhythm

42. Heart and Conduction System

43. Resting Membrane Potential of a Cardiac Cell

44. Abnormal Heart Rhythms
Arrhythmia
BPM
tachycardia
bradycardia
<60
atrial flutter
atrial fibrilation
>350
prem. atrial cont.
variable
prem. vent. cont.
vent. fibrilation

45. Premature Ventricular Contraction

46. Action Potential
A change in the distribution of ions causes cardiac cells to become excited.
The movement of ions across the cardiac cell’s membrane results in the propagation of an electrical impulse.
This electrical impulse leads to contraction of the myocardial muscle.

47. Action Potentials: Phases (SA Node)

48. Action Potentials: Purkinje Fiber

49. Action Potentials: Intervals

50. Abnormal Heart Rhythms
Caused by:
ischemia, infarction, alteration of body chemicals
Symptoms:
palpitations, syncope, lightheadedness, visual disturbances, pallor, cyanosis, weakness, sweating, chest pain, hypotension