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

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

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

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)

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

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

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

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

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*

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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