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Chapter 23
Antianginal Drugs
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2. 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
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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
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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 or variant angina)
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6. Classroom Response Question
A patient is mowing his lawn on a hot Saturday afternoon. He begins to notice chest pain. What should his first action be?
Take his nitroglycerin tablet
Stop mowing and sit or lie down
Go inside the house to cool off and get a drink of water
Call 911
Correct answer: B
Rationale: At the first sign of chest pain, the person should stop all activity and sit or lie down before taking the nitroglycerin tablet.
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Drugs for Angina
Nitrates/nitrites
Beta blockers
Calcium channel blockers
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8. 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 adverse effects as possible
Prevent or delay the worst possible outcome: MI
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Nitrates/Nitrites
Available forms
Sublingual*
Chewable tablets
Oral capsules/tablets
Intravenous solutions*
Transdermal patches*
Ointments
Translingual sprays*
*Bypass the liver and the first-pass effect
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10. Mechanism of Action Drug Effects
Cause vasodilation because of relaxation of smooth muscles
Potent dilating effect on coronary arteries
Result: oxygen to ischemic myocardial tissue
Used for prevention and treatment of angina
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Nitrates/Nitrites
Rapid-acting forms
Used to treat acute anginal attacks
Sublingual tablets; intravenous infusion
Long-acting forms
Used to PREVENT anginal episodes
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12. Classroom Response Question
A patient with extremely high blood pressure is in the emergency department. The physician will be ordering therapy with nitroglycerin to manage the patient’s blood pressure. Which form of nitroglycerin is most appropriate?
Sublingual spray
Transdermal patch
Oral capsule
IV infusion
Correct answer: D
Rationale: The IV infusion of nitroglycerin will have the fastest effect, and the dose will be titrated to the patient’s response.
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Nitrates
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
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Nitrates (cont’d)
Adverse effects
Headaches
Usually diminish in intensity and frequency with continued use
Reflex tachycardia
Postural hypotension
Tolerance may develop
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15. Classroom Response Question
A patient who was walking his dog developed chest pain and sat down. He continues to experience chest pain when sitting down. When should he call 911?
Immediately
If the pain becomes more severe
If one sublingual tablet does not relieve the pain after 5 minutes
If the pain is not relieved after three sublingual tablets, taken 5 minutes apart
Correct answer: C
Rationale: With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe. The patient should sit or lie down and take 1 sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes after 1 dose, the patient (or family member) should call 911 immediately. The patient can take 1 more tablet while awaiting emergency care, and a third tablet 5 minutes later, but no more than 3 tablets total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction.
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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
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Beta Blockers
atenolol (Tenormin)
metoprolol (Lopressor)
propranolol (Inderal)
nadolol (Corgard)
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18. Beta Blockers: Mechanism of Action
Block beta1 receptors on the heart
Decrease HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart
Decrease myocardial contractility, helping to conserve energy or decrease demand
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19. Beta Blockers: Mechanism of Action (cont’d)
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
Beta blockers block the harmful effects of catecholamines, thus improving survival after an MI
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20. Beta Blockers: Indications
Angina
Antihypertensive
Cardiac dysrhythmias
Cardioprotective effects, especially after MI
Some used for migraine headaches, essential tremors, and stage fright
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21. Beta Blockers: Adverse Effects
Body System
Adverse Effects
Cardiovascular Metabolic
Bradycardia, hypotension, atrioventricular block Hyperglycemia and/or hypoglycemia, hyperlipidemia
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22. Beta Blockers: Adverse Effects (cont’d)
Body System
Adverse Effects
CNS Other
Dizziness, fatigue, depression, lethargy Impotence, wheezing, dyspnea
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23. Classroom Response Question
A patient who has had a myocardial infarction is on a beta blocker. What is the main benefit of beta blocker therapy for this patient?
Vasodilation of the coronary arteries
Increased force of cardiac contraction
Slowing of the heart rate
Maintaining adequate blood pressure
Correct answer: C
Rationale: Slowing the heart rate in patients with ischemic heart disease reduces myocardial oxygen demand and allows the coronary arteries time to fill with oxygen- and nutrient-rich blood. Beta blockers also block the irritating effects of circulating catecholamines on the heart.
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Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

24. Calcium Channel Blockers
verapamil (Calan, Isoptin)
diltiazem (Cardizem)
nifedipine (Procardia)
amlodipine (Norvasc)
nicardipine (Cardene)
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25. Calcium Channel Blockers: Mechanism of Action
Cause coronary artery vasodilation
Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance
Reduce the workload of the heart
Result: decreased myocardial oxygen demand
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26. Calcium Channel Blockers: Indications
Angina
Hypertension
Supraventricular tachycardia
Coronary artery spasms (Prinzmetal angina)
Short-term management of atrial fibrillation and flutter
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27. Calcium Channel Blockers: Adverse Effects
Limited
Primarily relate to overexpression of their therapeutic effects
May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea, other adverse effects
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Nursing Implications
Before administering, perform a complete health history to determine presence of conditions that may be contraindications for use or those that may call for cautious use
Obtain baseline VS, including respiratory patterns and rate
Assess for drug interactions
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29. Nursing Implications (cont’d)
Patients should not take any medications, including over-the-counter medications, without checking with their physician
Patients should be encouraged to limit caffeine intake
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30. Nursing Implications (cont’d)
Patients should report:
Blurred vision
Persistent headache
Dry mouth
Edema
Fainting episodes
Weight gain of 2 pounds in 1 day or 5 pounds in 1 week
Pulse rates less than 60
Dyspnea
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31. Nursing Implications (cont’d)
Alcohol consumption and spending time in hot baths or 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
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32. Nursing Implications (cont’d)
Nitroglycerin
Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain
Instruct patients never to chew or swallow the sublingual form
Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent
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33. Nursing Implications (cont’d)
Nitroglycerin (cont’d)
Instruct patients to keep a fresh supply of sublingual medication on hand; potency is lost in about 3 months after the bottle has been opened
To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler
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34. Nursing Implications (cont’d)
Nitroglycerin (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
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35. Nursing Implications (cont’d)
Nitroglycerin (cont’d)
Instruct patients to take prn nitrates at the first hint of anginal pain
Monitor vital signs frequently during acute exacerbations of angina and during IV administration
If experiencing chest pain, the patient taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension
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36. Nursing Implications (cont’d)
Nitroglycerin (cont’d)
If anginal pain occurs:
Stop activity and sit or lie down, and take a sublingual tablet
If no relief in 5 minutes, call 911/Emergency Services immediately and take a second sublingual tablet
If no relief in 5 minutes, take a third sublingual tablet
Do not try to drive to the hospital
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37. Nursing Implications (cont’d)
Nitroglycerin (cont’d)
IV forms of nitroglycerin 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
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38. Nursing Implications (cont’d)
Beta blockers
Patients taking beta blockers should monitor pulse rate daily and report any rate lower than 60 beats per minute or symptoms of relative bradycardia
Instruct patients to report dizziness or fainting
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39. Nursing Implications (cont’d)
Beta blockers (cont’d)
Inform patients that these medications should never be abruptly discontinued
Inform patients that these medications are for long-term prevention of angina, not for immediate relief
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40. Nursing Implications (cont’d)
Calcium channel blockers
Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods
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41. Nursing Implications (cont’d)
Antianginal drugs
Monitor for adverse reactions
Allergic reactions, headache, lightheadedness, hypotension, dizziness
Monitor for therapeutic effects
Relief of angina, decreased BP, or both
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42. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
The nurse is preparing to educate a group of patients on the management of angina.
Which drug groups are most often used to treat patients with angina?
1. The nitrates and nitrites, the beta blockers, and the calcium channel blockers (CCBs) are the drugs most often used to treat patients with angina pectoris.
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Case Study (cont’d)
One of the patients asks the nurse to tell her more about a new drug the patient has been prescribed called ranolazine (Ranexa). Which response by the nurse is accurate?
“We do not know how Ranexa works.”
“This drug is the first medication your health care provider will use to treat your angina.”
“This drug must be given intravenously.”
“Ranexa is safe to use in patients with liver failure.”
Correct answer: A
Rationale: The mechanism of action of Ranexa is not known. Ranexa is used only after treatment with other antianginals have not been effective. Ranexa is administered by mouth and is contraindicated for use in patients with liver failure.
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Case Study (cont’d)
What information will the nurse include when teaching the patients about taking beta2-blocking drugs for the treatment of angina?
“Call your health care provider if you heart rate is 64 beats per minute.”
“These drugs are safe to use in patients who have asthma.”
“Call your health care provider if you experience a weight gain of 2 pounds or more in 24 hours or 5 pounds or more in 1 week.”
“Avoid taking these medications with grapefruit juice.”
Correct answer: C
Rationale: Weight gain can indicate serious adverse effects of beta2-blocking drugs, so the health care provider should be called. A pulse of 64 is acceptable; these drugs should be avoided in patients with asthma and there is no interaction with grapefruit juice. Calcium channel blockers should not be administered with grapefruit juice.
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Case Study (cont’d)
A patient asks how to apply transdermal nitroglycerin. What is the nurse’s best response?
“Always apply the transdermal patch over the area of your chest where your heart is.”
“Keep the previous patch on for one full day so you always have 2 patches on at a time.”
“Apply the patch to hairless areas of the body.”
“First apply vaseline to your body, then apply the transdermal patch.”
Correct answer: C
Rationale: The transdermal patch should be applied to a hairless, residual free area of the body with the sites being rotated each time. The old transdermal patch should be completely removed and a new one applied.
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