Chapter 23 Antianginal Drugs Copyright 2014 by Mosby

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

Ischemia Ø Poor blood supply to an organ Ischemic heart disease Poor blood supply to the heart muscle Ø Atherosclerosis Ø Coronary artery disease Ø Myocardial infarction (MI) Necrosis, or death, of cardiac tissue Ø Disabling or fatal Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 3

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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 4

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

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? A. Take his nitroglycerin tablet B. Stop mowing and sit or lie down C. Go inside the house to cool off and get a drink of water D. Call 911 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

Drugs for Angina Nitrates/nitrites Beta blockers Calcium channel blockers Copyright © 2014 by Mosby,

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 9

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 10

Nitrates/Nitrites Rapid-acting forms Used to treat acute anginal attacks Ø Sublingual tablets; intravenous infusion Ø Long-acting forms Ø Used to PREVENT anginal episodes Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11

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? A. Sublingual spray B. Transdermal patch C. Oral capsule D. IV infusion Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12

Nitrates Nitroglycerin Prototypical nitrate Ø Large first-pass effect with oral forms Ø Used for symptomatic treatment of ischemic heart conditions (angina) Ø IV form used for BP control in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

Nitrates (cont’d) Adverse effects Headaches Ø Usually diminish in intensity and frequency with continued use Reflex tachycardia Postural hypotension Tolerance may develop Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

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? A. Immediately B. If the pain becomes more severe C. If one sublingual tablet does not relieve the pain after 5 minutes D. If the pain is not relieved after three sublingual tablets, taken 5 minutes apart Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15

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 Ø Transdermal forms: remove patch at bedtime for 8 hours, then apply a new patch in the morning Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Beta Blockers atenolol (Tenormin) metoprolol (Lopressor) propranolol (Inderal) nadolol (Corgard) Copyright © 2014 by

Beta Blockers: Mechanism of Action Block beta 1 receptors on the heart Decrease HR, resulting in decreased myocardial oxygen demand increased oxygen delivery to the heart Decrease myocardial contractility, helping to conserve energy or decrease demand Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

Beta Blockers: Indications Angina Antihypertensive Cardiac dysrhythmias Cardioprotective effects, especially after MI Some used for migraine headaches, essential tremors, and stage fright Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20

Beta Blockers: Adverse Effects Body System Cardiovascular Adverse Effects Bradycardia, hypotension, atrioventricular block Metabolic Hyperglycemia and/or hypoglycemia, hyperlipidemia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

Beta Blockers: Adverse Effects (cont’d) Body System CNS Adverse Effects Other Impotence, wheezing, dyspnea Dizziness, fatigue, depression, lethargy Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

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? A. Vasodilation of the coronary arteries B. Increased force of cardiac contraction C. Slowing of the heart rate D. Maintaining adequate blood pressure Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23

Calcium Channel Blockers verapamil (Calan, Isoptin) diltiazem (Cardizem) nifedipine (Procardia) amlodipine (Norvasc) nicardipine (Cardene)

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25

Calcium Channel Blockers: Indications Angina Hypertension Supraventricular tachycardia Coronary artery spasms (Prinzmetal angina) Short-term management of atrial fibrillation and flutter Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29

Nursing Implications (cont’d) Patients should report: Blurred vision Ø Persistent headache Ø Dry mouth Ø Edema Ø Fainting episodes Ø Weight gain of 2 pounds in 1 day or 5 pounds in 1 week Ø Pulse rates less than 60 Ø Dyspnea Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35

Nursing Implications (cont’d) Nitroglycerin (cont’d) If anginal pain occurs: Stop activity and sit or lie down, and take a sublingual tablet Ø If no relief in 5 minutes, call 911/Emergency Services immediately and take a second sublingual tablet Ø If no relief in 5 minutes, take a third sublingual tablet Ø Do not try to drive to the hospital Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39

Nursing Implications (cont’d) Calcium channel blockers Constipation is a common problem; instruct patients to take in adequate fluids and eat highfiber foods Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40

Nursing Implications (cont’d) Antianginal drugs Monitor for adverse reactions Ø Allergic reactions, headache, lightheadedness, hypotension, dizziness Monitor for therapeutic effects Ø Relief of angina, decreased BP, or both Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41

Case Study The nurse is preparing to educate a group of patients on the management of angina. 1. Which drug groups are most often used to treat patients with angina? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 42

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? A. “We do not know how Ranexa works. ” B. “This drug is the first medication your health care provider will use to treat your angina. ” C. “This drug must be given intravenously. ” D. “Ranexa is safe to use in patients with liver failure. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 43

Case Study (cont’d) What information will the nurse include when teaching the patients about taking beta 2 -blocking drugs for the treatment of angina? A. “Call your health care provider if you heart rate is 64 beats per minute. ” B. “These drugs are safe to use in patients who have asthma. ” C. “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. ” D. “Avoid taking these medications with grapefruit juice. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 44

Case Study (cont’d) A patient asks how to apply transdermal nitroglycerin. What is the nurse’s best response? A. “Always apply the transdermal patch over the area of your chest where your heart is. ” B. “Keep the previous patch on for one full day so you always have 2 patches on at a time. ” C. “Apply the patch to hairless areas of the body. ” D. “First apply vaseline to your body, then apply the transdermal patch. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 45