Chap 23 Antianginal Drugs

Question 1

Angina Pectoris

Answer 1

Result of myocardial ischemia caused by imbalance between myocardial blood supply and oxygen demand

Angina or chest pain is common

Question 2

Ischemia

Answer 2

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

Question 3

Types of Angina

Answer 3

Stable Angina*
“effort angina” triggered by physical or mental exertion
resolves with rest or nitrates

Unstable Angina*
new onset or worsening angina - unpredictable
rest/meds do not resolve
acute coronary syndrome; may lead to MI

Vasospastic Angina*
aka, variant/prinzmetal
occurs spontaneously, often at rest, common at night/early morning, especially exercise
more common in women and smokers
responds to nitrates: CCBs suppress(beta blockers do not)

Microvascular Angina*
Angina due to coronary microvascular dysfunction or vasospasm
accounts or chest pain up to 50% of pts w/out obstructive epicardial CAD
can occur with exertion or at rest
may respond less with exertion or at rest
be difficult to distinguish from epicardial angina, diagnose with PET or CMR

Question 4

Drugs for Angina

Answer 4

Nitrates* or nitrites*
Beta blockers*
Calcium channel blockers (CCBs)
Goal: to increase blood flow to the ischemic myocardium, decrease myocardial oxygen demand, or both

Question 5

Nitrates and Nitrites Forms& exs.

Answer 5

Available forms
Sublingual*
Chewable tablets
Oral capsules/tablets
Intravenous (IV) solutions*
Transdermal patches*
Ointments
Translingual sprays*

*Bypass the liver and the first-pass effect.

Nitroglycerin (both rapid and long acting)
Isosorbide dinitrate* (both rapid and long acting)*
Isosorbide mononitrate* (primarily long acting)

Question 6

Nitrates and Nitrites:
Mechanism of Action and Drug Effects

Answer 6

Cause vasodilation* because of relaxation of smooth muscles
Potent dilatingeffect on coronary arteries
Result:* oxygen to ischemic myocardial tissue
Used for prevention and treatment of angina

Question 7

Nitrates and Nitrites: Indications

Answer 7

Treat stable, unstable, and vasospastic angina
Rapid-acting forms
Used to treat acute* anginal attacks*
Sublingual tablets; IV infusion
Long-acting forms*
Used to PREVENT anginal episodes

Question 8

Nitrates: Contraindications

Answer 8

Known drug allergy
Severe anemia
Closed-angle glaucoma
Hypotension
Severe head injury*
Use of the erectile dysfunction drugs sildenafil (Viagra), tadalafil* (Cialis), and vardenafil *(Levitra)

Question 9

Nitrates Adverse Effects

Answer 9

mostly due to vasodilatation
most common is throbbing headache 60% of pts
postural hypotension*
facial flushing
tachycardia

Tolerance develops rapidly on continued use
most practical way prevent nitrate tolerance, provide nitrate free intervals everyday
interval typically 10-12 hrs at night cause decreased demand on heart

Question 10

Nitrate Tolerance

Answer 10

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

Question 11

Nitroglycerin

Answer 11

Prototypical nitrate

important drug used in symptomatic treatment of ischemic heart conditions such as angina

Routes—PO, SL, metered-dose aerosol that is sprayed under the tongue, IV, and topical

Large first-pass* effect with oral* forms

Question 12

Beta Blockers

Answer 12

Mainstay in the treatment of several cardiovascular diseases
Angina*
MI*
Hypertension*
Dysrhythmias *

Question 13

Cardioselective Beta Blockers mnemonic

HINT: M—E

Answer 13

Metoprolol
Atenolol
Nebivolol
Bisoprolol
Acebutolol
Betaxolol
Esmolol

B1 = 1 Heart
B2 = 2 Lungs

Question 14

Beta Blockers: 
Mechanism of Action

Answer 14

Block beta1 receptors on the heart

Decrease heart rate, resulting in decreased* myocardial oxygen demand* and increased* oxygen delivery to the heart*

Decrease myocardial contractility, helping to conserve energy or decrease demand

Question 15

Beta Blockers: Indications

Answer 15

Angina*
Antihypertensive*
Cardiac dysrhythmias*
Cardioprotective* effects, especially after MI*
Some used for migraine* headaches, essential tremors, and stage fright

Question 16

Beta Blockers Nursing Implications

Answer 16

Beta blockers*
Patients taking beta blockers should monitor* their pulse* rates daily* and report* any rate lower* than 60* beats/min or symptoms of relative bradycardia.

Instruct patients to report dizziness or fainting.
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.

Question 17

Beta Blockers: Contraindications

Answer 17

Systolic HF
Serious conduction disturbances
Caution: bronchial asthma because any level of blockade of beta2 receptors can promote bronchoconstriction
Diabetes mellitus: can mask hypoglycemia-induced tachycardia
Peripheral vascular disease: may further compromise cerebral or peripheral blood flow

Question 18

Beta Blockers: Adverse Effects

Answer 18

Cardiovascular*
Bradycardia, hypotension, atrioventricular (AV) block

Metabolic*
Hyperglycemia, hypoglycemia, hyperlipidemia

Central nervous system
Dizziness, fatigue, depression, lethargy*

Other
Impotence*, wheezing, dyspnea

Question 19

Atenolol (Tenormin)

Answer 19

Cardioselective beta1-adrenergic receptor blocker

Indication: prophylactic* treatment of angina pectoris*

Use of atenolol after MI has been shown to decrease mortality.

Question 20

Metoprolol (Lopressor, Toprol-XL)

Answer 20

Cardioselective beta1-adrenergic receptor blocker
Indication: prophylactic treatment of angina
Many of the same characteristics as atenolol
Reduces mortality rate in patients after MI and in treating angina
Forms: oral (immediate release and long acting) and parenteral (injectable) forms
IV metoprolol is commonly administered to hospitalized patients after an MI and is used for treatment of hypertension in patients unable to take oral medicine.

Question 21

CCBs for Chronic Stable Angina

Answer 21

Amlodipine*
Diltiazem (DILT)
Nicardipine
Nifedipine
Verapamil

Question 22

CCBs:
Mechanism of Action

Answer 22

Cause coronary artery vasodilation

Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistance

Reduce the workload of the heart

Result: decreased myocardial oxygen demand

Dysrhythmias: depression of the automaticity of and conduction through the sinoatrial and AV nodes

Question 23

Calcium Channel Blockers:
Indications& Contraindications

Answer 23

Indications
Angina
Hypertension
Supraventricular tachycardia
Coronary artery spasms (Prinzmetal angina)
Short-term management of atrial fibrillation and flutter
Migraine headaches
Raynaud’s disease
Nimodipine: cerebral artery spasms associated with aneurysm rupture

Contraindications
Known drug allergy
Acute MI
Second- or third-degree AV block (unless the patient has a pacemaker)
Hypotension

Question 24

Calcium Channel Blockers: 
Adverse Effects

Answer 24

Limited

Primarily relate to overexpression of their therapeutic effects

May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea, other adverse effects

Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods

Question 25

Diltiazem* (Cardizem, Dilacor, Tiazac)

Answer 25

effective for the txt angina pectoris from coronary insufficiency and HTN

Used in txt of A-Fib/flutter with paroxysmal SVT

Question 26

Amlodipine (Norvasc)

Answer 26

Indicated for both angina and hypertension
Available only for oral use

Question 27

Nursing Implications

Answer 27

Patients should report:
Blurred vision*
Persistent* headache*
Dry mouth
Edema*
Fainting episodes
Weight* gain* of 2 lb in 1 day or 5 lb in 1 week
Pulse* rate less than 60 beats/min*
Dyspnea*

Alcohol and hot baths/whirlpools, hot tubs, or saunas result vasodilation, hypotension, possibility of fainting.

Teach 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.

Question 28

Nitroglycerin Implications

Answer 28

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.*
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*

If anginal* pain occurs:*
Stop activity* and sit or lie down and take* a sublingual* tablet.
If there is no relief in 5 minutes, call 911* or emergency services immediately* and take* a second* sublingual tablet.
If there is no relief in 5 minutes, take a third* sublingual tablet.
Do not* try to drive* to the hospital.
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.