Chapter 23: Antianginal Drugs

Question 1

Drugs for angina

Answer 1

Nitrates/nitrites
Beta blockers
Calcium channel blockers

Question 2

Therapeutic objectives

Answer 2

Minimize the frequency of attacks and decrease the duration and intensity of anginal pain
Improve the pts functional capacity with as few adverse effects as possible
Prevent or delay the worst possible outcome: MI

Question 3

Nitrates/Nitrites available forms

Answer 3

Sublingual, intravenous solutions, transdermal patches, ointments, translingual sprays (all of these bypass the liver and the first-pass effect)
Oral capsules/tablets, chewable tablets (first-pass effect occurs)

Question 4

Used to treat acute anginal attacks

Sublingual tablets; intravenous infusion

Answer 4

Rapid-acting forms of nitrates/nitrites

Question 5

Used to PREVENT anginal episodes

Answer 5

Long-acting forms of nitrates/nitrites

Question 6

NTG. Prototypical nitrate. Large first-pass effect with oral forms. Sublingual/meter dosed used for treatment of acute chest pain/angina. Used for symptomatic treatment of ischemic heart conditions (angina). IV form used for BP control (vasodilation of venous system) in perioperative hypertension, tx of HF, ischemic pain, pulmonary edema (vasodilation of venous system) associated with acute MI, and hypertensive emergencies (vasodilation of venous system)

Answer 6

Nitroglycerin (Nitro-Bid, Nitrostat). Nitrate.

Question 7

PO: 5-20 mg BID/TID.
PO: 40-80 mg @0800 and 1300 for sustained release.
Rapid-acting, sublingual tablets, IR tablets and long-acting.
Exerts same effects as other nitrates.
When metabolized in liver, it is broken down into two active metabolites: isosoribide deniitrate and isosoribide mononitrate.

Answer 7

Isosorbide Dinitrate (Isordil)

Question 8

PO: 20 mg BID given 7 hr apart.
PO: 30-120 mg/day for sustained release
Produce consistent, stead therapeutic response, less variation between pts because it is only one drug

Answer 8

Isosorbide Mononitrate (Imdur)

Question 9

Adverse effects of nitrates

Answer 9

Headaches: b/c of cerebral arterial dilation. Usually diminish in intensity and frequency with continued use.
Reflex tachycardia (baroreceptors sense decrease in BP, increase HR in response. Short-lived response).
Postural hypotension
Tolerance may develop

Question 10

Tolerance with nitrates

Answer 10

Occurs in pts 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

Beta blockers

Answer 11

atenolol (Tenormin)
metopropolol (Lopressor)
propanolol (Inderal): passes through the BBB=good for migranes, stage-fright (small doses)
nadolol (Corgard)

Question 12

Cardio-selective Beta-1 adrenergic blocker (decrease demand, increase supply/perfusion).
PO
Prevent MI in pts with hx
Tx of HTN, angina, thyrotoxicosis

Answer 12

Atenolol (Tenformin)

Question 13

Cardio-selective Beta-1 adrenergic blockers
PO, IVP
Prophylactic tx of angina
Shown to increase survival in pts experiencing MI
Used for tx of HTN in pts unable to take PO
Contraindicated in pts with asthma/resp disorders

Answer 13

Metopropolol (Lopressor, Toprol XL)

Question 14

Indications of beta blockers

Answer 14

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

Question 15

Adverse effects of beta blockers

Answer 15

CV: bradycardia, hypotension, atrioventricular block
Metabolic: hyperglycemia and/or hypoglycemia
CNS: dizziness, fatigue, depression, lethargy
Other: impotence, wheezing, dyspnea

Question 16

Calcium channel blockers

Answer 16

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

Question 17

High affinity for cardiac conduction system
Effective in the tx of angina pectoris resulting from coronary insufficiency and HTN
One of the few CCB available in parenteral form (used for afib/flitter, PSVT)
Cardizem SR- PO BID
Cardizem CD- PO daily.

Answer 17

Diltiazem (Cardizem). Calcium channel blocker

Question 18

Indications for CCBs

Answer 18

Angina
HTN
Supraventricular tachycardia
Coronary artery spasms (Prinzmetal angina)
Short-term management of atrial fibrillation and flutter

Question 19

Adverse effects of CCBs

Answer 19

Limited
Primarily r/t overexpression of their therapeutic effects
May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspnea, other adverse effects

Question 20

Pts should not take any medications, including OTCs, without checking with their PCP. Pts should be encouraged to limit caffeine intake. 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 pts to slowly change positions to avoid postural BP changes.
Encourage pts to keep a record of their anginal attacks, including precipitation factors, number of pills taken, and therapeutic effects.

Answer 20

Nursing implications for anti-anginas drugs

Question 21

Pts should report

Answer 21

Blurred vision, persistent headache, dry mouth, edema, fainting episodes, weight gain of 2# in one day or 5# in one week, pulse rates less than 60, dyspnea

Question 22

Instruct pts in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain. Instruct pts never to chew or swallow the sublingual form. Instruct pts that a burning sensation felt with sublingual forms indicates that the drug is still potent. Instruct pts 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 filter.

Answer 22

Nursing implications for sublingual nitroglycerin

Question 23

Instruct pts in the proper application of nitrate topical ointments and transdermal form, including site rotation and removal of old medication. To reduce tolerance, the pt may be instructed to remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period.

Answer 23

Topical nitro nursing implications

Question 24

Instruct pts to take PRN nitrates at the fist hint of anginal pain. Monitor vital sings frequently during acute exacerbations of angina and during IV administration. If experiencing chest pain, the pt taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension.

Answer 24

More nursing implications for nitroglycerin use

Question 25

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 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.

Answer 25

More Nitro nursing implications

Question 26

IV forms of nitro must be given with special non-PVC tubing and bags.
Discard parenteral solution that is blue, green, or dark red.
Follow specific manufacturer instructions for IV administration

Answer 26

Nursing implications for IV nitroglycerin

Question 27

Pts taking beta-blockers should monitor pulse rate daily and report any rate lower than 60 bp or sx of relative bradycardia
Instruct the pts to report dizziness or fainting.
Weight gain 2# or more in 1 day, 5# of more in a weeks should be reported. Inform pts that these medications should never be abruptly discontinued. Inform pts that these medications are for long-term prevention of angina, not for immediate relief.

Answer 27

Nursing implications for beta blockers

Question 28

Abrupt withdrawal can precipitate rebound HTN and worsening acute ischemia. Weight needs to be monitored, continuously monitor for edema and SOB. Instruct pt to change positions slowly/cautiously to prevent syncope. Constipation is a common problem; instruct pts to take in adequate fluids and eat high-fiber foods. NO GRAPEFRUIT JUICE.

Answer 28

Nursing implications for calcium channel blockers

Question 29

Nursing implications for antiginal drugs as a whole

Answer 29

Monitor for adverse reactions (allergic reactions, headache, lightheadedness, hypotension, dizziness)
Monitor for therapeutic effects (relief of angina, decreased BP, or both)