Download Chapter 24 - The RedZone

CHAPTER 24
Antianginal Drugs
Mosby items and derived items © 2011, 2007, 2004 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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Ischemia

Ischemia


Ischemic heart disease




Poor blood supply to an organ
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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’s or variant angina)
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
4
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
5
Drugs for Angina



Nitrates/nitrites
Beta-blockers
Calcium channel blockers
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
6
Therapeutic Objectives

Increase blood flow to ischemic heart muscle
and/or

Decrease myocardial oxygen demand
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
7
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
8
Nitrates/Nitrites
Available forms





Sublingual*
Buccal*
Chewable tablets
Oral capsules/tablets
Intravenous solutions*



Transdermal patches*
Ointments*
Translingual sprays*
*Bypass the liver and the first-pass effect
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
9
Nitrates/Nitrites (cont’d)



Cause vasodilation because of relaxation of
smooth muscles
Potent dilating effect on coronary arteries
Used for prevention and treatment
of angina
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
10
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
11
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
12
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
13
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
14
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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

Transdermal forms: remove patch at bedtime for 8
hours, then apply a new patch in the morning
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
16
Beta-Blockers




atenolol (Tenormin)
metoprolol (Lopressor)
propranolol (Inderal)
nadolol (Corgard)
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
17
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
19
Beta-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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
20
Beta-Blockers (cont’d)
Adverse effects
Body System
Adverse Effects
Cardiovascular
Bradycardia, hypotension,
second- or third-degree heart
block; heart failure
Altered glucose and lipid
metabolism
Metabolic
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
21
Beta-Blockers (cont’d)
Adverse effects (cont’d)
Body System
CNS
Other
Adverse Effects
Dizziness, fatigue,
mental depression, lethargy,
drowsiness, unusual dreams
Impotence, wheezing,
dyspnea
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
22
Calcium Channel Blockers





verapamil (Calan, Isoptin)
diltiazem (Cardizem)
nifedipine (Procardia)
amlodipine (Norvasc)
Others
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
23
Calcium Channel Blockers
(cont’d)

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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
24
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
25
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
26
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
27
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
28
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 pounds in
1 week, pulse rates less than 60, and
dyspnea
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
29
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
30
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
31
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
32
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
33
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
34
Nursing Implications (cont’d)
Nitroglycerin (cont’d)
 If anginal pain occurs:





Stop activity and sit or lie down
Take a sublingual tablet, and call 911/Emergency
Services immediately!
If no relief in 5 minutes, take a second sublingual
tablet
If no relief in 5 minutes, take a third sublingual
tablet
Do not try to drive to the hospital
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
35
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
36
Nursing Implications (cont’d)
Calcium channel blockers
 Constipation is a common problem; instruct
patients to take in adequate fluids and eat
high-fiber foods
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate 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
 Instruct patients to report dizziness or fainting
 Constipation is a common problem; instruct
patients to take in adequate fluids and eat
high-fiber foods
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
38
Nursing Implications (cont’d)
Beta-blockers (cont’d)
 Inform patients that these medications should
never be abruptly discontinued because of
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 © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
39
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
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
40