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Transcript
Agents That Dilate Coronary Blood Vessels Introduction Most common use is the treatment of coronary artery and peripheral artery disease Caused by inadequate flow of blood, nutrients & oxygen to tissue, resulting in an ischemic state, which is the #1 cause of death from disease in U.S. Coronary Vasodilators Used primarily for angina pectoris and pain The primary cause of ischemic heart disease is coronary artery disease (CAD) Results from atherosclerosis-plaque build up on vessel walls Decreases Ischemic oxygen and nutrient delivery to the heart muscle event leads to Chest Pain (angina) Increase heart of lactic acid that irritates pain receptors around the Angina Pectoris When the supply of oxygen and nutrients in the blood is insufficient, the heart muscle aches Older men have increased incidence of suffering from angina, MI, or other forms of CAD On average the patient will die with in 10 years of being diagnosed The use of nondrug therapy can also be beneficial Nitrates Effective anti angina agent Acts by relaxing vascular smooth muscle, stimulating the productions of intracellular cyclic guanosine monophosphate Also relaxes veins, preventing preload and afterload, decreasing the hearts workload Types of nitrates: Amyl nitrite, Nitroglycerin, isosorbide dinitrate, & isosorbide mononitrate Nitrate Stems from pharmacological action on the cardiovascular system: Headache Orthostatic Reflex hypotension tachycardia Dizziness Weakness Syncope Tolerance Dermatitis • Monitor BP (Severe hypotension) • Avoid use of tobacco • Wear gloves when administering nitrates Nitrate Amyl Nitrite Volatile crushed liquid in crushable glass capsules and vaporized to be inhaled Nitrates Nitroglycerin-(NTG, Nitro-Bid, Nitrol, Nitro-Dur, Nitrolingual, Nitromist, Pumpspray) Causes central and peripheral vasodilation (relaxes smooth muscle) Potent dilating effect on coronary arteries Used for prophylaxis and acute treatment of angina IV infused using volumetric infusion requiring constant monitoring Tingling or burning sensation is a good sign of potency with SL tabs Nitrate Nitroglycerin cont. Given: Sublingual, transdermal (Box 17-1 pg 549), topical, oral (sustained release only), translingual, & IV Large first pass effect when taken orally Transdermal is very effective, but if AE present, remove and call prescriber IV: HTN, CHF, MI, Ischemic pain, Pulmonary edema Do not mix IV form with other drugs How do nitrates relieve angina pain? How do nitrates relieve angina pain? Relaxing vascular smooth muscle by stimulating production cyclic GMP to increase blood flow and improve delivery of oxygen to ischemic tissue Non-Nitrate Blocking Agents Beta-Adrenergic Blocking Agents Used in the treatment of angina pectoris is well documented Act by decreasing heart rate and contractility, thereby reducing myocardial oxygen consumption Most effective when used with the nitrate in the prophylaxis of angina attacks Should be administered PRIOR to the nitrate Contraindicated in clients with obstructive pulmonary disease or reactive airway disease (may induce bronchoconstriction) Used with nitrate may increase chances of hypotension Ex: propranolol, nadolol, atenolol, or metoprolol) Calcium-Channel Blocking Agents Act by inhibiting the passage of calcium into vascular smooth muscle cells, thereby resulting in coronary vasodilation and increased coronary blood flow Ex: nifedipine, diltiazem HCl, verapamil, snf nicardipine HCl Misc. Antianginal agent pg550 Ranolazine (Ranexa) is classified as an antianginal agent BUT does not fit into the previous antianginal classification. Used for Tx of chronic angina and reserved for clients who have not achieved an adequate response from the commonly used Antianginal agents A Misc. Antianginal agents cont. pg550 Not used as a 1st line antianginal agent because its effect prolonging the QT inverval May be used with beta-adrenergic blocking agents, nitrates, Ca+ channel blockers, antiplatelet agents, ACE inhibitors and lipid- lowering drug therapy Contraindications: Is not for used with clients who have pre-exsisting QT prolongation, caution use in renal or hepatic function NOT FOR USE IN CHILDREN ADVERSE EFFECTS: Dizziness, headache, constipation, nausea, low BP, orthostatic A hypotension, lightheadness Multiple Drug interactions pg550,558 When taking Ranolazine: increase serum levels of digoxin and simvastatin Drugs that INCREASE Ranolazine serums: Macrolides (clarithromycin) Antivirals (indinavir, nelfinavir, saquinavir) Antidepressant (nefazodone,) Antifungal (itraconozole, ketoconazole) Protease inhibitors Antirrhythmic Ca+ channel blockers (diltiazem, quinidine, verapamil) Atypical Antipsychotic (ziprasidone) Antipsychotic (thoridazine) Anti-Rhuematic K+ channel blocker ( sotalol) A Multiple Drug interactions pg5588 Drugs that may DECREASE Ranolazine serum: Anticonvulsant ( carbamazepine, phenytoin) Barbiturate ( phenobartbital) Antitubular (rifabutin, rifampin, rifapentine) St. John’s Wort A Nursing Interventionspg558 Can be taken without food Clients should know to swallow tablets whole DO NO CRUSH, BREAK or CHEW Do not take Antianginal with grapefruit juice or any grapefruit containing product A Question When taking Ranolazine what food or food product should a client avoid? MYOCARDIAL INFARCTION Acute myocardial infarction occur when an area of the heart muscle dies as a result of insufficient oxygen. Myocardial Infarction More than 1.2 million AMIs occur annually in the United States with a prevalence of 74 per 1,000 at ages 85-94 in men experiencing their first major cardiovascular event. Although the number of deaths has decrease it still causes almlost 500,000 deaths per year. Treatment In addition to intravenous fluids, the first line of treatment for AMI is pharmacotherapeutics. A number of agent classifications are used in combination to sustain life by increasing oxygen-rich blood to the myocardium. Treatment cont. According to the guidelines the first drug to be administered in the event of AMI is 162-325 mg aspirin. The aspiring prevents further clotting and coronary artery constriction. Morphine sulfate administered IV remains the opioid of choice for clients experiencing AMI. It causes vascular muscle relaxation resulting in coronary artery vasodilation in addition to its action as an effective opioid analgesic. Morphine is a critical adjunct to nitroglycerin that is administered to decrease the heart’s workload and to increase myocardial blood supply. Morphine also reduces myocardial oxygen demand. However, because of its depressant effects, clients must be closely monitored for cardiopulmonary depression.
