Download Adverse Effects

Chapter 23
Antianginal Drugs
Copyright © 2014 by Mosby, an imprint 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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2
Ischemia

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
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, an imprint of Elsevier Inc.
7
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
Sublingual tablets; intravenous infusion
Long-acting forms

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
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
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
13
Nitrates (cont’d)


Adverse effects
Headaches




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

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 Mosby, an imprint 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
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
Dizziness, fatigue,
depression, lethargy
Other
Impotence, wheezing,
dyspnea
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)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
24
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
 Persistent headache
 Dry mouth
 Edema
 Fainting episodes
 Weight gain of 2 pounds in 1 day or 5 pounds in
1 week
 Pulse rates less than 60
 Dyspnea
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
 If no relief in 5 minutes, call 911/Emergency Services
immediately 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
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


Allergic reactions, headache, lightheadedness,
hypotension, dizziness
Monitor for therapeutic effects

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 beta2-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