Download Ch. 21-Drugs Used to Treat Angina, Peripheral Vascular Disease

Chapter
21
Drugs Used to Treat
Angina, Peripheral
Vascular Disease, &
Heart Failure
Delegation Guidelines
Drug Used to Treat Angina, Peripheral
Vascular Disease, and Heart Failure:

Some drugs used to treat angina, peripheral vascular
disease and heart failure are given parenterally- by
subcutaneous, intramuscular or intravenous injection.
Because you do NOT give parenteral dose forms, they
are not included in this chapter. Should a nurse delegate
the administration of such to you, you must:
- remember that parenteral dosages are often very
different from dosages other routes
-Refuse the delegation. Make sure to explain why.
Do NOT just ignore the request. Make sure the nurse
knows that you cannot give drug and why
Cardiovascular system disorders are leading
causes of death in the US
Angina:
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coronary arteries are in the heart
they supply the heart with blood
in coronary artery disease (CAD), the arteries become
hardened and narrow
one or all are affected
the heart muscle ends up getting less blood and
oxygen
most common cause is atherosclerosis (ch.18)
plaque collects on the arterial walls
narrow arteries block flow
angina cont…
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blockage may be total or partial
blood clots can also form along the plaque and block
flow
major complications of CAD are:
 angina
 myocardial infarction (MI)
 dysrhythmias
 sudden death

the more risk factors the increased chance of CAD
and it’s complications
Box 21-1: RISK FACTORS FOR CAD

Risk Factors that CANNOT be controlled:
 gender- men at increased risk
 age- males, risk increases after 45
women, risk increases after 55
 family history
 race- african americans at greatest risk
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Risk Factors that CAN be controlled:
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being over-weight
lack of exercise
high cholesterol
smoking
diabetes
stress (anger, worry, arguing)
angina cont…
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angina: chest pain, its from reduced blood flow to part of
the heart muscle
occurs when heart needs more oxygen
normally blood flow to heart increases when the need for
oxygen increases, in CAD narrow vessels prevent
increased blood flow
chest pain is described as tightness, pressure, squeezing,
or burning in chest (fig 21-1 p. 272)
pain can occur in shoulders, arms, neck, jaw or back
pain in jaw , neck, and down 1 or both arms is
common
person may be pale, feel faint, and perspire, dyspnea
is common, as well as nausea, fatigue and weakness
angina cont….
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some people complain of gas or indigestion
rest often alleviates symptoms is 3-15 minutes
rest reduces the heart’s need for oxygen, so normal
blood flow is achieved and heart damage is
prevented
things that cause angina are avoided:
 over-exertion
 heavy meals
 over-eating
 emotional stress
angina cont…
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person needs to stay indoors during cold or hot
weather, exercise programs are helpful, supervised
by doctor
some people need drugs to reduce the hearts work
load and relieve systems
other drugs are given to prevent MI or sudden death
drugs can delay need for medical/surgical
procedures that open or bypass diseased arteries
(fig 21-2 p. 272)
goal is to increase blood flow to heart, this may
prevent or lower risk of MI and death
angina cont…
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with angina, coronary arteries cannot deliver enough
oxygen to meet heart’s demands
7 groups of drugs to treat angina:
nitrates
 beta blockers
 ACE inhibitors
 calcium channel blockers
 statins (ch.18)
 platelet-active agents (ch.23)
 fatty oxidase enzyme inhibitors

drugs used to treat angina…
Nitrates:
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oldest effective therapy for angina
relieve angina by:
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relaxing peripheral vascular smooth muscles (arteries and veins dilate,
reducing venous blood flow to heart, decreases oxygen demands on
heart)
dilating coronary arteries (enhances blood flow and myocardial oxygen
supply)
Nitroglycerin is drug of choice in tx of angina.
various dose forms
goals of nitrate therapy:
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relieve pain of angina during an attack
reduce frequency and severity of anginal attacks
increase activity and exercise tolerance
Assisting With the Nursing Process
Nitrates:
ASSESSMENT: ask about severity, location, duration, intensity and
pattern of pain, ask when last dose was taken, ask if relief was obtained,
measure BP
PLANNING: see table 21-1 p. 273 for “Dose Forms”
IMPLEMENTATION: see box 21-2 p. 274 for administration of nitrate
dose forms (sublingual tablets, sustained release tablets, transmucosal
tablets, translingual spray, topical ointment, transdermal disk)
EVALUATION: report and record:
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hypotension, dizziness, nausea, flushing, fainting: may need to adjust dose
headache: most common side effect (can be mild or severe) most people
will develop a tolerance in a few weeks
tolerance (increasing dosage to obtain relief): can develop rapidly
especially if large doses are given often, smallest dose for satisfactory
result should always be used
drugs used to treat angina…
Beta blockers (Beta-adrenergic Blocking Agents):
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block the beta-adrenergic receptors in the heart
prevents stimulation from norepineprhine and epinephrine (ch. 14),
normally this stimulation would increase the heart rate and increase
myocardial oxygen demands
heart rate, oxygen demand, and BP are reduced by blocking the
receptors
all beta blockers are effective in treating angina
goals of therapy:
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reduce # of angina attacks
reduce nitroglycerin use
improve activity and exercise tolerance
Assisting With the Nursing Process
Beta Blockers:
ASSESSMENT: measure BP (supine/standing), ask about
respiratory signs and symptoms, measure blood glucose if person
has diabetes
PLANNING: see table 14-2 (p. 179) for “Oral Dose Forms”
IMPLEMENTATION: see table 14-2 (pg.179) for “Adult Dosage
Range”. Onset of action is fairly rapid, may take days/weeks for
stabilization
EVALUATION: most adverse effects of beta blockers are dose
related
report and record:
- cardiovascular: bradycardia, peripheral vasoconstriction (purple,
mottled skin)
- respiratory: broncho-spasm, wheezing
- persons with diabetes: signs/symptoms of hypoglycemia:
headache, weakness, decreased coordination, general
apprehension, sweating, hunger, blurred or double vision
- persons with heart failure: increase in edema, dyspnea,
bradycardia, orthopnea
drugs used to treat angina…
Calcium Ion Antagonists (Calcium Channel Blockers):
 inhibit the movement of calcium ions across cell
membranes (ch.19)
 they do the following:
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decrease myocardial oxygen demand
dilate coronary arteries, which improves blood flow, this
increases myocardial blood supply
dilate peripheral vessels, this decreases resistance to blood
flow which reduces heart workload
goals of therapy:
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decrease frequency of attacks
decrease the severity of angina attacks
increase activity and exercise tolerance
Assisting With the Nursing Process
Calcium Channel Blockers (Calcium Ion Antagonists:
ASSESSMENT: measure BP (supine/standing), observe for
signs/symptoms of heart failure (pg. 279)
PLANNING: see table 21-2 (p. 275) for “Oral Dose Forms”
IMPLEMENTATION: see table 21-2 (p. 275) for “Adult Dosage
Range”
EVALUATION: report and record:
hypotension and fainting: may occur in first week,
decline when dosage is stabilized, provide for safety
edema: measure weight daily, measure intake/output
drugs used to treat angina…
Angiotensin-Converting Enzyme (ACE) Inhibitors :
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prevent vaso-constriction, the blood vessels dilate
drugs also prevent blood clots from forming
see ch. 19 for more info
used to prevent MI
Assisting With the Nursing Process
ACE Inhibitors:
ASSESSMENT: measure BP (supine/standing), measure
heart rate and rhythm for 1 minute (apical pulse), ask
about bowel elimination, ask if person has a cough
PLANNING: see table 19-1 (p. 245) for “oral dose forms”
IMPLEMENTATION: see table 19-1 (p. 245) for “Adult
Dosage Range”, Captopril (Capoten) is given 2x/day 1
hour before or 2 hours after meals, all other ACE
inhibitors are given once/day
EVALUATION: report and record:
hypotension and fainting: may occur in first week,
decline when dosage is stabilized, provide for
safety
edema: measure weight daily, measure intake/output
drugs used to treat angina…
Fatty Oxidase Enzyme Inhibitor:
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drug that reduces oxygen need by myocardial cells to
cause muscle contractions
oxygen demand is reduced, thus symptoms of
angina are reduced
example: ranolazine (Ranexa)
does NOT affect BP or heart rate, used with a
calcium channel blocker, beta-blocker or nitrates
goal of therapy:
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decrease frequency of angina attacks
decrease severity of angina attacks
increase activity and exercise tolerance
reduce the use of nitroglycerin in anginal attacks
Assisting With the Nursing Process
ranolazine (Ranexa):
ASSESSMENT: ask nurse if measurements are needed
PLANNING: oral dose form is 500mg extended-release tablets
IMPLEMENTATION: usual dose is 500mg 2x/day, may be
increased to 1000mg 2x/day, drug may be taken
with/without food, tablets should be swallowed whole
EVALUATION: report and record:
dizziness, headache, constipation, nausea: usually mild
Peripheral Vascular Disease (PVD):
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involves the blood vessels in the arms and legs
can be arterial or venous in origin:
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deep vein thrombosis: see ch. 23
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arteriosclerosis obliterans: results from atherosclerosis (ch.18), of
the lower aorta and major arteries supplying the legs
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gradual narrowing of the arteries with thrombus (clot) formation
cholesterol, hypertension, smoking and diabetes are causes
symptoms occur when there is significant narrowing (75% or more) of
major arteries and arterioles in the legs
blood flow is obstructed, tissues do NOT get needed oxygen
pain pattern usually described as aching, cramping, tightness or weakness
in the calves usually during walking, relieved with rest (called intermittent
claudication)
as disease progresses person may have pain at rest, numbness and tingling.
gangrene is a risk
Peripheral Vascular Disease (PVD) cont….
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Raynaud’s disease:
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exposure to cold or strong emotions trigger blood vessel
spasms- vaso-spasms
vaso-spasm: sudden contraction of blood vessels causing
vaso-constriction
vaso-spasms obstruct blood flow to fingers, toes, ears and
nose
disease is more common in women
risk factors:
 arterial diseases
 repeated trauma (vibrations caused by typing, playing piano,
air hammers)
 some drugs
 strong emotions
 exposure to cold
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Raynaud’s disease cont…
fingers, toes, ears or nose become white from lack of blood flow
they then turn blue, tiny blood vessels dilate to allow more blood to
stay in tissues
when blood flow returns the area becomes red
later it returns to normal color
swelling, tingling and painful throbbing may occur
attacks last minutes to hours
as disease progresses fingers become thin an tapered, with smooth,
shiny skin
ulcers and gangrene may result if artery becomes completely
blocked
see box 21-3 (p. 277, or next slide) for treatment of arteriosclerosis
obliterans and Raynaud’s disease
goals of drug therapy:
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reverse disease progression
improve blood flow
provide pain relief
prevent skin ulcers and gangrene
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Box 21-3: Treatment of Peripheral Vascular Disease
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Arteriosclerosis Obliterans:
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control of existing diseases (diabetes, hypertension, angina, high
cholesterol)
weight control
daily exercise (walking)
proper foot care (feet kept warm/dry, shoes fit properly)
avoiding cold
raising the head of the bed 12-16 inches
medical or surgical procedures to improve blood flow
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Raynaud’s Disease:
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avoiding:
-cold temps
-emotional stress
-tobacco use
keeping hands and feet warm with gloves/socks
using foam “wrap arounds” when handling iced beverages
Treatment of Peripheral Vascular Disease cont…
Hemorrheologic Agent:
 prevents the clumping of red blood cells and platelets
 blood flow to small vessels increases, they receive more
oxygen
 goals of therapy:
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improve the blood and oxygen supply to tissues
reduce the frequency of pain
improve exercise tolerance
improve pulses in legs
the following is a hemorrheologic agent:
pentoxifylline (Trental): used to treat intermittent claudication
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Assisting With the Nursing Process
pentoxifylline (Trental):
ASSESSMENT: ask about nausea, vomiting, indigestion or poor
tolerance to caffeine products(coffee, tea, chocolate, colas), ask
about dizziness, headache, cardiac symptoms, ask person to
rate their pain (ch.17)
PLANNING: oral dose form is 400mg extended-release tablets
IMPLEMENTATION: usual dose is 400mg 3x/day, if adverse
effects then dose is reduced or drug discontinued. give drug
with food or milk if directed to by nurse or MAR
EVALUATION: report and record:
- nausea, vomiting, indigestion: usually mild and resolve
- dizziness, headache: usually mild and resolve, provide for
safety
- chest pain, dysrhythmias, shortness of breath: signal a cardiac
even, tell nurse immediately
- nausea, tachycardia: may signal intolerance to drugs/caffeine
Treatment of Peripheral Vascular Disease cont…
Vaso-Dilators:
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drugs that widen blood vessels to increase blood flow
goals of therapy:
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improve blood and oxygen supply to tissues
reduce frequency of pain
improve exercise tolerance
improve pulses in legs
Vaso-dilators used:
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isoxsuprine hydrochloride (Vasodilan): causes vaso-dilation of the
smooth muscles of blood vessels
papaverine hydrochloride (Pavagen): relaxes smooth muscles, coronary
and cerebral blood vessels dilate, inhibits premature atrial contactions
and premature ventricular contractions and ventricular arrythmias
phenoxybenzamine hydrochloride (Dibenzyline): relaxes smooth
muscles of blood vessels, results in vaso-dilation and improved blood
flow to peripheral tissues
Assisting With the Nursing Process
isoxsuprine hydrochloride (Vasodilan):
ASSESSMENT: ask person to rate their pain (ch.17),
measure vital signs
PLANNING: oral dose forms are 10 and 20 mg tablets
IMPLEMENTATION: usual dose 10-20mg, 3-4x/day
EVALUATION: report and record:
- flushing, tingling, sweating, nausea, vomiting:
resolve with continued therapy
- hypotension, tachycardia: provide for safety
- rash: tell nurse at once, check with nurse before
giving next dose
- nervousness, weakness: may develop as therapy
progresses
Assisting With the Nursing Process
papaverine hydrochloride (Pavagen TD):
ASSESSMENT: ask person to rate their pain (ch.17),
measure vital signs
PLANNING: oral dose forms 150 mg time-released
capsules
IMPLEMENTATION: usual dose 150mg every 8 hours
or 300mg every 12 hours
EVALUATION: report and record:
- flushing, sweating, nausea, abdominal distress,
tachycardia, dizziness, drowsiness, headache:
usually mild and dose related. Measure vital signs
Assisting With the Nursing Process
phenoxybenzamine hydrochloride (Dibenzyline):
ASSESSMENT: ask person to rate their pain (ch.17),
measure vital signs
PLANNING: oral dose forms 10 mg capsules
IMPLEMENTATION: initial does 10mg per day, after
4 or more days the dose is increased 10mg every few
days to a max of 60mg/day, several weeks of
therapy are usually required to observe the full effect
EVALUATION: report and record:
- nasal congestion, pinpoint pupils, hypotension,
tachycardia. Measure BP and pulse. Provide for
safety
Treatment of Peripheral Vascular Disease cont…
Platelet Aggregation Inhibitor:
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platelets are needed for blood clotting
these drugs prevent platelets from clumping together
also causes vaso-dilation
goals of therapy:
 improve the blood and oxygen supply to tissues
 reduce frequency of pain
 improve exercise tolerance
 improve pulses in the legs
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the following drug is used:
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cilostazol (Pletal): used in tx of intermittent claudication
Assisting With the Nursing Process
cilostazol (Pletal):
ASSESSMENT: ask about dizziness, headache, ask person
to rate their pain (ch.17), ask about cardiac symptoms
PLANNING: oral dose forms 50 and 100mg tablets
IMPLEMENTATION: usual dose 100mg 2x/day, dose is
given 30 minutes before or 2 hours after breakfast and
dinner. Symptom relief may start within 2-4 weeks, make
take 12 weeks for full effect
EVALUATION: report and record:
indigestion, diarrhea: usually mild, tend to resolve
dizziness, headache: usually mild, tend to resolve,
provide for safety
chest pain, palpitations, dysrhythmias, shortness of
breath: signal cardiac event, tell nurse at once
Heart Failure:
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heart failure or congestive heart failure (CHF) occurs when
heart is weakened and cannot pump normally
blood backs up, tissue congestion occurs
when left side of heart cannot pump blood normally blood
backs up into the lungs, respiratory congestion occurs
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person has dyspnea, increased sputum, cough, gurgling sounds in
lungs
the rest of the body also does not get enough blood
poor blood flow to brain causes confusion, dizziness and fainting
kidneys produce less urine
skin is pale
BP falls
heart failure cont…
 when right side of heart cannot pump blood
normally, blood backs up into venous system
feet and ankles swell
 neck veins bulge
 liver congestion affects liver function
 abdomen becomes congested with fluid
 right side of heart pumps less blood to lungs
 normal blood flow does NOT occur from lungs to the left
side of heart
 left side has less blood to pump to body
 organs receive less blood
 signs/symptoms occur as described for left side failure

heart failure cont…
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very severe form of heart failure: pulmonary edema,
this is fluid in the lungs, it’s an emergency, person
can die
damaged or weakened heart usually causes heart
failure. CAD, MI, hypertension, age, diabetes,
dysrhythmias (ch.20), damaged heart valves, and
kidney diseases are common causes
treatment involves the cause of the heart failure
drug therapy is common
goals of therapy
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reduce signs and symptoms
increase exercise tolerance
prolong life
Drugs used to treat heart failure:
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usually treated with a combination of vaso-dilator,
inotropic, diuretic therapy
if failure is acute most drugs give with IV
vaso-dilators :
widen blood vessels (reduces hearts workload, tissues receive
more blood and oxygen
 reduce the amount of blood returning to heart (decreases lung
congestion, person breathes easier)
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inotropic agents:
stimulate the heart to increase the force of contractions
increases cardiac output (amount of blood pumped with each
heartbeat)
 digitalis glycosides are inotropic agents
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diuretics:
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given to increase sodium and water excretion (ch. 22)
relieves congestion and the heart’s workload
heart failure cont…
Digitalis Glycosides:
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among the oldest agents to treat heart failure
only digitalis glycoside available in US is: digoxin (Lanoxin)
increases the force of heart muscle contraction
slows the heart rate
heart is able to fill and empty more completely, which improves
circulation
with improved circulation, swelling in lungs and tissues is
reduced. Heart size returns to normal. Edema lessens
because of improved circulation to kidneys
digoxin used to treat heart failure that does NOT respond to
diuretics, beta blockers, ACE inhibitors
may be used to treat dysrhythmias –atrial fibrillation, atrial
flutter and paroxysmal tachycardia
Digitalization: giving a larger dose of digoxin for the first 24
hours, then the person is given a daily dose
heart failure cont…
Assisting With the Nursing Process
digoxin (Lanoxin):
ASSESSMENT: observe for dyspnea, chest pain, fatigue,
edema, fainting, palpitations. Measure BP, apical pulse
for 1 min and respirations. Weigh daily. Measure
intake/output
PLANNING: oral dose forms 0.125 and 0.25mg tablets,
0.05, 0.1 and 0.2mg gelcaps
IMPLEMENTATION: see pg. 280 for dosage guidelines
EVALUATION: report and record:
signs/symptoms of digoxin toxicity (box 21-4, see next
slide)
nausea, vomiting, diarrhea, excessive urinary output.
person is at risk for low serum potassium levels
(hypokalemia)
heart failure cont…
Box 21-4 Signs and Symptoms of Digoxin Toxicity:
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bradycardia
tachycardia
anorexia
nausea
vomiting
diarrhea
fatigue: extreme
weakness: arm and leg
nightmares
agitation
listlessness
hallucinations
vision problems: hazy or blurred vision, problems reading, problems
seeing red and green
heart failure cont…
Angiotensin-Converting Enzyme (ACE) Inhibitors:
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useful in treating heart failure because they:
prevent vaso-constriction: BP is reduced
inhibit aldosterone secretion: blood volume is reduced
Assisting With the Nursing Process
see slide 17 and Ch. 19
heart failure cont…
Beta-Adrenergic Blocking Agent:
 useful in treatment of heart failure:
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lower heart rate
reduce cardiac output
lower BP
prevent sodium and water retention by blocking renin
release
Assisting With the Nursing Process
see slide 13 or Ch. 19