Antianginal Drugs 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 Ischemia o Ischemia Poor blood supply to an organ o Ischemic heart disease Poor blood supply to the heart muscle Atherosclerosis Coronary artery disease o Myocardial infarction MI Necrosis or death of cardiac tissue Disabling or fatal Types of Angina o Chronic stable angina also called classic or effort angina o Unstable angina also called preinfarction or crescendo angina o Vasospastic angina also called Prinzmetal or variant angina Drugs for Angina Nitrates nitrites o Sildenafil Tadalafil and Vardenifil o AmylNitrate rapid o NIG rapid and long o Isosorbide Isordil long Beta blockers Calcium channel blockers 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 Nitrates Nitrites Available forms Sublingual Most common Chewable tablets Oral capsules tablets Intravenous solutions Transdermal patches Second most common Ointments and Translingual sprays o Bypass the liver and the first pass effect Drug Effects o Cause vasodilation because of relaxation of smooth muscles o Potent dilating effect on coronary arteries o Result oxygen to ischemic myocardial tissue o Used for prevention and treatment of angina Nitrates Nitrites Rapid acting forms Used to treat acute anginal attacks o Sublingual tablets intravenous infusion Long acting forms Used to PREVENT anginal episodes o Isosorbide Isordil Nitroglycerin o Prototypical nitrate o Large first pass effect with oral forms o Used for symptomatic treatment of ischemic heart conditions angina o IV form used for BP control in perioperative hypertension treatment of HF ischemic pain pulmonary edema associated with acute MI and hypertensive emergencies Adverse effects o Headaches Usually diminish in intensity and frequency with continued use Most common complaint o Reflex tachycardia Usual only in the IV form o Postural hypotension o Tolerance may develop o When taking IV form make sure patient is sitting down and watch the cardiac monitor INTERACTIONS WITH NITRATE NITRITES o Cealis Celdenafel Lavese and Viagra Erectile dysfunction medications Because both are vasodilators Tolerance Occurs in patients taking nitrates around the clock or with long acting forms o Happens less often with the short acting Prevented by allowing a regular nitrate free period to allow enzyme pathways to replenish o Transdermal forms remove patch at bedtime for 8 hours then apply a new patch in the morning Don t need at night for tolerance Beta Blockers atenolol Tenormin metoprolol Lopressor propranolol Inderal and nadolol Corgard INTERACTIONS WITH BETA BLOCKERS o Tigamed or Cimetidime Pulse rate will decrease by 10 to 15 bpm alone Reduce together by 45 bpm Mechanism of Action o Block beta1 receptors on the heart o Decrease HR resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart o Decrease myocardial contractility helping to conserve energy or decrease demand o 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 o Beta blockers block the harmful effects of catecholamines thus improving survival after an MI Beta Blockers Indications o Angina o Antihypertensive o Cardiac dysrhythmias o Cardioprotective effects especially after MI o Some used for migraine headaches essential tremors and stage fright o Reduces recurring MI o Used to make a heart rhythm more regular Beta Blockers Adverse Effects o Cardiovascular Bradycardia hypotension atrioventricular block o Metabolic Hyperglycemia and or hypoglycemia masks this with patients with diabetes II hyperlipidemia o CNS Dizziness fatigue depression lethargy o Other Impotence wheezing dyspnea sexual dysfunction loss of lavigo desire DON T GIVE TO PATIENTS WITH ASTHMA Calcium Channel Blockers verapamil Calan Isoptin diltiazem Cardizem nifedipine Procardia amlodipine Norvasc and nicardipine Cardene o ANGINA HYPERTENSION DISRHYTHMIAS ARRHYTHMIAS Mechanism of Action o Cause coronary artery vasodilation o Cause peripheral arterial vasodilation thus decreasing systemic vascular resistance o Reduce the workload of the heart o Result decreased myocardial oxygen demand o Perfusion to the extremities Indications o Angina o Hypertension o Supraventricular tachycardia o Coronary artery spasms Prinzmetal angina o Short term management of atrial fibrillation and flutter Adverse Effects o Limited o Primarily relate to overexpression of their therapeutic effects o May cause hypotension palpitations tachycardia or bradycardia constipation nausea dyspnea other adverse effects Nursing Implications o 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 o Obtain baseline VS including respiratory patterns and rate o Assess for drug interactions o Patients should not take any medications including over the counter medications without checking with their physician o Patients should be encouraged to limit caffeine intake o Patients should report o o o o o 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 Unless a long distance runner then less than 45 Dyspnea Alcohol consumption and spending time in hot baths or whirlpools hot tubs or saunas will result in vasodilation hypotension and the possibility of fainting Alcohol and heart medication do NOT go together 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 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 causes a little stinging Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent Instruct patients to keep a fresh supply of sublingual medication on hand potency is