Antianginal DrugsAngina 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 organo Ischemic heart disease Poor blood supply to the heart muscle Atherosclerosis Coronary artery diseaseo Myocardial infarction (MI) Necrosis, or death, of cardiac tissue Disabling or fatal- Types of Anginao 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/nitriteso Sildenafil, Tadalafil, and Vardenifil o AmylNitrate – rapid o NIG – rapid and long o Isosorbide/Isordil – long - Beta blockers- Calcium channel blockersTherapeutic 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: MINitrates/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 Effectso Cause vasodilation because of relaxation of smooth muscleso Potent dilating effect on coronary arterieso Result: oxygen to ischemic myocardial tissueo Used for prevention and treatment of anginaNitrates/Nitrites - Rapid-acting forms – Used to treat acute anginal attackso Sublingual tablets; intravenous infusion- Long-acting forms – Used to PREVENT anginal episodeso Isosorbide/Isordil - Nitroglycerino Prototypical nitrateo Large first-pass effect with oral formso 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 effectso Headaches Usually diminish in intensity and frequency with continued use Most common complaint o Reflex tachycardia Usual only in the IV form o Postural hypotensiono Tolerance may developo When taking IV form, make sure patient is sitting down and watch the cardiac monitor- *INTERACTIONS WITH NITRATE/NITRITESo 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 formso Happens less often with the short acting - Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenisho 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 Actiono Block beta1 receptors on the hearto Decrease HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the hearto Decrease myocardial contractility, helping to conserve energy or decrease demando 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 dysrhythmiaso Beta blockers block the harmful effects of catecholamines, thus improving survival after an MI- Beta Blockers: Indicationso Anginao Antihypertensiveo Cardiac dysrhythmiaso Cardioprotective effects, especially after MIo Some used for migraine headaches, essential tremors, and stage frighto Reduces recurring MIo Used to make a heart rhythm more regular - Beta Blockers: Adverse Effectso Cardiovascular – Bradycardia, hypotension, atrioventricular blocko Metabolic – Hyperglycemia and/or hypoglycemia (masks this with patients with diabetesII), hyperlipidemiao CNS – Dizziness, fatigue, depression, lethargyo Other – Impotence, wheezing, dyspnea, sexual dysfunction, loss of lavigo (desire), *DON’T GIVE TO PATIENTS WITH ASTHMACalcium Channel Blockers- verapamil (Calan, Isoptin), diltiazem (Cardizem), nifedipine (Procardia), amlodipine (Norvasc), and nicardipine (Cardene)o ANGINA, HYPERTENSION, DISRHYTHMIAS, ARRHYTHMIAS- Mechanism of Actiono Cause coronary artery vasodilationo Cause peripheral arterial vasodilation, thus decreasing systemic vascular resistanceo Reduce the workload of the hearto Result: decreased myocardial oxygen demando Perfusion to the extremities- Indicationso Anginao Hypertensiono Supraventricular tachycardiao Coronary artery spasms (Prinzmetal angina)o Short-term management of atrial fibrillation and flutter- Adverse Effectso 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 Implicationso 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 useo Obtain baseline VS, including respiratory patterns and rateo Assess for drug interactionso Patients should not take any medications, including over-the-counter medications, without checking with their physiciano Patients should be encouraged to limit ***caffeine intake***o 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 (Unless a long distance runner, then less than 45), Dyspneao 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 o Teach patients to change positions slowly to avoid postural BP changeso Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of pills taken, and therapeutic effectso Nitroglycerin Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain Instruct patients never to chew or swallow the sublingual