Pharmacology: Angina Management

Pharmacology Basics

• Pharmacology is closely related to physiology, so it's essential to remember physiology when studying pharmacology.
• Drugs are categorized medically by "classes".
• Medications can be categorized as an agonist or antagonist:
  • Agonist: alters the physiology of a cell by binding to plasma membrane or intracellular receptors, typically increasing a response, secretion, or response by an organ.
  • Antagonist: inhibits or blocks responses caused by agonists.

Routes of Drug Administration

• Oral (PO): by mouth, self-administered, absorption affected by gastric motility.
• Sublingual: under the tongue, self-administered, not concerned about GI motility.
• Rectal (PR): beneficial for unconscious or vomiting patients, small children.
• Inhalation: rapid absorption, self-administration.
• Topical: through the skin, for dermatologic, ophthalmologic, nasal, vaginal, and otic prescriptions.
• Transdermal: delivered via "patch" applied to the skin.
• Buccal: placing drugs between gum and cheek, dissolves and is absorbed into the blood.
• Parenteral: around the GI tract: intravenous (IV), intramuscular (IM), subcutaneous (SubQ, SC).

Autonomic Nervous System

• Sympathetic Nervous System: "fight or flight" response.
• Parasympathetic Nervous System: "rest and digest" response, characterized by:
  • Sluggish heart beat
  • Digestive tract activity
  • Increased secretions
  • Heavy breathing
  • Increased defecation and urination
  • Constricted pupils

Alpha Receptors

• Alpha 1 Receptors:
  • Constriction of arterioles and veins
  • Decreased secretion of glands
  • Decreased GI motility
  • Constriction of radial muscle of the eye
• Alpha 2 Receptors:
  • Decrease sympathetic outflow from the brain
  • Decrease norepinephrine release at CNS pre-synaptic terminals
  • Decrease islet cells of the pancreas
• Alpha Receptors (unknown):
  • Contraction of urinary bladder sphincter
  • Contraction of pregnant uterus
  • Ejaculation of penis

Beta Receptors

• Beta 1:
  • Increases heart rate (SA node)
  • Increases contractility
  • Increases conduction velocity
  • Increases automaticity
  • Increases renin secretion at the kidney
• Beta 2:
  • Relaxation of trachea and bronchioles
  • Relaxation of uterine contractions in pregnancy
  • Dilation of arterioles and veins (except in skin or brain)
• Beta Receptors (unknown):
  • Relaxation of ciliary eye muscles (minimal effect)
  • Relaxation of detrusor muscle
  • Internal effect

Cardiovascular Medications

• Alpha Adrenergic Antagonistic Agents:
  • Action: reduce peripheral vascular tone by blocking alpha-1 adrenergic receptors, allowing for dilation of arterioles and veins, decreasing blood pressure.
  • Indications: hypertension, benign prostatic hyperplasia, CHF.
• Angiotensin-Converting Enzyme (ACE) Inhibitors:
  • Action: decrease blood pressure (and afterload) by blocking conversion of angiotensin 1 to angiotensin 2 (vasoconstrictor) in the lung.
  • Indications: hypertension, CHF.
• Anticoagulant Agents:
  • Action: inhibit blood coagulation, platelet aggregation, and thrombus formation.
  • Indications: prevention of DVT and PE postoperative, maintaining circulation during open heart surgery and renal hemodialysis, ischemic heart disease, rheumatic heart disease.
• Anti-hyperlipidemia Agents:
  • Action: inhibit enzyme action in cholesterol synthesis, break down LDL, decrease triglyceride levels, and increase HDL levels.
  • Indications: hyperlipidemia, atherosclerosis, prevent coronary artery events in patients with existing coronary disease, diabetes, or peripheral vascular disease.
• Anti-thrombotic (Antiplatelet) Agents:
  • Action: inhibit platelet aggregation and clot formation.
  • Indications: post myocardial infarction, atrial fibrillation, prevent arterial thrombus formation.
• Beta-Blocker Agents:
  • Action: decrease the myocardial oxygen demand by decreasing heart rate and contractility by blocking B1-adrenergic receptors.
  • Indications: hypertension, angina, arrhythmias, heart failure, migraines, essential tremor.
• Calcium Channel Blocker Agents:
  • Action: decrease entry of calcium into vascular smooth muscle cells, resulting in diminished myocardial contraction, vasodilation, and decreased oxygen demand on the heart.
  • Indications: hypertension, angina pectoris, congestive heart failure, arrhythmias.
• Diuretic Agents:
  • Action: increase the excretion of sodium and urine, resulting in a reduction in plasma volume, which decreases blood pressure.
  • Indications: hypertension, edema associated with heart failure, pulmonary edema, glaucoma.
• Nitrate Agents:
  • Action: decrease ischemia through smooth muscle relaxation and dilation of peripheral vessels.
  • Indications: angina pectoris, may be used before exercise or stress to prevent ischemic exercise.
• Positive Ionotropic Agents:
  • Action: increase the force and velocity of myocardial contraction, slow heart rate, decrease conduction velocity through the AV node, and decrease the degree of activation of the sympathetic nervous system.
  • Indications: heart failure, atrial fibrillation, hypoventilation, cardiogenic shock.
• Thrombolytic Agents:
  • Action: degrade clots that have already formed.
  • Indications: acute myocardial infarction, pulmonary embolism, ischemic stroke, arterial or venous thrombosis.

Arrhythmia Treatment

• Class 1: Na+ Channel Blockers:
  • Action: slow conduction velocity and prolong refractory period.
  • Indications: atrial tachycardia, premature atrial depolarization, premature ventricular depolarization, atrial flutter, ventricular tachycardia.
• Class 2: Antagonistic Adrenergic Receptors:
  • Action: decrease heart rate, contractility, and automaticity, prolong A-V conduction time and refractoriness.
  • Indications: sinus tachycardia, atrial flutter, atrial fibrillation, A-V re-entry.
• Class 3: Prolong Repolarization:
  • Action: reduce potassium efflux, reduce automaticity of SA node, reduce conduction velocity, and increase refractoriness.
  • Indications: ventricular fibrillation, atrial fibrillation or flutter, ventricular tachycardia.
• Class 4: Block Slow Inward (Ca2+ Driven):
  • Action: reduce calcium entry into myocardial cells, sa node, and ectopic foci automaticity, increase refractory period of AV node.
  • Indications: multifocal atrial tachycardia, atrial flutter.

Endocrine System

• Hormone Replacement Agents:
  • Action: restore normal endocrine function when endogenous production of a particular hormone is deficient or absent.
  • Indications: decrease in endogenous hormone secretion.
• Hyperfunction Agents:
  • Action: manage hyperactive endocrine function to allow for inhibition of hormone function.
  • Indications: hyperactive or excessive endocrine function, excessive hormone levels.

Musculoskeletal System

• Nonopioid Agents:
  • Action: provide analgesia and pain relief, produce anti-inflammatory effects, and initiate anti-pyretic properties.
  • Indications: mild to moderate pain, fever, headache, muscle ache, inflammation (except acetaminophen), primary dysmenorrhea, reduction of risk of myocardial infarction (aspirin only).
• NSAIDs:
  • Action: inhibit thromboxanes and prostaglandin synthesis, also increase temperature in the hypothalamus.
  • Indications: mild to moderate pain, fever, headache, muscle ache, inflammation, primary dysmenorrhea, flu, colds, sprains/strains, anti-thrombotic.
• Opioid Agents (Narcotics):
  • Action: provide analgesia for acute severe pain management, stimulate opioid receptors within the CNS to prevent pain impulses from reaching their destination.
  • Indications: moderate to severe pain, induction of conscious sedation prior to a diagnostic procedure, management of opioid dependence, relief of severe and persistent cough (codeine).
• Glucocorticoid Agents (Corticosteroid):
  • Action: decrease inflammation, suppress immune response, and aid in glucose metabolism.
  • Indications: inflammation, immune system disorders, cancer treatment.
• Disease Modifying Anti-rheumatic Agents:
  • Action: slow or stop the progression of rheumatoid arthritis.
  • Indications: rheumatoid arthritis.

Genitourinary Management

• Overactive Bladder Agents:
  • Action: relieve the symptoms of an overactive bladder, noted by involuntary contractions of the bladder (detrusor muscle).
  • Indications: urinary urgency, urinary frequency, urge incontinence, nocturia.
• Urinary Anti-Infective Agents:
  • Action: treat urinary tract infections, but are### Pain Management
• Opioid analgesics (e.g., Morphine, Oxycodone, Codeine, Meperidine (Demerol)) are used for patient-controlled analgesia and may not accurately describe pain while on medication.

Glucocorticoid Agents (Corticosteroids)

• Action: Provide hormonal, anti-inflammatory, and metabolic effects, including suppressing articular and metabolic diseases.
• Indications: Replacement therapy for endocrine dysfunction, anti-inflammatory and immunosuppressive effects, treatment of rheumatic, respiratory, and other disorders.
• Side effects: Muscle atrophy, GI distress, glaucoma, adrenocortical suppression, drug-induced Cushing's syndrome, weakening/breakdown of supporting tissues (bone, ligament, tendon, skin), mood changes, HTN.
• Implications for PT: Mask required due to immunosuppression while on glucocorticoid therapy. Signs of toxicity include moon face, buffalo hump, and personality changes. Patients are at risk for osteoporosis and muscle wasting.

Glucorticoid Toxicity

• Symptoms: Moon face, buffalo hump, and personality changes.

Disease Modifying Anti-rheumatic Agents (DMARD)

• Action: Slow or halt the progression of rheumatic disease.
• Indications: Rheumatic disease.
• Side effects: Nausea, headache, joint pain and swelling, toxicity, GI distress, sore throat, fever, liver dysfunction, hair loss, potential for sepsis, retinal damage.
• Implications for PT: Monitor for signs of toxicity.

Methotrexate Toxicity

• Symptoms: Skin lesions.

Neuromuscular Management

Antiepileptic Agents

• Action: Reduce or eliminate seizure activity in the brain.
• Indications: Seizure activity (partial, generalized, or unclassified seizures).
• Side effects: Ataxia, skin issues, behavioral changes, GI distress, headache, blurred vision, weight gain.
• Implications for PT: Know seizure protocol for patients. May be more sensitive to certain lights or noises.

Antispasticity Agents

• Action: Promote relaxation in spastic muscles.
• Indications: Increased tone, spasticity, SCI, CVA, MS.
• Side effects: Drowsiness, confusion, headache, dizziness, muscle weakness, tolerance, dependence.
• Implications for PT: Balance the need to decrease spastic muscles with the loss of function that a patient may experience with the reduction of hypotonicity.

Dopamine Replacement Agents

• Action: Help relieve symptoms of Parkinson's disease by improving planning, initiation, and execution of movement.
• Indications: Parkinson's disease, Parkinsonism.
• Side effects: Arrythmias (levodopa), GI distress, orthostatic hypotension, dyskinesia, mood and behavioral changes, tolerance.
• Implications for PT: Schedule therapy 1 hour after administration of levodopa, monitor BP for possible orthostatic hypotension.

Muscle Relaxant Agents

• Action: Promote relaxation in muscles that typically present with spasm.
• Indications: Muscle spasm.
• Side effects: Sedation, drowsiness, dizziness, nausea, vomiting, headache, tolerance, dependence.
• Implications for PT: Use PT to increase active muscle relaxation.

Airway and Lung Disease Management

Antihistamine Agents

• Action: Block the effects of histamine, resulting in a decrease in nasal congestion, mucosal irritation, and symptoms of the common cold, sinusitis, conjunctivitis, and allergies.
• Indications: Respiratory seasonal allergies, rhinitis, sneezing from the common cold, allergic conjunctivitis, motion sickness, Parkinson's disease.
• Side effects: Arrythmias, postural hypotension, GI distress, dizziness, drowsiness, headache, blurred vision, fatigue, nausea, thickening of bronchial secretions.
• Implications for PT: Increased guarding when moving into sitting or lying position due to orthostatic hypotension. Monitor vitals during therapy.

Anti-inflammatory Agents

• Action: Inhaled corticosteroids, leukotriene modifiers, and mast-cell stabilizers help prevent inflammatory-mediated bronchoconstriction.
• Indications: Bronchospasm, asthma.
• Side effects: Risk is slightly lower due to delivery method of medication, damage of supporting tissues, skin breakdown, osteoporosis, decreased bone density, glaucoma, and delayed growth. Local effects include nasal irritation and dryness, sneezing, and bloody mucus.
• Implications for PT: Educate patients about rinsing their mouth after using an inhaler to avoid irritation of local mucosa. Refer to MD if there are signs of liver dysfunction.

Bronchodilator Agents

• Action: Relieve bronchospasm by stimulating the receptors that cause bronchial smooth muscle relaxation or by blocking the receptors that trigger bronchoconstriction.
• Indications: Bronchospasm, wheezing, SOB in asthma and COPD.
• Side effects: Bronchospasm, dry mouth, GI distress, chest pain, palpitations, tremor, nervousness.
• Implications for PT: Advise patients to take bronchodilator as prescribed before therapy and have on hand during session in case they are necessary. Cardiac or vision abnormalities may indicate toxicity and should be referred to MD.

Expectorant Agents

• Action: Increase respiratory secretions to help loosen mucus.
• Indications: Cough associated with respiratory tract infections, sinusitis, pharyngitis, bronchitis, asthma when complicated by tenacious mucus or congestion.
• Side effects: GI distress, drowsiness.
• Implications for PT: PT may assist by using airway clearance intervention one hour after administration of drug. Encourage patients to drink water with medication.

Mucolytic Agents

• Action: Decrease the viscosity of mucus secretions by altering their composition and consistency, making them easier to expectorate.
• Indications: Viscous mucus secretions due to PNA, emphysema, chronic bronchitis, and cystic fibrosis.
• Side effects: Pharyngitis, oral mucosa inflammation, rhinitis, and chest pain.
• Implications for PT: PT may assist by using airway clearance intervention one hour after administration of drug.

Psychiatric Management

Anti-anxiety Medication

• Action: Antianxiety target the CNS through targeting dopamine and serotonin within the brain.
• Indications: General anxiety disorder, social anxiety, obsessive-compulsive disorder, post-traumatic stress syndrome.
• Side effects: Drowsiness, sedation, withdrawal symptoms including rebound anxiety, dysarthria, ataxia, dermatitis.
• Implications for PT: Integration of alternative methods to decrease stress: exercise, massage, relaxation techniques, and stress management education.

Antidepressant Agents

• Action: Normalize neurotransmission activity.
• Indications: Depression, possible anxiety disorders.
• Side effects: Depends on class of drugs. Sedation, blurred vision, tachycardia, dry mouth, insomnia, weight gain, sexual dysfunction.
• Implications for PT: Monitor for improvement in patient's affect with medical intervention. Be mindful of side effects: sedation, fatigue, hypertension, orthostatic hypotension, further signs of depression or suicidal tendencies.

Antipsychotic Agents (Neuroleptic Agents)

• Action: Reduce the overactivity of dopamine transmitted in the limbic system.
• Indications: Schizophrenia, psychotic disorders, Alzheimer's (certain cases).
• Side effects: Traditional agents produce increased extrapyramidal (motor) effects: tardive dyskinesia, pseudoparkinsonism, akathisia, sedation, constipation, dry mouth, atypical agents can produce weight gain, diabetes, or hyperlipidemia.
• Implications for PT: Agents allow for increased participation in PT sessions by improving sense of self, attention span, and improving affect. Early detection of extrapyramidal effects is beneficial and may assist medical and pharmacological intervention.

Bipolar Disorder Agents

• Action: Focus on prevention of manic episodes in order to avoid extreme mood swings.
• Indications: Bipolar or manic-depressive disorders.
• Side effects: GI distress, tardive dyskinesia, fatigue, confusion, nystagmus, lethargy, tremor, Parkinsonism, seizures, diabetes, toxicity, coma, risk of death.
• Implications for PT: Familiarize with side effects of particular medication, especially symptoms of toxicity as they relate to lithium. Long-term use of lithium may result in osteoporosis, impacting plan of care.

Sedative-Hypnotic Agents

• Action: Sedative agents produce a calming and relaxation. Hypnotic agents induce sleep.
• Indications: Anxiety, postoperative sedation, insomnia.
• Side effects: Drowsiness, decreased motor performance, anterograde amnesia, tolerance, dependency, rebound insomnia with withdrawal; barbiturates are highly addictive and can be fatal.
• Implications for PT: May be beneficial to treat when peak blood levels of agent exist so patient is calm, relaxed, and can focus on the treatment regimen. However, may be problematic if patient is experiencing side effects of drowsiness and impairments of motor control. Increased risk of falling.

This quiz tests your understanding of pharmacology, specifically how nitroglycerine helps to control angina symptoms in patients with cardiac disease.