Antianginals- Chapter 23.pptx

Chapter 23 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.  The...

Chapter 23 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.  There is a fine balance between oxygen supply and demand. 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 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) 4  Audience Response System Question #1 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. NOTE: No input is required to proceed. 5  Answer to System Question #1 ANS: B At the first sign of chest pain, the person should stop all activity and sit or lie down before taking the nitroglycerin tablet. 6  Drugs for Angina  Nitrates or nitrites  Beta blockers  Calcium channel blockers (CCBs) 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. 8  Audience Response System Question #2 A patient with extremely high blood pressure (BP) is in the emergency department. The physician will order therapy with nitroglycerin to manage the patient’s BP. Which form of nitroglycerin is most appropriate? A.Sublingual spray B.Transdermal patch C.Oral capsule D.IV infusion NOTE: No input is required to proceed. 9  Answer to System Question #2 ANS: D The IV infusion of nitroglycerin will have the fastest effect, and the dose will be titrated to the patient’s response. 10  Nitrates and Nitrites  Available forms  Sublingual*  Chewable tablets  Oral capsules/tablets  Intravenous (IV) solutions*  Transdermal patches*  Ointments  Translingual sprays* *Bypass the liver and the first-pass effect. 11  Nitrates and Nitrites (Cont.)  Nitroglycerin (both rapid and long acting)  Isosorbide dinitrate (both rapid and long acting)  Isosorbide mononitrate (primarily long acting) 12  Nitrates and Nitrites: Mechanism of Action and 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 13  Nitrates and Nitrites: Indications  Treat stable, unstable, and vasospastic angina  Rapid-acting forms  Used to treat acute anginal attacks  Sublingual tablets; IV infusion  Long-acting forms  Used to PREVENT anginal episodes 14  Audience Response System Question #3 The nurse is obtaining a medication history on a patient presenting with chest pain. What drug classification would necessitate the nurse informing the provider before beginning the prescribed nitroglycerin? A. Proton pump inhibitor B. Phosphodiesterase inhibitors (erectile dysfunction medications) C. Inhaled beta blocker D. Aspirin NOTE: No input is required to proceed. 15  Answer to System Question #3 ANS: B Phosphodiesterase inhibitors (erectile dysfunction medications) are potent vasodilators and therefore nitrates are contraindicated when the patient is taking this classification of medications. All other medication classifications can safely be used with nitrates. 16  Nitrates: Contraindications  Known drug allergy  Severe anemia  Closed-angle glaucoma  Hypotension  Severe head injury  Use of the erectile dysfunction drugs sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) 17  Nitrates: Adverse Effects  Headaches  Usually diminish in intensity and frequency with continued use  Reflex tachycardia  Postural hypotension  Skin irritation with topical application  Tolerance may develop. 18  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 19  Audience Response System Question #4 A patient with a known history of angina was walking his dog and developed chest pain. The patient immediately stops walking and sits 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 NOTE: No input is required to proceed. 20  Answer to System Question #4 ANS: C With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe. The patient should sit or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes after one dose, the patient (or family member) should call 911 immediately. The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later but no more than three tablets in total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate an MI. 21  Isosorbide dinitrate (Isordil)  Organic nitrate  Available in rapid-acting sublingual tablets, immediate-release tablets, and long-acting oral dosage forms  Produces more consistent, steady, therapeutic response 22  Nitroglycerin  Prototypical nitrate  The most important drug used in the symptomatic treatment of ischemic heart conditions such as angina  Routes—PO, SL, metered-dose aerosol that is sprayed under the tongue, IV, and topical 23  Nitrates  Nitroglycerin  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 heart failure (HF), ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies 24  Beta Blockers  Mainstay in the treatment of several cardiovascular diseases  Angina  MI  Hypertension  Dysrhythmias 25  Antianginal Beta Blockers  Atenolol  Metoprolol  Propranolol  Nadolol 26  Beta Blockers: Mechanism of Action  Block beta1 receptors on the heart  Decrease heart rate, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart  Decrease myocardial contractility, helping to conserve energy or decrease demand 27  Beta Blockers: Mechanism of Action (Cont.)  After an MI, a high level of circulating catecholamines irritates 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. 28  Beta Blockers: Indications  Angina  Antihypertensive  Cardiac dysrhythmias  Cardioprotective effects, especially after MI  Some used for migraine headaches, essential tremors, and stage fright 29  Beta Blockers: Contraindications  Systolic HF  Serious conduction disturbances  Caution: bronchial asthma because any level of blockade of beta2 receptors can promote bronchoconstriction  Diabetes mellitus: can mask hypoglycemia- induced tachycardia  Peripheral vascular disease: may further compromise cerebral or peripheral blood flow 30  Beta Blockers: Adverse Effects Body system Adverse effects Cardiovascular Bradycardia, hypotension, atrioventricular (AV) block Metabolic Hyperglycemia, hypoglycemia, hyperlipidemia 31  Beta Blockers: Adverse Effects (Cont.) Body system Adverse effects Central nervous system Dizziness, fatigue, depression, lethargy Other Impotence, wheezing, dyspnea 32  Atenolol (Tenormin)  Cardioselective beta1-adrenergic receptor blocker  Indication: prophylactic treatment of angina pectoris  Use of atenolol after MI has been shown to decrease mortality. 33  Metoprolol (Lopressor, Toprol-XL)  Cardioselective beta1-adrenergic receptor blocker  Indication: prophylactic treatment of angina  Many of the same characteristics as atenolol  Reduces mortality rate in patients after MI and in treating angina  Forms: oral (immediate release and long acting) and parenteral (injectable) forms  IV metoprolol is commonly administered to hospitalized patients after an MI and is used for treatment of hypertension in patients unable to take oral medicine. 34  Audience Response System Question #5 A patient who has had an MI is taking 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 BP NOTE: No input is required to proceed. 35  Answer to System Question #5 ANS: C Slowing the heart rate in patients with ischemic heart disease reduces myocardial oxygen demand and allows the coronary arteries time to fill with oxygen- and nutrient-rich blood. Beta blockers also block the irritating effects of circulating catecholamines on the heart. 36  Calcium Channel Blockers for Chronic Stable Angina  Amlodipine  Diltiazem  Nicardipine  Nifedipine  Verapamil 37  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  Dysrhythmias: depression of the automaticity of and conduction through the sinoatrial and AV nodes 38  Calcium Channel Blockers: Indications  Angina  Hypertension  Supraventricular tachycardia  Coronary artery spasms (Prinzmetal angina)  Short-term management of atrial fibrillation and flutter  Migraine headaches  Raynaud’s disease  Nimodipine: cerebral artery spasms associated with aneurysm rupture 39  Calcium Channel Blockers: Contraindications  Known drug allergy  Acute MI  Second- or third-degree AV block (unless the patient has a pacemaker)  Hypotension 40  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 41 Diltiazem (Cardizem, Dilacor, Tiazac)  Very effective for the treatment of angina pectoris resulting from coronary insufficiency and hypertension  Used in the treatment of atrial fibrillation and flutter along with paroxysmal supraventricular tachycardia 42  Amlodipine (Norvasc)  Indicated for both angina and hypertension  Available only for oral use 43  Miscellaneous Antianginal Drug  Ranolazine (Ranexa)  Mechanism of action is unknown.  Known to prolong the QT interval on the electrocardiogram  Reserved for patients who have failed to benefit from other antianginal drug therapy  Contraindications: pre-existing QT prolongation or hepatic impairment, in those taking other QT- prolonging drugs  Drug interactions 44  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 vital signs, including respiratory patterns and rate.  Assess for drug interactions. 45  Nursing Implications (Cont.)  Patients should not take any medications, including over-the-counter medications, without checking with their physicians.  Patients should be encouraged to limit caffeine intake. 46  Nursing Implications (Cont.)  Patients should report:  Blurred vision  Persistent headache  Dry mouth  Edema  Fainting episodes  Weight gain of 2 lb in 1 day or 5 lb in 1 week  Pulse rate less than 60 beats/min  Dyspnea 47  Nursing Implications (Cont.)  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. 48  Nursing Implications (Cont.)  Nitroglycerin—part 1  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.  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. 49  Nursing Implications (Cont.)  Nitroglycerin—part 2  To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler.  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. 50  Nursing Implications (Cont.)  Nitroglycerin—part 3  Instruct patients to take as-needed 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. 51  Nursing Implications (Cont.)  Nitroglycerin—part 4  If anginal pain occurs: Stop activity and sit or lie down and take a sublingual tablet. If there is no relief in 5 minutes, call 911 or emergency services immediately and take a second sublingual tablet. If there is no relief in 5 minutes, take a third sublingual tablet. Do not try to drive to the hospital.  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. 52  Nursing Implications (Cont.)  Beta blockers  Patients taking beta blockers should monitor their pulse rates daily and report any rate lower than 60 beats/min or symptoms of relative bradycardia.  Instruct patients to report dizziness or fainting.  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. 53  Nursing Implications (Cont.)  CCBs  Constipation is a common problem; instruct patients to take in adequate fluids and eat high-fiber foods.  Antianginal drugs  Monitor for adverse reactions: allergic reactions, headache, lightheadedness, hypotension, dizziness.  Monitor for therapeutic effects: relief of angina, decreased BP, or both. 54  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? NOTE: No input is required to proceed. 55 Answer to Case Study Question #1 1. The nitrates and nitrites, the beta blockers, and the CCBs are the drugs most often used to treat patients with angina pectoris. 56  Case Study A patient asks the nurse to tell her more about a new drug the patient has been prescribed called ranolazine (Ranexa). 2. Which response by the nurse is accurate? A. “This drug does not reduce blood pressure or heart rate.” 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.” NOTE: No input is required to proceed. 57 Answer to Case Study Question #2 ANS: A The mechanism of action of Ranexa is not known, but, unlike other drugs for angina, it does not reduce BP or the heart rate. Ranexa is used only after treatment with other antianginals have not been effective. Ranexa is administered by mouth and is contraindicated for use in patients with liver failure. 58  Case Study 3. 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/min.” 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 lb or more in 24 hours or 5 lb or more in 1 week.” D. “Avoid taking these medications with grapefruit juice.” NOTE: No input is required to proceed. 59 Answer to Case Study Question #3 ANS: C Weight gain can indicate serious adverse effects of beta2-blocking drugs, so the health care provider should be called. A pulse of 64 beats/min is acceptable; these drugs should be avoided in patients with asthma, and there is no interaction with grapefruit juice. CCBs should not be administered with grapefruit juice. 60  Case Study A patient asks how to apply transdermal nitroglycerin. 4. 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 1 full day so you always have two patches on at a time.” C. “Apply the patch to hairless areas of the body.” D. “First apply petroleum jelly to your body; then apply the transdermal patch.” NOTE: No input is required to proceed. 61 Answer to Case Study Question #4 ANS: C The transdermal patch should be applied to a hairless, residual-free area of the body with the sites being rotated each time. The old transdermal patch should be completely removed and a new one applied. Petroleum jelly should not be applied to the skin before applying the patch; the skin should be clean and dry. 62