02 L E C

Pharmacology 26
Prof’s name here 21 O1
Cardiac Glycosides / Anti- Angina

OUTLINE If the left side of the heart is not pumping really well,
I Congestive Heart Failure (CHF) then the blood cannot properly go into the left side of
II Normal Heart the heart.
III Angina
A Anti – Anginals Or if your blood goes into the left side of the heart the
B Types of Angina heart can properly pump it out, so there will be
C Types of Anginal Drugs congestion leading to pulmonary problems.
IV NITRATES
So any pulmonary problems with chronic congestive
i heart failure that is probably due to left sided heart
Congestive
ii Heart Failure (CHF) failure like your pulmonary edema, cough, and
• Anemia is derived from the Greek word anaimia, anything that crackles.
-Condition in which the heart fails to effectively pump Flow of How a Congestive Heart or a Problematic
blood around the body due to damaged or Heart Can Lead to a Worsening Condition
overworked heart muscle.

-Causes:

• Coronary artery disease

• Cardiomyopathy

-Any problems with the cardiac muscle

• Hypertension
• Valvular heart disease
Can be right sided heart failure or left sided heart
failure
The blood from our system goes through the vena
cava so we have this superior vena cava and the
inferior vena cava.
So if there is a problem with the right side of your
heart, then the blood coming from your system will
become congested because the right of the heart
connect properly manage or pump or receive the
blood from the system, leading to a congestion.
Examples of systematic congestion, we have like
societies, or we have our portal hypertension. So any
congestion in the body or in the system that would be
probably because of the right side and heart failure or
a congestive heart failure, specifically at the right side
of the heart.
1. If there is a decreased myocardial function if there's
a problem with the heart, then there is a decrease
cardiac output.
2. So if there is a decrease cardiac output, there is a
decrease output, the blood to the system your
baroreceptors inside the heart, will be able to sense
this and signal your sympathetic nervous system to
increase the blood pressure, increase the pulse
respiration, the cardiac output, and increase the heart
contractility for the heart, to be able to pump up
enough blood to the system.
3. Because of the sympathetic activation also it will
increase aldosterone synthesis and release leading to
increase sodium retention, potassium excretion, and
water retention, which may lead to an increase blood
volume that's my water retention and because there
is increased blood volume the heart will then receive
an increase in the workload to work properly.

How about the left side? We know that the blood that 4. But because there's already myocardial dysfunction
goes inside to the left side of the heart comes from or a decrease myocardial function, this condition may
the lungs.
really lead to further decrease in heart function, or
worse, cases of a failure.
5. On the other side of the flow chart, decreased
cardiac output may also lead to a decrease blood flow
in the kidney if the kidney will detect, it will activate
the RAAS.
6. So if the RAAS is activated there's also an increase
in BP and increase in a cardiac output, then again
triggering an increase in aldosterone synthesis and
release okay and leading again to the process of
increase aldosterone synthesis and release leading to
increase sodium retention, potassium excretion, and
water retention ending in a worsening condition.
Normal Heart
There is an oxygenated blood that goes inside your
right side and it pumps everything out to the lungs
where blood gets oxygenated then goes back inside
the left and goes back to the system.
Cardiac Glycosides Cardiac Glycosides
-Originally derived from poisonous fox- glove or
digitalis plant
-Used by William Withering of England to alleviate
“dropsy” – which is defined as edema of extremities
caused by cardiac and kidney insufficiency secondary
to CHF
• Just to give you an idea your congestive heart
failure and knowing that there will be
problems with blood flow already in the body,
due to a weak heart, it may lead to further
complications, such as your kidney
insufficiency that will again worsen the
condition if left untreated.
-Example:
▪ digoxin (Lanoxin, Lanoxicaps) = PO, IV
- Given orally or parenterally
- Mode of Action: inhibits Na- K pump which increases
intracellular calcium and allow more calcium to enter
myocardial cells during depolarization causing:
 (+) inotropic action (inc myocardial
contraction)
 (-) chronotropic action (dec heart rate)
 (-) dromotropic action (dec conduction
velocity)
 (-) Increase cardiac output and renal perfusion
When your heart is in a resting state, your heart has
negative ions inside. Their sodium potassium pump is
the one that regulates the entry of your sodium and
potassium as well as how they also exit the heart.
If that happens, if there is a sodium potassium pump,
the calcium will then have a hard time going inside the
heart.
Now we know that calcium is actually responsible for
your heart contraction. The higher the calcium then
the stronger the contraction.
If the profession pump is open, then the calcium, will
have a hard time going inside the heart because of the
sodium and potassium.
-Uses: CHF, AF, Atrial flutter,
**** rapid onset, excreted thru kidney, has a
narrow margin of safety
Effective level should be maintained at a narrow
because if it is too high, it is considered toxic.
• Digitalis toxicity: anorexia, diarrhea, N/V,
bradycardia, cardiac dysrhythmias, HA,
malaise, blurred vision, visual illusions (white,
green, yellow halos around objects),
confusion and delirium
*your digitalis or cardiac glycosides are trying to make
your heart work effectively. Now kung nasobrahan na
yung digitalis or pag nasobrahan na yung gamot mo, it
will render the heart’s function ineffective. It means
pangit nanaman ang blood flow ng heart kasi nagging
toxic na yung gamot and hindi na siya effective. Kung
pangit na yung blood flow papunta sa system niyo, it
will also result in effects nakikita. For example kung
kulang yung blood flow mo sa utak, pwede ka mag
nausea and vomiting*
*one effect of digitalis is it decreases heart rate*
• Antidote: digoxin immune fab (intoxication
with serum level of > 10ng/ mL)
 - Binds with digoxin to form complex
molecules that can be excreted in the
urine
*the digoxin immune Fab binds with the drug and
tries to excrete it through the urine. Binababaan niya
ang concentration levels ng gamot sainyong
katawan.*
• CI: hypersensitivity, ventricular tachycardia
and fibrillation, heart block, MI, renal
insufficiency, electrolyte imbalance (inc Ca,
dec K & Mg)
*binibigay lang siya sa mga may problems with the
atrial fibrillation and atrial flutter*
*hindi binibigay with ventricular problems such as V
tach (ventricular tachycardia), V fib (ventricular
fibrillation)*
• + verapamil, quinidine, quinine, erythromycin,
tetracycline, cyclosporine
= increase digitalis toxicity effect
+ loop diuretics/ hydrochlorothiazide
= hypokalemia (increase the effect at its
myocardial cell action site)
*yung diuretics, nagpapadecrease ng fluids sa
katawan kaso hindi siya potassium sparing. It will also
waste the potassium. It will also cause exretion ng
potassium kaya nagkakaroon ng hypokalemia.*
+ cortisone preparations
= sodium retention & potassium excretion
+ thyroid hormones, metoclopramide
= renders the drug less effective
+ antacids
= decreases digitalis absorption
NURSING CONSIDERATIONS
• Consult prescriber about loading dose
*remember, your digitalis or digoxin may cause
toxicity and has a narrow safety margin. Always check
the loading dose within the normal levels.*
• Monitor apical pulse in one full minute,
monitor for quality and rhythm
*this will tell you if the heart is working or maybe if
the heart is causing harm already to the patient.*
• Check dosage & preparation carefully
• Check pediatric dose with extreme care
• Follow dilution carefully for IV preparation
• Administer IV dose very slow over at least 5
minutes
*wag biglain. Baka mabigla din ang puso*
• Weigh patient
*digitalis may also cause fluid loss*
• Avoid administering oral drug with food or
antacid
• Maintain emergency equipment on standby =
lidocaine (arrhythmias), phenytoin (seizure),
atropine S04 (to increase cardiac rate), cardiac
monitor
• Monitor therapeutic level of digoxin (0.5 – 2
ng/ mL), digoxin toxicity
GIVE HEALTH TEACHINGS
• Potassium Rich Foods: banana, avocado, dried
fruits, oranges, nuts, potato, prunes, tomato
• Sodium Rich Foods: buttermilk, margarine,
canned goods, processed foods, fast foods,
preserved foods, tomato ketchup
Angina ANGINA
- A type of temporary chest pain, pressure
or discomfort.
- Narrowed artery
- Ischemia
- Heart muscle is not receiving enough
oxygen due to a narrowed coronary
artery.
Anti – Anginals
Anti – Anginals
• Coronary Artery Disease (CAD) – lumen of
blood vessels become narrow, thus blood is
no longer able to flow freely to the muscles.
*we all know that the coronary artery is the passage
way of the blood papunta sa heart. Although it pumps
blood to the system, it also needs blood to work/ to
be effective. If a coronary artery is blocked or
narrowed, there is a disease in blood supplies to the
heart.
 • Angina Pectoris – “suffocation of the chest”,
occurs when myocardial demand for oxygen
cannot be met by narrowed blood vessels
*CAD can lead to Angina Pectoris. Dahil kulang na ang
supply ng heart, nasusuffocate na ang puso kasi
kulang na ang oxygen na pumupunta sa puso. This will
now cause an angina pain*
• Anginal pain: chest tightness, pressure in the
center of the chest, and pain radiating down
the neck and left arm.
*pag hindi naagapan, it may lead to Myocardial
Infarction*
• Myocardial Infarction (MI) – occurs when
coronary vessels is completely occluded and
the cells that depend on the vessels for
oxygen become ischemic, then necrotic and
die
Types
Typesof Angina:
of Angina:
1. Classic (stable) – occurs with stress exertion
*sumasakit lang yung chest upon exertion or stress
exertion
2. Unstable (preinfarction) – occurs frequently over
the course of a day with progressive severity
*ito yung kahit naka rest ka or nag eexcert ka ng
stress, masakit. Habang tumatagal mas sumasakit so
nag proprogress siya. So regardless if youre resting or
not sumasakit siya. Unstable ungine kai emergency
angina
3. Variant (Prinzmetal, vasopastic) – Occurs during
rest
v Time
Types of Anginal Drugs:
1. Non-nitrates (beta blockers, calcium channel
blockers)
Beta blockers ay kailangan para ma decrees yung
workload ng heart. Calcium is needed for the
contractility of the heart. Now in angina kailangna
natin ih decrees yung trabaho ni heart kaya kailangan
natin ih boblock
2. Nitrates: isosorbide mononitrate (imdur, isoket,
isordil); nitroglycerin (deponit, nitrostat)
NITRATES NITRATES
MOA: dilation of the veins = less blood return to the
heart (decrease preload)
*dahil dilated yung veins sa system, decreased yung
pressure sa vein so decreased din yung preload or
blood volume na kailangan ih pump ng heart
: dilation of arteries = less vasoconstriction and
resistance (decrease afterload)
*dahil sa system natin, for example, dahil dilated yung
arteries sa system natin the blood flow is increased to
the parts of the body. So hindi na tritriger yung heart
natin kung increased in workload, kasi enough pa
yung oxygen for blood na napupunta sa other system
ng body. Therefor a decreased in afterload. Hindi niya
kailangan mag exert ng effort to supply blood sa
katawan.
Uses: treatment & prevention of angina, dec BP
SE: HA (most common), dizziness, hypotension, reflex
tachycardia, decrease CR, GI distress, flushing
AE: some degree of hepato/nephrotoxicity
Nursing Considerations:
• Assess chest pain:
Precipitating factors
*before mag bigay ng angina, ask first sa
patient kung ano yung na e experience niya.
Tanungin mo bakit may chest pain. identify
other factors why patient is experiencing
chest pain.
Quality
* What is the quality of chest pain
Radiation
*hanggang saan ba nafefeel ng patient yung
sakit. Hanggang leeg ba? Is it radiating to the
shoulder? Or left arm?
Severity/symptoms, and
*time where it happen
• PO: take on empty stomach; undergoes
hepatic first pass effect
• SL: every 5 min x 3 doses; effect lasts for 10
minutes
; store in dry and dark bottle
: check expiration date (up to six months only)
; take sips of water BEFORE administration
; allow drugs to dissolve before taking
anything PO
; burning/stinging sensation means the drug is
potent
*sign drug is working
• Buccal: place drug between upper lip and gum
or between check and gum
 • IV infusion: dilute drug in glass IVF bottles
via infusion pump, onset 1-3 minutes
same with SL
• Topical Ointment: remove previous
application
: spread drug over a 6x6 in area on chest,
back, upper arm, and cover with a plastic
wrap
: rotate site, avoid touching the ointment
• Patch
; patch is water proof
; apply wearing gloves at anterior chest wall,
non-hairy portion REFERENCES
*for better absorpiton
; remove previous patch, rotate sites “PROF’S PPT ON QUIPPER AND LECTURE”
; remove after 12 hours to prevent tolerance
; do not apply defibrillator paddles over the
drug, may cause burn
• Spray: lift tongue then spray, avoid inhaling
the drug
• General: withhold: BP < 90/60, HR<60,
acetaminophen for HA, reassess chest pain
after 2-5 minutes (SL, spray, except PO)

Nitroglycerin Patch

Nitro patch and Ointment