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Anti-Anginal Drugs
by Manasseh PMN 310 Anti-Anginal Drugs Mvula BSc. N 8/20/12 III Student.

*PMN 310

Overview

Angina is a syndrome of paroxysmal left sided chest pain, which is produced when the oxygen demands of the heart exceed the oxygen supply. There are four kinds of angina

stable angina unstable angina variant angina, and refractory angina.


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Stable angina: results from atherosclerotic plaques (deposits on the inner wall of the artery in atherosclerosis).

Precipitated by stress and relieved by rest.

Unstable rapture.

angina:

develops

due

to

plaque

Characterised by new onset severe angina or sudden worsening of previously stable angina. It is also characterised by more severe symptoms. it is less responsive to treatment. It is intermediate syndrome between stable angina and myocardial infarction.
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Variant (Prizmetals) angina

This type is not caused by atherosclerotic narrowing, but results from a coronary artery spasms. This angina does not necessarily occur with exertion.

Refractory (intractable) angina

This type of angina is characterised by incapacitating pain that does 8/20/12 PMN 310 Anti-Anginal 44
Drugs

Treatment

Coronary vasodilators (antianginal drugs), rest, oxygen, and control of precipitating factors such as stress and smoking. Antianginal drugs

O2 requirements of the myocardium blood flow to the ischaemic heart muscle

Acute anginal attacks are treated with short acting NTG (Nitroglycerin) products. Long term stable angina

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oral or

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Organic Nitrates

Are the first line of defence in the prevention and treatment of angina. They relax smooth muscles in the blood vessel walls, and thus, help to stop the pain of angina attacks. The organic nitrates redistribute flow to ischaemic areas of the myocardium, which improves the perfusion of the heart.

These agents dilate the veins, reducing venous pressure and venous Anti-Anginal 8/20/12 PMN 310 return. 66

Drugs

They also decrease blood volume and pressure within the heart, thereby reducing the preload.

force that stretches the Preload is the distending

ventricular muscle prior to electrical excitation and contraction of the heart muscle.

Organic nitrates dilate coronary blood arteries and increase blood flow to ischaemic by dilating collateral vessels. They dilate arterioles, which lowers peripheral vascular resistance. Further, they reduce afterload which is the load the heart muscle must move during contraction.
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Therapeutic uses

Acute angina attacks Unstable angina Chronic angina Acute and chronic heart failure.
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Adverse effects

Pounding or pulsating headache.

The most frequent side effect

Hypotension Dizziness and weakness Syncope Nausea and vomiting


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Contraindications

Allergy to nitrates Clients with severe anaemias, and Head trauma because nitrates can cause intracranial pressure. NB: Organic nitrates should not be given intravenously to clients with severe hypotension or hypovolaemia because they can cause shock due to vasodilatation.
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Precautions

Ventricular outflow obstruction disease Severe hypertension Carotid disease Renal/hepatic dysfunction Fluid depletion due to diuretic therapy Low blood pressure (less than 90mmHg systolic) Constrictive pericarditis
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Important drugs

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Nitroglycerine abbrev. as NTG ( aka Nitro-Bid, Nitrostat)


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NTG is a prototype for the organic nitrates. preload and afterload. Relaxes vascular smooth muscle in venous return. arterial blood pressure. myocardial O2 consumption. Can be taken sublingually to relieve an angina attack. It has a rapid onset (1-3min) and a short duration (1-2 hrs.).
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Dosage and Preparations

Dosage: 0.3, 0.4, 0.6 mg SL


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The

client usually takes one tablet every 5-10 minutes three consecutive times.
If

pain is not relieved the patient should contact the 14 14 health care provider

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NTG 2% is available also as an ointment patch.

These are worn for12 hours and removed for 12 hours to avoid tolerance as an adjuvant treatment of Raynauds disease.

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NTG sustained release: 2.5-9mg q12hr. Increase to q8hr PRN.

Doses as high as 26 mg qid

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Nitroglycerine Translingual (Nitrolingual) is metered aerosol spray 0.4 mg/metred dose.

At onset of attack, spray 1-2 metred doses into the oral mucosa but not more than 3 doses in 15 minutes.

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NTG I.V. (Nitro-Bid I.V, Tridil) is used to treat acute unstable angina, acute heart failure and hypertension. NTG I.V. is usually mixed with 5% Dextrose normal saline or 0.9% normal saline.

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Isosorbide dinitrate (Isordil)

This drug is for long term prophylaxis. It can either be taken sublingually or orally. Dosage:

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40-80mg po q8-12hr or 2.55mg stat. 5-10 mg SL chewable tab.q2-3hr in acute

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Pentaerythitol tetranitrate (peritrate)

A nitrate taken SL and has a duration of up to 12 hrs.

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END OF NITRATES

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Beta-Adrenergic Blockers

These act to interrupt adrenergic stimulation to 1- or 2-receptors by competing with NE for available -adrenergic receptor sites. -blockers that block 1 receptors act to blood pressure, the contraction of the heart muscle, and CO.

PMN 310 Anti-Anginal PMN 310 Anti-Anginal Drugs Drugs

These agents are used to control angina pectoris.

-blockers that inhibit 2-receptors cause vasodilatation in skeletal muscle arterioles.

They are used to control angina pectoris and BP.

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blocking agents are used for prophylaxis only because they do not act quickly enough to alleviate an on-going anginal attack. blockers are the mainstay of prophylactic treatment of chronic stable angina. They are often combined with Isosorbide dinitrate (Isordil) because the combined effects are more therapeutic.

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*Members of the -blockers


Lipophilic Timolol Metoprolol Betaxolol Carvedilol

Balanced (ISA)

Hydrophilic

Non-selective Propranolol Pindolol

Nadolol

1- selective Vasodilators

Bisoprolol Celiprolol

Atenolol Esmolol

(- blocking (-agonist
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Uses

Chronic stable angina (to decrease oxygen demand, myocardial contractility, heart rate, and blood pressure) Dysrhythmias to slow sinus node conduction and prolong conduction through the AV node, thereby slowing ventricular response Hypertension to lower blood pressure Myocardial infarction to decrease the incidence of catecholamine-induced

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Adverse Effects
Bradycardia Orthostatic Shortness Oedema Reduced

hypertension of breath

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tolerance to heart failure

exercise
congestive
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Precautions

-adrenergic blockers should be administered with caution to clients with a history of:
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Asthma emphysema heart failure Hypotension sinus bradycardia heart block.

Diabetics taking insulin because they can mask the symptoms of hypoglycaemia.

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Peripheral vascular insufficiency because they reduce blood flow to the extremities.

Kidney or liver disease because they accumulate in the serum of clients with these diseases, and cause toxic effects. Beta-adrenergic blockers should not be stopped abruptly because a client with angina is at four times greater risk of developing an angina attack, or a mild myocardial infarction within 30 days of discontinuation. Beta blockers should not be taken with alcohol.

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Beta blockers are not always effective for AfricanAmerican clients, and thus are usually combined 25 25 with a diuretic.

Important drugs

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Propranolol hydrochloride (Inderal) Propranolol is a prototype for beta-blocking agents. It is used to treat angina, dysrhythmias, and myocardial infarction. Propranolol is available in a wide dosage range
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Atenolol
Is

used to treat angina pectoris, hypertension, and myocardial infarction. It is a hydrophilic 1 selective blocker. It is available in tablets 50 and 100mg given once daily.
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Pindolol

Is used to treat angina pectoris and hypertension. Pindolol is a non-selective balanced beta blocker. It possesses prominent intrinsic sympathomimetic action so it results in less reduction in the HR and BP. It is preferred in patients with low HR and CO. Pindolol is contraindicated in severe renal impairment.
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Dosage

Hypertension, initially 5 mg 23 times daily or 15 mg once daily, increased as required at weekly intervals; usual maintenance 1530 mg daily; max. 45 mg daily. Angina, 2.55 mg up to 3 times daily.

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Antidote

IV injection of atropine is required to treat bradycardia and hypotension (3 mg for an adult, 40 micrograms/kg (max. 3 mg) for a child). Cardiogenic shock unresponsive to atropine is probably best treated with an IV injection of glucagon 210 mg (child 50150 micrograms/kg) in glucose 5% (with precautions to protect the airway in case of vomiting) followed by an IV infusion of 50 micrograms/kg/hour. PMN 310 8/20/12 If glucagon is not available, Antiintravenous

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Calcium Channel Blockers

Calcium channel blockers act to:


Prevent the flow of Ca2+ ions into the cells Relax arterial smooth muscle and decrease contraction of the heart muscle Slow AV conduction Slow heart rate Dilate coronary and peripheral arteries coronary vascular resistance coronary blood flow myocardial O2 demand

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Uses

Calcium channel blockers prevent and control supraventricular tachyarrhythmias, prevent post myocardial infarction complications, treat hypertension, treat chronic stable angina, treat and prevent unstable angina, and they treat and prevent vasospastic angina.
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Adverse Effects

Calcium channel blockers are associated with:


Constipation Nausea Headache Hypotension Dizziness Bradycardia Heart block Dyspnoea and wheezing Peripheral oedema.
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Contraindications

Calcium channel blockers are contraindicated for clients with these conditions: Hepatic or renal disease Heart block Hypotension Severe bradycardia Aortic stenosis Severe left ventricular dysfunction Women who are pregnant or PMN 310 Anti8/20/12 lactating

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Caution
These agents should be administered with caution to clients with: Serious respiratory disorders Heart failure because calcium channels blockers can worsen heart failure. Ca2+ channel blockers should be administered with caution to elderly patients PMN 310 Anti- they can because 8/20/12

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Important drugs

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Verapamil hydrochloride (Calan)


It is the drug of choice for clients with supraventricular tachycardias who may or may not have angina. This drug is also used to treat vasospastic (Prinzmetals) angina, unstable angina, chronic stable angina, and hypertension.

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Verapamil depresses the myocardium and prolongs AV conduction time.

Dosage

Usual maintenance dose: 320480mg/day.

Do not give with albumin, ampicillin, nafcillin, oxacillin, sodium bicarbonate, amphotericin B, hydralazine, aminophylline because of Y-site incompatibilities. Decreased metabolism and risk of toxic effects if combined with grapefruit juice; avoid this combination.

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Parenteral: IV use only. Initial dose, 510mg over 2 min; may repeat dose of 10mg 30 min after first dose if initial response is inadequate.

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Oral: Initial dose, 80120mg tid; increase dose every 12 days to achieve optimum therapeutic effects.

Nifedipine (Procardia)

This drug is used to treat vasospastic (Prinzmetals) angina, chronic stable angina, and hypotension. It should be administered cautiously to patients with serious cardiac disease because it may precipitate heart failure or MI.

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Dosage

Initial dose is 10mg tid PO Maintenance range: 1020mg tid.

Higher doses (2030mg tidqid) may be required, depending on patient response. Adjust over 714 days. More than 180mg/day is not recommended.

Sustained-release: 3060mg PO once daily. Adjust over 714 days. Usual maximum dose is 90 120mg/day. Increased effects with cimetidine.

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Diltiazem hydrochloride (Cardizem)


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Dosage: Initially, 30 mg PO qid before meals and gradually increase dosage at 1- to 2-day intervals to

PMN 310 AntiAnginal Drugs

This drug is used to treat spastic angina, chronic stable angina, and hypertension.

Amlodipine (Norvasc)

Dosage: Initially, 5mg PO daily; dosage may be gradually increased over 1014 days to a maximum dose of 10mg PO

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Nicardipine hydrochloride (Cardene SR)

Dosage: Initially, 30 mg PO qid before meals and gradually increase dosage at 1- to 2-day intervals to 180360 mg PO in

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PMN 310 AntiAnginal Drugs

This drug is also used to treat angina and is usually given in combination with betablockers.

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Therapeutic Nursing Interventions when Administering Anti Angina Drugs.

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Assessment

Assess the client for signs of coronary artery disease, and ask the client to describe his/her angina attack. Inquire about:

Pain:

Onset Typesharp, dull, squeezing

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Location

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What activities appear to precipitate attacks.eg exercises The clients current use of antianginal drugs to relieve pain.eg rest Do some physical assessment which include; BP, pulse rate (Apical/radial), and resp. rate after the pt. has rested for 10min. Depending on the heart disease,
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Nursing Diagnoses
v

Pain; related to myocardial ischaemia 2 to narrowing of the coronary artery. Anxiety; related to diagnosis, pain and anticipation of pain Fear; related to diagnosis, chest pain risk for ineffective mgt. of therapeutic regimen; related to lack of knowledge of medication regimen, adverse drug effects.

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The following Nsg. diagnoses may apply to a pt. on anti-anginal drugs.

Planning and Implementation


v

Relief of pain; monitor BP 3-4 hrs. or more frequently when the client complains of dizziness and frequent chest pains.

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evaluate pt. response to therapy

PMN 310 AntiAnginal Drugs

Major goals of the patient include a reduction in anxiety, fear, relief of pain, and an understanding of the post- discharge medication regimen.

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Adverse drug rxns; observe pts. Receiving these drugs for headaches, hypotension. Notify the physician for a dose change if necessary Anxiety and fear; reassure the pt. that the medication will relieve the pain and that the physician will be contacted if pain is not relieved.

Allow patient to discuss their concerns about their diagnosis,

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Evaluation and Expected Outcomes


Anxiety is reduced Fear is reduced Pt. verbalizes and understanding of treatment modalities ADRs are identified and reported to the physician. Pt. and family demonstrate understanding of drug regimen

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Pain is relieved

Client education

Take sustained-release (SR) form of calcium blockers with food or milk to prevent gastric discomfort. Do not drink alcohol with anti anginal drugs because alcohol acts as a vasodilator and can cause acute BP and extreme dizziness.

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Avoid discontinuing medication abruptly without consulting the health care provider. Notify dentists and other health care providers of medication regimen Schedule regular follow-up appointments with the

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*Thank you for attention!


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