ASSIGNMENT CASE STUDY: ANGINA PECTORIS

NAME: Kimberly George

COURSE CODE: PHAR 3205
STUDENT ID NUMBER: 813117977
Case study Angina pectoris

Mr AG, a 57-year-old taxi driver of Indian origin, attends your community pharmacy with a new
prescription for: glyceryl trinitrate (GTN) spray 400 micrograms one or two puffs as required.
You dispense this item and speak with him and he tells you that his GP thinks he has angina and
has asked him to use the spray the next time he gets any minor chest pain or tightness. You
counsel Mr AG on the correct use of the spray.

Mr AG returns a few days later complaining of a headache following the use of the spray. He is
reluctant to use the spray again. He asks your advice on managing his headache. He also smokes
about five cigarettes a week and asks if he should now stop.

Questions

1. What is angina?

Angina is chest pain or discomfort caused when your heart muscle doesn't get enough oxygen-
rich blood. When the obstruction caused by an uncomplicated atheromatous plaque exceeds a
critical value, myocardial oxygen demand during exercise becomes too much for the stenosed
vessel to supply oxygenated blood thus resulting in chest pain brought on by exertion and
relieved within a few minutes on resting (angina pectoris) (Ritter, 2008).

2. What typical symptoms could a patient with angina present with?

The typical symptoms that a patient with angina could be present with are

Central chest tightness or heaviness that may radiate to arms, neck, jaw or teeth.
Other associated symptoms include: dyspnoea (shortness of breath), nausea,
sweatiness and faintness (Ritter, 2008).

3. What are the risk factors for developing angina?

Modifiable (those that are able to be changed) risk factors include smoking, hypertension,
hypercholesterolaemia, diabetes mellitus, obesity and lack of exercise (Ritter, 2008).

Non-modiable (those that cannot be changed) risk factors (those we cannot change) include:
age, gender, family history, ethnicity (Ritter, 2008).
 4. What, if any, risk factors does Mr AG have for developing stable angina?

The risk factors that Mr.AG has to develop stable angina are: his age, Indian origin, having a
sedentary job or possible lack of exercise, smoking and gender because men are at increased
risk (Ritter, 2008).

5. What group of drugs does GTN spray belong to?

The group of drugs that GTN belong to is the nitrates. They are potent coronary vasodilators
and their principal benefit follows from a reduction in venous return which reduces left
ventricular work (BNF., 2014).

6. What are the side-effects of GTN spray?

The side effects of the GTN spray are:

- Postural hypotension
- Tachycardia
- Throbbing headache
- Dizziness
- Less commonly nausea
- Vomiting
- Heartburn
- Fluching
- Syncope
- Temporary hypoxaemia
- Rash
- Application site reactions with transdermal patches
- Very rarely angle-closure glaucoma (BNF., 2014)

7. How would you counsel Mr AG on the use of his spray?

The patient should be instructed to:

- remove the cap and to hold the spray upright (vertically),

- prime the spray before using for the rst time,
- spray one or two sprays under the tongue and close the mouth immediately afterwards,
and
- sit down and rest until the pain subsides (Dhillon and Raymond, 2009).

8. What other formulations of GTN are available? List their advantages and
disadvantages.

FORMULATION ADVANTAGE DISADVANTAGE

1. GTN sublingual - Rapid onset (<30 - Limited shelf-life

tablets 300 seconds) or short due to the volatility
micrograms or 500 acting of the tablets. It
micrograms - Cheap (BNF., 2014) should be discarded
around six weeks
after the bottle is
opened.
- Headache and
dizziness are
common (BNF.,
2014)

2. GTN spray 400 - Rapid onset (<30 - Headache and

micrograms seconds) or short dizziness
acting - More expensive than
- Long expiry date tablets (BNF., 2014)
(years) compared to
sublingual tablets
- Used for patients
who find difficulty
in dissolving
sublingual
 preparations. (BNF.,
2014)
3. GTN patches - Self adhesive - Skin reactions may
- Transparent occur, although
- Prolonged duration uncommon (between
of action (BNF., 0.1 and 1%)
2014) - Headache and
dizziness (BNF.,
2014)

4. GTN buccal tablets - Rapid onset but - Headache and

slightly slower than dizziness are
sublingual tablets common (BNF.,
(BNF., 2014) 2014)

5. GTN injection - Dose by infusion can - Not suitable for day-

be carefully to-day use as
controlled and injection only for
titrated against chest unstable angina.
pain in acute - Needs to be carefully
situations. (BNF., diluted before use or
2014) undiluted with
syringe pump
- Requires the use of
specic types of
syringes and infusion
lines. (BNF., 2014)

9. Mr AGs headache may be caused by his use of GTN spray. What can you
recommend to him to help manage his headache?
 The correct way to use the GTN spray is at the onset of an attack or before the attack occurs
Mr.AG should use the dose: 1-2 400mcg metered doses sprayed under the tongue. It is
advised that no more than 3 metered doses are to be taken at any one time and that there
should be a minimum interval of 15 minutes between consecutive treatments.

If an angina attack has been brought on by exercise or other precipitating conditions, then the
dose used should be 1-2 400mcg metered doses should be sprayed under the tongue
immediately before the event. Therefore, in order for Mr.AG to manage his headache he
should take paracetamol up to 4g daily in which the dose is 1-2 500mg tablets every 4-6
hours, maximum 8 tablets per 24 hours. Mr AG can be advised to take paracetamol up to 4 g
daily (i.e. one or two 500 mg tablets, every 46 hours; maximum eight tablets per 24 hours)
to relieve his headache. However, if his headache persists or worsens than he should see is
doctor for further or an alternative treatment (Dhillon and Raymond, 2009).

10. What advice would you give Mr AG in relation to his smoking?

Smoking is one of the modifiable risk factors that cause angina pectoris in patients. Therefore
Mr. AG should be advised to reduce the amount of cigarettes that he smokes per day until he
has completely cut it out of his routine. He should also avoid any second hand smoke (Ritter,
2008).

REFERENCES:

BNF. (2014). British national formulary 67. London: Royal Pharmaceutical Society.

Dhillon, S., & Raymond, R. (2009). Pharmacy case studies. London: Pharmaceutical Press.

Ritter, J. (2008). A textbook of clinical pharmacology and therapeutics. London: Hodder

Arnold.