Drugs for Angina

Pectoris
and Myocardial
Infarction
Coronary artery disease (CAD),

also called coronary heart disease, is a leading cause of

death in the United States.
The primary defining characteristic of CAD is narrowing or
occlusion of a coronary artery. The narrowing deprives
cells of needed oxygen and nutrients, a condition known
as myocardial ischemia.
 Angina pectoris

is acute chest pain caused by insufficient

oxygen to a portion of the myocardium.
 Types of angina
Stable Angina - When angina occurrences are fairly
predictable as to frequency, intensity, and duration. The
pain associated with stable angina is typically relieved by
rest.
Unstable Angina -When episodes of angina arise more
frequently, become more intense, or occur during periods
of rest.
 Vasospastic or Prinzmetals angina occurs when
the decreased myocardial blood flow is caused by
spasms of the coronary arteries. The vessels
undergoing spasms may or may not contain
atherosclerotic plaque. Vasospastic angina pain
occurs most often during periods of rest, although
it may occur unpredictably, and be unrelated to
rest or activity.
Silent angina is a form of the disease that occurs
in the absence of chest pain.
Nonpharmacologic Management of Angina
Limit alcohol consumption to small amounts.
Eliminate foods high in cholesterol or saturated fats.
Keep blood cholesterol and other lipid indicators within the
normal ranges.
Do not use tobacco.
Keep blood pressure within the normal range.
Exercise regularly and maintain optimum weight.
Keep blood glucose levels within normal range.
Limit salt (sodium) intake.
Treating Angina with Organic Nitrates
The primary therapeutic action of the organic nitrates is their ability to relax
both arterial and venous smooth muscle. Dilation of veins reduces the amount
of blood returning to the heart (preload), so the chambers contain a smaller
volume. With less blood for the ventricles to pump, cardiac output is reduced
and the workload on the heart is decreased, thereby lowering myocardial
oxygen demand.
Organic nitrates are of two types, short acting and long acting. The short-
acting nitrates, such as nitroglycerin, are taken sublingually to quickly
terminate an acute angina episode. Long-acting nitrates, such as isosorbide
dinitrate (Dilatate, Isordil), are taken orally or delivered through a
transdermal patch to decrease the frequency and severity of angina episodes.
ORGANIC NITRATES

isosorbide dinitrate (Dilatrate SR, Isordil)

isosorbide mononitrate (Imdur, Ismo, Monoket)
nitroglycerin (Nitrostat, Nitro-Dur,
Nitro-Bid, others)
Treating Angina with Beta-Adrenergic
Blockers
Beta-adrenergic antagonists or blockers reduce the
cardiac workload by slowing the heart rate and reducing
contractility. These drugs are as effective as the organic
nitrates in decreasing the frequency and severity of
angina episodes caused by exertion.
Unlike the organic nitrates, tolerance does not develop to
the antianginal effects of the beta blockers.
They are ideal for patients who have both hypertension
and CAD because of their antihypertensive action. They
have been shown to reduce the incidence of MI.
BETA ADRENERGIC BLOCKERS
atenolol (Tenormin)
metoprolol (Lopressor, Toprol XL))
nadolol (Corgard)
propranolol (Inderal, Inderal LA) (timolol (Betimol)
Treating Angina with Calcium Channel Blockers
Blockade of calcium channels has a number of effects on the
heart, most of which are similar to those of beta blockers.
Like beta blockers, calcium channel blockers (CCBs) are used
for a number of cardiovascular conditions, including
hypertension.
amlodipine (Norvasc)
bepridil (Vascor)
diltiazem (Cardizem, Cartia XT, Dilacor XR,
others)
nicardipine (Cardene)
nifedipine (Adalat, Procardia, others)
verapamil (Calan, Covera-HS)
Nursing Process Focus PATIENTS RECEIVING
PHRAMACOTHERAPY WITH ORGANIC NITRATES
ASSESSMENT
Obtain a complete health history including cardiovascular
(including previous MI, HF, valvular disease), cerebrovascular
and neurologic (including level of consciousness, history of
stroke, head injury, increased intracranial pressure), renal or
hepatic dysfunction, dysrhythmias, and pregnancy or lactation.
Obtain a drug history including allergies, current prescription
and over-the-counter (OTC) drugs, herbal preparations, and
alcohol use.
Be aware that use of erectile dysfunction drugs (e.g.,
sildenafil [Viagra]) within the past 24 to 48 hours may cause
profound and prolonged hypotension when nitrates are
administered. Be alert to possible drug interactions.
 Obtain baseline weight, vital signs (especially blood pressure [BP]
and pulse), and ECG. Assess for location and character of angina if
currently present.
Evaluate appropriate laboratory findings, electrolytes, renal
function studies, and lipid profiles. Troponin and/or CK-MB
laboratory values may be ordered to rule out MI.
Continue periodic monitoring of ECG for ischemia or infarction.
Continue frequent monitoring of BP and pulse whenever IV nitrates
are used or when giving rapid-acting (e.g., sublingual) nitrates. With
sublingual nitrates, take BP before and 5 minutes after giving the
dose and hold the drug if BP is less than 90/60, pulse is over 100, or
parameters as ordered, and consult with the health care provider
before continuing to give the drug.
 Assess for and promptly report adverse effects: excessive hypotension, dysrhythmias,
reflex tachycardia (from too-rapid decrease in BP or significant hypotension),
headache that does not subside within 1520 minutes or when accompanied by
neurologic changes, or decreased urinary output.
Immediately report severe hypotension, seizures, or dysrhythmias. Chest pain that
remains present after three sublingual nitroglycerin tablets given 5 minutes apart
should be reported immediately, even if the pain has lessened, because this may be a
sign of an impending ischemia or infarction.
IMPLEMENTATION
For patients on transdermal nitroglycerin patches, remove the
patch for 612 hours at night, or as directed by the health care
provider. (Removing the patch at night helps to prevent or delay
the development of tolerance to nitrates. Removing the patch at
night, when cardiac workload is lessened, helps avoid possible
anginal attacks during the daytime when workload is greater.)
 Continue to monitor vital signs frequently. Be cautious
with older adults who are at increased risk for
hypotension, patients with a pre-existing history of
cardiac or cerebrovascular disease, or patients with
recent head injury, which may be worsened by
vasodilation. Notify the health care provider immediately
if the angina remains unrelieved or if BP or pulse decrease
beyond established parameters, or if hypotension is
accompanied by reflex tachycardia. (Nitrates may cause
vasodilation, resulting in the potential for hypotension
accompanied by reflex tachycardia. Reflex tachycardia
increases myocardial oxygen demand, worsening angina.)
 Review the medications taken by the patient
before discharge, and review all prescription as
well as OTC medications with the patient. Current
use of erectile dysfunction drugs is
contraindicated with nitrates. (Erectile
dysfunction drugs lower BP and, when combined
with nitrates, can result in severe and prolonged
hypotension.)
 Continue frequent physical assessments,
particularly neurologic, cardiac, and respiratory.
Immediately report any changes in level of
consciousness, headache, or changes in heart or
lung sounds. (Nitrate therapy may worsen pre-
existing neurologic, cardiac, or respiratory
conditions as BP drops and perfusion to vital
organs diminishes. Lung congestion may signal an
impending HF.)
MYOCARDIAL INFARCTION
Heart attacks or myocardial infarctions (MIs) are
responsible for a substantial number of deaths each
year. Some patients die before reaching a medical
facility for treatment, and many others die within 48
hours following the initial MI.
An MI occurs when a coronary artery becomes
completely occluded. Deprived of its oxygen supply,
the affected area of myocardium becomes ischemic,
and myocytes begin to die in about 20 minutes unless
the blood supply is quickly restored. Necrosis of
myocardial tissue, which may be irreversible, releases
certain marker enzymes, which can be measured in
the blood to confirm that the patient has experienced
an MI versus unstable angina.
Treatment Goals!!!!!!
To quickly relieve the patients chest pain with
nitrates or morphine and
To administer antiplatelet drugs such as aspirin
and clopidogrel (Plavix) that will prevent the clot
from enlarging.
Treating Myocardial Infarction with
Thrombolytics
Quick restoration of cardiac circulation (reperfusion) with
thrombolytic therapy reduces mortality caused by acute
MI. After the clot is successfully dissolved, anticoagulant
therapy is initiated to prevent the formation of additional
clots.
Thrombolytics are most effective when administered from
20 minutes to 12 hours after the onset of MI symptoms. If
administered after 24 hours, the drugs are mostly
ineffective.
 The primary risk of thrombolytics is excessive
bleeding due to interference with the normal
clotting process. Vital signs must be monitored
continuously; signs of bleeding call for
discontinuation of therapy. Because these drugs
are rapidly destroyed in the blood, stopping the
infusion normally results in the rapid termination
of adverse effects.
ADJUNCT DRUGS FOR TREATMENT OF
ACUTE MYOCARDIAL INFARCTION
The most immediate needs of the patient with MI
are to ensure that the heart continues functioning
and that permanent damage from the infarction is
minimized.
 Antiplatelet and Anticoagulant Drugs Unless
contraindicated, 160 to 325 mg of aspirin is given as
soon as an MI is suspected. Aspirin use in the weeks
following an acute MI dramatically reduces mortality,
probably due to its antiplatelet action.
and continued for 12 hours after the procedure is
completed. On diagnosis of MI in the emergency
department, patients are immediately placed on the
anticoagulant heparin to prevent additional thrombi
from forming. Heparin therapy is generally continued
for 48 hours, or until PCI is completed, at which time
patients are switched to warfarin (Coumadin) or a
low-molecular-weight heparin such as enoxaparin
(Lovenox).
Pain Management for M.I.
The pain associated with an MI can be
debilitating. Pain control is essential to ensure
patient comfort and to reduce stress. Opioids
such as morphine sulfate or fentanyl are given to
ease extreme pain and to sedate the anxious
patient.