Antianginal agents

1. Antianginal AgentsAntianginal Agents

2. Antianginal AgentsAntianginal Agents
•NitratesNitrates
•Beta blockersBeta blockers
•Calcium channel blockersCalcium channel blockers

3. Angina Pectoris (Chest Pain)Angina Pectoris (Chest Pain)
•When the supply of oxygen and nutrients in When the supply of oxygen and nutrients in
the blood is insufficient to meet the demands the blood is insufficient to meet the demands
of the heart, the heart muscle of the heart, the heart muscle achesaches..
•The heart demands a large supply of oxygen The heart demands a large supply of oxygen
to meet the demands placed on it.to meet the demands placed on it.

4. Types of AnginaTypes of Angina
•Chronic stable angina Chronic stable angina
(also called classic or effort angina)(also called classic or effort angina)
•Unstable anginaUnstable angina
(also called preinfarction or crescendo angina)(also called preinfarction or crescendo angina)
•Vasospastic anginaVasospastic angina
(also called Prinzmetal’s or variant angina)(also called Prinzmetal’s or variant angina)

5. Antianginal Agents:Antianginal Agents:
Therapeutic ObjectivesTherapeutic Objectives
•Increase blood flow to ischemic heart muscleIncrease blood flow to ischemic heart muscle
and/orand/or
•Decrease myocardial oxygen demandDecrease myocardial oxygen demand

6. Antianginal Agents:Antianginal Agents:
Therapeutic ObjectivesTherapeutic Objectives
•Minimize the frequency of attacks and decrease the Minimize the frequency of attacks and decrease the
duration and intensity of anginal painduration and intensity of anginal pain
•Improve the patient’s functional capacity with as few Improve the patient’s functional capacity with as few
side effects as possibleside effects as possible
•Prevent or delay the worst possible outcome, MIPrevent or delay the worst possible outcome, MI

7. Antianginal Agents: NitratesAntianginal Agents: Nitrates
Available forms:Available forms:
SublingualSublingual OintmentsOintments
BuccalBuccal Transdermal patchesTransdermal patches
Chewable tabletsChewable tablets Inhalable spraysInhalable sprays
CapsulesCapsules Intravenous solutionsIntravenous solutions

8. Antianginal Agents: NitratesAntianginal Agents: Nitrates
•Cause vasodilation due to relaxation of Cause vasodilation due to relaxation of
smooth musclessmooth muscles
•Potent dilating effect on coronary arteriesPotent dilating effect on coronary arteries
•Used for prophylaxis and treatment Used for prophylaxis and treatment
of anginaof angina

9. Antianginal Agents: Nitrates Antianginal Agents: Nitrates
NitroglycerinNitroglycerin
•Prototypical nitratePrototypical nitrate
•Large first-pass effect with PO formsLarge first-pass effect with PO forms
•Used for symptomatic treatment of ischemic heart Used for symptomatic treatment of ischemic heart
conditions (angina)conditions (angina)
•IV form used for BP control in perioperative IV form used for BP control in perioperative
hypertension, treatment of CHF, ischemic pain, hypertension, treatment of CHF, ischemic pain,
and pulmonary edema associated with acute MIand pulmonary edema associated with acute MI

10. Antianginal Agents: Nitrates Antianginal Agents: Nitrates
•isosorbide dinitrate isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate SR)(Isordil, Sorbitrate, Dilatrate SR)
•isosorbide mononitrate isosorbide mononitrate
(Imdur, Monoket, ISMO)(Imdur, Monoket, ISMO)
Used for:Used for:
•Acute relief of anginaAcute relief of angina
•Prophylaxis in situations that may provoke anginaProphylaxis in situations that may provoke angina
•Long-term prophylaxis of anginaLong-term prophylaxis of angina

11. Antianginal Agents: Nitrates Antianginal Agents: Nitrates
Side EffectsSide Effects
•HeadacheHeadache
–Usually diminish in intensity and frequency Usually diminish in intensity and frequency
with continued usewith continued use
•Tachycardia, postural hypotensionTachycardia, postural hypotension
•Tolerance may developTolerance may develop

12. Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers
•atenolol (Tenormin)atenolol (Tenormin)
•metoprolol (Lopressor)metoprolol (Lopressor)
•propranolol (Inderal)propranolol (Inderal)
•nadolol (Corgard)nadolol (Corgard)

13. Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers
Mechanism of ActionMechanism of Action
•Decrease the HR, resulting in decreased myocardial Decrease the HR, resulting in decreased myocardial
oxygen demand and increased oxygen delivery to oxygen demand and increased oxygen delivery to
the heartthe heart
•Decrease myocardial contractility, helping to Decrease myocardial contractility, helping to
conserve energy or decrease demandconserve energy or decrease demand

14. Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers
Therapeutic UsesTherapeutic Uses
•AntianginalAntianginal
•AntihypertensiveAntihypertensive
•Cardioprotective effects, especially after MICardioprotective effects, especially after MI

15. Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers
Side EffectsSide Effects
Body SystemBody System EffectsEffects
CardiovascularCardiovascular bradycardia, hypotensionbradycardia, hypotension
second- or third-degree heart blocksecond- or third-degree heart block
heart failureheart failure
MetabolicMetabolic Altered glucose and lipidAltered glucose and lipid
metabolismmetabolism

16. Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers
Side EffectsSide Effects
Body SystemBody System EffectsEffects
CNSCNS dizziness, fatigue, dizziness, fatigue,
mental depression, lethargy,mental depression, lethargy,
drowsiness, unusual dreamsdrowsiness, unusual dreams
OtherOther impotenceimpotence
wheezing, dyspneawheezing, dyspnea

17. Antianginal Agents: Antianginal Agents:
Calcium Channel BlockersCalcium Channel Blockers
•verapamil (Calan)verapamil (Calan)
•diltiazem (Cardizem)diltiazem (Cardizem)
•nifedipine (Procardia)nifedipine (Procardia)

18. Antianginal Agents: Antianginal Agents:
Calcium Channel BlockersCalcium Channel Blockers
Mechanism of ActionMechanism of Action
•Cause peripheral arterial vasodilationCause peripheral arterial vasodilation
•Reduce myocardial contractility Reduce myocardial contractility
(negative inotropic action)(negative inotropic action)
•Result: decreased myocardial oxygen demandResult: decreased myocardial oxygen demand

19. Antianginal Agents: Antianginal Agents:
Calcium Channel BlockersCalcium Channel Blockers
Therapeutic UsesTherapeutic Uses
•First-line agents for treatment of angina, First-line agents for treatment of angina,
hypertension, and supraventricular tachycardiahypertension, and supraventricular tachycardia
•Short-term management of atrial fibrillation and Short-term management of atrial fibrillation and
flutterflutter
•Several other usesSeveral other uses

20. Antianginal Agents: Antianginal Agents:
Calcium Channel BlockersCalcium Channel Blockers
Side EffectsSide Effects
•Very acceptable side effect and safety profileVery acceptable side effect and safety profile
•May cause hypotension, palpitations, tachycardia May cause hypotension, palpitations, tachycardia
or bradycardia, constipation, nausea, dyspneaor bradycardia, constipation, nausea, dyspnea

21. Antianginal Agents: Antianginal Agents:
Nursing ImplicationsNursing Implications
•Before administering, perform a complete Before administering, perform a complete
health history to determine presence of health history to determine presence of
conditions that may be contraindications conditions that may be contraindications
for use or call for cautious use.for use or call for cautious use.
•Obtain baseline VS, including respiratory Obtain baseline VS, including respiratory
patterns and rate.patterns and rate.
•Assess for drug interactions.Assess for drug interactions.

22. Antianginal Agents: Antianginal Agents:
Nursing ImplicationsNursing Implications
•Patients should not take any medications, Patients should not take any medications,
including OTC medications, without checking including OTC medications, without checking
with the physician.with the physician.
•Patients should report blurred vision, Patients should report blurred vision,
persistent headache, dry mouth, dizziness, persistent headache, dry mouth, dizziness,
edema, fainting episodes, weight gain of edema, fainting episodes, weight gain of
2 pounds in 1 day or 5 or more pounds in 2 pounds in 1 day or 5 or more pounds in
1 week, pulse rates under 60, and any 1 week, pulse rates under 60, and any
dyspnea.dyspnea.

23. Antianginal Agents: Antianginal Agents:
Nursing ImplicationsNursing Implications
•Alcohol consumption and hot baths or spending Alcohol consumption and hot baths or spending
time in jacuzzis, hot tubs, or saunas will result in time in jacuzzis, hot tubs, or saunas will result in
vasodilation, hypotension, and the possibility of vasodilation, hypotension, and the possibility of
fainting.fainting.
•Teach patients to change positions slowly to avoid Teach patients to change positions slowly to avoid
postural BP changes.postural BP changes.
•Encourage patients to keep a record of their anginal Encourage patients to keep a record of their anginal
attacks, including precipitating factors, number of attacks, including precipitating factors, number of
pills taken, and therapeutic effects.pills taken, and therapeutic effects.

24. Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin
Nursing ImplicationsNursing Implications
•Instruct patients in proper technique and guidelines Instruct patients in proper technique and guidelines
for taking sublingual NTG for anginal pain.for taking sublingual NTG for anginal pain.
•Instruct patients never to chew or swallow the Instruct patients never to chew or swallow the
SL form.SL form.
•Instruct patients that a burning sensation felt with Instruct patients that a burning sensation felt with
SL forms indicates that the drug is still potent.SL forms indicates that the drug is still potent.

25. Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin
Nursing ImplicationsNursing Implications
•Instruct patients to keep a fresh supply of NTG on Instruct patients to keep a fresh supply of NTG on
hand; potency is lost in about 3 months after the hand; potency is lost in about 3 months after the
bottle has been opened.bottle has been opened.
•Medications should be stored in an airtight, dark Medications should be stored in an airtight, dark
glass bottle with a metal cap and no cotton filler glass bottle with a metal cap and no cotton filler
to preserve potency.to preserve potency.

26. Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin
Nursing ImplicationsNursing Implications
•Instruct patients in the proper application of nitrate Instruct patients in the proper application of nitrate
topical ointments and transdermal forms, including topical ointments and transdermal forms, including
site rotation and removal of old medication.site rotation and removal of old medication.
•To reduce tolerance, the patient may be instructed to To reduce tolerance, the patient may be instructed to
remove topical forms at bedtime, and apply new remove topical forms at bedtime, and apply new
doses in the morning, allowing for a nitrate-free doses in the morning, allowing for a nitrate-free
period.period.

27. Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin
Nursing ImplicationsNursing Implications
•Instruct patients to take prn nitrates at the first hint Instruct patients to take prn nitrates at the first hint
of anginal pain.of anginal pain.
•If experiencing chest pain, the patient taking SL If experiencing chest pain, the patient taking SL
NTG should be lying down to prevent or decrease NTG should be lying down to prevent or decrease
dizziness and fainting that may occur due to dizziness and fainting that may occur due to
hypotension.hypotension.
•Monitor VS frequently during acute exacerbations Monitor VS frequently during acute exacerbations
of angina and during IV administration.of angina and during IV administration.

28. Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin
Nursing ImplicationsNursing Implications
•IV forms of NTG must be contained in glass IV IV forms of NTG must be contained in glass IV
bottles and must be given with infusion pumps.bottles and must be given with infusion pumps.
•Discard parenteral solution that is blue, green, Discard parenteral solution that is blue, green,
or dark red.or dark red.
•Follow specific manufacturer’s instructions for IV Follow specific manufacturer’s instructions for IV
administration. Use special IV tubing provided or administration. Use special IV tubing provided or
non-PVC tubing.non-PVC tubing.

29. Antianginal Agents: Antianginal Agents:
Calcium Channel Blockers Calcium Channel Blockers
Nursing ImplicationsNursing Implications
•Blood levels should be monitored to ensure they Blood levels should be monitored to ensure they
are therapeutic.are therapeutic.
•Oral CCBs should be taken before meals and Oral CCBs should be taken before meals and
as ordered.as ordered.
•Patients should be encouraged to limit Patients should be encouraged to limit
caffeine intake.caffeine intake.

30. Antianginal Agents: Beta Blockers Antianginal Agents: Beta Blockers
Nursing ImplicationsNursing Implications
•Patients taking beta blockers should monitor pulse Patients taking beta blockers should monitor pulse
rate daily and report any rate lower than 60 beats rate daily and report any rate lower than 60 beats
per minute.per minute.
•Dizziness or fainting should also be reported.Dizziness or fainting should also be reported.
•Constipation is a common problem. Instruct patients Constipation is a common problem. Instruct patients
to take in adequate fluids and eat high-fiber foods.to take in adequate fluids and eat high-fiber foods.

31. Antianginal Agents: Beta Blockers Antianginal Agents: Beta Blockers
Nursing ImplicationsNursing Implications
•These medications should never be abruptly These medications should never be abruptly
discontinued due to risk of rebound hypertensive discontinued due to risk of rebound hypertensive
crisis.crisis.
•Inform patients that these medications are for Inform patients that these medications are for
long-term prevention of angina, not for long-term prevention of angina, not for
immediate relief.immediate relief.

32. Antianginal Agents: Antianginal Agents:
Nursing ImplicationsNursing Implications
•Monitor for adverse reactionsMonitor for adverse reactions
–Allergic reactions, headache, light-headedness, Allergic reactions, headache, light-headedness,
hypotension, dizzinesshypotension, dizziness
•Monitor for therapeutic effectsMonitor for therapeutic effects
–Relief of angina, decreased BP, or bothRelief of angina, decreased BP, or both