Antianginal drug

anti anginal drugs with nursing consideration

1. ANTIANGINAL DRUGS PRESENTED BY PANKAJ SINGH RANA NURSE PRACTITIONER IN CRITICAL CARE SRHU, HCON

2. Introduction : Angina pectoris is characterized by sudden severe pressing chest pain or heaviness radiating to the neck, jaw, back and arms. It is often associated with diaphoresis, tachypnea and nausea. Angina is caused by coronary flow that is insufficient to meet oxygen demands of the myocardium.

3. There are three types of Angina : Stable Angina ( Most common) Unstable Angina Prinzmetal (variant) angina

4. Stable Angina Attacks are predictably provoked by exercise, emotion etc. It lasts for several seconds and subsides on rest . “ Stable ” indicates the reproducible nature of the angina; the same activity at the same intensity faithfully produces symptoms.

5. Unstable Angina The unstable angina is characterized by recurrent attacks of angina. It occurs with minimal exertion. It is precipitated due to combination of athero scleroti -plaque, platelet aggregation at ruptured plaque and vasospasm .

6. Prinzmetal (Variant) Angina This is a relatively uncommon pattern of myocardial ischemia usually occurring at rest or during sleep and often in young individuals. It is induced by coronary artery vasospasm, it generally responds promptly to vasodilators.

7. ANTIANGINAL DRUGS: Nitrates : Glyceryl trinitrate (Nitroglycerin) Isosorbide dinitrate , Isosorbide mononitrate Beta-blocker Atenolol , propranolol , metoprolol Calcium channel blocker Nifedipine , amlodipine 4. Potassium channel opener N icorandil

8. NITRATES

9. NITRATES They act directly on all the smooth muscle of the body & relax them. Nitrates release nitric oxide which is a powerful muscle relaxants. Most predominant in the vascular smooth muscles ( i.e walls of arteries & veins).

10. Action of nitrates

11. Preload reduction Nitroglycerin relaxes vascular smooth muscle and dilates both arterial and venous vessels. Dilation of veins is more predominant than dilation of arteries, resulting in peripheral pooling of blood & decreased venous return. decreased preload

12. Afterload reduction Nitrates also produce some arteriolar dilatation Decrease peripheral resistance Reduction of afterload

13. Redistribution of coronary flow Dilatation of coronary arteries Increase blood supply to the myocardium

14. Effects on other smooth muscles Relax the bronchi, biliary tracts & esophagus muscles. Also dilates cutaneous vessels & meningeal vessels .

15. Available forms Sublingual Tablets. Topical Ointment and Transdermal Patches. Translingual Spray. Transmucosal Tablets. Intravenous (IV).

16. Therapeutic uses of antianginal drugs Nitrates :- Angina pectoris MI Congestive cardiac failure Biliary colic Cyanide poisoning Oesophageal spasm

17. Nitroglycerine Preparation Dose Route Onset/Duration of action Trade name Tablets 1,2,3 mg 0.5 mg Sublingual 1 -3 min/30 min Angised spray 0.4 – 0.8 mg Sublingual 2 min/60 min Nitrolingual capsule 5-15 mg oral 20min/4-8 hr Angispan-tr Transdermal patch,5-10 mg one patch for 14 to 16 hr per day skin Max. 24 hrs Nitroderm-tts Injection 5mg/ml 5-20 microgram/min intravenous 2min/5 min Nitroject ointment 2% skin 30 min/12 hr Nitrol

18. SIDE EFFECTS Headache flushing, hypotension dizziness

19. CONTRAINDICATION Hypersensitivity Severe anaemia Increased ICP Cerebral haemorrhage

20. Isosorbide 1.Isosorbide mononitrate 2.Isosorbide dinitrate

21. Is a nitrate. Like nitroglycerin, and is used for treating and preventing angina. It is NOT used to treat HTN. Is given Sublingual or Per Oral . SL Isosorbide has a slower onset and a longer duration of action compared to SL nitroglycerin . Because SL isosorbide does NOT relieve chest pain as rapidly as introglycerin , Isosorbide is limited to treating acute angina in patients intolerant or unresponsive to SL nitroglycerin .

22. Dose & Route 1.Isosorbide mononitrate :- 20 to 40 mg orally 2.Isosorbide dinitrate : 5 -1o mg sublingually or orally

23. CALCIUM CHANNEL BLOCKER

24. CCB have negative chronotropic effect and dromotropic action on heart COMMON CALCIUM CHANNEL BLOCKER USED ARE VERAPEMIL ( most potent) NIFIDEPINE DILTIZEM ( least potent)

25. Ca++ channel blockers

26. ADVERSE EFFECTS NAUSEA VOMITTING BRADYCARDIA ANKLE EDEMA OCCASIONNALY HYPOTENTION TACHYCARDIA

27. BETA BLOCKERS DECREASE CORONARY SUPPLY DECREASE THE HEART RATE BY BLOCKING BETA RECEPTOR DECREASE THE WORK OF HEART DECREASE O2 CONSUMPTION INCREASE REDISTRIBUTION OF BLOOD

28. DRUGS MAINLY TWO DRUGS USED ATENOLOL METOPROLOL

29. ADVERSE EFFECT Hypotension Depression Bradycardia Heart block CHF

30. CONTRAINDICATION OF BETA BLOCKERS: heart block pulmonary edema cardiogenic shock

31. K CHANNEL OPNER

32. DRUG USED NICORANDIL 5-10 MG TAB 2MG/VIAL

33. ADVRSE EFFECT FLUSHING PALPITATION WEAKNESS DIZZINESS NAUSEA VOMITING

34. NURSING RESPONSIBILITY Nursing intervention Client teaching

35. Nursing intervention History collection Assess the duration,time started & character of pain. Monitor vital signs. Assist in various diagnostic test like ECG, Echo & other blood investigation. Nitrates should be kept away from flame. Store nitrates in original container. An analgesic can be given to treat headache .

36. IN IV NTG: Do not mix NTG with other drugs Do not use PVC tubing's for IV administration because its absorb the nitrates. Use glass bottles & tubing's provided by manufacturer. It is Given by infusion pump.

37. Ointment/ transdermal patch Remove transdermal patches before defibrillation to prevents burns. Rotate ointment & transdermal patches sites. Remove ointment & previous patch before applying new ointment or patch. Do not trim transdermal patch to alter dose. Do not rub or massage the area after application of ointment. Apply to the chest, upper arm, or upper thigh to promote absorption and increase onset of systemic action.

38. Do not get ointment on hands as it can cause headache. Wash hands after application. Apply to a nonhairy sites, avoid application to skin folds or irritated sites.

39. Transmucosal Tablets: The nurse should place one tablet between lip and gum above incisors or between cheek and gum to promote slow dissolving and extended absorption. Sublingual tablets: Place under the tongue.

40. Spray Do not shake when administering & hold vertically & spray under the tongue. Advise do not swallow immediately.

41. CLIENT TEACHING NTG loose potency if exposed to light, moisture or heat. Avoid alcohol, hot bath as they cause vasodilation & lead to hypotension. Teach about adverse effects. Encourage client to discontinue tobacco which causes vasoconstriction. Encourage to eat high fiber rich diet .

42. Instruct client do not chew SL tablets,place under the tongue. Do not eat food or smoke until tablets dissolve. SUBLINGUAL TABLETS; In cute anginal attacks, teach client to lie down & take NTG tablets as soon as possible; upto 3 NTG tablets in every 5 min. If no relief go for emergency services.