Pharm exam 3 - Drugs for for Angina Pectoris

Angina pectoris

chest pain that occurs when the heart muscle isn't getting enough oxygen

Ischemia

tissue not receiving enough blood and oxygen

Atherosclerosis

plaque buildup that narrows the arteries

Myocardial infarction (MI)

a heart attack; heart muscle is damaged or dies

Preload

the blood filling the heart before it pumps

Afterload

the resistance the heart must pump against

Vasodilation

widening of the blood vessels

First-pass effect

the liver inactivates much of an oral drug before it can work

Orthostatic hypotension

blood pressure drops on standing, causing dizziness

Reflex tachycardia

the heart speeds up to make up for a low blood pressure

Bradycardia

a slow heart rate, under 60 beats per minute

Prophylaxis

prevention; stopping a problem before it starts

Tolerance

the body adapts and the drug works less well over time

QT prolongation

slowed electrical reset of the heart; raises arrhythmia risk

Angina

Mid-sternal chest pressure, radiating to the left arm, shoulder and/or jaw
Oxygen demand > oxygen supply
A symptom of a problem (atherosclerosis)

Angina three types:

• Stable

• Variant

• Unstable

Angina treatment aims:

◦ Prevent ischemia & pain
◦ Prevent MI & death

Antianginal Drugs

Organic Nitrates
Beta Blockers
Calcium Channel Blockers
Ranolazine

Organic Nitrates prototype:

Nitroglycerin (NTG)

Nitroglycerin MOA:

within vascular smooth muscle, converted to nitric oxide, which causes vasodilation

Nitroglycerin at normal doses what does it affect?

mainly veins

Nitroglycerin uses stable and unstable angina:

vein dilation decreases venous return, thereby decreasing preload and reducing O2 demand on the heart

Nitroglycerin uses for variant angina:

relaxes the coronary vasospasm, increasing O2 supply

Nitroglycerin Pharmacokinetics

Administration
◦ highly lipid soluble,
◦ given SL, PO, transdermal, IV
Metabolism
◦ rapidly inactivated by hepatic enzymes
◦ highly affected by first-pass effect

Nitroglycerin adverse effects:

Headache
Orthostatic hypotension
Reflex tachycardia

Nitroglycerin interactions:

Other HTN drugs
Erectile dysfunction drugs - contraindicated with NTG
Beta blockers, CCB: verapamil & diltiazem

Nitroglycerin Sublingual Tablets or Spray

◦ Bypasses first-pass effect
◦ Tablets protected from light & moisture

Nitroglycerin onset to relieve chest pain:

1 to 3 minutes

Nitroglycerin dose intervals:

5 minutes x 3 doses max

Nitroglycerin teaching regards:

administration & storage

Nitroglycerin Sustained-Release Capsule uses:

long-term prophylaxis of angina control

Nitroglycerin Sustained-Release Capsule facts:

Rapidly inactivated by hepatic enzymes
Highly affected by first-pass effect

Nitroglycerin Sustained-Release Capsule dose intervals:

lasts 10-12 hrs, taken twice daily

What is Nitroglycerin Transdermal?

Patches or ointment
Slowly absorbed through the skin into the blood

What are Nitroglycerin Transdermal uses:

to prevent angina attacks

Nitroglycerin Transdermal onset:

30-60 minutes

Nitroglycerin Transdermal watch for:

tachycardia & hypotension

Nitroglycerin Transdermal application:

Applied daily
CLEAN site upon removal
Patch-free interval each day

Nitroglycerin Intravenous Infusion (IV) uses:

Unstable angina, HF from acute MI, perioperative HTN

What is special about Nitroglycerin Intravenous Infusion (IV)

Glass bottle, requires special tubing

Nitroglycerin Intravenous Infusion (IV) doses:

Starting dose 5mcg/min, titrate up/down

Nitroglycerin Intravenous Infusion (IV) onset:

Seconds

Nitroglycerin Intravenous Infusion (IV) nursing considerations:

Must carefully monitor HR & BP
Must taper when discontinuing

Beta Blockers therapeutic uses:

Stable & Unstable Angina (↓ oxygen demand & ↑ oxygen supply)
Hypertension
Tachycardia (NTG-induced)
Post-MI
Heart failure (new use)
Hyperthyroidism
Migraines (prophylaxis)
Stage fright/anxiety
Glaucoma (eye drops)

Beta Blockers adverse effects:

Bradycardia
Reduced cardiac output
Precipitation of heart failure
AV heart block
Rebound cardiac excitation
◦ (if withdrawn abruptly) – sensitive to catecholamines
fatigue, depression often reported

CCB - Verapamil Diltiazem uses:

used to treat Stable Angina
◦ Relaxes & dilates peripheral arterioles → Reduces peripheral resistance (decreases afterload) → Reduces cardiac oxygen demand
◦ Vasodilation also relaxes vasospasm → helps variant angina also

Ranolazine (Ranexa) treats what?

Stable Angina

Ranolazine (Ranexa) Action / Effects:

Improves oxygen use in heart muscle
↓ chest pain episodes (stable angina)
Does not affect heart rate or blood pressure

Ranolazine (Ranexa) Indications:

Chronic stable angina (used when other antianginals aren’t enough)

Ranolazine (Ranexa) Contraindications / Precautions:

Severe liver disease
QT prolongation or history of arrhythmia
Use cautiously with kidney disease
Avoid grapefruit juice or CYP3A inhibitors (interactions)

Ranolazine (Ranexa) common side effects:

dizziness, headache, constipation, nausea

Ranolazine (Ranexa) serious side effects:

irregular heartbeat (QT prolongation)

Ranolazine (Ranexa) Nursing / Teaching Points:

Obtain baseline ECG and monitor for QT interval changes
Teach to report palpitations, fainting, or new chest pain
Take ER tablets whole (don’t crush or chew)
Keep follow-up appointments for labs & ECG
Avoid grapefruit products

Stable angina drugs:

1. Organic nitrates
2. Beta-blockers
3. Calcium channel blockers
4. Ranolazine

Variant angina drugs:

1. Organic nitrates
2. Calcium channel blockers

Unstable angina drugs:

1. Organic nitrates
2. Oxygen
3. Beta Blocker
4. Anti-platelets (treated more like an MI)

What findings require immediate provider notification in a patient with angina?

• Chest pain not relieved

• Worsening ECG changes

• New palpitations

• Hypotension with chest pain

When should the nurse hold a beta blocker in a patient with angina?

• HR <50 bpm

• SBP <90 mmHg

Notify the provider.

What are expected findings with antianginal medications?

• Nitroglycerin → headache, ↓ BP

• Beta blocker → mild bradycardia

What are concerning findings with antianginal medications?

• HR <50

• QT prolongation (Ranolazine)

• Persistent chest pain

What are the priority nursing actions for acute angina?

• Rest the patient

• Administer O₂ if ordered/needed

• Give SL nitroglycerin per protocol

• Monitor ECG and vital signs

• Reassess pain

What outcomes indicate antianginal therapy is effective?

• Chest pain relieved

• Stable BP/HR

• Improved ECG

• Patient knows how to use nitroglycerin correctly

• No dizziness, fainting, or QT prolongation