CH.54

Anginal pain

Occurs when cardiac oxygen supply is insufficient to meet cardiac oxygen demand.

Cardiac oxygen demand

Determined by heart rate, contractility, preload, and afterload.

Cardiac oxygen supply

Determined by myocardial blood flow.

Angina pectoris

Has three forms: chronic stable angina, variant angina, and unstable angina.

Stable angina

Caused primarily by coronary artery atherosclerosis.

Variant angina

Caused primarily by coronary artery spasm.

Nitroglycerin

A vasodilator that relieves pain of stable angina by dilating veins.

Mechanism of nitroglycerin

Converted to nitric oxide, requiring a sulfhydryl source.

Vasodilation from nitroglycerin

Causes decreased preload, therefore reducing oxygen demand.

Nitroglycerin absorption

Readily absorbed through skin and oral mucosa due to lipid solubility.

Sublingual nitroglycerin

Bypasses liver, allowing for smaller doses compared to oral administration.

Nitroglycerin side effects

Include headache, orthostatic hypotension, and reflex tachycardia.

Preventing reflex tachycardia

Use β-blockers, verapamil, or diltiazem with nitroglycerin.

Nitroglycerin tolerance

Develops within 24 hours due to sulfhydryl group depletion.

Preventing tolerance

Use the lowest effective dose and allow 8 hours drug-free period daily.

Nitroglycerin PRN use

Used to abort ongoing anginal attacks.

Long-acting nitroglycerin use

Provides extended protection against anginal attacks.

Nitroglycerin with erectile dysfunction drugs

Contraindicated when used with sildenafil and other PDE5 inhibitors.

β-blockers in angina

Decrease heart rate and contractility to reduce cardiac oxygen demand.

Fixed schedule administration

What β-blockers are administered on, not PRN.

CCBs in angina

Reduce cardiac oxygen demand and relax coronary vasospasm.

Dihydropyridine CCBs

Preferred when used in combination with β-blockers.

Ranolazine action

Helps heart generate energy more efficiently.

Ranolazine prescription

Should be combined with a nitrate, β-blocker, or amlodipine.

Ranolazine risks

May increase QT interval, posing risk for serious dysrhythmia.

MI and death prevention

Can be achieved with antiplatelet agents and cholesterol-lowering drugs.

Antianginal drug prevention

Includes long-acting drugs supplemented with sublingual nitroglycerin.

Revascularization criteria

Indicated only after failure of two or three antianginal drugs.

Therapeutic goal of Nitroglycerin

Reduction of frequency and intensity of anginal attacks.

Baseline data collection

Includes frequency and intensity of attacks, pain location, precipitating factors.

Risk factors for angina

Includes hypertension and hyperlipidemia.

Patients with low BP

Use nitroglycerin with caution.

Headache relief

Can be relieved with aspirin or acetaminophen.

Orthostatic hypotension advice

Patients should move slowly when changing positions.

Avoiding alcohol with nitroglycerin

To minimize hypotension effects.

Nitroglycerin administration site

Should be on a hairless area of skin.

Sublingual tablet instructions

Place under tongue until fully dissolved.

Emergency instructions for anginal pain

If pain not relieved in 5 minutes, call emergency services.

Transdermal patch removal

Should be applied for 12-14 hours with 10-12 drug-free hours.

Technique for transdermal cream application

Apply a ribbon to a specified area and cover with plastic wrap.

Sustained-release capsules

Should be swallowed intact without chewing or crushing.

Storage instructions for nitroglycerin

Keep in a dry place at room temperature in original container.

Isosorbide Mononitrate and Dinitrate

Have pharmacologic actions identical to nitroglycerin.

Differences in Isosorbide forms

Related only to dosage forms and administration routes.