introduction to clinical pharmacology chapter 36- antianginal drugs

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Introduction to Clinical Pharmacology

Chapter 36-Antianginal Drugs

Introduction to Clinical Pharmacology

Chapter 36-Antianginal Drugs


Antianginal Drugs: ActionsAntianginal Drugs: Actions• Nitrates: Act by relaxing the smooth muscle layer of

blood vessels, increasing the lumen of the artery or arteriole and increasing the amount of blood flowing through the vessels

• Calcium channel blockers: Act by inhibiting the movement of calcium ions across cell membranes of cardiac and arterial muscle cells; effects on the heart: slowing the conduction velocity of the cardiac impulse; depression of myocardial contractility; dilating coronary arteries and arterioles

• Peripheral vasodilators block alpha adrenergic nerve receptors

deleted "of conduction" after velocity


Antianginal Drugs: UsesAntianginal Drugs: Uses

• Nitrates: Relieve pain of acute anginal attack; prevent angina attacks; control perioperative hypertension associated with surgical procedures

• Calcium channel blocker: Anginal pain associated with certain forms of angina, such as vasospastic angina; chronic stable angina; hypertension

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Antianginal: Adverse Reactions Antianginal: Adverse Reactions • Nitrates:

– CNS reactions: headache (may be severe and persistent), dizziness, weakness, and restlessness

– Other body system reactions: hypotension, flushing, and rash

• Calcium channel blockers:

– CNS reactions: dizziness, light-headedness, headache, nervousness, asthenia (loss of muscular strength), and fatigue


Antianginal: Adverse ReactionsAntianginal: Adverse Reactions

• Calcium channel blockers (cont’d):

– Gastrointestinal reactions: nausea, constipation, and abdominal discomfort

– Cardiovascular reactions: peripheral edema, hypotension, arrhythmias, and bradycardia

– Other body system reactions: rash, flushing, nasal congestion, and cough


Antianginal: Contraindications and PrecautionsAntianginal: Contraindications and Precautions

• Nitrates:

– Contraindicated: In patients with known hypersensitivity to the drugs, severe anemia, closed angle glaucoma, postural hypertension, early myocardial infarction (MI), head trauma, cerebral hemorrhage (may increase intracranial hemorrhage), allergy to adhesive (transdermal system), or constrictive pericarditis; amyl nitrite: pregnancy

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Antianginal: Contraindications and PrecautionsAntianginal: Contraindications and Precautions• Nitrates (cont’d):

– Precautions: In patients with severe hepatic or renal disease; severe head trauma; acute MI; hypothyroidism; during pregnancy and lactation

• Calcium channel blockers:

– Contraindicated: Patients who are hypersensitive to the drug; those with sick sinus syndrome; second or third-degree atrioventricular (AV) block; hypotension (systolic pressure less than 90 mm Hg); ventricular dysfunction; cardiogenic shock

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Antianginal: InteractionsAntianginal: Interactions• Interactions

– Phosphodiesterase inhibitors

•Severe hypotension and CV collapse may occur

– Alcohol

•Severe hypotension and CV collapse may occur


Nursing Process: AssessmentNursing Process: Assessment

• Preadministration Assessment:

– Before administering an antianginal drug: obtain and record a thorough description of the patient’s anginal pain as well as a history of allergy to the nitrates or calcium channel blockers and of other disease processes that would contraindicate administration of the drug

– Assess the physical appearance of the patient, auscultate the lungs for adventitious sounds, and obtain a baseline ECG and vital signs

– **display 36.1

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Nursing Process: AssessmentNursing Process: Assessment

• Ongoing assessment:

– Monitor the patient for the frequency and severity of any episodes of anginal pain; report to the primary health care provider any chest pain that does not respond to three doses of nitroglycerin given every 5 minutes for 15 minutes; take the patient’s vital signs before administration and frequently during administration; assess patients receiving the calcium channel blockers (if HR below 50 bpm or SBP below 90 mmHg, hold drug) for signs of CHF: dyspnea, weight gain, peripheral edema, abnormal lung sounds (crackles/rales), and jugular vein distention

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Nursing Process: PlanningNursing Process: Planning

• Expected outcomes for the patient depend on the specific reason for administration of an antianginal drug but may include:

– Optimal response to drug therapy

– Meeting of patient needs related to the management of common adverse drug reactions

– Understanding of the post-discharge drug regimen

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Nursing Process: ImplementationNursing Process: Implementation

• Promoting an optimal response to therapy:

– Nitrates: Administered by the sublingual (under the tongue), buccal (between the cheek and gum), oral, IV, or transdermal route; nitroglycerin administered: by the sublingual, buccal, topical, transdermal, oral, or IV route; if the buccal form of nitroglycerin prescribed: instruct the patient to place the buccal tablet between the cheek and gum or between the upper lip and gum above the incisors and allow it to dissolve

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Nursing Process: ImplementationNursing Process: Implementation• Promoting an optimal response to therapy:

– Nitrates (cont’d): Nitroglycerin also administered by a metered spray canister to abort an acute anginal attack; instruct the patient to call the nurse if pain not relieved in three doses

•Administering topical nitroglycerin: Dose measured in inches or millimeters; before measuring and applying the drug obtain patient’s blood pressure and pulse rate: compare with baseline and previous vital signs, if blood pressure lower, or pulse rate higher- contact primary health care provider before applying

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Nursing Process: ImplementationNursing Process: Implementation• Promoting an optimal response to therapy

– Nitrates

•Administering topical nitroglycerin (cont’d): Applicator paper supplied with drug; one paper per application; express the prescribed amount of ointment onto paper, while holding the paper-a thin layer over at least a 21/4 by 3.5 inch area; remove paper from previous administration and cleanse area; rotate application sites to prevent inflammation of skin

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• Promoting an optimal response to therapy

– Nitrates (cont’d)

•Administering transdermal nitroglycerin: Convenient and easier to use; drug absorbed through skin; has the drug impregnated in a pad

•Applied to the skin every 10-12 hours

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• Promoting an optimal response to therapy

– Nitrates (cont’d)

•Administering IV nitroglycerin: Administered: Diluted in normal saline solution or in water by continuous infusion using infusion pump to ensure rate; by using glass IV bottles and sets provided by manufacturer; regulate dosage according to patient’s response and as per PHCP’s instruction

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Nursing Process: ImplementationNursing Process: Implementation• Promoting an optimal response to therapy

(cont’d)

– Calcium channel blockers: Taken without regard to meals, unless GI upset occurs, then give with meals; verapamil and bepridil cause gastric upset, hence taken with meals; verapamil tablets opened and sprinkled on foods or mixed in liquids

•Monitor pts. For crackles, dyspnea and peripheral edema while taking Ca channel blockers

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Nursing Process: ImplementationNursing Process: Implementation• Monitoring and managing patient needs:

– GERIATRICS-ED drugs and nitrates can cause hypotension, use together is CONTRAINDICATED!

– Risk for injury: Assist patient having episodes of postural hypotension with all ambulatory activities, instruct the patient to take the drug in the sitting or supine position and keep the position till symptoms disappear; monitor blood pressure frequently in patient with dizziness and light-headedness

– Poppers (amyl nitrite, butyl nitrite) provide a head rush, euphoria, uncontrollable laughter or giggling and other sensations that result from the blood pressure drop-could cause fainting

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Nursing Process: ImplementationNursing Process: Implementation• Educating the patient and family:

– Nitrates

• h/a adverse reaction, loss of h/a may mean decrease in drug effectiveness; ASA or acetaminophen may be used for h/a relief

– Oral Nitrates

• Store capsules and tabs in the original container-NTG must be in a dark container

• Replace caps or covers tightly-air deteriorates drug

– Translingual Nitrates

• At onset of anginal attack, spray 1-2 metered doses onto or under the tongue, do not exceed 3 metered doses within 15 minutes

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• Administering vasodilating drugs

– Monitor if HR of 20 bpm or more above normal

– Rapid wt. gain of 5lbs or more

– Unusual swelling of the extremities, face, abdomen

– Dyspnea, angina, severe indigestion or fainting


Nursing Process: EvaluationNursing Process: Evaluation

• The therapeutic effect is achieved and pain is relieved

• Adverse reactions are identified, reported to the primary health care provider, and managed successfully through nursing interventions

• The patient verbalizes an understanding of the treatment modalities

• The patient and family demonstrate an understanding of the drug regimen

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introduction to clinical pharmacology chapter 36- antianginal drugs

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