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ANTIANGINAL DRUGS

Antianginal drugs are used primarily to restore the balance between the
oxygen supply and demand of the heart. These drugs dilate the coronary
vessels to increase the flow of oxygen to the ischemic regions. Other than
that, they also decrease the workload of the heart so the organ would have
less demand for oxygen. Learn about antianginal drugs, nitrates, beta-
blockers, and calcium channel blockers in this simplified guide for nursing
pharmacology.

Contents
 1 Table of Common Drugs and Generic Names
 2 Disease spotlight: Coronary Artery Disease
 3 Nitrates
o 3.1 Description
o 3.2 Therapeutic Action
o 3.3 Indications
o 3.4 Pharmacokinetics
o 3.5 Contraindications and Cautions
o 3.6 Adverse Effects
o 3.7 Interactions
o 3.8 Nursing Management
 4 Beta-Adrenergic Blockers
o 4.1 Description
o 4.2 Therapeutic action
o 4.3 Indications
o 4.4 Pharmacokinetics
o 4.5 Contraindications and Cautions
o 4.6 Adverse Effects
o 4.7 Interactions
o 4.8 Nursing Considerations
 5 Calcium-Channel Blockers
o 5.1 Description
o 5.2 Therapeutic Action
o 5.3 Pharmacokinetics
o 5.4 Contraindications and Cautions
o 5.5 Adverse Effects
o 5.6 Interactions
o 5.7 Nursing Considerations
 6 Practice Quiz: Antianginal Drugs
 7 See Also
 8 Further Reading and Resources

Table of Common Drugs and Generic Names


Classification Generic Name Brand Name

amyl nitrate Vaporole

Isosorbide mononitrate Imdur, Monoket


Nitrates and Nitrites
Isosorbide dinitrate Isordil, Sorbitrate

Nitroglycerin Nitro-Bid, Nitrostat

acebutolol Sectral

esmolol Brevibloc

metoprolol Toprol, Toprol XL


Beta-adrenergic blockers
nadolol Corgard

propranolol Inderal, Lopressor

timolol Blocadren

amlodipine Norvasc
Calcium-channel blockers
diltiazem Diltiazem, Diltiazem SR
Classification Generic Name Brand Name

nicardipine Cardene

nifedipine Adalat, Procardia

verapamil Calan, Isoptin

Others:

Piperazineacetamides ranolazine Ranexa

Nonnitrate coronary vasodilators dipyridamole Persantine

Disease spotlight: Coronary Artery Disease

Coronary Artery Disease (CAD) is the narrowing of blood vessels


supplying oxygen and nutrients to the heart, primarily due to the
development of fatty tumors (atheromas) in the lumen of blood vessels in a
process called atherosclerosis.

 This pathologic process attracts platelets and clotting factors to the


area, causing a much larger obstruction to the vessels. The vessels
also lose their natural ability to be elastic, resulting to inability to
dilate and constrict. The heart stimulates the bloodvessels to deliver
more blood but blood delivery is limited by narrow vessel diameter,
resulting to low oxygen supply of the heart.
 As a consequence of hypoxia, pain (angina) is felt.
 There are two types of angina:
 classic angina (of exercise), which occurs due to diminished
coronary blood flow to the heart; and
 vasospastic/Prinzmetal’s/variant angina, which is caused by
reversible vasospasm even at rest. Both types decrease oxygen
supply of the heart.
Nitrates

Description

 Nitrates are antianginal agents that provide fast action to directly


relax smooth muscles and depress muscle tone without affecting
nerve activity.
 Nitrates reduce preload and myocardial muscle tension by dilating
the veins. Also, they reduce afterload by dilating the arteries. Both
of these actions lower oxygen demand by decreasing the workload
of the heart.

Therapeutic Action

 The main effect is drop in systemic blood pressure.


 It compensates by increasing blood flow to healthy arteries and
veins because affected vessels already lose their elasticity.

Indications

 Children: May be used only for congenital heart defects and


cardiac surgery because they can cause potentially dangerous
changes in blood pressure.
 Adults: Should be educated on drug’s various forms and their
proper administration, storage, effectiveness, and manifestations
that would warrant prompt medical help. Lifestyle modifications
such as smoking cessation, low-fat diet, and weight loss should be
encouraged to promote effectiveness of Antianginal therapy.
 Older adults: Safety measures should be instituted as they
are prone to adverse effects like arrhythmias and hypotension. They
should receive initial low dose because of probably hepatic and renal
impairments which can interfere with metabolism and excretion of
drugs.
 Use during pregnancy is not established.
 Sublingual nitroglycerin is most effective for recurrent variant
angina.
 Continuous infusion or transdermal patch for unstable angina.

Pharmacokinetics
Route Onset Duration

IV 1-2 min 3-5 min

Sublingual tablet 1-3 min 30-60 min

Translingual spray 2 min 30-60 min

Transmucosal tablet 1-2 min 3-5 min

Oral SR tablet 20-45 min 8-12 h

Topical Ointment 30-60 min 4-8 h

Transdermal 30-60 min 24 h

T1/2: 1-4 min


Metabolism: liver
Excretion: kidney (urine)

Contraindications and Cautions

 Allergy to nitrates – prevent hypersensitivity reactions


 Severe anemia – decreased cardiac output (CO) caused by nitrates
is dangerous for blood with low-oxygen binding capacity
 Head trauma and cerebral hemorrhage – relaxation of cerebral
vessels can lead to intracranial bleeding
 Pregnancy and lactation – potential harm to fetus
 Hepatic and renal disease – alteration in drug metabolism and
excretion
 Conditions that can limit CO (e.g. hypovolemia, hypotension, etc.
Adverse Effects

 CNS: throbbing headache, dizziness, weakness


 GI: nausea, vomiting, incontinence
 CV: hypotension, reflex tachycardia, syncope
 EENT: pallor, flushing, sweating
 Large dose leads to methemoglobinemia and cyanosis.

Interactions

 Ergot derivatives: risk for hypertension; decreased antianginal effect


 Heparin: decreased therapeutic effect of nitrates
 PDE-5 inhibitors: risk for severe hypotension

Nursing Management

Nursing Assessment

 Presence of mentioned contraindications and cautions


 Skin color and integrity, especially for transdermal or topical forms
of nitrates
 Pain and activity level
 Neurological status (level of consciousness, affect, reflexes, etc.)
 Cardiopulmonary status (BP; take heart rate in full minute)
 Electrocardiogram as ordered
 Laboratory tests (e.g. CBC, liver and kidney function tests, etc.)

Nursing Diagnoses

 Decreased cardiac output related to vasodilation and hypotensive


effects of the drug
 Risk for Injury related to adverse effects on neurological and
cardiovascular status
 Ineffective Tissue Perfusion related to low oxygen supply to
myocardial cells

Implementation with Rationale


 Instruct patient not to swallow sublingual preparations to ensure
therapeutic effects. Take three tablets with a 5-minute interval, for
a total of three doses. If the pain does not subside, seek medical
help.
 Ask for presence of burning sensation to ensure drug potency.
 Protect drug from sunlight to maintain drug potency.
 For sustained release forms, take drug with water and do not crush
for these preparations need to reach GIT intact.
 Rotate injection sites and provide skin care as appropriate to
prevent skin abrasion and breakdown.
 Avoid abrupt stop of long-term therapy. Taper doses for 4-6 weeks
to prevent myocardial infarction.
 Provide comfort measures: small frequent meals, appropriate room
temperature and lights, noise reduction, ambulation assistance,
reorientation, and skin care.

Evaluation

 Monitor patient response to therapy (pain assessment).


 Monitor for presence of mentioned adverse effects.
 Monitor for effectiveness of comfort measures.
 Monitor for compliance to drug therapy regimen.
 Monitor laboratory tests.

Beta-Adrenergic Blockers

Description

 Beta-adrenergic blockers are drugs which block or lyse the


effects of sympathetic stimulation. Hence, they are also called
as sympatholytics.

Therapeutic action
 Main effects include decreased blood pressure, contractility and
heart rate by blocking the beta-receptors in the heart and
juxtaglomerular apparatus of the kidneys. These combined effects
reduce the oxygen demand of the heart.
 Usually used in therapy with nitrates because of reduced adverse
effects and increased exercise tolerance.
 Not indicated for variant angina because therapeutic effect of drugs
can cause vasospasm.

Indications

 Nadolol is used for management of chronic angina. It is the drug of


choice in angina patients with hypertension.
 Propranolol is the prototype drug of this class. It is used for
treatment of angina and syncope.
 Nebivolol, the newest adrenergic blocking agent does not produce
the same adverse effects seen in propranolol.

Pharmacokinetics
Route Onset Peak Duration

Oral 15 min 90 min 15-19 h

IV Immediate 60-90 min 15-19 h

T1/2: 3-4 h
Metabolism: liver
Excretion: kidney (urine)

 Food increases bioavailability of propranolol.


 Propranolol is the only drug under this class that can cross the
blood-brain barrier.

Contraindications and Cautions


 Bradycardia, heart block, and cardiogenic shock – blocking effect of
drugs exacerbates these conditions
 Pregnancy and lactation – potentially harmful effects to the fetus or
neonate
 Diabetes, chronic obstructive pulmonary disease (COPD),
thyrotoxicosis, and peripheral vascular diseases – blocking effect
prevents maintaining homeostatic requirements of these diseases

Adverse Effects

 CNS: emotional depression, dizziness, fatigue, sleep disturbances


 GI: gastric pain, nausea, vomiting, colitis, diarrhea
 CV: heart failure, reduced cardiac output, arrhythmia
 Respiratory: dyspnea, cough, bronchospasm

Interactions

 Clonidine: increased rebound hypertension


 NSAIDs: decreased antihypertensive effects
 Epinephrine: hypertension followed by bradycardia
 Ergot alkaloids: peripheral ischemia
 Insulin and oral hypoglycemic agents: alteration in
blood glucose levels without the patient experiencing manifestations
of hypo- or hyperglycemia

Nursing Considerations

Nursing Assessment

 Assess for presence of mentioned contraindications and cautions.


 Assess neurological status to determine presence of neurological
adverse effects. Focus on level of orientation and sensory function.
 Monitor blood pressure and heart rate accurately. Be sure to count
the heart rate in one full minute.
 Auscultate lungs to determine presence of possible respiratory
adverse effects.
 Check color and sensation of extremities. Measure capillary refill.
This is to evaluate presence of insufficiencies in the peripheral
vascular system.
 Monitor laboratory test results (e.g. electrolyte levels and renal
function tests) to ascertain risk for arrhythmia and discern whether
dose adjustment is needed.

Nursing Diagnosis

 Decreased Cardiac Output related to decreased heart rate, blood


pressure, and contractile properties of the heart
 Ineffective Tissue Perfusion related to decreased blood flow to the
heart
 Risk for Injury related to possible alterations in CNS while on drug
therapy

Implementation with Rationale

 Give drug as ordered following safe and appropriate administration


to ensure therapeutic effects.
 Provide comfort measures: ambulation assistance, raised siderails,
appropriate room light and temperature, and rest periods
 Monitor cardiopulmonary status closely to detect possible alterations
in vital signs which signal need for dose adjustment and to prevent
related adverse effects.
 Educate client about the need to not abruptly stop therapy as this
can lead to rebound hypertension and myocardial infarction.