dr.Datten Bangun MSc.

SpFK
&
dr.Tri Widyawati Msi,PhD
Dept.Farmakologi & Therapeutik
Fak.Kedokteran USU
MEDAN
 Ischemic heart disease
Asymptomatic Symptomatic

Angina
“silent’
myocardial
ischemia
 Ischemic heart disease

Asymptomatic
Symptomatic

Angina
“silent’ myocardial
ischemia

Myocardial
Infarction
Ischemic heart disease

Asymptomatic
Symptomatic
Angina
“silent’ myocardial
ischemia

Myocardial
Infarction
 Ischemic heart disease

Asymptomatic
Symptomatic
Angina
“silent’ myocardial
ischemia
DEATH

Myocardial
Infarction
 Ischemic Heart Disease
Clinical Syndromes of Myocardial Ischemia

Stable Syndromes
-Chronic stable angina pectoris (classic
or effort angina)
Unstable Syndromes
-unstable angina ( preinfarction,crescendo
angina
--- acute myocardial infarction
---- sudden death
Other Syndromes
- Silent ischemia
- Vasospastic or
Variant (Prinzmetal’s) angina
 Risk Factors
 Hypertension
 Smoking
 Hyperlipidaemia
 Hyperglycemia
 Male
 Post-menopausal
 Objektif Pengobatan

 Meringankan symptoms
Mencegah proses perjalanan penyakit
 Mengurangi proses perkembangan penyakit
 Mencegah myocardial infarction
 Mengurangi mortalitas
Angina - Precipitating Factors
Angina - Precipitating Factors

 Exercise
Angina - Precipitating Factors

 Exercise

 Emotional Stress
Angina - Precipitating Factors

 Exercise

 Emotional Stress

 Sex
Angina - Precipitating Factors

 Exercise

 Emotional Stress
Sympathetic
Activity  Sex
 Angina - Precipitating Factors
Sympathetic Activity

HR
CF Work of Myocardial
the = Oxygen
wall tension heart Demand

TPR
Angina - Precipitating Factors

Myocardial Myocardial
Oxygen
Oxygen ≠ Supply
Demand

ISCHEMIA
 Antianginal Drugs
Drugs used in Angina Pectoris

Vasodilators Cardiac depressants

Nitrates Calcium Blockers Beta-blockers

Long duration

Intermediate

Short Duration
Apa obatnya??
I. Nitrovasodilators

-Nitroglycerin

-Isosorbide Dinitrate

-Amyl Nitrate
Mechanism of Action
 Mechanism of action: most nitrates are prodrugs,
------decomposing to form nitric oxide (NO),
which activates guanylyl cyclase, theraby increasing
the levels of cylic guanosine monophosphate
(cGMP).

 cGMP decreases the concentration of intracellular

free Ca2+ and activates the cGMP-dependent protein
kinase which inhibits the contractive protein leading
to vasodilation.
Nitrates relieve angina by:
 Arteriolar dilatation:
= cardiac afterload == myocardial
work and oxygen demand

 Peripheral venodilatation:
= venous return ==
cardiac preload and myocardial
workload

 Relieving coronary vasospasm

 redistributing myocardial blood flow to

ischaemic areas of the myocardium
 Nitroglycerin
-Tolerance terjadi dengan cepat
- Mengalami first-pass metabolism
yang extensive
- Menstimulasi saraf sympathetic

- Dapat merangsang terjadi angina pada

bbrp pasien via reflex tachycardia
 Adverse Drug Reactions
 Headache-----’throbbing headache’
 Increase dose slowly

 Postural Hypotension
 Jangan bangun mendadak
Antianginal Agents: Nitrates
Available forms:
Sublingual Ointments
Buccal Transdermal patches
Chewable tablets Inhalable sprays
Capsules I.V solutions
Antianginal Agents: Nitrates
 isosorbide dinitrate
(Isordil, Sorbitrate, Dilatrate SR)
 isosorbide mononitrate
(Imdur, Monoket, ISMO)

Used for:
 Acute relief of angina
 Prophylaxis in situations that may
provoke angina
 Long-term prophylaxis of angina
How to Administer Nitroglycerine?

 Under tongue
 Take at first sign of symptoms
 If no relief in 5 minutes take a second SL
tablet
 If no relief in 5 minutes take a third SL tablet
 If no relief after 3rd tablet, call GP or
hospital
 Beta Blockers
- atenolol (Tenormin)
- metoprolol (Lopressor)
- propranolol (Inderal)
- nadolol (Corgard)

 Beta blockers are reversible antagonists of the

1 or 1/2 receptors
 These agents block the physiological
responses to norepinephrine and
epinephrine-----mengurangi beban atau
kerja jantung
 Beta Blockers

 Beta blockers decrease three major

determinants of myocardial oxygen demand

- Heart rate
-Contractility
- Systolic wall tension

 Beta blockers also allow improved perfusion

of the subendocardium by increasing diastolic
perfusion time
Antianginal Agents: Beta Blockers
Therapeutic Uses
 Antianginal
 Antihypertensive
 Cardioprotective effects, especially after
MI
Antianginal Agents: Beta Blockers
Side Effects
Body System Effects
Cardiovascular:
= bradycardia,
=hypotension,
= second-
= or third-degree heart block,
= heart failure
Metabolic: Altered glucose and lipid
metabolism
Adverse Effects - Beta Blockers

 Tiredness /fatigue
 Lethargy
 Impotence
 Bradycardia
 Bronchospasm
Calcium Channel Blockers

 Prevent calcium influx into myocytes and

smooth muscle lining arteries and atrerioles
by blocking the voltage dependent L-Type
calcium channel
 Diltiazem and verapamil also reduce heart
rate
● Bepridil also has action to block
fast sodium channels
Calcium Channel Blockers - Uses
Angina Pectoris
Variant Angina
Heart Failure
Hypertension; arrhythmias; subarachnoid
hemorrhage

Diltiazem (Benzothiazepine)
Nifedipine (Dihydropyridine)
Verapamil (Diphenylalkylamine)
Bepridil (other)
 Calcium Channel Blockers

 CCBs reduce arterial vascular tone (e.g., produce only

arterial vasodilatation)
 reduce after load and thus myocardial work load

 Verapamil and Diltiazem reduce myocardial heart rate

and contractility
 reduce myocardial oxygen requirements

 CCBs may also produce coronary vasodilatation

Adverse Drug Reactions

 Ankle edema
 Headache
 Flushing
 Palpitation
 Antiplatelet Agents
 Low dose ASPIRIN (75-150 mg)

 The formation of platelet aggregates are

important in the pathogenesis of angina,
unstable angina and acute MI

 Aspirin is a potent inhibitor of platelet

thromboxane production
 (Thromboxane stimulates platelet aggregation
and vasoconstriction)
Other approaches:

I.Management of underlying diseases:

= hypertension
= hyperlipidemia
= DM

II. Non-pharmacological approach:

= life –style :- pola makan
- stop smoking
- stop alcohol
- exercise
Patient Teaching
 Keep in original dark
container
 Replace every 6
months krn nitrat
cepat dirombak oleh
panas dan cahaya
 Headache and
dizziness may occur
 Avoid OTC meds
 Avoid Alcohol
 Prophylactic use
Nursing Actions
 Check Blood Pressure and Heart
Rate BEFORE each dose
 Observe for relief of chest pain
 Observe for hypotension,
dizziness, tachycardia, headache

Change positions slowly

Notify physician if
experience blurry vision,
persistent headache (over 20
minutes) or dry mouth
Antianginal Agents:
Nursing Implications
 Patients should not take any medications,
including OTC medications, without checking
with the physician.

 Watch for fainting episodes, weight gain of

2 pounds in 1 day or 5 or more pounds in
1 week, pulse rates under 60, and any dyspnea.

Instruct patients to take prn nitrates at the first hint of

anginal pain.
If experiencing chest pain, the patient taking SL NTG
should be lying down to prevent or decrease dizziness
and fainting that may occur due to hypotension.
Antianginal Agents:
Nursing Implications
 Alcohol consumption and hot baths or spending time
in jacuzzis, hot tubs, or saunas will result in
vasodilation, hypotension, and the possibility of
fainting.

 Teach patients to change positions slowly to

avoid postural BP changes.

 Encourage patients to keep a record of their

anginal attacks, including precipitating
factors, number of pills taken, and
therapeutic effects.
Antianginal Agents: Nitroglycerin
Nursing Implications
 Instruct patients in proper technique and
guidelines for taking sublingual NTG for
anginal pain.
 Instruct patients never to chew or swallow the
SL form.
 Instruct patients that a burning sensation felt
with SL forms indicates that the drug is still
potent.

Nitrate topicals should be spread thin. Rotate sites used.

Transdermal patches need to be applied to hairless parts
of body
Antianginal Agents: Nitroglycerin

Nursing Implications
 Instruct patients to keep a fresh supply of
NTG on hand; potency is lost in about 3
months after the bottle has been opened.
 Medications should be stored in an airtight,
dark glass bottle with a metal cap and no
cotton filler to preserve potency.
 Antianginal Agents: Nitroglycerin

 Instruct patients in the proper application of

nitrate topical ointments and transdermal
forms, including site rotation and removal of
old medication.

 To reduce tolerance, the patient may be

instructed to remove topical forms at
bedtime, and apply new doses in the
morning, allowing for a nitrate-free period
Antianginal Agents: Beta Blockers
Nursing Implications
 These medications should never be abruptly
discontinued due to risk of rebound
hypertensive crisis.
 Inform patients that these medications are for
long-term prevention of angina, not for
immediate relief.

= Monitor pulse rate and report when less than 60

=Dizziness or fainting should also be reported.
=Constipation is a common problem---- Instruct
patients to take in adequate fluids and eat high-fiber
foods
Antianginal Agents: Beta Blockers

 =Monitor pulse rate and report when less

than 60
 =Dizziness or fainting should also be
reported.
 =Constipation is a common problem----
Instruct patients to take in adequate fluids
and eat high-fiber foods
By-pass Graft
Percutaneous Transluminal
Coronary Angioplasty
 Stent in an Artery

 Maintains patency of blood vessel