Chapter 36

Antianginal & Vasodilating Drugs

Mrs. Davis, MSN/RN

2020
 Key Definitions
 Atherosclerosis: disease characterized by deposits of fatty plaques on the
inner walls of arteries

 Angina: acute pain in the chest resulting from decreased blood supply to
the heart muscle
 Angina
 Angina is a disorder characterized by atherosclerotic plaque formation in
the coronary arteries which causes decreased oxygen supply to the heart
muscle and results in chest pain or pressure

Any activity that increases the workload of the heart such as exercise or
simply climbing stairs can precipitate a painful angina attack

Antianginal drugs relieve chest pain or pressure by dilating coronary

arteries which increases the blood supply to the myocardium

Increasing blood flow to an area may results in complete/partial relief

of symptoms; drug therapy may provide minimal/temporary relief;
calcium channel blockers are the primary treatment for angina;
calcium channel blockers are also used to treat hypertension
 Angina
 Chest pain can also be a symptom of another issue: pulmonary arterial
hypertension (PAH)
PAH is a condition where the pulmonary artery (from the heart to the
lungs) has too much pressure
right side of the heart has to work harder and it can result in HF if not
treated
Unrecognized disease has a high mortality rate
 short of breath
 chest pain
 Fatigue
 Edema
Vasodilating drugs relax the smooth muscle layer of arterial blood
vessels
 Antianginal 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
 nitrate drugs primary purpose is to increase blood supply to an area by
dilating blood vessels; adrenergic blocking and calcium channel
blockers used in antianginal treatment 

 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 to
deliver more oxygen to cardiac muscle; increased blood flow results in an
increase in the oxygen supply to surrounding tissues
 Antianginal Drugs: Uses
 Relieve pain of acute anginal attacks
 Prevent angina attacks (prophylaxis)
 Treat chronic stable angina pectoris

 Nitrates: relieve pain of acute anginal attack; prevent angina attacks; treat
chronic stable angina pectoris; relieve symptoms when an anginal attack
happens

 Calcium channel blocker: anginal pain associated with certain forms of

angina, such as vasospastic angina; chronic stable angina; hypertension;
verapamil affects the conduction system of the heart and is used to treat
cardiac arrhythmias; prevent angina from occurring by taking the drug on
a regular basis
 Intravenous (IV) nitroglycerin is used to control perioperative
hypertension associated with surgical procedures
Antianginal Drugs: Adverse Reactions

 Nitrates: (sublingual; translingual spray; transdermal; parenteral)

sublingual nitroglycerin may cause a local burning or tingling in the
oral cavity
Contact dermatitis may occur from use of the transdermal delivery
system

CNS reactions: headache (may be severe and persistent);

dizziness; weakness; restlessness

Other body system reactions: hypotension; flushing; rash

If adverse reactions become severe the physician may lower the dose
until symptoms subside; dose may then be slowly increased if the lower
dosage does not provide relief from the symptoms of angina
Antianginal Drugs: Adverse Reactions

 Calcium channel blockers: (not serious; rarely require discontinuation of

drug therapy)

CNS reactions: dizziness; lightheadedness; headache; nervousness;

asthenia (loss of muscular strength); fatigue

Gastrointestinal reactions: nausea; constipation; abdominal discomfort

Cardiovascular reactions: peripheral edema; hypotension;

arrhythmias; bradycardia

Other body system reactions: rash; flushing; nasal congestion; cough

 Antianginal Drugs:
Contraindications & Precautions
 Nitrates:
Contraindicated in patients with known hypersensitivity to the drugs;
severe anemia; closed-angle glaucoma; postural hypertension;
myocardial infarction (MI) (sublingual form); head trauma; cerebral
hemorrhage (may increase intracranial hemorrhage); allergy to
adhesive (transdermal system); constrictive pericarditis
Patients taking phosphodiesterase inhibitors (drugs for erectile
dysfunction [ED]) should not use nitrates
Review
Lifespan Considerations
amyl nitrite – during pregnancy
pg. 412

Precautions: in patients with severe hepatic/renal disease; severe head

trauma; hypothyroidism; during pregnancy and lactation (pregnancy
category C)
 Antianginal Drugs:
Contraindications & Precautions
 Calcium channel blockers:
Contraindicated: patients who are hypersensitive to the drug; sick
sinus syndrome; second- or third-degree atrioventricular (AV) block;
hypotension (systolic pressure less than 90 mm Hg); ventricular
dysfunction; cardiogenic shock

Precautions: in patients with congestive heart failure; hypotension;

renal impairment; hepatic impairment; during pregnancy and lactation
 Antianginal Drugs:
Interactions
Interacting drug: Effect of interaction:
Nitrate Alcohol – severe hypotension &
cardiovascular collapse
Aspirin Increased nitrate plasma
concentrations & action
Calcium channel blockers Increased symptomatic
orthostatic hypotension
Dihydroergotamine Increased risk of hypertension
& decreased antianginal effect
Heparin Decreased effect of heparin
 Antianginal Drugs:
Interactions
Interacting drug: Effect of interaction:
Calcium channel blockers cimetidine or ranitidine -
increased effects of calcium
channel blockers
Theophylline Increased pharmacologic &
toxic effects of theophylline
St. John’s wort Reduced serum concentrations
of calcium channel blocker
(nifedipine)
Digoxin Increased risk for digitalis
toxicity
Rifampin Decreased effect of calcium
channel blocker
 Nursing 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
nitrates or calcium channel blockers and other disease processes that would
contraindicate administration of the drug

Assess the physical appearance of the patient:

auscultate the lungs for adventitious sounds
obtain a baseline ECG and vital signs (orthostatic hypotension)
Weigh the patient
Stress test
Chest x-ray
Review
Labs
Box 36.1
pg. 412
Pregnancy test
Birth control
 Nursing Process: Assessment
 Ongoing assessment:
Monitor the patient for the frequency and severity of any episodes of
anginal pain
report to the physician/911 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; heart rate falls below 50 bpm or the systolic
blood pressure drops below 90 mm Hg, hold the drug and notify
physician (dosage adjustment may be necessary)
assess patients receiving the calcium channel blockers for signs of CHF:
dyspnea; weight gain; peripheral edema; abnormal lung sounds
(crackles/rales); jugular vein distention
 Notify physician immediately
 When the drug is being titrated to a therapeutic dose the patient is
typically monitored by telemetry
 Nursing Process: Diagnosis
 Risk for Injury related to hypotension; dizziness; lightheadedness

 Pain related to narrowing of peripheral arteries; decreased blood supply

to the extremities
 Nursing Process: Planning
 Expected outcomes:
Optimal response to drug therapy

Support patient needs related to the management of common adverse

drug reactions

Understanding of the post-discharge drug regimen

 Nursing Process: Implementation
 Promoting an optimal response to therapy:
Nitrates administered by the sublingual (under the tongue); buccal
(between the cheek and gum); oral; IV; transdermal route
Review
WEAR GLOVES Nursing Alert
pg. 413
Oral nitrates Nitrates available as oral tablets that are swallowed;
sustained-release preparation may not be crushed or chewed; give on
empty stomach; nausea occurs after administration notify physician;
taking tablet/capsule with food may be ordered to relieve nausea; due to
tolerance physician may prescribe short-acting two to three times per
day until 7 p.m. and long-acting twice daily

nitroglycerin buccal form 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
 Nursing Process: Implementation
nitroglycerin also administered by a metered spray canister to stop an
acute anginal attack; spray on or under the tongue; Do Not shake the
canister or inhale the spray; instruct the patient to call the nurse if pain
not relieved in three doses; worsens; increases in frequency; physician
may have to change dose or order Morphine for pain Review
WEAR GLOVES Nursing Alert
Administering topical nitroglycerin: (ointment) pg. 413
 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 is higher contact physician before applying

 applicator paper supplied with drug: one paper per application;

express the prescribed amount of ointment onto paper while holding
the paper; remove paper from previous administration and cleanse
area; rotate application sites to prevent inflammation of skin; The
ointment is usually applied to the chest or back
 Nitroglycerin ointment is also used to treat anal fissures
Nursing Process: Implementation
Wear Gloves

 Administering transdermal nitroglycerin: convenient and easier to

use; drug absorbed through skin; has the drug impregnated in a pad;
apply for 10-12 hours a day; tolerance to vascular and anginal effects
of nitrates with patients taking higher dosages: prescribed longer-
acting products; on dosing schedules
 nursing interventions when applying transdermal system on patient:
 when applying transdermal system inspect skin site: dry; free of
hair (shave site); not subject to excessive rubbing or movement

 Apply the same time of day; rotate sites (chest; abdomen; thighs);
apply after bath/shower

 Remove patches for cardioversion or defibrillation to avoid burns

 Nursing Process: Implementation
 Administering IV nitroglycerin: administer diluted in normal saline
solution/D5W by continuous infusion using infusion pump to ensure
rate; glass IV bottles and sets provided by manufacturer; nurses
titrate dosage according to patient’s response and physician’s
instructions;  Nitroglycerin solutions should not be mixed with any
other drugs or blood products

 Calcium channel blockers (Preventing an Attack): taken without

regard to meals unless GI upset occurs then give with meals
 verapamil and bepridil cause gastric upset hence taken with meals
 verapamil capsules - open and sprinkle on foods or mix in liquids
 patient with difficulty swallowing diltiazem: tablets can be crushed
and mixed with food or liquid

Administering Vasodilating Drugs: Carefully monitor the patient

receiving minoxidil because the drug increases the heart rate; notify the
physician of the following:
 Nursing Process: Implementation

Administering Vasodilating Drugs: Carefully monitor the patient

receiving minoxidil because the drug increases the heart rate; notify the
physician of the following:
 Heart rate of 20 bpm or more above the normal rate
 Rapid weight gain of 5 lb or more
 Unusual swelling of the extremities; face; abdomen
 Dyspnea; angina; severe indigestion; fainting
 Nursing Process: Implementation
 Monitoring and managing patient needs: carefully monitor for adverse
reactions; hypotension could be accompanied by bradycardia/increased
angina
Adverse reactions such as headache; flushing; postural hypotension
become less severe or disappear after a period of time

Review
Lifespan Considerations x 2
pg. 414
 Nursing Process: Implementation
Risk for injury: assist patient having episodes of postural hypotension
with ambulatory activities; instruct the patient to take the drug in the
sitting/supine position and keep the position until symptoms disappear;
monitor blood pressure frequently in patient with dizziness and
lightheadedness

Pain: evaluate response to therapy by questioning about anginal pains;

pain may be relieved entirely; less intense; less frequent; may occur
with prolonged exercise; record information on patient’s chart - helps
for future therapy and making dosage adjustments
 Nursing Process: Implementation
 Educating the patient and family:
Patient and family should have a thorough understanding of treatment
of chest pain with an antianginal drug; the drug therapy is to either
prevent chest pain or ease chest pain
explain the therapeutic regimen to the patient (dose; time of day drug is
taken; how often to take the drug; how to take/apply the drug)

adapt the teaching plan to the type of antianginal drug prescribed:

 Avoid the use of alcohol
 Keep this medication isolated from other drugs
 Call 911/physician if drug does not relieve pain; pain becomes more
intense Review
 Follow the recommendations regarding frequency of use Patient Teaching
 Keep an adequate supply of the drug on hand pg. 415
 Keep a record of the frequency of acute anginal attacks (date; time of
the attack; drug; dose used to relieve the acute pain)
 Nursing Process: Evaluation
 The therapeutic effect is achieved; pain is relieved

 Adverse reactions are identified; reported; managed successfully through

nursing interventions

 No evidence of injury

 The patient and family demonstrate an understanding of the drug

regimen
 Question #1
Is the following statement true or false?

When the fatty deposits of atherosclerosis involve the coronary vessels

supplying the heart, anginal pain can occur.
 Answer to Question #1
True

When the fatty deposits of atherosclerosis involve the coronary vessels

supplying the heart, anginal pain can occur.
 Question #2
Is the following statement true or false?

Antianginal drugs vasodilate and relax the smooth muscle of arterioles

around the heart; this promotes blood flow and reduces pain.
 Answer to Question #2
True

Antianginal drugs vasodilate and relax the smooth muscle of arterioles

around the heart; this promotes blood flow and reduces pain. Some drugs
are used for immediate relief of pain; others are used routinely to prevent
painful episodes.
 Question #3
Is the following statement true or false?

Men taking antianginals need to be assessed and cautioned for use of

erectile dysfunction medications because these drugs also cause
vasodilation.
 Answer to Question #3
True

Men taking antianginals need to be assessed and cautioned for use of

erectile dysfunction medications because these drugs also cause
vasodilation.
 REVIEW:
Review
Key Points
pg. 416

Review
Drug Table
pg. 416

Complete:
Key Terms
&
Chapter Review