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Anti-Anginal Drugs
by Manasseh PMN 310 Anti-Anginal Drugs Mvula BSc. N 8/20/12 III Student.
*PMN 310
Overview
Angina is a syndrome of paroxysmal left sided chest pain, which is produced when the oxygen demands of the heart exceed the oxygen supply. There are four kinds of angina
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Stable angina: results from atherosclerotic plaques (deposits on the inner wall of the artery in atherosclerosis).
Unstable rapture.
angina:
develops
due
to
plaque
Characterised by new onset severe angina or sudden worsening of previously stable angina. It is also characterised by more severe symptoms. it is less responsive to treatment. It is intermediate syndrome between stable angina and myocardial infarction.
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This type is not caused by atherosclerotic narrowing, but results from a coronary artery spasms. This angina does not necessarily occur with exertion.
This type of angina is characterised by incapacitating pain that does 8/20/12 PMN 310 Anti-Anginal 44
Drugs
Treatment
Coronary vasodilators (antianginal drugs), rest, oxygen, and control of precipitating factors such as stress and smoking. Antianginal drugs
Acute anginal attacks are treated with short acting NTG (Nitroglycerin) products. Long term stable angina
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oral or
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Organic Nitrates
Are the first line of defence in the prevention and treatment of angina. They relax smooth muscles in the blood vessel walls, and thus, help to stop the pain of angina attacks. The organic nitrates redistribute flow to ischaemic areas of the myocardium, which improves the perfusion of the heart.
These agents dilate the veins, reducing venous pressure and venous Anti-Anginal 8/20/12 PMN 310 return. 66
Drugs
They also decrease blood volume and pressure within the heart, thereby reducing the preload.
ventricular muscle prior to electrical excitation and contraction of the heart muscle.
Organic nitrates dilate coronary blood arteries and increase blood flow to ischaemic by dilating collateral vessels. They dilate arterioles, which lowers peripheral vascular resistance. Further, they reduce afterload which is the load the heart muscle must move during contraction.
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Therapeutic uses
Acute angina attacks Unstable angina Chronic angina Acute and chronic heart failure.
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Adverse effects
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Contraindications
Allergy to nitrates Clients with severe anaemias, and Head trauma because nitrates can cause intracranial pressure. NB: Organic nitrates should not be given intravenously to clients with severe hypotension or hypovolaemia because they can cause shock due to vasodilatation.
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Precautions
Ventricular outflow obstruction disease Severe hypertension Carotid disease Renal/hepatic dysfunction Fluid depletion due to diuretic therapy Low blood pressure (less than 90mmHg systolic) Constrictive pericarditis
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Important drugs
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NTG is a prototype for the organic nitrates. preload and afterload. Relaxes vascular smooth muscle in venous return. arterial blood pressure. myocardial O2 consumption. Can be taken sublingually to relieve an angina attack. It has a rapid onset (1-3min) and a short duration (1-2 hrs.).
PMN 310 Anti-Anginal PMN 310 Anti-Anginal Drugs Drugs
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The
client usually takes one tablet every 5-10 minutes three consecutive times.
If
pain is not relieved the patient should contact the 14 14 health care provider
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These are worn for12 hours and removed for 12 hours to avoid tolerance as an adjuvant treatment of Raynauds disease.
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At onset of attack, spray 1-2 metred doses into the oral mucosa but not more than 3 doses in 15 minutes.
NTG I.V. (Nitro-Bid I.V, Tridil) is used to treat acute unstable angina, acute heart failure and hypertension. NTG I.V. is usually mixed with 5% Dextrose normal saline or 0.9% normal saline.
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This drug is for long term prophylaxis. It can either be taken sublingually or orally. Dosage:
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END OF NITRATES
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Beta-Adrenergic Blockers
These act to interrupt adrenergic stimulation to 1- or 2-receptors by competing with NE for available -adrenergic receptor sites. -blockers that block 1 receptors act to blood pressure, the contraction of the heart muscle, and CO.
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blocking agents are used for prophylaxis only because they do not act quickly enough to alleviate an on-going anginal attack. blockers are the mainstay of prophylactic treatment of chronic stable angina. They are often combined with Isosorbide dinitrate (Isordil) because the combined effects are more therapeutic.
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Balanced (ISA)
Hydrophilic
Nadolol
1- selective Vasodilators
Bisoprolol Celiprolol
Atenolol Esmolol
(- blocking (-agonist
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Uses
Chronic stable angina (to decrease oxygen demand, myocardial contractility, heart rate, and blood pressure) Dysrhythmias to slow sinus node conduction and prolong conduction through the AV node, thereby slowing ventricular response Hypertension to lower blood pressure Myocardial infarction to decrease the incidence of catecholamine-induced
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Adverse Effects
Bradycardia Orthostatic Shortness Oedema Reduced
hypertension of breath
exercise
congestive
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Precautions
-adrenergic blockers should be administered with caution to clients with a history of:
PMN 310 Anti-Anginal PMN 310 Anti-Anginal Drugs Drugs
Diabetics taking insulin because they can mask the symptoms of hypoglycaemia.
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Peripheral vascular insufficiency because they reduce blood flow to the extremities.
Kidney or liver disease because they accumulate in the serum of clients with these diseases, and cause toxic effects. Beta-adrenergic blockers should not be stopped abruptly because a client with angina is at four times greater risk of developing an angina attack, or a mild myocardial infarction within 30 days of discontinuation. Beta blockers should not be taken with alcohol.
Beta blockers are not always effective for AfricanAmerican clients, and thus are usually combined 25 25 with a diuretic.
Important drugs
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Propranolol hydrochloride (Inderal) Propranolol is a prototype for beta-blocking agents. It is used to treat angina, dysrhythmias, and myocardial infarction. Propranolol is available in a wide dosage range
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Atenolol
Is
used to treat angina pectoris, hypertension, and myocardial infarction. It is a hydrophilic 1 selective blocker. It is available in tablets 50 and 100mg given once daily.
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Pindolol
Is used to treat angina pectoris and hypertension. Pindolol is a non-selective balanced beta blocker. It possesses prominent intrinsic sympathomimetic action so it results in less reduction in the HR and BP. It is preferred in patients with low HR and CO. Pindolol is contraindicated in severe renal impairment.
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Dosage
Hypertension, initially 5 mg 23 times daily or 15 mg once daily, increased as required at weekly intervals; usual maintenance 1530 mg daily; max. 45 mg daily. Angina, 2.55 mg up to 3 times daily.
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Antidote
IV injection of atropine is required to treat bradycardia and hypotension (3 mg for an adult, 40 micrograms/kg (max. 3 mg) for a child). Cardiogenic shock unresponsive to atropine is probably best treated with an IV injection of glucagon 210 mg (child 50150 micrograms/kg) in glucose 5% (with precautions to protect the airway in case of vomiting) followed by an IV infusion of 50 micrograms/kg/hour. PMN 310 8/20/12 If glucagon is not available, Antiintravenous
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Prevent the flow of Ca2+ ions into the cells Relax arterial smooth muscle and decrease contraction of the heart muscle Slow AV conduction Slow heart rate Dilate coronary and peripheral arteries coronary vascular resistance coronary blood flow myocardial O2 demand
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Uses
Calcium channel blockers prevent and control supraventricular tachyarrhythmias, prevent post myocardial infarction complications, treat hypertension, treat chronic stable angina, treat and prevent unstable angina, and they treat and prevent vasospastic angina.
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Adverse Effects
Constipation Nausea Headache Hypotension Dizziness Bradycardia Heart block Dyspnoea and wheezing Peripheral oedema.
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Contraindications
Calcium channel blockers are contraindicated for clients with these conditions: Hepatic or renal disease Heart block Hypotension Severe bradycardia Aortic stenosis Severe left ventricular dysfunction Women who are pregnant or PMN 310 Anti8/20/12 lactating
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Caution
These agents should be administered with caution to clients with: Serious respiratory disorders Heart failure because calcium channels blockers can worsen heart failure. Ca2+ channel blockers should be administered with caution to elderly patients PMN 310 Anti- they can because 8/20/12
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Important drugs
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It is the drug of choice for clients with supraventricular tachycardias who may or may not have angina. This drug is also used to treat vasospastic (Prinzmetals) angina, unstable angina, chronic stable angina, and hypertension.
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Dosage
Do not give with albumin, ampicillin, nafcillin, oxacillin, sodium bicarbonate, amphotericin B, hydralazine, aminophylline because of Y-site incompatibilities. Decreased metabolism and risk of toxic effects if combined with grapefruit juice; avoid this combination.
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Parenteral: IV use only. Initial dose, 510mg over 2 min; may repeat dose of 10mg 30 min after first dose if initial response is inadequate.
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Oral: Initial dose, 80120mg tid; increase dose every 12 days to achieve optimum therapeutic effects.
Nifedipine (Procardia)
This drug is used to treat vasospastic (Prinzmetals) angina, chronic stable angina, and hypotension. It should be administered cautiously to patients with serious cardiac disease because it may precipitate heart failure or MI.
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Dosage
Higher doses (2030mg tidqid) may be required, depending on patient response. Adjust over 714 days. More than 180mg/day is not recommended.
Sustained-release: 3060mg PO once daily. Adjust over 714 days. Usual maximum dose is 90 120mg/day. Increased effects with cimetidine.
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Dosage: Initially, 30 mg PO qid before meals and gradually increase dosage at 1- to 2-day intervals to
This drug is used to treat spastic angina, chronic stable angina, and hypertension.
Amlodipine (Norvasc)
Dosage: Initially, 5mg PO daily; dosage may be gradually increased over 1014 days to a maximum dose of 10mg PO
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Dosage: Initially, 30 mg PO qid before meals and gradually increase dosage at 1- to 2-day intervals to 180360 mg PO in
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This drug is also used to treat angina and is usually given in combination with betablockers.
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Assessment
Assess the client for signs of coronary artery disease, and ask the client to describe his/her angina attack. Inquire about:
Pain:
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Location
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What activities appear to precipitate attacks.eg exercises The clients current use of antianginal drugs to relieve pain.eg rest Do some physical assessment which include; BP, pulse rate (Apical/radial), and resp. rate after the pt. has rested for 10min. Depending on the heart disease,
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Nursing Diagnoses
v
Pain; related to myocardial ischaemia 2 to narrowing of the coronary artery. Anxiety; related to diagnosis, pain and anticipation of pain Fear; related to diagnosis, chest pain risk for ineffective mgt. of therapeutic regimen; related to lack of knowledge of medication regimen, adverse drug effects.
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Relief of pain; monitor BP 3-4 hrs. or more frequently when the client complains of dizziness and frequent chest pains.
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Major goals of the patient include a reduction in anxiety, fear, relief of pain, and an understanding of the post- discharge medication regimen.
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Adverse drug rxns; observe pts. Receiving these drugs for headaches, hypotension. Notify the physician for a dose change if necessary Anxiety and fear; reassure the pt. that the medication will relieve the pain and that the physician will be contacted if pain is not relieved.
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Anxiety is reduced Fear is reduced Pt. verbalizes and understanding of treatment modalities ADRs are identified and reported to the physician. Pt. and family demonstrate understanding of drug regimen
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Pain is relieved
Client education
Take sustained-release (SR) form of calcium blockers with food or milk to prevent gastric discomfort. Do not drink alcohol with anti anginal drugs because alcohol acts as a vasodilator and can cause acute BP and extreme dizziness.
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Avoid discontinuing medication abruptly without consulting the health care provider. Notify dentists and other health care providers of medication regimen Schedule regular follow-up appointments with the
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