Karch Focus on Pharmacology Chapter 46- Antianginal Agents

A group of students are reviewing the various antianginal agents. The students demonstrate a need for additional review when they identify what as a beta blocker? Propranolol Isosorbide Metoprolol Nadolol

Isosorbide Isosorbide is a nitrate. Metoprolol is a beta blocker. Nadolol is a beta blocker. Propranolol is a beta blocker.

A patient arrives at the community health care center reporting chest pain and is diagnosed with angina pectoris. Which drug is administered for treating angina? Isospin Cilostazol Nicardipine Papaverine

Nicardipine Nicardipine is the drug used in the treatment of angina. Nicardipine is a calcium channel blocker used as an anti-anginal drug. -Isospin, papaverine, and cilostazol are peripheral vasodilating drugs used in the treatment of peripheral vascular diseases.

A patient arrives at the community health care center reporting chest pain and is diagnosed with angina pectoris. Which drug is administered for treating angina? Isospin Nicardipine Cilostazol Papaverine

Nicardipine Nicardipine is the drug used in the treatment of angina. Nicardipine is a calcium channel blocker used as an anti-anginal drug. -Isospin, papaverine, and cilostazol are peripheral vasodilating drugs used in the treatment of peripheral vascular diseases.

Classifications of antianginal agents include

Nitrates (organic) Beta Blockers Calcium Channel Blockers

For relief of acute angina and for prophylaxis before events that cause acute angina, what is the primary drug of choice?

Nitroglycerin For relief of acute angina and for prophylaxis before events that cause acute angina, nitroglycerin (sublingual tablets or translingual spray) is usually the primary drug of choice.

A nurse is giving discharge instructions to a client receiving nitroglycerin for angina. The nurse recognizes the client needs additional information when the client makes what statement? "I may get a headache after I take this medication." "I will take a pill every 15 minutes until the pain subsides." "Before I take my medication, I will lie down." "I will keep my medication in the original container."

"I will take a pill every 15 minutes until the pain subsidies." When experiencing angina, the client may take one pill every five minutes times three doses. Nitroglycerin needs to be stored in its original dark container and may cause a headache. It is important the client lie down prior to taking nitroglycerin because it may cause hypotension.

A 52-year-old client who experienced a myocardial infarction has an order for discharge. Part of the discharge teaching includes prior administration of nitroglycerin for chest pain. Which statement by the client indicates understanding of the teaching provided? "I will take three tables every 5 minutes until the chest pain subsides." "I will take one tablet and lay down for an hour." "I will take three nitroglycerin tablets 5 minutes apart, and if I do not have any relief I will seek emergency care immediately." "I will take two nitroglycerin tablets 15 minutes apart, and if I do not have any relief I will contact my health care provider."

"I will take three nitroglycerin tablets 5 minutes apart, and if I do not have any relief I will seek emergency care immediately." The client with stable or unstable angina will be prescribed sublingual nitroglycerin to relieve chest pain symptoms. The client may take up to three tablets of sublingual nitroglycerin 5 minutes apart. If the chest pain is unrelieved, the client needs to seek emergency medical care immediately.

A client, diagnosed with erectile dysfunction, is taking nitroglycerin for chest pain. What is the best explanation for why a nitrate-like sildenafil would be contraindicated? "Nitroglycerin decreases the effect of sildenafil for erectile dysfunction." "Nitroglycerin and sildenafil can lead to prostate cancer." "Nitroglycerin and sildenafil will diminish the effectiveness of chest pain relief." "Nitroglycerin and sildenafil cause a severe decrease in blood pressure."

"Nitroglycerin and slidenafil cause a severe decrease in blood pressure." Nitrates and phosphodiesterase enzyme type 5 inhibitors like sildenafil decrease blood pressure, and the combined effect can produce profound, life-threatening hypotension. None of the remaining options are accurate statements regarding sildenafil.

A male patient who uses sublingual nitroglycerin tells the nurse that when he puts it under his tongue, he feels a fizzing sensation. Which response by the nurse would be most appropriate? "You might have an irritation that's causing this." "That's a normal report we hear." "That means that the drug is still potent and working." "You need a new supply because the drug has deteriorated."

"That means that the drug is still potent and working." Fizzing indicates potency, not irritation or deterioration.

A client is diagnosed with erectile dysfunction. He asks what effect sildenafil (Viagra) has because he is taking nitroglycerin for chest pain. What is the best explanation for why nitrates are contraindicated with sildenafil? "Nitroglycerine decreases the effect of sildenafil for erectile dysfunction." "Taking the drugs together can lead to prostate cancer." "Nitroglycerine and sildenafil will diminish the effectiveness of chest pain relief." "The combination can cause a severe decrease in blood pressure."

"The combination can cause a severe decrease in blood pressure." Nitrates and phosphodiesterase enzyme type 5 inhibitors decrease blood pressure, and the combined effect can produce profound, life-threatening hypotension. The other options do not accurately describe the risk posed by concurrent use of the two medications.

A client is diagnosed with angina pectoris. What would the nurse include when explaining this condition to the client? "The heart muscle has grown larger to compensate." "The arteries are narrowed due to fatty deposits." "The heart muscle isn't getting enough oxygen." "The heart muscle has become damaged due to blocked blood flow."

"The heart muscle isn't getting enough oxygen." The body's response to a lack of oxygen in the heart muscle is pain, which is called angina. The narrowing of arteries due to fatty deposits is called atherosclerosis. -Although left ventricular enlargement may occur with coronary artery disease, it is not the underlying mechanism involved with angina. -Damage to the heart muscle in response to ischemia is called a myocardial infarction.

The nurse is caring for a male client with a history of hypertension and Prinzmetal angina who is currently taking amlodipine 10 mg orally every day, and minoxidil 25 mg orally twice a day. The client stated that he is concerned about a recent enlargement of his breasts. What is the best therapeutic response to the client's concern? "You have a history of severe hypertension, and unfortunately, you have to stay on the medications prescribed, so you may try wearing lose clothing." "Don't worry, this is an expected side effect of minoxidil, and it is hardly noticeable, and your blood pressure is stable with the meds." "If you lose some weight, it will help your blood pressure and decrease the breast size, and you will feel much better about how you look." "The increase in breast size is an adverse effect of minoxidil, and I will notify your primary care provider so other options may be explored."

"The increase in breast size is an adverse effect of minoxidil, and I will notify your primary care provider so other options may be explored." The best therapeutic response is factual and involves action to help the client. Telling a client to not worry and that the breasts are hardly noticeable is nontherapeutic and patronizing. It is incorrect to tell the client he must stay on the prescribed meds because there are other drugs in the same categories available that do not lead to gynecomastia. Telling the client that he needs to lose weight to help his blood pressure and decrease the breast size is blaming the client for the situation.

The client tells the nurse he does not like taking his prescription isosorbide because it makes him feel weak, dizzy, flushed, and he gets a severe headache. What is the nurse's best response? "You are experiencing severe reactions and the medication needs to be stopped immediately." "It is important to take your medications no matter how badly they make you feel." "With time, these adverse reactions often subside." "Your physician may need to change your medications."

"With time, these adverse effects often subside." Adverse reactions such as headache, flushing, and postural hypotension that are seen with the administration of the antianginal drugs often become less severe, or even disappear, after a period of time. The client should continue to take the medication.

Angina pectoris (chest pain)

"suffocation of the chest"; pain caused by the imbalance between oxygen being supplied to the heart muscle and demand for oxygen by the heart muscle

A client may administer a maximum of how many doses of sublingual nitroglycerin in a 15-minute period? 4 3 1 2

3 A client may administer a maximum of 3 doses of sublingual nitroglycerin in a 15- minute period.

A 75-year-old client is being treated for type 2 diabetes, hypertension, gout, angina, coronary artery disease, and peptic ulcer disease. The nurse is concerned because the client is taking a traditional antianginal drug in combination with seven other medications. The nurse understands that what could be the consequence? Decreased effectiveness of the antihypertensive A greater incidence of adverse drug effects A greater incidence of hyperglycemic episodes Decreased effectiveness of the antianginal drug

A greater incidence of adverse drug effects Traditional antianginal drugs that act via hemodynamic mechanisms (e.g., beta-blockers, calcium antagonists, nitrates) can pose a problem in older adults because of the associated higher risk of drug interactions and greater incidence of adverse drug effects.

The nurse is providing education to a client who has been prescribed nitroglycerin transdermal spray. What instruction should the nurse provide the client concerning how to administer the spray? Administer the spray as soon as chest pain develops. Administer the spray if the angina pain is unrelieved by 30 minutes of rest. Administer the spray after consulting with the health care provider or a nurse. Do not administer more than one dose.

Administer the spray as soon as chest pain develops Administration transdermal spray is essential as soon as chest pain develops. -It is unnecessary and inappropriate to delay administration. -The client can administer as many as three doses.

The physician is considering prescribing a beta blocker for a patient who is experiencing angina. For which condition should the patient be assessed before the physician orders the medication? Chronic obstructive pulmonary disease (COPD) Asthma Diabetes All the above

All of the above Beta blockers should be used with caution in patients with diabetes, peripheral vascular disease, asthma, COPD, or thyrotoxicosis because the drugs' blockade of the sympathetic response blocks normal reflexes that are necessary for maintaining homeostasis in patients with these diseases. Many patients with these complicating disorders receive beta-blockers, and these patients need to be monitored carefully to avoid serious adverse effects.

A client reports substernal chest pain that radiates to the neck. The pain lasts 5 minutes and then subsides with relaxation. What is the most likely cause of the chest pain? Angina pectoris Myocardial infarction Intermittent claudication Hypertension

Angina pectoris Classic angina pain related to angina pectoris is substernal chest pain that can radiate to the jaw. Chest pain that lasts longer than 5 minutes is not associated with angina but is associated with myocardial infarction. Hypertension is usually a condition in which the client is pain free. Intermittent claudication is not associated with chest pain.

What is the primary purpose of antianginal agents?

Antianginal agents are used to help restore the appropriate supply-and-demand ratio in oxygen delivery to the myocardium.

Following the administration of a scheduled dose of 50-mg atenolol PO, the nurse should prioritize what assessment? Oxygen saturation levels Blood pressure Level of consciousness (LOC) Oral temperature

Blood pressure Atenolol and other beta-blockers have an antihypertensive effect, making the monitoring of blood pressure a priority. -They are unlikely to affect temperature, LOC, or oxygen saturation levels.

When caring for a patient with angina, the nurse instructs the patient to place the nitroglycerin tablet between the cheek and the gums. Which route of administration is the nurse referring to? Translingual Sublingual Transdermal Buccal

Buccal

The 47-year-old client is experiencing chest pain and has taken three sublingual nitroglycerin tablets, but the pain remains. What should the client do next? Notify his healthcare provider. Call 911. Take another nitroglycerin and call 911. Have someone take him to the emergency department.

Call 911 Nitroglycerin should be administered every five minutes, times three doses. If the pain persists, 911 or the emergency system should be activated. The client should not take additional medication. It is not safe to be transported by private car having chest pain.

After teaching a group of students about angina, the instructor determines that the teaching was successful when the students describe stable angina as: Chest pain that is relieved by rest Chest pain that occurs with coronary artery disease Chest pain that occurs at rest Chest pain that occurs due to vasospasm

Chest pain that is relieved by rest Stable angina is characterized as chest pain that is relieved with rest. -Unstable angina is chest pain that occurs at rest. -Prinzmetal angina is chest pain that results from vasospasm. -Chest pain is associated with coronary artery disease due to a supply and demand problem.

A patient has been prescribed a beta-adrenergic blocker to help control angina. What effect might the patient experience as a result of the drug therapy? Increased oxygen consumption Increased heart rate Increased blood pressure Decreased cardiac output

Decreased cardiac output Beta-adrenergic blockers reduce heart rate, cardiac output, and blood pressure. This reduces the heart's oxygen demand, which in turn decreases angina.

Beta-adrenergic blocking agents decrease the oxygen demands of the heart by what mechanism? Increasing blood pressure, which increases the amount of blood returned to the heart Decreasing the heart rate, allowing for longer filling time and increased blood to the heart Increasing conduction to the atrioventricular node, thereby increasing cardiac output Increasing cardiac output, thereby increasing the oxygen supplied to the heart

Decreasing the heart rate, allowing for longer filling time and increased blood to the heart Beta-blockers prevent the beta-adrenergic receptors from being stimulated. These drugs have multiple effects on the heart and cardiovascular system, including slowing the heart rate, depressing atrioventricular (AV) conduction, decreasing cardiac output, and reducing systolic and diastolic blood pressure at rest and during exercise. These effects decrease the oxygen demands of the heart and thereby decrease angina.

A male client does not respond to traditional treatment for his chronic angina. The health care provider orders ranolazine (Ranexa) and orders a baseline ECG prior to medication administration. Three months later, the health care provider orders a repeat ECG. For what reason is the provider monitoring the client? Dose-dependent QT prolongation Dose-dependent ST elevation Dose-dependent ectopic beats Dose-dependent premature ventricular beats

Dose-dependent QT prolongation Ranolazine (Ranexa) represents a new classification of antianginal medication, metabolic modulators, used in people with chronic angina. The drug is labeled for use in combination with amlodipine, beta-blockers, or nitrates. After oral administration, peak plasma concentrations are reached within 2 to 5 hours. The drug is rapidly and extensively metabolized in the liver. Because of a risk of dose-dependent QT prolongation on electrocardiogram, ranolazine is reserved for the treatment of clients with chronic angina who have not achieved a satisfactory antianginal response with traditional drugs.

When a nurse is obtaining a history from a client regarding anginal pain, what information should be included? Select all that apply. Description of the pain Duration of the pain Events that relieve anginal pain Whether the pain radiates Events that trigger anginal pain

Duration of the pain Events that relieve anginal pain Events that trigger anginal pain Description of the pain Whether the pain radiates

The client is taking a calcium-channel blocker. What adverse effects might the client experience? Palpitations and tingling of extremities Fever and bronchospasm Headache and dizziness Hypertension and tachycardia

Headache and dizziness Adverse effects of calcium channel blockers include hypotension, headache, dizziness, lightheadedness, weakness, edema, nausea, and constipation.

A nurse is caring for a 59-year-old client who has been prescribed nitroglycerin to control angina. Which adverse effect might the nurse observe in this client? Hypotension Renal insufficiency Hypokalemia Sedation

Hypotension Adverse effects of nitroglycerin include hypotension, dizziness, lightheadedness, palpitations, and headache. Adverse reactions of nitroglycerine do not include hypokalemia, renal insufficiency or sedation.

A nurse is caring for a 59-year-old client who has been prescribed nitroglycerin to control angina. Which adverse effect might the nurse observe in this client? Renal insufficiency Hypokalemia Sedation Hypotension

Hypotension Adverse effects of nitroglycerin include hypotension, dizziness, lightheadedness, palpitations, and headache. Adverse reactions of nitroglycerine do not include hypokalemia, renal insufficiency or sedation.

A client taking amlodipine (Norvasc) is having chest pain and is ordered sublingual nitroglycerin. The nurse evaluates the client for: Hyperkalemia Hypotension Hypertension Hypokalemia

Hypotension When combined, nitrates and calcium channel blockers can cause symptomatic orthostatic hypotension.

A client with a history of angina has sustained a mild head injury in a motor vehicle accident. When the client reports chest pain, what explanation should the nurse provide to support the decision not to treat the angina-related pain with nitroglycerin tablets? Nitroglycerin will increase intracranial pressure. Nitroglycerin will raise the client's blood pressure. Nitroglycerin will decrease blood glucose. Nitroglycerin will cause decreased cerebral edema.

Nitroglycerin will raise intracranial pressure Nitroglycerin should be used cautiously in the presence of a head injury or cerebral hemorrhage because it may increase intracranial pressure. Nitroglycerin will lower blood pressure. Nitroglycerin can increase cerebral edema. Nitroglycerin does not have a direct effect on blood glucose.

A patient is using propranolol for treatment of angina. The nurse understands that this drug is administered by which route? Intravenous Transdermal Oral Sublingual

Oral

Anti-anginal drugs are used in the treatment of cardiac disease for what purposes? (Select all that apply.) Increase high-density lipoproteins (HDL). Treatment chronic stable angina pectoris. Prevent angina attacks. Decrease serum triglyceride. Relieve the pain of acute anginal attacks.

Relieve the pain of acute anginal attacks. Prevent angina attacks Treatment chronic stable angina pectoris

The nurse would avoid administering nitrates to clients using which medication? Sildenafil Lisinopril Simvastatin Albuterol

Sildenafil Clients taking phosphodiesterase inhibitors (erectile dysfunction drugs), such as sildenafil, should not use nitrates. -Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. -Simvastatin is an HMG-CoA reductase inhibitor known as a statin used to lower cholesterol and triglycerides. -Albuterol is a bronchodilator used in the treatment of asthma to open airways to the lungs.

Which statement correctly distinguishes between the therapeutic effects of sublingual isosorbide and sublingual nitroglycerin? Sublingual isosorbide has a slower onset and a longer duration of action than sublingual nitroglycerin. Sublingual isosorbide has a lesser sustained effect than sublingual nitroglycerin. Sublingual isosorbide has a faster onset and a shorter duration of action than sublingual nitroglycerin. Sublingual isosorbide is not as effective as sublingual nitroglycerin.

Sublingual isosorbide has a slower onset and a longer duration of action than sublingual nitroglycerin. Sublingual isosorbide has a slower onset and a longer duration of action than sublingual nitroglycerin. Because sublingual isosorbide does not relieve chest pain as rapidly as nitroglycerin, isosorbide is limited to treating acute angina in patients intolerant of or unresponsive to sublingual nitroglycerin. -Although nitroglycerin may be used occasionally, with adequate monitoring during the early phases of acute MI, isosorbide should never be used, because of its greater sustained effects.

A recent episode of chest pain while doing yard work prompted a 70-year-old man to seek care and he has been subsequently diagnosed with chronic stable angina. The nurse should recognize what guiding principle in the treatment of this client's angina? The client indicates a need for daily low-molecular weight heparin therapy The client will likely have a trial of antiplatelet drugs before being prescribed nitrates. The client would benefit from a weekly intravenous dose of a beta blocker. The client's angina may necessitate the use of a calcium channel blocker.

The client's angina may necessitate the use of a calcium channel blocker. Calcium channel blockers are used in chronic stable angina when the client cannot tolerate beta blockers, or if the symptoms are not adequately controlled while on this therapy. -Regularly scheduled beta blockers are not administered intravenously. -Low molecular weight heparin is not typically used in the treatment of stable angina, and antiplatelet medications do not need to precede the use of nitrates.

A client experiences pain in the chest that radiates to the jaw, occurring when the client is at rest. The nurse would interpret this as: Unstable angina Myocardial infarction Stable angina Prinzmetal angina

Unstable angina Unstable angina is chest pain that occurs when the client is at rest. -Stable angina is chest pain that occurs with activity and is relieved by rest. -Prinzmetal angina is chest pain due to vessel spasm. -Myocardial infarction indicates ischemia and subsequent necrosis of the heart muscle.

Coronary artery disease (CAD)

characterized by progressive narrowing of coronary arteries, leading to a decreased delivery of oxygen to cardiac muscle cells; leading killer of adults in the Western world

Prinzmetal angina

drop in blood flow through the coronary arteries caused by a vasospasm in the artery, not by atherosclerosis

Nitrates

drugs used to cause direct relaxation of smooth muscle leading to vasodilation and decreased venous return to the heart with decreased resistance to blood flow; this rapidly decreases oxygen demand in the heart and can restore the balance between blood delivered and blood needed in the heart muscle of patients with angina

Myocardial infarction (MI)

end result of vessel blockage in the heart; leads to ischemia and then necrosis of the area cut off from the blood supply; dead cells replaced by scar tissue

Unstable angina

episode of myocardial ischemia with pain due to the imbalance of myocardial oxygen supply and demand when the person is at rest and/or unpredictable times

When prescribed for angina, how does oral nifedipine achieve a therapeutic effect? inhibiting the influx of calcium through slow channels. binding extracellular sodium ions with chloride ions preventing the outflow of intracellular potassium potentiating the effect of B-type natriuretic peptide

inhibiting the influx of calcium through slow channels. Nifedipine inhibits the influx of calcium entering through slow channels, producing vasodilation of the peripheral blood vessels and coronary arteries.

Atherosclerosis

narrowing of the arteries caused by buildup of atheromas, swelling, and accumulation of platelets; leads to a loss of elasticity and responsiveness to normal stimuli

Stable angina

pain due to the imbalance of myocardial oxygen supply and demand; the pain is relieved by rest or stoppage of activity

Atheroma

plaque in the endothelial lining of arteries; contains fats, blood cells, lipids, inflammatory agents, and platelets; leads to narrowing of the lumen of the artery, stiffening of the artery, and loss of distensibility and responsiveness

Several forms of nitroglycerin have been developed to relieve acute angina pectoris, prevent exercise-induced angina, and decrease anginal episodes in frequency and severity. What characteristic(s) of nitrate therapy can contribute to the ineffectiveness of the medication when prescribed via the oral route? Select all that apply. delayed pain relief slow onset of action large doses reaching systemic circulation rapid metabolism by the liver short duration of action

slow onset of action delayed pain relief rapid metabolism by the liver Oral dosage forms are rapidly metabolized in the liver, and only relatively small proportions of doses reach the systemic circulation. In addition, oral doses act slowly and do not help relieve acute chest pain. The duration of action is 4 to 8 hours.

Pulse pressure

the systolic blood pressure minus the diastolic blood pressure; reflects the filling pressure of the coronary arteries