Drugs for Angina Pectoris & Management of STEMI

What does the nurse instruct a patient, who is prescribed nitroglycerin patches do to prevent the development of tolerance to nitrates?

"Apply the nitroglycerin patch every other day." "Use the nitroglycerin patch for acute episodes of angina only." "Use sublingual nitroglycerin if your systolic blood pressure is 140 mm Hg." "Apply the nitroglycerin patch each day, and remove it for 10 hours at night."- Tolerance can be prevented by maintaining a 10- to 12-hour nitrate-free period each day. Applying the patch every other day will not have the therapeutic effects. Sublingual nitroglycerin is more effective for chest pain. The patch is removed for 10 hours every night, and a new patch is applied in the morning. Sublingual nitroglycerin is administered for treating acute episodes of angina.

The cardiac unit nurse is providing discharge education to a patient with stable angina. The patient has been prescribed nitroglycerin for treatment of the angina. Which statement by the patient indicates an accurate understanding of the education provided?

"I shouldn't take the nitroglycerin for mild chest pain." "It mostly helps by increasing oxygen supply to my heart." "I should call 911 if the chest pain isn't relieved after two doses of nitroglycerin." "The nitroglycerin works mostly on my veins, causing them to open wider."- Nitroglycerin, a nitrate, acts directly on vascular smooth muscle to promote vasodilation and acts predominantly on veins. It should be taken when chest pain begins; the patient should not wait for it to become more severe. The main effect of nitroglycerin is through decreasing cardiac oxygen demand, not increasing oxygen supply. The patient should call 911 after taking one dose of the nitroglycerin.

The nurse is providing discharge teaching for a patient with a new prescription for a nitroglycerin transdermal patch. Which statement by the patient indicates a need for further teaching?

"I will limit my alcohol to one drink per day."- "I will move slowly when changing positions." "I will remove my patch at bedtime each evening." "I will not use sildenafil as long as I am on nitroglycerin." Alcohol can intensify the hypotensive effects of nitrates, so the patient should avoid alcohol. Patients develop tolerance to nitrates rather quickly. Patients receiving transdermal nitrates are recommended to have 10 to 12 hours of patch-free time each evening. Sildenafil and other drugs for erectile dysfunction also can cause significant hypotension with nitroglycerin and are contraindicated. Nitroglycerin causes orthostatic hypotension; therefore, patients should change positions slowly.

A patient is admitted to the emergency department with a diagnosis of ST-segment elevation myocardial infarction (STEMI). Which is the priority nursing action?

"Stop taking the tablets immediately." "These effects will subside over time."- "You should take a lower dose of the drug." "You should get diagnostic testing immediately." Headache and flushing are the most common side effects of nitroglycerin and will subside with continued use. The nurse does not tell the patient to lower the dose because it may not have a therapeutic effect. It may be risky to stop the medication because it may cause withdrawal symptoms. It is not necessary to get diagnostic testing because these are brief side effects of the drug.

The nurse is preparing to administer an intravenous (IV) nitroglycerin infusion. For which patient should the nurse question the health care provider's prescription to administer IV nitroglycerin infusion?

A patient with an inferior wall myocardial infarction (MI) and blood pressure of 170/60 mm Hg A patient with a right ventricular infarction, confirmed by right-sided electrocardiogram changes- A patient with an anterior wall MI who has pulmonary congestion and heart rate of 92 beats/min A patient with chest pain unrelieved by 3 sublingual nitroglycerin tablets and who took tadalafil 4 days ago Nitroglycerin should be avoided in patients with hypotension (systolic blood pressure below 90 mm Hg), severe bradycardia (heart rate below 50 beats/min), marked tachycardia (heart rate above 100 beats/min), or suspected right ventricular infarction. If the patient has taken sildenafil, avanafil, or vardenafil in the past 24 hours or tadalafil in the past 48 hours, nitroglycerin should not be given. According to current guidelines, the patient should receive 3 doses of sublingual nitroglycerin before a continuous infusion is considered. Signs of pulmonary congestion also warrant use of intravenous (IV) nitroglycerin.

What is the most appropriate outcome criteria for a patient who has been prescribed a calcium channel blocker?

Absence of chest pain- Increased cardiac output Systolic blood pressure 140 mm Hg Weight gain in one week greater than or equal to 5 lb The most appropriate outcome criteria when taking a calcium channel blocker is the absence of chest pain. Calcium channel blockers may alter cardiac output, but it is not the most appropriate outcome for the treatment of angina. Calcium channel blockers may decrease blood pressure below 140 mm Hg and do not cause weight gain.

A patient with heart failure and chronic stable angina presents to the provider with complaints that the current treatment, which includes atenolol and sublingual nitroglycerin, is not controlling the anginal pain. Which drug does the nurse anticipate the health care provider will prescribe next to help control the pain?

Aliskerin Nifedipinep- Metoprolol Transdermal nitroglycerin Treatment of anginal pain is approached sequentially. Initially, treatment consists of sublingual nitroglycerine and a beta-blocker, such as atenolol. If that is ineffective, a calcium channel blocker is added. In the case of a patient with heart failure, a dihydropyridine-type calcium channel blocker, such as nifedipine, should be used. Aliskerin is a vasodilator approved only for the treatment of hypertension; it cannot be used to treat angina. Metoprolol is a beta-blocker and would not be an appropriate next step as atenolol has already been ineffective. Transdermal nitroglycerin is used if the calcium channel blocker is inadequate or contraindicated.

Which instruction will be included in the discharge teaching for a patient with a transdermal nitroglycerin patch?

Apply the patch to a hairless, nonfatty area of the upper torso or arm."- "Apply the patch to the same site each day to maintain consistent drug absorption." "If you get a headache, remove the patch for 4 hours and then reapply." "If you experience chest pain, apply a second patch right next to the first patch." A nitroglycerin patch should be applied to a hairless, nonfatty area for the best and most consistent absorption rates. The sites should be rotated to prevent skin irritation. Headache is a brief side effect of the therapy, but it soon diminishes. Nitroglycerin is administered via the sublingual route to relieve chest pain.

Which drug would be contraindicated in the treatment plan for a patient who will undergo a primary percutaneous coronary intervention (PCI)?

Aspirin Heparin Diltiazem- Clopidogrel Diltiazem is not indicated for a patient undergoing primary PCI. All patients undergoing PCI should receive an anticoagulant, such as intravenous heparin or bivalirudin, combined with antiplatelet drugs, such as aspirin, plus either clopidogrel, ticagrelor, or prasugrel.

For all patients undergoing percutaneous coronary intervention (PCI), which drug is recommended to be combined with clopidogrel?

Aspirin- Heparin Alteplase Angiotensin-converting enzyme (ACE) inhibitor In patients undergoing PCI, clopidogrel is used in combination with aspirin to align with the goal of two antiplatelets. Aspirin suppresses platelet aggregation, thereby reducing mortality by reducing the likelihood of reinfarction or stroke. Heparin is an anticoagulant that may be used in addition, but is not considered as use in conjunction with clopidogrel. An ACE inhibitor will be initiated after the completion of PCI. Alteplase is a clot buster that would be used in place of PCI.

Which drugs are included in the treatment plan to minimize possible myocardial necrosis while awaiting definitive diagnosis of ST-elevation myocardial infarction (STEMI)? Select all that apply.

Aspirin- Morphine- Beta-blockers- Nitroglycerine- Nonsteroidal antiinflammatory drugs (NSAIDs) Drugs used to immediately address STEMI before a definitive diagnosis include aspirin to produce an immediate antiplatelet effect; morphine to treat STEMI-associated pain; beta-blockers to reduce cardiac pain, infarct size, and short-term mortality; and nitroglycerin to reduce preload and thereby oxygen demand, increase collateral blood flow in the ischemic region of the heart, control hypertension caused by anxiety, limit infarct size, and improve left ventricular function. NSAIDs should not be used since they can increase the risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture.

A patient receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. The nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's priority action?

Assess the patient's lung sounds. Decrease the intravenous nitroglycerin by 10 mcg/min.- Stop the nitroglycerin infusion for 1 hour and then restart. Continue the infusion and recheck the patient's vital signs in 15 minutes. Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. The patient should be monitored while changing the rate of the intravenous nitroglycerin infusion. Stopping the infusion completely may result in recurrence of the chest pain. Continuing the current infusion rate may further lower the patient's blood pressure. The nurse may also assess the patient's lung sounds; however, that is not the priority.

What does the nurse administer when a patient has a sudden attack of angina?

Atenolol Nifedipine Nitroglycerin- Transdermal nitroglycerin patch Sublingual nitroglycerin works quickly to relieve pain and cause vasodilation during an angina attack. A nitroglycerin transdermal patch has an onset of action of 30 to 60 minutes and may be ineffective in relieving a sudden attack of angina. A calcium channel blocker is used for cerebral artery spasms associated with aneurysm rupture. Atenolol is available only in the oral form and is more effective in patients after myocardial infarction.

What is the primary cause of ischemic heart disease in a patient?

Atherosclerosis- Angina pectoris Coronary artery disease Myocardial infarction (MI) Atherosclerosis is a disease of the coronary arteries that involves fatty plaque deposits in the arterial walls. The disease causes ischemic heart disease in a patient. MI is an acute result of coronary heart disease and of ischemic heart disease. Angina pectoris is chest pain secondary to insufficient supply of blood carrying oxygen to the heart. Coronary artery disease is caused by a decrease in the supply of oxygen to meet the demands of the heart.

Which assessment finding in a patient with cardiac risk factors needs to be reported if the patient is taking a nonselective beta blocker?

Chest pain Weight loss History of asthma- History of alcohol abuse Beta blockers need to be used cautiously in patients who have a history of asthma because the drugs induce bronchoconstriction and increased airway resistance, which may further cause dyspnea and wheezing. Weight loss is not a concern in the patient; instead, weight gain may indicate edema. Beta blockers are effective in the treatment of angina or chest pain. Beta blockers can interact with alcohol and cause adverse effects such as hypotension. However, a history of alcohol abuse is not a concern if the patient no longer engages in such behavior.

Which side effects will the nurse report after administering nitrates? Select all that apply.

Cough Headache- Tachycardia- Contact dermatitis Postural hypotension- Tachycardia and postural hypotension are seen in the patient if the nitrate-induced vasodilation occurs rapidly. It may further result in syncope in the patient. Headache is a brief side effect of the therapy, and it diminishes soon after starting the therapy. Contact dermatitis may occur in response to various topical nitrate dosages, but it is not an emergency. Cough is not a side effect of nitrates.

Which condition will the nurse assess in a patient who takes nitrates on a long-term basis?

Drug toxicity Drug interactions Liver dysfunction Tolerance to the drug's effects- Patients who are on nitrate therapy on a long-term basis are at risk for tolerance to the drug's effects. It is important to assess the patients to understand if the drug is having the desired effect. Drug interactions that may cause hypotension or bradycardia are seen in a patient immediately after taking multiple drugs. Drug toxicity is seen in patients with impaired hepatic function because the drug is not excreted effectively. The drug does not cause liver dysfunction, but if the patient has liver dysfunction, it may result in ineffective excretion of the drug.

The nurse in the emergency department receives a report on a patient diagnosed with ST-elevation myocardial infarction (STEMI). What are the common biochemical markers and symptoms for a STEMI? Select all that apply.

Elevated troponin T level- Decreased troponin I level Weakness and diaphoresis- Elevated creatinine kinase level- Chest pain and electrocardiographic (ECG) -changes Patients experiencing STEMI typically present with chest pain, an elevated ST segment on the ECG, elevated (not decreased) levels of cardiac cell components (eg, troponin and creatinine kinase), sweating, weakness, and a sense of impending doom.

The nurse is monitoring a patient during intravenous (IV) nitroglycerin infusion. Which assessment finding will cause the nurse to take action?

Flushing Headache Chest pain- Blood pressure 110/90 mm Hg The patient should not continue to have chest pain while on IV nitroglycerin. This would prompt the nurse to intervene. Blood pressure of 110/90 mm Hg is not cause for concern and is expected with nitroglycerin. Headache and flushing are common side effects of nitroglycerin.

The nurse is caring for a patient who is receiving enteral feedings because of dysphagia. The health care provider prescribes isosorbide mononitrate 60 mg SR daily via the enteral tube. What is the most appropriate action by the nurse?

Have the patient swallow the pill, because it cannot be crushed. Call the health care provider about an alternative form of nitrate for administration.- Place the nitrate under the patient's tongue and let it dissolve, because the person has dysphagia. Crush the isosorbide mononitrate into a fine powder, dilute it with water, and administer it via the enteral tube. The nurse should contact the prescriber for an alternaive form of nitrate, such as a non-sustained-release pill, transdermal patch, topical ointment, or immediate release. Because isosorbide mononitrate is a sustained-release pill, it cannot be crushed. Because the patient has dysphagia, attempting to administer the pill orally could result in aspiration. Sustained-release tablets must be administered whole.

The nurse should understand that patients receiving nitroglycerin are at risk for which side effects? Select all that apply.

Headache- Wheezing Dizziness- Tachycardia- Bradycardia The primary adverse effects of nitroglycerin are headache; orthostatic hypotension, which can lead to dizziness; and reflex tachycardia. Wheezing and bradycardia are not expected side effects of nitroglycerin.

A phosphodiesterase type 5 inhibitor has been ordered for a patient. Which condition in the patient's history is a contraindication to this medication?

Hypokalemia Hypotension- Dysrhythmias Increased intracranial pressure Phosphodiesterase type 5 inhibitors cause vasodilation, and thus a drop in blood pressure occurs. They are contraindicated in the presence of hypotension. These drugs are not contraindicated in the setting of hypokalemia, dysrhythmias, or increased intracranial pressure.

Which statement by the nursing student about the use of organic nitrates indicates understanding?

Nitrates slow conduction. Nitrates are used for atrial fibrillation. These drugs have no adverse effects. Organic nitrates dilate all blood vessels.- Nitrates dilate all blood vessels because they have a vasodilator effect. They have cardiovascular effects like tachycardia and postural hypotension. The beta blockers slow conduction through the atrioventricular node. Calcium channel blockers are used for the management of atrial fibrillation. All drugs have the potential for adverse effects.

Which form of nitroglycerin is likely to have a large first-pass effect?

Oral- Sublingual Intravenous Transdermal Oral nitroglycerin goes to the liver and is metabolized before it can become active in the body. As a result, a large amount of nitroglycerin is removed from circulation. This is known as a large first-pass effect. Sublingual nitroglycerin has an onset of action of 2 to 3 minutes and is absorbed quickly because the area under the tongue is highly vascular. Transdermal nitroglycerin has an onset of action of 30 to 60 minutes. It is used for long-term management of angina pectoris because it allows for the continuous, slow delivery of nitroglycerin. Intravenous nitroglycerin is quickly absorbed in the blood and has an onset of action of 1 to 2 minutes.

Which medication combination is useful in the treatment of variant angina?

Propranolol and diltiazem Metoprolol and ranolazine Isosorbide dinitrate and metoprolol Diltiazem and isosorbide mononitrate- Variant angina, also known as Prinzmetal's or vasospastic angina , is a result of coronary artery vasospasm. Drug combinations used to prevent and/or relax the coronary artery are calcium channel blockers (eg, diltiazem) and organic nitrates (eg, isosorbide mononitrate). Beta blockers (metoprolol and propranolol) and ranolazine, although effective for stable angina, are ineffective for treating variant angina.

A patient is receiving isosorbide dinitrate 20 mg 3 times per day for management of newly diagnosed stable angina. Which assessment finding would require an immediate nursing intervention?

Report of increased frequency of urination A change in blood pressure from 122/70 to 108/66 mm Hg A headache the patient rates as a 5 on a pain scale of 0 to 10 An increase in the resting heart rate to 110 beats/min from baseline rate of 72 beats/min- Because nitrates lower blood pressure, isosorbide dinitrate can activate the baroreceptor reflex, causing sympathetic stimulation of the heart; this negates the benefits of treatment with nitrates because it increases the cardiac oxygen demand. For these reasons, addressing the tachycardia becomes the nurse's immediate priority. A decrease in blood pressure would be expected, and there is no indication the patient is experiencing side effects of decreased cardiac output. Headache is an adverse effect and should be treated (eg, with acetaminophen), but it does not require immediate intervention. Increased frequency of urination requires follow-up, but it is not the immediate concern.

The home health nurse observes the patient for proper use of topical nitroglycerin ointment. Which action by the patient indicates the need for further teaching?

Rotates the application sites to minimize skin irritation Uses the applicator paper to measure the prescribed dose Removes ointment from a previous dose before applying the next dose Applies the prescribed ribbon of ointment to the applicator paper and always places it over the heart- Once the prescribed ribbon of ointment has been squeezed onto the applicator paper provided, the paper is used to spread the ointment over an area at least 2.5 by 3.5 inches. It is then covered with plastic wrap to prevent the ointment from being absorbed into the clothing. There is no mechanistic advantage to applying the ointment over the heart. The ointment can be applied to the back, abdomen, or anterior thigh, as well as the chest. Sites should be rotated to minimize skin irritation.

Which are the main types of drugs used to prevent or relieve anginal pain? Select all that apply.

Statins Nitrates- Beta blockers- Platelet inhibitors Calcium channel blockers- The three main types of antianginal drugs are beta blockers, organic nitrates, and calcium channel blockers. Platelet inhibitors and statins (unless contraindicated) are incorporated into the treatment plan to reduce the risk of myocardial infarction and atherosclerosis.

A patient has not had relief from angina using beta blockers, calcium channel blockers (CCBs), and nitrates. What is the patient's next choice?

Take daily acetaminophen. Start antidysrhythmic medications. Add opioids to the medication regimen. Assess the need for coronary artery bypass grafting (CABG).- If combined treatment with a beta blocker, CCBs, and long-acting nitrate fails to provide relief, CABG surgery or percutaneous coronary intervention may be indicated. Note that these invasive procedures should be considered only after more conservative treatment has been tried. Acetaminophen, antidysrhythmic medications, and opioids will not correct the underlying problem associated with angina, which is blockage of the coronary arteries.

An elderly patient experiences chest pain every day at the same time without any physical activity or stress factors. What action does the nurse take?

Takes blood pressure and pulse Measures the patient's height and weight Obtains an order for electrocardiogram (ECG)- Administers nitroglycerin to the patient If the chest pain occurs at the same time of day, it may indicate vasospastic angina. It results from spasms in the layer of smooth muscle that surrounds atherosclerotic coronary arteries. Vasospastic angina does not have any precipitating cause and occurs even when the patient is at rest. The condition is confirmed by the changes in the ECG reports accompanied by dysrhythmias. Intravenous nitroglycerin is administered to patients during an acute angina episode. The nurse may take blood pressure and pulse readings to assess the change in the vital signs, but it may not help the nurse understand the cause of the chest pain. The nurse needs to measure the patient's height and weight before starting nitroglycerin therapy.

Which condition indicates a need for administering acetaminophen to a patient who is on nitroglycerin therapy?

The patient feels dizzy. The patient has a headache.- The patient has drug-induced fever. The patient has drug-induced cough. Acetaminophen is administered to a patient for drug-induced headache. Dizziness is caused by drug-induced hypotension, which can be prevented by asking the patient to turn slowly. Acetaminophen is indicated for cough and fever, but nitroglycerin does not cause cough or fever in the patient.

Which are types of chest pain? Select all that apply.

Unstable angina- Hypotensive angina Vasospastic angina- Chronic stable angina- Nitrate-induced angina Chronic stable angina is a type of chest pain that is caused by atherosclerosis. It is triggered by exertion or stress. Unstable angina occurs in the early stages of coronary heart disease and ends in a myocardial infarction. Vasospastic angina occurs as a result of spasms of the coronary arteries. These three are the only types of chest pain.

The nurse understands that ventricular fibrillation is a common cause of death after myocardial infarction (MI). Which drug should be readily available to treat ventricular fibrillation?

Valsartan Dobutamine Propranolol Amiodarone- The priority treatment of ventricular fibrillation involves defibrillation, followed by intravenous amiodarone infusion for 24 to 48 hours. The other agents may be used in the treatment of a patient with MI, but amiodarone is the specific agent used to treat ventricular fibrillation.

The nurse is caring for a patient receiving nitrates for relief of angina. Which pharmacodynamic action is responsible for the relief of anginal pain with nitrates?

Vasoconstriction leads to improved cardiac output. Decreased force of contraction leads to decreased oxygen demand. Influx of calcium ions leads to relaxation of vascular smooth muscle. Vasodilation leads to decreased preload, which decreases oxygen demand.- The primary action of nitroglycerin is vasodilation (not vasoconstriction), which leads to decreased venous return, decreased ventricular filling, and decreased preload, thus reducing oxygen demand on the heart. Nitroglycerin does not alter contractile force or calcium ions.