Chapter 23 "Antianginal Drugs" NEW

Angina pectoris

Chest pain that occurs when the heart's supply of blood carrying oxygen is insufficient to meet the demands of the heart.

Nitro-Bid IV

IV formulation. Use glass bottle and special tubing (comes with medication). Titrate the dose to desired response (initially 5 mcg/min). Continuous infusion, always on the pump.

The overall goal of antianginal drug therapy is to-

Increase blood flow to the ischemic myocardium, decrease myocardial oxygen demand, or both.

Which of the following describes a rationale for the administration of nitroglycerin by the sublingual route? A. The first pass effect is avoided. B. Side effects are lessened. C. Patients can self-administer. D. It can be used in patients with swallowing problems.

A. The first pass effect is avoided.

Adverse effects of Nitrates/Nitrites

(Usually diminish with use) Headache** Orthostatic hypotension Reflex tachycardia Dizziness/syncope

Types of angina

*Chronic stable angina*- A chronic narrowing usually caused by atherosclerosis: occurs with predictable stress of exertion; also called exertional angina — angina triggered by physical exercise, nicotine, caffeine; usually subsides within 15 minutes. *Unstable angina*- Acute, can be triggered by a rupture of a coronary artery; can end in an MI; pain may occur at rest. *Vasospastic angina (Prinzmetal)*- coronary artery vasospasm; can occur at rest and without a precipitating factor; also called *variant angina*.

Indications and Contraindications for use of Beta blockers

*Indications*- exertional (exercise induced) angina (not used to treat acute angina). Also used to treat MI, hypertension, cardiac dysrhythmias, and essential tremor. *Contraindications*- acute heart failure, heart block. *Cautious use in patients with*- diabetes mellitus, heart failure, AV block.

Patients who are taking beta blockers for angina need to be taught which information? A. These drugs are for long-term prevention of angina episodes. B. These drugs must be taken as soon as angina pain occurs. C. These drugs will be discontinued if dizziness is experienced. D. These drugs need to be carried with the patient at all times in case angina occurs.

A. These drugs are for long-term prevention of angina episodes.

Patient teaching for Nitroglycerin

1. Keep a journal of angina attacks and triggers. 2. Never crush or chew extended release tablets. 3. How to store sublingual (SL) Nitroglycerin- keep in its original amber-colored glass container with metal lid to avoid loss of potency from exposure to heat, light, moisture, and cotton filler. 4. After taking SL nitro, patient should feel a burning or stinging sensation, if not then the drug has lost its potency. 5. Avoid alcohol and hot conditions. 6. Include nitro free periods. 7. Always keep a fresh supply (drug is potent for 3-6 months).

What is the purpose of antianginal drugs?

1. Minimize the frequency of attacks 2. Improve the patient's functional capacity 3. Prevent or delay MI

What are the three types of antianginal drugs?

1. Nitrates (Nitroglycerin) 2. Beta blockers (Atenolol, Metoprolol) 3. Calcium channel blockers (Diltiazem, Amlodipine)

Adverse effects of Beta blockers

- bradycardia - decreased cardiac output (decreased contractility) - decreased conduction - bronchoconstriction - hypoglycemia *Black box alert*- rebound cardiac excitability if abruptly d/c.

Nitrate contraindications:

-Severe anemia (not enough blood) -closed angle glaucoma -Hypotension -Severe head injury -Use of erectile dysfunction drugs

Three main therapeutic objectives of antianginal drugs-

1) Minimize the frequency of attacks and decrease the duration and intensity of the anginal pain. 2) Improve the patient's functional capacity with as few adverse effects as possible. 3) Prevent or delay the worst possible outcome: myocardial infarction.

Beta Blockers "olol's" drug Indication:

1. Angina, esp. exertional angina 2. MI, hypertension, cardiac dysrhythmias

Beta Blockers "olol's" drugs:

1. Atenolol 2. Metoprolol

Nitrate adverse effects:

1. Headaches (most common; can take tylenol) 2. Tachycardia 3. Postural hypotension 4. Topical nitrate- contact dermatitis 5. Tolerance

Name the three types of nitrates:

1. Nitroglycerin (rapid and long acting) 2. Isosorbide dinitrate (rapid and long acting) 3. Isosorbide mononitrate (long acting)

Three types of angina:

1. chronic stable angina 2. Unstable angina (doesn't go away=>MI) 3. vasospastic angina

When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."

ANS: A Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 374 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's

ANS: A Classic, or chronic stable, angina is triggered by either exertion or stress and usually subsides within 15 minutes with either rest or drug therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 363 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4 (The patient taking nitroglycerin should expect the therapeutic effect of absence of chest pain. It is unrealistic to expect that the patient's blood pressure, heart rate, and ECG will all be in completely normal range since variations in blood pressure and heart rate will occur as part of daily life and the patient may have some underlying cardiac disease that is producing the angina. )

A nurse is monitoring a patient with angina for therapeutic effects of nitroglycerin (Nitrostat). Which assessment finding indicates that the nitroglycerin has been effective? 1 Blood pressure of 120/80 mm Hg 2 Heart rate of 70 beats per minute 3 Electrocardiogram (ECG) without evidence of ST changes 4 Patient stating that pain is 0 out of 10

2 (Sildenafil (Viagra) can cause blood pressure to fall when administered with a nitrate such as isosorbide mononitrate (Imdur); therefore, these medications should not be prescribed concurrently. The nurse should question this prescription with the health care provider to ensure the patient's safety. Coadministering sildenafil and isosorbide mononitrate does not increase blood pressure, increase the risk for hypoglycemia, or increase the risk for increased intraocular pressure. )

A patient who has erectile dysfunction (ED) is prescribed sildenafil (Viagra). The nurse notes that the patient is also prescribed isosorbide mononitrate (Imdur). Which complication should the nurse expect if these drugs are coadministered? 1 Increased blood pressure 2 Increased risk for hypotension 3 Increased risk for hypoglycemia 4 Increased risk for increased intraocular pressure

Which statement by the patient reflects the need for *additional* patient education about the calcium channel blocker diltiazem (Cardizem)? A. "I can take this drug to stop an attack of angina." B. "I understand that food and antacids alter the absorption of this oral drug." C. "When the long-acting forms are taken, the drug cannot be crushed." D. "This drug may cause my blood pressure to drop, so I need to be careful when getting up."

A. "I can take this drug to stop an attack of angina."

The nurse is reviewing drug interactions with a male patient who has a prescription for isosorbide dinitrate (Isordil) as treatment for angina symptoms. Which substances listed below could potentially result in a drug interaction? (Select all that apply) A. A glass of wine B. Thyroid replacement hormone C. Tadalafil (Cialis), an erectile dysfunction drug. D. Metformin (Glucophage), an antidiabetic drug. E. Carvedilol (Coreg), a beta blocker.

A. A glass of wine C. Tadalafil (Cialis), an erectile dysfunction drug. E. Carvedilol (Coreg), a beta blocker.

During his morning walk, a man begins to experience chest pain. He sits down and takes one nitroglycerin sublingual tablet. After 5 minutes, the chest pain is worsening. What action would be the priority in this situation? A. Call 911 (emergency medical services) B. Take another nitroglycerin tablet. C. Take two more nitroglycerin tablets at the same time. D. Sit quietly to wait for the pain to subside.

A. Call 911 (emergency medical services)

The nurse is reviewing dosage forms of nitroglycerin (Nitrostat). This drug can be given by which routes? (Select all that apply) A. Continuous intravenous drip B. Intravenous bolus C. Sublingual spray D. Oral dosage forms E. Topical ointment F. Rectal suppository

A. Continuous intravenous drip C. Sublingual spray D. Oral dosage forms E. Topical ointment

The nurse would recognize which of the following symptoms as descriptive of a side effects of nitrates? A. Reflex tachycardia B. Hypertension C. Nausea D. Cough

A. Reflex tachycardia

Nitrate interactions:

Anti-hypotensive drugs (tans, prils) [additive effect] Sildenifil, tadalafil, and vardenafil (can cause severe hypotension)

A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago

ANS: A Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 364 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.

ANS: A, C, E, G With sublingual forms, the medication is taken at the first sign of chest pain, not delayed until the pain is severe. The patient needs to sit down or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. Placing a tablet between the gum and cheek is the buccal route. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) a. Type 2 diabetes mellitus b. Prolonged QT interval on the electrocardiogram c. Heart failure d. Closed-angle glaucoma e. Decreased liver function

ANS: B, E Ranolazine is contraindicated in patients with pre-existing QT prolongation or hepatic impairment. The other options are not contraindications. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 370 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.

ANS: C According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough

ANS: C Adverse effects of beta blockers include bradycardia, hypotension, dizziness, lethargy, impotence, and several other effects, but not dry cough or nervousness. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.

ANS: C The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise

ANS: C Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 366 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."

ANS: D Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.

ANS: D Constipation is a common effect of CCBs, and a high-fiber diet and plenty of fluids will help to prevent it. Grapefruit juice decreases the metabolism of CCBs. Extended-release tablets must never be chewed or crushed. These medications should never be discontinued abruptly because of the risk for rebound hypertension. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.

ANS: D The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care

What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.

ANS: D To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 365 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

Mechanism of action of Nitrates/Nitrites

Acts directly on vascular smooth muscle. Dilates veins and arteries (primarily veins) which will reduce preload. Can also directly dilate coronary arteries.

Interactions with Nitrates/Nitrites

Alcohol Anti-hypertensives Erectile dysfunction drugs

Indications for use of Nitrates/Nitrites

All forms of angina (stable, unstable, vasospastic). Long-acting forms are used for prophylaxis (prevention) Rapid-acting forms are used to treat acute angina attacks.

Contraindications to the use of Calcium channel blockers

Allergy Acute MI Second- or third-degree AV block Hypotension

Contraindications to the use of Nitrates/Nitrites

Allergy. Hypotension. Increased intracranial pressure (ICP). Patients using erectile dysfunction medications. Anemia. Closed-angle glaucoma.

Preload:

Amount of blood returning to the heart

Angina

An imbalance of oxygen supply and demand.

Nitrate Indication:

Angina Long acting: used for prevention Short acting: used for treatment

A 68-year-old male patient has been taking the nitrate isosorbide dinitrate (Isordil) for 2 years for angina. He recently has been experiencing erectile dysfunction and wants a prescription for sildenafil (Viagra). Which response would the nurse most likely hear from the prescriber? A. "He will have to be switched to isosorbide mononitrate if he wants to take sildenafil." B. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists." C. "I'll write a prescription, but if he uses it, he needs to stop taking the isosorbide for one dose." D. "These drugs are compatible with each other, so I'll write a prescription."

B. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists."

A patient with coronary artery spasms will be most effectively treated with which type of antianginal medication? A. Beta blockers B. Calcium channel blockers C. Nitrates D. Nitrites

B. Calcium channel blockers

3 (Isosorbide mononitrate (Imdur) is a vasodilator and thus can cause hypotension. It is important to assess blood pressure before administering.)

Before the nurse administers isosorbide mononitrate (Imdur), what is a priority nursing assessment? 1 Assess serum electrolytes. 2 Measure blood urea nitrogen and creatinine. 3 Assess blood pressure. 4 Monitor level of consciousness

Beta Blockers "olol's" drug MOA:

Block beta1 adrenergic receptors in the heart's conduction system and throughout myocardium to decrease HR/AV conduction time

The nurse will teach a patient who will be taking nitroglycerin (Nitrostat) about which common adverse effect of this drug? A. Blurred vision B. Dizziness C. Headache D. Weakness

C. Headache

A nurse with adequate knowledge about the administration of intravenous Nitroglycerin will recognize that which statement is correct? A. The intravenous form is given by IV push injection. B. Because the intravenous forms are short-lived, the dosing must be every 2 hours. C. Intravenous Nitroglycerin must be protected from exposure to light through use of special tubing. D. Intravenous nitroglycerin can be given via gravity drip infusions.

C. Intravenous Nitroglycerin must be protected from exposure to light through use of special tubing.

What is the purpose of antianginal drug therapy? A. To increase myocardial oxygen demand. B. To increase blood flow to peripheral arteries. C. To increase blood flow to ischemic cardiac muscle. D. To decrease blood flow to ischemic cardiac muscle.

C. To increase blood flow to ischemic cardiac muscle.

A patient has a new prescription for transdermal Nitroglycerin patches. The nurse teaches the patient that these patches are most appropriately used for which reason? A. To relieve exertional angina. B. To prevent palpitations. C. To prevent the occurrence of angina. D. To stop an episode of angina.

C. To prevent the occurrence of angina.

Interactions with Beta blockers

Calcium channel blockers Insulin Oral anti-diabetic meds Diuretics Other anti-hypertensives

Calcium channel blockers

Can increase supply and decrease demand. Blocks calcium channels in vascular smooth muscle (primarily arterioles); resulting in arterial dilation and decreased peripheral resistance (decrease in afterload). Used to treat chronic stable and vasospastic (variant) angina.

While assessing a patient with angina who is to start beta blocker therapy, the nurse is aware that the presence of which condition may be a problem if these drugs are used? A. Hypertension B. Essential tremors C. Exertional angina D. Asthma

D. Asthma

For a patient using transdermal nitroglycerin patches, the nurse knows that the prescriber will order which procedure for preventing tolerance? A. Leave the old patch on for 2 hours while applying a new patch. B. Apply a new patch every other day. C. Leave the patch off for 24 hours once a week. D. Remove the patch at night for 8 hours and then apply a new patch in the morning.

D. Remove the patch at night for 8 hours and then apply a new patch in the morning.

A patient with angina has been given a prescription for a calcium channel blocker. The nurse knows that this class of drugs is used to treat which type of angina? A. Effort B. Unstable C. Crescendo D. Vasospastic

D. Vasospastic

Beta blockers

Decrease oxygen demand. Beta blockers used to treat angina- propranolol, atenolol, metoprolol, nadolol. *Mechanism of action*- - block beta 1 receptors in the heart; heart is in diastole longer which increases perfusion. - decreases sympathetic nervous stimulation and reduces the workload of the heart.

Beta Blockers "olol's" drug help angina/MI?

Decreases HR

Beta Blockers "olol's" drug help after an MI?

Decreases remodeling; prevents future mortality from the MI's

Interactions with Calcium channel blockers

Digoxin Beta blockers Grapefruit juice

Nitrate MOA:

Dilates blood vessels (primarily venous beds and coronary arteries)

Calcium channel blockers used to treat Angina

Diltiazem (Cardizem) Verapamil (Calan) Nifedipine (Procardia) Amlodipine (Norvasc) Nicarpidine (Cardene SR)

What would you teach the patient regarding side effects?

Dizziness - safety- driving, changing positions, hot conditions.

Adverse effects of Calcium channel blockers

Hypotension. Headache, dizziness. Bradycardia, reflex tachycardia. Flushing. Edema. Constipation.

When cells do not receive enough oxygen?

Ischemia

When heart cells do not have enough oxygen?

Ischemic heart disease

Coronary artery disease =>

MI

Nitrates/Nitrites

Mainstay for angina therapy because they can increase supply and decrease demand. Many formations are available. Includes- - Nitroglycerin - Isosorbide dinitrate - Isosorbide mononitrate

Why are nitrates used?

Mainstay treatment for angina Used both as treatment and prophylaxis

Ranolazine (Ranexa)

Mechanism of action is unknown. Decreases oxygen demand and decreases anginal pain. Used only to treat chronic angina. Can widen the QT interval which can lead to a fatal dysrhythmia. Interacts with many medications; also with grapefruit juice. Adverse effects: dizziness, headache, constipation, dry mouth, increased blood pressure (hypertension).

Isosorbide dinitrate (Isordil)

Nitrate Available in sub-lingual and oral formulations. 5 mg (sublingual), 80 mg P.O. bid or tid. *Patient teaching*- - do not abruptly stop. - sublingual form should be taken at the first sign of an angina attack. - take P.O. formulations on an empty stomach. - change positions slowly. - store drug in a cool, dry place.

Isosorbide mononitrate (Imdur)

Nitrate. Oral formulation only. Sustained release- designed to release a drug at a predetermined rate in order to maintain a constant drug concentration for a specific period of time with minimum side effects. 60-240 mg/day.

Three main classes of drugs used to treat angina pectoris

Nitrates/Nitrites Beta blockers Calcium channel blockers

What are the different preparations for nitrates?

Oral capsules ointment patches translingual spray IV

Antianginal drugs: therapeutic effects (picture)

Page 364

Nitrostat

Sublingual. 0.3 - 0.5 mg prn. Rapid onset, short duration. Used to treat an acute anginal attack, or right before an activity that can cause an attack.

Patient education for sublingual nitroglycerin (nitrostat)

Take as soon as the pain begins. If the pain is not relieved in 5 minutes, call 911. Can take a second tablet in 5 minutes, and a 3rd tablet in 5 minutes. Leave the tablet under the tongue until it dissolves. Should be stored at room temperature, away from light and moisture-free.

3 (If the patient consumes grapefruit juice, it can reduce the metabolism of the calcium channel blockers (CCB), especially nifedipine. The other drinks can be used by the patient when taking nifedipine as they have no significant interaction.)

Which beverage is contraindicated when the patient is taking nifedipine (Adalat)? 1 Milk 2 Earl Grey tea 3 Grapefruit juice 4 Mango juice

1 (Diltiazem (Cardizem) is a calcium-channel blocker (CCB) used for treating Prinzmetal's angina. Atenolol (Tenormin) is a beta blocker used for hypertension. When these two medications are coadministered, bradycardia can occur; therefore, the nurse should assess the patient's heart rate prior to administering these medications. The combination of beta blockers and an antidiabetic agent can result in hypoglycemia, which would require a nurse to monitor the patient's blood glucose. While assessing pain is important, it is not required prior to administering these two medications together. A nurse would not need to specifically monitor urine output when administering these two medications concurrently. )

The nurse is caring for a patient who is prescribed diltiazem (Cardizem) for Prinzmetal's angina. Upon reviewing the patient's medical history, the nurse notes that the patient is also prescribed atenolol (Tenormin) for hypertension. What should the nurse assess prior to administering these medications? 1 Heart rate 2 Blood glucose 3 Pain level 4 Urinary output

1 (Nitroglycerin (Nitrostat) is a medication that is often prescribed for the treatment of angina. The medication is administered sublingually to have a quick effect and avoid the first-pass effect. The statement by the patient indicating that the tablet is placed under the tongue indicates a correct understanding of the information presented. The patient can take up to three nitroglycerin tablets, spaced five minutes apart, to treat the angina. If the patient is still experiencing angina after three doses, emergency medical care should be sought. Hot showers should be avoided, as this will exacerbate vasodilation and increase the chance of orthostatic hypotension and syncope. Blurred vision may be experienced each time nitroglycerin is taken, not just during the first week of therapy.)

The nurse is teaching a patient about the safe administration of nitroglycerin (Nitrostat). Which patient statement indicates a correct understanding of the information presented? 1 "I should place the tablet under my tongue." 2 "I can take up to five tablets if my chest pain is not relieved." 3 "I should take hot showers daily during the course of therapy." 4 "I may have blurry vision during the first week of therapy."

Nitro-Bid (Nitropaste)

Topical ointment. Measure with paper applicator. Apply to a hairless area of the body, cover with plastic wrap, and do *not* rub it in. Avoid touching with your hands.

Nitro-dur

Transdermal patch. Apply to a non-hairy part of the skin (chest, back, or abdomen). Remove patch before defibrillation. Gradually discontinue. Do not cut the patch. Remove the old patch entirely before applying the new patch. Remove at night for 8-12 hours for a nitrate free period.

Nitrolingual

Translingual spray. Do not inhale! One spray = one sublingual nitro.

Tolerance can develop rapidly to Nitrates/Nitrites (esp with high dose therapy), to avoid tolerance:

Use lowest effective dose. Long-acting formulations need an 8-hour nitrate free period. Can be reversed by withholding nitrates for a short period.

2 (Although nitroglycerin needs to be kept in a cool, dry place, it should not be placed in an ice chest where it could freeze. It should not be locked up and needs to be kept away from light, not in a clear plastic bag.)

What does the nurse instruct a patient about storing nitroglycerin (Nitrostat) while travelling? 1 "You can protect it from heat by placing the bottle in an ice chest." 2 "It is best to keep it in its original container away from heat and light." 3 "You can put a few tablets in a sealed bag and carry it in your pocket." 4 "Lock it in the glove compartment of your car to protect it from heat and light."

1 (The calcium channel blockers decrease the afterload and reduce the workload of the heart by preventing muscle contraction and promoting muscle relaxation. The beta blockers are more effective in reducing exercise-induced heart rate elevations, as they decrease blood pressure and heart rate promptly. CCBs are contraindicated in patients with acute MI. Ranolazine (Ranexa) is used to prolong the QT interval on the ECG.)

What is the primary effect of calcium channel blockers (CCBs)? 1 To decrease the afterload and reduce the workload of the heart 2 To reduce exercise-induced elevations in heart rate 3 To treat acute myocardial infarction (MI) 4 To prolong the QT interval on the electrocardiogram (ECG)

1 (If chest pain is not relieved after taking nitroglycerin (Nitrostat), it indicates MI in the patient. In this case the patient needs to report to the primary health care provider immediately to seek prompt treatment. Headache is a common side effect of nitroglycerin. It diminishes soon after the therapy is started. The patient feels dizzy due to the drug-induced hypotension. However, the patient can be asked to restrict movement or turn slowly to avoid dizziness. Sudden and severe hypotension is seen when a patient is administered intravenous nitroglycerin (Nitro-Bid) rapidly.)

Which condition indicates a myocardial infarction (MI) in a patient who is taking nitroglycerin (Nitrostat) for angina? 1 Chest pain is not relieved by administering nitroglycerin. 2 The patient has a headache after taking the drug. 3 The patient complains of feeling dizzy when trying to move. 4 There is sudden and severe hypotension in the patient.

1 (A nitroglycerin patch should be applied to a nonhairy, 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 (Nitro-Bid) is administered via the sublingual route to relieve chest pain.)

Which instruction will be included in the discharge teaching for a patient with a transdermal nitroglycerin patch? 1 "Apply the patch to a nonhairy, nonfatty area of the upper torso or arm." 2 "Apply the patch to the same site each day to maintain consistent drug absorption." 3 "If you get a headache, remove the patch for 4 hours and then reapply." 4 "If you experience chest pain, apply a second patch right next to the first patch."

1 (The workload in the heart should be decreased with the vasodilation from the calcium channel blocker. With less strain, the patient should have fewer incidences of angina as afterload is decreased. Diuretics are used to decrease edema in the ankles and feet. Dizziness may be a side effect of the medication. Calcium channel blockers may cause fatigue.)

Which patient assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? 1 Absence of chest pain 2 Decreased swelling in the ankles and feet 3 Patient denies dizziness. 4 Patient states that she feels stronger.

3 (A patient with coronary heart disease who complains of chest pain will benefit from nitroglycerin therapy because it decreases the intensity of angina pain. Nitrates will compromise the already-reduced tissue oxygenation in patients with anemia due to drug-induced hypotension. The vasodilatory effects of nitrates can worsen hypotension and head injury in a patient.)

Which patient will the nurse expect to be given nitroglycerin (Nitrostat)? 1 A patient with angina who shows indications of hypotension 2 A patient with chest pain who has a history of anemia 3 A patient with coronary heart disease who complains of chest pain 4 A patient with severe head injury who complains of chest pain

4 (Nitroglycerin is a vasodilator and can cause orthostatic hypotension, resulting in dizziness. Three doses can be taken 5 minutes apart. The tablet should be placed under the tongue to dissolve. The medication should be kept in a readily accessible location for immediate use should chest pain occur.)

Which statement indicates to the nurse that the patient understands sublingual nitroglycerin medication instructions? 1 "I will take up to five doses every 3 minutes for chest pain." 2 "I can chew the tablet for the quickest effect." 3 "I will keep the tablets locked in a safe place until I need them." 4 "I should sit or lie down after I take a nitroglycerin tablet."

Angina pectoris (angina):

chest pain caused by imbalance of oxygen

Afterload:

the amount of resistance to ejection of blood from the ventricle