The Cardiovascular Drugs Questions and Answers
Antianginal Drugs
Angina Pectoris (chest pain)
When the supply of oxygen and nutrients in the blood is
... [Show More] insufficient to meet the demands of the heart, the heart muscle “aches.”
The heart requires a large supply of oxygen to meet the demands placed on it.
Ischemia
Ischemia
Poor blood supply to an organ Ischemic heart disease
Poor blood supply to the heart muscle
Atherosclerosis Coronary artery disease
Myocardial infarction
Necrosis, or death, of cardiac tissue Disabling or fatal
Type of angina
Chronic stable angina (also called classic or effort angina) Unstable angina (also called preinfarction angina) Vasospastic angina (also called Prinzmetal or variant angina)
Goal of medical management
• Minimize the frequency, decrease the durations and intensity of angina attacks
• Improve functional capacity with few adverse effects
• Prevent or delay MI
A person who is mowing the lawn on a hot Saturday afternoon begins to notice chest pain. What should this person’s first action be?
A. Take a nitroglycerin tablet.
B. Stop mowing and sit or lie down.
C. Go inside the house to cool off and get a drink of water.
D. Call 911.
Correct answer: B
Rationale: At the first sign of chest pain, the person should stop all activity and sit or lie down before taking the nitroglycerin tablet.
Drugs for Angina
Nitrates and nitrites ß-Blockers
Calcium channel blockers
Nitrates and Nitrites
Available forms
Sublingual* Chewable tablets Oral capsules/tablets
Intravenous solutions* Transdermal patches* Ointments Translingual sprays*
*Bypass the liver and the first-pass effect
Mechanism of Action and Drug Effects
Cause vasodilation because of relaxation of smooth muscles Potent dilating effect on coronary arteries
Result: oxygen to ischemic myocardial tissue Used for prevention and treatment of angina
Rapid-acting forms
Used to treat acute anginal attacks Sublingual tablets or spray; IV infusion
Long-acting forms
Used to prevent anginal episodes
nitroglycerin (both rapid and long acting) isosorbide dinitrate (both rapid and long acting) isosorbide mononitrate (primarily long acting)
A patient with extremely high blood pressure (BP) is in the emergency department. The health care provider will order therapy with nitroglycerin to manage the patient’s blood pressure. Which form of nitroglycerin is most appropriate?
A. Sublingual spray
B. Transdermal patch
C. Oral capsule
D. Intravenous infusion
Correct answer: D
Rationale: The IV infusion of nitroglycerin will have the fastest effect, and the dose will be titrated to the patient’s response.
Nitrates
Nitroglycerin
Prototypical nitrate
Large first-pass effect with oral forms
Used for symptomatic treatment of ischemic heart conditions (angina) Intravenous form used for control of blood pressure in perioperative hypertension, treatment of heart failure, ischemic pain, pulmonary edema associated with acute myocardial infarction, and hypertensive emergencies
Adverse effects
Headaches
Usually diminish in intensity and frequency with continued use
Reflex tachycardia Postural hypotension Tolerance may develop.
A patient who was walking a dog developed chest pain and sat down. The patient continues to experience chest pain when sitting down. When should the patient call 911?
A. Immediately
B. If the pain becomes more severe
C. If one sublingual tablet does not relieve the pain after 5 minutes
D. If the pain is not relieved after three sublingual tablets, taken 5 minutes apart
Correct answer: C
Rationale: With sublingual nitroglycerin, the medication should be taken at the first sign of chest pain and not be delayed until the pain is severe. The patient should sit 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 one dose, the patient (or family member) should call 911 immediately. The patient can take one more tablet while awaiting emergency care and a third tablet 5 minutes later but no more than three tablets total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate an MI.
Tolerance
Occurs in patients taking nitrates around the clock or with long-acting forms Prevented by allowing a regular nitrate-free period to allow enzyme pathways to replenish
Transdermal forms: may be instructed to remove patch at bedtime for 8 hours, then apply a new patch in the morning
Contraindications
Known drug allergy Severe anemia
Closed-angle glaucoma Hypotension
Severe head injury
Use of the erectile dysfunction drugs sildenafil citrate (Viagra®), tadalafil (Cialis®), and vardenafil hydrochloride (Levitra®)
Isosorcide Dinitrate
Organic nitrate
Available in rapid-acting sublingual tablets and long-acting oral dosage forms Slower onset, not first choice for acute angina episodes
Nitroclycerin
Prototypical nitrate
The most important drug used in the symptomatic treatment of ischemic heart conditions such as angina
Routes: oral, sublingual, metered-dose aerosol that is sprayed under the tongue, intravenous, and topical
Nursing Implications Nitroglycerin
o Instruct patients in proper technique and guidelines for taking sublingual nitroglycerin for anginal pain.
o Instruct patients never to chew or swallow the sublingual form.
o Instruct patients that a burning sensation felt with sublingual forms indicates that the drug is still potent.
o Instruct patients to keep a fresh supply of sublingual medication on hand; potency is good for about 3 to 6 months.
o To preserve potency, medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler.
o Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including site rotation and removal of old medication.
o To reduce tolerance, the patient may be instructed to remove topical forms at bedtime and apply new doses in the morning, allowing for a nitrate-free period.
o Instruct patients to take as-needed nitrates at the first hint of anginal pain.
o Monitor vital signs frequently during acute exacerbations of angina and during intravenous administration.
o If experiencing chest pain, the patient taking sublingual nitroglycerin should lie down to prevent or decrease dizziness and fainting that may occur because of hypotension.
o If anginal pain occurs tell patient to
o stop activity and sit or lie down and take a sublingual tablet.
o Call 911 or emergency services immediately and take a second sublingual tablet if there is no relief in 5 minutes.
o Take a third sublingual tablet If there is no relief in 5 minutes.
o Do not try to drive to the hospital.
o Intravenous forms of nitroglycerin must be given with special non– polyvinyl chloride tubing and bags.
o Discard parenteral solutions that not clear and are discoloured.
o Follow specific manufacturer’s instructions for intravenous administration.
Beta Blockers
Mainstay in the treatment of several cardiovascular diseases
o Angina
o Myocardial infarction
o Hypertension
o Dysrhythmias
Antianginal Beta Blockers
o atenolol
o metoprolol
o propranolol hydrochloride
o nadolol
Mechanism of Action
o β1-receptors located in hearts conduction system and through myocardium
o Normally stimulated by epinephrine and norepinephrine which are released in exercise, or stress – causes heart to contract more strongly and causes the heart to spend more time in systole
o When beta receptors are blocked by beta blockers the rate which the pacemaker (SA node) fires decreases
o =slow heart rate =reduce myocardial oxygen demand=less angina
Block β1-receptors on the heart
o Decrease heart rate, resulting in decreased myocardial oxygen demand and increased oxygen delivery to the heart
o Decrease myocardial contractility, helping to conserve energy or decrease demand
o After a myocardial infarction, a high level of circulating catecholamines irritates the heart, causing an imbalance in supply and demand ratio and even leading to life-threatening dysrhythmias.
o β-blockers block the harmful effects of catecholamines, thus improving survival after a myocardial infarction.
o Beta blockers also supress renin which is a potent vasoconstrictor released by the kidneys. Results in blood vessels to and in the kidney to dilate = reduced blood pressure. [Show Less]