antianginal agents

Copyright © 2002, 1998, Elsevier Science (USA). All rights reserved.

Antianginal AgentsAntianginal Agents


Antianginal AgentsAntianginal Agents

• NitratesNitrates

• Beta blockersBeta blockers

• Calcium channel blockersCalcium channel blockers


Angina Pectoris (Chest Pain)Angina Pectoris (Chest Pain)

• When the supply of oxygen and nutrients in When the supply of oxygen and nutrients in the blood is insufficient to meet the demands the blood is insufficient to meet the demands of the heart, the heart muscle of the heart, the heart muscle achesaches..

• The heart demands a large supply of oxygen The heart demands a large supply of oxygen to meet the demands placed on it.to meet the demands placed on it.


Types of AnginaTypes of Angina

• Chronic stable angina Chronic stable angina (also called classic or effort angina)(also called classic or effort angina)

• Unstable anginaUnstable angina(also called preinfarction or crescendo angina)(also called preinfarction or crescendo angina)

• Vasospastic anginaVasospastic angina(also called Prinzmetal’s or variant angina)(also called Prinzmetal’s or variant angina)


Instructors may wish to insert Instructors may wish to insert EIC Image # 68: EIC Image # 68:

Angina Drug TherapyAngina Drug Therapy


Antianginal Agents:Antianginal Agents:

Therapeutic ObjectivesTherapeutic Objectives

• Increase blood flow to ischemic heart muscleIncrease blood flow to ischemic heart muscle

and/orand/or

• Decrease myocardial oxygen demandDecrease myocardial oxygen demand


Antianginal Agents:Antianginal Agents:

Therapeutic ObjectivesTherapeutic Objectives

• Minimize the frequency of attacks and decrease the Minimize the frequency of attacks and decrease the duration and intensity of anginal painduration and intensity of anginal pain

• Improve the patient’s functional capacity with as few Improve the patient’s functional capacity with as few side effects as possibleside effects as possible

• Prevent or delay the worst possible outcome, MIPrevent or delay the worst possible outcome, MI


Antianginal Agents: NitratesAntianginal Agents: Nitrates

Available forms:Available forms:

SublingualSublingual OintmentsOintments

BuccalBuccal Transdermal patchesTransdermal patches

Chewable tabletsChewable tablets Inhalable spraysInhalable sprays

CapsulesCapsules Intravenous solutionsIntravenous solutions


Antianginal Agents: NitratesAntianginal Agents: Nitrates

• Cause vasodilation due to relaxation of Cause vasodilation due to relaxation of smooth musclessmooth muscles

• Potent dilating effect on coronary arteriesPotent dilating effect on coronary arteries

• Used for prophylaxis and treatment Used for prophylaxis and treatment of anginaof angina


Antianginal Agents: Nitrates Antianginal Agents: Nitrates

NitroglycerinNitroglycerin

• Prototypical nitratePrototypical nitrate

• Large first-pass effect with PO formsLarge first-pass effect with PO forms

• Used for symptomatic treatment of ischemic heart Used for symptomatic treatment of ischemic heart conditions (angina)conditions (angina)

• IV form used for BP control in perioperative IV form used for BP control in perioperative hypertension, treatment of CHF, ischemic pain, hypertension, treatment of CHF, ischemic pain, and pulmonary edema associated with acute MIand pulmonary edema associated with acute MI



• isosorbide dinitrate isosorbide dinitrate (Isordil, Sorbitrate, Dilatrate SR)(Isordil, Sorbitrate, Dilatrate SR)

• isosorbide mononitrate isosorbide mononitrate (Imdur, Monoket, ISMO)(Imdur, Monoket, ISMO)

Used for:Used for:

• Acute relief of anginaAcute relief of angina

• Prophylaxis in situations that may provoke anginaProphylaxis in situations that may provoke angina

• Long-term prophylaxis of anginaLong-term prophylaxis of angina



Side EffectsSide Effects

• HeadacheHeadache

– Usually diminish in intensity and frequency Usually diminish in intensity and frequency with continued usewith continued use

• Tachycardia, postural hypotensionTachycardia, postural hypotension

• Tolerance may developTolerance may develop


Antianginal Agents: Beta BlockersAntianginal Agents: Beta Blockers

• atenolol (Tenormin)atenolol (Tenormin)

• metoprolol (Lopressor)metoprolol (Lopressor)

• propranolol (Inderal)propranolol (Inderal)

• nadolol (Corgard)nadolol (Corgard)



Mechanism of ActionMechanism of Action

• Decrease the HR, resulting in decreased myocardial Decrease the HR, resulting in decreased myocardial oxygen demand and increased oxygen delivery to oxygen demand and increased oxygen delivery to the heartthe heart

• Decrease myocardial contractility, helping to Decrease myocardial contractility, helping to conserve energy or decrease demandconserve energy or decrease demand



Therapeutic UsesTherapeutic Uses

• AntianginalAntianginal

• AntihypertensiveAntihypertensive

• Cardioprotective effects, especially after MICardioprotective effects, especially after MI




Body SystemBody System EffectsEffects

CardiovascularCardiovascular bradycardia, hypotensionbradycardia, hypotensionsecond- or third-degree heart blocksecond- or third-degree heart blockheart failureheart failure

MetabolicMetabolic Altered glucose and lipidAltered glucose and lipidmetabolismmetabolism




Body SystemBody System EffectsEffects

CNSCNS dizziness, fatigue, dizziness, fatigue, mental depression, lethargy,mental depression, lethargy,drowsiness, unusual dreamsdrowsiness, unusual dreams

OtherOther impotenceimpotencewheezing, dyspneawheezing, dyspnea


Antianginal Agents: Antianginal Agents: Calcium Channel BlockersCalcium Channel Blockers

• verapamil (Calan)verapamil (Calan)

• diltiazem (Cardizem)diltiazem (Cardizem)

• nifedipine (Procardia)nifedipine (Procardia)



Mechanism of ActionMechanism of Action

• Cause peripheral arterial vasodilationCause peripheral arterial vasodilation

• Reduce myocardial contractility Reduce myocardial contractility (negative inotropic action)(negative inotropic action)

• Result: decreased myocardial oxygen demandResult: decreased myocardial oxygen demand



Therapeutic UsesTherapeutic Uses

• First-line agents for treatment of angina, First-line agents for treatment of angina, hypertension, and supraventricular tachycardiahypertension, and supraventricular tachycardia

• Short-term management of atrial fibrillation and Short-term management of atrial fibrillation and flutterflutter

• Several other usesSeveral other uses




• Very acceptable side effect and safety profileVery acceptable side effect and safety profile

• May cause hypotension, palpitations, tachycardia May cause hypotension, palpitations, tachycardia or bradycardia, constipation, nausea, dyspneaor bradycardia, constipation, nausea, dyspnea


Antianginal Agents: Antianginal Agents: Nursing ImplicationsNursing Implications

• Before administering, perform a complete Before administering, perform a complete health history to determine presence of health history to determine presence of conditions that may be contraindications conditions that may be contraindications for use or call for cautious use.for use or call for cautious use.

• Obtain baseline VS, including respiratory Obtain baseline VS, including respiratory patterns and rate.patterns and rate.

• Assess for drug interactions.Assess for drug interactions.



• Patients should not take any medications, Patients should not take any medications, including OTC medications, without checking including OTC medications, without checking with the physician.with the physician.

• Patients should report blurred vision, Patients should report blurred vision, persistent headache, dry mouth, dizziness, persistent headache, dry mouth, dizziness, edema, fainting episodes, weight gain of edema, fainting episodes, weight gain of 2 pounds in 1 day or 5 or more pounds in 2 pounds in 1 day or 5 or more pounds in 1 week, pulse rates under 60, and any 1 week, pulse rates under 60, and any dyspnea.dyspnea.



• Alcohol consumption and hot baths or spending Alcohol consumption and hot baths or spending time in jacuzzis, hot tubs, or saunas will result in time in jacuzzis, hot tubs, or saunas will result in vasodilation, hypotension, and the possibility of vasodilation, hypotension, and the possibility of fainting.fainting.

• Teach patients to change positions slowly to avoid Teach patients to change positions slowly to avoid postural BP changes.postural BP changes.

• Encourage patients to keep a record of their anginal Encourage patients to keep a record of their anginal attacks, including precipitating factors, number of attacks, including precipitating factors, number of pills taken, and therapeutic effects.pills taken, and therapeutic effects.


Antianginal Agents: Nitroglycerin Antianginal Agents: Nitroglycerin

Nursing ImplicationsNursing Implications

• Instruct patients in proper technique and guidelines Instruct patients in proper technique and guidelines for taking sublingual NTG for anginal pain.for taking sublingual NTG for anginal pain.

• Instruct patients never to chew or swallow the Instruct patients never to chew or swallow the SL form.SL form.

• Instruct patients that a burning sensation felt with Instruct patients that a burning sensation felt with SL forms indicates that the drug is still potent.SL forms indicates that the drug is still potent.




• Instruct patients to keep a fresh supply of NTG on Instruct patients to keep a fresh supply of NTG on hand; potency is lost in about 3 months after the hand; potency is lost in about 3 months after the bottle has been opened.bottle has been opened.

• Medications should be stored in an airtight, dark Medications should be stored in an airtight, dark glass bottle with a metal cap and no cotton filler glass bottle with a metal cap and no cotton filler to preserve potency.to preserve potency.




• Instruct patients in the proper application of nitrate Instruct patients in the proper application of nitrate topical ointments and transdermal forms, including topical ointments and transdermal forms, including site rotation and removal of old medication.site rotation and removal of old medication.

• To reduce tolerance, the patient may be instructed To reduce tolerance, the patient may be instructed to remove topical forms at bedtime, and apply new to remove topical forms at bedtime, and apply new doses in the morning, allowing for a nitrate-free doses in the morning, allowing for a nitrate-free period.period.




• Instruct patients to take prn nitrates at the first hint Instruct patients to take prn nitrates at the first hint of anginal pain.of anginal pain.

• If experiencing chest pain, the patient taking SL If experiencing chest pain, the patient taking SL NTG should be lying down to prevent or decrease NTG should be lying down to prevent or decrease dizziness and fainting that may occur due to dizziness and fainting that may occur due to hypotension.hypotension.

• Monitor VS frequently during acute exacerbations Monitor VS frequently during acute exacerbations of angina and during IV administration.of angina and during IV administration.




• IV forms of NTG must be contained in glass IV IV forms of NTG must be contained in glass IV bottles and must be given with infusion pumps.bottles and must be given with infusion pumps.

• Discard parenteral solution that is blue, green, Discard parenteral solution that is blue, green, or dark red.or dark red.

• Follow specific manufacturer’s instructions for IV Follow specific manufacturer’s instructions for IV administration. Use special IV tubing provided or administration. Use special IV tubing provided or non-PVC tubing.non-PVC tubing.


Antianginal Agents: Antianginal Agents: Calcium Channel Blockers Calcium Channel Blockers


• Blood levels should be monitored to ensure they Blood levels should be monitored to ensure they are therapeutic.are therapeutic.

• Oral CCBs should be taken before meals and Oral CCBs should be taken before meals and as ordered.as ordered.

• Patients should be encouraged to limit Patients should be encouraged to limit caffeine intake.caffeine intake.


Antianginal Agents: Beta Blockers Antianginal Agents: Beta Blockers


• Patients taking beta blockers should monitor pulse Patients taking beta blockers should monitor pulse rate daily and report any rate lower than 60 beats rate daily and report any rate lower than 60 beats per minute.per minute.

• Dizziness or fainting should also be reported.Dizziness or fainting should also be reported.

• Constipation is a common problem. Instruct patients Constipation is a common problem. Instruct patients to take in adequate fluids and eat high-fiber foods.to take in adequate fluids and eat high-fiber foods.


Antianginal Agents: Beta Blockers Antianginal Agents: Beta Blockers


• These medications should never be abruptly These medications should never be abruptly discontinued due to risk of rebound hypertensive discontinued due to risk of rebound hypertensive crisis.crisis.

• Inform patients that these medications are for Inform patients that these medications are for long-term prevention of angina, not for long-term prevention of angina, not for immediate relief.immediate relief.



• Monitor for adverse reactionsMonitor for adverse reactions

– Allergic reactions, headache, light-headedness, Allergic reactions, headache, light-headedness, hypotension, dizzinesshypotension, dizziness

• Monitor for therapeutic effectsMonitor for therapeutic effects

– Relief of angina, decreased BP, or bothRelief of angina, decreased BP, or both

antianginal agents

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