Chapter 46:

Antianginal Agents

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Coronary Artery Disease (Definitions)
 Atheromas
o Fatty tumors in the intima of the heart vessels
 Atherosclerosis
o Narrowing of the heart vessels
 Angina Pectoris
o “Suffocation of the chest”
 Myocardial Infarction
o Cells in the myocardium become necrotic and die

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Illustration of an atheromatous
plaque (a) and thrombus of
an atherosclerotic plaque (b)

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Types of Angina
 Stable Angina
o No damage to heart muscle; basic reflexes
surrounding the pain restore blood flow
 Unstable Angina
o Episodes of ischemia occur even when at rest
 Prinzmetal’s Angina
o Caused by spasm of the blood vessels, not just by
vessel narrowing

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Acute Myocardial Infarction

 If a coronary vessel becomes completely occluded and is

unable to deliver blood to the cardiac muscle the area of
muscle that depends on that vessel for oxygen becomes
ischemic and then necrotic
o Resulting in excruciating pain, nausea and severe
sympathetic stress reaction

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Actions of Antianginal Drugs

 Improve blood delivery to the heart muscle by dilating

blood vessels
o Increasing the supply of oxygen
 Improve blood delivery to the heart muscle by
decreasing the work of the heart
o Decreasing the demand for oxygen

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Factors Affecting Myocardial Oxygen
Demand and the Effect of Antianginals

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Use of Antianginal Agents Across the
Lifespan

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Types of Antianginal Drugs
 Nitrates
 Beta-Adrenergic Blockers
 Calcium Channel Blockers

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Nitrates #1

 Help restore the appropriate supply-and-demand ratio in

oxygen delivery to the myocardium when rest is not
enough
o Amyl nitrate (generic)
o Isosorbide dinitrate (Isordil)
o Isosorbide mononitrate (Monoket)
o Nitroglycerin (Nitro-Bid, Nitrostat, and others)

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Nitrates #2

 Actions
o Act directly on smooth muscle to cause relaxation
and depress muscle tone
 Indications
o Prevention and treatment of attacks of angina
pectoris
 Pharmacokinetics
o Very rapidly absorbed
o Metabolized in the liver
o Excreted in the urine

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Nitrates #3

 Contraindications
o Allergy
o Severe anemia
o Head trauma or cerebral hemorrhage
o Pregnancy and lactation
 Caution
o Hepatic or renal disease
o Hypotension, hypovolemia, and conditions that limit
cardiac output

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Nitrates #4

 Adverse Effects
o Related to the vasodilatation and decreased in blood
flow
o CNS – Headache, dizziness, and weakness
o GI – Nausea, vomiting
o CV – Hypotension
o Misc. – Flushing, pallor increased perspiration
 Drug-to-Drug Interactions
o Ergot derivatives
o Heparin

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Routes for Nitroglycerin

 IV
 Sublingual
 Translingual Spray
 Transmucosal Tablet
 Oral, SR Tablet
 Topical Ointment
 Transdermal

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Nursing Considerations for Nitrates

 Assess:
o History and Physical Exam and known allergy
o Early MI, head trauma, cerebral hemorrhage,
hypotension, hypovolemia, anemia, or low-cardiac-
output states; and current status of pregnancy or
lactation
o Skin, complaint of pain, including onset, duration,
intensity, location, and measures used to relieve it.
o Respirations, LS, cardiac status, BP, baseline ECG
and appropriate lab values

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Prototype Nitrates

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Question #1

The patient asks the nurse to explain the type of angina

he is experiencing. The nurse explains the pain is due to
the imbalance of myocardial supply and demand. What
type of angina does this describe?
A. Unstable
B. Prinzmetal’s
C. Stable
D. Ischemic

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Answer to Question #1

C. Stable

Rationale: Stable angina: No damage to heart muscle;

basic reflexes surrounding the pain restore blood flow

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Beta Blockers #1

 Block the stimulatory effects of the sympathetic nervous

system
o Atenolol (Tenormin)
o Metoprolol (Toprol XL)
o Propranolol (Inderal)
o Nadolol (Corgard)

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Beta Blockers #2

 Actions
o Blocks beta-adrenergic receptors in the heart and
kidneys, decreases the influence of the SNS on these
tissues; decreases cardiac output and the release of
renin
 Indications
o Treats stable angina pectoris and hypertension,
prevents reinfarction in MI patients; treats stable
CHF
 Pharmacokinetics
o Absorbed in GI tract, undergoes hepatic metabolism,
excreted in the urine

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Beta Blockers #3

 Contraindications
o Bradycardia
o Heart block
o Cardiogenic shock
o Asthma or COPD
o Pregnancy and lactation
 Caution
o DM
o PVD
o Thyrotoxicosis

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Beta Blockers #4

 Adverse Effects
o Related to their blockage of sympathetic nervous
system
o CNS – Dizziness, fatigue, emotional depression
o GI – Nausea, vomiting, colitis
o CV – CHF, decreased cardiac output, and
arrhythmias
o Respiratory – Bronchospasm, dyspnea, and cough
 Drug-to-Drug Interactions
o Clonidine

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Nursing Considerations for Beta Blockers

 Assess:
o History and Physical Exam and known allergy
o See chapter 31 for nursing considerations associated
with Beta Blockers

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Prototype Beta Blockers

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Calcium Channel Blockers #1

 Inhibit the movement of calcium ions across the

membranes of myocardial and arterial muscle cells
o Amlodipine (Norvasc)
o Diltiazem (Cardizem)
o Nicardipine (Cardene)
o Nifedipine (Adalat CC, Procardia)
o Verapamil (Calan)

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Calcium Channel Blockers #2

 Actions
o Inhibit the movement of calcium ions across the
membranes of myocardial and arterial muscle cells,
altering the action potential and blocking muscle cell
contraction
 Indications
o Prinzmental’s angina
 Pharmacokinetics
o Well absorbed
o Metabolized in the liver
o Excreted in the urine

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Calcium Channel Blockers #3

 Contraindications
o Allergy
o Heart block or sick sinus syndrome
o Renal or hepatic dysfunction
o Pregnancy or lactation

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Calcium Channel Blockers #4

 Adverse Effects
o Hypotension
o Cardiac arrhythmias
o GI upset
o Skin reactions
o Headache
 Drug-to-Drug Interactions
o Vary with each drug

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Nursing Considerations for Calcium
Channel Blockers

 Assess:
o History and Physical Exam, known allergy
o Impaired liver or kidney function
o Pregnancy and lactation
o Baseline status, skin, complaint of pain, including
onset, duration, intensity, and location, and
measures used to relieve the pain
o Cardiopulmonary status, baseline ECG, respirations,
LS and appropriate lab values

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Prototype Calcium Channel Blockers

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Question #2

Please answer the following statement as true or false.

Older adults are more likely to develop adverse effects

associated with the use of these drugs—dysrrhythmias,
hypertension, and congestive heart disease.

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Answer to Question #2

False

Rationale: Older adults frequently are prescribed one of

these drugs. They are more likely to develop adverse
effects associated with the use of these drugs—
arrhythmias, hypotension, and congestive heart disease.
Safety measures may be needed if these effects occur
and interfere with the patient’s mobility and balance.

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