Antianginal Drugs

ROGER JOSEPH II R. JECINO, M.D.

Terminology
 Angina pectoris – chest pain, caused by the imbalance between oxygen being supplied to the heart
muscle and demand for oxygen by the heart muscle
 Atheroma – plaque in the endothelial lining of arteries
 Atherosclerosis – narrowing of the arteries caused by buildup of atheromas.
 Coronay Artery Disease – characterized by progressive narrowing of coronary arteries
 Myocardial Infarction – end result of vessel blockage in the heart, leads to ischemia and then
necrosis of the area cut off from the blood supply.
 Stable Angina – pain due to imbalance of myocardial oxygen supply and demand that is relieved
by rest.
 Unstable Angina - pain due to imbalance of myocardial oxygen supply and demand that persists
even at rest.
Coronary Artery Disease
Coronary Artery Disease
Antianginal Agents
 Helps restore the appropriate supply and demand ratio in oxygen
delivery to the myocardium when rest is not enough.
 Improve blood flow through the following mechanisms:
 Dilate blood vessels – increase the supply of oxygen
 Decrease the work of the heart - decrease the demand of oxygen
 Antianginal Agents
 Nitrates

 Beta-Blockers

 Calcium Channel Blockers

 Piperazineacetamide
Nitrates
 Short Acting – Nitroglycerine
 Long Acting – Isosorbide Dinitrate (Isordil) and Isosorbide Mononitrate
(Imdur)
 Mechanism of Action
 Relax and Dilate veins, arteries and capillaries allowing increase blood flow through the
coronary vessels. Dilates the Veins more than the Arteries
 Dilation of arteries leads to a decrease in SVR thus leading to a drop in blood pressure thus
decreasing the afterload
 Dilation of veins also leads to pooling of blood in veins and capillaries decreasing preload
 Indication
 Prevention and Treatment of attacks of Angina Pectoris
Pharmacokinetics:
 Nitroglycerine
 Sublingual
 Check under the tongue
 Have the patient take a sip of water before taking the medication
 Caution patient not to swallow the drug
 Encourage the patient to alternate sides of the tongue
 Transbuccal
 Check the inside of the cheeks
 Caution the patient not to swallow the drug
 Transdermal
 When applying a new patch, always clean the are every after removing the old transdermal patch.
 Intravenous
 Amyl Nitrate – inhalational
 ISDN/ISMN – oral forms
Contraindications and Cautions
 Allergy to nitrates
 Severe anemia – decrease in cardiac output could be detrimental in patients
who already has a decrease ability to deliver oxygen
 Head trauma/cerebral hemorrhage – relaxation of blood vessels could
further aggravate the bleeding
 Pregnancy and lactation
 Caution
 Hepatic and renal failure
 Hypotension/hypovolemia
 Conditions that limit cardiac output (e.g. cardiac tamponade)
Adverse Events
 Adverse events are related to vasodilation
 CNS
 Headache, dizziness, and weakness
 GI
 Nausea, vomiting and incontinence
 Cardiovascular
 Hypotension, reflex tachycardia, syncope and antianginal
 Transdermal patch
 Contact dermatitis
 Local hypersensitivity reaction
Clinically Important Drug-Drug Interaction
 Ergot derivatives – increases the risk of hypertension and decreased
antianginal effect
 Heparin – decreases therapeutic effect of heparin
 Sildenafil – causes serious hypotension and cardiovascular events
Nursing Consideration
 Assessment
 Assess for contraindications or cautions
 Perform physical assessment to establish baseline status before and after
beginning therapy
 Skin inspection
 Assess the complaint of chest pain
 Assess the neurologic status
 Obtain ECG as ordered to evaluate the heart rate and rhythm
 Monitor laboratory results
Nursing Consideration
 Nursing Diagnoses
 Decreased cardiac output related to vasodilation and hypotensive effects
 Risk for injury related to CNS or cardiovascular effects
 Ineffective tissue perfusion related to hypotension
 Deficient knowledge regarding the drug therapy
Nursing Consideration
 Implementation
 Give sublingual preparations under the tongue or in the buccal pouch end encourage
the patient not to swallow.
 Ask the patient if the tablets fizzles or burns
 Instruct the patient that a sublingual dose may be repeated in 5 minutes if relief is not
felt for a maximum of 3 doses
 Give sustained release form with water, caution not to chew or crush the drug
 Rotate the sites of topical forms to decrease the risk of skin abrasions and breakdown
 Make sure that the translingual spray is used under the tongue and not inhaled
Beta-Blockers
 MOA: blocks the stimulatory effects of the sympathetic
nervous system this results in the following:
 Decrease in the excitability of heart
 Decrease in the cardiac output
 Decrease in the cardiac oxygen consumption
 Lowering of blood pressure
 Indications:
 Long term treatment of angina pectoris caused by atherosclerosis
 Used in combination with nitrates to increase exercise tolerance
Calcium Channel Blockers
 MOA:
 inhibit the movement of calcium ion across the membranes of myocardial and
arterial muscle cells, altering the action potential and blocking muscle cell
contraction.
 Decreases the preload and afterload which decreases cardiac workload and
decrease oxygen consumption
 Indication:
 Treatment of prinzmetal angina
 Treatment for chronic angina, effort associated angina and hypertension
Lipid-Lowering Agents
ROGER JOSEPH II R. JECINO, R.N., M.D.
Bile Acid Sequestrants
 Drugs: Cholestyramine, colestipol, colesevelam
 Mechanism of action
 Bind with bile acids in the intestine to form an insoluble complex that is then excreted
in the feces.
 Indications
 Used to reduce serum cholesterol in patients with primary hypercholesterolemia
(manifested by high cholesterol and high LDL)
 Pharmacokinetics
 Not absorbed systematically
 Act while in the intestine and excreted directly in the feces
Bile Acid Sequestrants
 Contraindications and cautions:
 Hypersensitivity reaction
 Complete biliary obstruction
 Abnormal intestinal function
 Pregnancy and lactation
 Adverse effect
 Vitamin A and D deficiency
 Increased bleeding tendency due to decrease absorption of vitamin K
 Drug to drug interaction
 Bile acid sequestrants decreases or delays the absorption of thiazide, digoxin, warfarin, thyroid
hormones, and corticosteroids. If to be taken should be 1 hour before or 4-6 after the BAS.
HMG-CoA Reductase Inhibitors
 Drugs: Simvastatin, Atorbastatin, Rosuvastatin
 MOA:
 Blocks the early rate limiting enzyme (HMG CoA Reductase) in the synthesis of cellular cholesterol
 Indications:
 For patients with high cholesterol and LDL
 Prevention of Myocardial Infarction in patient with multiple risk factors
 Pharmacokinetics:
 Absorbed in the GI tract and undergo first pass metabolism
 Excreted through the feces and urine
 Effective at night
 Crosses the placenta and is present in milk
HMG-CoA Reductase Inhibitors
 Contraindication and Cautions:
 Hypersensitivity

 Active liver disease and alcohol liver disease

 Pregnancy and lactation
 Adverse Events:
 Most common: Flatulence, abdominal pain, cramps, nausea, vomiting and
constipation
 Increased concentrations of liver enzymes
 Acute Liver Failure
 Rhabdomyolysis
Cholesterol Absorption Inhibitors
 Drugs: ezetimibe
 MOA: decrease the absorption of dietary cholesterol from the brush border of the
small intestine
 Indication: adjunct to diet and exercise to lower cholesterol
 Pharmacokinetics: absorbed well after oral administration, metabolized in the liver
and small intestine and excreted in the urine and feces
 Contraindications: hypersensitivity reaction, when used with statin it should not be
used during pregnancy and lactation or with severe liver disease
 Adverse effect: Mild abdominal pain and diarrhea – most common
Fibrates
 Drugs: Fenofibrate and Gemfibrozil
 MOA: stimulate the breakdown of lipoproteins from the tissue and
their removal in the plasma.
 Fenofibrate – inhibits the triglyceride synthesis in the liver, resulting in
reduction of LDL
 Indication: used for patient with high Triglyceride
 Gemfibrozil – inhibits peripheral breakdown of lipids,
 Indication: used for patient with high triglyceride and LDL and also in patient with low
HDL.
Vitamin B3 (Niacin)
 Inhibits the release of free fatty acids from adipose tissue, increases the rate of
triglyceride removal from the plasma.
 Reduces LDL and Triglyceride levels
 Increases HDL levels
 Decreases the levels of apoprotein
 Side effect: cutaneous flushing, nausea and abdominal pain
 Increases uric acid and may predispose patient to GOUT
Thank You