Angina Pectoris Drugs

Front 1

Nitrates

Back 1

Nitroglycerin

Front 2

Mechanism of Action

Back 2

Nitrates are venous dilators
• Nitrates are converted to nitric oxide (NO) that acts at a cellular level through a chain of chemical reactions to ultimately relax vascular smooth muscle
• Reduced arteriolar and venous tone =  preload and  afterload and  myocardial O2 demand
• Nitrates also promote increased blood flow to deep myocardial muscle

Front 3

Adverse Effects

Back 3

• flushing
• venous pooling
• headache (acute HA from SL nitroglycerin is very common & resolves within mins to hrs)
• hypotension & orthostatic hypotension (light-headedness, dizziness)

Front 4

Nitrate Tolerance

Back 4

• Partial or complete nitrate tolerance will occur to some degree in most patients upon multiple dosing or use of long-acting formulations.
• Some patients will be instructed to provide themselves with drug-free interval of 8 – 12 hours per day. This can be done by removing patches at bedtime & applying a new patch each morning or taking twice daily tabs/caps at 7am and 2pm instead of the usual 9am/9pm that you would see with a drug dosed twice daily
• Some prescribers are concerned with reports of some rebound ischemia during the nitrate-free interval and therefore may not instruct their patients to provide a nitrate-free interval

Front 5

Nitrate Formulations

Back 5

Nitroglycerin Sublingual Tablets (Nitrostat) & Sublingual Spray
• Used to treat acute anginal attacks or taken prior to exercise to prevent attacks.
• Rapid onset of action (1 – 2 minutes)

Nitroglycerin Topical Ointment
• Dosed in inches; applied every 6 – 8 hours. Quick onset of action (15-30 minutes)
• Can easily titrate dose based on response. Can be removed quickly if adverse effects occur
• Very messy to use. Makes it somewhat difficult for outpatient use

Nitroglycerin Transdermal Patches (Nitro-Dur, Minitran)
• Are NOT effective for acute attacks; used prophylactically to reduce frequency of exertional or variant angina attacks
• They provide a steady constant release of drug over 24 hours
• Patches are applied once daily

Nitroglycerin Sustained Release Capsules (Nitro-Bid)
• Are NOT effective for acute attacks; used prophylactically to reduce frequency of exertional or variant angina attacks

Front 6

Nitrate Formulations

Back 6

Isosorbide dinitrate & Isosorbide mononitrate tablets
• Isosorbide dinitrate tablets (Isordil) (eye soe SORE bide dye NYE trate
• Isosorbide mononitrate tablets (Ismo, Monoket) (eye soe SORE bide mon oh NYE trate)
• Are NOT effective for acute attacks; used prophylactically to reduce frequency of exertional or variant angina attacks

Front 7

B-blockers
(help patient live longer)

Back 7

• Increased sympathetic activity is a common feature in exertional anginal attacks
• B-blockers reduce the O2 demands of the heart by decreasing myocardial oxygen requirements during exertion and stress
• Reduced heart rate & contractility =  myocardial O2 demand
• B-blockers have the strongest evidence supporting their ability to reduce morbidity & mortality in patients with CAD
• B-blockers are used prophylactically to reduce the frequency of exertional angina attacks

Front 8

Calcium Channel Blockers

Back 8

• Reduced arteriolar tone = decreases afterload and decreases myocardial O2demand
• Beneficial effects on coronary arteries may also increase myocardial oxygenation
• Diltiazem & verapamil also mimic the B-blockers effects of reduced heart rate & contractility
• CCBs are used prophylactically to reduce frequency of exertional or variant angina attacks

Front 9

Signs/Symptoms of Angina Attacks

Back 9

• Pain/discomfort often described as pressure, squeezing, burning, or tightness in chest
• Pain/discomfort usually starts behind the breastbone
• Pain can radiate to or begin in arms, shoulders, neck, jaw, throat, or back
• Pain may feel like indigestion
• Patient may also have nausea, fatigue, shortness of air, sweating, feel light-headed or weak

Front 10

Treatment of Acute Attacks

Back 10

• Only sublingual nitroglycerin tablets or spray work quickly enough to use
• Patient Instructions: Dissolve 1 tablet under tongue; may repeat every 3 – 5 minutes until pain is relieved or until 3 tablets have been taken. Contact physician or call 911 if pain persists. Some patients will be instructed to call 911 if the first tablet is ineffective. The patient definitely does not have to wait 15 minutes before calling 911
• Pain not responding to nitroglycerin or lasting greater than 15 minutes may represent MI. Patients should not to drive themselves to the ER

Front 11

Patients with Stable Exertional Angina Should be Prescribed

Back 11

• A chronic daily medication (prophylactic therapy) to prevent attacks. β-blockers are the drugs of choice because they not only prevent attacks but also improve morbidity/mortality. Daily nitroglycerin and/or CCBs may also be prescribed
• SL nitroglycerin will be prescribed for acute attacks. Patients with angina should carry the product with them, especially to any PT appointments
• Antiplatelet therapy (e.g. daily aspirin or clopidogrel (Plavix) or others) will be prescribed to reduce risk of MI & stroke
• A statin and/or other cholesterol lowering drugs will be prescribed to reduce total cholesterol, LDL, & increase HDL as well as reduce risk of MI/stroke & improve M/M

Front 12

Patients with Coronary Artery Spasm/Variant Angina Should be Prescribed

Back 12

• Usually a chronic daily medication (prophylactic therapy) to prevent attacks. β-blockers are ineffective for variant angina so a CCB and/or daily nitroglycerin will be prescribed
• SL nitroglycerin will be prescribed for acute attacks. Patients with angina should carry the product with them. Attacks are more likely to occur at rest
• Because this type of angina is not caused by atherlosclerotic plaques, patients may or may not be prescribed other preventive therapies such as antiplatelet drugs or statins

Front 13

Exercise recommendations for patients with angina pectoris

Back 13

• Benefits of regular exercise outweigh potential risks. Fitness improves exercise tolerance, reduces symptoms, & improves M/M
• At the cellular level, exercise improves endothelial function, increases nitric oxide release, reduces inflammation, and decreases triglycerides & increases HDL (good cholesterol)
• Habitually sedentary patients who engage in strenuous activity are at increased risk of MI & death. Such patients should engage in low-intensity, supervised activity initially
• Low intensity aerobic training 3 x weekly initially (<40% of max aerobic capacity; 50-70% of max HR). Exercise intensity may progressively be increased as tolerated
• An exercise stress test can determine a safe exercise prescription including target HR. Should ischemia or angina symptoms occur during exercise testing, the target HR should generally be fixed at 10 beats/min below the observed ischemic threshold
• Avoid physical exertion in very cold or hot, humid conditions

Front 14

Exercise recommendations for patients with angina pectoris

Back 14

• Provide adequate warm up and cool down
• If angina symptoms occur, stop activity immediately, have the patient sit & rest
• Have the patient use his/her SL nitroglycerin if available
• Be prepared to communicate pertinent health information to EMS persons
• Clients may deny the need for medical attention. You must balance between respecting the individual’s boundaries & taking prudent action on the person’s behalf