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Premium member Presentation Transcript ATI Book: Unit 4 CHAPTER 42 & 44: ATI Book: Unit 4 CHAPTER 42 & 44 DRUGS FOR ANGINA PECTORIS: Nitrates AND Calcium Channel BlockersDRUGS FOR ANGINA PECTORIS: pg 624: DRUGS FOR ANGINA PECTORIS: pg 624 Sudden pain beneath the sternum, often radiating to left shoulder and arm Oxygen supply to the heart is insufficient to meet oxygen demand Prevention of myocardial infarction and death Prevention of myocardial ischemia and anginal pain Angina pectoris Two goals of angina drug therapyDrugs for Angina Pectoris: Drugs for Angina Pectoris Three families of antianginal agents (table 42-3) Organic nitrates Nitroglycerin Beta blockers: discussed in Chapter 18 Example: propranolol Calcium channel blockers Example: verapamilChronic Stable Angina (Exertional): Chronic Stable Angina ( Exertional ) Stable angina is often predictable. Same amount of exertion may cause anginal pain to occure & angina should diminish or go away when exertion stops Therapeutic agents (provide symptomatic relief) Organic nitrates : dilates veins, reduces venous return which decreases cardiac effort & thus o2 demand Nondrug therapy (page 624) Avoid factors that can precipitate angina: i.e stress, exertion Decrease risk factors: i.e weight, smokingVariant Angina (Prinzmetal’s – Vasospastic): Variant Angina ( Prinzmetal’s – Vasospastic ) Pathophysiology Coronary artery spasm Treatment strategy Increasing cardiac oxygen supply Therapeutic agents Organic nitrates: prevents or reduces vasospasm increasing oxygen supplyUnstable Angina – Medical Emergency: Unstable Angina – Medical Emergency Severe CAD complicated by vasospasm Pathophysiology Symptoms of angina at rest New-onset exertional angina Intensification of existing angina Treatment strategy Maintain oxygen supply Decrease oxygen demandAnti-Ischemic Therapy: Anti-Ischemic Therapy M : IV morphine O : Supplemental O2 N: Nitroglycerin A : ASA Add: Beta blockersAntiplatelet/Anticoagulant Therapy: Antiplatelet/Anticoagulant Therapy Aspirin (indefinitely) Clopidogrel (Plavix) Abciximab ( ReoPro ) Eptifibatide ( Integrilin ) Anticoagulant therapy Subcutaneous LMW heparin or IV unfractionated heparinOrganic Nitrates: Organic Nitrates Nitroglycerin: page 625 Stable and variant angina Vasodilator Adverse effects Headache Orthostatic hypotension Reflex tachycardia: HR goes way up because of sudden drop in BPOrganic Nitrates: Organic Nitrates Tolerance Can develop rapidly To minimize, use the lowest effective dose Patch: 10-12 hours patient should be “patch-free” Drug interactions Hypotensive drugs Beta blockers, verapamil, and diltiazemOrganic Nitrates: Organic Nitrates Therapeutic uses summarized Acute anginal therapy: SL every 5 minutes x 3 doses IV for perioperative control of blood pressure, and treatment of heart failure with MI, unstable angina, and uncontrolled exacerbations of chronic anginaSPECIAL CONSIDERATIONS: NTG Page 626 : SPECIAL CONSIDERATIONS: NTG Page 626 12 #1 complaint: Headache **educate patient that the med. is working as it should Dizziness, postural hypotension Avoid ETOH- potentiates hypotension Contraindicated in pts taking phosphodiesterase inhibitors (PDE-5) inhibitors--drugs for ED- these drugs are vasodilators too!!!Calcium Channel Blockers (page 666): Calcium Channel Blockers (page 666) Calcium helps open the “electrical gates” for the SA node to fire Serves as a mediator in prompting the other cardiac cells to beat or “contract” CCBs are drugs that block calcium ions from entering cellsCalcium Channel Blockers : Calcium Channel Blockers VERY : Verapamil NICE: nifedipine DRUGS : Diltiazem 14CALCIUM CHANNEL BLOCKERS: page 628: CALCIUM CHANNEL BLOCKERS: page 628 Verapamil, diltiazem, nifedipine Block calcium channels in vascular smooth muscle (VSM) Used for stable and variant angina Adverse effects Reflex tachycardia Hypotension Bradycardia AV blockClassification and Sites of Action : Classification and Sites of Action Verapamil and Diltiazem Agents that act on vascular smooth muscle and the heart Hemodynamic effects Direct effects on the heart and blood vesselsGreatest impact on heart and blood vessels: Greatest impact on heart and blood vessels By dilating the arteries, CCBs reduce arterial pressure makes it easier for the heart to pump blood CCBs also slow the rate at which the heart beats Used for treating certain types of abnormally rapid heart rhythmsVerapamil (Calan, Covera-HS, Isoptin, Verelan): Verapamil (Calan, Covera-HS, Isoptin, Verelan) Drug interactions Digoxin : increased risk of heart block, bradycardia Beta-adrenergic blocking agents : both have the same effect so risk of excessive cardiosuppression (admin. Iv verapamil & beta blockers hours apart) Toxicity Severe hypotension Bradycardia and AV blockDiltiazem (Cardizem, Cartia XT, Dilacor, Diltia XT, Tiazac): Diltiazem (Cardizem, Cartia XT, Dilacor, Diltia XT, Tiazac) Therapeutic uses Angina pectoris Hypertension Cardiac dysrhythmias Atrial flutter, atrial fibrillation, paroxysmal tachycardiaNifedipine (Adalat, Nifedical, Nifediac, Procardia) : Nifedipine (Adalat, Nifedical, Nifediac, Procardia) Vasodilation by blocking calcium channels Blocks in vascular smooth muscle Significant blockade of calcium channels in blood vessels Minimal blockade of calcium channels in the heart Because very little blockade of heart Ca channels CANNOT be used to treat dysrhythmiasNifedipine (Adalat, Nifedical, Nifediac, Procardia) : Nifedipine (Adalat, Nifedical, Nifediac, Procardia) Direct effects Limited to blockade of Ca channels in VSM Indirect effects—reflex tachycardia Lowered BP activates baroreceptor reflex Primarily with fast-acting versus sustained release Can prevent w/ a betablockerCCBs…. Adverse effects : CCBs…. Adverse effects Flushing Dizziness Headache Gingival hyperplasia: associated with poor dental hygiene & higher doses of CCBsNifedipine (Adalat, Nifedical, Nifediac, Procardia): Nifedipine (Adalat, Nifedical, Nifediac, Procardia) Adverse effects (cont’d) Rapid-acting nifedipine (not sustained) Has been associated with increased mortality in patients with MI and unstable angina No cause and effect relationship established NHLBI recommends these be used with great caution You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.