Patients' Knowledge In Usage Of Sublingual Glyceryl Trinitrate

1. RESEARCH TITLE:
PATIENTS’ KNOWLEDGE IN USAGE OF
SUBLINGUAL GLYCERYL TRINITRATE
BY :
KAVITHA SATHASIVAN
AMAL MUSLIHA BINTI MOHD SIRAN
OCT 2012

2. INTRODUCTION
• Angina pectoris can be described a clinical syndrome
characterized by discomfort in the chest, jaw, shoulder, back, or
arms.
(ESC Guideline, 2006)
• Glyceryl trinitrate is used to treat and prevent chest pain, which
is symptom of angina and other heart conditions.
• It widens the arteries that carry blood to the heart msucle and
relax the vein that return blood from the body to the heart.
(Micromedex, 2010)

3. INTRODUCTION
• It is important for the patients to know how to use the glyceryl trinitrate
tablet because it helps one during a life-threatening situation
• Poor knowledge on SLGTN usage may lead to poor management of cardiac
condition. (Ming-I Fan et. al, 2009)
• But there is no formal studies have been conducted to evaluate the patients’
understanding about it’s use.

4. BACKGROUND LITERATURE
• Patients showed a depressing lack of knowledge of their drug treatment, and
many did not know how to take sublingual glyceryl trinitrate tablets correctly.
(George R Bailie et. al, 1988)
• E.M. McGovern et. al, 2001 has studied on Pharmaceutical care needs of
patients with angina.
Result:
1) GTN administration technique in almost one third of
angina patients was poor
2) knowledge of when appropriate medical help should be sought was poor.

5. AIM & OBJECTIVES
AIM
• To increase Hospital Putrajaya patient’s awareness on the importance of
knowledge on the proper way of using the GTN tablet prescribed to them.
OBJECTIVE OF STUDY
• To evaluate the significance of counseling on SLGTN among patients.
• To assess patient’s knowledge in usage of sublingual glyceryl trinitrate in
Hospital Putrajaya.
• To identify the significance between the demographic characteristics and
knowledge of the subjects on GTN.

6. STUDY DESIGN
METHOD
Data obtained are then evaluated, organized and
analyzed using paired T-Test, independent T-Test and
one-way ANOVA in SPSS software

7. METHOD
• Type of study : Survey (questionnaire)
• Study design : Observational study
• Study area : Outpatient Pharmacy (OPD), Putrajaya
Hospital
• Study period : April - July 2012

8. METHOD
• Population sample : All OPD patients prescribed with SLGTN
(first time users, partial medication or partial-partial medication)
• Sampling technique / procedure : Convenience Sampling

9. METHOD
• Data Collection Tools:
– 15 questionnaires
• Section A: Demographic of patients
• Section B : Knowledge of SLGTN
• Data analysis :
• SPSS 15
• Descriptive analysis
• Independent T-test
• Paired T-test
• One-way ANOVA Test

10. METHOD

12. METHOD
PATIENT SELECTION CRITERIA
INCLUSION CRITERIA
• Patients from OPD of HPJ who are prescribed with sublingual GTN.
EXCLUSION CRITERIA
• Patients who are not prescribed with GTN.
• Patients from other hospital who comes to collect their partial sublingual
GTN tablets in Hospital Putrajaya.
• Patients who send their relatives or representatives to collect their partial
GTN medication.
• 4) Patients who have not attempted first assessment of questionnaire.
• 5) Patients who collect their partial medication via ‘Sistem Perubatan Ubat
Bersepadu’ and ‘Ubat Melalui Pos’.

13. Demographic Data
Variables n Percentage (%)
Gender Male 39 70.9
Female 16 29.1
Age 31-40 6 10.9
41-50 10 18.2
51-60 19 34.5
61-65 12 21.8
>65 8 14.5
Status Single 0 0
Married 50 90.9
Divorced 3 5.5
Widow 2 3.6
Race Malay 39 70.9
Chinese 7 12.7
Indian 7 12.7
Others 2 3.6
Education level Primary 10 18.2
Secondary 23 41.8
Tertiary 22 40

14. STATISTICAL ANALYSIS
Before Intervention
• Descriptive analysis was done to analyze the demographic data.
• Independent T-Test was used to determine the significance of gender with
the knowledge level regarding sublingual glyceryl trinitrate. (SLGTN)
• One-way ANOVA test was used to determine the significance between
education level and the knowledge level regarding sublingual glyceryl
trinitrate.
After Intervention
• Paired T-Test was used to compare the mean score of the participants before
and after intervention.
*Performed by using SPSS 16.0, Chicago, IL. For all tests, a p < 0.05 was
defined as statistically significant.

15. RESULT ANALYSIS
• Scoring system was used.
• Total score of 11 and above were considered the patient has a good
knowledge.
• Comparison of the score between the results of pre-intervention and post-
intervention.

16. Pre & Post Intervention Result
Comparison of level of SLGTN knowledge in patients in pre and
post intervention
n Mean (+SD) P value
Pre -intervention 55 8.36 (+2.4) P ≤ 0.01
Post-intervention 55 12.41 (+1.15)
Discussion
• From the data, there was significance difference after the intervention is done
which indicates that the participants’ knowledge was improved significantly.
• It is known that repetition of patient counseling increases patients’ recall of
education advice (Jowett and Thompson ,2003).

17. Knowledge Description
Pre Post
Question f(n) (%) f(n) (%) Pvalue
MOA GTN 38 69.1 52 94.5 P≤0.01
When to take GTN 50 90.9 55 100 P=0.02
Can GTN prevent chest pain? 30 54.5 42 76.4 P=0.02
Right way to consume GTN 51 92.7 55 100 P=0.04
Appropriate body position when
taking GTN 35 63.6 55 100 P≤0.01
GTN Storage 36 65.5 51 92.7 P=0.01
GTN onset action 6 10.9 38 69.1 P=0.01
GTN Duration of action 4 7.3 6 10.9 P=0.53
Action when first dose GTN
ineffective 36 65.5 54 98.2 P≤0.01
Gap time before another tablet 22 40 54 98.2 P≤0.01
Max GTN dose over 15 min 24 43.6 49 89.1 P≤0.01
Action if 3 doses ineffective 50 90.9 55 100 P=0.02
GTN side effects 9 16.4 19 34.5 P=0.01
Expiry awareness 49 89.1 55 100 P=0.01
Expiry date 20 36.4 43 78.2 P≤0.01

18. Knowledge Description
All showed significance
difference except for
duration of action P=0.53

19. RESULT ANALYSIS
n=38
(69.1%)
n=6
(10.9%)
post-pre=
58.2%

20. RESULT ANALYSIS
n=6
(10.9%)
Wrong answer– 60%
n=4 Right answer – 40%
(7.3%)
N=28
50.9%
N=5
9.1%

21. RESULT ANALYSIS
n=54
(98.2)
Wrong answer– 83.6%
Right answer – 16.4%
n=22
(40%)
N=2
3.6%
post-pre=
58.2%

22. RESULT ANALYSIS
n=49
(89.1%)
Wrong answer–
n=24
63.4%
(43.6%) Right answer – 36.4%
N=20
post-pre=
36.4% 45.5%
•Patients who do not understand dose limitations are at risk of using
SLGTN ineffectively while having chest pain.
•Thus decrease their enabling skills to manage their chronic cardiac
condition (Timmins and Kaliszer, 2003).

23. RESULT ANALYSIS
n=19
(34.5%)
Wrong answer–
63.4%
Right answer – 36.4%
n=9
(16.4%)
N=20
36.4%
post-pre=
18.1%

24. RESULT ANALYSIS
n=43
(78.2%)
n=20
(36.4%)
post-pre=
41.8%
•This finding is similar to a study where 33% of the patients do not know the new
expiry date after opening the bottle.
•Possibility of patients using medication with reduced potency. Thus, being
ineffective in improving myocardial oxygen supply for symptom control
immediately (Ming-I Fan et.al, 2009).

25. Result: Education Level
• Significance between education level and level of SLGTN
knowledge in pre intervention
Comparison of education level P value
Primary Tertiary 0.641
Secondary Primary 0.783
Tertiary Secondary 1.0
Discussion
•From the data, there was no significant difference between groups of different
education background.
•This shows education level does not effect the knowledge of patient on SLGTN
usage.
•This is contradicting with finding of a study stating that the more educated do
appear to be better informed, and appear to make use of health related
information (Cutler et al. 2006)

26. Result: Gender
Significance between gender and level of SLGTN knowledge in pre
intervention
Variable n Mean (+SD) P value
Male 39 12.41 (+1.19) P ≤ 0.75
Female 16 12.44 (+ 1.09)
Discussion
•As of the gender, there was no significant difference between the male and
female participants’ knowledge of SLGTN.
•This result is similar to a study conducted in a hospital in Australia (Ming-I Fan
et al, 2009) which concludes that there is no significant difference between
gender differences on SLGTN knowledge.

27. DISCUSSION
• In this study most of the participants have lack of knowledge
regarding the onset time (10.9% ,n=6), expiry date (36.4% ,n=20), gap
time in between tablets of SLGTN (40.0% ,n=22), duration of action
(7.3% ,n=4), and the side effects of this medication (16.4% ,n=9).
• Findings suggested patients need to improve their knowledge level in
using and management which may further support self-care of their
cardiac condition (Lehne, 2004).

28. DISCUSSION
• Before the intervention, the minimum score was 2.00. This depicted that
the patients do not understand about the SLGTN.
• This can be very dangerous since the deficit in patients’ knowledge may
cause poor management of their cardiac condition and more frequent
episodes of angina (Adams et al 2005).

29. LIMITATION
• Small samples size
–number of patients taking SLGTN in Hospital Putrajaya is small in size.
• Sampling errors
- biased (partial users also included)
• Counseling by pharmacist was not standardized
- counseling points differ
• Knowledge reassessment
- was conducted via phone call , not conducted face to face to really ensure that
the same person has been interviewed.

30. CONCLUSION
1) There is improvement in patient’s knowledge on SLGTN usage after
they were given counseling (P ≤ 0.01).
2) Patients need to improve their knowledge on the administration and
dose of GTN, side effects and expiry of GTN.
3) There is no significant difference of education level and gender on
patients’ knowledge on SLGTN usage.

31. RECOMMENDATION
• To develop a checklist comprising of a standard guideline of
counseling points on SLGTN usage
• Written information is beneficial in increasing patients’ knowledge on
their medicines especially when combined with oral information.
(George R Bailie et. al, 1988)

32. REFERENCES
• Amal, N.M. et al., 2011. Prevalence of Chronic Illness and Health Seeking
Behaviour in Malaysian Population ( NHMS III ) 2006. Med J Malaysia,
66(1), p.36-41.
• Cheah W.L. et al., 2010. A Preliminary Study on the Prevalence of
Cardiovascular Disease Risk Factors in Selected Rural Communities in
Samarahan and Kuching Division, Sarawak, Malaysia Malaysian J Med Sci,
18(2), p.58-6
• World health Organization. The Basic Document, 32th edition. Geneva,
Switzerland: World Health Orgnization; 1982.

33. REFERENCES
• Guidelines on The Management of Angina Pectoris, European Heart Journal,
2006 http://www.escardio.org/guidelines-surveys/esc-
guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf Accesed on 18
February 2012 at 7.00 pm
• Maclean, F.K. et al., 1980. An assessment of the clinical use of glyceryl
trinitrate in a hospital outpatient population. Australian and New Zealand
journal of medicine, 10(1), p.12-14.
• Ingram N., 1999. Cardiac patients' perceived education and use of sub-lingual
glyceryl trinitrate on commencement of outpatient cardiac rehabilitation.
Coronary Health Care (3)3, P. 128–134

34. REFERENCES
• Fang M., 2006. Cardiac patients’ knowledge and use of sublingual glyceryl
trinitrate (SLGTN). Australian Journal of Advanced Nursing, 26(3), p.32-38
• Manufacturer's PIL, Glyceryl Trinitrate Tablets, Actavis UK Ltd, electronic
Medicines Compendium http://www.medicines.org.uk/emc/document.aspx?
documentId=18092 Accessed on 18 February 2012 at 9.00 pm
• MIMS USA online
• http://www.mims.com/USA/drug/info/glyceryl%20trinitrate/glyceryl
%20trinitrate?type=full Accessed on 18 February 2012 at 9.10 pm

35. REFERENCES
• Jowett, N. and Thompson, D. 2003. Comprehensive coronary care (3 rd
ed). Bailliere Tindail: London, UK
• Lehne, R. 2004. Pharmacology for cursing care (5 th ed). W.B.
Saunders, St. Louis, Missouri, USA.
• Timmins, F. and Kaliszer, M. 2003. Information needs of myocardial
infarction patients. European Journal of Cardiovascular Nursing, 2
(1), p.57-65.

36. APPENDIX
SLGTN Counseling Guideline