This document discusses drugs used to treat angina pectoris. It describes three main classes of drugs: organic nitrates, beta blockers, and calcium channel blockers. Organic nitrates work by dilating blood vessels to reduce preload and afterload on the heart. Beta blockers slow the heart rate and reduce contractility. Calcium channel blockers relax blood vessels to lower blood pressure and heart rate, reducing cardiac workload. The goals are to decrease oxygen demand on the heart muscle and bring more oxygen to it in order to relieve chest pain and prevent further heart issues.

1. Cardiovascular Drugs
Angina Pectoris
By Mr Asif Ali Lashari
Nursing Lecturer

2. Physiology
All tissues and organs of the body are dependent on a
continuous arterial supply of oxygen and other vital
nutrients to support life and health.
With its high metabolic requirements, the heart is especially
demanding of a steady source of oxygen.

3. Preload and Afterload
Preload:
Preload, also known as the left ventricular end-diastolic pressure
(LVEDP), is the amount of ventricular stretch at the end of
diastole.
Think of it as the heart loading up for the next big squeeze of the
ventricles during systole.
Afterload:
Afterload, also known as the systemic vascular resistance (SVR),
is the amount of resistance the heart must overcome to open the
aortic valve and push the blood volume out into the systemic
circulation.

4. What will happen if Myocardium becomes
compromised of the oxygen supply ?

5. Angina pectoris
Angina pectoris is acute chest pain caused by
insufficient oxygen to a portion of the myocardium.
The classic presentation of angina pectoris is steady,
intense pain in the anterior chest, sometimes
accompanied by a crushing or constricting sensation.

7. Angina: Goals of Pharmacologic
Management
The primary goal is to reduce the intensity and frequency
of angina episodes.
Additionally, successful pharmacotherapy should improve
exercise tolerance and allow the patient to actively
participate in activities of daily living.
Long-term goals include extending the patient’s life span
by preventing serious consequences of ischemic heart
disease such as dysrhythmias, HF, and MI.

8. Antianginal medications may be placed into two basic categories:
 Those that terminate an acute angina episode in progress.
 And those that decrease the frequency of angina episodes.
Antianginal drugs accomplish these goals by reducing the
myocardial demand for oxygen.

9. This may be accomplished by the following
mechanisms:
Slowing the heart rate.
Dilating veins so the heart receives less blood
(reduced preload).
Causing the heart to contract with less force
(reduced contractility).
Lowering blood pressure, thus offering the heart less
resistance when ejecting blood from its chambers
(reduced afterload).

10. Angina: Pharmacologic Management
The pharmacotherapy of angina consists of three classes of drugs:
Organic nitrates.
Rapid-acting organic nitrates are drugs of choice for terminating an
acute angina episode.
Long-acting nitrates, given by the oral or transdermal routes, are
effective alternatives for prophylaxis
Beta-adrenergic antagonists.
First-line drugs for preventing angina pain.
Calcium channel blockers.
Used when beta blockers are not tolerated well by a patient.

11. Angina: Pharmacologic Management
Ranolazine (Ranexa) is a newer drug for angina that is believed to
act by shifting the metabolism of cardiac muscle cells so that they
use glucose as the primary energy source rather than fatty acids.
This decreases the metabolic rate and oxygen demands of
myocardial cells.
Thus, this is the only antianginal that acts through its metabolic
effects, rather than hemodynamic effects.
It is used to prevent anginal episodes.
It will not terminate an acute attack.
The drug is approved only for chronic angina that has not
responded to other drugs.

13. Organic Nitrates
The primary therapeutic action of the organic nitrates is their ability to
relax both arterial and venous smooth muscle.
Dilation of veins reduces the amount of blood returning to the heart
(preload), so the chambers contain a smaller volume.
With less blood for the ventricles to pump, cardiac output is reduced
and the workload on the heart is decreased, thereby lowering
myocardial oxygen demand.
The therapeutic outcome is that chest pain is alleviated and episodes
of angina become less frequent.
Organic nitrates also have the ability to dilate coronary arteries.

14. Organic Nitrates
This action, however, is crucial in treating vasospastic angina, in which
the chest pain is caused by coronary artery spasm.
The organic nitrates can relax these spasms, allowing more oxygen to
reach the myocardium, thereby terminating the pain.
The organic nitrates can relax these spasms, allowing more oxygen to
reach the myocardium, thereby terminating the pain.
Organic nitrates are of two types, short acting and long acting.
The short-acting nitrates, such as nitroglycerin, are taken sublingually
to quickly terminate an acute angina episode.
Long-acting nitrates, such as isosorbide dinitrate, are taken orally or
delivered through a transdermal patch to decrease the frequency and
severity of angina episodes.

15. Organic Nitrates

17. Nursing Process for patients receiving
Organic Nitrates

18. Assessment
Obtain a complete health history including cardiovascular (including
previous MI, HF, valvular disease), cerebrovascular and neurologic
(including level of consciousness, history of stroke, head injury,
increased intracranial pressure), renal or hepatic dysfunction,
dysrhythmias, and pregnancy or lactation.
Obtain a drug history including allergies, current prescription and over-
the-counter (OTC) drugs, herbal preparations, and alcohol use.
Obtain baseline weight, vital signs (especially blood pressure [BP] and
pulse), and ECG. Assess for location and character of angina if
currently present.

19. Assessment throughout administration
Assess for desired therapeutic effects (e.g., chest pain has subsided
or has significantly lessened), heart rate and BP remain within
normal limits, and ECG remains within normal limits without signs of
ischemia or infarction.
Continue periodic monitoring of ECG for ischemia or infarction.
Continue frequent monitoring of BP and pulse whenever IV nitrates
are used or when giving rapid-acting (e.g., sublingual) nitrates. With
sublingual nitrates, take BP before and 5 minutes after giving the
dose and hold the drug if BP is less than 90/60, pulse is over 100, or
parameters as ordered, and consult with the health care provider
before continuing to give the drug.

20. Nursing Diagnosis
Decreased Cardiac Output.
Acute Pain.
Fatigue.
Activity Intolerance.
Deficient Knowledge (drug therapy).
Risk for Decreased Cardiac Tissue Perfusion, related to
adverse drug effects.
Risk for Falls, related to adverse drug effects.
Risk for Injury, related to adverse drug effects.

21. Nursing Interventions
Continue frequent assessments as above for therapeutic effects. (Because
nitrates cause vasodilation, preload and afterload diminish, decreasing
myocardial oxygenation needs, and chest pain diminishes).
Continue to monitor ECG, BP, and pulse. (Nitrates cause vasodilation and
possible hypotension. BP assessment aids in determining drug frequency and
dose. ECG monitoring helps detect adverse effects such as reflex tachycardia,
ischemia, or infarction).
For patients on transdermal nitroglycerin patches, remove the patch for 6–12
hours at night, or as directed by the health care provider. (Removing the patch
at night helps to prevent or delay the development of tolerance to nitrates.
Removing the patch at night, when cardiac workload is lessened, helps avoid
possible anginal attacks during the daytime when workload is greater.)

22. Beta Adrenergic Blockers
Beta-adrenergic antagonists or blockers reduce the cardiac workload
by slowing the heart rate and reducing contractility.
These drugs are as effective as the organic nitrates in decreasing the
frequency and severity of angina episodes caused by exertion.
Unlike the organic nitrates, tolerance does not develop to the
antianginal effects of the beta blockers.
They are ideal for patients who have both hypertension and CAD
because of their antihypertensive action.
Beta-adrenergic blockers are drugs of choice for the prophylaxis of
stable angina.

23. Beta Adrenergic Blockers
Not effective for treating vasospastic angina and may, in fact,
worsen this condition.
Side Effects

25. Calcium Channel Blockers
Used for a number of cardiovascular conditions, including hypertension.
CCBs relax arteriolar smooth muscle, thus lowering BP.
This reduction in afterload decreases myocardial oxygen demand.
Some of the CCBs also slow conduction velocity through the heart,
decreasing heart rate and contributing to the reduced cardiac workload.
An additional effect of the CCBs is their ability to dilate the coronary
arteries and bring more oxygen to the myocardium.
This is especially important in patients with vasospastic angina.