Antianginal drug

1. ANTIANGINAL
DRUGS
Presented by :- Pankaj rana
Nurse Practitioner Critical care

2. Introduction :
• Angina pectoris is characterized by sudden
severe pressing chest pain or heaviness
radiating to the neck, jaw, back and arms.
• It is often associated with diaphoresis,
tachypnea and nausea.
• Angina is caused by coronary flow that is
insufficient to meet oxygen demands of the
myocardium.

3. There are three types of Angina :
1. Stable Angina
2. Unstable Angina
3. Prinzmetal (variant) angina

4. Stable Angina
• Attacks are predictably provoked
by exercise, emotion etc. It lasts
for several seconds and subsides
on rest.
• “Stable” indicates the
reproducible nature of the
angina; the same activity at the
same intensity faithfully
produces symptoms.

5. Unstable Angina
• The unstable angina is
characterized by recurrent
attacks of angina.
• It occurs with minimal
exertion.
• It is precipitated due to
combination of athero
scleroti-plaque, platelet
aggregation at ruptured
plaque and vasospasm.

6. Prinzmetal (Variant) Angina
• This is a relatively uncommon pattern of
myocardial ischemia usually occurring at rest
or during sleep and often in young individuals.
• It is induced by coronary artery vasospasm, it
generally responds promptly to vasodilators.

7. Antianginal Drugs:
1. Nitrates:
• Glyceryl trinitrate (Nitroglycerin)
• Isosorbide dinitrate, Isosorbide mononitrate
2. Beta-blocker
• Atenolol, propranolol, metoprolol
3. Calcium channel blocker
• Nifedipine, amlodipine
4. Potassium channel opener
Nicorandil

8. Nitrates:
• They act directly on all the smooth muscle of
the body & relax them.
• Nitrates release nitric oxide which is a
powerful muscle relaxants.
• Most predominant in the vascular smooth
muscles (i.e walls of arteries & veins).

9. Action of nitrates
Effects on
other smooth
muscles
Redistribution
of coronary
flow
Afterload
reduction
Preload
reduction

10. Preload reduction
Nitroglycerin relaxes vascular smooth muscle and
dilates both arterial and venous vessels.
Dilation of veins is more predominant than dilation of
arteries, resulting in peripheral pooling of blood &
decreased venous return.
decreased preload

11. Afterload reduction
Nitrates also produce some arteriolar dilatation
Decrease peripheral resistance
Reduction of afterload

12. Redistribution of
coronary flow
Dilatation of coronary arteries
Increase blood supply to the myocardium

13. Effects on other smooth
muscles
• Relax the bronchi, biliary tracts & esophagus
muscles.
• Also dilates cutaneous vessels & meningeal
vessels .

14. Ca++ channel blockers
vasodilation
Decreased intracellular ca++ & causes smooth muscles
relaxation
Block the entry of ca++ ions into the smooth & cardiac
muscles

15. Beta blockers
It reduces the cardiac work & O2 consumption.
Potassium channel opener
Prominent action is relaxation of smooth
muscles

16. Therapeutic uses of
antianginal drugs
Nitrates:-
• Angina pectoris
• MI
• Congestive cardiac failure
• Biliary colic
• Cyanide poisoning
• Oesophageal spasm

17. Beta & calcium channel blockers:
• Hpertension
• Angina
• Cardiac arrhythmias

18. Adverse effects of Antianginal
drugs:
1.nitrates
• Postural hypotension & syncope particularly with
sublingual use.
• Headache & flushing
• Methemaglobinemia
• Contact dermatitis

19. 2.Calcium channel blockers:-
constipation
headache
dermatitis
3. beta blockers:
Hypotension
Depression
Bradycardia
Heart block
CHF

20. Contraindication of antianginal
drugs
• Nitrates:
hypersensitivity
severe hypotension
anemia
• Beta blockers:
heart block
pulmonary edema
cardiogenic shock

21. Common Drugs are :-
1. Glyceryl trinitrate (Nitroglycerin)
2. Isosorbide dinitrate, Isosorbide
mononitrate,

22. Nitroglycerin

23. Action
• Decreased preload
• Decreased afterload
• Dilates coronary arteries
• Dilates arterial or venous bed systematically

24. Indication
• Stable angina pectoris
• CHF

25. Available
forms
1. Sublingual Tablets.
2. Topical Ointment and
Transdermal Patches.
3. Translingual Spray.
4. Transmucosal Tablets.
5. Intravenous (IV).

28. Nitroglycerine
Preparation Dose Route Onset/Dura
tion of
action
Trade name
Tablets
1,2,3 mg
0.5 mg Sublingual 1 -3 min/30
min
Angised
spray 0.4 – 0.8 mg Sublingual 2 min/60 min Nitrolingual
capsule 5-15 mg oral 20min/4-8 hr Angispan-tr
Transdermal
patch,5-10 mg
one patch for
14 to 16 hr per
day
skin Max. 24 hrs Nitroderm-tts
Injection
5mg/ml
5-20
microgram/min
intravenous 2min/5 min Nitroject
ointment 2% skin 30 min/12 hr Nitrol

29. Side effects
• Headache, flushing, hypotension, dizziness
Contraindication
Hypersensitivity
Severe anaemia
Increased ICP
Cerebral haemorrhage

30. Isosorbide
1.Isosorbide mononitrate
2.Isosorbide dinitrate

31. •Is a nitrate.
•Like nitroglycerin, and is used for treating and preventing
angina.
•It is NOT used to treat HTN.
•Is given Sublingual or Per Oral .
•SL Isosorbide has a slower onset and a longer duration of
action compared to SL nitroglycerin .
•Because SL isosorbide does NOT relieve chest pain as
rapidly as introglycerin, Isosorbide is limited to treating
acute angina in patients intolerant or unresponsive to SL
nitroglycerin .

32. Dose & Route
1.Isosorbide mononitrate:-
20 to 40 mg orally
2.Isosorbide dinitrate:
5 -1o mg sublingually or orally

33. NURSING
RESPONSIBILITY
Nursing intervention
Client teaching

34. Nursing intervention
• History collection
• Assess the duration, time started & character of
pain.
• Monitor vital signs.
• Assist in various diagnostic test like ECG, Echo &
other blood investigation.
• Nitrates should be kept away from flame.
• Store nitrates in original container.
• An analgesic can be given to treat headache.

35. In Iv NTG:
• Do not mix NTG with other drugs
• Do not use PVC tubings for IV administration
because its absorb the nitrates.
• Use glass bottles & tubings provided by
manufacturer.
• It is Given by infusion pump.

36. Ointment/transdermal patch
• Remove transdermal patches before defibrillation to
prevents burns.
• Rotate ointment & transdermal patches sites.
• Remove ointment & previous patch before applying
new ointment or patch.
• Do not trim transdermal patch to alter dose.
• Do not rub or massage the area after application of
ointment.
• Apply to the chest, upper arm, or upper thigh to
promote absorption and increase onset of systemic
action.

37. • Do not get ointment on hands as it can cause
headache.
• Wash hands after application.
• Apply to a non hairy sites, avoid application to
skin folds or irritated sites.

38. Transmucosal Tablets:
The nurse should place one tablet between
lip and gum above incisors or between cheek
and gum to promote slow dissolving and
extended absorption.
Sublingual tablets:
Place under the tongue.

39. Spray
• Do not shake when administering & hold
vertically & spray under the tongue.
• Advise do not swallow immediately.

40. Client teaching
• NTG loose potency if exposed to light,
moisture or heat.
• Avoid alcohol, hot bath as they cause
vasodilation & lead to hypotension.
• Teach about adverse effects.
• Encourage client to discontinue tobacco which
causes vasoconstriction.
• Encourage to eat high fiber rich diet.

41. • Instruct client do not chew SL tablets,place
under the tongue.
• Do not eat food or smoke until tablets
dissolve.
• Sublingual tablets;
In cute anginal attacks, teach client to lie
down & take NTG tablets as soon as possible;
upto 3 NTG tablets in every 5 min.
If no relief go for emergency services.