Angina pectoris is a syndrome characterized by sudden severe pressing substernal chest pain or heaviness radiating to the neck, jaw, back and arms. Those drugs used to prevent, abort or terminate angina are anti angina drugs.

1. Drugs presentation
Prepared by
Aasma Poudel
Roll no 01
Critical Care Nursing
BNS 3RD YEAR

2. ANTI-ANGINAL DRUGS
Angina pectoris is a syndrome characterized by sudden severe pressing
substernal chest pain or heaviness radiating to the neck, jaw, back and
arms.
Those drugs used to prevent, abort or terminate angina are anti
angina drugs.

3. Classification of Antianginal Agents
Nitrates:
• Short acting first line treatment for acute angina symptoms (10 minutes):
Glyceryl trinitrate (GTN and Nitroglycerine) emergency
• Long acting (1 Hour): Isosorbide dinitrate (short acting by sublingual route)
Isosorbide mononitrate, Erythrityl tetranitrate, Pentaerythritol tetranitrate
Calcium Channel Blockers:
• Phenyl alkylamine: Verapamil
• Benzothiazepin: Diltiazem
• Dihydropyridines: Nifedipine, Felodipine, Amlodipine, Nitrendipine and
Nimodipine

4. Classification contd…
Beta adrenergic Blockers: Propranolol, Metoprolol, Atenolol and
others
Potassium Channel openers: Nicorandil
Others: Dipyridamole, Trimetazidine, Ranolazine and oxyphedrine

5. Clinical Classification
Used to abort or terminate attack : GTN, Isosorbide dinitrate
(sublingually).
Used for chronic prophylaxis : All other drugs

6. Nitroglycerine/ Glyceryl trinitrate
It is a volatile liquid, which is adsorbed on the inert matrix of the
tablet and rendered nonexplosive
Chemical class: Nitrate
Therapeutic class: Antianginal, Antihypertensive, vasodilator
Pregnancy category: C

7. Mechanism of action

8. Preparations Dose and Route
 Angised 0.5 mg tab  0.5 mg sublingual  10 to 30 minutes
 Nitrolingual, GTN 0.4 mg per spray  0.4–0.8 mg sublingual.
Spray 10–30 min
 Trans lingual spray Adults.
For treatment, one or two metered doses (0.4 or 0.8 mg) onto or
under tongue, repeated every 5 min as needed( Max 3 tab) For
prevention, one or two metered doses (0.4 or 0.8 mg) onto or
under tongue 5 to 10 minutes before activities that could lead to
acute attack.

9. Preparations dose and route contd…
 Angispan-tr 2.5, 6.5 mg nitrocontin, corodil 2.6, 6.4 mg tabs  SR cap5 -
15 mg oral  4–8 hr
 Nitroderm TTS 5 or 10 mg patch one patch for 14–16 hr. per day max 24
hr. till applied
 Myovin, Millisrol, Nitroject 5–20 μg/min  i.v.
• Diluted in D5, D5W, 0.9% NaCl for infusion to 200-400 mcg/ml,
depending on patient’s fluid status; common dilution 50 mg/250 ml,
• Increased by 5 mcg/ min every 3 to 5 min to 20 mcg/min, as prescribed and
then by 10 to 20 mcg/min every 3 to 5 min until desired effect occurs.

10. Uses
Chronic Stable Angina Pectoris,
Prophylaxis Of Angina Pain,
CHF,
Acute MI,
Controlled Hypotension For Surgical Procedures,
Anal Fissures

11. Contraindications
Hypersensitivity to this Product Or Nitrites
Severe Anemia, Increased Intracranial Pressure,
Cerebral Hemorrhage, hypovolemia
Closed-Angle Glaucoma,
Cardiac Tamponade,
Cardiomyopathy,
Constrictive Pericarditis
Hyperthyroidism

12. Precautions
Pregnancy (C),
Breastfeeding,
Children,
Postural Hypotension,
Severe Renal/Hepatic Disease,
Abrupt Discontinuation,

13. Adverse reaction
CNS: Agitation, anxiety, dizziness, headache, insomnia, restlessness,
syncope, weakness
CV: Arrhythmias (including tachycardia), edema, hypotension, orthostatic
hypotension, palpitations
EENT: Blurred vision, burning or tingling in mouth (buccal, S.L. forms),
dry mouth
GI: Abdominal pain, diarrhea, indigestion, nausea, vomiting
GU: Dysuria, impotence, urinary frequency

14. Adverse reaction contd…
HEME: Methemoglobinemia
MS: Arthralgia
RESP: Bronchitis, pneumonia
SKIN: Contact dermatitis (transdermal forms), flushing of face and neck,
rash

15. Isosorbide dinitrate
It is a solid but similar in properties to GTN; can be used sublingually
at the time of attack (slightly slower in action than GTN, peak in 5–8
min) as well as orally for chronic prophylaxis. The half-life is 40 min,
but sustained release formulation may afford protection for 6–10
hours. Last dose should not be taken later than 6 PM to allow
nitrate level to fall during sleep at night.

16. Isosorbide mononitrate:
This is an active metabolite of isosorbide dinitrate. When
administered orally it undergoes little first pass metabolism:
bioavailability is high, inter individual differences are minimal and it
is longer acting (t½ 4–6 hr.). Last dose is to be taken in the afternoon;
SR tablet once a day in the morning.

17. Nursing responsibility:
 Use nitroglycerin cautiously in elderly patients.
 Plan a nitroglycerin-free period of about 10 hours each day, as
prescribed, to maintain therapeutic effects and avoid tolerance.
 Place E.R. buccal tablets in buccal pouch with patient in sitting or lying
position.
 Do not break or crush E.R. tablets or capsules. Have patient swallow
them completely with a full glass of water.
 Place S.L. tablet under patient’s tongue and make sure it dissolves
completely.

18. Nursing responsibility contd…
If patient needs cardioversion or defibrillation, remove transdermal
patch.
Do not shake Trans lingual spray container before administering.
Have patient inhale and hold her breath, and then spray drug under or
on tongue.
Be aware that I.V. nitroglycerin should be diluted only in D5W or
normal saline solution and should not be mixed with other infusions.

19. Nursing responsibility contd…
 The pharmacist should add drug to a glass bottle, not a container made
of polyvinyl chloride. Do not use a filter because plastic absorbs drug.
 Administer with infusion pump.
 Check vital signs before every dosage adjustment and often during
therapy.
 Frequently monitor heart and breathe sounds, level of consciousness,
fluid intake and output, and pulmonary artery wedge pressure, if
possible.
 Store premixed containers in the dark but do not freeze them.

20. Patients teaching
 Teach patient to recognize signs and symptoms of angina pectoris.
 Instruct patient to read and follow package instructions .
 Instruct patient to swallow E.R. tablets and take with a full glass of water.
 For sublingual or buccal use, advise patient to place tablet under her tongue
or in buccal pouch when angina starts and then to sit or lie down.
 If angina does not subside, instruct patient to place another tablet under her
tongue or in buccal pouch after 5 minutes and to repeat, if needed, for three
doses total. If pain doesn’t subside after 20 minutes seek medical help.

21. Patient teaching contd…
 Advise patient to carry S.L. tablets in their original brown bottle in a purse
or jacket pocket, but not one that will be affected by body heat. Instruct to
store drug in a dry place at room temperature and to discard cotton from
container. Advise to discard and replace S.L. tablets after 6 months.
 Advise patient using transdermal ointment or patch to rotate sites to avoid
skin sensitization.
 Inform patient that swimming or bathing doesn’t affect transdermal forms.
Caution against inhaling translingual spray. Before first use, tell patient to
press actuator button 10 times to prime container and then hold container
upright with forefinger on top of actuator button.

22. Nursing responsibility contd…
Do not spit out the drug or rinse mouth for 5 to 10 minutes after
translingual spray.
Remind patient to periodically check level of fluid in container. If it reaches
the top or middle hole on side of container, more should be obtained.
Caution patient not to let level of liquid get to bottom of hole.
 Inform patient that nitroglycerin commonly causes headache, which
typically resolves after a few days of continuous therapy. Suggest taking
acetaminophen, as needed.

23. Nursing responsibility contd…
 Advise patient to notify prescriber immediately about blurred vision,
dizziness, and severe headache.
 Suggest that patient change positions slowly to minimize orthostatic
hypotension.
 Advise patient to avoid hazardous activities until drug’s CNS effects
are known.
 Urge patient to avoid alcohol and erectile dysfunction drugs during
therapy.

24. ANTIPLATELETS
Antiplatelet agents are drugs that inhibit enzymes or receptors
required for platelet activation, platelet aggregation, and/or thrombus
formation.

25. Mechanism Of Action
The antiplatelets are divided into the platelet aggregation inhibitors,
platelet adhesion inhibitors, and the glycoprotein IIb, IIIa inhibitors.
The platelet aggregation inhibitors work by action on thrombin; the
platelet adhesion inhibitors work by inhibition of phosphodiesterase; and
the glycoprotein IIb, IIIa inhibitors work by preventing fibrin from
binding to glycoprotein IIb, IIIa receptors.

26. Indications
Antiplatelets are used to prevent MI and stroke; other products are
used for coronary syndromes.

27. Classification
Platelet aggregation inhibitors: Cilostazol Clopidogrel, Ticlopidine,
Acetylsalicylic acid
Platelet adhesion inhibitors: Dipyridamole
Glycoprotein IIb, IIIa inhibitors: Eptifibatide Tirofiban

28. ASPIRIN (ACETYLSALICYLIC ACID)
Chemical class: Salicylate
Therapeutic class: Anti-inflammatory, antiplatelet, antipyretic, non-
opioid analgesic
Pregnancy category: D

29. Indications and doses
To relieve mild pain or fever
• Adults and adolescents: 1,000 mg every 6 hour.
To relieve mild to moderate pain from inflammation, as in rheumatoid arthritis
and osteoarthritis.
• Adults and adolescents. 3.2 to 6 g daily in divided doses. Maximum: 6 g daily.
To treat juvenile rheumatoid arthritis
• Children ages 2 to 14. 60 to 110 mg/kg daily in divided doses every 6 to 8 hr.
To treat acute rheumatic fever
• Adults and adolescents. 5 to 8 g daily in divided doses.

30. Indication and dose Contd...
To reduce the risk of recurrent transient ischemic attacks or stroke in men.
• Adults. 650 mg twice daily or 325 mg four times daily
To reduce the severity of or prevent acute MI
• Adults. Initial: 160 to 162.5 mg (half of a 325-mg tablet or two 80- or 81-
mg tablets) as soon as MI is suspected. Maintenance: 160 to 162.5 mg
daily for 30 days.
To reduce risk of MI in patients with previous MI or unstable angina.
• Adults: 325 mg daily.

31. Mechanism Of Action
Blocks the activity of cyclooxygenase (the enzyme needed for prostaglandin
synthesis. Prostaglandins, important mediators in the inflammatory response,
cause local vasodilation with swelling and pain).
With blocking of cyclooxygenase and inhibition of prostaglandins,
inflammatory symptoms subside. Pain is also relieved because prostaglandins
play a role in pain transmission from the periphery to the spinal cord.
 Aspirin inhibits platelet aggregation by interfering with production of
thromboxane A2, a substance that stimulates platelet aggregation.
Aspirin acts on the heat-regulating center in the hypothalamus and causes
peripheral vasodilation, diaphoresis, and heat loss.

32. Contraindication
Allergy to tartrazine dye
Asthma
Bleeding problems (such as hemophilia)
Hypersensitivity to aspirin or its components
Peptic ulcer disease.

33. Adverse reaction
CNS: Confusion, CNS depression
EENT: Hearing loss, tinnitus
GI: Diarrhea, GI bleeding, heartburn, hepatotoxicity, nausea, stomach pain,
vomiting
HEME: Decreased blood iron level, leukopenia, prolonged bleeding time,
shortened life span of RBCs, thrombocytopenia
SKIN: Ecchymosis, rash, urticaria
Other: Angioedema, Reye’s syndrome, salicylism with regular use of large
doses

34. Nursing consideration
Don’t crush timed-release or controlled release aspirin tablets unless directed.
Ask about tinnitus. This reaction usually occurs when blood aspirin level
reaches or exceeds maximum for therapeutic effect.
Advise parents not to give aspirin to a child or adolescent with chickenpox or
flu symptoms because of risk of Reye’s syndrome. Tell them to consult
prescriber for alternative drugs.
Advise adult patient taking low-dose aspirin not to also take ibuprofen
because it may reduce the cardioprotective and stroke preventive effects of
aspirin.

35. Nursing responsibility Contd...
Instruct patient to stop taking aspirin and notify prescriber if any
symptoms of stomach or intestinal bleeding occur such as passage of
black, bloody, or tarry stools or if patient is coughing up blood or vomit
that looks like coffee grounds.
Tell patient to consult prescriber before taking aspirin with any
prescription drug for blood disorder, diabetes, gout, or arthritis.
Tell patient not to use aspirin if it has a strong vinegar-like odor.

36. CLOPIDOGREL BISULFATE
Chemical class: Thienopyridine derivative
Therapeutic class: Platelet aggregation inhibitor
Pregnancy category: B

37. Indication And Doses
To reduce atherosclerotic events, such as stroke and MI, in patients with
atherosclerosis documented by recent stroke, MI, or peripheral artery disease
• -Adults: 75 mg daily.
To reduce atherosclerotic events, such as stroke and MI, in patients with
acute coronary syndrome (unstable angina or non–Q-wave MI)
• -Adults: Loading dose: 300 mg and Maintenance: 75 mg daily.
To reduce rate of death, reinfarction, or stroke in patients with ST-segment
elevation acute MI.
• -Adults: 75 mg once daily. loading dose of 300 mg followed by 75 mg
once daily.

38. Mechanism Of Action
Binds to adenosine diphosphate (ADP) receptors on the surface of activated
platelets.
 This action blocks ADP, which deactivates nearby glycoprotein IIb/IIIa
receptors and prevents fibrinogen from attaching to receptors.
Without fibrinogen, platelets can’t aggregate and form thrombi.

39. Contraindication
Active pathological bleeding, including peptic ulcer and intracranial
hemorrhage.
Hypersensitivity to clopidogrel or its components.

40. Side Effects
CNS: Confusion, depression, dizziness, fatal intracranial bleeding, fatigue, fever,
hallucinations, headache CV: Chest pain, edema, hypercholesterolemia,
hypertension, hypotension, vasculitis
EENT: Altered taste; conjunctival, ocular, or retinal bleeding; epistaxis; rhinitis;
stomatitis; taste disorders.
GI: Abdominal pain; acute liver failure; colitis; diarrhea; duodenal, gastric, or
peptic ulcer; elevated liver function test results; gastritis; gastrointestinal and
retroperitoneal hemorrhage, indigestion; nausea; noninfectious hepatitis;
pancreatitis.
GU: Elevated serum creatinine level, glomerulopathy, UTI

41. Side effects contd...
HEME: Agranulocytosis, aplastic anemia, neutropenia, pancytopenia, prolonged
bleeding time, thrombocytopenic purpura, thrombotic thrombocytopenic purpura,
unusual bleeding or bruising.
MS: Arthralgia, back pain, musculoskeletal bleeding, myalgia.
RESP: Bronchitis, bronchospasm, cough, dyspnea, eosinophilic pneumonia,
interstitial pneumonitis, respiratory tract bleeding, upper respiratory tract infection.
SKIN: Bullous dermatitis, drug rash with eosinophilia and systemic symptoms
(DRESS), eczema, erythema multiforme, lichen planus, pruritus, purpura, rash,
skin bleeding, StevensJohnson syndrome, toxic epidermal necrolysis, urticaria.

42. Nursing consideration
Determine if patient has a history of hypersensitivity to any other
thienopyridine drug, such as prasugrel or ticlopidine, because allergic cross
reactivity has been reported.
Use clopidogrel cautiously in patients with severe hepatic or renal disease,
risk of bleeding from trauma or surgery, or conditions that predispose to
bleeding.
Expect to give aspirin with clopidogrel in patient with acute coronary
syndrome,.
Clopidogrel prolongs bleeding time so stop it 5 days before elective surgery.

43. Nursing consideration Contd...
Obtain blood cell count, as ordered, whenever signs and symptoms suggest a
hematologic problem.
Monitor patient who takes aspirin closely because risk of bleeding is
increased.
Discourage use of NSAIDs, including OTC preparations, during clopidogrel
therapy because of potential for bleeding.
Caution patient that bleeding may continue longer than usual. Instruct him to
report unusual bleeding or bruising.

44. Nursing consideration Contd...
Urge patient to inform all other healthcare providers, including dentists,
that he takes clopidogrel before having surgery or other procedures or
taking a new drug because he has an increased risk of bleeding.
Advise patient to notify prescriber promptly if he experiences fever,
weakness, extreme skin paleness, purple skin patches, yellowing of his
skin or eyes, or neurologic changes.
Instruct patient not to discontinue clopidogrel abruptly or without first
consulting prescriber.

45. References
Tripathi, K.D. (2013). Essentials of Medical Pharmacology (7th Ed.). New Delhi: Jaypee
Brothers Medical Publishers.
Ruth, S. (2014). Mosby’s Nursing Drug References (27th Ed.). Philadelphia: Mosby
Wilson, B.A., Shannon, T.M. & Stang, C.L. (2014). Nurses Drug Guide. New Jersey:
Pearson Prentice Hall
Karch, A.M. (2006). Lippincott’s Nursing Drug Guide. Philadelphia: Lippincott William
and Wilkins.
Deglin, J.H. & Vallerland, A.H. (2005). Drug Guide for Nurses (5th Ed.). Philadelphia:
F.A. Davis Company

46. what is sex of respondent
Frequency Percent Valid Percent Cumulative Percent
Valid male 85 60.3 60.3 60.3
female 56 39.7 39.7 100.0
Total 141 100.0 100.0