Angina
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| Angina Pectoris | Is sudden pain beneath the sternum, often radiating to the LEFT shoulder and arm.
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| Angina Pectoris CAUSED by...DISEASE OR SYMPTOM? | By 02 supply not meeting the 02 demands of the heart. Anemia may cause this also.
Angina Pectoris is a symptom not a disease!
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| When having angina Pectoris what is the 1st intervention? | Put patient on 02 1st.
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| Drug therapy has 2 GOALS for ANGINA PECTORIS | 1) PREVENTION OF MI and DEATH
2) PREVENTION OF MYOCARDIAL ISCHEMIA & ANGINAL PAIN.
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| If the heart is not getting enough 02 the EKG will show | Reserved T waves.
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| 02 demand is determined by... 4 factors | 1) Heart rate, 2) contractility, 3)Preload, & 4)Afterload.
Drugs that reduce these factors reduce 02 demand.
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| What are the 3 types of antianginal families of drugs? | 1) Beta blockers, 2)Calcium Channel Blockers, 3) Organic NITRATES
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| What is CARDIAC 02 supply determined by and how is it accommodated? | BLOOD FLOW
To accommodate an increase in cardiac 02 demand must increase BLOOD FLOW.
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| When does Myocardial perfusion occur? | Only during Diastole (when the heart relaxes).
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| What triggers Chronic Stable angina known as EXERTIONAL ANGINA | Triggered most often by an increase in physical activity (also emotional excitement, large meals, & cold exposure)
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| GOAL of antianginal therapy is to... | To reduce the intensity and frequency of angina attacks.
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| How does antianginal therapy work by... (organic nitrates, BB, CCBs) | Decrease cardiac 02 demand by DECREASING HEART RATE, CONTRACTILITY, AFTERLOAD, AND PRELOAD.
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| What is Variant angina (Prinzmetal's angina, Vasopastic angina) caused by... | Caused by Coronary Artery spasm which restricts blood flow to the myocardium.
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| When does Variant angina (Prinzmetal's angina, Vasopastic angina) OCCUR? | Can occur at any time including REST and SLEEP
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| GOAL of VARIANT ANGINA | To reduce the intensity & severity of attacks
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| How do you treat VARIANT ANGINA? | TX. increasing cardiac 02 supply (VASODILATORS).
Drugs used: NITRATES, CCBs
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| What is UNSTABLE ANGINA? | IT IS AN EMERGENCY. May present with either symptoms of angina at rest, new-onset exertional angina, & Intensification of existing angina.
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| RISK OF UNSTABLE ANGINA THAN STABLE? | Much GREATER RISK OF DEATH THAN STABLE, but
SMALLER RISK OF DEATH than MI.
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| Treatment for UNSTABLE ANGINA CONSISTS OF? | Anti-ischemic therapy (NTG, BB, 02, ACE1)
Anti-platelet therapy (ASA, PLAVIS)
Anti-coagulant therapy (HEPARIN)
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| ORGANIC NITRATES-OPENS VEINS 8 QUESTIONS | NITROGLYCERIN
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| What is the oldest 1879 drug & most frequently used?? | NITROGLYCERIN
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| What is Drug of choice for ACUTE ANGINA attacks? | Nitroglycerin
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| Nitroglycerin ACTION | Causing VASODILATION on vascular smooth muscle (VSM).
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| Nitroglycerin act on veins or arteries? | At usual doses, ACTS ON VEINS, dilation of arterioles is MODEST.
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| In the biochemical event of NITROGLYCERIN what is the most important ASPECT. | Is the conversion of NITRATE to its ACTIVE FORM--NITRIC OXIDE-- in the presence of a SULFHYDRYL source.
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| HOW does Nitroglycerin work in STABLE ANGINA? | Works by decreasing cardiac 02 demand (decreases VENOUS return to the heart-----DECREASING VENTRICULAR filling)
This decrease in wall tension (preload) decreases 02 demand).
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| Does nitroglycerin in STABLE ANGINA increase blood flow to ischemic area of the heart? | It DOES NOT, (does not dilate atherosclerotic arteries). Does not RELIEVE PAIN, pain relief from effects on peripheral blood flow.
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| How does NITROGLYCERIN work in VARIANT ANGINA? | NTG relaxes or prevents spasm (decreases spasms) in coronary arteries-thus increasing 02 supply.
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| What is the pharmacokinetics for NITROGLYCERIN? | Is HIGHLY LIPID SOLUBLE & CROSSES MEMBRANES EASILY.
Has rapid inactivation by HEPATIC ENZYMES in 1st pass-HALF LIFE 5-7 minutes.- goes under tongue.
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| What are the adverse effects NITROGLYCERIN & TX.? | 1) HA--- (use ASA & tylenol)
2) Orthostatic hypotension from relaxation of VSM resulting in pooling of blood in veins when standing- (sit or lie down if occurs, elevating feet helps promote venous return)
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| Cont. of adverse effects NITROGLYCERIN & TX.? | 3) Reflex Tachycardia can occur form low BP (baroreceptor response to increase HR), & negate benefits of therapy--- PRETREATMENT with a CCB or BB can prevent sympathetic stimulation of the heart.
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| What are drug interactions with NITROGLYCERIN? | CAN INTENSIFY the effects of HYPOTENSIVE drugs (BB, CCB, & OTHERS).
Use with PHOSPHODIESTERASE type 5 inhibitors (VIAGRA, CIALIS, LEVITRA) INTENSIFY NTG effects---LIFE THREATENING HYPOTENSTION can occur---**CONTRAINDICATED WITH THESE DRUGS.
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| What drugs are CONTRAINDICATED WITH nitroglycerin? | PHOSPHODIESTERASE TYPE 5 INHIBITORS (VIAGRA, CIALIS, LEVITRA) INTENSIFY NTG effects--- LIFE THREATENING hypotension can occur.
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| How FAST can TOLERANCE occur for NITROGLYCERIN? | Occurs rapidly (OVER 1 DAY) FROM depletion of SULFHYDRYL groups in VSM.
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| Do those who develop (tolerance to nitroglycerin) show a cross-tolerance to all other nitrates? | YES
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| When does tolerance to nitroglycerin most occur? | Most occurring with HIGH-DOSE uninterrupted therapy.
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| To prevent Tolerance to nitroglycerin it is best use in? | Use in lowest effective dose, Try to allow 8 drug free hours a day usually at NIGHT.
**CAN add BB OR CCB if angina is experienced during drug free time.
--reason to off the patch to prevent tolerance.
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| What PREPARATIONS & ROUTES OF ADMINISTRATION DOES NITROGLYCERIN come in? | Sublingual
Sustained-release oral capsules
Transdermal delivery system
Translingual spray
Transmucosal (buccal) tablets
Topical ointment
IV infusion
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| Sublingual Nitroglycerin works by... | Absorbed directly through oral mucosa into blood stream (BYPASSES the liver).
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| Sublingual nitroglycerin is used in high or low doses? | Used in very low doses.
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| How rapid are sublingual nitroglycerin? | Effects rapid (1-3min) & lasts up to 1hour.
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| What is SUBLINGUAL NITROGLYCERIN used for? | Used for terminating ongoing attack & shorterm prophylaxis when EXERTION is anticipated.
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| Morphine is given for chest pain why? | Not as much affect on BP, dilates heart blood vessels, & calms patient.
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| When should you replace nitroglycerin? | When the tablet loses the tingle.
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| What would you want to teach patients with sublingual nitro with chest pain? | If pain not relieved in 5mins, CALL 911; can take 2nd or third every 5 mins up to 3.
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| How should teach patient on nitroglycerin about storage of sublingual tablets? | Store in closed, dark container. After opening can keep for up to 24 months. ***Teach not to carry in pocket, will get hot that will inactive it.
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| What form of nitroglycerin is used for long-term prophylaxis only? | Sustained-Release oral capsules.
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| What is sustained-release oral nitroglycerin capsules used for long-term prophylaxis only? Can it cause tolerance? How do you take this medication? | Cannot act fast enough for acute attack.
Can cause Tolerance
Take once or twice a day.
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| What preparation and route is nitroglycerin that comes in a patch, absorbed through the skin then to blood? | Transdermal Delivery System
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| How does the Transdermal Delivery System nitro work by? Is its release constant? When does it begin to work, & last up to how long? | It works by releasing constant beginning in 30-60 min, & lasting up to 14 hours.
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| When is the patient tolerant to Transdermal Delivery System nitro? What is the patch free-time? Is this used for acute attacks? | Tolerance if 24Hours.
Patch free time 10-12 hrs helps (on in am & removed in at pm).
NOT FOR ACUTE ATTACK.
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| What type of nitro is delivered to the oral mucosa in a metered dose spray device? How do you teach pt. to use it? | Translingual spray nitro
Use like sublingual. DO NOT INHALE SPRAY.
spray on tongue
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| How is Transmucosal (buccal) tablets nitro used (put where)? How long does this tablet take to dissolve? Where is it absorbed at? | Between upper lip and gum or between cheek and gum. Dissolves in 3-5 hours.
Absorbed through oral mucosa into blood.
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| What kind of onset does Transmucosal (buccal) tablets nitro have? Are these used for Acute Attack? | They have a rapid onset (CAN BE USED FOR ACUTE ATTACK).
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| If it is in paste form, how should the nurse administrator it? | If it is paste form, wear gloves to give to prevent HA.
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| Topical nitro ointment is a ... | sustained protection!
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| What areas can you place nitro ointment? | Chest, back, abdomen, or anterior high.
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| When does effect of topical nitro ointment begin? How long does it last? | Topical ointment begins in 20-60mins and last up to 12 hours.
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| Do do you dispense topical ointment nitro from tube? | Usually 1-2inches every 4-8 hours.
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| How much does 1in of nitro ointment equal in mg? | 15mg of NTG.
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| How do you spread topical nitro ointment on patient? | Spread to 2.5-3.5 inch and cover with plastic wrap.
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| Is IV infusion nitro rare to use? | Yes, rare for angina except with failure to respond to other medications.
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| When is IV infusion nitro used? | In MI, CHF, & production of controlled hypotension for surgery.
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| What is the duration for IV infusion nitro? | VERY SHORT duration of action.
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| How does IV infusion nitro come packaged? | In a glass bottle with special tubing.
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| How do you discontinue nitroglycerin? | Slowly to avoid vasospasm.
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| What type of nitroglycerin comes in ampules, broken and inhaled? | Amyl nitrate
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| Amyl nitrate effects in how long, and terminates when? What can this medication Intensify? | Effects in 30 sec, and terminates 3-5 min.
Intensifies SEXUAL ORGASM, and has been abused for that purpose.
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| Beta Blockers are important for what type of angina? And are not effective for? | Important for stable angina (not effective for vasospastic)
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| What kind of schedule should you take Beta Blockers of chest pain? | On a fixed schedule
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| Why should you take beta blockers on a fixed schedule? | Provides protection against effort-induced angina,
exercise tolerance is increased and the frequency and intensity of attacks are lowered.
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| What do ALL BB equally effective at? | Decreasing risk of death especially in those with prior MI.
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| How does BB work on the heart with chest pain? | Works decreasing 02 demand by blockade of beta 1 in the heart (reduced rate & contractility) &
modest reduction in arterial pressure (afterload).
Helps increase 02 supply by slowing rate & increasing diastole (myocardial perfusion).
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| What are adverse side effects of BB? | Bradycardia,
Decreased AV conduction,
reduced contractility (NOT USED in SICK sinus syndrome)
Insominia
Depression
Bazaar dreams
Sexual dysfunction.-if non-selective bronchospasm.
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| What three CCBs are most frequently used? | Verapamil (kalen)
Diltiazem (cardizem)
Nifedipine (Procardia)
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| How do these three CCB work? | All 3 block calcium channels in VSM, primarly in arterioles (reduction in peripheral resistance (afterload)) and can relax coronary vasospasm.
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| Which two CCB block calcium channels in the heart (decrease rate, AV conduction, contractility)? | Verapamil (kalen) & Diltiazem (cardizem)
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| Verapamil & Diltiazem treat which types of angina? | Stable and Variant angina.
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| How does CCB work in variant angina? | Produces relaxation of coronary spasm thus increasing 02 supply.
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| How does CCB work in stable angina? | Produce relaxation of peripheral arterioles thus reducing afterload (Reduces 02 demand).
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| How does Verapamil & Diltiazem further reduce 02 demand by? | Reducing heart rate and contractility.
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| What are the drugs to prevent Myocardial Infarction and Death? | Antiplatelet drugs
Cholesterol-lowering drugs
ACE inhibitors
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| How do antiplatelet drugs prevent myocardial infaraction? | Decrease platelet aggregation thus decrease risk of thrombus formation in coronary arteries.
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| How do cholesterol-lowering drugs prevent myocardial infaraction? | Can slow progression of CAD, stabilize artherosclerotic plaques and even cause plaque reduction.
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| How do ACE Inhibitors drugs prevent myocardial infaraction? | May greatly reduce the incidence of adverse outcomes in those with CAD. Great po-MI with BB.
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