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Shine Stephen
Angina Pectoris
Most common condition involving tissue
ischemia ISCHEMIA Chest pain caused by accumulation of metabolites resulting from myocardial ischemia Strangling or pressure-like pain caused by myocardial ischemia
Angina Pectoris
Located substernally but sometimes perceived in the neck, shoulder or epigastrium Primarily caused by imbalance between the oxygen requirement of the heart and oxygen supplied to it by the coronary vessels
Determinants of Oxygen
DIASTOLIC FACTOR Blood volume Venous tone SYSTOLIC FACTOR Peripheral resistance Heart rate Ejection time
Pathophysiology of Angina
Variables that contribute to muscle tension
1. PRELOAD (diastolic filling pressure) 2. AFTERLOAD (arterial blood pressure) 3. HEART RATE double product 4. CARDIAC CONTRACTILITY ejection time (relationship to oxygen requirement and force of contraction)
Types of Angina
1. Atherosclerotic angina Angina of effort or Classic angina Associated with atheromatous plaques that partially occlude one or more of the coronaries Constitutes 90% of cases Rest leads to relief of pain in 5-15 minutes
Types of Angina
2. Vasospastic angina Rest angina, Variant angina or Prinzmetals angina Involves reversible spasm of coronaries, usually at the site of an atherosclerotic plaque Spasm may occur anytime, even during sleep May deteriorate to unstable angina
Types of Angina
3. Unstable angina Crescendo angina, Acute coronary syndrome Increased frequency and severity of attacks that result from atherosclerotic plaques, platelet aggregation at fractured plaques and vasospasm Immediate precursor of myocardial infarction (MI) Medical emergency
Pathophysiology of Angina
C. Therapeutic strategies
The defect that causes anginal pain is inadequate
Pathophysiology of Angina
Newer investigational approach Shifting the energy substrate
reference of the heart from fatty acid to glucose Partial fatty acid oxidation inhibitors (Eg, Ranolazine, Trimetazidine)
Treatment
NITRATES
CALCIUM CHANNEL BLOCKERS BETA BLOCKERS
Treatment
NITRATES NITROGLYCERINE (NTG) Active ingredient in dynamite Most important of the nitrates Available forms
Sublingual (10-20 min) Transdermal (8-10 h)
NITRATES
Rapidly denitrated in the liver and smooth
muscle Nitroglycerin (Glyceryl) Dinitrate Mononitrate First-pass effect is 90% (because of high enzyme activity in the liver) Efficacy of oral (swallowed) NTG results from high levels of glyceryl dinitrate (which have a significant vasodilating effect)
NITRATES
MECHANISM OF ACTION Denitration causes release of nitric oxide (NO) within smooth muscle cells which stimulates guanyl cyclase and causes an increase in cGMP leading to smooth muscle relaxation
NITRATES
ISOSORBIDE DINITRATE Another commonly used nitrate Available in sublingual and oral form Rapidly denitrated in the liver and smooth muscle to isosorbide mononitrate which is also active
NITRATES
ISOSORBIDE MONONITRATE Available as a separate drug Oral form AMYL NITRITE Volatile and rapidly acting vasodilator Inhalational route Rarely prescribed
NITRATES
ORGAN SYSTEM EFFECTS
1. Cardiovascular System
Smooth muscle relaxation
peripheral venodilation reduced cardiac size and CO through reduced preload Reduced afterload because of arteriolar dilation increase in ejection and further decrease in cardiac size Sensitivity veins >> arteries > arterioles
NITRATES
Venodilation
decreased diastolic heart size and fiber tension
Arteriolar dilation
reduced peripheral resistance and BP
O2 consumption and double product No direct effects on the cardiac muscle Can cause reflex tachycardia and increased force of contraction when reducing BP
NITRATES
2. Other smooth muscle effect
Relaxation of the smooth muscle of the
bronchi, GIT, GUT Effects are too small to be clinically significant 3. Action on platelets Decrease platelet aggregation 4. Nitrite ion + hemoglobin methemoglobin Methemoglobin has low affinity for oxygen Pseudocyanosis, tissue hypoxia, death
NITRATES
D. CLINICAL USES Sublingual tablet Standard form for treatment of acute anginal pain Duration of action 10-30 minutes Oral (Swallowed) Normal-release Duration of action 4-6 hours Sustained-release Longer duration
NITRATES
Transdermal formulations Ointment or patch Maintains blood level up to 24 hours Tolerance develops after 8-10 hours with rapidly diminishing effectiveness Remove after 10-12 hours to allow recovery of sensitivity to the drug
NITRATES
Toxicities Tachycardia (baroreceptor reflex) Orthostatic hypotension Throbbing headache (from meningeal artery vasodilatation) Interact with Sildenafil (Viagra) and similar drugs promoted for erectile dysfunction Synergistic relaxation of vascular smooth muscle with potentially dangerous hypotension and hypoperfusion of critical
NITRATES
Monday disease
Contamination of nitrates in the workplace Alternating development of tolerance (during work
week) and loss of tolerance (over the weekend) for the vasodilating action Headache, tachycardia, dizziness Occurs every Monday Nitrites cause methemoglobinemia at high blood concentration, therefore potential antidote for cyanide poisoning
atherosclerotic angina Migraine Preterm labor Stroke Raynauds phenomenon Nimodipine is used for hemorrhagic stroke
Nimodipine
Member of the dihydropyridine family
Bepridil
Similar structure to verapamil, Longer duration of action,
dependent conduction in the AV node of the heart) May be used to treat AV nodal arrythmia
EFFECTS
Beneficial effects
Decreased heart rate Decreased cardiac force Decreased BP
Detrimental effects
Increased heart size Longer ejection period
vasospastic form Combination with nitrates reduces the undesirable compensatory effects like tachycardia and increased cardiac force
Nursing Responsibilities
Check blood pressure and heart rate before each dose of an antianginal drug. Withhold the drug if systolic blood pressure is below 90
mm Hg. If the dose is omitted, record and report to the health care provider. Give antianginal drugs on a regular schedule, at evenly spaced intervals. If oral nitrates and topical nitroglycerin are being used concurrently, stagger times of administration.
For sublingual nitroglycerin and isosorbide dinitrate, instruct the client to place the tablets under the tongue until they dissolve. For oral isosorbide dinitrate, regular and chewable tablets are available. Be sure each type of tablet is taken appropriately. For sublingual nitroglycerin, check expiration date on the container.
the
special paper to measure the dose. Place the ointment on a nonhairy part of the body, and apply with the applicator paper. Cover the area withplastic wrap or tape. Rotate application sites and wipe off previous ointment before applying a new dose. For nitroglycerin patches, apply at the same time each day to clean, dry, hairless areas on the upper body or arms. Rotate sites. Avoid applying below the knee or elbow or in areas of skin irritation or scar tissue.
For intravenous (IV) nitroglycerin, dilute the drug and give by continuous infusion, with frequent monitoring of blood pressure and
heart rate. Use only with the special administration set supplied by the manufacturer to avoid drug adsorption onto tubing. With IV verapamil, inject slowly, over 23 min.
With calcium channel blockers, observe for hypotension, dizziness, lightheadedness, weakness, peripheral edema, headache,
heart failure, pulmonary edema, nausea, and constipation. Bradycardia may occur with verapamil and diltiazem; tachycardia may occur with nifedipine and nicardipine.
END
Determinants of Oxygen
DIASTOLIC FACTOR Blood volume Venous tone SYSTOLIC FACTOR Peripheral resistance Heart rate Ejection time