Pharmacologic Profile

General Use

Nitrates are used to treat and prevent attacks of angina. Only nitrates (sublingual, lingual spray, topical, or intravenous) may be used in the acute treatment of attacks of angina pectoris. Calcium channel blockers, beta blockers, and ranolazine are used prophylactically in long-term management of angina.

General Action and Information

Several different groups of medications are used in the treatment of angina pectoris. The nitrates (isosorbide dinitrate, isosorbide mononitrate, and nitroglycerin) are available as a translingual spray, sublingual tablets, sublingual powder, intravenous solution, transdermal patch, topical ointment, and sustained-release oral dosage forms. Nitrates dilate coronary arteries and cause systemic vasodilation (↓ preload). Calcium channel blockers dilate coronary arteries (some also slow heart rate). Beta blockers ↓ myocardial oxygen consumption via a ↓ in heart rate. Ranolazine ↓ myocardial oxygen consumption.

Contraindications

Hypersensitivity. Avoid use of beta blockers or calcium channel blockers in advanced heart block, cardiogenic shock, or decompensated HF.

Precautions

Beta blockers should be used cautiously in patients with diabetes mellitus, pulmonary disease, or hypothyroidism.

Interactions

Nitrates, calcium channel blockers, and beta blockers may cause hypotension with other antihypertensives or acute ingestion of alcohol. Verapamil, diltiazem, and beta blockers may have additive myocardial depressant effects when used with other agents that affect cardiac function. Verapamil, diltiazem, and ranolazine have a number of other significant drug-drug interactions.

Nursing Implications

Assessment

• Assess location, duration, intensity, and precipitating factors of patient's anginal pain.
• Monitor BP and pulse periodically throughout therapy.

Potential Nursing Diagnoses

• Acute pain (Indications)
• Ineffective tissue perfusion (Indications)
• Deficient knowledge related to disease processes and medication regimen (Patient/Family Teaching)

Implementation

• Available in various dose forms. See specific drugs for information on administration.

Patient/Family Teaching

• Instruct patient on concurrent nitrate therapy and prophylactic antianginals to continue taking both medications as ordered and to use sublingual/translingual nitroglycerin as needed for anginal attacks.
• Advise patient to contact health care professional immediately if chest pain does not improve; worsens after therapy; is accompanied by diaphoresis or shortness of breath; or if severe, persistent headache occurs.
• Caution patient to make position changes slowly to minimize orthostatic hypotension.
• Advise patient to avoid concurrent use of alcohol with these medications.

Evaluation/Desired Outcomes

• Decrease in frequency and severity of anginal attacks.
• Increase in activity tolerance.