Description of Anti-angina and Anti – PST04211 Basic Pharmacology

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NTA Level 4 • Semester 2 • PST04211

Description of Anti-angina and Anti

Basic Pharmacology • Source Session/Topic 29
Full source-text version: all educational wording from the extracted learning source is retained; only presenter/tutor metadata and web-layout noise are removed, while formatting is improved for readability.

Session 29: Description of Anti-angina and Anti-

Arrhythmic Drugs

Total Session Time: 120 minutes

Prerequisites

• None

Learning Tasks

By the end of this session students are expected to be able to:

• Outline classes of anti-angina and anti-arrhythmic drugs
• List indications of anti-angina and anti-arrhythmic drugs
• List Contraindication of anti-angina and anti-arrhythmic drugs
• Describe dose, dosage and course of anti-angina and anti-arrhythmic drugs
• List side effects and adverse effects of anti-angina and anti-arrhythmic drugs
• Describe interaction and precaution of anti-angina and anti-arrhythmic drugs

Resources Needed:

• Flip charts, marker pens, and masking tape
• Black/white board and chalk/whiteboard markers
• Overhead projector and computer

SESSION OVERVIEW

Activity/

Step Time Content

Method

1 05 minutes Presentation Introduction, Learning Objectives

Classes of Anti-angina and Anti-arrhythmic

2 10 minutes Presentation

Drugs

Presentation/ Indications of Anti-angina and Anti-

3 15 minutes

Buzzing arrhythmic Drugs

Presentation/ Contraindications of Anti-Angina and Anti-

4 10 minutes

brainstorming arrhythmic Drugs

Dose, Dosage and Course of Anti-angina and

5 30 minutes Presentation

Anti-Arrhythmic Drugs

Presentation/ Side Effects and Adverse Effects of Anti-

6 20 minutes

brainstorming angina and Anti-arrhythmic Drugs

Interactions and Precautions of Anti-Angina

7 15 minutes Presentation

and Anti-Arrhythmic Drugs

8 05 minutes Presentation Key Points

9 10 minutes Presentation Evaluation

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SESSION CONTENTS

STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)

READ or ASK students to read the learning tasks and clarify

ASK students if they have any question(s) before continuing.

STEP 2: Classes of Anti-angina and Anti-arrhythmic Drugs (10 minutes)

• Antianginal drugs are drugs that are used to manage angina by either improving perfusion

of the myocardium, reducing the metabolic demand of the heart, or both

• There are three classes of antianginal drugs; organic nitrates, Beta-adrenoreceptor

antagonists and calcium channel blockers

• Organic Nitrares and adrenoceptor antagonists are vasodilators and improve myocardial

perfusion, and reduced metabolic demand of the myocardium

• Beta-adrenoreceptor antagonists slow the heart rate therefore reduces metabolic demand

of the heart

• Antiarrhythmic drugs are a group of pharmaceuticals that are used to suppress abnormal

rhythms of the heart (cardiac arrhythmias), such as atrial fibrillation, atrial flutter,

ventricular tachycardia, and ventricular fibrillation

• They are classified according to their general effect;

o Class I: Fast sodium (Na) channel blockers

o Class II: Beta blockers

o Class III: Potassium (K) channel blockers

o Class IV: Slow calcium (Ca) channel blockers

STEP 3: Indications of Anti-angina and Anti-arrhythmic Drugs

(15 minutes)

Activity: Buzzing (5 minutes)

ASK students to pair up and buzz on the following question for 2 minutes

• What are the indications of anti-angina and anti-arrythmic drugs?

ALLOW few pairs to respond and let other pairs to add on points not mentioned

WRITE their response on the flip chart/board

CLARIFY and SUMMARIZE by using the content below

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• Anti-angina drugs

o Nitrates (Nitroglycerin – glyceryl trinitrate, isosorbide dinitrate and isosorbide-5-

mononitrate) are indicated for;

 Unstable angina

 Immediate treatment of angina (s.l.)

 Severe, recurrent rest angina (i.v.)

 Maintenance therapy of angina (slow release forms)

 Prinzmetal‘s angina

 Control myocardial ischemia,

 Reduce infarction size

 Treatment of acute angina episodes

 Prophylaxis of chronic angina

 Treatment of moderate to severe congestive heart failure and myocardial

infarction

 Control of blood pressure in cardiac surgical procedure

o Calcium channel blockers (Nifedipine, Verapamil) are indicated for:

 Stable angina

 Unstable angina

 Variant angina

o Beta-adrenoreceptor (Atenolol, Metoprolol, Nadolol, Propranolol) are indicated for;

 Stable angina

 Unstable angina

 Acute myocardial infarction

• Anti-arrhythmic drugs

o Class I: Fast sodium (Na) channel blockers (Lidocaine) are indicated for the treatment

of ventricular arrhythmias

o Class II: Beta blockers (Atenolol, propanolol) are indicated for

 Treatment of hypertension,

 Reduce infarct size in the periinfarction period, as adjuncts for rate control in

atrial fibrillation or flutter

o Class III: Potassium (K) channel blockers(Amiodarone) are effective for both

supraventricular and ventricular arrhythmias

o Class IV: Slow calcium (Ca) channel blockers (Amlodipine, verapamil) are not

effective antiarrhythmic drugs because they have little effect on cardiac Ca2+

channels

PST 04211 Basic Pharmacology NTA Level 4 Semester 2 Facilitator Guide

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STEP 3: Contraindications of Anti-angina and Anti-arrhythmic Drugs

(10 minutes)

Activity: Brainstorming (5 minutes)

Ask students to brainstorm on the following question:

• What are the contraindications of anti-angina and anti-arrhythmic drugs?

ALLOW few students to respond

WRITE their responses on the flip chart/ board

CLARIFY and SUMMARISE by using the content below

Table 16.1: Contraindications of anti-angina and anti-arrhythmic drugs

Drug class Contraindications

Nitrates • Hypersensitivity

• Head trauma
• Cerebral hemorrhage
• Severe anemia
• Pericardial tamponade
• Constrictive pericarditis

Calcium channel blockers • Severe hypotension

• Severe aortic stenosis
• Extreme bradycardia
• Moderate to severe heart failure
• Cardiogenic shock
• Sick sinus syndrome

Beta-adrenoreceptor • Contraindicated in variant angina

• Bradyarrhythmias
• Atrioventricular block
• Peripheral vascular disease

Anti-arrhythic drugs • Hypersensitivity to the antiarrhythmic

drugs

• During pregnancy and lactation.
• Second- or third-degree atrioventricular

block (if the patient has no artificial

pacemaker)

• Severe congestive heart failure (CHF)
• Aortic stenosis
• Hypotension
• Cardiogenic shock

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STEP 5: Dose, Dosage and Course of anti-angina and anti-arrhythmic

Drugs (30 minutes)

• Nitroglycerin
o PO Immediate-release tablets, 2.5–9 mg 2 or 3 times per day PO
o Sustained-release tablets or capsules, 2.5 mg 3 or 4 times per day
o SL 0.15–0.6 mg PRN for chest pain
o Translingual spray, one or two metered doses (0.4 mg/dose) sprayed onto oral mucosa

at onset of anginal pain, to a maximum of 3 doses in 15 min

o Transmucosal tablet, 1 mg q3–5h while awake, placed between upper lip and gum or

cheek and gum

o Topical ointment, 1⁄ 2–2 inches q4–8h; do not rub in Topical transdermal disc, applied

once daily IV 5–10 mcg/min initially, increased in 10- to 20-mcg/min increments up
to 100 mcg/min or more if necessary to relieve pain
• Isosorbide dinitrate
o Treatment and prevention of angina SL 2.5–10 mg PRN or q2–4h PO Regular tablets,
10–60 mg q4–6h PO Chewable tablets, 5–10 mg q2–3h PO Sustained-release
capsules, 40 mg q6–12h
• Isosorbide mononitrate
o Treatment and prevention of angina, PO 20 mg twice daily, with first dose on arising
and the second dose 7 h later PO. Extended-release tablets 30–60 mg once daily in the
morning, increased after several days to 120 mg once daily if necessary
• Lidocaine
o Ventricular arrhythmias 50—100 mg IV bolus, 1—4 mg/min IV infusion 20- 50
g/kg/min; 300 mg IM
• Propanolol

o Cardiac arrhythmias: 10—30mg, PO 3-4 times daily

o Life-threatening arrhythessential tremor:1—3 mg IV, repeat once in 2 min
o Angina pectoris: 80—320 mg/d PO in 2—4 divided doses
o Hypertension: initially, 40 mg PO BID or 80 mg sustained released once daily
o Maintenance dose: up to 640 mg/d PO in divided doses

o Long-term management of angina, to reduce frequency and severity of anginal

episodes, PO 10–80 mg 2 to 4 times per day IV 0.5–3 mg q4h until desired response

is obtained

• Atenolol

o Long-term management of angina, to reduce frequency and severity of anginal

episodes, PO 50 mg once daily, initially, increased to 100 mg/d after 1 week if

necessary

• Amiodarone
o Life-threatening Malaise, fatigue, tremor: Loading dose: 800–1600 mg/d PO in

divided doses

o Maintenance dose: 400 mg/d PO; up to 1000 mg/d over 24 h IV

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• Verapamil

o Superventricular arrhythmia, atrial fllutter/fibrillation, (Adults) Oral—initial dose

80–120 mg TID; maintenance dose 320–480 mg/d, 240 mg PO
o Angina, PO 80–120 mg 3 times daily
• Amlodipine
o Angina, PO 5–10 mg once daily
• Nifedipine
o Angina, immediate-release, PO 10–30 mg 3 times daily, sustainedrelease, PO 30–60

mg once daily

STEP 6: Side Effects and Adverse Effects of anti-angina and anti-

arrhythmic Drugs (20 minutes)

Activity: Brainstorming (5 minutes)

Ask students to brainstorm on the following question:

• What are side effects and adverse effects of antihypertensive drugs?

ALLOW few students to respond

WRITE their responses on the flip chart/ board

CLARIFY and SUMMARISE by using the content below

• Nitrates: Headache, postural hypotension, tachycardia, increased intraocular pressure,

methemoglobinemia

• Calcium channel blocker: Sinus bradycardia, Conduction disturbances, Constipation

(Verapamil). Fatigue, nonspecific gastrointestinal complaints, rarely elevations of hepatic

enzymes and acute hepatic injury (all Ca-blokers)

• Beta-blockers: Bradyarrhytmias, Bronchoconstriction, hypoglycemia, Impotence

Depression, Sleep disturbances

• Class I (lidocaine): Light-headedness, nervousness, generic bradycardia, hypotension,

drowsiness, apprehension

• Class II (propanolol): Fatigue, weakness, depression, bradycardia, dizziness, vertigo,

hypertension, rash, decreased libido, hypotension, hyperglycemia

• Class III( amlodarone): Malaise, fatigue, tremor, nausea, vomiting, constipation, ataxia,

anorexia, bradycardia, photosensitivity

• Class IV (verapamil): Constipation, dizziness, , light-headedness, headache, asthenia,

nausea, peripheral edema, hypotension, proarrhythmias, Congestive Heart Failure

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STEP 7: Interactions and Precautions of anti-angina and anti-arrhythmic

Drugs (15minutes)

• Precautions during Nitrate therapy:

o Never stop nitrate therapy suddenly

o Do not take double dose. (to prevent Nitate syncope from happening only in case

combined with Nitoglycerine in attacks otherwise we don‘t give double dose)

o Do not use it after expiry date; nitroglycerin is volatile; shelf-life ~6w after opening

must be stored in cool, tightly capped, dark container

o Nitrates and Phosphodiesterase inhibitors are both vasodilatror and should not be

taken together because they will lead to syncope and sever drop in blood pressure and

thus lead to reflect tachycardia and impairment of coronary syndrome so it can

precipitate acute attack

o Use with caution in patient with Glaucoma, hypertrophic cardiomyopathy, Renal and

liver disease, ventricular outflow obstruction and mitral valve syndrome

• - blockers

o Should be withdrawn gradually as sudden stoppage give rise to a withdrawal

manifestations: Rebound angina, arrhythmia, myocardial infarction and hypertension

because of up-regulation of -receptors

o Non-selective are better avoided as they blocks vasodilatory effects of sympathetic

stimulation, afterload an oxygen consumption

o Not used in variant angina as it worsen symptoms and aggrevate condition

o Should be given with caution to diabetics with ischemic heart disease [Benefits >

hazards)

• Anti-arrhythmic drugs

o Should be used cautiously in patients with renal or hepatic disease

Step 8: Key Points (5minutes).

• Antianginal drugs are drugs that are used to manage angina by either improving perfusion

of the myocardium, reducing the metabolic demand of the heart, or both

• There are three classes of antianginal drugs; organic nitrates, Beta-adrenoreceptor

antagonists and calcium channel blockers

• Antiarrhythmic drugs are a group of pharmaceuticals that are used to suppress abnormal

rhythms of the heart (cardiac arrhythmias), such as atrial fibrillation, atrial flutter,

ventricular tachycardia, and ventricular fibrillation

• Antiarrhythmic drugs are classified according to their general effect as; Class I: Fast

sodium (Na) channel blockers, Class II: Beta blockers, Class III: Potassium (K) channel

blockers and Class IV: Slow calcium (Ca) channel blockers

PST 04211 Basic Pharmacology NTA Level 4 Semester 2 Facilitator Guide

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STEP 9: Evaluation (10minutes)

• What are the anti-angina and anti-arrhythmic drugs?
• How do we classify anti-angina and anti-arrhythmic drugs?
• What are the indications of anti-angina and anti-arrhythmic drugs?
• What are the contraindications of anti-angina and anti-arrhythmic drugs?
• What are the side effects and adverse effects of anti-angina and anti-arrhythmic drugs?

PST 04211 Basic Pharmacology NTA Level 4 Semester 2 Facilitator Guide

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References

Ministry Of Health and Social Welfare. (2013). Standard Treatment Guidelines &

National Essential Medicines List Tanzania Mainland (4th ed.). Dar es salaam,

Tanzania government printers.

Robert, L. T., Gary, C.Y., Gary, R.M, Barbara, G.W., Michael, L. (2014).

Pharmacotherapy: A Pathophysiologic Approach (9th ed.). New York, McGraw-Hill

Education.

Sally S.R, & Jeanne C.S. (2000). Introductory Clinical Pharmacology (6th ed)

New York, Lippincott Williams and Wilkins.

School of Pharmaceutical sciences. (2011). Tanzania Pharmaceutical Handbook

(2nd ed.). Dar es Salaam, ARDHI University press.

The Royal Pharmaceutical Society of Great Britain. (2007). Martindale: The

Extra Pharmacopoeia (5TH ed). London, pharmaceutical press.

The Royal Pharmaceutical Society of Great Britain. (2009). British National

Formulary (59th ed). London, BMJ Group and RPS Publishing.

PST 04211 Basic Pharmacology NTA Level 4 Semester 2 Facilitator Guide

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