Drugs for Angina Pectoris
and Myocardial Infarction
Opioid
Opioids are a class of drugs that include the
illegal drug heroin, synthetic opioids such as
Nitroglycerin
fentanyl, and pain relievers available legally
by prescription.
Reteplase
BRAND NAME NITROGLYCERIN (nye-tro-gli-ser-in)
PHARMACOKINETICS:
GENERIC NAME: nitroglycerin extended-release capsules
Absorption: Nitro-Time,
Well absorbedNitrogard
after oral,SR
buccal, and sublingual
administration. Also absorbed through skin. Orally
administered nitroglycerin is rapidly metabolized, leading
nitroglycerin intravenous
topbioavailability.
Nitro-Bid IV, Tridil
Distribution: Unknown.
Metabolism and Excretion: Undergoes rapid and almost complete metabolism by
nitroglycerin translingualby
the liver; also metabolized spray
enzymes in bloodstream.
Nitrolingual, Nitromist
Half-life: 1 – 4 min.
TIME/ACTION PROFILEointment
nitroglycerin (cardiovascular effect)
Nitro-Bid
nitroglycerin sublingual tablets
Nitrostat
ROUTE
nitroglycerin transdermal patch
ONSET
Minitran, Nitro-Dur
PEAK
DURATION
CLASSIFICATIONS:
Therapeutic: Antianginals
Pharmacologic: Nitrates
PREGNANCY CATERGORY: C
INDICATIONS: Acute (translingual, SL, ointment) and long-term prophylatic
SL/Translingual (oral, transder-mal) management of angina pectoris. PO:
1 – 3 min Adjunct treatment of HF. IV: Adjunct treat-ment of acute MI.
Production of controlled hypotension during surgical
unknown procedures. Treatment of HF associated with acute MI.
30 – 60 min
ADVERSE REACTIONS/SIDE EFFECTS:
NURSING IMPLICATIONS:
CNS: dizziness, headache, apprehension, restlessness,
weakness.
Assessment
EENT: blurred vision.
Assess
Q location, duration, intensity, and precipitating factors of patient’s
CV: hypotension, anginal
tachycardia, pain.
syncope.
Monitor BP and pulse before and after administration.
GI: Patients
abdominal receiving
pain, IV vomiting.
nausea, nitro-glycerin require continuous
ECG and BP monitoring. Additional hemodynamic pa-rameters may be monitored.
Derm: contact dermatitis (transdermal).
Lab Test Considerations: May causequrine catecholamine and urine vanillyl-mandelic acid concentrations.
Misc: alcohol intoxication (large IV doses only), cross-
Excessive doses may causeqmethemoglobin concentrations.
tolerance, flushing, tolerance.
May cause falselyqserum cholesterol levels.
INTERACTIONS:
Potential Nursing Diagnoses
Drug-Drug: Concurrent use of nitrates in any form with sildenafil, tada-
Acute pain (Indications) lafil, and vardenafilqrisk of serious and potentially fatal
hypotension; concurrent use is contraindicated. Additive
Ineffective tissue perfusion (Indications) hypotension with antihypertensives, acute ingestion of alcohol,
beta blockers, calcium channel blockers, haloperidol, or
phenothiazines. Agents having anticholinergic properties
Implementation (tricyclic antidepres-sants, antihistamines, phenothiazines)
maypabsorption of translingual or sublingual nitroglycerin.
PO: Administer dose 1 hr before or 2 hr after meals with a full glass of water for faster absorption.
Sustained-release preparations should be SL
ROUTE/DOSAGE: swallowed whole;
(Adults): 0.3 do notmg;
– 0.6 break,
maycrush, or chew.
repeat q 5 min for 2 additional
doses for acute attack.
SL: Tablet should be held under tongue until dissolved. Avoid eating, drinking, or smoking until tablet is
dissolved.
Translingual spray: Spray Nitrolingual under tongue. Spray Nitromist on or under tongue.
Translingual Spray (Adults): 1 – 2 sprays; may be repeated q
5 min for 2 additional doses for acute attack. Both may also be
used prophylactically 5 – 10 min before ac-tivities that may
IV Administration precipitate an acute attack.
pH: 3.0 – 6.5.
IV: Doses must be diluted and administered as an infusion. Standard
PO (Adults): 2.5 – 9 mg q 8 – 12 hr.
infusion sets made of polyvinyl chloride (PVC) plastic may absorb up to
80% of the nitroglyc-erin in solution. Use glass bottles only and special
tubing provided by manufac-turer.
IV (Adults):
Continuous Infusion:5 Diluent:
mcg/min;qby
Vials 5must
mcg/min q 3 – in
be diluted 5 min
D5Wto or
20 0.9%
NaCl. Premixed infusions already diluted in D5W and are ready to be
administered (no further dilution needed). Admixed solutions stable for 48
Patient/Family Teaching
BRAND NAME: Reteplase (re-te-plase)
Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as
remembered
GENERIC unless next dose is scheduled
NAME: within 2 hr (6 hr with extended-release preparations). Do
retavase
not double doses. Do not discontinue abruptly; gradual dose reduction may be necessary to prevent
rebound angina.
CLASSIFICATIONS:
Therapeutic: thrombolytics
Caution patient to change positions slowly
Pharmacologic: to minimize
plasminogen orthostatic hypotension. First dose should be
activators
taken while in a sitting or reclining position, especially in ger-iatric patients.
PREGNANCY CATERGORY: C
Advise patient to avoid concurrent use of alcohol with this medication. Patient should also consult
health care professional before taking OTC medications while taking nitroglycerin.
INDICATIONS: Acute myocardial infarction (MI).
Inform patient that headache is a common side effect
Unlabeled Use:that shouldcentral
Occluded decrease with continuing
venous therapy.
ac-cess devices.
Aspirin or acetaminophen may be ordered
Deepto treat headache.
venous Notify
thrombosis health
(DVT). Acutecare professional
peripheral if
arterial
headache is persistent or severe. thrombosis.
Advise patient to notify health care professional if dry mouth or blurred vision oc-curs.
ACTION: Directly converts plasminogen to plasmin, which then
Acute Anginal Attacks: Advise patient to sit down and use medication at first sign of attack. Relief
degrades clot-bound fibrin.
usually occurs within 5 min. Dose may be repeated if pain is not relieved in 5 – 10 min. Call health
care professional or go to nearest emergency room if anginal pain is not relieved by 3 tablets in 15
THERAPEUTIC EFFECTS: Lysis of thrombi in coronary arteries, with improvement of
min.
ventricular function, and reduced risk of heart failure or death.
Restoration of can-nula or catheter function. Restoration of
blood flow following lysis of peripheral ve-nous or arterial
SL: Inform patient that tablets shouldthrombi.
be kept in original glass container or in spe-cially made metal
containers, with cotton removed to prevent absorption. Tablets lose potency in containers made of
plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and
PHARMACOKINETICS:
moisture also causes loss of po-tency. Instruct patient not to open bottle frequently, handle tablets,
or keep bottle of tablets next to body (i.e.,
Absorption: shirt pocket)
Complete after IVor in automobileIntracoronary
administration. glove compartment. Advise
patient that tablets should be replacedadministration
6 mo after opening to maintain po-tency.
or administration into occluded catheters or
cannulae has a more localized effect.
Lingual Spray: Instruct patient to lift tongue and spray dose under tongue (Ni-trolingual,
NitroMist) or on tongue (NitroMist). Unknown.
Distribution:
Evaluation/Desired Outcomes
Metabolism and Excretion: Cleared primarily by the liver and kidneys.
Decrease in frequency and severity of13
Half-life: anginal attacks.
– 16 min.
TIME/ACTION PROFILE (fibrinolysis)
INTERACTIONS:
ROUTE
Drug-Drug: Aspirin, other NSAIDs, warfarin, heparin and heparin-like agents,
ONSET abciximab, eptifibatide, tirofiban, clopidogrel, ticlopidine, or dipy-
ridamole— concurrent useqrisk of bleeding, although these agents
PEAK are frequently used together or in sequence. Effects may bepby
antifibrinolytic agents, including aminocaproic acid or tranexamic
DURATION
acid.
Drug-Natural Products: anticoagulant effect and bleeding risk with anise, ar-nica,
chamomile, clove, dong quai, fenugreek, feverfew, garlic, ginger,
ginkgo, Panax ginseng, licorice, and others.
IV
ROUTE/DOSAGE: IV (Adults): 10 units, followed 30 min later by an additional 10
30 min units.
30 – 90 min
NURSING
48 hr IMPLICATIONS
Assessment
Begin therapy as soon as possible after the onset of symptoms.
Monitor vital signs, including temperature, continuously for myocardial infarction and at least every 4 hr
during therapy for other indications. Do not use lower ex-tremities to monitor BP. Notify health care
professional if systolic BP 180 mm Hg or diastolic BP 110 mm Hg. Thrombolytic therapy should not be
given if hyper-
CONTRAINDICATIONS/PRECAUTIONS:
tension is uncontrolled. Inform health care professional if hypotension occurs.
Hypotension may result from the drug, hemorrhage, or cardiogenic shock.
Contraindicated in: Active internal bleeding; History of cerebrovascular acci-dent;
Recent
Assess patient carefully for bleeding every (within
15 min 2 mo)
during the intracranial or intraspinal
1st hr of therapy, injury
every 15– or
30 min
trauma;
during the next 8 hr, and at least every 4 hr forIntracranial
the durationneoplasm, arteriovenous
of therapy. malformation,
Frank bleeding may occur or
aneurysm;
from sites of invasive procedures or from bodySevere uncontrolled
orifices. hyperten-sion;
Internal bleeding may also Known bleeding
occur (de-creased
neurologic
tendencies;status; abdominal pain with coffee-grounds emesis or black, tarry stools; hematuria; joint
Hypersensitivity.
pain). If uncontrolled bleeding occurs, stop medication and notify health care professional immedi-
ately. Use Cautiously in: Recent (within 10 days) major surgery, trauma, GI or GU
bleeding; Left heart thrombus; Severe hepatic or renal disease;
Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling
Hemorrhagic oph-thalmic conditions; Septic phlebitis;
around the eyes, wheezing). If these oc-cur, inform health care professional promptly. Keep
Previous puncture of a noncompressible vessel; Subacute
epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic
bacterial endocarditis or acute pericarditis; Geriatric
reaction.
patients ( 75 yr; in- creased risk of intracranial bleeding);
Implementation
High Alert: Overdosage and under-dosage of thrombolytic medications have re-sulted in patient harm or
death. Have second practitioner independently check original order, dosage calculations, and infusion pump
settings. Do not confuse the abbreviation t-PA for alteplase (Activase) with the abbreviations TNK t-PA for
tenecteplase (TNKase) and r-PA for reteplase (Retevase). Clarify orders that con-tain any of these
abbreviations.
Thrombolytic agents should be used only in settings in which hematologic func-tion and clinical response
can be adequately monitored.
Starting two IV lines before therapy is recommended: one for the thrombolytic agent, the other for any
additional infusions.
Avoid invasive procedures, such as IM injections or arterial punctures, with this therapy. If such procedures
must be performed, apply pressure to all arterial and venous puncture sites for at least 30 min. Avoid
venipunctures at noncompressible sites (jugular vein, subclavian site).
Acetaminophen may be ordered to control fever.
IV Administration
pH: 5.7 – 6.3.
Intermittent Infusion: Diluent: Vials are packaged with sterile water for in-jection (without preservatives)
to be used as diluent. Do not use bacteriostatic water for injection. Reconstitute 10.4 unit vials with 10 mL.
Avoid excess agitation during dilution; swirl or invert gently to mix. Solution may foam upon reconstitu-tion.
Bubbles will resolve upon standing a few min. Solution should be reconsti-tuted immediately prior to use,
but is stable for 4hr at room temperature. Rate: Prior to and after administering reteplease, flush line with
normal saline or D5W.
Two bolus doses are used for Myocardial Infarction— each is administered over 2 minutes.
Y-Site Incompatibility: heparin, No other medication should be infused or in-jected into line used for
reteplase.
Patient/Family Teaching
