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OCTOBER 2014PROFESSIONAL DEVELOPMENT AND PRACTICE SUPPORT FOR THE SELF CARE PROGRAM

Vol.15 NUMBER 9

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AnginaQCPP

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(Counter Connection)

2 inPHARMation October 2014 I © Pharmaceutical Society of Australia Ltd.

John Bell says

Vol.15 NUMBER 9

OCTOBER 2014

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Contents

PHARMACIST CPD 4 Facts Behind the Fact Card: Angina

PHARMACY ASSISTANT’S EDUCATION12 Counter Connection: Angina

REGULARS03 Health column

16 Noticeboard

Angina isn’t a disease but a symptom of an underlying cardiovascular problem.See page 4, Facts Behind the Fact Card: Angina

3inPHARMation October 2014 I © Pharmaceutical Society of Australia Ltd.

Angina and cardiovascular diseaseBy Maureen Narayan-Ram

Cardiovascular disease (CVD) is an umbrella term for diseases of the heart and circulatory system, including angina, myocardial infarction, heart failure, heart valve diseases, cardiomyopathy, genetic heart conditions, and stroke. Healthcare expenditure on CVD remains high in Australia, despite improvements in treatment and care. CVD continues to cause illness, disability and premature death in a high number of Australians.

Angina and myocardial infarction (heart attack) are diseases of the coronary arteries – arteries that supply blood to the heart. There are different types of angina with different causes, but most often angina and heart attacks are caused by the process of atherosclerosis. Atherosclerosis is the build-up of fatty waxy deposits (atheroma) in the blood vessels supplying the heart, causing them to become narrow. Narrowing of the arteries reduces oxygen and blood flow to the heart, causing angina. When a bit of atheroma breaks away it can cause a blood clot. If the blood clot completely blocks a coronary artery, it causes a heart

attack. If the blood clot travels to the brain and blocks an artery, it causes a stroke.

Angina is typically described as squeezing, pressure, heaviness, tightness or pain in the chest. The pain can radiate to the arms, neck, shoulder or jaw. The person may also experience shortness of breath and dizziness. Symptoms of angina and myocardial infarction can sometimes be difficult to differentiate, and either of these conditions can even sometimes be mistaken for indigestion. Angina generally responds well to rest and medicines. If a person’s chest pain does not respond to medicines within 10 minutes or you are unsure about the symptoms, the Heart Foundation recommends phoning Triple Zero (000) for an ambulance. If the person is actually experiencing a heart attack, the longer it is left untreated, the more damage it can do to the heart muscles.

Community pharmacies are easily accessible to the public, placing them in an ideal environment to provide and promote CVD prevention and management services.

Health column

The services could explain the links between the different cardiovascular diseases and how these can be managed with medicines and lifestyle modification. Pharmacists and staff can discuss modifiable risk factors, including high blood cholesterol, high blood pressure, diabetes, smoking, obesity, diet and physical activity.

This issue of inPHARMation outlines the causes, symptoms and management of angina and its links to other CVDs. It discusses the pharmacological and non-pharmacological strategies that can be used to treat symptoms of angina. The Counter Connection article focuses on how to recognise symptoms of a heart attack and what steps to take if someone is experiencing this in the pharmacy.

PSA Self Care Fact Cards such as High blood pressure, Exercise and the heart, Fat and cholesterol, Smoking, Weight and health and Warnings signs of heart attack also provide valuable information about cardiovascular health.

P: 1300 369 772 » [email protected] » www.psa.org.au/selfcare

Heart healthfor your patients

» Step by step guide to implementing cardiovascular professional services

» Position your pharmacy as a health destination

» Access PPIs and other income streams

» Train your staff

Cardiovascular ACTION kit coming soon!

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John Bell says

AnginaBy Maureen Narayan-Ram

Learning objectivesAfter reading this article, pharmacists should be able to:

• Discuss the symptoms and causes of angina

• Discuss the current treatment options for angina

• Identify precautions and adverse effects of medicines used for angina

• Recognise signs of a heart attack and know what to do in case of an emergency.

Competencies addressed (2010): 1.2, 1.3, 2.3, 4.2, 6.1, 6.2, 6.3, 7.1.

Although angina does not damage the heart, it increases the risk of having a heart attack.

This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

2GROUP 2

UP

TO

CPD CREDITS

Mr Taylor (50 years old) is a customer who gets his medicines from your pharmacy. His regular medicines include aspirin, Plavix (clopidogrel), Lipitor (atorvastatin), Lipidil (fenofibrate), Noten (atenolol), and Micardis Plus (telmisartan and hydrochlorothiazide). Mr Taylor presents to the pharmacy today with a prescription for Nitrolingual Pumpspray (glyceryl trinitrate). From his past history you know he had a myocardial infarction about two years ago and received coronary angiography with stent insertion. He tells you he has not really been using his Nitrolingual pumpspray much even though he has been getting chest pain sometimes while playing golf. It has been about 2 years since he got his last supply of Nitrolingual pumpspray.

Facts Behind the Fact Card Angina Pharmacist CPD Module number 253

The prevalence of angina worldwide ranges between 5–7% and varies by country.1 Pharmacists should initiate discussions with customers about managing their angina as quite often, these people present to the pharmacy with worsening disease.

What is angina?Angina (also called angina pectoris) causes discomfort or pain, most often in the chest area. This occurs as a result of temporary ischaemia to parts of the cardiac muscle.2 In angina the coronary arteries narrow temporarily, which reduces the amount of blood that can pass through them. The narrowing of arteries is usually caused by atherosclerosis but may also occur from coronary artery spasm.2

Angina isn’t a disease but a symptom of an underlying cardiovascular problem such as coronary heart disease (CHD), also called coronary artery disease (CAD). About 58% of people with CHD experience symptoms of angina.3

Angina is a type of coronary ischaemic syndrome. Coronary ischaemic syndromes include stable angina (SA) and acute coronary syndromes (ACS).4 ACS include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA). See Figure 1.

SymptomsPeople with angina will feel discomfort or pain in the chest area (behind the breastbone).5 The pain or discomfort can radiate to their neck, jaw, teeth, fingers, arm or their back. Patients typically describe the pain as feelings of heaviness, squeezing sensation or pressure on the chest. The pain may be a vague ache, but may rapidly become a severe, intense crushing sensation. The pain can be brought on by exertion, eating heavy meals, exposure to cold temperatures or by emotional stress.

Some people may not get any chest pain but experience indigestion such as feeling bloated, having gas build up or feeling abdominal distress.


Practice point 1

Counselling about sublingual (S/L) glyceryl trinitrate (GTN)• The potency of S/L GTN products

decreases over time. The shelf life of S/L GTN tablets is 90 days, but the spray is typically two years.1 The S/L GTN tablets should be kept in their original container.

• Advise people to prime the Nitrolingual Pumpspray (glyceryl trinitrate) before use. The CMI states to spray in the air five times. If the spray has not been used for one week, spray 1 puff into air before using it again. If it has not been used for more than 4 months, prime it by spraying into the air five times.

• Recommended dose of GTN for an acute attack of angina13:- one spray sublingually (400 mcg)

and repeat every 5 minutes if pain persists. Use a maximum of three sprays (1200 mcg).

- one S/L tablet (600 mcg) and repeat every 5 minutes if pain persists. Take up to a maximum of three tablets (1800 mcg)

- if angina pain or discomfort is not completely relieved by two doses of S/L GTN within 10 minutes, call Triple Zero (000).25

• To avoid tolerance to GTN patches, advise patient to have a nitrate-free period of about 10–12 hours a day.12,13

Facts Behind the Fact CardAngina Pharmacist CPD Module number 253

Other symptoms they may experience include1,6:

• shortness of breath

• nausea

• sweating

• dizziness or light-headedness

• fatigue/weakness.

Types of anginaThere are different types of angina and the pattern and severity of pain can differ.

Angina can be classified as stable, unstable, variant (i.e. Prinzmetal), or microvascular.7 Symptoms vary with each type and require different treatment strategies.7

Stable angina

This is the most common type of angina.7 It has a ‘regular pattern’ so can be predicted. The predictable pattern refers to what triggers the pain, how severe the pain is and how often it occurs. Pain in stable angina is relieved with rest or medicines.

Stable angina symptoms don’t necessarily suggest an imminent myocardial infarction, but do indicate one is likely to occur in future. Pain is more likely to occur during physical exertion or activity such as when walking or climbing stairs. Angina may also be triggered by strong emotions or a heavy meal. Duringthese times there is an increase in demand for myocardial oxygen,

which the narrowed coronary arteries can’t adequately supply.

Exercise that is tolerated one day may precipitate angina the next because of variations in arterial tone (i.e. degree of constriction).

Unstable angina

In unstable angina there is no set pattern as pain may occur even at rest.7 The pain experienced may be more severe than stable angina. The pain may not be relieved by rest or medicines. Unstable angina can be a sign of an imminent myocardial infarction and therefore requires emergency treatment.

Variant (Prinzmetal) angina

Variant angina is caused by a spasm in the coronary artery and is quite rare.7 The pain can be severe and usually occurs at rest. It usually occurs during sleep (midnight to early morning). It responds well to medicines.

Microvascular angina

In microvascular angina the heart’s smallest coronary vessels are affected. These tiny arteries do not get atherosclerotic plaque build-up but have damage in their inner walls and lining causing spasms and ischaemia. The pain can be severe and last quite a long time (more than 10 minutes and even up to 30 minutes).8

Figure 1. Coronary ischaemic syndromesReproduced with permission from Cardiovascular Expert Group. Coronary ischaemic syndromes (Figure 3.1) [revised 2012 Feb]. In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2014 Mar.

coronary ischaemic syndromes

stable angina (SA) acute coronary syndromes (ACS)

STEMI NSTEACS

NSTEMI unstable angina (UA)


John Bell says

Practice point 2

Counselling in angina• Counsel your patient on how to use

their S/L GTN in either spray or tablet form, especially give advice about taking it before physical activity that may precipitate an attack.

• Advise to store S/L GTN tablets in original container, away from heat and light, and advise to discard 90 days after opening. Use Cautionary advisory label 7b.

• Discuss and warn about potential side effects and drug interactions of nitrates.

• Provide customers with a CMI for their medication.

• Discuss any lifestyle issues such as weight loss, eating healthy and encourage smoking cessation.

• If patient also has hyperlipidaemia, hypertension and/or diabetes, emphasise the importance of adherence to all their medicines.

• Depression can be common in patients with cardiovascular disease.26 Screen patients for possible signs of depression and refer for treatment.

• Give patients the Heart Foundation’s leaflet Will you recognise your heart attack? (available on their website). Give other resources such as Self Care Fact Cards.

Facts Behind the Fact Card Angina Pharmacist CPD Module number 253

Risk factorsRisk factors for angina that can be modified include2,5,9:

• hyperlipidaemia

• hypertension

• smoking

• diabetes

• central obesity

• poor diet and nutrition

• being physically inactive.

Addressing these risk factors helps improve the prognosis in angina.

Risk factors that cannot be modified include family history of cardiovascular disease (CVD), advancing age and male gender.9

DiagnosisA medical diagnosis of angina may include tests such as5,6:

• an ECG (electrocardiography) – measures electrical activity of heart and can show any abnormalities

• graded exercise stress test

• chest x-ray – should be normal in angina but may show cardiomegaly or other conditions

• blood tests – lipids, glucose, c-reactive protein (CRP); high levels of CRP increase the risk of heart disease

• coronary angiography – a special dye is injected into the coronary arteries and an x-ray shows up any blockage.

Differential diagnosesApart from angina, chest pain may indicate other medical problems and a thorough investigation by the patient’s doctor will help with this. Some conditions that may also cause chest pain include10:

- cardiac – aortic stenosis, hypertrophic cardiomyopathy, disease of the mitral valve, aortic dissection, arrhythmias, pericarditis

- respiratory – pneumonia, pleurisy, pneumothorax, pulmonary embolism, lung cancer

- gastrointestinal – gastro-oesophageal reflux disease (GORD), peptic ulcer disease, oesophageal spasm or rupture, cholecystitis, pancreatitis, gastritis

- musculoskeletal – trauma, rib pain (from fracture, osteoporosis or bone metastases), fibromyalgia,

- breast disease

- psychological – depression, stress, anxiety, panic attacks

- skin – shingles

- others – mononeuritis due to diabetes.

PrognosisAlthough the long-term prognosis of stable angina is favourable, outcomes vary according to severity of disease. Adverse outcomes with angina include worsening angina (i.e. unstable angina), myocardial infarction or death from arrhythmias.2,11

Patients with concomitant diabetes have increased risk of mortality.2 The results of one study of people with stable angina pectoris suggested that impaired fasting blood glucose, i.e. hyperglycaemia, rather than the diagnosis of diabetes itself was a strong predictor of poor prognosis.11 This study also reported that elevated serum creatinine (superior to creatinine clearance), was a marker of CV risk. Elevated serum creatinine in combination with either diagnosed diabetes or impaired glucose tolerance, was especially unfavourable. In addition, this study found sexual impairment was a negative predictor of prognosis in men.

Prognosis of angina worsens with advancing age and increasing severity of symptoms. The presence of anatomical lesions in the heart and poor ventricular function also leads to poor prognosis.2

The long-term prognosis of angina can be improved with the use of appropriate medicines and a healthier lifestyle.

ManagementManagement principles of angina include2,6,12:

• rest at onset of pain

• medicines for relief of acute symptoms. Long term medicines may be added for preventive therapy

• revascularisation – e.g. angioplasty (with or without stents), or coronary artery bypass graft surgery (CABG)

• lifestyle management.


Practice point 3

List of further resources

Websites:

• The Heart Foundation www.heartfoundation.org.au

• Heart Attack Facts www.heartattackfacts.org.au

• Better Health Channel Heart conditions – angina www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Angina

Free publications to download from the Heart Foundation:

• Reducing risk in heart disease – an expert guide to clinical practice for secondary prevention of coronary heart disease (for health professionals). At: www.heartfoundation.org.au/information-for-professionals/publications/Pages/Q-R.aspx

• Will you recognise your heart attack? Fact sheet and action plan (for patients). At: www.heartfoundation.org.au/information-for-professionals/publications/Pages/H.aspx

• My heart, my life (comprehensive booklet for people with coronary heart disease). At: www.heartfoundation.org.au/SiteCollectionDocuments/MHML%20preview.pdf

• Heart attack warning signs: fact sheet about delays in patient response (for health professionals). At: www.heartfoundation.org.au/information-for-professionals/publications/Pages/H.aspx

Facts Behind the Fact Card

Related Fact Cards Exercise and the heart

Fat and cholesterol

High blood pressure

Warning signs of heart attack

Weight and health

Staying a non smoker

Angina Pharmacist CPD Module number 253

Angina medicines

Angina medicines (see Table 2 page 9) help to balance the myocardial oxygen supply and demand. The aim of treating angina is to provide relief from symptoms and increase exercise/effort tolerance and also to reduce the risk of a myocardial infarction or death.12,13 Making lifestyle changes and addressing reversible risk factors are also important.13

Medicines to treat an acute attack of angina

• Glyceryl trinitrate (GTN) used sublingually as a spray or tablet will rapidly relieve pain or discomfort. Sublingual (S/L) GTN can be sold as a Schedule 3 item by a pharmacist. See Practice point 1 and Table 1 for doses of S/L GTN.

Medicines to prevent symptoms of angina

• First line agents are beta-blockers (atenolol or metoprolol), OR a non-dihydropyridine calcium channel blocker (CCB) e.g. verapamil or diltiazem. If monotherapy with a beta-blocker or a non-dihydropyridine CCB is not effective, an alternative is to add amlodipine or slow release nifedipine to a beta-blocker. Amlodipine or slow release nifedipine are not recommended to be used with either verapamil or diltiazem.

• Second line agents include long-acting nitrates (oral or transdermal), ivabradine, nicorandil or perhexiline. A second line agent can added to a first line agent if symptoms are not controlled, or used instead if the patient is not tolerating any first line agent.

Use of glyceryl trinitrate

One report stated that more than a third of patients with coronary artery disease were not prescribed S/L GTN as part of their regimen.1 This report quoted a study where of the patients who did get a prescription for S/L GTN, only 43% received instructions on how to use it properly. It also quoted another study where 31% of patients did not use the correct dose of GTN to treat their symptoms.

In the same report, patients from another study stated the average time since their last instruction on how to use GTN was about 3 years.1 GTN is a significant part of angina therapy, and its correct use and adequate potency is important. A good opportunity to check technique and provide regular updates on instructions for use can be at each new dispensing or when patients complain that their GTN tablets or spray is not providing adequate relief.

Secondary prevention

Secondary prevention in angina is important to reduce long-term risks of cardiovascular events.19 The benefits of lipid lowering therapy with statins in CVD are well established.19

While antiplatelet therapy has a definite role after a myocardial infarction, use of aspirin for primary prevention in CHD is controversial. Results from two randomised trials suggest that using aspirin in stable angina reduced the risk of non-fatal myocardial infarction.19 However, there was no evidence of an effect on fatal events and low dose aspirin showed a trend towards increased bleeding risk.

Table 1. Comparison of sublingual GTN tablets with spray1,12

S/L nitrolingual tablets S/L nitrolingual spray

Place tablet under tongue, do not chew or swallow. Spray under tongue, do not inhale.

Tops may be difficult to open for older people. More readily absorbed than tablets.

Requires adequate saliva for dissolution (chewing gum or artificial saliva products may help).

Requires priming at initial use (see Practice point 1).

Expiry 90 days after opening. Expiry typically 2 years.

Must be kept in original container and stored away from direct heat or light. Do not store close to body.

Store in a cool dry place away from direct heat. Flammable item so keep away from open flames.

If chest pain subsides patient can spit tablet out to avoid adverse effects such as headache.

Spray should not be shaken before use. Useful for infrequent angina is it has a longer expiry date.


John Bell saysFacts Behind the Fact Card

Practice point 4

Angina or heart attack?

It can be difficult to tell the difference between angina and a heart attack. People with angina can be at risk of a heart attack and should be educated about the warning signs. Become familiar with the Heart Foundation’s Will you recognise your heart attack? fact sheet.

Angina Pharmacist CPD Module number 253

Revascularisation

Angioplasty and coronary artery bypass surgery5

Despite adequate use of medicines, if patients still get symptoms of angina they may require intervention with cardiac catheterisation.

The two main types of cardiac catheterisation are:

• coronary angioplasty, also called percutaneous coronary intervention (PCI), with or without stents

• coronary artery bypass graft (CABG).

Patients with stent therapy are at risk of thrombosis. Dual antiplatelet therapy with aspirin plus either clopidogrel, ticagrelor or prasugrel is therefore recommended for 6 weeks to 6 months when a bare metal stent is used, or no longer than 12 months when a drug-eluting stent is used.20 Dual antiplatelet therapy beyond these times increases risk of bleeding.

Lifestyle management

Addressing modifiable risk factors will help improve the prognosis of angina and the person’s overall cardiovascular risk.

Advise people with angina to6:

• avoid stressful situations

• avoid large or heavy meals

• be smoke-free

• be physically active

• take medicines as prescribed

• maintain a healthy body weight.

Lifestyle factors such as smoking cessation, dietary control, and increased exercise are particularly important.

Smoking cessation

There is a well-established link between smoking and cardiovascular disease.21 Smoking cessation is an important lifestyle intervention to prevent CAD. A pharmacy is an ideal environment for consumers to learn about smoking cessation options such as nicotine replacement therapy, or be referred to a doctor for prescription medicines.

Diet

All patients who are newly diagnosed with angina should be given dietary advice and referred to a dietician if necessary. The 2013 Australian dietary guidelines advise eating a wide variety of nutritious foods from the five food groups. It recommends limiting foods high in saturated fat, added salt and added sugars, and limiting alcohol.13 Following a healthy diet can prevent or reduce high blood pressure and high blood cholesterol, and help maintain a healthy weight.

Exercise

Patients who have a sedentary lifestyle have an increased risk of developing CVD. People with angina (or any CVD) should consult with their doctor before starting on any exercise regimen. Glyceryl trinitrate can be used prior to exercise to prevent angina symptoms occurring.1

People should be encouraged to increase their physical activity. New guidelines published recently recommend that people should be active on most, but preferably on all days of the week.12 They also recommend that people minimise the amount of prolonged sitting and break long periods of sitting as often as possible.

People with angina should avoid heavy, sudden and unaccustomed exercise.

Pharmacist’s roleA Canadian survey found that 30% of people with chronic stable angina said their chest pain was only controlled ‘on occasion’, ‘rarely’ or ‘never’.24 Optimal use of angina medicines can help to eliminate, or nearly eliminate, angina pain resulting in improved patient quality of life.

Pharmacists play an important role in educating people about the use of their angina medicines. See Practice point 2 for counselling people with angina. Practice point 3 has a list of further resources. It is also essential to give people with angina information on the warning signs of heart attack (see Practice point 4, Figure 2).

Figure 2. Will you recognise your heart attack? fact sheetReproduced with permission. © 2014 National Heart Foundation of Australia.

Will you recognise your heart attack?

3 CALL 000* Triple Zero

• Ask for an ambulance.• Don’t hang up.• Wait for the operator’s instructions.*If calling Triple Zero (000) does not work on your mobile phone, try 112.

1 STOP and rest now

Do you feel any

In one or more of your

You may also feel

Yes

tightnessheavinesspressurepain

jaw arm/s back shoulder/sneckchest

dizzy short of breatha cold sweatnauseous

2 TALK Tell someone how you feel

Yes

If you take angina medicine• Take a dose of your medicine.• Wait 5 minutes. Still have symptoms?

Take another dose of your medicine.• Wait 5 minutes. Symptoms won’t

go away?

© 2010 National Heart Foundation of Australia ABN 98 008 419 761.

Are your symptoms

severe or getting

worse?

or

Have your symptoms

lasted 10

minutes?



Table 2. Medicines used in treatment of angina12-14

Drug Mechanism of action Common side effects Significant drug interactions*

Nitrates

Short-acting

S/L GTN tablets or spray

S/L Isosorbide dinitrate

All nitrates are predominantly venodilators so reduce venous return and preload to heart, thereby decreasing myocardial oxygen demand.

S/L forms are rapidly absorbed and avoid first pass metabolism. Their quick onset of action provides immediate relief of angina symptoms.

GTN spray has a longer shelf life than GTN S/L tablets, so is more suitable for people with infrequent symptoms. Headache, palpitations, skin flushing,

syncope, orthostatic hypotension, peripheral oedema.

Contraindicated with phosphodiesterase 5 (PDE5) inhibitors (e.g. sildenafil, tadalafil, vardenafil). Do not administer a nitrate unless it is >24 hours since last dose of sildenafil and vardenafil, or >48 hours for tadalafil.

Additional hypotensive effects with other blood pressure lowering agents.

Long-acting (LA)

Isosorbide dinitrate

Isosorbide mononitrate

Transdermal GTN patch

LA nitrates may be added to a first line agent if symptoms are not satisfactorily controlled.15 They may also be used when either a beta-blocker or CCB is contraindicated.

Helpful in variant (Prinzmetal) angina.

LA tablets – use once daily only.

Patches – keep on for maximum of 14 hours a day, then take off.

Tolerance to LA nitrates develops with continuous use so a nitrate-free interval of 10–12 hours is important.12

Beta-blockers

Atenolol

Metoprolol

Carvedilol

Bisoprolol

Preferred first line preventive agents. Decrease heart rate and contractility, and thus myocardial oxygen demand.16

Carvedilol, bisoprolol or metoprolol are suitable choices if the patient has concomitant heart failure. Beta-blockers are not recommended in variant angina.

Bradycardia, GI upset (nausea, diarrhoea), bronchospasm, dyspnoea, cold extremities, heart failure, heart block, fatigue, dizziness, abnormal vision, decreased concentration, hallucinations, insomnia, nightmares, depression, altered lipid and glucose metabolism, exacerbation of Raynaud’s phenomenon, hypotension.

Increased risk of bradycardia, hypotension or heart failure if co-administered with other drugs that have this effect.

Avoid beta-blockers with verapamil unless on specialist advice

Antagonise beta-agonists; can therefore affect asthma control.

Calcium channel blockers (CCBs)

Non-dihydropyridine

Verapamil

Diltiazem

Reduce vascular resistance and myocardial oxygen need by acting on coronary arteriolar smooth muscle.12 Suitable alternatives when beta-blockers are contraindicated. Verapamil and beta-blockers should not be used together as there is a risk of severe bradycardia and or heart failure. Diltiazem may be used cautiously with a beta-blocker.

Nausea, headache, flushing, dizziness, hypotension, peripheral oedema (common with dihydropyridines).

Diltiazem and verapamil are substrates and inhibitors of enzyme CYP3A4 so may interact with drugs that also inhibit, induce or are substrates of CYP3A4 (e.g. carbamazepine, simvastatin, HIV-protease inhibitors, azole antifungals, phenytoin, clarithromycin, cyclosporin, erythromycin, St John’s wort, grapefruit juice)

Verapamil may significantly increase digoxin levels.18 Although there is risk of additive bradycardia when combining diltiazem with digoxin, diltiazem does not significantly increase digoxin levels.

Dihydropyridine

Amlodipine

Slow release (SR)

nifedipine

Amlodipine or SR nifedipine can be added to beta-blockers if combination therapy is required as they are non-heart-rate limiting.17 They may initially worsen angina (reflex cardiac stimulation) but less likely with slow-release or controlled release form.

CCBs are preferred to beta-blockers in variant (Prinzmetal) angina, as beta-blockers may exacerbate symptoms.

All CCBs can have additive hypotensive effects with other antihypertensive drugs.

Others

Ivabradine For patients still in sinus rhythm. Reduces heart rate and therefore cardiac workload and myocardial oxygen demand. Suitable if beta-blockers or calcium channel blockers are not effective or not tolerated.

Transient areas of enhanced brightness in the visual field, bradycardia, ventricular extrasystoles, dizziness.

Ivabradine is metabolised via enzyme CYP3A4, so may interact with drugs that inhibit or induce CYP3A4 (e.g. diltiazem, verapamil carbamazepine, HIV-protease inhibitors, azole antifungals, phenytoin, grapefruit juice, clarithromycin, erythromycin, St John’s wort. Ivabradine is contraindicated with potent CYP3A4 inhibitors. The manufacturer does not recommend use with diltiazem or verapamil which inhibit CYP3A4 and also lower heart rate.12

Nicorandil A potassium-channel opener leading to systemic and coronary vasodilation.17 It reduces the heart rate and cardiac workload.

Headache on initiation, dizziness, nausea, lethargy, flushing, palpitations, myalgia, flushing.

Nicorandil is contraindicated with PDE5 inhibitors (sildenafil, tadalafil, vardenafil).

Additive hypotensive effects with other drugs that reduce blood pressure.

Perhexiline Unclear but may inhibit myocardial fatty acid metabolism with a corresponding increase in glucose utilisation, thus improving myocardial efficiency.

Headache, dizziness, weight loss, GI upset, ataxia, peripheral neuropathy, hepatitis.

Note: some Caucasians (6-10%) and asians (1–2%) are poor metabolisers so will require lower doses and monitoring of blood concentrations.12

Perhexiline may cause hypoglycaemia so caution with other agents that have the same effect e.g. sulphonylureas, insulin.

It inhibits and is metabolised via enzyme CYP 2D6 so may interact with other drugs that inhibit, induce or are metabolised via CYP2D6 (e.g. citalopram, fluoxetine, paroxetine, duloxetine, venlafaxine).

*Not an exhaustive list. Consult individual drug monographs.


John Bell saysFacts Behind the Fact Card Angina Pharmacist CPD Module number 253

Mr Taylor should be encouraged to continue playing golf as the exercise is good for him. Advise him that he can use his Nitrolingual Pumpspray (glyceryl trinitrate) before he plays. As it has been a while since he last used his spray, he may need a new one (expiry is usually 2 years). Demonstrate the technique to use the spray again as he may have forgotten about priming it and not shaking it before use.

Mr Taylor returns two months later to say that the spray had worked initially but now he has to use it several times at each golf session, and he plays up to 4 times a week. Mr Taylor would be an ideal candidate for a HMR review as he may require additional pharmacotherapy to control his angina symptoms.

His dual antiplatelet therapy should also be reviewed as he has been on it for about 18 months. Australian guidelines do not suggest any additional benefit of dual antiplatelet therapy beyond 6–12 months (depending on stent type).20,27 The NPS recommend re-assessing dual antiplatelet therapy after 12 months as there is increased risk of major bleeding.27

Key points• Angina occurs when part of the heart

muscle is temporarily unable to get enough blood and oxygen to meet its needs.

• Angina medicines help to balance myocardial oxygen demand and supply. Short-acting nitrates help relieve acute pain or can be taken before an activity that may bring on pain. Other long-term anti-anginal medicines may need to be taken depending on how severe the angina is and to help prevent attacks.

• Counselling patients on the correct use of S/L short-acting nitrates is important.

• Although angina does not damage the heart, it increases the risk of having a heart attack. Learning and acting upon the warning signs of a heart attack could significantly reduce the number of deaths and disability associated with heart attacks in people with CHD. See the Heart Foundation’s Will you recognise your heart attack? leaflet in Practice point 4.

• The Heart Foundation’s BeAWARE Pharmacy learning module can be used to familiarise yourself with the warning signs of a heart attack. This is available via the PSA website for members.

• Although chest pain is the most common warning sign of a heart attack, some people may not feel any chest pain but slight discomfort, indigestion or other symptoms as mentioned on page 4.

• Managing lifestyle factors such as obesity, physical inactivity, alcohol intake and smoking cessation are also important in managing angina or any CVD.

References1. Pharmacy Times. Considerations for the management

of angina pectoris with nitroglycerin. 2013. At: www.pharmacytimes.com/publications/health-system-edition/2013/September2013/R612_September2013

2. Pharmacy Times. Counselling patients with angina pectoris. 2011. At: www.pharmacytimes.com/publications/issue/2011/December2011/Counseling-Patients-with-Angina-Pectoris-#sthash.ghzpl3ZW.dpuf

3. The Merck Manual for health care professionals. Angina pectoris. 2013. At: www.merckmanuals.com/professional/cardiovascular_disorders/coronary_artery_disease/angina_pectoris.html#v934128

4. Heart Foundation. BeAWARE Pharmacy - the warning signs of heart attack. Online learning. Canberra: Pharmaceutical Society of Australia; 2013.

5. Cardiovascular conditions. National Heart Foundation. At: www.heartfoundation.org.au/your-heart/cardiovascular-conditions/Pages/angina.aspx

6. What is angina. National Heart, Lung and Blood Institute. 2011. At: www.nhlbi.nih.gov/health/health-topics/topics/angina/

7. Microvascular angina. American Heart Association. 2013. At: www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/Microvascular-Angina_UCM_450313_Article.jsp

8. Kahan T, Forslund L, Held C et al. Risk prediction in stable angina pectoris. Eur J Clin Invest. 2013;43(2):141–51.

9. Rossi et al. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2014.

10. Chest pain. Patient.co.uk. 2010. At: www.patient.co.uk/doctor/Chest-Pain.htm

11. Stable angina [revised Feb 2012].. In eTG complete. Melbourne: Therapeutic Guidelines; 2014. At: http://online.tg.org.au/complete/tgc.htm#

12. The Department of Health. Australia’s physical activity and sedentary behaviour guidelines. 2014. At: www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines#apaadult

13. National Health and Medical Research Council. Australian dietary guidelines. Canberra: National health and Medical Research Council; 2013. At: www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n55_australian_dietary_guidelines_130530.pdf

14. Smoking cessation [revised June 2013]. In eTG complete. Melbourne: Therapeutic Guidelines. ;2014. At: http://online.tg.org.au/complete/tgc.htm#

15. Prodigy study: duration of dual antiplatelet therapy under review. NPS Radar. 2012. At: www.nps.org.au/publications/health-professional/nps-radar/2012/august-2012/brief-item-dual-antiplatelets-therapy

16. Smiley, T. Symptomatic coronary artery disease: a call to action for pharmacists. Can Pharm J. 2010;143(6):302–8.

17. Coronary heart disease [revised Feb 2012]. In eTG complete. Melbourne: Therapeutic Guidelines; 2014. At: http://online.tg.org.au/complete/tgc.htm#

18. Tarkin J, Kaski J. Pharmacological treatment of chronic stable angina pectoris. Clin Med. 2013;13(1):63–70.

19. Henderson R, O’Flynn N. Management of stable angina: Summary of NICE guidance. Heart 2012;98(6):500–7.

20. National Institute for Health and Clinical Excellence. Clinical guideline 126. Management of stable angina. 2011 (modified Dec 2012). At: http://guidance.nice.org.uk/CG126

21. Risk factors for cardiovascular disease [revised Oct 2012].. In eTG complete. Melbourne: Therpeutic Guidelines; 2014. At: http://online.tg.org.au/complete/tgc.htm#

22. Alaeddini J. Angina pectoris.2014. At: www.emedicine.medscape.com/article/150215-overview

23. Coronary heart disease, anxiety and depression. beyondblue.2014. At: www.heartfoundation.org.au/SiteCollectionDocuments/Beyondblue_depression_CHD.pdf

24. Coronary artery stents [revised Feb 2012]. In eTG complete. Melbourne: Therapeutic Guidelines; 2014. At: http://online.tg.org.au/complete/tgc.htm#

25. Sansom LN ed. Australian pharmaceutical formulary and handbook. 22nd edn Canberra: Pharmaceutical Society of Australia; 2012.

26. Arrebola-Moreno A, Dungu J, Kaski J. Treatment strategies for chronic stable angina. Expert Opin Pharmacother. 2011;12(18):2833–44.

27. Baxter K, Preston CL (eds), Stockley’s Drug Interactions. London: Pharmaceutical Press. At: www.medicinescomplete.com/


Circle one correct answer from each of the following questions.

Before undertaking this assessment, you need to have read the Facts Behind the Fact Card article and the associated Fact Cards. This activity has been accredited by PSA as a Group 2 activity. Two CPD credits (Group 2) will be awarded to pharmacists with four out of five questions correct. PSA is accredited by the Australian Pharmacy Council to accredit providers of CPD activities for pharmacists that may be used as supporting evidence of continuing competence.

Assessment due 30 November 2014

Submit answers

Submit online at www.psa.org.au/selfcare

Fax: 02 6285 2869

Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600

Accreditation number: CS140009

This activity has been accredited for 1 hour Group 2 CPD (or 2 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan.

— — — — — —Personal ID number:

Full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AnginaAssessment questions for the pharmacist

Please retain a copy for your own purposes. Photocopy if you require extra copies.


1. Which of the following statements regarding use of nitrates for angina pectoris is INCORRECT?

a) Use of nitrates for angina is contraindicated in people who have concomitant hypertension.

b) Short-acting nitrates help to relieve acute angina pain.

c) Long-acting nitrates may be added to first line agents if symptoms are not satisfactorily controlled.

d) Short-acting nitrates may be used prophylactically before exercise.

2. Which of the following statements about the mechanism of action of angina medicines is INCORRECT?

a) Glyceryl trinitrate decreases heart rate.

b) Calcium channel blockers reduce vascular resistance and myocardial oxygen need.

c) Beta-blockers decrease heart rate.

d) Ivabradine reduces cardiac workload and myocardial oxygen demand.

3. Which of the following medicines may be used for the prophylaxis of stable angina but is not recommended for the management of variant angina?

a) Glyceryl trinitrate.

b) Metoprolol.

c) Verapamil.

d) Nifedipine.

4. A 48-year-old man with a history of angina is given a prescription for isosorbide dinitrate 20 mg twice daily. Which of the following should he be warned not to take?

a) Aspirin.

b) Grapefruit.

c) Vardenafil.

d) Verapamil.

5. A 71-year-old woman with stable angina is taking metoprolol 100 mg twice a day for preventive therapy and using nitrolingual spray as required. While metoprolol appears to be effective in reducing her heart rate, it has not provided adequate relief of her angina symptoms. At this point an additional drug that could be added to her drug regimen which may help improve her symptoms would be:

a) Sublingual isosorbide dinitrate.

b) Aspirin.

c) Isosorbide mononitrate.

d) Verapamil.


John Bell says

Mr Boyce is a 53-year-old regular customer at your pharmacy. He’s come in today requesting an antacid as he is getting bad indigestion. He tried the antacids he had at home but they didn’t provide relief. He takes ‘heart pills’ and does have Nitrolingual Pumpspray (glyceryl trinitrate) ‘angina spray’. He did not use the spray this morning because he only gets angina when he exerts himself. He woke up feeling queasy and thought it was indigestion due to the fish and chips he had last night.

AnginaBy Maureen Narayan-Ram This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Counter Connection Angina Pharmacy assistant’s education Module 253

What is angina?Angina is pain or discomfort, usually felt around the chest area. It is caused by a decreased amount of blood (and oxygen) flowing through the heart muscle. This reduction in blood flow is caused by narrowing of the small arteries in the heart (the coronary arteries).

What are the symptoms of angina?People with angina usually describe the pain in their chest area as tightness, crushing, squeezing, feeling pressure, heaviness or aching. The pain they feel can sometimes travel to their neck, shoulders, jaw, arms, upper or lower back area. Some people may not feel any pain but just some discomfort. They may also complain of other symptoms such as:

• nausea

• indigestion or heartburn (some people may say they feel ‘queasy’)

• sweating

• shortness of breath

• tiredness or weakness

• dizziness (light-headedness).

What causes angina and who is at risk?Angina is usually brought on when the heart muscle demands more oxygen than the coronary arteries can supply. This can be during physical exertion, severe emotional stress or after a heavy meal.

Angina is a symptom of an underlying heart problem such as coronary artery disease (CAD), also called coronary heart disease (CHD). The coronary arteries become narrowed by the formation of plaques (fatty/waxy substance). Over time this plaque hardens and causes the arteries to become narrowed and stiff. This process is called atherosclerosis. Atherosclerosis reduces the flow of blood through the arteries.

People are at an increased risk of CAD if they have diabetes, high levels of cholesterol, high blood pressure, or smoke tobacco.

Exercise and the heart

Benefits of exerciseSome of the health benefits of regular exercise are:

• lower blood pressure

• lower blood cholesterol

• lower risk of or better control of heart disease

• lower risk of or better control of diabetes

• lower risk of some cancers

• better weight control

• stronger and healthier bones, muscles and joints which reduces the risk of falls and injuries

• better posture

• increased feelings of wellbeing and relief of stress, anxiety and depression

• more energy

• better sleep.

Heart disease is the leading single cause of death in Australia. You can reduce your risk of heart disease by doing some exercise every day. Regular exercise helps lower your blood pressure, blood cholesterol and body weight. You can reduce your risk of heart disease even more by eating a healthy diet as well as doing regular exercise.

EXERCISE

Regular exercise is important for all people, no matter what their age, weight, health problems or abilities. Children and teenagers who do regular exercise are less likely to have high blood pressure, obesity, diabetes and heart disease when they are adults. Regular exercise also helps older people to stay healthy, independent and active.

The heart is a muscle that pumps blood through arteries and veins to all parts of the body. Blood gives body tissues the nutrients they need to work properly. The coronary arteries in the heart supply the heart muscle with blood.

A heart attack is a result of coronary heart disease. Coronary heart disease (also called ischaemic heart disease) is caused by the build up of fatty material called plaque on the inside walls of coronary arteries. Plaque is mostly cholesterol. A heart attack occurs when an area of plaque cracks and causes a blood clot that suddenly and completely blocks the flow of blood through the coronary artery. If the blockage is not cleared quickly, the part of the heart muscle that gets blood from that artery will start to die.

If you know the warning signs of a heart attack and immediately call Triple Zero (000) for an ambulance, you can

A heart attack is a sudden, complete blockage of a coronary artery which can cause part of the heart to die. Heart attacks are one of the most common causes of death of both men and women in Australia. Knowing the warning signs of heart attack and acting quickly can reduce the damage to your heart and increase your chance of survival.

get treatment to clear the blockage. Fast treatment can reduce the damage to your heart muscle and increase your chance of surviving a heart attack. Many people die because they wait too long before calling for an ambulance.

Warning signs of a heart attackThe warning signs of heart attack vary from person to person. They can also vary from one attack to another in the same person.

Warning signs of heart attack

GENERAL HEALTH

Clot preventing blood flow

Plaque buildup

Site of blockage

Damaged area

Illustration courtesy of the Heart Foundation

People with angina usually describe the pain in their chest area as tightness, crushing, squeezing, feeling pressure, heaviness or aching.


Counter ConnectionAngina Pharmacy assistant’s education Module 253

Other risk factors include unhealthy eating, lack of physical activity, obesity or being overweight and having a family history of CAD.

People with angina have a higher risk of having a heart attack. A heart attack occurs when one of the arteries in the heart becomes completely blocked by a blood clot and causes death of an area of heart muscle. Heart attacks can be fatal. See Practice point 4 on page 8.

What else can cause chest pain?Sometimes chest pain may be due to other causes such as anxiety, panic attacks, gall stones, respiratory conditions, anaemia (lack of iron), hyperthyroidism (overactive thyroid), or other heart conditions.

How is angina diagnosed?A doctor may do several tests to diagnose angina. Some may include:

• coronary angiography – a tube is passed through an artery in the arm or groin to the heart. A dye is injected into the artery and x-ray images are taken of the blood vessels in the heart.

• computerised tomography (CT) angiography – this test is less invasive than the coronary angiography. A needle is connected to an intravenous (IV) line and a dye is injected into the bloodstream. The dye highlights the blood vessels in the heart.

• electrocardiogram (ECG) – detects the heart’s electrical activity. It is done while exercising, usually done on a treadmill or exercise bicycle (exercise stress test).

• stress echocardiogram – an ultrasound of the heart before and after a treadmill exercise. It shows the internal structure of the heart, and how blood flows through it.

How is angina managed?Angina can be managed with:

• rest and medicines• surgical interventions (angioplasty with

or without stents, or coronary artery bypass surgery)

• lifestyle management.

Medicines

Medicines for angina:

• help to relieve angina pain• prevent angina attacks• reduce the risk of having a heart attack.

The main medicines used to manage angina are listed in Table 1. The common side effects of these medicines are listed in Table 2 on page 9.

Counselling customers about sublingual (S/L) glyceryl trinitrate (GTN)

The following are some counselling tips for customers who use S/L GTN tablets or spray.

• Use the spray or place the tablet under the tongue. S/L spray and tablets will not work if swallowed. Advise customers to avoid swallowing the spray or tablet to reduce chances of side effects.

• Advise people to prime the spray before using. See Practice point 1 on page 5.

• Discard S/L GTN tablets 3 months after opening the bottle even if all tablets are not used because they can lose their effect. The spray usually has a 2 year expiry (advise customers to check the pack).

• Keep S/L GTN tablets in their original bottle and store away from heat, sunlight and moisture. Advise customers not to carry the GTN tablets in their pocket or glove box of car as the heat can make it ineffective.

• Advise customers to sit down while using GTN and to stand up slowly after use because GTN can make people dizzy or lightheaded. They may also get a headache from this medicine.

Table 1. Main medicines for angina

Medicine How it works Schedule of medicine*

For angina attacks

Nitrates

Glyceryl trinitrate e.g. Nitrolingual pumpspray, Anginine tablets These open (dilate) blood vessels so more blood can flow to heart. Are absorbed rapidly so have a quick onset of action for immediate relief of pain.

S3

Sublingual isosorbide dinitrate e.g. Isordil S3

For prevention of angina symptoms

Beta-blockers

Atenolol e.g. Noten, Tenormin, Tensig

Metoprolol e.g. Betaloc, Lopresor, Minax

Lowers heart rate. S4

Calcium channel blockers

Verapamil e.g. Anpec, Cordilox SR, Isoptin SR, Veracaps SR

Diltiazem e.g. Cardizem, Dilzem, Vasocardol

Slow release nifedipine e.g. Adalat Oros, Addos, Adefin

Amlodipine e.g. Amlo, Nordip, Norvasc

Some open (dilate) blood vessels and some slow heart rate so more blood can flow to the heart.

S4

Long-acting nitrates

Oral isosorbide dinitrate e.g. Sorbidin Help to reduce angina symptoms over time. S3

Isosorbide mononitrate e.g. Monodur, Duride, Imdur S4

Preventative medicines

Low-dose aspirin e.g. Astrix, Cardiprin People with angina who have had a heart attack may be prescribed aspirin to reduce their risk of blood clots.

S2

Cholesterol lowering medicines Reducing blood cholesterol decreases a person’s risk of having heart disease or angina worsening.

S4

*S2=pharmacy medicine, S3=pharmacist only medicine, S4=prescription only medicine


John Bell saysCounter Connection Angina Pharmacy assistant’s education Module 253

This action plan is available in other languages and can be downloaded from the Heart Foundation website at www.heartattackfacts.org.au.

Ask Mr Boyce if he is experiencing any pressure, heaviness or tightness in his chest, neck, arm, back or shoulders. Listen for clues and key phrases as mentioned above. Check for other symptoms such as sweating, dizziness, shortness of breath, nausea.

Since Mr Boyce has already tried some antacids at home and they haven’t worked, refer him to the pharmacist.

Mr Boyce should be asked to use his Nitrolingual Pumpspray (glyceryl trinitrate) and see if he gets any relief. He should be counselled on the correct way to prime and use his spray.

If this still does not help, follow the STOP, TALK and CALL procedure above.

Surgical interventions

Angioplasty – a balloon is put at the end of a small wire and sent up to the heart via a vein in the groin or arm. This is then pushed to the blocked part of the coronary artery and the balloon is expanded to help widen the artery and improve blood flow. Sometimes a stent (small tube) is also inserted into the artery to help keep it open.

Coronary artery bypass surgery (CABG) – a healthy artery or vein from another part of the body is inserted or ‘grafted’ to the blocked part of the coronary artery. The new vein or artery bypasses or ‘goes around’ the blocked artery and improves blood flow around the heart.

Lifestyle advice

Provide information to your customers about lifestyle and discuss how to modify or reduce their risk of heart disease. For example, some lifestyle changes include:

• Slow down and take rest breaks if physical exertion triggers angina pain.

• Avoid eating large and rich meals as this can trigger angina.

• Learn ways to handle stress, for example learn some relaxation techniques to help relax the body and mind.

• Increase physical activity, but first ask a doctor what exercises are safe to do. Remind them to use their Nitrolingual Pumpspray (glyceryl trinitrate) or Anginine (glyceryl trinitrate) tablets before exercise if their doctor has advised them to.

• Keep to a healthy weight range. If they are overweight or obese, they should discuss a suitable weight loss plan with their doctor, dietician or pharmacist.

• Take all their prescribed medicines as directed, including medicines for high blood pressure, high blood cholesterol or diabetes.

• Quit smoking. Discuss the 5A’s protocol about smoking cessation; ‘Ask, Assess, Advise, Assist, Arrange’. Refer to PSA’s Self Care Smoking Cessation ACTION kit for further information.

• Advise them to limit alcohol to no more than 2 standard drinks per day. See Exercise and the Heart Self Care Fact Card.

Refer to Practice point 3 on page 7 for further resources on angina and ideas on what Self Care Fact Cards you can offer your customer.

What would you do if a customer was having a heart attack in the pharmacy?It can be difficult to tell the difference between the signs and symptoms of a heart attack and angina. Recognising the symptoms of a heart attack early and taking action will help to minimise damage to the heart muscle. See Practice point 4 on page 8.

When you are with customers, listen and watch for the following signs and key phrases that suggest a heart attack:

• ‘feels like…tightness, heaviness, pressure, ache’

• ‘feels like…an elephant sitting on my chest’

• ‘feels like…a belt being tightened around my chest’

• the patient is holding their chest

• the patient appears clammy and has a ‘grey’ complexion.

Ask the customer: Do you feel you require immediate or emergency medical attention?

The Heart Foundation’s action plan for heart attacks highlights the ‘STOP, TALK and CALL’ procedure. It suggests that if you are with someone who is experiencing the warning signs of heart attack, or someone who thinks they may be having a heart attack, you should help them do the following:

1. STOP: Get them to stop and rest.

2. TALK: Get them to tell you about how they feel.

3. If they use S/L GTN (spray or tablets), advise them to take a dose. Wait five minutes and see how they are feeling. If they still have symptoms, they should take another dose of medicine. Wait another five minutes.

4. Check if their symptoms are severe or getting worse, or have lasted 10 minutes.

5. CALL: If their symptoms have continued, call Triple Zero (000). Ask for an ambulance and don’t hang up, wait for the operator’s instructions.


Counter Connection

— — — — — —Personal ID number:

Full name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suburb: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Circle one correct answer from each of the following questions.

Before undertaking this assessment, you need to have read the Counter Connection article and the associated Fact Cards.

The pass mark for each module is five correct answers. Participants receive one credit for each successfully completed module. On completion of 10 correct modules participants receive an Achievement Certificate.

Assessment due 30 November 2014

Please retain a copy for your own purposes. Photocopy if you require extra copies.

AnginaAssessment questions for the pharmacy assistant

Submit answers

Submit online at www.psa.org.au/selfcare

Fax: 02 6285 2869

Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600

Angina Pharmacy assistant’s education Module 253

1. Which of the following statements describes the symptoms a person with angina may experience?

a) Chest pain which may be described as crushing, heaviness or tightness in the chest.

b) Shortness of breath, sweating or nausea may also be symptoms.

c) Pain in the neck, jaw or arm.

d) All of the above could be symptoms of angina.

2. Angina is best managed by:

a) Medicines alone.

b) Lifestyle changes alone.

c) Medicines and surgery.

d) Medicines and lifestyle changes, with surgical interventions if required.

3. Which of the following statements regarding sublingual glyceryl trinitrate is INCORRECT?

a) It is absorbed rapidly when used sublingually.

b) The sublingual tablet has a longer shelf life than the sublingual spray.

c) Light-headedness and headaches can be common side effects.

d) Swallowing sublingual GTN can increase the chances of side effects.

4. What lifestyle advice would you recommend to someone who has angina?

a) Quit smoking if they smoke.

b) Lose weight if they are overweight or obese.

c) Increase their physical activity.

d) All of the above.

5. If you’re with someone who is showing symptoms of a heart attack and the symptoms are not relieved by rest or their sublingual glyceryl trinitrate tablets, what should you do?

a) Call an ambulance by dialling Triple Zero (000).

b) Time the person’s attacks.

c) Offer the person a place to sit down and some water to drink.

d) Write down the symptoms the person is experiencing.

6. Sarah, 65, presents to your pharmacy with a request for glyceryl trinitrate (GTN) spray to manage her angina attacks. With respect to the supply of GTN spray, which of the following statements is correct?

a) GTN spray is a pharmacy medicine, therefore as long as she is not taking other medicines, you can sell Sarah a GTN spray without the involvement of the pharmacist.

b) GTN spray is a pharmacist only medicine, therefore you must involve the pharmacist in the sale.

c) GTN spray is only available with a doctor’s prescription.

d) None of the above.


John Bell says

What’s coming up in inPHARMation?Next month’s inPHARMation will focus on low-dose aspirin.Aspirin is one of the most commonly used drugs worldwide. Low-dose aspirin has an established role as an antiplatelet in the secondary prevention of cardiovascular events such MI, stroke and vascular death. Its role in primary prevention in consumers with cardiovascular disease (CVD) is limited by the risk of bleeding (mostly gastrointestinal) and is currently not recommended. However, with one-in-six Australians currently affected by CVD, research is continuing into the role of low-dose aspirin in primary CVD prevention. The November issue of inPHARMation will review the current place of low-dose aspirin in CVD management, which customers can and cannot take low-dose aspirin and the most appropriate advice that pharmacists and pharmacy staff can provide to customers taking low-dose aspirin.

Self Care achievers Self Care presents certificates to staff who successfully complete a year of Counter Connection modules. We would like to congratulate the following people:

ConferencesASMI Annual Conference18 NovemberWaterview Convention Centre, Sydney Olympic Parkwww.asmi.com.au

Australasian Pharmaceutical Sciences Association Conference6–7 DecemberBrisbane, Queensland

NAPSA Congress24–30 January, 2015Griffith University, Gold Coast, Queenslandwww.napsacongress.org

Australian Pharmacy Professional Conference and Trade Exhibition12–15 March, 2015Gold Coast Convention Centre, Queenslandwww.appconference.com

40th PSA Offshore Refresher Conference30 April–10 May, 2015Berlin and Pariswww.psa.org.au/refresher

13th National Rural Health Conference24–27 May, 2015Darwin Convention Centre, NT

National health calendar datesNovember

All month MOvember Changing the Face of Men’s Healthau.movember.com

All month Lung Awareness Monthlungfoundation.com.au

14 World Diabetes Daywww.diabetesaustralia.com.au

17–23 National Cervical Cancer Awareness Weekaccf.org.au

17–23 Antibiotic Awareness Weekwww.safetyandquality.gov.au

December

1 World AIDS Daywww.worldaidsday.org.au

3 International Day of People with Disabilitywww.dss.gov.au

5 International Volunteer Daywww.volunteering.nsw.gov.au

Conferences and calendar dates

Year 12Jean Bryant

Year 11Connie Crook

Susan Smith

Year 10Connie Crook

Susan Smith

Year 9Colleen Bryce

Gail Lilly

Kaye Neilson

Marlene Azzouni

Monika Trimarchi

Year 8Angela Hayles

Kerry Mills

Maria Papalia

Year 7Elizabeth Jovic

Kim Case

Tracey Blood

Year 6 Claire Zschoke

Dianne Fullarton

Kim Ruffels

Kylie Richardson

Tarea Kelly

Year 5Alida Bozzetto

Amelia Deren

Anne Kay

Dianne Barker

Felicity Barone

Gai Booth

Janet Quinell-Hughes

Judith Gallagher

Kylie Hibben

Linda Wulff

Marcia Dunn

Pam Biddle

Tina Lawrence

Year 4Carol Zschoke

Debbie Grantham

Karen Buhagiar

Sandra Atkins

Susan Spear

Year 3Beryl Baines

Carly Meade

Debbie Heinrich

Dee Locke

Jennifer Broadbent

Jenny McKenna

Jo Alfred Hurtado

Karen Carter

Karen Miller

Karen Parks

Karen Tree

Kathy Koehn

Leanne Hatch

Lisa Virgin

Lucy Torr

Margaret Borg

Melissa Rochester

Renae Kemp

Year 2Ahmed Al Assadi

Alexandra Purchase

Amelia Missaghian

Christine Dudman

Cristina Cortese

Haylee Strong

Ianna Williamson

Karen Morris

Kate Dossaer

Kellie Murphy

Louise Kitt

Lynda Thompson

Madison White

Maria Sten

Phuong Tieu

Sally Clark

Theresa Grimsey

Tracie Wallace

Yasmin Thus

Year 1Abbey Herron

Bree-anna Mulqueeny

Caitlyn Sterck

Carly Mitchell

Cathy Dunbar

Cathy See

Charmaine Paterson

Chloe Leonard

Elizabeth Hagley

Emily McCormack

Georgia Foley

Hannah Place

Isabella Gross

Jade George

Jane Lau

Jane Stoll

Kajal Charan

Kate Trpkoski

Kate Whalan

Kylie Pettiford

Lauren Sharman

Lisa Hearne

Maria Lantouris

Rebecca Cowling

Samantha Williams

Samatha Mullin

Sarah Tarrant

Shae Williams

Shellie Wells

Shey McLean

Steph Power

Teresa Devin

Vivienne Shannon

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