Definitions
• Angina pectoris: Chest pain brought about by myocardial ischemia
Atheroma: Fibrous cap composed of smoothmuscle cells that forms over lipid depositswithin arterial vessels and protrudes into thelumen of the vessel, narrowing the lumen andobstructing blood flow; also called plaque
Angina Pectoris
• Is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure inthe anterior chest.
• It is caused by insufficient coronary blood flowin relation to the need
• Severity of the symptoms of angina is basedon the magnitude of the precipitating activityand its effect on activities of daily living
Pathophysiology
The main cause of angina atherosclerotic disease.
• It is associated with obstruction of at least onemajor coronary artery
• The myocardium extracts a large amount ofoxygen from the coronary circulation to meet itscontinuous demands
• With an increased demand, flow through thecoronary arteries needs to be increased
• When there is blockage in a coronary artery, flow cannot be increased, resulting in ischemia
Types of Angina
• Stable angina: Predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycer in
• Unstable angina (also called preinfarction angina orcrescendo angina): symptoms increase in frequencyand severity; may not be relieved with rest ornitroglycerin
• Intractable or refractory angina: Severe incapacitating chest pain
Types of Angina (2)
• Variant angina (also called Prinzmetal’sangina): Pain at rest with reversible STsegment elevation; thought to be caused by coronary artery vasospasm
• Silent ischemia: Objective evidence of ischemia (such as ECG changes with a stress
test), but patient reports no pain
Factors Associated with Angina pain
• Physical exertion by increasing myocardial oxygen demand
• Exposure to cold causing vasoconstriction and elevated BP with increased oxygen demand
• Eating a heavy meal, increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply to the heart muscle
• Stress or any emotion-provoking situation, causing the release of catecholamine, which increases blood pressure, heart rate, and myocardial workload.
Clinical Manifestation
• Ischemia of the heart muscle may produce pain or other symptoms, varying in severity_
o mild indigestion
o choking
o heavy sensation in the upper chest
o severe apprehension
o feeling of impending death.
• The pain is often felt deep in the chest behind the sternum (retrosternal area).
• Pain or discomfort is poorly localized radiating from the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm.
• The patient often feels tightness or a heavy choking or strangling sensation
• The patient with diabetes mellitus may not have severe pain with angina because diabetic neuropathy can blunt nociceptor transmission, dulling the perception of pain
• Symptoms in women are more diffuse and affects long
segments of the artery and hands
• Shortness of breath
• Pallor
• Diaphoresis
• Dizziness or lightheadedness
• Nausea and vomiting may accompany the pain.
• Anxiety
• Angina is that it subsides with rest or administering
nitroglycerin.
• In many patients, anginal symptoms follow a stable,
predictable pattern.Unstable Angina
Unstable angina is characterized by
o Attacks that increase in frequency and severity
o Not relieved by rest and administration of
nitroglycerin.
• unstable angina require medical intervention
Angina and Age
• Dyspnea is the main presenting symptom in the elderly
• Sometimes there are no symptoms (“silent”CAD).
• Pharmacologic stress testing and cardiac catheterization may be used to diagnose CAD
• Medications are associated with an increase risk of adverse reactions –so caution to elders
Assessment and Diagnosis
• Patient’s history related to the clinical manifestations of ischemia
• A 12-lead ECG may show changes indicative of ischemia such as T-wave inversion
• CRP and cardiac biomarker values to rule Arterial Coronary Syndrome (ACS)
• The patient may also be referred for a nuclear scan or invasive procedure (eg, cardiac catheterization, coronary angiography).
Medical Management
The objectives are to decrease the oxygen demand of the myocardium and to increase the oxygen supply.
• This is met by pharmacologic therapy and control of risk factors
• Reperfusion procedures may be used to restore the blood supply to the myocardium.
• PCI procedures include percutaneous transluminal coronary angioplasty [PTCA],intracoronary stents, and atherectomy
Nursing Management- Assessment
Information about the patient’s symptoms and activities
• Ask about
o Location of the pain (or prodromal symptoms)
o Feeling of the pain
o Type of the pain
o Relationship with previous pain before
o Pain rate from 0 to 10 scale, with 10 being the most pain
o When pain began
o How long the pai last
o What brings on the pain
o Pain relief measure
o Other symptoms accompanying the pain
• The answers to these questions form the basis for designing an effective program of treatment and prevention.
• Risk factors for CAD
• Patient’s response to angina,
• Patient’s and family’s understanding of the
diagnosis
• Adherence to the current treatment plan
Nursing Management- Diagnosis
• Based on the assessment data, major nursing diagnoses may include:
• Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or other prodromal symptoms
• Death anxiety related to cardiac symptoms
• Deficient knowledge about the underlying disease and methods for avoiding complications
• Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes
Medication-- Atenolol, heparin and aspirin.
Nursing management –Planning Goals
• Immediate and appropriate treatment
• Prevention of angina
• Reduction of anxiety
• Awareness of the disease process
• Understanding of the prescribed care
• Adherence to the self-care program
• Avoidance of complications
Nursing Interventions
• Patient to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen requirements of the ischemic myocardium.
• Assess situation as informed in step of assessment
• Measure vital signs
• Observing signs of respiratory distress
• Obtain a 12-lead ECG is usually obtained and scrutinized
for ST segment and T-wave changes.
• If the patient has been placed on cardiac monitoring with continuous ST-segment monitoring
• Assess the ST segment for changes
Nursing Interventions
• Administer Nitroglycerin is administered sublingually
• Administer Oxygen at 2 L/min
• Reduce Anxiety by
o Guided imagery or music therapy, should be explored with the patient
o Addressing the spiritual needs of the patient and
o Family may assist in allaying anxieties and fears
Nursing Interventions (2)
Preventing Pain
• Alternates the patient’s activities with rest periods.
• Balance activity and rest is an important aspect of the educational plan for the patient
and family
Promoting Home and Community-Based Care
• The goals of education are to
o Reduce the frequency and severity of anginal attacks
o Delay the progress of the underlying disease if possible
o Prevent complications
Evaluation
Patient
• Reports pain relief
• Reports decreased anxiety
• Expresses acceptance of diagnosis
• Expresses control over choices within medical regimen
• Does not exhibit signs and symptoms that indicate a high level of anxiety
• Understands ways to avoid complications and is free of complications Describes the process of angina
• Explains reasons for measures to prevent complications
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