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Angina Pectoris

Mr. Gomez is fond of eating in fast food joints. He likes the convenience and the taste of the food they serve. This has gone for so many years until one day, while he was walking the flight of stairs to his apartment, he felt a sudden, crushing pain vibrating towards his neck and jaw. He sat down immediately when he reached his room, and the pain was relieved. This episode occurred thrice that week so he decided to visit a physician. The physician told him that he is experiencing angina pectoris.

Description


Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups.
  • Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest.
  • The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress.

Classification


There are five (5) classifications or types of angina.
  • Stable angina. There is predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin.
  • Unstable angina. The symptoms increase in frequency and severity and may not be relieved with rest or nitroglycerin.
  • Intractable or refractory angina. There is severe incapacitating chest pain.
  • Variant angina. There is pain at rest, with reversible ST-segment elevation and thought to be caused by coronary artery vasospasm.
  • Silent ischemia. There is objective evidence of ischemia but patient reports no pain.

Pathophysiology


Angina is usually caused by atherosclerotic disease.
  • Almost invariably, angina is associated with a significant obstruction of at least one major coronary artery.
  • Oxygen demands not met. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands.
  • Increased demand. When there is an increase in demand, flow through the coronary arteries needs to be increased.
  • Ischemia. When there is blockage in a coronary artery, flow cannot be increased, and ischemia results which may lead to necrosis or myocardial infarction.
  • Schematic Diagram for Angina Pectoris via Scribd.

Pathophysiology of Angina Pectoris by Osmosis


Check out this awesome pathophysiology and easy to understand video by Osmosis. Let us support them via Patreon to make more informative videos like this.

Causes


Several factors are associated with angina.
  • Physical exertion. This can precipitate an attack by increasing myocardial oxygen demand.
  • Exposure to cold. This can cause vasoconstriction and elevated blood pressure, with increased oxygen demand.
  • Eating a heavy meal. A heavy meal increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle; in a severely compromised heart, shunting of the blood for digestion can be sufficient to induce anginal pain.
  • Stress. Stress causes the release of catecholamines, which increased blood pressure, heart rate, and myocardial workload.

Clinical Manifestations


The severity of symptoms of angina is based on the magnitude of the precipitating activity and its effect on activities of daily living.
  • Chest pain. The pain is often felt deep in the chest behind the sternum and may radiate to the neck, jaw, and shoulders.
  • Numbness. A feeling of weakness or numbness in the arms, wrists and hands.
  • Shortness of breath. An increase in oxygen demand could cause shortness of breath.
  • Pallor. Inadequate blood supply to peripheral tissues cause pallor.

Gerontologic Considerations


Here’s what you need to know when caring for geriatric patients with angina pectoris:
  • The elderly person with angina may not exhibit the typical pain profile because of the diminished responses of neurotransmitters that occur with aging.
  • Often, the presenting symptom in the elderly is dyspnea.
  • Sometimes, there are no symptoms (“silent” CAD), making recognition and diagnosis a clinical challenge.
  • Elderly patients should be encouraged to recognize their chest pain–like symptom (eg, weakness) as an indication that they should rest or take prescribed medications.

Complications


  • Myocardial infarction. Myocardial infarction is the end result of angina pectoris if left untreated.
  • Cardiac arrest. The heart pumps more and more blood to compensate the decreased oxygen supply, and.the cardiac muscle would ultimately fail leading to cardiac arrest.
  • Cardiogenic shock. MI also predisposes the patient to cardiogenic shock.

Assessment and Diagnostic Findings

The diagnosis of angina pectoris is determined through:
  • ECG: Often normal when patient at rest or when pain-free; depression of the ST segment or T wave inversion signifies ischemia. Dysrhythmias and heart block may also be present. Significant Q waves are consistent with a prior MI.
  • 24-hour ECG monitoring (Holter): Done to see whether pain episodes correlate with or change during exercise or activity. ST depression without pain is highly indicative of ischemia.
  • Exercise or pharmacological stress electrocardiography: Provides more diagnostic information, such as duration and level of activity attained before onset of angina. A markedly positive test is indicative of severe CAD. Note: Studies have shown stress echo studies to be more accurate in some groups than exercise stress testing alone.
  • Cardiac enzymes (AST, CPK, CK and CK-MB; LDH and isoenzymes LD1, LD2): Usually within normal limits (WNL); elevation indicates myocardial damage.
  • Chest x-rayUsually normal; however, infiltrates may be present, reflecting cardiac decompensation or pulmonary complications.
  • Pco2, potassium, and myocardial lactate: May be elevated during anginal attack (all play a role in myocardial ischemia and may perpetuate it).
  • Serum lipids (total lipids, lipoprotein electrophoresis, and isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides; phospholipids): May be elevated (CAD risk factor).
  • EchocardiogramMay reveal abnormal valvular action as cause of chest pain.
  • Nuclear imaging studies (rest or stress scan): Thallium-201: Ischemic regions appear as areas of decreased thallium uptake.
  • MUGA: Evaluates specific and general ventricle performance, regional wall motion, and ejection fraction.
  • Cardiac catheterization with angiography: Definitive test for CAD in patients with known ischemic disease with angina or incapacitating chest pain, in patients with cholesterolemia and familial heart disease who are experiencing chest pain, and in patients with abnormal resting ECGs. Abnormal results are present in valvular disease, altered contractility, ventricular failure, and circulatory abnormalities. Note: Ten percent of patients with unstable angina have normal-appearing coronary arteries.
  • Ergonovine (Ergotrate) injection: On occasion, may be used for patients who have angina at rest to demonstrate hyperspastic coronary vessels. (Patients with resting angina usually experience chest pain, ST elevation, or depression and/or pronounced rise in left ventricular end-diastolic pressure [LVEDP], fall in systemic systolic pressure, and/or high-grade coronary artery narrowing. Some patients may also have severe ventricular dysrhythmias.)

Medical Management

The objectives of the medical management of angina are to increase the oxygen demand of the myocardium and to increase the oxygen supply.
  • Oxygen therapy. Oxygen therapy is usually initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and reduce pain.

Pharmacologic Therapy

  • Nitroglycerin gives long term and short term reduction of myocardial oxygen consumption through selective vasodilation within three (3) minutes.
  • Beta-blockers reduces myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart.
  • Calcium channel blockers have negative inotropic effects.
  • Antiplatelet medications prevent platelet aggregation; and anticoagulants prevent thrombus formation.

Nursing Management


The patient with angina pectoris should be managed by a cardiac nurse specifically.

Nursing Assessment

In assessing the patient with angina, the nurse may ask regarding the following:
  • Location of pain.
  • Characteristics of pain.
  • Health history.
  • Pain scale.
  • Onset of pain.
  • Cause of pain.
  • Measures that relieve pain.
  • Other symptoms that occur with pain.

Nursing Diagnosis

Based on the assessment data, major nursing diagnosis 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 complication
  • Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes.

Nursing Care Planning and Goals

Main Article: 4 Angina Pectoris (Coronary Artery Disease) Nursing Care Plans

Major patient goals include:
  • Immediate and appropriate treatment when angina occurs.
  • Prevention of angina.
  • Reduction of anxiety.
  • Awareness of the disease process and understanding pf the prescribed care.
  • Adherence to the self-care program.
  • Absence of complications.

Nursing Interventions

Nursing interventions for a patient with angina pectoris include:
  • Treating angina. The nurse should instruct the patient to stop all activities and sit or rest in bed in a semi-Fowler’s position when they experience angina, and administer nitroglycerin sublingually.
  • Reducing anxiety. Exploring implications that the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions.
  • Preventing pain. The nurse reviews the assessment findings, identifies the level of activity that causes the patient’s pain, and plans the patient’s activities accordingly.
  • Decreasing oxygen demand. Balancing activity and rest is an important aspect of the educational plan for the patient and family.

Evaluation

The expected patient outcomes are:
  • Reported pain is relieved promptly.
  • Reported decrease in anxiety.
  • Understood ways to avoid complications and is free pf complications.
  • Adhered to self-care program.

Discharge and Home Care Guidelines

The goals of education ate to reduce the frequency and severity of anginal attacks, to delay the progress of the underlying disease if possible, and to prevent complications.
  • Reduce anginal attacks. Activities should be planned to minimize the occurrence of angina episodes.
  • Follow-up monitoring. The patient may need reminders about follow-up monitoring, including periodic blood laboratory testing and ECGs.
  • Adherence. The home care nurse may monitor the patient’s adherence to dietary restrictions and to prescribed antianginal medications.

Documentation Guidelines

The focus of documentation in a patient with angina pectoris includes:
  • Nature, extent, and duration of problem.
  • Effect on independence and lifestyle.
  • Characteristics of pain, precipitators, and what relieves pain.
  • Pulses and BP.
  • Client’s fear and signs and symptoms exhibited.
  • Responses and actions of family/SOs.
  • Deviation from prescribed treatment plan and client’s reasons in own words.
  • Consequences of actions to date.
  • Plan of care.
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.

Practice Quiz: Angina Pectoris

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1. The pain of angina pectoris is produced primarily by: A. Vasoconstriction. B. Movement of thromboemboli. C. Myocardial ischemia. D. The presence of atheromas. 2. The nurse advises a patient that sublingual nitroglycerin should alleviate angina pain within: A. 3 to 4 minutes. B. 10 to 15 minutes. C. 30 minutes. D. 60 minutes. 3. The scientific rationale supporting the administration of beta-blockers is the drug’s ability to: A. Block sympathetic impulses to the heart. B. Elevate blood pressure. C. Increase myocardial contractility. D. Induce bradycardia. 4. Calcium channel blockers act by: A. Decreasing SA node automaticity. B. Increasing AV node conduction. C. Increasing the heart rate. D. Creating a positive inotropic effect. 5. All of the following are type of angina except for: A. Stable angina. B. Unstable angina. C. Refractory angina. D. Direct angina. Answers and Rational 1. Answer: C. Myocardial ischemia. Ischemia causes lactic acid production that triggers the pain. 2. Answer: A. 3 to 4 minutes. Nitroglycerin given sublingually alleviates angina pain within 3 minutes. 3. Answer: A. Block sympathetic impulses to the heart. Beta-blockers reduces myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart. 4. Answer: A. Decreasing SA node automaticity. Calcium channel blockers decrease sinoatrial node automaticity. 5. Answer: D. Direct angina. Direct angina is not a type of angina.

See Also


Posts related to this care plan:

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