CCN 612
ANGINA PECTORIS
COURSE OBJECTIVES
At the end of this lecture the students should be able
to
• Define Angina pectoris
• Describe the Pathophysiology Angina pectoris
• State Factors associated with typical angina pain
• Clinical Manifestations of Angina pectoris
• Types of Angina
• Assessment and Diagnostic Findings
• Management of Angina pectoris
ANGINA PECTORIS
Angina pectoris is a clinical syndrome usually
characterized by paroxysms (sudden or recurrence
attack) of pain or pressure in the anterior chest.
Causes
• The cause is usually insufficient coronary blood
flow.
This results in decreased oxygen supply to meet an
increased myocardial demand for oxygen in
response to physical exertion or emotional stress.
.
Pathophysiology
• Angina is usually caused by atherosclerotic
disease.
• Angina is associated with a significant
obstruction of a major coronary artery →
↓se oxygen supply to meet an ↑se oxygen
demand of the myocardial muscle → ischemia
and angina result.
Factors associated with Typical Angina pain:
• Several factors are associated with typical angina pain:
• Physical exertion: Increases myocardial oxygen demand.
• Exposure to cold: Causes vasoconstriction and an elevated blood
pressure, with increased oxygen demand.
• Eating a heavy meal: Increases the blood flow to the mesenteric
area for digestion, thereby reducing the blood
supply available to the heart muscle.
• Stress or any emotion-provoking situation: causing the release of
adrenaline and increasing blood pressure, which may accelerate
the heart rate and increase the myocardial workload.
• Atypical angina is not associated with the above listed factors. It
may occur at rest.
Clinical Manifestations
• Pain
Ischemia of the heart muscle may produce pain.
The pain is often felt deep in the chest behind the
upper or middle third of the sternum. Typically, the
pain or discomfort is poorly localized and may
radiate to 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 that has an
insistent quality.
Clinical Manifestations Cont.
The patient with diabetes mellitus may not have
severe pain with angina because of neuropathy
that accompanies diabetes.
A feeling of weakness or numbness in the arms,
wrists, and hands may accompany the pain,
shortness of breath, pallor, diaphoresis, dizziness or
light headedness, nausea and vomiting.
Anxiety may accompany angina.
Types of Angina
Some of the types of Angina are
• Stable angina: predictable and consistent pain that
occurs on exertion and is relieved by rest.
• Unstable angina (also called preinfarction angina
or crescendo angina): symptoms occur more
frequently and last longer than stable angina. The
threshold for pain is lower, and pain may occur at
rest.
• Silent ischemia: (electrocardiographic changes ), but
patient reports no symptoms
Assessment and Diagnostic Findings
• ECG and blood laboratory values help in making the
diagnosis. The patient may undergo an exercise in which
the heart is monitored by ECG, echocardiogram, or both.
• Invasive procedures e.g., coronary artery angiography.
• Manifestations of ischemia and the patient’s history.
• ECG and blood laboratory values help in making the
diagnosis.
• High blood levels of C-reactive protein (CRP)
• An elevated blood level of homocysteine / amino acid.
Management
• Medical Management
• The objectives of the medical management of angina are to
decrease the oxygen demand of the myocardium and to increase
the oxygen supply. Medically, these objectives are met through
• pharmacologic therapy
• control of risk factors and Revascularization procedures.
. Revascularization procedures: To restore the blood supply to
the myocardium, include -
percutaneous coronary interventional (PCI) procedures (e.g.,
percutaneous transluminal coronary angioplasty [PTCA],
intracoronary stents, and atherectomy),
Coronary Artery Bypass Surgery (CABS), and percutaneous trans
Pharmacologic therapy
Among medications used to control angina are
nitroglycerin, beta-adrenergic blocking agents, calcium
channel blockers, and antiplatelet agents.
Nitroglycerin (A vasoactive agent).
• Mode of action
• The objectives of the medical management of angina
are to decrease the oxygen demand of the myocardium
and to increase the oxygen supply. It helps to increase
coronary blood flow by preventing vasospasm and
increasing perfusion through the collateral vessels.
• Dilation of the veins causes venous pooling of blood
throughout the body.
Self-Administration of Nitroglycerin
Most patients with angina pectoris must self-administer nitroglycerin
as-needed basis.
A key nursing role in such cases is educating patients about the
medication and how to take it. Sublingual nitroglycerin
comes in tablet and spray forms.
• Teaching About Sublingual Nitroglycerin
Instruct the patient to make sure the mouth is moist, the tongue
is still, and saliva is not swallowed until the nitroglycerin tablet
dissolves. If the pain is severe, the patient can crush the tablet
between the teeth to hasten sublingual absorption.
Advise the patient to carry the medication at all times as a
precaution.
However, because nitroglycerin is very unstable, it should be carried
Self-Administration of Nitroglycerin Cont.
Explain that nitroglycerin is volatile.
Instruct the patient to renew the nitroglycerin supply every 6 months.
Inform the patient that the medication should be taken in anticipation
of any activity that may produce pain. Because nitroglycerin
increases tolerance for exercise and stress when taken
prophylactically (i.e., before angina-producing activity, such as
exercise, stair-climbing, or sexual intercourse), it is best taken
before pain develops.
Recommend that the patient note how long it takes for the nitroglycerin
to relieve the discomfort. Advise the patient that if pain
persists after taking three sublingual tablets at 5-minute intervals,
emergency medical services should be called.
Discuss possible side effects of nitroglycerin, including flushing,
throbbing headache, hypotension, and tachycardia.
Self-Administration of Nitroglycerin
cont.
Teaching About Topical Nitroglycerin
• Nitroglycerin is also available in a lanolin-petrolatum base that
is applied to the skin as a paste or a patch.
Patients who use topical nitroglycerin need additional
instruction.
Advise the patient to read the instructions that accompany the
product, because instructions vary according to the preparation.
Also remind the patient to rotate the site of application to avoid
skin irritation.
Explain that the area of application needs to be an area that is
well perfused for absorption to occur. Therefore, the medication
should not be applied to areas with extensive body hair or scar
tissue.
Beta-Adrenergic Blocking Agents.
• Beta-Adrenergic Blocking Agents.
• Beta-blockers such as propranolol, metoprolol, and atenolol.
• Mode of actions:
• It reduces myocardial oxygen consumption by blocking the
beta-adrenergic sympathetic stimulation to the heart.
Resulting in reduction of heart rate, slowed conduction of an
impulse through the heart, decreased blood pressure, and
reduced myocardial contractility (force of contraction) that
establishes a more favorable balance between myocardial
oxygen needs (demands) and the amount of oxygen available
(supply).
• This helps to control chest pain and delays the onset of
ischemia during work or exercise.
Calcium Channel Blocking Agents
• Calcium Channel Blocking Agents amlodipine,
verapamil and diltiazem .
Mode of actions
Calcium channel blockers increase myocardial
oxygen supply by dilating the smooth muscle
wall of the coronary arterioles; they decrease
myocardial oxygen demand by reducing
systemic arterial pressure and the workload of
the left ventricle.
Antiplatelet and Anticoagulant
Medications
• Antiplatelet and Anticoagulant Medications
(Aspirin, Plavix).
• Antiplatelet medications are administered to
prevent platelet aggregation, which impedes
blood flow.
• Aspirin prevents platelet activation and
reduces the incidence of MI and death in
patients with CAD.
Heparin:
• Heparin prevents the formation of new
blood clots. Use of heparin alone in treating
patients with unstable angina reduces the
occurrence of MI.
Oxygen Administration.
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 to
decrease pain.
• The therapeutic effectiveness of oxygen is
determined by observing the rate and rhythm of
respirations.
• Blood oxygen saturation is monitored by pulse
oximetry; the normal oxygen saturation (SpO2) level
is greater than 95%.
REDUCING ANXIETY
Patients with angina often fear loss of their roles within society
and the family. They may also be fearful that the pain may lead
to an MI or death.
• Providing information about the illness, its treatment, and
methods of preventing its progression are important nursing
interventions.
• Various stress reduction methods should be explored with the
patient. For example, music therapy, in which patients are given
the opportunity to listen to selected music has been shown to
reduce anxiety in patients who are in a coronary care unit.
• Addressing the spiritual needs of the patient and family may also
assist in allaying anxieties and fears.
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.
If the patient has pain frequently or with
minimal activity, the nurse alternates the patient’s
activities with rest periods.
• Balance of activity and rest is an important aspect
of the educational plan for the patient and family.
Promoting home and community-based
care
Teaching Patients Self-Care.
Learning about the modifiable risk factors that
contribute to the continued development of CAD
and resulting angina is essential.
The teaching program for the patient with angina is
designed so that the patient and family can explain
the illness, identify the symptoms of myocardial
ischemia, state the actions to take when symptoms
develop, and discuss methods to prevent chest pain
and the advancement of CAD.
Cont.
• The self-care program is prepared in
collaboration with the patient and family or
friends.
• Activities should be planned to minimize the
occurrence of angina episodes.
• The patient needs to understand that any
pain unrelieved within 15 minutes by the
usual methods should be treated at the
closest emergency center.
Potential complications
Potential complications that may develop include
the following,
• Acute pulmonary edema
• Congestive heart failure
• Cardiogenic shock
• Dysrhythmias and cardiac arrest
• MI
• Myocardial rupture
• Pericardial effusion.
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