ANGINA PECTORIS
ANGINA PECTORIS
A narrowing of
blood vessels to the coronary artery, secondary to arteriosclerosis, results in
inadequate blood flow through blood vessels of the heart muscle, causing chest pain.
An episode of angina is typically precipitated by physical activity, excitement,
or emotional stress. There are three categories of angina.
Ø Stable angina:
pain is relieved by rest or nitrates and symptoms are consistent.
Ø Unstable angina:
pain occurs at rest; is of new onset; is of increasing intensity, force, or
duration; isn't relieved by rest; and is slow to subside in response to
nitroglycerin.
Ø Prinzmetal’s or vasospastic angina:
usually
occurs at rest or with minimal formal exercise or exertion; often occurs at
night. Atherosclerotic heart disease occurs when there is a buildup of plaque
within the coronary arteries. Angina is often the first symptom that heart
disease exists. When the demand for oxygen by the heart muscle exceeds the
available supply, chest pain occurs.
PROGNOSIS
Patients can
often be managed with lifestyle modifications and medications to control
symptoms of angina. The most important factor is patient education. Patients
need to understand the importance of their symptoms and when to seek medical
attention. The pain must be evaluated initially and whenever a change in pattern
or lack of response to treatment occurs.
SIGNS
AND SYMPTOMS
Ø Chest
pain lasting 3 to 5 minutes—not all patients get substernal pain; it may be
described as pressure, heaviness, squeezing, or tightness. Use the patient’s words.
Ø Can
occur at rest or after exertion, excitement, or exposure to cold—due to increased
oxygen demands or vasospasm.
Ø Usually
relieved by rest—a chance to re-establish oxygen needs.
Ø Pain
may radiate to other parts of the body such as the jaw, back, or arms—angina
pain is not always felt in the chest. Ask if the patient has had similar pain
in the past.
Ø Sweating
(diaphoresis) increased work of body to meet basic physiologic needs; anxiety.
Ø Tachycardia
heart pumping faster trying to meet oxygen needs as anxiety increases.
Ø Difficulty
breathing, shortness of breath (dyspnea) increased heart rate increases
respiratory rate and increases oxygenation.
Ø Anxiety
not getting enough oxygen to heart muscle, the patient becomes nervous.
INTERPRETING
TEST RESULTS
Ø Electrocardiogram
during episode: T-wave inverted with initial ischemia, which is reduced blood
flow due to an obstructed vessel, usually first sign.
Ø ST-segment
changes occur with injury to the myocardium (heart muscle).
Ø Abnormal
Q-waves due to infarction of myocardium.
Ø Labs:
troponins, CK-MB, which is an enzyme released by damaged cardiac tissue 2 to 6
hours following an infarction, electrolytes.
Ø Chest
x-ray to determine signs of heart failure.
Ø Holter
monitoring: a portable EKG which the patient wears for 24 to 48 hours, giving
that many hours of continuous cardiac monitoring.
Ø Coronary
arteriography to determine plaque build-up in coronary arteries.
Ø Cardiac
PET (positron emission tomography) to determine plaque build-up in coronary
arteries.
Ø Stress
testing to determine symptoms when at exercise or under pharmacologic stress.
Ø Echocardiogram
or stress-echo to determine any abnormality of wall motion due to ischemia.
Ø Cardiology
consult.
Ø Nonemergent
labs: Complete Blood Count (CBC) used to determine the general health status of
the patient, chemistry (provides information about the status of eletrolytes,
kidneys, acid/base balance, blood sugar and calcium levels), Prothrombin Time
(PT/INR), Activated Partial Throboplastin Time (PTT) (helps to detect and
diagnose bleeding disorders and the effectivenessof anticoagulants), proBNP
(BNP) measures the presence and severity of heart failure.
Ø Cholesterol
panel to evaluate risk.
Ø Increased
risk for coronary artery disease with increased total cholesterol, increased
low-density lipoproteins (LDL), increased triglycerides and decreased high-density
lipoproteins (HDL).
TREATMENT
The goal of
treatment is to deliver sufficient oxygen to the heart muscle to meet its need.
When suspecting chest pain, always give oxygen as the first line of defense.
Medications are
used initially to treat symptoms and increase blood flow to the heart muscle.
Medications are used for symptom control and cholesterol management in the long
term. Cardiovascular interventions are used to maintain adequate blood flow
through the coronary arteries.
Ø 2
to 4 liters of oxygen.
Ø Administer
beta-adrenergic blocker this class has a cardioprotective effect, decreasing
cardiac workload and likelihood of arrhythmia.
Ø Drugs
like propranolol, nadolol, atenolol, metoprolol.
Ø Administer
nitrates aids in getting oxygenated blood to heart muscle.
Ø Nitroglycerin
sublingual tablets or spray; timed-release tablets.
Ø Topical
nitroglycerin paste or timed-released patch.
Ø Aspirin
for antiplatelet effect.
Ø Analgesic
typically morphine intravenously during acute pain. The medicine is very
fast-acting when given this way and will decrease myocardial oxygen demand as
well as decrease pain.
The following
should be watched separately.
Ø Percutaneous
transluminal coronary angioplasty. This is a nonsurgical procedure in which a
long tube with a small balloon is passed through blood vessels into the
narrowed artery. The balloon is inflated, causing the artery to expand.
Ø Coronary
artery stent. This is a small, stainless steel mesh tube that is placed within
the coronary artery to keep it open.
Ø Coronary
artery bypass graph (CABG). This is a surgical procedure in which a vein from a
leg or an artery from an arm or the chest is removed and graphed to coronary
arteries, bypassing the blockage and restoring free flow of blood to heart
muscles.
Ø Low-cholesterol,
low-sodium, and low-fat diet.
NURSING
DIAGNOSES
Ø Anxiety
Ø Decreased
cardiac output
Ø Acute
pain
NURSING
INTERVENTION
Ø Monitor
vital signs look for change in BP, P, R; irregular pulse; pulse deficit; when a
discrepancy is found between an atrial rate and a radial rate, when measured
simultaneously; pulse oximetry.
Ø Notify
physician if systolic blood pressure is less than 90 mmHg. Nitrates dilate
arteries to the heart and increase blood flow. You may have an order to hold
nitrates if SBP <90 mmHg to reduce risk of patient passing out from lack of
blood flow to brain.
Ø Notify
physician if heart rate is less than 60 beats per minute. Beta-adrenergic blockers
slow conduction through the AV node and reduce the heart rate and contractility.
You may have an order to hold beta blockers if heart rate goes below 60; you
should continuously monitor the patient’s pulse rate.
Ø Assess
chest pain each time the patient reports it.
Ø Remember
PQRST (an acronym for a method of pain assessment) as follows.
Determine the place,
quality (describe the pain—stabbing, squeezing, etc.), radiation
(does the pain travel anywhere else?), severity (on a scale of 1
to 10), and timing (when it started and how long it lasts and
what preceded the pain).
Ø Monitor
cardiac status using a 12-lead electrocardiogram (EKG) while the patient is
experiencing an angina attack. Each time the patient has pain, a new 12-lead
EKG is done to assess for changes, even if one was already done that day.
Ø Record
fluid intake and output. Assess for renal function.
Ø Place
patient in a semi-Fowler's position (semi-sitting with knees flexed).
Ø Explain
to patient: Rest when pain begins to decrease oxygen demands.
Ø Take
nitroglycerin when any pain begins it helps dilate coronary arteries and get
more oxygen to heart muscle.
Ø Avoid
stress and activities that bring on an angina attack.
Ø Call
911 if the pain continues for more than 10 minutes or as the patient is taking
the third nitroglycerine dose (1 sublingual dose every 5 minutes, if BP allows,
for maximum of 3 doses).
Ø Stop
smoking! Smoking is associated with heart disease.
Ø Adhere
to the prescribed diet and exercise plan. Lower cholesterol and fat intake to
decrease further plaque build-up, and decrease excess salt intake to help BP
control. Slowly increase exercise to build up activity tolerance.
Possibly
exercise with cardiac rehabilitation.
Ø How
to recognize the symptoms of a myocardial infarction: Pay attention to chest
pains as well as changes in patterns of pain and response to treatment.
Be aware of
changes in respiratory patterns, increase in shortness of breath, swelling, and
general feelings of malaise.
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