Angina (Angina Pectoris)

WHAT WENT WRONG?

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.

• Stable angina—pain is relieved by rest or nitrates and symptoms are consistent.

• 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.

• 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.

HALLMARK SIGNS AND SYMPTOMS

• 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.

• Can occur at rest or after exertion, excitement, or exposure to cold—due to

increased oxygen demands or vasospasm.

• Usually relieved by rest—a chance to re-establish oxygen needs. • 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.

• Sweating (diaphoresis)—increased work of body to meet basic physiologic

needs; anxiety.

• Tachycardia—heart pumping faster trying to meet oxygen needs as anxiety

increases.

• Difficulty breathing, shortness of breath (dyspnea)—increased heart rate

increases respiratory rate and increases oxygenation.

• Anxiety—not getting enough oxygen to heart muscle, the patient becomes

nervous.

INTERPRETING TEST RESULTS

• Electrocardiogram during episode:

• T-wave inverted with initial ischemia, which is reduced blood flow due to

an obstructed vessel, usually first sign.

• ST-segment changes occur with injury to the myocardium (heart muscle).

• Abnormal Q-waves due to infarction of myocardium.

• Labs: troponins, CK-MB, which is an enzyme released by damaged cardiac

tissue 2 to 6 hours following an infarction, electrolytes.

• Chest x-ray to determine signs of heart failure.

• Holter monitoring: a portable EKG which the patient wears for 24 to 48 hours,

giving that many hours of continuous cardiac monitoring.

• Coronary arteriography to determine plaque build-up in coronary arteries.

• Cardiac PET (positron emission tomography) to determine plaque build-up

in coronary arteries.

• Stress testing to determine symptoms when at exercise or under pharmacologic

stress.

• Echocardiogram or stress-echo to determine any abnormality of wall motion

due to ischemia.

• Cardiology consult.

• 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 effectiveness

of anticoagulants), proBNP (BNP) measures the presence and severity of

heart failure.

• Cholesterol panel to evaluate risk.

• 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.

• 2 to 4 liters of oxygen.

• Administer beta-adrenergic blocker—this class has a cardioprotective effect,

decreasing cardiac workload and likelihood of arrhythmia.

• Drugs like propranolol, nadolol, atenolol, metoprolol.

• Administer nitrates—aids in getting oxygenated blood to heart muscle.

• Nitroglycerin—sublingual tablets or spray; timed-release tablets.

• Topical nitroglycerin—paste or timed-released patch.

• Aspirin for antiplatelet effect.

• 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.

• 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.

• Coronary artery stent. This is a small, stainless steel mesh tube that is placed

within the coronary artery to keep it open.

• 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 andgraphed to coronary arteries, bypassing the blockage and restoring free flow

of blood to heart muscles.

• Low-cholesterol, low-sodium, and low-fat diet.

DIAGNOSES

• Anxiety

• Decreased cardiac output

• Acute pain

INTERVENTION

• 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.

• 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.

• 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.

• Assess chest pain each time the patient reports it.

• 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).

• 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.

• Record fluid intake and output. Assess for renal function.

• Place patient in a semi-Fowler's position (semi-sitting with knees flexed). • Explain to patient:

• Rest when pain begins to decrease oxygen demands.

• Take nitroglycerin when any pain begins—it helps dilate coronary arteries

and get more oxygen to heart muscle.

• Avoid stress and activities that bring on an angina attack.

• 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).

• Stop smoking! Smoking is associated with heart disease.

• 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.

• 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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