Angina Pectoris

Transient chest pain caused by insufficient blood flow to the myocardium resulting in myocardial ischemia. It results when myocardial oxygen demand exceeds myocardial oxygen supply. Pathophysiology: Angina pectoris (chest pain) is a symptoms of ischemia and is the primary symptom of coronary artery disease and heart attack. When an increased workload is placed on the heart, as in exercise or strenuous activity, there is an increased demand of oxygen. Normally, when the heart needs more oxygen, the coronary arteries dilate to carry more blood. However, with CAD, the narrowed vessels are unable to dilate and supply the heart with this extra blood and oxygen. This inability to supply more blood and oxygen causes myocardial ischemia and chest pain. Chest pain results from the ischemia but usually lasts only for a few minutes, especially if activity is stopped. If adequate blood supply to the myocardium is restored with rest, no myocardial damage usually occurs. Signs and Symptoms Anginal pain manifests itself in several ways. Patients often describe the pain as heaviness, tightness, squeezing, vise-like, or crushing pain in the center of the chest. The pain can radiate down one or both arms, with pain in the left arm can radiate down one or both arms, with pain tin the left arm being more common, into the shoulder, neck, jaw, or back. Patients may also describe heaviness in their arms or a feeling of impending doom. During the episode of pain, the patient may be pale, diaphoretic, or dyspneic. The pain is usually brought on by exertion and subsides with rest. It can be relieved with a vasodilator medication such as nitroglycerin (NTG). Episodes of chest pain may increase in frequency and severity over time. If patients do not heed this warning to stop their activity and rest, they may be at risk for a myocardial infarction or sudden death. Any event that increases oxygen demand can cause an angina attack. Most often precipitating events include large meals, exercise, cold, stimulant drugs such as cocaine or amphetamines, and emotional tension. Often angina may occur in the morning hours between 6:00 a.m and noon when the patient arises and the heart experiences increased workload. Women often exhibit atypical symptoms that shout be recognized as being cardiac related so that treatment is sought. Clinical Manifestations Pain Transient, paroxysmal subternal or precordial pain Described as heaviness or tightness or the chest, indigestion crushing

 Radiates down one or both arms, left shoulder, jaw, neck and back Precipitated by activity or exertion Relieved by rest and nitroglycerine S - ubsternal A nterior chest V ague (radiates) E exertion related R elieved by rest and nitroglycerine S hort duration (less than 30 minutes) Pallor Diaphoresis Dyspnea Faintness Palpitations Dizziness Digestive disturbances Angina: PQRST Pain assessement Method of assessment of chest pain P rovocative o What activities bring on the paine? Q uality o What does the pain feel like? R egion/Radiation o Where is the pain? S everity o How does the pain rate on a scale of 1 to 10? T iming/Treatment o When did the pain begin? o How long does it last? o What do you do to relieve the pain? o Are these measures effective?

Types of Angina Pectoris Stable Angina Chest pain lasts for less than 15 minutes Recurrence is less frequent Unstable Angina Chest pain lasts for more than 15 minutes but less than 30 minutes Recurrence is more frequent, may occur at night

Intensity of pain increases Variant Angina (Prinzmetals Angina) Chest pain is of longer duration and may occur at rest The attacks tend to occur in the early hours of the day May result from coronary artery spasm. Nocturnal Angina Occurs only during the night and is possibly associated with rapid eye movement (REM) sleep. Angina Decubitus Paroxysmal chest pain that occurs when the client sits or stands up Intractable Angina Chronic, incapacitating angina unresponsive to intervention Postinfarction Angina Occurs after MI, when residual ischemia may cause episodes of angina.

Precipitating Events of Angina Pectoris 1. 2. 3. 4. Exertion. Vigorous exercisedone very sporadically. Emotions. Excitement, sexual activity Eating a heavy meal Environment. Exposure to cold.

These events increases myocardial oxygen demands. Further disequilibrium between oxygen supply and oxygen demand occurs. Collaborative Management for Angina Pectoris 1. Medications Vasoodilators: Nitroglycerine, amyl Nitrate, Isosorbide o Effects: Direct relaxing effect on vascular smooth muscle, resulting in generalized vasodilation. Decrease peripheral resistance, decrease systolic pressure, produce venous pooling, and decrease preload. Coronary vasodilation redistributes myocardial blood flow more efficiently. Beta adrenergic blocking agents o Propranolol (Inderal) o Metoprolol (Lopressor) o Nadolol (Corgard) o Atenolol (Tenormin) o Pindolol (Visken) o Esmolol (Brvibloc)

o Effects Decrease myocardial oxygen demand by decreasing heart rate, BP, myocardial contractility and calcium output. Calcium channel blockers o Verapamil (iisoptin, Calan) o Nifedipine (procardia, Adalat, Calcibloc) o Diltiazem (Cardezem) o Amlodipine (Norvasc) o Nicardipine (Cardene) o Effects Inhibit calcium ion transportation into myocardial cells to depress inotropic and chronotropic activity, decreasing cardiac workload It has vasodilation effect It reduces coronary vasospasm. Other Medications o Platelet Aggregation Inhibitors ASA (Aspirin) Dipyridamole (Persantin) Clopidogrel (Plavix) Ticlopidine (Ticlid) Effects: inhibit platelet aggregation o Anticoagulants Heparin sodium (Clexane, Fragmin, Lovenox, Innohep) Effects: inactivates thrombin and other clotting factors inhibiting conversion of fibrinogen to fibrin, fibrin clot formation is prevented. Warfarin Sodium (Coumadin) Dicumarol Effect: Inhibit hepatic synthesis of Vit. K Nursing Intervention in Drug Therapy Nitroglycerine Therapy Assume sitting or supine position when taking the drug. To prevent hypostatic hypotension Take maximum of three doses at five minute interval Practice gradual change of position to prevent orthostatic hypotension If taken sublingual, the medication causes burning or stinging sensation under the tongue. This indicates that the medication is potent Sublingual route produces onset of action within 1 to 2 minutes, duration of action is 30 minutes. Offer sips of water before giving sublingual nitrates dryness of mouth may inhibit drug absorption

 Instruct client to avoid drinking alcohol to avoid hypotension, weakness and faintness. Advise client to always carry three tablets in his pocket Store nitroglycerine in cool dry place; ude dark/amber colored, air -tight container. Do not store nitroglycerine in the refrigerator. It may be destroyed by heat, light or moisture. Change stock of nitroglycerine every 3 months Observe for side effects: headache, flushed face, dizziness, faintness, tachycardia; these are common during first few doses of the medication do not discontinue the dureg. Transderm Nitropatch is applied once a day, usually in the morning. Rotation of skin sites is necessary, usually on the chest wall. Remove the patch during the night to prevent tolerance. Evaluate effectiveness: relief of chest pain. Beta Adrenergic Bockers Assess pulse rate before administration of the drug; withhold if bradycardia is present Administer with food to prevent GI upset Do not administer Inderal (Propranolol) to clients with asthma. It causes bronchoconstriction Do not administer Propranolol to clients with DM. It causes hypoglycaemia Give with extreme caution in clients with heart failure Observe for side effects which are as follows: nausea, vomiting, mental depression, mild diarrhea, fatigue and impotence. The antidote for beta blocker poisoning is Glucagon Calcium channel Blockers Assess heart rate and BP (blood pressure) Monitor hepatic and renal function Administer 1 hour before or 2 hours after meals. Food delays absorption and decreases plasma levels of the drug The antidote for calcium channel blocker poisoning is glucagon Platelet aggregation Inhibitors Assess for signs and symptoms of bleeding Avoid straining at stool. To prevent rectal bleeding. ASA should be given with food. To prevent GI upset Observe for ASA toxicity tinnitus (ringing of the ears) ASA may cause bronchoconstriction. Observe for wheezing.

1) Heparin Sodium Assess for signs and symptoms of bleeding Keep Protamine sulphate available. It is administered as antidote if bleeding occurs in heparin therapy If administered subcutaneously, do not aspirate, do not massage site of Heparin Injection. To prevent hematoma formation. Monitor PTT or APTT levels. (Therapeutic effect: PTT/APTT x 2 to 2.5) Used for a maximum of 2 weeks. 2) Coumadin (Warfarin Sodium) Assess for signs and symptoms of bleeding Keep Vit. K (e.g. Aquamephyton) readily available. It is administered as antidote if bleeding occurs in Coumadin therapy Monitor Prothrombin Time (Therapeutic effect: PT X 1.5 TO 2; INR = 2 to 3) Minimize green leafy vegetables in the diet. These contain Vit. K and antagonize the effect of Coumadin Do not give ASA amd Coumadin together. To prevent bleeding Treatment and Surgical Interventions Percutaneous Transluminal Coronary Angioplasty (PTCA) Mechanical dilatation of the coronary vessel wall by compressing the atheromatous plaque. A specially designed balloon tipped catheter is inserted under fluoroscopic guidance and advanced to the site of the coronary obstruction It is recommended for clients with single vessel coronary artery disease. Intravascular Stenting Biologic stent is produced through coagulation of collagen, elastin and other tissues in the vessel wall by laser, photocoagulation or radio frequency induced heat. Prosthetic intravascular cylindric stents maintain good luminal geometry after balloon deflation and withdrawal. Intravascular stenting is done to prevent restenosis after PTCA. Laser therapy Laser light produces necrosis, hemostasis, coagulation, evaporation of tissue Coronary Artery Bypass Graft (CABG) Reduces angina and improves activity tolerance

 It is recommended if severe narrowing of one or more branches of the coronary arteries exists. The main purpose of CABG is myocardial revascularization The commonly used grafts are the saphenous vein and internal mammary artery Nursing Interventions in Clients with Angina Pectoris Promoting comfort Relieve pain Nitroglycerine is the drug of choice for relief of pain from acute ischemic attacks Promoting Tissue Perfusion Instruct the client to avoid over fatigue Stop activity immediately in the presence of chest pain, dyspnea, lighteadedness or faintness which indicates low tissue perfusion Promoting Activity and Rest Encourage slower activity or shorter periods of activity with more rest periods. Avoid overexertions Plan for regular activity program Take nitroglycerine before exercise Increase extent of exercise gradually Promoting relief of anxiety and feeling of well being Facilitate reduction in the clients present level of anxiety Advise the client to minimize emotional outbursts, worry and tension Encourage to maintain an optimistic outlook to help relieve the work of the heart Diet Low sodium, low fat and lowe cholesterol, high fiver diet. Avoid saturated fats (animal fats) White meat, e.g. chicken without skin, turkey, fish are low in cholesterol Read labels Activity Activities are encouraged within the patients limitations

ASSESSMENT/ DATA COLLECTION Assess the patients description of pain. Note the type, lo cation, and pain radiation to other areas of the body. Note skin color and temperature, Note any factors that may make the pain worse or better. This will provide information to determine improvement or lack of improvement in pain. Ask how long the patient has had angina, triggering activities, and how the pain has been relieved in the past. Note the presence

of dyspnea, labored respiration, diaphoresis, or nausea. Obtain vital signs, blood pressure, apical pulse, respiration, and oxygen saturation to provide a baseline of the patient status. NURSING DIAGNOSIS, PLANNING, AND IMPLEMENTATION Acute pain related to reduced coronary artery blood flow and increased myocardial oxygen needs causing an imbalance between oxygen supply and demand Expected Outcome: The patient reposts an absence of pain. Ensure vascular access established. Intravenous access may be necessary to use to administer drugs for pain relief. Consult phyisician for pain management. Obtain a 12 lead ECG as ordered to determine ischemia or injury of the myocardium with evaluation of the ST segment. Administer analgesics or aspirin as prescribed to provide pain relief. Administer oxygen as ordered via nasal cannula to increase oxygen availability to myocardium. Administer sublingual NTG as ordered. Notify the physician if pain is unrelieved after three doses of nitroglycerin or as prescribed, or vital signs change. Remain with the patient and reassess the pain in 5 minutes after the administration of medication. A patient who is experiencing cchest pain should never be left alone Chest pain unrelieved by nitrates may present unstable angina or myocardial infarction Notify physician of ECG changes. ST segment changes may indicate a myocardial infarction. Offer the patient assureance and emotional support to decrease anxiety. Emotional support is important because patients and their families are often afraid that the patient may die. Promote rest and decrease anxiety for the patient with chest pain Document patient data in the medical record to communicate patients problem and outcome.

EVALUATION Interventions are successful if the patient is pain free.