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Coronary arteries are the blood

vessels that carry blood to the heart
muscle. Coronary artery disease
(also called CAD) is caused by a
thickening of the inside walls of the
coronary arteries. This thickening is
called atherosclerosis.

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Angina pectoris is a clinical

syndrome usually characterized by
episodes of pain or pressure in the
anterior chest. The cause is usually
insufficient coronary blood flow.

Insufficient flow results in a

decreased oxygen supply to meet an
increased myocardial demand for
oxygen in response to physical
exertion or emotional stress. In
other words, the need for oxygen
exceeds the supply.

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Angina is usually caused by

atherosclerotic disease. Almost
invariably, angina is associated
with a significant obstruction of a
major coronary artery.

Lumen

Smooth
muscle layer
Smooth muscle

Cross-section of a normal and an atherosclerotic artery.

(A) Cross-section of normal artery in which the lumen is
fully patent, or open. (B) Cross-section of artery with
diminished patency resulting from atheroma.

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http://www.youtube.com/watch?v=fBn9munofVs

http://www.youtube.com/watch?v=KEME4LtqxsM

http://www.youtube.com/watch?v=KEME4LtqxsM

Physical exertion, which can

precipitate an attack by increasing
myocardial oxygen demands.

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Exposure to cold, which can cause

vasoconstriction and an elevated
blood pressure, with increased
oxygen demand

Eating a heavy meal, which

increases the blood flow to the
mesenteric area for digestion,
thereby reducing the blood supply
available to the heart muscle

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Stress or any emotion-provoking

situation, causing the release of
adrenaline and increasing blood
pressure, which may accelerate the
heart rate and thus increase
myocardial workload

 A family history of atherosclerosis.

Hypertension (high blood
pressure).
Smoking
Diabetes mellitus.
 Obesity.

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A squeezing or heavy pressing

sensation on the chest.
 A sense of heaviness or numbness
in the arm, shoulder, elbow or hand
(usually on the left side).

The patient often feels a tightness

or a heavy, choking, or strangling
sensation.

The pain is often felt deep in the

chest behind the upper or middle
third of the sternum (retrosternal).

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 A constricting sensation in the

throat.

 The discomfort can radiate into

both arms, jaw, teeth, ears, stomach
or between the shoulder blades.

 Increased shortness of breath on

exercise.

 More severe unstable angina can

be associated with the same
symptoms at rest.

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Discomfort to agonizing pain

accompanied by severe
apprehension and a feeling of
impending death.

The patient with diabetes mellitus

may not have severe pain with
angina because the neuropathy
that accompanies diabetes can
interfere with neuroreceptors, thus
dulling the pain.

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 Stable angina:
predictable and consistent pain that
occurs on exertion and is relieved by
rest. Angina pectoris is said to be stable
when the pattern of its frequency,
intensity, ease of provocation, or
duration does not change over a
several-week period.

Pain usually lasts 3 to 5 minutes

Subsides when the precipitating

factor is relieved

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Unstable angina (also called

preinfarction angina or crescendo
angina): symptoms occur when the
patient is at rest; symptoms occur
more frequently and last longer.

Intractable Angina :

severe incapacitating chest pain . Variant

angina (also called Prinzmetal's angina):
pain at rest with reversible ST ­segment
elevation; thought to be due to coronary
artery vasospasm Seen in patients with a
history of migraine headaches

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 Nocturnal Angina
Occurs only at night but not necessarily
during sleep
 Angina Decubitus
Chest pain that occurs only while lying
down
Relieved by standing or sitting

Silent ischemia:
objective evidence of ischemia (such
as ECG changes with a stress test),
but patient reports no symptoms.
Associated with diabetes mellitus
and hypertension

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The diagnosis of angina is often

made by evaluating the clinical
manifestations of pain and the
patient's history.

ECG.

Exercise or pharmacologic stress

test.

Nuclear scan, or invasive

procedures (eg, cardiac
catheterization).

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Diagnostic Studies
 History and physical examination
 Laboratory data
Hemoglobin and hematocrit level
(Anemia)
Cardiac enzymes (CK2, Troponin I,
troponin T, cholesterol, triglyceride)
ECG (rest and stress)
Coronary angiography

Holter monitor

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Exercise Testing
 The goal of exercise testing is to induce a
controlled, temporary ischemic state during
clinical and ECG observation

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Echocardiography
Visualize cardiac structure and the motion of the valves and chambers

Cardiac Catheterization

 Its useful for evaluation of intracardiac

pressures.
 It may also serve therapeutic value in
the management of valvular lesions or
congenital heart diseases such as atrial
or ventricular septal defects

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Cardiac Catheterization

Transosophageal Echcardiography
 Using ultrasound wave to visualize the posterior
aspects of the myocardium

Chest X­ray

 To identify features of heart diseases such as

hypertension, heart failure, cardiomyopathy,
congenital heart diseases, pericardial effusion

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Cardiac MRI

Useful in the study of cardiac structure

Current gold standard for evaluation of left ventricular
hypertrophy

Cardiac enzymes and troponins

 Cardiac enzymes and troponins are markers of myocardiac
injury.

 The markers are elevated in myocardial infarction.

 Cardiac enzymes include ;

1. Creatine phosphokinase (CK)

2. Aspartate aminotransferase (AST)

3. Lactate dehydrogenase (LDH)

 Troponins include; troponin I and troponin T

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 Medical Management.
 Nursing Management.

The objectives of medical

management of angina are to
decrease the oxygen demands of the
myocardium and to increase the
oxygen supply.

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Management of Angina
Morphine
Oxygen
Nitrate
Aspirin

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1)NITROGLYCERIN
The nitrates remain the mainstay for
treating angina pectoris.
Nitroglycerin (Nitrostat, Nitrol,
Nitrobid IV) is administered to reduce
myocardial oxygen consumption, which
decreases ischemia and relieves pain.

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Nitroglycerin dilates primarily the veins and,

also the arteries.

Nitroglycerin may be administered by several

routes sublingual, topical, and intravenous.

Their main side effect is headache, but this

often disappears once the nitrate has been taken
for some weeks, Hypotension.

2)BETA­ADRENERGIC BLOCKING
AGENTS.
 Beta blockers such as (Inderal)
and appear to reduce myocardial
oxygen consumption by blocking
the beta­adrenergic sympathetic
stimulation to the heart. result is a
reduction in heart rate, blood
pressure, and myocardial

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contractility (force of contraction),

balance between myocardial oxygen
needs and the amount of oxygen
available.

 This helps to control chest pain

and allow the patient to work or
exercise.

Cardiac side effects include:

hypotension, bradycardia,
worsening of congestive heart
failure.
If a beta blocker is intravenously
for an acute cardiac event, the ECG,
blood pressure, and heart rate are
monitored closely for up to 2 hours

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 Patients taking beta­blockers are

cautioned not to stop taken them
abruptly, because angina may
worsen and MI may develop. Beta­
blocker therapy needs to be
decreased gradually over 5 days
before discontinuing it.

Diabetic patients on beta­bloker

therapy are instructed to assess
their blood glucose levels often to
identify their hypoglycaemia that
may result from medication.

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3)CALCIUM CHANNEL
BLOCKING AGENTS.
 Reduce the muscle tension in the
coronary arteries, expanding them.
They also slightly relax the heart
muscle, reducing the heart's need
for oxygen and reducing blood
pressure.

Channel blockers should be avoided or

used with great caution in people with heart
failure because they decrease myocardial
contractility. Hypotension may occur after
the intra-venous administration of any of
the calcium channel blockers.
Other side effects that may occur include
bradycardia, constipation, and gastric
distress.

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ANTI PLATELET AND

ANTICOAGULANT MEDICATIONS
Antiplatelet medications are
administered to prevent platelet
aggregation, which impedes blood
flow.

Aspirin prevents platelet

aggregation and has been shown to
reduce the incidence of MI and
death in patients with CAD.

Heparin prevents the formation of

new blood clots.

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 Because heparin increases the risk

of bleeding, however, the patient is
monitored for signs and symptoms
of external and internal bleeding,
such as low blood pressure, an
increased heart rate, and a decrease
in serum haemoglobin and
hematocrit values.

OXYGEN ADMINISTRATION.
Oxygen therapy is usually initiated
at the onset of chest pain to increase
the amount of oxygen delivered to
the myocardium and to decrease
pain.
 Patients should have an oxygen
saturation (Sp02) level of more than
93%.

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Nursing Diagnoses.
1)Altered myocardial tissue
perfusion secondary to CAD, as
evidenced by chest pain (or
equivalent symptoms)

Management:
When a patient senses chest pain,
the nurse should direct the patient
to stop all activities and sit or rest in
bed in a semi­Fowler's position to
reduce the oxygen requirements of
the ischemic myocardium.

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 The nurse assesses the patient's

pain,

 The nurse continues to assess the

patient, measuring vital signs and
observing for signs of respiratory
distress.

The nurse administers O2 therapy

as indicated if the patient's
respiratory rate is increased or the
O2 saturation level is decreased.

 O2 is usually administered at 2 L/
min by nasal canula, even without
evidence of respiratory distress

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 If the pain is significant and

continues. After these
interventions, the patient is usually
transferred to a higher acuity unit.

Nursing Diagnoses.
Anxiety related to fear of death

Management::
Management

 Patients with angina often fear

loss of their roles within society and
the family
family..

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 Exploring the implication 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.

Nursing Diagnoses.
Ineffective management of
therapeutic regimen,
Noncompliance, related to failure to
accept necessary lifestyle changes
Management:
 Learning to avoid, modify, or adapt
the triggers for anginal pain is
essential.

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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.

 goals of the educational program

are to reduce the frequency and
severity of anginal attacks, to delay
the progress of the underlying
disease if possible, and to provide
protection from other complication
 The self­care program is prepared
in collaboration with the pa­tient
and family or friends.

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 Activities should be planned to

mini­mize the occurrence of angina
episodes.
 The patient needs to understand
that any pain unrelieved within 30
minutes by the usual methods
should be treated at the closest
emergency centre.

health teaching of patient with angina

Goal : to improve the quality of life and promotion
of health

 Expected outcomes:

 Patient prevents an episode of anginal pain

 Patient cope with an attack of anginal pain

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health teaching of patient with angina ( Cont...)

 patient prevents an episode of anginal pain
 Uses moderation in all activities of life

 Participates in normal daily program of activities that don't

produce chest discomfort, shortness of breath& fatigue

 Avoid exercises requiring sudden bursts of activity

 refrain from engaging in physical exercise for 2 hours after

meals

 Avoid activities that require heavy effort

 Alternates activities with periods of rest

health teaching of patient with angina ( Cont...)

 Avoid situations that are emotionally stressful

 Maintain proper weight

 Avoid excessive caffeine intake which can increase the heart rate&
produce angina

 Stop smoking, since smoking increase the heart rate, blood

pressure&blood carbon monoxide levels

 Avoid cold weather if possible

 Walk more slowly in cold weather

 Avoid walking against the wind

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health teaching of patient with angina ( Cont...)

 patient cope with an attack of anginal pain
 Carries nitroglycerin at all times
 Places nitroglycerin under the tongue ( sublingually) at
first sign chest discomfort. It relieves pain within 3
minutes.
 Doesn't swallow saliva until the tablet has dissolved
 Stops activities and be in rest until all pain subsides

health teaching of patient with angina ( Cont...)

 Keep the upright position to potential the effect of nitroglycerin

 Usually another nitroglycerin tablet may be taken in 3-5 minutes if

pain persist

 If the anginal discomfort is un relived or if it reoccurs after short

interval, the patient must go to the nearest emergency facility

 Takes nitroglycerin prophylactically to avoid pain known to occur

with certain activities (stair- climbing- sexual intercourse)

 Be alert for the side effects of nitroglycerin, headache, flushing&

dizziness.

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MI is destruction of
myocardial tissue in region of the
heart abruptly deprived of adequate
blood supply because of reduced
coronary blood flow.

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MI refers to the process by which

areas of myocardial cells in the
heart are permanently destroyed.
Like unstable angina, MI is usually,
but not always, caused by reduced
blood flow in a coronary artery
due to atherosclerosis and a

complete occlusion of an artery by an

embolus or thrombus.
Other causes of an MI include
vasospasm (a sudden constriction
or narrowing) of a coronary artery,
decreased oxygen supply (from
acute blood loss, anaemia, or low
blood pressure),

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and increased demand for oxygen

(from rapid heart rate,
thyrotoxicosis, or ingestion of
cocaine).
In each case, a profound
imbalance exists between
myocardial oxygen supply and
demand.

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Chest pain that occurs suddenly

and continues despite rest and
medication is the primary
presenting symptom

 Patients may be anxious and

restless

 They may have cool, pale, and moist

skin.

 Their heart rate and respiratory rate

may be faster than normal.

The signs and symptoms of MI cannot

be distinguished from those of unstable
angina.

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 Epigastric pain (heartburn)

elderly, diabetics.

 Fatigue and weakness.

 Tachycardia, restlessness.
 Nausea and vomiting.
 Feeling of impending doom.

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 ↓ urine output.
 Crackles.
 Peripheral edema.

Diagnosis of MI is generally based

on:
History of the present illness.
 ECG.
Echocardiogram
 Cardiac Catheterization

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 Laboratory test results.

Living heart cells contain certain enzymes and proteins:

Creatinine phosphokinase (CK).

Lactic dehydrogenises (LDH).

 Troponin.

 Myoglobin.

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PATIENT HISTORY
The patient history has two parts:
The current complaint of pain.
History of previous illnesses
(include information about the
patient's risk factors for heart
disease) and family health history
( particularly of heart disease).

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1)Thrombolytic:
Thrombolytic (IV –directly into the
coronary artery in the cardiac
catheterization laboratory)

The purpose of thrombolytic:

Dissolve the thrombus in a coronary
artery (thrombolysis).
 Allowing blood to flow through
the coronary artery again
(reperfusion).
 Minimizing the size of the
infarction, and preserving
ventricular function

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 Thrombolytic reduce the patient's

ability to form a stabilizing clot, so
the patient is at risk for bleeding.
 Therefore, thrombolytic should
not be used if the patient is
bleeding or has a bleeding disorder.

Chest pain for longer than 20

minutes, unrelieved by
nitroglycerin

 All patients who receive

thrombolytic therapy are put on
bleeding precautions to minimize
the risk for bleeding.

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 This means minimizing the

number of punctures for inserting
intravenous lines, avoiding
intramuscular injections, preventing
tissue trauma, and applying pressure
for longer than usual after any
puncture.

Absolute Contraindications.
Active bleeding.
Known bleeding disorder.
History of haemorrhagic stroke.
History of intracranial vessel
malformation
Recent major surgery or trauma.
Uncontrolled hypertension.
Pregnancy

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2)Analgesics
The analgesic of choice for acute MI
remains mor­phine sulphate
administered in intravenous
 Not only does morphine reduce pain
and anxiety, but it also reduces preload,
which in turn decreases the workload of
the heart, and relaxes bronchioles to
enhance oxygenation.

Cardiovascular response to
morphine is monitored carefully,
particularly the blood pres­sure,
which can be lowered, and the
respiratory rate, which can be
depressed.

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Coronary artery bypass grafting

(CABG)
Percutaneous Transluminal
coronary Angioplasty (PTCA)
For patients not responding to
adequate medical therapy

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BACK MAIN EXIT INDEX NEXT

Nursing Diagnoses.
Decreased myocardial perfusion
related to reduced coronary blood
flow from coronary thrombus and
atherosclerotic balk .

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Management:
 Keeping the patient on bed or
chair rest is particularly helpful
in reducing myocardial oxygen
consumption .
Checking skin temperature
and peripheral pulses
frequently is important to
ensure adequate tissue
perfusion.

Oxygen may be administered to

enrich the supply of circulating
oxygen.

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Nursing Diagnoses
Potential impaired gas exchange
related to fluid overload
Management:
 Regular and careful assessment of
respiratory function can help the
nurse detect early signs of
complications associated with the
lungs.

Scrupulous attention to fluid

volume status prevents over­loading
the heart and hence the lungs.
Encouraging the patient to breathe
deeply and change position
frequently helps keep fluid from
pooling in the lung bases.

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Nursing Diagnoses

Anxiety related to fear of death .

Management:

 Developing a trusting and caring

relationship with the patient is
critical in reducing anxiety.

Frequent opportunities are

provided for the patient to share
concerns and fears privately.

An atmosphere of acceptance helps

the patient to know that these
feelings are both realistic and
normal.

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Nursing Diagnoses
Knowledge deficit about post­MI
self­care
Management:
 The most effective way to increase the probability that
the patient will comply with a self­care regimen after
discharge is to provide adequate education about the
disease process and to facilitate the patient's
involvement in a cardiac rehabilitation program.

 Working with patients in

developing plans to meet their
specific needs further enhances the
potential for compliance.
 See the accompanying chart,
Promoting Health After MI.

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Acute pulmonary oedema .

 Congestive heart failure .
 Cardiogenic shock.
 Pericardial effusion .
 Myocardial rupture .
 Dysrhythmias and cardiac arrest .

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