Angina Pectoris The term angina pectoris refers to the presence of intermittent chest pain caused by reversible myocardial

ischemia. Three major variants of angina pectoris: 1. Typical angina pectoris Refers to episodic chest pain associated with exertion or some other form of stress. The pain is classically described as a crushing or squeezing substernal sensation, which may radiate down the left arm. Often, but not invariably, associated with a fixed degree of atherosclerotic narrowing (usually 75% or greater) of one or more coronary arteries. The pain is usually relieved by rest (reducing demand) or nitroglycerin (This vasodilator reduces venous blood delivered to the heart by effecting venous dilation, and in larger doses increases blood supply to the myocardium by coronary vasodilation.

2. Prinzmetals, or variant angina Refers to angina that occurs at rest or, in some cases, awakens the patient from sleep. Associated with coronary artery spasm, usually near an atherosclerotic plaque. It also responds to administration of vasodilators.

3. Unstable angina pectoris Sometimes called crescendo angina Characterized by the increased frequency of anginal pain. The attacks tend to be precipitated by progressively less exertion, and they are more intense and often last longer than episodes of stable angina pectoris.

Clinical Manefistations Pressure, squeezing, burning, or tightness in the chest. It usually starts in the chest behind the breastbone. Pain may be accompanied by nausea, vomiting, weakness, dyspnea, indigestion, dizziness, anxiety, diaphoresis, pallor, hypotension, and pulse changes. A choking feeling in the throat. Chest pain that radiates to the jaw, teeth or earlobes. Heaviness, numbness, tingling or ache in the chest, arm, shoulder, elbow or hand usually on the left side. Pain between the shoulder blades.

Other symptoms may occur with an angina attack, as follows:

Shortness of breath Lightheadedness Fainting Anxiety or nervousness Sweating or cold, sweaty skin Nausea Rapid or irregular heart beat Pallor (pale skin) Feeling of impending doom

Diagnostic tests and procedures 1. Electrocardiogram An electrocardiogram is a simple test that detects and records the electrical activity of the heart. An electrocardiogram shows how fast the heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of the heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. However, some people with angina, and even some people who are having a heart attack, have a normal EKG. 2. Stress testing During stress testing, exercise makes the heart work hard and beat fast while heart tests are performed. If the patient can't exercise, medicine is given to speed up the heart rate. During exercise stress testing, blood pressure and EKG readings are checked while walking or running on a treadmill or pedaling a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, can be done at the same time. In those unable to exercise, a medicine can be injected into the bloodstream to make the heart work hard and beat fast. Nuclear heart scanning or echocardiography is then usually done. When the heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet the heart's needs. A stress test can show possible signs of CAD, such as:

Abnormal changes in heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in the heart's rhythm or its electrical activity

3. Chest x-ray A chest x-ray takes a picture of the organs and structures inside the chest, including the heart, lungs, and blood vessels. It can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD. 4. Coronary angiography and cardiac catheterization Coronary angiography may be needed if other tests or factors show possible CAD. This test uses dye and special x-rays to show the insides of the coronary arteries.

To get the dye into the coronary arteries, the doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in the arm, groin (upper thigh), or neck. The tube is then threaded into the coronary arteries, and the dye is released into the bloodstream. Special x-rays are taken while the dye is flowing through the coronary arteries. Cardiac catheterization is usually done in a hospital, while awake. It usually causes little to no pain, although there may be some soreness in the blood vessel at the location of the catheter. 5. Blood tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in the blood. Abnormal levels may show risk factors for CAD. The doctor may order a blood test to check the level of C-reactive protein (CRP) in the blood. Some studies suggest that high levels of CRP in the blood may increase the risk for CAD and heart attack. The doctor also may order a blood test to check for low hemoglobin in the blood. Hemoglobin is an iron-rich protein in the red blood cells that carries oxygen from the lungs to all parts of the body. If there is low hemoglobin, that may mean there is a condition called anemia.

Medical Surgical Management Oxygen therapy is administered at 2L/min by nasal cannula, even without evidence of respiratory distress. Sublingual nitroglycerin has been the mainstay of treatment for angina pectoris. Sublingual nitroglycerin can be used for acute relief of angina and prophylactically before activities that may precipitate angina. No evidence indicates that long-acting nitrates improve survival in patients with coronary artery disease. Beta-blockers are also used for symptomatic relief of angina and prevention of ischemic events. They work by reducing myocardial oxygen demand and by decreasing the heart rate and myocardial contractility. Beta-blockers have been shown to reduce the rates of mortality and morbidity following acute MI. Long-acting heart rateslowing calcium channel blockers can be used to control anginal symptoms in patients with a contraindication to beta-blockers and in those in whom symptomatic relief of angina cannot be achieved with the use of beta-blockers, nitrates, or both. Avoid short-acting dihydropyridine calcium channel blockers because they have been shown to increase the risk of adverse cardiac events. Anginal symptoms in patients with Prinzmetal angina can be treated with calcium channel blockers with or without nitrates. In one study, supplemental vitamin E

added to a calcium channel blocker significantly reduced anginal symptoms among such patients.

Nursing Management The nurse directs the patient to stop all activities and sit or rest in bed in a semiFowlers position to reduce the oxygen requirements of the ischemic myocardium. Administer oxygen to relieve ischemia at a flow rate based on institutional policy and the patients condition. Assess and document continuous ECG rhythm, vital signs, mental status, heart and lung sounds. Assess and document pain characteristics: location, duration, intensity (have patient grade pain on a scale from 1 to 10), precipitating factors, relief measures and any symptoms that indicate changes in these parameters. Assess vital signs with complaints of chest pain, and compare to baseline. Begin IV nitroglycerin titrated until acute pain is relieved; check blood pressure every 15 minutes or according to institutional policy; maintain systolic blood pressure greater than 90 mm Hg or according to institutional protocol; document the patients response to therapy. Administer IV morphine in small doses to relieve pain and decrease preload. Give sublingual, oral, or topical nitroglycerin prophylactically for chronic pain. Consider calcium channel blockers with Prinzmetals angina to block the influx of calcium into the cell; calcium channel blockers produce vasodilation of coronary and peripheral arteries. Use beta-adrenergic blockers to decrease myocardial oxygen demand by decreasing contractility, heart rate, and blood pressure. Notify the doctor and obtain a 12-lead ECG at the onset of recurring chest pain. Maintain activity restrictions based on the patients activity tolerance to reduce myocardial oxygen demands. Begin the patient on a low-cholesterol, low-sodium diet to alleviate the modifiable risk factors.