ANGINA PECTORIS

A MEDICAL OVERVIEW

ANGINA PECTORIS

• A major clinical manifestation of myocardial ischemia usually characterized by episodes of pain or pressure in the anterior chest

• Oftentimes a Precursor to Myocardial Infarction

Normal Cardiac Anatomy and Physiology

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RISK FACTORS

MODIFIABLE:

Atherosclerosis

Obesity

Diabetes

Hypertension

Sedentary Lifestyle

Metabolic Syndrome

Unopposed estrogen taking

NON-MODIFIABLE:

Age (Post Menopausal Women)

Race

Gender

Familial Tendency

TYPES

1. Stable Angina

2. Unstable Angina

3. Prinzmetal | Atypical | Variant

4. Angina Decubitus

* Syndrome X

PATHOPHYSIOLOGY

Risk Factors

Increased myocardial workload

Narrowed arterial coronary lumen

Exertion, Physical Activities

Increased myocardial oxygen demand

Narrowed coronary arteries unable to meet Myocardial demand

Myocardial IschemiaAnginal Pain, S/S

SIGNS AND SYMPTOMS

• CHEST PAIN

L- Retrosternal area

Q- Heavy Sensation, Feeling of impending death, squeezing, burning, choking sensation

R- Epigastrum, Back, Neck, Jaw, Shoulders, Inner aspects of the upper arm (usually left arm)

S- Severe (rated 7-10) in pain rating scale

T- Maybe precipitated or unprecipitated

• Palpitations• Pallor• Diaphoresis• Nausea and Vomiting• (+) Levine’s Sign• S3 and S4 heart sounds• Dizziness / Lightheadedness• Shortness of Breath

DIAGNOSTIC FINDINGS

• Blood testsReveal: ↑LDL, Triglyceride, VeryLDL, Erythrocyte Sedimentation rate, C-Reactive protein ; ↓HDL

• Electrocardiography (ECG) (Usually a 12-lead ECG is used)Stable and Unstable- ST DepressionPrinzmetal- ST Elevation

• Stress Test with ECG• Echocardiography

Normal ECG Tracing

Stress Test

Echocardiography

Coronary Angiography (Gold Standard)

Definition

• A Procedure performed to detect obstruction in the coronary arteries of the heart. During the procedure a catheter is inserted into an artery into the arm or groin (subclavian / femoral) and then threaded carefully into the heart The blood vessels of the heart are then studied by injection of contrast media through the catheter. A rapid succession of X-rays (fluoroscopy) is taken to view blood flow.

Nursing Considerations

• Assess patient allergy to iodine (seafood)• Assess blood test results for possible surgical

complications: hgb, aPTT, BUN, creatinine, plt, electrolyte levels

• During Procedure: Continuous BP and ECG monitoring, ensure IV line patency, Prepare resuscitation equipment incase any complication may occur

• Outpatient basis: 2-6 hours bed rest before ambulation

• After: Monitor for bleeding on catheter insertion site

Pharmacological Treatment

ANTIPLATELET

• Aspirin (ASA)

bleeding precautions, blood coagulation tests, don’t use in patients with severe anemia, caution in pt with gout

• Clopidogrel (Plavix) for patients with contraindications to aspirin

BETA-BLOCKERS

• Metoprolol, Atenolol, Propanolol

-Compete with endogenous catecholamines for beta-adrenergic receptors

-Contraindicated in CHF, Asthma, cardiogenic shock, AV conduction abnormalities

CALCIUM CHANNEL BLOCKERS

• Smooth muscle relaxation-peripheral arterial vasodilation

• Amlodipine(Norvasc), Diltiazem, Verapamil,

-May increase LFT, use with caution in hepatic and renal patients, A/E include constipation (valsalva maneuver)

Short-Acting Nitroglycerin

• Immediate relief of exertional or rest angina• Nitroglycerin (Nitrostat, Nitro-bid, Nitrol)

- Metered dose sprays and patches are used for prophylaxis

• Caution patients on vasodilating effects (headache), C/I in severe anemia, ischemia may worsen upon withdrawal

Long Acting Nitroglycerin

• Causes venous and arterial dilatation• Ideal for prinzmetal angina• Isosorbide (Isordil, ISMO)• For patients with poor prognosis

ACE Inhibitors

• Inhibits conversion of angiotensin I to angiotensin II thereby breaking RAAS chain resulting to vasodilation and reduced fluid retention (lowered aldosterone secretion)

• Ramipril (Altace)

Anti-ischemic Agents

• Ranolazine (Ranexa)

-prolongs QT interval (Torsades de Pointes), inhibits fatty acid oxidation

-indicated for Chronic Angina unresponsivce to other anti-anginal agents

-does not reduce blood pressure or heart rate

SURGICAL TREATMENTS

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Nursing Considerations:

• Assess blood test results for possible surgical complications: hgb, aPTT, BUN, creatinine, plt, electrolyte levels

• During Procedure: Continuous BP and ECG monitoring, ensure IV line patency, Prepare resuscitation equipment incase any complication may occur

• After: Monitor for bleeding on catheter insertion site

• Place 10lbs Sandbag on catheter insertion site (Femoral Artery) for max of 6 hours after surgery

Diet and Lifestyle Modifications

Specifics

• Reduce fat, sodium and cholesterol in the diet• Avoid stimulating agents such as those that

contain caffaine (coffee, chocolate)• Quit/ STOP smoking• Reduce Stress• Exercise• Treatment of Underlying Disease (DM, HTN,

Obesity)

Thank You!!!