icon Mneme

Angina Pectoris

10 min read

References:

  1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh (Ch. 23)

Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress. In order words, the need for oxygen exceeds the supply.

Angina is usually caused by atherosclerotic disease and is associated with a significant obstruction of at least one major coronary artery. This poses an issue when the myocardium requires a large amount of oxygen to meet its continuous demand yet flow cannot be increased due to a blockage. When this occurs, ischemia results. Several factors are associated with typical anginal pain:

  1. Physical exertion, increasing myocardial oxygen demand
  2. Exposure to cold, which causes vasoconstriction and elevates blood pressure along with increased oxygen demand
  3. Eating a heavy meal, which increases blood flow to the mesenteric area for digestion, reducing blood supply available to the heart muscle. This phenomenon may be enough to induce anginal pain in a severely compromised heart.
  4. Stress or any emotion-provoking situation, releasing catecholamines that increase blood pressure, heart rate, and myocardial workload.

Unstable angina is unrelated to these listed factors as it may occur at rest.

TypeDescription
Stable AnginaPredictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin.
Unstable Angina”Preinfarction angina” or “Crescendo angina”. This type of angina will produce symptoms that increase in frequency and severity, and may be relieved with rest or nitroglycerin
Intractable AnginaSevere incapacitating chest pain.
Variant AnginaPain at rest with reversible ST-segment elevation, posited to be caused by vasospasm.
Silent IschemiaAsymptomatic but objectively present ischemia (e.g. ECG changes during a stress test)

Clinical Manifestations

Pain is the primary symptom involved in angina, along with other symptoms varying from mild indigestion to a choking or heavy sensation in the upper chest. The severity ranges from discomfort to agonizing pain.

  • Severe apprehension may also appear; a sense of impending death or doom.
  • The pain is felt deep in the chest behind the sternum— “substernal” or “retrosternal” pain that is poorly localized, which may also radiate to the neck, jaw, shoulders, or inner aspects of the upper arms (usually the left arm).
  • A tightness or a heavy choking or strangling sensation that has a viselike, insistent quality is felt.
  • A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting, may accompany the pain.
  • Importantly, the pain produced by angina is reversible with rest or the use of nitroglycerin. This pain is often stable and predictable. Unstable angina is a finding requiring medical intervention, as they may fail to be relieved by rest and the administration of nitroglycerin.

Patients with Diabetes or those of Old Age may not experience severe pain to neuropathy.

The main presenting symptoms in adults is dyspnea. In some angina is silent making recognition and diagnosis a clinical challenge. Older adults should be encouraged to recognize their chest pain-like symptoms (e.g., weakness) for indications to rest or to take prescribed medications.

Diagnostic Findings

Diagnosis begins with the patient’s history related to the clinical manifestations of ischemia.

  1. 12-lead ECG: T-wave inversion, ST-segment elevation, abnormal Q wave
  2. Cardiac biomarker testing to rule out ACS.
  3. Exercise or pharmacologic stress test with ECG and/or ECHO
  4. Potential nuclear scan or invasive procedure (cardiac catheterization, coronary angiography)

Medical Management

The goals of medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively, reperfusion procedures may be used to restore the blood supply to the myocardium. These include PCI procedures and CABG.

  1. Nitrates; Nitroglycerin: reduction of myocardial oxygen consumption through selective vasodilation. This is the standard treatment for angina pectoris. Nitrates are potent vasodilators (primarily the veins, but also arteries to a lesser extent) that improve blood flow to the heart muscle and relieves pain. Venous dilation allows blood to pool in venous circulation, reducing the patient’s preload. This, however, produces a contraindication for patients who are hypovolemic as this may cause a significant decrease in cardiac output and blood pressure.
    • Venous and Arterial Vasodilation → ↓ Preload, ↓ Afterload, ↓ Blood pressure, ↓ Myocardial oxygen requirements

Nitroglycerin Administration

Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration.

  • Sublingual: placed under the tongue or buccal pouch (cheek), ideally relieving pain within 3 minutes. This is a common method used by patients who self-administer nitroglycerin on an as-needed basis. - Inform the patient: the mouth should be moist; the tongue is held still after administration; do not swallow saliva until administration is complete; do not crush the tablet. However, if the pain is severe, the patient can crush the tablet to hasten the absorption of the medication. - Storage: nitroglycerin is very unstable. It may be inactivated by heat, moisture, air, light, and time. The medication is not transferred from its original container (capped dark glass bottles). The patient should replace their supply every six months or according to manufacturer instructions. The patient should also carry the medication with them at all times as a precaution. - When to take: when symptoms appear, better if the patient takes it prophylactically if the patient expects symptoms to appear (e.g. when participating in physical activity) - When to stop taking: pain that persists after three sublingual tablets at 5-minute intervals should prompt the patient to seek emergency medical services.
  • Oral and topical: provides sustained effects. A problem arises with sustained use as it may lead to tolerance. A regimen in which the patches are applied in the morning and removed at bedtime allows for a nitrate-free period to prevent the development of tolerance.
  • Intravenous: used for hospitalized patients with recurring signs and symptoms of ischemia or after a revascularization procedure, either continuously or intermittently. The rate of infusion is titrated to pain level and blood pressure— administration is not recommended if the systolic blood pressure is less than 90 mm Hg. This therapy is converted into oral or topical preparations once the patient is symptom-free.

A common adverse effect of nitroglycerin use is a headache, which may limit the use of this drug in some patients.

Additionally, flushing, hypotension, and tachycardia can also occur as side-effects of nitroglycerin use. The patient should be instructed to sit down for a few minutes when taking nitroglycerin to avoid hypotension and syncope.

  1. Other pharmacologic interventions:
    • Beta-adrenergic blocking agents; “-olol”s: reduction of myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart.
    • Calcium channel blockers; “-dipine”s: negative inotropy, used if beta-blockers are ineffective. This is a primary treatment method for vasospasm.
    • Antiplatelet Medications: prevention of platelet aggregation. Aspirin is a common choice. Clopidogrel, Prasugrel, and Ticagrelor are other options.
    • Anticoagulants: prevention of thrombus formation. Heparin, Enoxaparin, and Dalteparin are commonly used.
  2. Oxygen Administration is initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and to decrease pain. Its therapeutic effect is based on the rate and rhythm of respirations and the color of skin and mucous membranes.

Nursing the Patient with Angina Pectoris

In the assessment phase, the nurse gathers information about the patient’s symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. Risk factors for CAD are identified, along with how the patient (and their family) understands and responds to the diagnosis. If they are currently undergoing treatment, their adherence is also noted.

A thorough assessment of the pain experienced by the patient is important:

  • “Where is the pain (or prodromal symptoms)? Can you point to it?”
  • “Can you feel the pain anywhere else?”
  • “How would you describe the pain?”
  • “Is it like the pain you had before?”
  • “Can you rate the pain on a 0–10 scale, with 10 being the most pain?”
  • “When did the pain begin?”
  • “How long does it last?”
  • “What brings on the pain?”
  • “What helps the pain go away?”
  • “Do you have any other symptoms with the pain?”

Nursing Diagnoses

  • Risk for impaired cardiac function
  • Anxiety associated with cardiac symptoms and possible death
  • Lack of knowledge about the underlying disease and methods for avoiding complications
  • Able to perform self care

Complications

  • ACS and/or MI
  • Arrhythmias and Cardiac Arrest
  • Heart Failure
  • Cardiogenic Shock

Planning includes immediate and appropriate treatment when angina occurs, prevention of angina, reduction of anxiety, awareness of the disease process, understanding of prescribed care, adherence to the self-care program, and absence of complications.

Interventions focus on:

  1. Treating Angina: once pain is reported (or cardiac ischemia), the nurse takes immediate action— stop all activities and sit or rest in a semi-Fowler position to reduce oxygen requirements.
    • The nurse assesses whether the anginal episode is typical for the patient or different (which may be ominous).
    • Continuous monitoring for the patient is important. Watch out for respiratory distress, watch ECG readings for ST-segment and T-wave changes.
    • Nitroglycerin is given sublingually and response is evaluated. Repetition of doses at 5-minute intervals is done up to three doses if the pain remains present. With each dose, vital signs assessment is done (pain, blood pressure, heart rate). If pain continues, the patient is further evaluated for acute MI and may be transferred to a higher-acuity nursing unit.
    • Oxygen therapy is begun if saturation levels are decreased. Normally, oxygen at 2 L/min is given via nasal cannula even without evidence of desaturation, though this practice has not been shown to have a positive effect on patient outcome.
    • Patient Outcome Evaluation Goals: Reports that pain is relieved promptly
      1. Recognizes symptoms
      2. Takes immediate action
      3. Seeks medical assistance if pain persists or changes in quality
  2. Reducing Anxiety: patients with angina fear the loss of roles within society and family, and MI or death. The nurse can explore the implications of the diagnosis with the patient by providing information about the illness, its treatment, and methods of preventing its progression.
    • Various stress reduction methods such as guided imagery or music therapy can be explored with the patient.
    • Spiritual needs are also addressed— these may also allay anxieties and fears.
    • Patient Outcome Evaluation Goals: Reports decreased anxiety
      1. Expresses acceptance of diagnosis
      2. Expresses control over choices within medical regimen
      3. Does not exhibit signs and symptoms that indicate a high level of anxiety
  3. Preventing Pain: the nurse must identify the level of activity that causes the patient’s pain or prodromal symptoms, then plan activities accordingly. If pain appears frequently or with minimal activity, the nurse should alternate activities with rest periods. Balancing activity and rest is an important aspect of the educational plan for the patient and family.
    • Patient Outcome Evaluation Goals: Understands ways to avoid complications and is free of complications
      1. Describes the process of angina
      2. Explains reasons for measures to prevent complications
      3. Exhibits stable ECG
      4. Experiences no signs and symptoms of acute MI
  4. Promoting Home, Community-based, and Transitional Care:
    • Self-care requires understanding of the illness, identification of symptoms, knowledge of the actions to take when symptoms develop, and awareness of methods to prevent chest pain and the advancement of CAD.
    • Continuing and Transitional Care is used for patients with special needs or disability. A home health or transitional care nurse can assist with scheduling, appointments, monitoring, and adherence.
    • Patient Outcome Evaluation Goals: Adheres to self-care program:
      1. Takes medications as prescribed
      2. Keeps health care appointments
      3. Implements plan to reduce risk factors

Graph View