Angina Pectoris

Angina pectoris is a clinical syndrome characterized by paroxysms of pain or a feeling of pressure in the anterior chest. The cause is insufficient blood flow, resulting in an inadequate supply of oxygen to meet the myocardial demand.  angina is usually the result of atherosclerotic (a form of arteriosclerosis characterized by the deposition of atheromatous plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries) heart disease and is associated with s significant obstruction of a major coronary artery. Factors affecting anginal pain are physical exertion, exposure to cold, eating a heavy meal, stress, or any emotion-provoking situation that increases myocardial workload. Atypical angina is not associated with the above and may at rest. Diabetic neuropathy can interfere with neuroreceptors, thus dulling the patient’s perception of pain.

CLINICAL MANIFESTATIONS

  • Pain varies from a feeling of indigestion to a choking or heavy sensation in the upper chest to agonizing pain. The patient with diabetes mellitus may not experience severe pain with angina.
  • Angina is a accompanied  by severe apprehension and a feeling of impending death.
  • The pain is usually retrosternal, deep in the chest behind the upper or middle third of the sternum.
  • Discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspect of the upper arms ( usually the left arm).
  • patient feels a tightness, heavy choking, or strangling sensation with a viselike (tight), insistent quality. Shortness of breath, pallor, diaphoresis, dizziness, light-headedness, nausea, and vomiting may be noted ( called angina-like signs if noted alone; may represent myocardial infarction).
  • Angina is accompanied by a feeling of weakness or numbness in the arms, wrists, and hands.
  • An important characteristics of anginal pain is that it subsides when the precipitating cause is removed or with nitroglycerin ( it is used  in medicine to dilate blood vessels). Chemical formula: C3H5N3O9

ASSESSMENT and DIAGNOSTIC METHODS

  • Evaluation of clinical manifestations of pain and patient history
  • Electrocardiogram changes ( 12-lead ECG), stress testing, blood tests
  • Echocardiogram, nuclear scan, or invasive procedures such as cardiac catheterization and coronary artery angiography

Gerontologic Considerations

The elderly person who experiences angina may not exhibit the typical pain profile because of age-related changes in neuroceptors. In older patients, pain may be sensed in the jaw or fainting  may occur. Advise patient to recognize feelings of weakness as an indication for rest or taking prescribed medications. During exposure to cold temperature, elderly patients may experience anginal symptoms more quickly than younger people. Encourage these patients to wear warm clothing as appropriate.

MEDICAL MANAGEMENT

The goals of medical management are to decrease the oxygen demands of the myocardium and to increase the oxygen supply through pharmacologic therapy and risk factor control.

SURGICAL MANAGEMENT

Frequently, therapy includes a combination of medicine and surgery. Surgically, the goals of management include revascularization ( the process of restoring the functionality of an affected organ) of the blood supply to the myocardium.

  • Coronary artery bypass surgery or minimally invasive direct coronary artery bypass (MIDCAB)
  • Percutaneous transluminal coronary angioplasty (PTCA) or percutaneous transluminal myocardial revascularization (PTMR)
  • Application of intracoronary stents and atherectomy to enhance blood flow.
  • Lasers to vaporize plaques
  • Percutaneous coronary endarterectomy to extract obstruction

PHARMACOLOGIC THERAPY

  • Nitrates, the mainstay of therapy (nitroglycerin)
  • Beta-adrenergic blockers (metoprolol [Tropol]
  • Calcium ion antagonists and calcium-channel blockers (amlodipine [Norvase] and diltiazem [Cardizeml])
  • Antiplatelet and anti-coagulant medications (aspirin, clopidogrel [Plavix], ticlodipine [Ticlid], or heparin)
  • Oxygen therapy

Reference:

Handbook for Brunner and Suddarth’s

Textbook of Medical-Surgical Nursing 11th edition

Joyce Young Johnson

Lippincott Williams & Wilkins pp.63-65

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