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ANGINA PECTORIS/MYOCARDIAL ISCHEMIA

Transient chest pain caused by insufficient blood flow to the myocardium resulting in myocardial ischemia. It results when myocardial oxygen demand exceeds myocardial oxygen supply.

Pathophysiology:

CLINICAL MANIFESTATION:

  1. PAIN - Transient, paroxysmal subternal or precordial pain. Describe as heaviness or tightness of the chest, indigestion, and crushing. Radiates down one or both arms, left shoulder, jaw neck, and back. Precipitate by activity and exertion. Relieved by rest and nitroglycerin.
  2. Pallor
  3. Diaphoresis
  4. Dyspnea
  5. Faintness
  6. Palpitations
  7. Dizziness
  8. Digestive disturbances (due to vagal stimulation)

TYPES OF ANGINA PECTORIS:

  1. STABLE ANGINA - chest pain last for less than 15 minutes. Recurrence is less frequent.
  2. UNSTABLE ANGINA (Preifarction Angina, Crescendo Angina, Intermittent Angina, Coronary Syndrome) - Chest pain last for more than 15 minutes but less than 30 minutes. Recurrence is more frequent, may occur at night. Intensity of pain increases.
  3. VARIANT ANGINA (Prinzmetal's Angina) - chest pain is of longer duration and may occur at rest. The attacks tend to occur in the early hours of the day. May result from coronary artery spasm.
  4. NOCTURNAL ANGINA - Occurs only during the night and is possibly associated with rapid eye movement (REM) sleep.
  5. ANGINA DECUBITUS - Paroxysmal chest pain that occurs when the client sits or stands up.
  6. INTRACTABLE ANGINA - Chronic, incapacitating angina unresponsive to intervention.
  7. POSTINFARCTION ANGINA - Occurs after MI, when residual ischemia may cause episodes of angina.

PRECIPITATING EVENTS OF ANGINA PECTORIS

  1. Exertion - Vigorous exercise done very sporadically.
  2. Emotions - Excitement and sexual activity
  3. Eating a heavy meal.
  4. Environment - exposure to cold.

COLLABORATIVE MANAGEMENT OF ANGINA PECTORIS
MEDICATIONS:
1. Vasodilators: Nitroglycerine, Amyl Nitrate, Isosorbide
Effects:

  • Direct relaxing effect on vascular smooth muscle, resulting in generalized vasodilation.
  • Decreased peripheral resistance, decreased systolic pressure, produce venous pooling, and decreased preload.
  • Coronary vasodilation redistributes myocardial blood flow more efficiently.

2. Beta-adrenergic blocking agents

  • Propanolol (Inderal)
  • Metoprolol (Lopressor)
  • Nadolol (Corgard)
  • Atenolol (Tenormin)
  • Pindolol (Visken)
  • Esmolol (Brevibloc)

Effects:

  • decrease myocardial oxygen demand by decreasing heart rate, BP, myocardial contractility and calcium output.

3. Calcium-channel blockers

  • Verapamil (Isoptin, Calan)
  • Nifedipine (Procardia, Adalat, Calcibloc)
  • Diltiazem (Cardizem)

Effects:

  • Inhibit calcium ion transportation into myocardial cells to depress inotropic and chronotropic activity, decreasing cardiac workload.
  • It has vasodilation effect.
  • It reduces coronary vasospasm.

OTHER MEDICATIONS
1. Platelet Aggregation Inhibitors

  • ASA
  • Dipyridamole (Persantin)
  • Ticlopidine (Ticlid)

Effect: inhibit platelet aggregation, thereby prevent thrombus formation.

2. Anticoagulants

  • Heparin Sodium

Effect: inactivates thrombin and other clotting factors inhibiting conversion of fibrinogen to fibrin, fibrin clot formation is prevented.

  • Warfarin Sodium (Coumadin)
  • Dicumarol

Effect: inhibit hepatic synthesis of vitamin K.

NURSING INTERVENTIONS IN DRUG THERAPY:

1. Nitroglycerine Therapy

  • Assume sitting or supine position when taking the drug. To prevent orthostatic hypotension.
  • Take maximum of three doses at five-minute interval.
  • Gradual change of position to prevent orthostatic hypotension.
  • If taken sublingual, the medication causes burning or stinging sensation under the tongue.
  • Sublingual route produces onset of action within 1-2 minutes, duration of action is 30 mins.
  • Offer sips of water before giving sublingual nitrates; dryness of mouth may inhibit drug absorption.
  • Instruct client to avoid drinking alcohol, to avoid hypotension, weakness and faintness.
  • Advice client to always carry 3 tablets in his pocket.
  • Store nitroglycerine in cool, dry place, use dark/amber/colored, air-tight container;may be destroyed by heat, light or moisture.
  • Change stock of nitroglycerine every 6 months.
  • Observe for side effects: headache, flushed face, dizziness, faintness, tachycardia; these are common during first few doses of the medication. Do not discontinue the drug.
  • Transderm-nitro patch is applied once a day, usually in the morning. Rotation of skin sites is necessary, usually on the chest wall.
  • Evaluate effectiveness: relief of chestpain.


2. Beta-adrenergic blockers

  • Assess pulse rate before administration of the drug; withhold if bradycardia is present.
  • Administer with food to prevent GI upsets.
  • Do not administer propranolol to clients with asthma. It causes bronchoconstriction.
  • Do not administer propranolol to clients with DM. It causes hypoglycemia.
  • Give with extreme caution in clients with heart failure.
  • Observe for side effects which are as follows: nausea, vomiting, mental retardation, mild diarrhea, fatigue and impotence.

3. Calcium-channel blockers

  • Assess heart rate and BP.
  • Monitor hepatic and renal function.
  • Administer 1hour before or 2hours after meals. Food delays absorption and decreases plasma levels of the drug.

4. Platelet Aggregation Inhibitors

  • Assess for signs and symptoms of bleeding.
  • Avoid straining at stool.
  • Do not give aspirin with coumadin.
  • ASA should be given with food.
  • Observe for ASA toxicity-tinnitus.

5. Heparin Sodium

  • Assess for signs and symptoms of bleeding.
  • Keep protamine sulfate available. it is the antidote of heparin Na.
  • If administered SC, do not aspirate, do not massage to prevent hematoma formation.
  • Monitor PTT or APTT levels.
  • Use for a maximum of 2 weeks.

6. Coumadin

  • Assess for signs and symptoms of bleeding.
  • Keep Vitamin K readily available. It is the antidote of coumadin.
  • Monitor Prothombin Time.
  • Minimize green leafy vegetable in the diet. These contain Vitamin K.

TREATMENT:

1. Percutaneous Transluminal Coronary Angioplasty (PTCA)

  • Mechanical Dilatation of the coronary vessel wall by compressing the atheromatous plaque.
  • It is recommended for clients with single-vessel coronary artery disease.
  • A specially designed balloon-tipped catheter is inserted under flouroscopic guidance and advanced to the site of the coronary obstruction.

2. Intravascular Stenting

  • Biologic stent is produced through cougulation of collagen, elastin, and other tissues in the vessel wall by laser, photocoagulation or radio frequency-induced heat.
  • Prosthetic intravascular cylindric stents maintain good luminal geometry after ablloon deflation and withdrawal.
  • Intravascular stenting is done to prevent restenosis after PTCA.

3. Laser Therapy

  • Laser light produces necrosis, hemostasis, coagulation, evaporation of tissue.

NURSING INTERVENTION:

1. Diet

  • low Na, low fat and low cholesterol, high fiber diet.
  • saturated fats (animal fats).
  • white meat, e.g. chicken without skin, fish are low in cholesterol.
  • read labels.

2. Activity

  • no restrictions are placed on activity within the patients limitations.

SURGICAL MANAGEMENT OF ANGINA PECTORIS
Coronary Artery Bypass Graft (CABG)

  • reduces angina and improves activity tolerance
  • it is recommended if severe narrowing of one or more branches of the coronary arteries exist.
  • the main purpose of CABG is myocardial revascularization.
  • the commonly used grafts are the saphenous vein and internal mammary artery.

NURSING MANAGEMENT IN CABG

1.Promoting comfort

  • relieve pain
  • nitroglycerin is the drug of choice for relief of pain from acute ischemic attacks.

2. Promoting Tissue Perfusion

  • instruct the client to avoid over-fatigue.
  • stop activity immediately in the presence of chest apin, dyspnea, lightheadedness or faintness which indicate low tissue perfusion.

3. Promoting activity and rest

  • encourage slower activity or shorter periods activity with more rest periods. Avoid overexertions.
  • plan for regular activity program.
  • take nitroglycerin before exercise.
  • increase extent of exercise gradually.

4. Facilitating Learning

  • promote a positive attitude and active participation of the client and the family to encourage compliance.

5. Promoting Relief of Anxiety and Feeling of Well Being

  • facilitates in the clients present level of anxiety.
  • advice the client to minimize emotional outburst, worry and tension.
  • encourage to maintain an optimistic outlook to help relieve the work of the heart.