ANGINA PECTORISA MEDICAL OVERVIEW

ANGINA PECTORISA major clinical manifestation of myocardial ischemia usually characterized by episodes of pain or pressure in the anterior chestOftentimes a Precursor to Myocardial Infarction

Normal Cardiac Anatomy and Physiology

RISK FACTORSMODIFIABLE:AtherosclerosisObesityDiabetesHypertensionSedentary LifestyleMetabolic SyndromeUnopposed estrogen taking

NON-MODIFIABLE:Age (Post Menopausal Women)RaceGenderFamilial Tendency

TYPESStable AnginaUnstable AnginaPrinzmetal | Atypical | VariantAngina Decubitus* Syndrome X

PATHOPHYSIOLOGYRisk FactorsIncreased myocardial workload

Narrowed arterial coronary lumenExertion, Physical ActivitiesIncreased myocardial oxygen demandNarrowed coronary arteries unable to meet Myocardial demandMyocardial IschemiaAnginal Pain, S/S

SIGNS AND SYMPTOMSCHEST PAINL- Retrosternal areaQ- Heavy Sensation, Feeling of impending death, squeezing, burning, choking sensationR- Epigastrum, Back, Neck, Jaw, Shoulders, Inner aspects of the upper arm (usually left arm)S- Severe (rated 7-10) in pain rating scaleT- Maybe precipitated or unprecipitated

PalpitationsPallorDiaphoresisNausea and Vomiting(+) Levines SignS3 and S4 heart soundsDizziness / LightheadednessShortness of Breath

DIAGNOSTIC FINDINGSBlood testsReveal: LDL, Triglyceride, VeryLDL, Erythrocyte Sedimentation rate, C-Reactive protein ; HDLElectrocardiography (ECG) (Usually a 12-lead ECG is used)Stable and Unstable- ST DepressionPrinzmetal- ST ElevationStress Test with ECGEchocardiography

Normal ECG Tracing

ST Elevation

Stress Test

Echocardiography

Coronary Angiography (Gold Standard)

DefinitionA 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 ConsiderationsAssess patient allergy to iodine (seafood)Assess blood test results for possible surgical complications: hgb, aPTT, BUN, creatinine, plt, electrolyte levelsDuring Procedure: Continuous BP and ECG monitoring, ensure IV line patency, Prepare resuscitation equipment incase any complication may occurOutpatient basis: 2-6 hours bed rest before ambulationAfter: Monitor for bleeding on catheter insertion site

Pharmacological Treatment

ANTIPLATELETAspirin (ASA)bleeding precautions, blood coagulation tests, dont use in patients with severe anemia, caution in pt with goutClopidogrel (Plavix) for patients with contraindications to aspirin

BETA-BLOCKERSMetoprolol, Atenolol, Propanolol-Compete with endogenous catecholamines for beta-adrenergic receptors-Contraindicated in CHF, Asthma, cardiogenic shock, AV conduction abnormalities

CALCIUM CHANNEL BLOCKERSSmooth muscle relaxation-peripheral arterial vasodilationAmlodipine(Norvasc), Diltiazem, Verapamil, -May increase LFT, use with caution in hepatic and renal patients, A/E include constipation (valsalva maneuver)

Short-Acting NitroglycerinImmediate relief of exertional or rest anginaNitroglycerin (Nitrostat, Nitro-bid, Nitrol)- Metered dose sprays and patches are used for prophylaxisCaution patients on vasodilating effects (headache), C/I in severe anemia, ischemia may worsen upon withdrawal

Long Acting NitroglycerinCauses venous and arterial dilatationIdeal for prinzmetal anginaIsosorbide (Isordil, ISMO)For patients with poor prognosis

ACE InhibitorsInhibits 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 AgentsRanolazine (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)

Description

Nursing Considerations:Assess blood test results for possible surgical complications: hgb, aPTT, BUN, creatinine, plt, electrolyte levelsDuring Procedure: Continuous BP and ECG monitoring, ensure IV line patency, Prepare resuscitation equipment incase any complication may occurAfter: Monitor for bleeding on catheter insertion sitePlace 10lbs Sandbag on catheter insertion site (Femoral Artery) for max of 6 hours after surgery

Diet and Lifestyle Modifications

SpecificsReduce fat, sodium and cholesterol in the dietAvoid stimulating agents such as those that contain caffaine (coffee, chocolate)Quit/ STOP smokingReduce StressExerciseTreatment of Underlying Disease (DM, HTN, Obesity)

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