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

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. 2. 3. 4. * Stable Angina Unstable Angina Prinzmetal | Atypical | Variant Angina Decubitus Syndrome X

PATHOPHYSIOLOGY
Risk Factors Narrowed arterial coronary lumen Exertion, Physical Activities Increased myocardial workload Increased myocardial oxygen demand Narrowed coronary arteries unable to meet Myocardial demand Anginal Pain, S/S Myocardial Ischemia

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 (+) Levines Sign S3 and S4 heart sounds Dizziness / Lightheadedness Shortness of Breath

DIAGNOSTIC FINDINGS
Blood tests Reveal: LDL, Triglyceride, VeryLDL, Erythrocyte Sedimentation rate, C-Reactive protein ; HDL Electrocardiography (ECG) (Usually a 12lead ECG is used) Stable and Unstable- ST Depression Prinzmetal- 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, dont 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!!!