Angina Pectoris

ANGINA PECTORIS
Ns. Nury Sukraeny, S.Kep., MNS.

Faculty of Nursing and Health Science
University of Muhammadiyah Semarang
e-mail: nury_sukreny@yahoo.com
Definition
Angina pectoris means pain in the chest.
Angina pectoris is the result of myocardial
ischemia caused by an imbalance between
myocardial blood supply and oxygen demand.
It is a common presenting symptom (typically,
chest pain) among patients with coronary
artery disease (CAD).

Etiology
Nonmodifiable risk factors are age, gender,
and family history of heart disease and renal
disease.
Major modifiable CAD risk factors are
identified as hyperlipidemia, hypertension,
smoking, and diabetes melitus, obesity, and
sedentary lifestyle.
Physical exertion, emotional stress, smoking,
exposure to extreme cold or heavy meals, or
an arterial spasm
Types of Angina
Stable angina
Unstable angina
Prinzmetals variant angina
Silent angina
Syndrome X
Stable angina; a stable, fixed, obstructive
atheromatous plaque with a thick fibrous cap in one
or more coronary arteries. Ischemic episodes are
precipitated by factors that increase oxygen demand
(ex:exercise), or reduce oxygen supply (ex:anemia).
Chest pain occurs predictably with the same onset,
duration, and intensity and is relieved when the
precipitating factor is removed or with nitroglycerin
administration.
Myocardial ischemia is a temporary inadequate
blood and oxygen supply to the myocardial tissues.
The person experiences chest pain or angina
pectoris when this temporary Ns.condition
Nury Sukraeny,occurs.
S.Kep., MNS.
Unstable angina; an increase in frequency, duration,
and intensity of symptoms at lower levels of activity
and even at rest. Unstable angina is often the
precursor to MI. Unstable angina and MI are now
classified as acute coronary syndrome. This
syndrome is the result of rupture of an unstable or
vulnerable plaque.

Prinzmetals variant angina; in the case of
coronary artery spasm. Ischemia occurs
because of transient focal decreased oxygen
supply unrelated to oxygen demand
Silent angina ; referred as ischemia that occur
with no pain at all. Common in people with
diabetes, suggesting that pain receptors may
be altered in this condition. An alarming 80%
of patients have episodes of asymptomatic
ischemia. Asymptomatic ischemia has the
same prognosis as symptomatic ischemia.
Syndrome X refers to patients with classic
angina symptoms without angiographic
evidence of CAD. Evidence of ischemia is
demonstrated on diagnostic evaluation such
as stress electrocardiogram (ECG), nuclear
scans, and echocardiogram. The etiology of
this disorder is unknown. The hypothesis is
that small vessels, too small to be visualized
on angiogram, are unable to dilate effectively
during episodes of increased myocardial
oxygen demand
Symptoms
Retrosternal chest discomfort (pressure,
heaviness, squeezing, burning, or choking
sensation) as opposed to frank pain
Pain localized primarily in the epigastrium, back,
neck, jaw, or shoulders
Pain precipitated by exertion, eating, exposure to
cold, or emotional stress, lasting for about 1-5
minutes and relieved by rest or nitroglycerin
Pain intensity that does not change with
respiration, cough, or change in position
The following should be taken into
account in the physical examination:
For most patients with stable angina, physical
examination findings are normal
A positive Levine sign suggests angina pectoris
Signs of abnormal lipid metabolism or of diffuse
atherosclerosis may be noted
Examination of patients during the angina attack
may be more helpful
Pain produced by chest wall pressure is usually of
chest wall origin
PATHOPHYSIOLOGY
Atherosclerosis begins with injury to the endothelial lining
that allows abnormal accumulation of lipids and progresses to
development of fibrous plaques with lipid rich cores and
hardening of the arterial wall. Finally these plaques become
complicated lesions that are stable or vulnerable. This process
is the basis for the development of atherosclerotic lesions
over time (atherogenesis).
Stable plaques usually have a thick fibrous cap protecting a
small lipid core with high levels of smooth muscle and low
levels of inflammatory cells. This lesion can produce
significant arterial narrowing but is less likely to rupture. On
the other hand, vulnerable plaqueNs.has a Sukraeny,
Nury thin fibrous
S.Kep.,cap
MNS.
protecting a large lipid core University
with high levels of inflammatory
of Muhammadiyah Semarang
cells. e-mail: nury_sukreny@yahoo.com
The usual response to increased oxygen demand is
increased oxygen supply through coronary artery dilation
and increased blood flow rate. In CAD, the stenotic and
hardened coronary arteries are unable to meet the
increased oxygen demand. This is because of their
inability to effectively dilate and because the artery
beyond the obstruction is already chronically dilated. A
coronary artery with a significant stenosis may be able to
meet low oxygen demands at rest, but it is usually unable
to meet any increase in oxygen demand caused by
precipitating factors, such as exercise.
At the cellular level, ischemic myocardial cells convert
from aerobic to anaerobic metabolism. Anaerobic
metabolism produces lactic acid and other by-products
that accumulate. These factors are believed to stimulate
peripheral pain receptors in the cervical and thoracic
distribution, accounting for typical anginal pain
Diagnoses
Electrocardiogram; During an episode of angina, T wave
flattening or inversions and ST segment depression may
be seen on the ECG due to subendocardial ischemia.
When angina subsides, the ECG changes resolve.
Between episodes of angina the ECG is usually normal
Chest radiography: Usually normal in angina pectoris but
may show cardiomegaly in patients with previous MI,
ischemic cardiomyopathy, pericardial effusion, or acute
pulmonary edema
Graded exercise stress testing: This is the most widely
used test for the evaluation of patients presenting with
chest pain and can be performed alone and in
conjunction with echocardiography or myocardial
perfusion scintigraphy University of Muhammadiyah Semarang
Coronary angiogram, or heart catheterization,
is an invasive procedure that is considered the
gold standard for diagnosis of CAD. This
procedure directly visualizes the coronary
artery anatomy and assesses hemodynamic
parameters and ventricular function.
Coronary artery calcium (CAC) scoring by fast
CT: The primary fast CT methods for this
application are electron-beam CT (EBCT) and
multi detector CD (MDCT)
Nursing Diagnoses
Acute pain (angina) related to the imbalance between
myocardial oxygen supply and demand
Ineffective tissue perfusion (myocardial) related to
coronary arterial occlusions
Anxiety related to pain, perceived threat of death,
possible lifestyle changes, and diagnosis of CAD
Activity intolerance related to angina, pulmonary
congestion, fatigue, and inadequate tissue oxygenation
Ineffective therapeutic regimen management related
to lack of knowledge regarding disease process,
prognosis, and treatment strategies
Planning and Implementation
The nurse has two main goals in the treatment
of stable angina. The first goal is to improve
quality of life by decreasing episodes of angina
and ischemia. The second goal is to increase
quantity of life by preventing progression to
MI and death.
Treatment of stable angina focuses on use of
medications, risk factor modification, and
patient and family education.
Collaborative Management
Pharmacology
Surgery

Pharmacology
There are three classifications of pharmacological
agents used to prevent angina: nitrates, beta-
adrenergic blockers, and calcium channel
blockers. These agents decrease the workload of
the heart and increase myocardial perfusion.
Three classifications of pharmacological agents
are used to prevent MI and death: antiplatelets,
angiotensin-converting enzyme (ACE) inhibitors,
and therapy that lowers lipids levels.
Aspirin also plays a role in the treatment of heart
disease. It inhibits blood clots, decreases pain,
and can reduce the risk of death, especially in the
elderly. Faculty of Nursing and Health Science
Surgery
Percutaneous coronary interventions (PCI) are
commonly used for the treatment of significant
CAD and emergent treatment in AMI.
Percutaneous transluminal coronary angioplasty
(PTCA) is performed during the heart
catheterization procedure.
Coronary artery bypass grafting (CABG) is a
surgicalprocedure in which veins and arteries are
used as a conduit to bypass the coronary artery
stenosis
Lifestyle Modifications
Smoking cessation and avoidance of
secondhand smoke are strongly advised.
Weight management is strongly encouraged. A
diet high in fresh fruits, vegetables, and low-
fat dairy should be adhered to. Alcohol and
sodium consumption should be limited.

Evaluation of Outcomes
Acute pain (angina) related to the imbalance
between myocardial oxygen supply and demand.
Verbalize relief of chest pain and demonstrate
ability to manage chest pain that is not relieved.
Ineffective tissue perfusion myocardial coronary
arterial occlusion. Maintain adequate tissue
perfusion to all organ systems and extremities
including stable vital signs, pulses, oxygenation,
and ECG tracings.
Anxiety related to pain, perceived threat of
death, possible lifestyle changes and diagnosis of
CAD. Demonstrate effective coping strategies and
verbalize reduced anxiety.
Activity intolerance related to angina, pulmonary
congestion, fatigue, and inadequate tissue
oxygenation. Return to baseline level of activity.
Ineffective therapeutic regimen management
related to lack of knowledge regarding disease
process, prognosis, and treatment strategies.
Verbalize understanding of disease process,
prognosis, and complies with treatment
strategies. Faculty of Nursing and Health Science

Angina Pectoris

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ANGINA PECTORIS

Ns. Nury Sukraeny, S.Kep., MNS.

Ns. Nury Sukraeny, S.Kep., MNS.

Ns. Nury Sukraeny, S.Kep., MNS.

Ns. Nury Sukraeny, S.Kep., MNS.

Ns. Nury Sukraeny, S.Kep., MNS.

Ns. Nury Sukraeny, S.Kep., MNS.

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