 Angina pectoris is a clinical syndrome usually characterized by

episodes or paroxysms of pain or pressure in the anterior chest.

 The cause is insufficient coronary blood flow, resulting in a
decreased oxygen supply when there is increased myocardial
demand for oxygen in response to physical exertion or emotional
stress.

Pathophysiology

Angina is usually caused by atherosclerotic disease.

 Almost invariably, angina is associated with a significant obstruction

of at least one major coronary artery.
 Oxygen demands not met. Normally, the myocardium extracts a
large amount of oxygen from the coronary circulation to meet its
continuous demands.
 Increased demand. When there is an increase in demand, flow
through the coronary arteries needs to be increased.
 Ischemia. When there is blockage in a coronary artery, flow cannot
be increased, and ischemia results which may lead to necrosis
or myocardial infarction.

Causes

Several factors are associated with angina.

 Physical exertion. This can precipitate an attack by increasing

myocardial oxygen demand.
 Exposure to cold. This can cause vasoconstriction and elevated
blood pressure, with increased oxygen demand.
  Eating a heavy meal. A heavy meal increases the blood flow to the
mesenteric area for digestion, thereby reducing the blood supply
available to the heart muscle; in a severely compromised heart,
shunting of the blood for digestion can be sufficient to induce
anginal pain.
 Stress. Stress causes the release of catecholamines, which increased
blood pressure, heart rate, and myocardial workload

Clinical Manifestations

The severity of symptoms of angina is based on the magnitude of the

precipitating activity and its effect on activities of daily living.

 Chest pain. The pain is often felt deep in the chest behind

the sternum and may radiate to the neck, jaw, and shoulders.
 Numbness. A feeling of weakness or numbness in the arms, wrists
and hands.
 Shortness of breath. An increase in oxygen demand could cause
shortness of breath.
 Pallor. Inadequate blood supply to peripheral tissues cause pallor.

Complications

 Myocardial infarction. Myocardial infarction is the end result of

angina pectoris if left untreated.
 Cardiac arrest. The heart pumps more and more blood to
compensate the decreased oxygen supply, and.the cardiac muscle
would ultimately fail leading to cardiac arrest.
  Cardiogenic shock. MI also predisposes the patient to cardiogenic
shock.

Assessment and Diagnostic Findings

The diagnosis of angina pectoris is determined through:

 ECG: Often normal when patient at rest or when pain-

free; depression of the ST segment or T wave inversion signifies
ischemia. Dysrhythmias and heart block may also be present.
Significant Q waves are consistent with a prior MI.
 24-hour ECG monitoring (Holter): Done to see whether pain
episodes correlate with or change during exercise or activity. ST
depression without pain is highly indicative of ischemia.
 Exercise or
pharmacological stress electrocardiography: Provides more
diagnostic information, such as duration and level of activity
attained before onset of angina. A markedly positive test is indicative
of severe CAD. Note: Studies have shown stress echo studies to be
more accurate in some groups than exercise stress testing alone.
 Cardiac enzymes (AST, CPK, CK and CK-MB; LDH and isoenzymes
LD1, LD2): Usually within normal limits (WNL); elevation indicates
myocardial damage.
 Chest x-ray: Usually normal; however, infiltrates may be present,
reflecting cardiac decompensation or pulmonary complications.
 Pco2, potassium, and myocardial lactate: May be elevated during
anginal attack (all play a role in myocardial ischemia and may
perpetuate it).
 Serum lipids (total lipids, lipoprotein electrophoresis, and
isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides;
phospholipids): May be elevated (CAD risk factor).
  Echocardiogram: May reveal abnormal valvular action as cause of
chest pain.
 Nuclear imaging studies (rest or stress scan): Thallium-
201: Ischemic regions appear as areas of decreased thallium uptake.
 MUGA: Evaluates specific and general ventricle performance,
regional wall motion, and ejection fraction.
 Cardiac catheterization with angiography: Definitive test for CAD
in patients with known ischemic disease with angina or
incapacitating chest pain, in patients with cholesterolemia and
familial heart disease who are experiencing chest pain, and in
patients with abnormal resting ECGs. Abnormal results are present
in valvular disease, altered contractility, ventricular failure, and
circulatory abnormalities. Note: Ten percent of patients with
unstable angina have normal-appearing coronary arteries.
 Ergonovine (Ergotrate) injection: On occasion, may be used for
patients who have angina at rest to demonstrate hyperspastic
coronary vessels. (Patients with resting angina usually experience
chest pain, ST elevation, or depression and/or pronounced rise in
left ventricular end-diastolic pressure [LVEDP], fall in systemic
systolic pressure, and/or high-grade coronary artery narrowing.
Some patients may also have severe ventricular dysrhythmias.)

Medical Management

The objectives of the medical management of angina are to increase the

oxygen demand of the myocardium and to increase the oxygen supply.

 Oxygen therapy. Oxygen therapy is usually initiated at the onset of

chest pain in an attempt to increase the amount of oxygen delivered
to the myocardium and reduce pain.
Pharmacologic Therapy

 Nitroglycerin gives long term and short term reduction of

myocardial oxygen consumption through selective vasodilation
within three (3) minutes.
 Beta-blockers reduces myocardial oxygen consumption by blocking
beta-adrenergic stimulation of the heart.
 Calcium channel blockers have negative inotropic effects.
 Antiplatelet medications prevent platelet aggregation;
and anticoagulants prevent thrombus formation.

Nursing Management

The patient with angina pectoris should be managed by a

cardiac nurse specifically.

Nursing Assessment

In assessing the patient with angina, the nurse may ask regarding the
following:

 Location of pain.
 Characteristics of pain.
 Health history.
 Pain scale.
 Onset of pain.
 Cause of pain.
 Measures that relieve pain.
 Other symptoms that occur with pain
Nursing Diagnosis

Based on the assessment data, major nursing diagnosis may include:

 Ineffective cardiac tissue perfusion secondary to CAD as

evidenced by chest pain or other prodromal symptoms.
 Death anxiety related to cardiac symptoms.
 Deficient knowledge about the underlying disease and methods
for avoiding complication
 Noncompliance, ineffective management of therapeutic
regimen related to failure to accept necessary lifestyle changes.

Nursing Care Planning  and Goals

Main Article: 4 Angina Pectoris (Coronary Artery Disease) Nursing Care

Plans

Major patient goals include:

 Immediate and appropriate treatment when angina occurs.

 Prevention of angina.
 Reduction of anxiety.
 Awareness of the disease process and understanding pf the
prescribed care.
 Adherence to the self-care program.
 Absence of complications.

Nursing Interventions

Nursing interventions for a patient with angina pectoris include:

  Treating angina. The nurse should instruct the patient to stop all
activities and sit or rest in bed in a semi-Fowler’s position when they
experience angina, and administer nitroglycerin sublingually.
 Reducing anxiety. Exploring implications that the diagnosis has for
the patient and providing information about the illness, its
treatment, and methods of preventing its progression are important
nursing interventions.
 Preventing pain. The nurse reviews the assessment findings,
identifies the level of activity that causes the patient’s pain, and
plans the patient’s activities accordingly.
 Decreasing oxygen demand. Balancing activity and rest is an
important aspect of the educational plan for the patient and family.

Evaluation

The expected patient outcomes are:

 Reported pain is relieved promptly.

 Reported decrease in anxiety.
 Understood ways to avoid complications and is free pf
complications.
 Adhered to self-care program.

Discharge and Home Care Guidelines

The goals of education ate to reduce the frequency and severity of anginal
attacks, to delay the progress of the underlying disease if possible, and to
prevent complications.

 Reduce anginal attacks. Activities should be planned to minimize

the occurrence of angina episodes.
  Follow-up monitoring. The patient may need reminders about
follow-up monitoring, including periodic blood laboratory testing
and ECGs.
 Adherence. The home care nurse may monitor the patient’s
adherence to dietary restrictions and to prescribed antianginal
medications.

Documentation Guidelines

The focus of documentation in a patient with angina pectoris includes:

 Nature, extent, and duration of problem.

 Effect on independence and lifestyle.
 Characteristics of pain, precipitators, and what relieves pain.
 Pulses and BP.
 Client’s fear and signs and symptoms exhibited.
 Responses and actions of family/SOs.
 Deviation from prescribed treatment plan and client’s reasons in
own words.
 Consequences of actions to date.
 Plan of care.
 Teaching plan.
 Response to interventions, teaching, and actions performed.
 Attainment or progress toward desired outcomes.
 Modifications to plan of care.