Angina Pectoris

• severe pain riginating from the

heart
• inadequate oxygen supply to the
myocardial cells.
• pain of angina : radiate down the
left arm, to the back, to the jaw,
or into the abdominal area
• workload of any tissue increases  oxygen
demand increase
• Inc. oxygen demand increases  the
coronary arteries dilate and bring more blood
flow and oxygen to the muscle.
• If the coronary arteries are stiffened or
narrowed with atherosclerosis and cannot
dilate in response to an increased demand for
oxygen, myocardial ischemia (inadequate
blood supply) occurs
• Anaerobic glycolysis
• is very inefficient
• production of lactic acid.
• Lactic acid
• decreases myocardial pH and causes the pain associated
with angina pectoris.

• If the energy demands of the cardiac cells are

lessened, the oxygen supply becomes
adequate and the muscle cells revert to
oxidative phosphorylation for energy
production.
 Types of Angina
• There are three types of
angina:
• Stable
• Prinzmetal's (variant)
• Unstable.
 Stable angina

• also called classic angina

• occurs when
atherosclerotic coronary
arteries cannot dilate to
increase flow when oxygen
demand is increased.
• Increased work of the heart can
accompany physical exercise such as
sports participation or climbing stairs.
• Exposure to the cold
• increases the metabolic demands of
the heart
• a strong stimulator of classic angina.
 Stable angina

• Mental stress
• anger
• mental tasks such as mathematic
. The pain of stable angina typically
goes away when the individual
stops the activity.
 Prinzmetal's angina

• without any obvious increase in

the workload of the heart
• during rest or sleep
• a coronary artery undergoes a
spasm
• Sometimes the site of spasm is
related to atherosclerosis.
•
 Prinzmetal's angina
• damage to the endothelial layer may be
present.
• This allows vasoactive peptides access
directly to the smooth muscle layer,
causing its contraction.
• Dysrhythmias are common with variant
angina.
 Unstable angina

• combination of classic and

variant angina
• individual with worsening
coronary artery disease.
• accompanies an increased
workload of the heart
• result from coronary
atherosclerosis, characterized by
a growing, spasm-prone
thrombus.
• Spasm occurs in response to
vasoactive peptides released
from platelets drawn to the area
of damage
• The most potent constrictors
released by the platelets are
• Thromboxane
• Serotonin
• platelet-derived growth factors.
Clinical Manifestations
• Constricting or squeezing pain in the pericardial
or substernal area of the chest
• radiating to the arms, jaw, or thorax.
• Stable and unstable angina
• pain is typically relieved by rest.
• Prinzmetal's angina
• unrelieved by rest
• usually disappears in about 5 minutes.
 Diagnostic Tools
• Alteration in the ST segment of the
ECG may occur.
• Areas of reduced blood flow may be
observed using radioactive imaging
during an induced angina episode as
part of an exercise stress test.
• Cardiac enzymes and proteins may
be measured to rule out MI.
 Treatment

• Prevention:
• Aspirin is sometimes prescribed
to prevent anginal symptoms.
• Avoid stressors
• They are strongly encouraged
not to smoke.
 Treatment

• Invasive techniques
• percutaneous transluminal
coronary angioplasty (PTCA)
• coronary artery bypass surgery
• reduce episodes of classic
angina.
 Treatment
• PTCA
• the atherosclerotic lesion is dilated
by a catheter inserted through the
skin into the femoral or brachial
artery and fed into the heart.
• Once in the affected coronary
vessel, a balloon in the catheter is
inflated.
• This cracks the plaque and stretches
the artery
 Treatment
• Bypass surgery
• the diseased piece of a coronary artery is
tied off
• an artery or vein taken from elsewhere in
the body is connected to nondamaged
areas.
• Flow is reinstated through this new vessel.
• saphenous vein and the internal mammary
artery.
 Treatment
• Treatment is geared at reducing energy
demands:
• Rest
• allows the heart to pump out less blood
(decreased stroke volume) at a slower rate
(decreased heart rate).
• therefore its oxygen requirements.
• Sitting is the preferable posture for rest,
since lying down increases blood return to
the heart, leading to increased end-diastolic
volume, stroke volume, and cardiac output.
 Treatment
• Nitroglycerin and other nitrates
• act as potent dilators of the venous system
• decreasing venous return of blood to the heart
• A decreased venous return decreases end diastolic
volume, allowing the heart to decrease stroke volume.
• Nitrates dilate the arterial system as well, reducing the
afterload against which the heart must pump, and
increasing coronary blood flow.
•
 Treatment

• Beta-adrenergic blockers
• reduce angina by reducing
heart rate and contractility
of the heart, thereby
reducing its oxygen
demands.
• Calcium channel blockers
• reduce the afterload against
which the heart must pump by
dilating the arteries and
arterioles downstream and are
particularly effective in reducing
the spasm of variant angina..
• Oxygen therapy eases demands
on the heart.
Coronary Artery Anatomy
Myocardial Ischemia
• Lack of blood flow in
a coronary artery
causes injury to the
heart
• Improvement in
blood flow will
reverse the injury
 Myocardial Infarction
• Prolonged lack of
blood flow leads to
death of myocardial
cells
• This is called a
myocardial infarction
(“heart attack in
layman’s terms)
• MIs are irreversible
 Pathophysiology
Risk Factors

Non-modifiable Modifiable

Stress, diet, sedentary living, Smoking, Alcohol,

Age, gender, HPN, DM, Obesity, Contraceptive pills,
race, heredity Hyperlipidemia/hypercholesterolemia

Endothelial injury

Desquamation of endothelial
lining (peeling off)
Increased permeability/
adhesion of molecules

LDLs & platelets

assimilate into the area

Plaques begins to form

Decreased coronary
tissue perfusion

Coronary ischemia

Decreased myocardial
oxygenation

MYOCARDIAL
ANGINA PECTORIS
INFARCTION
 Risk factors for Coronary
Artery Disease
• Age
• Gender
• Family history
• Hyperlipidemia
• Smoking
• Hypertension
• Diet
• Diabetes
• Obesity
 Diagnosis of CAD
• Patient History

• Physical exam
• Lab studies
• Diagnostic studies
• Invasive studies
 Symptoms
Angina - classic description is a heavy, tight
sensation under the sternum that is
provoked with exertion
Arm pain
Jaw pain
Indigestion
Shortness of breath
 Symptoms
• Lightheadedness
• Palpitations
• Fear or dread
• Diaphoresis (sweating)
• Atypical (often in women)
• Cardiac arrest/Sudden death
 Diagnosis
• Acute - infarcted
heart cells release
chemicals in blood
• Lab Studies stream:
• Troponin
• CPK isoenzyme
• Stable
• Lipid studies
• Blood glucose
 Diagnosis
• Acute - looks for • Resting EKG
specific changes

• Stable - looks for

signs of prior MIs
 Diagnosis
• Stress testing is used to evaluate
patients for ischemia when they are
stable
• EKG tracings at rest are compared
with those during taken during
exercise
 Diagnosis
• Myocardial perfusion study- uses
radioactive contrast in conjunction
with a “stressor” medication
 Diagnosis
• Cardiac catheterization
 Acute Treatment
• Emergent care - cardiovascular resuscitation
• Oxygen
• Aspirin
• Nitrates
• Thrombolytic therapy (“clot busters”)
• Surgical management
 Treatment
• Balloon angioplasty
Treatment

• Coronary artery
bypass grafting
 Chronic Treatment
Decrease Risk Factors
Drugs that reduce clots:
• Aspirin
• Plavix
Drugs that reduce work
on heart:
• Nitrates (nitroglycerine)
• Calcium channel blockers
• Beta-blockers
Anti-lipid therapy
 Buerger’s Disease

• Also known as Thromboangiitis

obliterans
• Usually a disease of heavy cigarette
smoker/tobacco user men
• 25-40y/o
• Inflammatory arterial disorder that
causes thrombus formation often
extends to adjacent veins & nerves

http://nursinglectures.blogspot.co
m
• Affects medium-sized arteries (usually plantar &
digital vessels in the foot or lower legs)
• unknown pathogenesis but it had been suggested
that:
• tobacco may trigger an immune response or
• unmask a clotting defect;
→ these 2 can incite an inflammatory reaction of
the vessel wall
 Manifestations

Pain – predominant symptom;

R/T distal arterial ischemia
 Intermittent claudication in
the arch of foot & digits
Increased sensitivity to cold
(due to impaired circulation
Absent/diminished peripheral
pulses
Color changes in extremity (cyanotic on
dependent position; digits may turn
reddish blue)
Thick malformed nails (chronic ischemia)
Disease progression ulcerate tissues &
gangrenous changes may arise; may
necessitate amputation
 Diagnosis & Treatment
• Diagnostic methods – those that
assess blood flow (Doppler
ultrasound & MRI)
• Tx: mandatory to stop smoking or
using tobacco
• Meds to increase blood flow to
extremities
• Surgery (surgical sympathectomy)
• amputation
 Rynaud’s Disease
Mechanism: intensive
vasospasm of arteries &
arterioles in the fingers
Cause: unknown
Usually affects young women
Precipitated by exposure to
cold & strong emotions
• Raynaud’s phenomenon – associated
with previous injury
• Frostbite, occupational trauma
associated with use of heavy vibrating
tools, collagen diseases, neuro d/o,
chronic arterial occlusive d/o)
 Manifestations
• Period of ischemia (ischemia due to vasospasm)
• change in skin color = pallor to cyanotic
• 1st noticed at the fingertips later moving to distal phalanges
• Cold sensation
• Sensory perception changes (numbness & tingling)
• Period of hyperemia – intense redness
• Throbbing
• Paresthesia
• of fingers (rare occasions)

http://nursinglectures.blogspot.co
m
• Return to normal color
• Note: although all of the fingers are
affected symmetrically, only 1-2digits
may be involved
• Severe cases: arthritis may arise
(due to nutritional impairment)
• Brittle nails
• Thickening of the skin of fingertips
• Ulceration & superficial gangrene
Diagnosis & Treatment

Dx: initial = based on Hx of

vasospastic attacks
 Immersion of hand in cold water
to initiate attack aids in the Dx
 Doppler flow velocimetry – used
to quantify blood flow during
temperature changes
 Serial Computed thermography
(finger skin temp) – for
diagnosing the extent of disease
Tx: directed towards eliminating
factors causing vasospasm &
protecting fingers from injury
during ischemic attacks
 PRIORITIES: Abstinence in
smoking & protection from cold
 Avoidance of emotional stress
(anxiety & stress may precipitate
vascular spasm)
 Meds: avoid vasoconstrictors (i.e..
Decongestants)
-Calcium channel blockers (Diltiazem,
Nifedipine,
ine Nicardipine) – decrease
episodes of attacks
 Care Plan for Clients with Altered
Cardiovascular Oxygenation
A. Assessment:
1. Hx of symptoms (pain,
esp. chest pain;
palpitations; dyspnea)
2. v/s
B. Nursing Dx:
1. ineffective tissue
perfusion
(cardiopulmonary)
2. Impaired gas exchange
3. Anxiety due to fear of
death (clients with MI or
Angina)
An
C. Goals:
1. Relief of pain &
symptoms
2. Prevention of further
cardiac damage
D. Nursing Interventions:
1. Pain control
2. Proper medications
3. Decrease client’s
anxiety
4. Health teachings
(meds, activities, diet,
exercise, etc)