Angina Pectoris (Chest Pain)

TYPES OF ANGINA

1. Stable :- Increases O, demand (short duration and easily relieved)
2. Unstable:- During rest chest pain (severe long lasting, not relieved by rest or medication).
3. Variant:- No evidence of chest pain but ECG changes reflect ischemia
4. Nocturnal :- Occurs at night during sleep.
5. Decubitus :- When patient raised up after lying
6. Post infarction :- After myocardial infarction.

CAUSES

There are two main causes for this:

1. Decrease blood supply in heart
2. Increase blood demand in heart.

1.Decrease blood supply in heart:

• Coronary artery disease
• Circulatory disorders, e.g., Aortic valve stenosis
• Aortic aneurysm (distension of coronary artery lumen)
• Blood disorders, e.g., Severe anaemia.
• Hypoxia (decrease O, level in cell/tissues).

2 . Increase blood demand in heart:

• Excessive exercise
• Excessive food intake.
• Excessive emotional level

3. Others:

• Hypertension.
• Some other heart diseases.

CLINICAL MANIFESTATIONS

• Chest pain radiates to the extremities, neck or jaw
• Increases and decreases blood pressure
• Tachycardia (pulse rate more than 100)
• Palpitation (rapid and irregular heart rate)
• Nausea
• Pallor and cold skin
• Dizziness
• SOB
• Sweating
• Dyspnoea
• Pressure like discomfort
• Feeling of suffocation
• Squeezing and tightness feeling in chest.

Special Characteristics of Chest Pain

1. Location - To left of sternum
2. Severity - Mild to moderate
3. Onset - May quick or slow
4. Radiation - Generally in neck, left shoulder and upper left arm and downward 4th and 5th fingers
5. Sensation - Burning, bursting, sensation, patient have gas problem and Indigestion
6. Duration - Less than 5 minutes.

DIAGNOSTIC EVALUATIONS

• Characteristics of chest pain
• By ECG (ST elevation)
• Nitroglycerin test (patient feel relief after taking nitroglycerine)
• Coronary Angiography (it shows CAD)
• Cardiac catheterization (it shows blockage site of coronary artery).

COMPLICATIONS

• Myocardial Infarction (M.I)
• Heart failure.

MANAGEMENT

Medical Management

1. Vasodilators: They increase blood flow in myocardium (muscles in heart) without affected O2, requirement and B.P. change. Nitrates: Explained previously in hypertension.
2. B-Blockers decreases work load in heart) by vasodilation action. Examples:
   • Propranolol - 20-40 mg
   • Atenolol-20-50 mg.
3. Calcium channel blockers: They improve coronary blood flow. Examples:
   • Nifedipine.
   • Verapamil
4. Opiates analgesics (for reduce pain). Example: Morphine sulphates.
5. Antiplatelate drugs. Example: Aspirin-75-150 mg.

Surgical Management

• PTCA (Percutaneous transluminal coronary angioplasty)
• CABG (Coronary artery bypass grafting).
• Coronary arteriactomy
• Insertion of coronary shunt

Dietary Management

• We should advice to patient for low fat and low cholesterol diet. They increase extra pressure on heart.
• Advice to take light and fibers diet
• Avoid caffeine intake.
• Avoid alcohol and smoking.
• Advice to take low sodium diet.

Health Education [ 5. A's ]

Nursing Management

1. Nurse should instruct patient to notify immediately when chest pain occurs.
2. Assess the pain, location, severity, intensity, onset and radiation, frequency.
3. We should provide quiet and calm environment and comfort measures to reducing anxiety
4. Elevate head of bed if patient is SOB.
5. Instruct to take light meals and take rest for 1 hour after meals.
6. Demonstrates healthy lifestyle behaviours such as proper diet, regular exercise, cessation of alcohol and tobacco use.
7. Administer anti angina drugs as prescribed, e.g., nitroglycerines, B-blockers, Ca' channel blockers, morphine sulphate.

Nursing Diagnosis

• Acute pain related to myocardial ischemia.
• Risk for decrease cardiac output related to prolonged myocardial ischemia, alteration in electrical conductivity.
• Anxiety related to disease process, altered image; threat to change health status.
• Deficient knowledge related to disease condition, treatments, self-care.