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Angina Pectoris NWT Clinical Practice Guidelines for Primary Community Care Nursing - Cardiovascular System Angina Pectoris Definition area, radiating down one or both arms for 5 Heart disease that occurs as a result of inadequate minutes or less, precipitated by exercise or oxygen and blood supply to the myocardium. emotional stress and relieved by rest or nitroglycerin. Types Stable Angina Unstable Angina Predictable pattern of exertional pressure sensation More severe anginal pain that lasts more than 30 in the anterior chest relieved by rest or minutes or that occurs during rest and is not nitroglycerin. No change in frequency, severity or relieved by rest or sublingual nitroglycerin. duration of angina episodes during the preceding 6 weeks. Associated Symptoms • Dyspnea Unstable Angina • Nausea or vomiting Angina that is of new onset, or is changing, so that • Sweating it is occurring with increasing severity, frequency • Weakness or duration or is occurring at rest. • Palpitations Myocardial Infarction Physical Findings For details of this type of angina, refer to • Diaphoresis "Emergencies of the Cardiovascular System," • Apprehension below, this chapter. • Oxygen saturation (may be normal or abnormal in myocardial infarction) Causes • Blood pressure (may be elevated or reduced in Angina pectoris is the result of myocardial myocardial infarction) ischemia, which occurs when the cardiac workload • Tachycardia and myocardial oxygen demands exceed the • S4 gallop ability of the coronary arteries to supply oxygenated blood. It is the main clinical These findings are transient in stable angina and expression of coronary artery disease (subintimal disappear when the pain resolves. People with deposition of atheromas in the large and medium- stable angina are usually seen in a clinic after an sized arteries serving the heart). attack because of the mild, short, episodic nature of the discomfort. After an episode there are Risk Factors usually no significant physical findings. • Hypertension • Hyperlipidemia Differential Diagnosis • Diabetes mellitus • Chest-wall pain • Cigarette smoking • Other musculoskeletal discomfort • Family history of premature coronary artery • Peptic ulcer disease disease (e.g. father died of coronary artery • Gastroesophageal reflux disease before reaching 60 years of age) • Esophageal spasm • Use of oral contraceptives • Indigestion • Sedentary lifestyle • Anxiety attack • Obesity (particularly with a truncal distribution) • Pulmonary emboli History • Pericarditis Stable Angina • Aortic dissection Chest pain described as tightness, pressure or • Pneumothorax (spontaneous) aching that is typically located in the substernal September 2004 Angina Pectoris - Adult 1 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Cardiovascular System Complications Monitoring and Follow-Up • Unstable angina • Follow up every 6 months once client's • Future myocardial infarction symptoms are stable • Monitor symptoms and identify any changes, Diagnostic Tests especially increases • Electrocardiogram (ECG) changes (depression • Monitor weight and smoking of ST segment, inversion of T wave) • Monitor blood pressure and pulse • Compare current ECG tracing with previous • Obtain regular blood work as directed one, if available; look for signs of ischemia • Monitor adherence and response to long-term (depression of ST segment, inversion of T wave, lifestyle modifications and medications (e.g. ß- new changes) blockers) • Obtain complete blood count, and determine blood glucose, creatinine and cholesterol levels Referral Refer all previously undiagnosed clients and any Management Of Stable Angina clients whose symptoms are not controlled on Goals of Treatment current therapy to a physician for a thorough • Decrease or prevent recurrence of pain evaluation. Once the condition has been stabilized, the client should be assessed by a physician at • Identify and manage risk factors least annually. • Improve exercise tolerance • Prevent complications Management Of Unstable Angina For anyone who has pain on presentation at the Appropriate Consultation clinic, anyone with a history of angina of recent Consult a physician as soon as possible for help onset or anginal symptoms at rest, and anyone with diagnosis and treatment options. with known heart disease and an increase or change in anginal pattern and ECG changes. Client Education • Ensure that client understands disease process Appropriate Consultation • Encourage client to make lifestyle changes (e.g. Consult a physician as soon possible. dietary modifications to reduce fat and cholesterol) Adjuvant Therapy • Encourage client to reduce weight, stop • Oxygen to keep saturation > 97% smoking, avoid strenuous exercise but increase • Start IV therapy with normal saline to keep vein moderate exercise (e.g. walking) open Pharmacologic Interventions Nonpharmacologic Interventions For prophylaxis against thrombus formation: Bed rest for clients experiencing pain on enteric-coated acetylsalicylic acid (ASA) (A class presentation. drug), 325 mg od, if not contraindicated and client is not already using Pharmacologic Interventions nitroglycerin (C class drug), 0.3-mg SL tab stat; For acute episodes of angina: repeat dose twice, q5min nitroglycerin (C class drug), 0.3- to 0.6-mg SL tabs or lingual spray (0.4 mg) prn If the client is hypotensive or has bradycardia on presentation, do not give nitroglycerin without For long-term prophylaxis: according to physician first consulting a physician. If pain is not relieved, order. treat as myocardial infarction (see "Myocardial Infarction," this chapter). September 2004 Angina Pectoris - Adult 2 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Cardiovascular System Monitoring and Follow-Up Referral Continue to closely monitor pain, vital signs Medevac as soon as possible. (including oxygen saturation), heart and lung sounds, and ECG results. Coronary artery bypass surgery or angioplasty may be indicated for any client who continues to have significant symptoms despite maximal medical therapy. September 2004 Angina Pectoris - Adult 3.
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