Angina pectoris is a clinical syndrome characterized by paroxysms of pain or a feeling of pressure in the anterior chest.

The cause is decreased coronary blood ow, resulting in an inadequate supply of oxygen to meet the myocardial demand. Angina is usually a result of atherosclerotic heart disease and is associated with a signicant obstruction of a major coronary artery. Factors affecting anginal pain are physical exertion, exposure to cold, eating a heavy meal, or stress or any emotionprovoking situation that increases blood pressure, heart rate, and myocardial workload. Unstable angina is not associated with the above and may occur at rest.

Clinical Manifestations of Angina Pectoris

Pain may vary from a feeling of indigestion to a choking or heavy sensation in the upper chest ranging from discomfort to agonizing pain. The patient with diabetes mellitus may not experience severe pain with angina. Angina is accompanied by severe apprehension and a feeling of impending death. The pain is usually retrosternal, deep in the chest behind the upper or middle third of the sternum. Discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspect of the upper arms (usually the left arm). A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting, may accompany the pain. Anxiety may occur with angina. An important characteristic of anginal pain is that it subsides when the precipitating cause is removed or with nitroglycerin.

Gerontologic Considerations
The elderly person with angina may not exhibit the typical pain prole because of the diminished responses of neurotransmitters that occur with aging. Often, the presenting symptom in the elderly is dyspnea. Sometimes, there are no symptoms (silent CAD), making recognition and diagnosis a clinical challenge. Elderly patients should be encouraged to recognize their chest painlike symptom (eg, weakness) as an indication that they should rest or take prescribed medications.

Assessment and Diagnostic Methods of Angina Pectoris

Evaluation of clinical manifestations of pain and patient history Electrocardiogram changes (12lead ECG), stress testing, blood tests Echocardiogram, nuclear scan, or invasive procedures such as cardiac catheterization and coronary angiography

Medical Management of Angina Pectoris

The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Medically, these objectives are met through pharmacologic therapy and control of risk factors. Alternatively, reperfusion procedures may be used to restore the blood supply to the myocardium. These include PCI procedures (eg, percutaneous transluminal coronary angioplasty [PTCA], intracoronary stents, and atherectomy) and coronary artery bypass graft (CABG).

Pharmacologic Therapy of Angina Pectoris

Nitrates, the mainstay of therapy (nitroglycerin) Betaadrenergic blockers (metoprolol and atenolol) Calcium channel blockers/calcium ion antagonists (amlodipine and diltiazem)

Antiplatelet and anticoagulant medications (aspirin, clopidogrel, heparin, glycoprotein [GP] IIb/IIIa agents [abciximab, tiroban, eptibatide]) Oxygen therapy

Nursing Process
Assessment
Gather information about the patients symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. In addition, assess the patients risk factors for CAD, the patients response to angina, the patients and familys understanding of the diagnosis, and adherence to the current treatment plan.

Diagnosis
Nursing Diagnoses for Angina Pectoris Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain or other prodromal symptoms Death anxiety Decient knowledge about underlying disease and methods for avoiding complications Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes

Collaborative Problems/Potential Complications Potential complications of angina include ACS and/or MI, dysrhythmias and cardiac arrest, heart failure, and cardiogenic shock.

Planning and Goals

Goals include immediate and appropriate treatment when angina occurs, prevention of angina, reduction of anxiety, awareness of the disease process and understanding of the prescribed care, adherence to the selfcare program, and absence of complications.

Nursing Interventions for Angina Pectoris

Treating Angina Take immediate action if patient reports pain or if the persons prodromal symptoms suggest anginal ischemia Direct the patient to stop all activities and sit or rest in bed in a semiFowlers position to reduce the oxygen requirements of the ischemic myocardium. Measure vital signs and observe for signs of respiratory distress. Administer nitroglycerin sublingually and asses the patients response (repeat up to three doses). Administer oxygen therapy if the patients respiratory rate is increased or if the oxygen saturation level is decreased. If the pain is signicant and continues after these interventions, the patient is further evaluated for acute MI and may be transferred to a higher acuity nursing unit.

Reducing Anxiety Explore implications that the diagnosis has for patient. Provide essential information about the illness and methods of preventing progression. Explain importance of following prescribed directives for the ambulatory patient at home. Explore various stress reduction methods with patient (eg, music therapy).

Preventing Pain

Review the assessment ndings, identify the level of activity that causes the patients pain or prodromal symptoms, and plan the patients activities accordingly. If the patient has pain frequently or with minimal activity, alternate the patients activities with re st periods. Balancing activity and rest is an important aspect of the educational plan for the patient and family.

Teaching Patients Self Care The teaching program for the patient with angina is designed so that the patient and family understand the illness, identify the symptoms of myocardial ischemia, state the actions to take when symptoms develop, and discuss methods to prevent chest pain and the advancement of CAD. The goals of education are to reduce the frequency and severity of anginal attacks, to delay the progress of the underlying disease if possible, and to prevent complications. Collaborate on a selfcare program with patient, family, or friends. Plan activities to minimize angina episodes.

Teach patient that any pain unrelieved within 15 minutes by the usual methods, including nitroglycerin, should be treated at the closest emergency center.

Evaluation for Angina Pectoris

Expected Patient Outcomes Reports that pain is relieved promptly Reports decreased anxiety Understands ways to avoid complications and demonstrates freedom from complications Complies with selfcare program