Angina Pectoris Desease - Coursework Example

Angina Usually angina or angina pectoris is a recurring chest pain or uneasiness caused by the decreased oxygenated blood supply to the heart muscle.Normally this decreased blood flow to the heart is caused due to the blocked coronary artery. In other words the heart muscle is not receiving enough oxygen and nutrients through the blocked blood vessel. Angina may not cause a heart attack or permanent damage to the heart muscles, unless it endures for more than twenty minutes and is not relieved by adequate rest or medicine (Main Line Health, 2006). Angina is an indication of the heart condition, typically coronary artery disease (CAD). Coronary artery disease crop up when a plaque builds up on the interior walls of the coronary blood vessel. The plaque buildup causes the coronary arteries to become constricted and stiff obstructing the flow of oxygenated blood to the heart muscle. Angina may be felt like a pinching pain in the chest and the pain can also felt on shoulders, arms, neck, jaw, or back. There are basically three types of angina - stable angina unstable angina and variant angina. The stable angina occurs when the heart strains more than usual. This pain from stable angina disappears while relaxing or after taking the angina medicine such as nitroglycerin. Unstable angina is a very unsafe form and requires urgent treatment. This may be an indication of a heart attack that may occur soon. Unstable angina can happen with or without physical strain and it isnt relieved by rest or medicine. Variant angina is because of spasm in a coronary blood vessel which has a narrowing effect on artery, in turn stops or slows down the blood flow to the heart muscles. This type of angina can be treated by medicine. Lastly, there may be secondary UA occurs because of other reasons such as fever, hypotension, thyrotoxicosis, or anemia (Disease and Condition Index, 2007). Atherosclerotic coronary artery disease generally causes unstable angina/ Non-ST- segment elevation myocardial infarction, which is related to cardiac death. It is hard to distinguish clinically those patients with acute coronary syndrome and patients having similar indications that do not have coronary artery disease. The patients showing the signs and symptoms indicative of acute coronary syndrome must be observed with uninterrupted electro-cardio-graphic (ECG) monitoring. It is necessary to have facility in obtaining a 12-lead ECG and defibrillation if required. The other helpful clinical information comprises cardiac markers which detect myocardial necrosis and prognosis. Cardiac markers will be positive if there has been myocardial necrosis and is helpful in the diagnosis. Patients who are noted to have an acute myocardial infraction must get instant reperfusion treatment. From the first examination there are mainly four possible diagnoses: ACS, non-ACS cardiac condition, non-cardiac condition with some other specific disease, or a non-cardiac condition which is not diagnosed. (Braunwald, E. et al 2002) Preliminary assessment and management of patients assumed of having ACS must be treated fast. Patients those who are having symptoms of ACS, should be referred to a facility with the capacity to carry out 12-lead ECG and the health care providers must be conversant with the assessment of ACS. Patients with complaint of ACS, who have chest uneasiness for more than 20 minutes, must be taken to an Emergency Department (ED) without delay. (Braunwald, E. et al 2002) In order to decide an accurate diagnosis of ACS and suitable interventions patients must go through early risk stratification. The patients with high risk for ACS are those patients with chest pain or left arm pain, known history of CAD or MI, hypotension, diaphoresis, pulmonary edema, ST-segment deviation and so on. (Braunwald, E. et al 2002) Preliminary assessment of patients supposed to have ACS should comprise differential diagnoses that explain the symptoms. The patients suspected of having UA/NSTEMI are categorized as those patients with earlier known CAD and those patients with new ischemic signs and indications. There are few aspects required to decide the probability of CAD ischemia: nature of the angina, history of CAD, gender, age, and the number of risk factors for CAD. (Braunwald, E. et al 2002) Even though heart disease remains to be the primary cause of death for men and women in the United States, there seems to be a variation in the type of ACS they experience. Women are more prone to STEMI, where as men more than women will be diagnosed with NSTEMI. (Hochman, J.S et al 1999) Women with STEMI be inclined to have a worse result than men with STEMI. Women have better results with UA and outcomes are quite comparable for men and women with NSTEMI (Hochman, J.S. et al 1997), ( Scirica, B.M., et al 1999). The patients who are hemodynamically stable also should be under uninterrupted ECG monitoring and careful observation. Patients hemodynamically unstable should be monitored in a coronary care unit until they are free of major complications. The objective of care is to ease ischemia and avoid grave adverse outcomes and difficulties. Pharmacological agents used are combination of treatments and interventions are selected based on recurrence of symptoms and risk stratification. The following are recommendations for anti-ischemic treatment. 1) Bed rest is insisted upon while ischemia is ongoing, as ischemia is resolved patients can be allowed to sit in a chair or use a bedside commode. 2) Nitrates are administered to dilate coronary arteries and this in turn decreases myocardial preload and oxygen consumption. Nitroglycerin (NTG) also supports collateral flow and redistributes blood flow to the ischemic regions. Nitrates should be initiated in the ED sublingually. Nitrates should not be used within 24 hours of sildenafil (Viagra) because it can cause intense hypotension, MI and even death (Cheitlin, M.D., et al 1999) 3) Supplemental oxygen should be given if arterial oxygen saturation decreases to less than 90%. 4) Morphine can help to relieve pain if it is not relieved by NTG and reduces myocardial oxygen demand. Morphine also causes vasodilatation and mild reduction in heart rate (Braunwald, E. et al 2002). 5) Beta adrenergic blockers reduce the cardiac strain and myocardial oxygen demand. These medicines reduce myocardial contractility, sinus node rate and AV node transmission. They also slow down catecholamine reactions at the beta adrenergic receptor in the myocardium. Beta blockers reduce the risk of AMI, mortality, and ventricular remodeling. 6) Calcium antagonists for example, verapamil and diltiazem can be used to manage sustained ischemia in patients not responding to beta blockers and nitrates or to manage hypertension in UA patients. 7) ACE inhibitors avoid the change of angiotenson I to angiotenson II, a potent vasoconstrictor. ACE inhibitors can be given to all patients with impaired functioning of left ventricular and can also be used to ease angina in high risk CAD patients. On discharge from hospital patients should be educated in restarting activities to an optimal level and reducing current lifestyle risk factors for CAD. Discharge summary should comprise when the patient should meet their health care provider to follow-up. Higher risk patients should follow-up within 1 to 2 weeks. Patients that have no angina symptoms at follow-up should continue on long-term medical treatment for CAD (Braunwald, E. et al 2002). Patients and the patients family should be educated in detail regarding medication type, purpose, dose, frequency, and adverse effects. If the patients angina symptoms change from the patients usual pattern, the patient should be instructed to meet their health care provider for necessary testing or treatment. Patients should be given specific education on smoking cessation, maintenance of healthy weight, daily exercise, and healthy eating habit. The medicines that used to control ischemia in the hospital should be continued also at home for those patients that do not have revascularization, failed revascularization, or patients that have recurring symptoms after revascularization. Treatment can be directed by the mnemonic ABCDE: aspirin and antianginals, beta blockers, cholesterol and cigarettes, diet and diabetes, and education and exercise (Gibbons, R.J., et al 1999). CAD patients should be given sublingual or NTG spray along with directions on its use. Patients should be educated on signs and symptoms of AMI and precautions they should follow and also how to get help (Braunwald, E. et al 2002). Patients should receive medication to keep the LDL cholesterol within the permissible limit. They should also get the medicines for improving high-density lipoprotein (HDL) if it is less than 40 mg/dL. Hypertension should be maintained at 130/85 mm Hg. An angina pattern is the way the angina pain is experienced by an individual. This pattern may vary from person to person. Even though all angina is not a symptom of heart attack, if one experience persistent chest pain or a feeling of pressure or tightness in chest especially if its along with other signs and symptoms, such as shortness of breath, sweating, nausea, and dizziness one has to look for emergency medical care without delay. In this essay the various precautions; the specific nursing care, assessment and observations required, pharmacological agents used, nursing interventions to prevent complications, patient education, and discharge planning to be followed in case of angina is explained briefly. References Braunwald, E. et al (2002) Guidelines for Diagnosis and Management of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction The Internet Journal of Advanced Nursing Practice ISSN: 1523-6560 [Online] Available from [04 January 2008] Cheitlin, M.D., et al (1999) Use of sildenafil (viagra) in patients with cardiovascular disease. Am J Cardiol; 33: 273-282. Diseases and Condition Index, (November, 2007) What Is Angina? U.S. Department of Health & Human Services, National Institute of Health, National Heart Lung and Blood Institute. [Online] Available from [04 January 2008] Gibbons, R.J., et al (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). J Am Coll Cardiol; 33(7):2092-2197. Hochman, J.S et al (1999) Sex, Clinical presentation, and outcome in patients with acute coronary syndromes. NEJM; 341 (4): 226-232. Hochman, J.S. et al (1997) Outcome and profile of women and men presenting with acute coronary syndromes: A report from IMI IIIB. J Am Coll Cardiol; 30 (1): 141-148. Main Line Health, (2006) Heart Disease, Heart Health and Rehabilitation [Online] Available from [04 January 2008] Scirica, B.M., et al (1999) Differences between men and women in the management of unstable angina pectoris (the guanrantee registry). Am J Cardiol; 85 (10): 1145-1150. Read More