1. Prepared by Miss Fatima Hirzallah

2.  Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest.  The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress

3.  Angina is usually caused by atherosclerotic disease. Almost invariably, angina is associated with a significant obstruction of a major coronary artery.  Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When there is an increase in demand, flow through the coronary arteries needs to be increased. When there is blockage in a coronary artery, flow cannot be increased, and ischemia results.

4.  Physical exertion, which can precipitate an attack by increasing myocardial oxygen demand  Exposure to cold, which can cause vasoconstriction and elevated blood pressure, with increased oxygen demand

5.  Eating a heavy meal, which increases the blood flow to the mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle. In a severely compromised heart, shunting of blood for digestion can be sufficient to induce anginal pain.  Stress or any emotion-provoking situation, causing the release of catecholamines, which increases blood pressure, heart rate, and myocardial workload

6.  Nonmodifiable Risk Factors for CAD 1. Family history of coronary heart disease 2. Increasing age 3. Gender (heart disease occurs three times more often in men than in women) 4. Race (higher incidence of heart disease in African Americans than in Caucasians) 6

7.  Modifiable Risk Factors for CAD 1. High blood cholesterol level 2. Cigarette smoking, tobacco use 3. Hypertension 4. Diabetes mellitus 5. Lack of estrogen in women 6. Obesity 7

8.  Stable angina : predictable and consistent pain that occurs on exertion and is relieved by rest  Unstable angina (also called preinfarction angina symptoms occur more frequently and last longer than stable angina. The threshold for pain is lower, and pain may occur at rest.  Intractable or refractory angina: severe incapacitating chest pain  Silent ischemia : objective evidence of ischemia (such as ECG changes with a stress test), but patient reports no symptoms

9.  The pain is often felt deep in the chest behind the sternum (retrosternal area).  Typically, the pain or discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm. The patient often feels tightness or a heavy choking.

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11.  A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis  dizziness or lightheadedness  nausea and vomiting, may accompany the pain. Anxiety may occur with angina.  An important characteristic of angina is that it subsides with rest or nitroglycerin.

12.  history related to the clinical manifestations of ischemia.  A 12-lead electrocardiogram (ECG)  blood laboratory values

13.  Enzymes – CK, CK-MB, LDH  Other important cardiac biomarkers that are assessed include the myoglobin and troponin T or I. Myoglobin

14.  The patient may undergo an exercise or pharmacologic stress test in which the heart is monitored by ECG, echocardiogram, or both. The patient may also be referred for invasive procedure (eg, cardiac catheterization, coronary artery angiography).

15.  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 CABG.

16.  Aspirin  Nitroglycerin  Oxygen Administration  Morphine

17.  Nitroglycerin  Nitrates remain the mainstay for treatment of angina pectoris. A vasoactive agent, nitroglycerin is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain.

18.  Nitroglycerin dilates primarily the veins and, in higher doses, also the arteries. Dilation of the veins causes venous pooling of blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload) is reduced.

19.  Oxygen Administration  Oxygen therapy is usually initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and to decrease pain.  The therapeutic effectiveness of oxygen is determined by observing the rate and rhythm of respirations.

20.  Antiplatelet and Anticoagulant Medications  Antiplatelet medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow

21.  Aspirin  Aspirin prevents platelet activation and reduces the incidence of MI and death in patients with CAD. A 160- to 325-mg dose of aspirin should be given to the patient with angina as soon as the diagnosis is made (eg, in the emergency department or physician's office) and then continued with 81 to 325 mg daily.

22.  Clopidogrel and Ticlopidine  Clopidogrel (Plavix) or ticlopidine (Ticlid) is given to patients who are allergic to aspirin or given in addition to aspirin in patients at high risk for MI.

23.  Heparin  IV unfractionated heparin prevents the formation of new blood clots. Treating patients with unstable angina with heparin reduces the occurrence of MI.

24.  Beta-Adrenergic Blocking Agents  Beta-blockers such as metoprolol (Lopressor, Toprol) and atenolol  reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is a reduction in heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility (force of contraction) to balance the myocardial oxygen needs (demands) and the amount of oxygen available (supply).

25.  Calcium Channel Blocking Agents. (calcium ion antagonists) have different effects. Some decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction.  The calcium channel blockers most commonly used are amlodipine (Norvasc), verapamil (Calan, Isoptin, Verelan), and diltiazem (Cardizem, Dilacor, Tiazac). They may be used by patients who cannot take beta-blockers. 25

26.  Based on the assessment data, major nursing diagnoses may include:  Ineffective cardiac tissue perfusion secondary to CAD, as evidenced by chest pain or equivalent symptoms  Death anxiety  Deficient knowledge about the underlying disease and methods for avoiding complications  Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes