Glossary of Medsurg: Cardiovascular: Angina Pectoris

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Pathophysiology of Angina pectoris
The imbalance between myocardial blood supply and demand causes temporary and reversible myocardial ischemia.
Reduced O2 -> anaerobic metabolism -> Lactic acid build up -> cell membrane permeability increases -> cell releases histamine, kinins, and enzyme -> stimulate terminal nerve fibers in cardiac muscle -> causes pain in upper body
How long does it takes until ischemic cardiac cells becomes necrosis cells (irreversible)?
30 minutes
Name the 4 types of agina
1. Stable angina
2. Prinzmetal's (Variant) angina
3. Unstable angina
4. Silent myocardial ischemia (asymtomatic ischemia)
The most common and predictable form of angina.
Stable angina
Type of angina that occurs with predictable amount of activity or stress.
Stable angina
Type of angina that is a common manifestation of CHD.
Stable angina
Type of angina that usually occurs when the work of the heart is increased by physical exertion, exposure to cold, or by stress.
Stable angina
Type of angina that is releved by rest and nitrate.
Stable angina
The type of angina that is atypical and occurs unpredictably (unrelated to activity).
Prinzmetal's (Variant) angina
The type of angina that often occurs at night.
Prinzmetal's (Variant) angina
The type of angina that caused by coronary artery spasm with or without an atherosclerotic lesion.
Prinzmetal's (Variant) angina
Prinzmetal's (Variant) angina may result from (3)
1. hyperactive sympathetic nervous system responses
2. altered calcium flow in smooth muscle
3. reduced prostagladins to promote vasodilation.
The type of angina that occurs with increasing frequency, severity, and duration.
Unstable angina
The type of angina that have unpredictable pain and occurs with decreasing level of activity or stress and may occur at rest.
Unstable angina
The type of angina that puts the client at risk for MI.
Unstable angina
The type of ischemia that is thoght to be common in people with CHD.
Silent myocardial ischemia
(asymtomatic ischemia)
The type of ischemia that occurs with either activity or with mental stress.
Silent myocardial ischemia
(asymtomatic ischemia)
How does mental stress contributes to Silent myocardial ischemia
(asymtomatic ischemia)?
Mental stress -> increases HR and BP -> increasing myocardial oxygen demand.
What is the cardinal manifestation of angina?
Chest pain
Angina pain is typically precipitated by (5)
1. physical activity
2. strong emotion
3. stress
4. eating heavy meal
5. cold exposure
Describe locations of angina pain (3)
1. tight, squeezing, heavy pressure, or constricting sensation
2. begins beneath sternum and may radiate to jaw, neck, or arm.
3. maybe felt in jaw, epigastric region, or back
Describe the duration of anginal pain
usually lasts less than 15 minutes
What are the associated manifestation of angina? (5)
1. Dyspnea
2. Pallor
3. Tachycardia
4. Anxiety
5. Fear
Relieving factors for anginal pain (3)
1. rest
2. position change
3. nitroglycerine
List the diagnostic tests for angina pectoris (5)
1. electrocardiography
2. stress electrocardiography
3. radionuclide testing
4. echocardiography
5. coronary angiography
How does the ECG appeared during the period of ischemia? (2)
1. ST segement is depressed or downward slopping
2. T wave may flatten or invert
What are the purposes of the radionuclide testing?
to evaluate myocardial perfusion and left vetricular function.
Decribe the process of the radionuclide testing?
A very small amount of radioisotope (Thallium 201) is injected intraveneously, and the heart is scanned with radiation detector. The ischemic or infarcted cells of the myocardium do not take up the radioisotope normally, appearing as a "cold spot" on the scan.
How does radionuclide testing evaluate left ventricular function?
the ejection fraction (portion of blood ejected from the left ventricle during systole) normally increases during exercise, may actually decrease in CHD and stress-induced ischemia.
How is radionuclide testing done on cleint who are physically unable to exercise or to detect subclinical myocardial ischemia?
In combination with vasodilator is injected to induced the same ischemic changes that occurs with exercise in the disease heart.
Decribe myocardial steal syndrome during radionuclide testing.
Coronary arteries unaffected by atherosclerosis dilate in response to the vasodilator drug, increasing blood flow to the already well-perfused tissue. This reduces flow to the ischemic muscle called myocardial steal syndrome.
How does echocardiography work?
High-frequency sound waves emitted from a transducer are reflected off of heart structures back to the transducer as echoes. These echoes are displayed on a screen revealing heart structure.
This machine uses ultrasound to identify abnormal blood flow patterns as well as cardiac structures.
Transesophageal echocardiography (TEF)
What is the standard diagnostic test used for evaluating the coronary arteries?
Coronary angiography
How does Coronary angiography works?
Guided by fluoroscopy, a catheter introduced into the femoral or brachial artery is treaded into the coronary artery. Dye is injected into each coronary opening, allowing visualization of the main coronary branches and any abnormalities such as stenosis or obstruction.
What drug maybe injected into Pt. who is receiving angiogram and why?
Ergonovine, to reduce coronary artery spasm and diagnose Prinzmetal's angina.
Preoperative teaching:
Coronary angiography (6)
1. You will be awake
2. It takes 1 to 2 hours
3. You may feel warm when the dye is injected
4. You may taste metalic in you mouth when the dye is injected.
5. You may experience "rapid pulse" or "skipped heart beat", this is normal
6. Void prior to going to cardiac cath lab.
Does Pt. continues to receive regullarly ordered cardiac medications prior to receiving Coronary angiography?
Yes, unless contraindicated.
Preoperative assessment:
Coronary angiography (5)
1. Pt's and family's knowlwdge and understanding of the procedure.
2. Hypersensitivity to iodine, radiologic contrast media, or seafood.
3. Baseline vital signs, height, and weight.
4. Mark the location of peripheral pulses
5. Document pulse equality and amplitude.
Postoperative assessment:
Coronary angiography (4)
1. vital signs
2. cath site for bleeding and hematoma
3. peripheral pulses
4. neurovascular status
How often should postoperative assessment of Pt. who underwent coronary angiography ?
every 15 minutes for the first hour, every 30 minutes for the nest hour, then hourly for 4 hours or until discharge.
Postoperative Pt. teaching:
Coronary angiography
1. Maintain bed rest as ordered
2. Elevate head of the bed by 30 degree
3. Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site.
4. Avoid flexing or hyperextending the affected extremity for 12 to 24 hours.
5. Liberal fluid intake
6. Provide instruction on dressing changes
7. Followup appointment
8. Information on potential complications.
Postoperative Pt. teaching Coronary angiography: what are signs that should be reported promptly?
1. Deminished peripheral pulses
2. Formation of new hematoma or enlargement of and existing one
3. Severe pain at the insertion site or at the affected extremity
4. Chest pain
5. Dyspnea
What is the goal of drug treatment for angina pectoris?
To reduce oxygen demand and increase oxygen supply to the myocardium.
What are the three main classes of drugs used to treat angina?
1. Nitrate
2. Beta Blockers
3. Calcium channel blockers
Nitroglycerin (8)
1. Nitropaste
2. Nitro-Dur
3. Nitro-Bid
4. Nitrol
5. Transderm-Nitro
6. Nitrogard
7. Nitrodisc
8. Tridil
Class: Organic Nitrates
Isosorbide dinitrate
Class: Organic Nitrates
Isosorbide mononitrate
Class: Organic Nitrates
Amyl Nitrate
Class: Organic Nitrates
What are indications of Nitrates? (2)
1. Treat acute angina attacks
2. To prevent angina
What is the drug of choice to treat acute angina? Why?
Sublingual nitroglycerine; It acts within 1 to 2 minutes.
Rapid-acting nitroglycerine is available in what forms?
1. Sublingual nitroglycerine
2. Buccal Spray
3. Metered system
How does fast-acting nitroglycerin works? (2)
1. Decreasing myocardial work and oxygen demand through venous and arterial dilation.
2. Improve myocardial oxygen supply by dilating collateral blood vessels and reducing stenosis.
What is the purpose of Longer-acting nitroglycerin?
To prevent attacks of angina, not to treat an acute attack.
What is the primary problem with long-term nitrate?
The development of tolerance.
How is development of tolerance to long-term nitrate prevented?
By setting a dosing schedule that allows a nitrate-free period of at least 8 to 10 hours daily. This is usually schedule at night.
What are the common side effects of Nitrate?
1. Headache
2. Nausea
3. Dizziness
4. Hypotension
How does coronary vasodilation relieves anginal pain?
Vasodilation increases blood flow to the heart and in turns increases oxygen supply.
How does venous dilation relieves anginal pain? (4)
Venous dilation allows
1. Peripheral blood pooling
2. Reducing venous return
3. Reducing preload
4. Reducing cardiac work
How does arterial dilation relieves anginal pain? (3)
1. Reduces vascular resistance
2. Reduces preload
3. Reduces cardiac work
Nitrate: Nursing responsibilities: IV Nitroglycerin (3)
1. Dilute before infusing
2. Use only glass bottle for mixing
3. Use non-PVC infusion tubing
Nitrate: Nursing responsibilities: Nitroglycerine paste (3)
1. Wear gloves when applying paste
2. Measure does carefully
3. Spread evenly in a 2-by-3 inch area
Client teaching: What form of nitrate can be used to treat acute angina?
1. Sublingual
2. Buccal
3. Spray
Name the 4 types of revascularization procedures
1. Percutaneous coronary revascularization (PCR)
2. Coronary artery bypass grafting
3. Minimally invasive coronary artery surgery
4. Transmyocardial laser revascularization
Percutaneous Coronary Revascularization (PCR) is used to treat client with:
1. Moderately severe, chronic stable angina unrelieved by medical therapy
2. Mild angina but objective evidence of coronary ischemia
3. Unstable angina
4. Acute myocardial infarction
PCR procedures
1. A catheter is introduce into the arterial circulation is guided into the opening of the narrowed coronary artery.
2. A flexible guidewire is then used to thread an angioplasty ballon, arterial stent, or other therapeutic device into the narrowed segment of the artery.
What kind of anesthesia is use during PCR procedures?
Local anesthesia
What is Percutaneous transluminal coronary angioplasty (PTCA) is primary use in combination with? Why?
Stent placement or atherectomy; PTCA has a high risk of abrupt vessel closure and restenosis.
What are the complications of PCR procedures (8)?
1. Hematoma at the catheter reinsertion site
2. Embolism
3. Hypersensitivity to contrast dye
4. Dysrhythmias
5. Bleeding
6. Vessel perforation
7. Restenosis
8. Reocclusion of the treated vessel
PCR: Preoperative teaching.
Possible sensation:
1. Flushing or warm sensations as contrast dye is injected
2. Metallic taste in the mouth as contrast dye is injected
3. Feeling of pressure or chest pain during the balloon inflation
PCR: Postoperative assessment.
1. Head to Toe assessment
2. Note any complaint of chest pain
3. Note evidence of decrease cardiac output or MI
PCR: Post operative monitoring
1. Vital signs and cardiac monitoring continuously
2. Signs of ischemia (if develop, obtain a 12-lead EKG and notify physician)
3. Chest pain
4. Distal pulses, color, movement, sensation, and temperature of the effected leg.
5. I&O
6. Serum electrolytes, BUN, Creatinine, CBC, PTT, and cardiac enzyme
How often should the nurse monitor distal pulses, color, movement, sensation, and temperature of the effected leg of a patient who underwent PCR?
Every 15 minutes for the first hour, every 30 minutes for the next hour, every 8 hours for next 8 hours, then every 4 hours.
PCR: During sheath removal, what should the nurse monitor for?
1. Bradycardia
2. Lightheadedness
3. Hypotension
4. Diaphoresis
5. Loss of consciousness
PCR: During sheath removal the nurse must be sure to have what at the bed site and why?
Atropine, because vasovagal reaction. Atropine decreases vagal tone and increases heart rate.
What is coronary artery bypass grafting (CABG)
A patent blood vessel from another part of the body is grafted to the affected coronary artery distal to the lesion. The new vessel bypasses the obstruction.
What vessels are the most commonly used in CABG?
1. Internal mammary arteries.
2. Greater or lesser saphenous veins from the legs
3. Basilic veins
CABG is recommended for what types of patient?
1. Multiple vessel disease
2. Impaired left ventricular function
3. Diabetes
4. Significant obstruction of the left main coronary artery
CABG: Preoperative laboratory and diagnostic tests
1. CBC
2. Coagulation profile
3. Urinalysis
4. Chest X-Ray
5. Coronary angiogram
6. Type and Cross match
Patient underwent CABG usually leave the operating room with what in place?
1. Systemic arterial catheter
2. Pulmonary artery catheter
What are the early complications from heart surgery?
1. Hypotension or hypertension
2. Hemorrhage
3. Dysrhythmias
4. Decreased cardiac output
5. Fluid and electrolyte imbalance
6. Pericardial bleeding
7. Fever or hypothermia
8. Poor gas exchange
9. Gastric distension
10. Changes in level of consciousness
What are the sings of cardiac tamponade?
1. Increase heart rate
2. Decrease BP
3. Decrease urine output
4. Increase central venous pressure
5. Sudden increase in chest tube output
6. Muffle/distance heart sounds
7. Diminish distal pulses
What are the main goals of nursing care for patient with angina?
1. Reduce myocardial oxygen demand
2. Improve oxygen supply
Name two nursing diagnosis for patient with angina
1. Ineffective tissue perfusion: Pain
2. Risk for ineffective therapeutic regimen management
What are the nursing interventions for ineffective tissue perfusion: pain, due to angina?
1. Have nitroglycerin tablets at bed side.
2. Start oxygen at 4 to 6 L/min
3. Teach about long-acting and short-acting medications.
4. Instruct Pt. to take sublingual nitroglycerin prior to activities that precipitate angina.
5. Encourage Pt. to implement and maintain an exercise program.
6. Refer to a smoking cessation program
What are the nursing interventions for risk for ineffective therapeutic regimen management?
1. Assess knowledge and understanding of angina.
2. Teach about angina as needed.
3. Provide written and oral instructions about prescribed medications and their use.
4. Stress the importance of chest pains seriously while maintaining a positive attitude.
5. Refer to a cardiac rehabilitation program or other organized activities and support group.
What teaching should be included in home care for patient with angina?
1. The relationship between the pain and reduce blood flow to the heart muscle.
2. Use and effects of prescribed medications.
3. Do not stop medications abruptly.
4. Nitroglycerine use for acute angina.
5. The importance of calling 911 or going to the ER immediately for unrelieved chest pain.
6. Appropriate storage of notroglycerine
Teaching: Nitroglycerine use for acute angina
1. Always carry several tablets (not entire supply)
2. Prophylactic use before activities that often cause chest pain
3. Take tablet at first indication of pain rather than waiting to see of the pain develops
4. Seek immediate medical assistance if three nitroglycerine tablets over 15 to 20 minutes do not relieve the pain
5. Storage in cool, dry, dark place.
6. No more than 6 month supply should be kept on hand.
Teaching for Pt. undergone cardiac surgery should include:
1. Respiratory care, activity, and pain management
2. The importance of actively participating in rehabilitation
3. Manifestation of infection or other potential complications and their management.

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