Angina Pectoris

Dr. Hanan Tork

Objectives
1. 2. 3. 4. 5. 6. 7. 8. Define Angina Pectoris List Angina Risk Factors Enumerate the classification of angina Manifestations of Angina Pectoris Identify the diagnosis of Angina Explain Stable Angina & its Management Discus Unstable Angina & its Management Explain Variant Angina & its Management

Myocardial Blood Flow Myocardial O2 Demands

Transient Myocardial ischemia

Severe Chest pain

Angina Pectoris
3

Angina Risk Factors

Obesity Physical inactivity Smoking Hypertension Stress High blood cholesterol

Can regulate

Age Gender Family history

Inherent

Classification of angina

1. Stable Angina.

2. Unstable Angina.
3. Variant Angina.
5

Classification of angina
Stable/ Exertional angina Atherosclerotic, Classic due to obstruction of coronaries by atheroma. 2. Unstable angina. Due to spasm and partial obstruction of coronaries. 3. Variant, Vasospastic angina due to Spasm of coronaries.
1.

Manifestations of Angina Pectoris

An uncomfortable pressure, fullness, squeezing, or

pain in the center of the chest

Tightness, burning, or a heavy weight . It may spread to shoulders, neck, or arms . Pain may located in the upper abdomen, back, or jaw . Intensity of pain may ranged from mild to severe .

Other symptoms may occur with an angina attack

Shortness of breath Fainting (is a temporary loss of consciousness) Sweating or cold, sweaty skin Nausea, pallor Rapid or irregular heart beat

I. Stable Angina
The commonest cause is ADVANCED ATHEROSCELEROSIS
Retrosternal pain
Radiating to left arm & shoulder Lasting less than 15 min.

I. Stable Angina
Predisposing factors Relieving factors

Emotion

Exertion

Rest

Heavy meals

Exposure to cold weather

BACK

sublingual nitroglycerin
10
MAIN EXIT INDEX NEXT

Stable Angina
Anginal pain is often associated with Depression of ST segment Exercise ECG showing typical severe down sloping ST segment

Standing

1 min.

Note: In between attacks : ECG is entirely NORMAL

3 min.

7 min.

11
BACK MAIN EXIT INDEX NEXT

Diagnosis of Angina
ECG Exercise tolerance tests Stress test A chest x ray can reveal signs of heart failure Repeat cardiac catheterization to see if the dilated

artery is still open and/or a surgical bypass graft is still open or closed

Management of Stable Angina

1- General measures.

2- Drug Treatment. 3- Coronary artery revascularization.

13

1. General measures
Treat Hypertension , Hypercholesterolemia and Diabetes
Stop smoking Reduce weight

AVOID Severe exertion

Heavy meal

Emotions

Cold Weather
14

2. Drug Treatment
A. For an acute attack
B. C.

D.

For immediate pre-exertional prophylaxis For long-term prophylaxis Antiplatelet therapy.

15

A. Treatment of an acute attack of angina

Sublingual nitroglycerin (0.5 mg ) or isosorbide dinitrate (5 mg ) or
Oral spray nitroglycerin (0.4 mg/metered dose), isosorbide dinitrate(1.25 mg/metered dose) Relief within 1-3 min.

Persistence of pain Repeat nitroglycerin at 5 min. interval (3 tab. max.)

Relief
HOSPITALIZATION not relieved

Infarction

16

B. Immediate pre-exertional prophylaxis

Sublingual nitroglycerin (0.5 mg) or isorbide dinitrate (5 mg) should be taken 5 min. (before effort).

C. For Long term prophylaxis: D. Antiplatelet therapy:

Long acting nitrates, Ca++ channel blockers, b-blockers.

Aspirin in small dose (75-150 mg daily orally)

3. Coronary artery revascularization

Coronary artery bypass grafting (CABG) Percutaneous Transluminal coronary Angioplasty (PTCA)
For patients not responding to adequate medical therapy

18

II. Unstable Angina

Increased frequency, severity or duration of pain in a

patient of Stable Angina

Myocardial infarction may occur in 10-20% of patients

N.B. Pain occurs with less exertion or at rest

19

Atherothrombosis: a Generalized and Progressive process

Normal Fatty streak Fibrous Athero-sclerotic plaque plaque

Plaque rupture/ fissure & thrombosis

Unstable angina }ACS

MI
Ischemic stroke/TIA

Critical leg ischemia

Clinically silent

Stable angina Intermittent claudication

Increasing age

Cardiovascular death

ACS, acute coronary syndrome; TIA, transient ischemic attack

The underlying cause

Fissuring of atherosclerotic plaques Platelet aggregation Thrombosis Coronary artery spasm

Atherosclerotic changes
21

Management of Unstable Angina

Nitrate + b-blocker + Aspirin (low dose) and/or Heparin or Thrombolytic (Stryptokinase) to minimize risk of infarction
22

Antianginal drugs
Organic nitrates.
- adrenoceptor blockers. Calcium channel blockers.
23

Organic Nitrates

NITRATES Relaxation of smooth muscles Dilatation Veins

Arteries
24

Effect of Nitrates
On Stable Angina:
1Venodilatation Preload Arteriolar dilatation Afterload

Myocardial Oxygen demand

2- Redistribution of coronary flow towards subendocardium

On Variant Angina
Relax smooth muscles of the epicardial coronaries relieve coronary artery spasm

On Unstable Angina
Dilatation of epicardial coronary arteries + reducing O2 demands
26

Preparations
For acute attacks Nitroglycerin (sublingual, buccal spray) Isosorbide dinitrate(sublingual, buccal spray)
27

Short acting

anginal prophylaxis Nitroglycerin oral (6.25-12mg) 2-4 times/day 2% ointment (1-1.5 inch/4hrs) patches (1 patch=25mg)/day Isosorbide dinitrate (oral) 10-40mg t.d.s.

Long acting

Adverse Reactions
1- Postural Hypotension & Syncope

2- Tachycardia

4- Facial Flushing

3- Skin Rash

5- Throbbing Headache
28

Nitrates - Overdose
Palpitations Dizziness Blurred vision Headache

Flushing followed by pallor

Methaemoglobinaemia

- adrenoceptor blockers
b-blockers are effective in STABLE & UNSTABLE angina In contrast they are not useful for vasospastic angina (Variant) {Prinzmetal}& may worsen

the condition.

III. Variant Angina (Prinzmetal)

Chest pain at rest due to coronary artery spasm

ECG changes

The baseline ECG

With chest pain , marked ST segment elevation

Return of the ST segment to the baseline after nitroglycerin administration

31

Acute elevation of ST segment

Management of Variant Angina

Nitrates and/or Ca++ Channel blockers For the acute attack & prophylaxis

32

Nursing management
I. Assessment
Assess& record Chest pain, characteristic: its location, frequency, duration & if radiate to the shoulders, arms, neck, jaw, or upper abdomen.

II. Nursing diagnosis

Acute pain related to decreased myocardial blood flow

III. Planning
After 8 hours of nursing intervention the patient will: Remain free from pain Maintain stable vital signs. Maintain relaxed body posture.

IV. Nursing Intervention

Assess for vital signs and symptoms of pain such as

facial grimacing, rubbing of neck or jaw

Administer sublingual nitroglycerin as ordered. Instruct the patient to notify a nurse immediately

when experiencing pain

Keep pt. in bed rest in a semi- to high Fowlers

position.

Cont.
Teach pt. some strategies to relive pain as:

distraction, relaxation, continuous stimulation

Stay with the patient during chest pain episodes. Obtain a 12-lead ECG immediately during acute

chest pain.
Administer oxygen as ordered.

Use a pain rating scale to assess the patients

perception of the pains severity.

V. Evaluation
After 8 hours of nursing intervention the patient

was free from pain, maintains stable vital signs, and relaxed body posture.
Pain rating scale revealed that pt. have no pain.