Angina Pectoris PDF

1/16/24, 10:22 PM Realizeit for Student Introduction 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 myocar...

1/16/24, 10:22 PM Realizeit for Student Introduction 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. In other words, the need for oxygen exceeds the supply. Angina Pectoris Pathophysiology Angina is usually caused by atherosclerotic disease and most often is associated with a significant obstruction of at least one major coronary artery. Normally, the myocardium extracts a large amount of oxygen from the coronary circulation to meet its continuous demands. When demand increases, flow through the coronary arteries needs to be increased. When there is a blockage in a coronary artery, flow cannot be increased and ischemia results. Several factors are associated with typical anginal pain: •Physical exertion, which precipitates an attack by increasing myocardial oxygen demand •Exposure to cold, which causes vasoconstriction and elevated blood pressure, with increased oxygen demand •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 Unstable angina is not closely associated with these listed factors. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 1/4 1/16/24, 10:22 PM Realizeit for Student Clinical Manifestations Ischemia of the heart muscle may produce pain or other symptoms, varying from mild indigestion to a choking or heavy sensation in the upper chest. The severity ranges from discomfort to agonizing pain. The pain may be accompanied by severe apprehension and a feeling of impending death. It 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 or strangling sensation that has a viselike, insistent quality. The patient with diabetes may not have severe pain with angina because autonomic neuropathy can blunt nociceptor transmission, dulling the perception of pain (Norris, 2019). 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. An important characteristic of angina is that it subsides with rest or administration of nitroglycerin. In many patients, anginal symptoms follow a stable, predictable pattern. Unstable angina is characterized by attacks that increase in frequency and severity and are not relieved by rest and administration of nitroglycerin. Patients with unstable angina require medical intervention. Gerontologic Considerations The older adult with angina may not exhibit a typical pain profile because of the diminished pain transmission that can occur with aging. Often the presenting symptom https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 2/4 1/16/24, 10:22 PM Realizeit for Student in older adults is dyspnea. Sometimes there are no symptoms (“silent” CAD), making recognition and diagnosis a clinical challenge. Older patients should be encouraged to recognize their chest pain–like symptom (e.g., weakness) as an indication that they should rest or take prescribed medications. Pharmacologic stress testing and cardiac catheterization may be used to diagnose CAD in older patients. Medications used to manage angina are given cautiously in older adults because they are associated with an increased risk of adverse reactions (Frandsen & Pennington, 2021). Invasive procedures (e.g., PCI) that were once considered too risky in older adults are now being performed successfully, and many older adults benefit from symptom relief and longer survival (Lattuca, Kerneis, & Zeitouni, 2019). Assessment and Diagnostic Findings The diagnosis of angina begins with the patient’s history related to the clinical manifestations of ischemia. A 12-lead electrocardiogram (ECG) may show changes indicative of ischemia, such as T-wave inversion, ST-segment elevation, or the development of an abnormal Q wave (Norris, 2019). Laboratory studies are performed; these generally include cardiac biomarker testing to rule out ACS (see later discussion). The patient may undergo an exercise or pharmacologic stress test in which the heart is monitored continuously by an ECG, echocardiogram, or both. The patient may also be referred for a nuclear scan or invasive procedure (e.g., cardiac catheterization, coronary angiography). Medical Management 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 (e.g., percutaneous transluminal coronary angioplasty [PTCA] and intracoronary stents) and CABG. 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 and the color of skin and mucous membranes. Blood oxygen saturation is monitored by pulse oximetry; the normal oxygen saturation (SpO2) level is >95% on room air (Urden et al., 2019). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 3/4 1/16/24, 10:22 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbfuwFjUs0mdxkPeVey4KH2F7i%2fH0LC0NH7inQLoUzK%2fM… 4/4