Part II - Coronary Vascular Disorders (narrated)

Angina Pectoris : 

Angina Pectoris

Angina Pectoris : 

Angina Pectoris Syndrome characterized by episodes of paroxysmal pain/pressure in the anterior chest. Most often r/t CAD. Physical exertion or emotional stress increases myocardial oxygen demand causing coronary vessels to supply insufficient blood flow to meet the oxygen demand.

Types of Angina : 

Types of Angina Refer to Chart 28-2, p. 762 Precipitating factors: Physical exertion (increased O2 demand) Exposure to cold (d/t vasoconstriction and increased BP, increases O2 demand)) Eating a heavy meal increases blood to mesenteric arteries, thereby decreasing blood available to perfuse heart Emotional stress, causes release of catecholamines (adrenal hormones), increasing BP, HR and myocardial workload. Difference with unstable angina (USA) is that is often occurs at rest.

Clinical Manifestations : 

Clinical Manifestations Described as mild indigestion, tightness, choking, or a heavy sensation. Often retrosternal, may radiate to neck, jaw, shoulders, back or arms (usually left). Anxiety accompanies the pain (feeling of impending death) Other symptoms: dyspnea/shortness of breath, dizziness, nausea, weakness, pallor, or diaphoresis. Typical angina subsides with rest or NTG. Unstable angina (USA) characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention! Diabetics may have no pain d/t neuropathy Elderly may have silent ischemia. Most often presenting symptom is SOB.

Assessment/Diagnostics : 

Assessment/Diagnostics Patient history r/t symptoms of ischemia CRP (c –reactive protein) and cardiac biomarkers to r/o ACS (acute coronary syndrome) Exercise (treadmill) or pharmacologic (Persantine cardiolyte) stress test. Echocardiogram Cardiac cath/coronary angiography ECG changes indicative of ischemia (T wave inversion)

Treatment : 

Treatment Goal: Decrease myocardial oxygen demand and increase oxygen supply Medications (see table 28-3, p. 764) Oxygen Reduce and control risk factors Reperfusion therapy via PCI (percutaneous coronary interventions) such as PTCA (percutaneous transluminal coronary angioplasty), stents, atherectomy or may use more invasive CABG (“cabbage” – coronary artery bypass graft)

Nitroglycerin : 

Nitroglycerin Reduces myocardial O2 consumption  decreasing ischemia  relieving pain. Caution: Hypotension. At higher doses significantly decreases CO and BP. Routes: SL (tab or spray): see chart 28-3, p. 764 Topical (patch or ointment): Should be removed at HS to prevent tolerance. Be certain not to get on fingers (causes HA and low BP). Ensure old patch removed prior to application of new one (document location of administration) IV: Continuous or intermittent. Titrate for symptom relief (avoiding hypotension). Held if SBP <90 mmHg.

Beta-Adrenergic Blockers B(-olol, -lol) (i.e. metoprolol, atenolol, labetolol, sotalol etc.) : 

Beta-Adrenergic Blockers B(-olol, -lol) (i.e. metoprolol, atenolol, labetolol, sotalol etc.) Reduce myocardial oxygen consumption by blocking sympathetic (“fight or flight”) stimulation Reduces HR, BP and conduction (longer times on the ECG), whereby decreases CP, d/t decreases ischemia Goal is a resting HR of 50-60 bpm. Nursing Considerations: Hold for hypotension, HR < 50 bpm, 2nd degree (type I or II) or 3rd degree (complete heart block). IV administration: Monitor BP, HR and ECG closely. Other SE: depression, fatigue, decreased libido, masks hypoglycemia Diabetics should monitor BG often and monitor for s/s of hypoglycemia. DO NOT STOP ABRUPTLY!! (wean off) Nonselective b-blockers cause bronchoconstruction, so contraindicated in pts w/ chronic lung disorders (i.e. COPD, asthma)

Ca++ Channel Blockersamlodipine (Norvasc), diltiazem (Cardizem) : 

Ca++ Channel Blockersamlodipine (Norvasc), diltiazem (Cardizem) Antagonize calcium ions, decreasing SA & AV node conduction; slowing HR & decreasing strength of contraction, decreasing workload of the Also, relaxes blood vessels; decreasing BP and increasing coronary artery perfusion. Nursing Considerations: Hold for bradycardia, heart block (2nd or 3rd degree), and caution with heart failure.

Antiplatelet Medicationsaspirin (ASA), clopidogrel (Plavix) : 

Antiplatelet Medicationsaspirin (ASA), clopidogrel (Plavix) Prevent platelet aggregation (makes them “slippery”) ASA: reduces incidence of MI and death in pts with CAD. Give immediately after angina 160-325 mg dose. Routine dose 81 (baby ASA) to 325 mg daily. Should take ASA even when taking acetaminophen (Tylenol, APAP) With GI upset/bleeding may use H2 blocker (i.e. famotidine (Pepcid)) or proton pump inhibitor (i.e. omeprazole (Prilosec) or pantoprazole (Protonix)) Clopidogrel (Plavix): given in addition to ASA in pts at high risk for MI Given more than one platelet inhibitor because the medications act in different ways to block platelet activation Plavix takes a few days to achieve antiplatelet effects. ASA & Plavix contraindicated if actively bleeding.

Heparin & glycoprotein IIB/IIIa agents : 

Heparin & glycoprotein IIB/IIIa agents Anticoagulant prevents formation of new thrombi IV bolus and continuous infusion (unractionated heparin drip) Titrated according to PTT with goal PTT of 2-3 times normal value May give low molecular weight heparin (enoxaparin (Lovenox)), SQ instead of IV unfractionated heparin. Benefit: no PTT monitoring needed. Monitor for s/s of bleeding( BP, HR) and place on Bleeding precautions. Monitor for HIT (heparin induced thrombocytopenia in pt who have received heparin withing 3 months and those receiving unfractionated heparin for 5-15 days. Glycoprotein IIB/IIIa agents given IV for USA and adjuvant therapy for PCI (percutaneous coronary interventions). Examples: eptifibatide (Integrilin), tirofiban (Aggrastat), abciximab (ReoPro) Prevent platelet aggregation. Bleeding is major side effect to be monitored Bleeding precautions should be initiated including: longer pressure to puncture sites, no IM injections, avoid tissue injury from trauma or constrictive devices (continuous automatic BP cuff), soft bristle tooth brush, electric shaver

Supplemental Oxygen : 

Supplemental Oxygen Initiated at onset of CP to increase O2 available to supply the myocardium Evaluate effectiveness based on respiratory rate and rhythm (i.e. decreasing tachypnea and increasing regularity of resps) Titrate to goal O2 sat of > 93%

Nursing Process: Patient with Angina : 

Nursing Process: Patient with Angina Be sure to review this section (p. 766-768) Additionally review chart 28-4 (Assessing angina), p. 766 and chart 28-5 (Home Care Checklist for Angina), p. 767.