ANGINA (Coronary Artery Disease/acute Coronary Syndrome) Nursing Management

The classic symptom of coronary artery disease (CAD) is angina—pain caused by loss of oxygen and nutrients to the myo­cardial tissue because of inadequate coronary blood flow. In most, but not all, clients presenting with angina, CAD symptoms are caused by significant atherosclerosis. Unstable angina is sometimes grouped with myocardial infarction (MI) under the diagnosis of acute coronary syndrome. Angina has three major forms: (1) stable— precipitated by effort, of short duration, and easily relieved, (2) unstable—longer lasting, more severe, may not be relieved by rest/nitroglycerin; may also be new onset of pain with exertion or recent acceleration in severity of pain, and (3) variant—chest pain at rest with ECG changes due to coronary artery spasm. The AHCPR guidelines of May 1994 state that unstable angina is a transitory syndrome that causes significant disability and death in the United States.

Care Setting

Clients judged to be at intermediate or high likelihood of significant CAD are often hospitalized for further evaluation and therapeutic intervention. Classification of angina (provided by Canadian Cardiovascular Society Classification [CCSC]) aids in determining the risk of adverse outcomes for clients with unstable angina and, therefore, level of treatment needs. Class III angina is identified as occurring if the client walks less than two blocks and normal activity is markedly limited, and class IV angina occurs at rest or with minimal activity and level of activity is severely limited. These two classes may require inpatient evaluation/therapeutic adjustments.

Related Concerns

Cardiac surgery: postoperative care

Dysrhythmias

Heart failure: chronic

Myocardial infarction

Psychosocial aspects of care

Client Assessment Database

Activity/Rest

May report: Sedentary lifestyle, weakness

Fatigue, feeling incapacitated after exercise

Chest pain with exertion or at rest

Awakened by chest pain

May exhibit: Exertional dyspnea

Circulation

May report: History of heart disease, hypertension, obesity in self/family

May exhibit: Tachycardia, dysrhythmias

Blood pressure normal, elevated, or decreased

Heart sounds: May be normal; late S₄ or transient late systolic murmur (papillary muscle dysfunction) may be evident during pain

Moist, cool, pale skin/mucous membranes in presence of vasoconstriction

Ego Integrity

May report: Stressors of work, family, others

May exhibit: Apprehension, uneasiness

Food/Fluid

May report: Nausea, “heartburn”/epigastric distress with eating

Diet high in cholesterol/fats, salt, caffeine, liquor

May exhibit: Belching, gastric distention

Pain/Discomfort

May report: Note: Reports of pain location and severity differ between men and women.

Substernal or anterior chest pain that may radiate to jaw, neck, shoulders, and upper extremities (to left side more than right). Women may report pain between shoulder blades, back pain.

Quality: Varies from transient/mild to moderate, heavy pressure, tightness, squeezing, burning. Women may report dull aching pain.

Duration: Usually less than 15 min, rarely more than 30 min (average 3 min)

Precipitating factors: Physical exertion or great emotion, such as anger or sexual arousal; exercise in weather extremes; or may be unpredictable and/or occur during rest or sleep in unstable angina

Relieving factors: Pain may be responsive to particular relief mechanisms (e.g., rest, antianginal medications [women may not respond to these]).

New or ongoing chest pain that has changed in frequency, duration, character, or predictability (i.e., unstable, variant, Prinzmetal’s)

May exhibit: Facial grimacing, placing fist over midsternum, rubbing left arm, muscle tension, restlessness

Autonomic responses; e.g., tachycardia, blood pressure changes

Respiration

May report: Dyspnea worse with exertion

History of smoking

May exhibit: Respirations: Increased rate/rhythm and alteration in depth

Teaching/Learning

May report: Family history or risk factors of CAD, obesity, sedentary lifestyle, hypertension, stroke, diabetes, cigarette smoking, hyperlipidemia

Use/misuse of cardiac, hypertensive, or OTC drugs. History of hormone replacement therapy in post-menopausal women

Use of vitamins/herbal supplements; e.g., niacin, coenxyme Q10, ginger, bilberry, comfrey, garlic, L-carnitine

Regular alcohol use, illicit drug use; e.g., cocaine, amphetamines

Discharge plan considerations: Alteration in medication use/therapy

Assistance with homemaker/maintenance tasks

Changes in physical layout of home

Refer to section at end of plan for postdischarge considerations.

Diagnostic Studies

ECG: Often normal when client at rest or when pain-free; depression of the ST segment or T wave inversion signifies ischemia. Dysrhythmias and heart block may also be present. Significant Q waves are consistent with a prior MI.

24-hour ECG monitoring (Holter): Done to see whether pain episodes correlate with or change during exercise or activity. ST depression without pain is highly indicative of ischemia.

Exercise or pharmacologic stress electrocardiography: Provides more diagnostic information, such as duration and level of activity attained before onset of angina. A markedly positive test is indicative of severe CAD. Note: Studies have shown stress echo studies to be more accurate in some groups than exercise stress testing alone.

Cardiac enzymes ( troponin I and cardiac troponin T, CPK, CK and CK-MB; LDH and isoenzymes LD₁, LD₂): Usually within normal limits (WNL); elevation indicates myocardial damage.

Chest x-ray: Usually normal; however, infiltrates may be present, reflecting cardiac decompensation or pulmonary complications.

Pco₂, potassium, and myocardial lactate: May be elevated during anginal attack (all play a role in myocardial ischemia and may perpetuate it).

Serum lipids (total lipids, lipoprotein electrophoresis, and isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides; phospholipids): May be elevated (CAD risk factor).

Echocardiogram: Motion-mode (M-mode) or two-dimensional (2-D or cross-sectional) echocardiography helps diagnose cardiomyopathy, HF, pericarditis, and abnormal valvular action that might be cause of chest pain.

Nuclear imaging studies (rest or stress scan):

Thallium-201: Ischemic regions appear as areas of decreased thallium uptake.

MUGA: Evaluates specific and general ventricle performance, regional wall motion, and ejection fraction.

Calcium scoring (also called coronary artery calcium scoring): Ultrafast CT scan that measures the amount of calcium in the coronary arteries. Elevated calcium scoring in client with other risk factors (e.g., family history, hypertension, diabetes, hypercholesterolemia) is an indication of some level of coronary artery disease [CAD])

Cardiac catheterization with angiography: Definitive test for CAD in clients with known ischemic disease with angina or incapacitating chest pain, in clients with cholesterolemia and familial heart disease who are experiencing chest pain, and in clients with abnormal resting ECGs. Abnormal results are present in valvular disease, altered contractility, ventricular failure, and circulatory abnormalities. Note: Ten percent of clients with unstable angina have normal-appearing coronary arteries.

Nursing Priorities

1. Relieve/control pain.

2. Prevent/minimize development of myocardial complications.

3. Provide information about disease process/prognosis and treatment.

4. Support client/SO in initiating necessary lifestyle/behavioral changes.

Discharge Goals

1. Achieves desired activity level; meets self-care needs with minimal or no pain.

2. Free of complications.

3. Disease process/prognosis and therapeutic regimen understood.

4. Participating in treatment program, behavioral changes.

5. Plan in place to meet needs after discharge.

 

NURSING DIAGNOSIS: acute Pain

May be related to

Decreased myocardial blood flow

Increased cardiac workload/oxygen consumption

Possibly evidenced by

Reports of pain varying in frequency, duration, and intensity (especially as condition worsens)

Narrowed focus

Distraction behaviors (moaning, crying, pacing, restlessness)

Autonomic responses; e.g., diaphoresis, blood pressure and pulse rate changes, pupillary dilation, increased/decreased respiratory rate

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Pain Level (NOC)

Report anginal episodes decreased in frequency, duration, and severity

Demonstrate relief of pain as evidenced by stable vital signs, absence of muscle tension and restlessness.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Instruct client to notify nurse immediately when chest pain occurs. Assess and document client response/effects of medication. Identify precipitating event, if any; frequency, duration, intensity, and location of pain. Observe for associated symptoms; e.g., dyspnea, nausea/vomiting, dizziness, palpitations, desire to micturate. Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side). Place client at complete rest during anginal episodes. Elevate head of bed if client is short of breath. Monitor heart rate/rhythm.

RATIONALE Pain and decreased cardiac output may stimulate the sympathetic nervous system to release excessive amounts of norepinephrine, which increases platelet aggregation and release of thromboxane A2. This potent vasoconstrictor causes coronary artery spasm, which can precipitate, complicate, and/or prolong an anginal attack. Unbearable pain may cause vasovagal response, decreasing BP and heart rate. Provides information about disease progression. Aids in evaluating effectiveness of interventions, and may indicate need for change in therapeutic regimen. Helps differentiate this chest pain, and aids in evaluating possible progression to unstable angina. (Stable angina usually lasts 3–15 minutes and is often relieved by rest and sublingual nitroglycerin [NTG]; unstable angina is more intense, occurs unpredictably, may last longer, and is not usually relieved by NTG/rest.) Decreased cardiac output (which may occur during ischemic myocardial episode) stimulates sympathetic/parasympathetic nervous system, causing a variety of vague sensations that client may not identify as related to anginal episode. Cardiac pain may radiate; e.g., pain is often referred to more superficial sites served by the same spinal cord nerve level. Reduces myocardial oxygen demand to minimize risk of tissue injury/necrosis. Facilitates gas exchange to decrease hypoxia and resultant shortness of breath. Clients with unstable angina have an increased risk of acute life-threatening dysrhythmias, which occur in response to ischemic changes and/or stress. .

Monitor vital signs every 5 min during initial anginal attack. Stay with client who is experiencing pain or appears anxious. Maintain quiet, comfortable environment; restrict visitors as necessary. Provide light meals. Have client rest for 1 hour after meals. Collaborative Provide supplemental oxygen as indicated.

Blood pressure may initially rise because of sympathetic stimulation, then fall if cardiac output is compromised. Tachycardia also develops in response to sympathetic stimulation and may be sustained as a compensatory response if cardiac output falls. Anxiety releases catecholamines, which increase myocardial workload and can escalate/prolong ischemic pain. Presence of nurse can reduce feelings of fear and helplessness. Mental/emotional stress increases myocardial workload. Decreases myocardial workload associated with work of digestion, reducing risk of anginal attack.     Increases oxygen available for myocardial uptake/reversal of ischemia.

Administer antianginal medication(s) promptly as indicated: Nitroglycerin: sublingual (Nitrostat), extended release tablets/capsules (Imdur, Isobid, Isordil, Nitrong, Nitrocot); chewable tablets (Isordil, Sorbitrate), metered-dose spray (Nitrolingual); transdermal patch (Nitro-Dur, Nitrodisc); transdermal ointment (Nitro-Dur, Transderm-Nitro); β-blockers; e.g., acebutolol (Sectral), atenolol (Tenormin), nadolol (Corgard), metroprolol (Lopressor), propranolol (Inderal); Calcium channel blockers; e.g., bepridil (Vascor), amlodipine (Norvasc), nifedipine (Procardia), felodipine (Plendil), isradipine (DynaCirc), diltiazem (Cardizem); Analgesics; e.g., acetaminophen (Tylenol); Morphine sulfate (MS). Monitor serial ECG changes.

Nitroglycerin has been the standard for treating and preventing anginal pain for more than 100 years. Today, it is available in many forms and is still the cornerstone of antianginal therapy. Rapid vasodilator effect lasts 10–30 minutes and can be used prophylactically to prevent, as well as abort, anginal attacks. Long-acting preparations are used to prevent recurrences by reducing coronary vasospasms and reducing cardiac workload. May cause headache, dizziness, light-headedness—symptoms that usually pass quickly. If headache is intolerable, alteration of dose or discontinuation of drug may be necessary. Note: Isordil may be more effective for clients with variant form of angina. Reduce angina by reducing the heart’s workload. (Refer to ND: risk for decreased Cardiac Output, following, p. 000) Note: Often, these drugs alone are sufficient to relieve angina in less severe conditions. Produce relaxation of coronary vascular smooth muscle; dilate coronary arteries; decrease peripheral vascular resistance. Usually sufficient analgesia for relief of headache caused by dilation of cerebral vessels in response to nitrates. Potent narcotic analgesic may be used in acute onset because of its several beneficial effects; e.g., causes peripheral vasodilation and reduces myocardial workload, has a sedative effect to produce relaxation, interrupts the flow of vasoconstricting catecholamines and thereby effectively relieves severe chest pain. MS is given IV for rapid action and because decreased cardiac output compromises peripheral tissue absorption. Ischemia during anginal attack may cause transient ST segment depression or elevation and T wave inversion. Serial tracings verify ischemic changes, which may disappear when client is pain-free. They also provide a baseline against which to compare later pattern changes.

NURSING DIAGNOSIS: risk for decreased Cardiac Output

Risk factors may include

Inotropic changes (transient/prolonged myocardial ischemia, effects of medications)

Alterations in rate/rhythm and electrical conduction

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Cardiac Pump Effectiveness (NOC)

Demonstrate increased activity tolerance.

Report/display decreased episodes of dyspnea, angina, and dysrhythmias.

Participate in behaviors/activities that reduce the workload of the heart.

ACTIONS/INTERVENTIONS Hemolytic Regulation (NIC) Independent Maintain bed/chair rest in position of comfort during acute episodes. Monitor vital signs (e.g., heart rate, BP) and cardiac rhythm. Auscultate breath sounds and heart sounds. Listen for murmurs. Provide for adequate rest periods. Assist with/perform self-care activities, as indicated. Stress importance of avoiding straining/ bearing down, especially during defecation. Encourage immediate reporting of pain for prompt administration of medications as indicated. Monitor for and document effects of/adverse response to medications, noting BP, heart rate, and rhythm (especially when giving combination of calcium antagonists, β-blockers, and nitrates). Assess for signs and symptoms of heart failure. Evaluate mental status, noting development of confusion, disorientation. Note skin color and presence/quality of pulses.

RATIONALE Decreases oxygen consumption/demand, reducing myocardial workload and risk of decompensation. Tachycardia may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. Changes may also occur in BP (hypertension or hypotension) because of cardiac response. ECG changes reflecting ischemia/dysrhythmias indicate need for additional evaluation and therapeutic intervention. S3, S4, or crackles can occur with cardiac decompensation or some medications (especially β-blockers). Development of murmurs may reveal a valvular cause for chest pain (e.g., aortic stenosis, mitral stenosis) or papillary muscle rupture. Conserves energy, reduces cardiac workload. Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which may impair cardiac output. Timely interventions can reduce oxygen consumption and myocardial workload and may prevent/minimize cardiac complications. Desired effect is to decrease myocardial oxygen demand by decreasing ventricular stress. Drugs with negative inotropic properties can decrease perfusion to an already ischemic myocardium. Combination of nitrates and β-blockers may have cumulative effect on cardiac output. Angina is only a symptom of underlying pathology causing myocardial ischemia. Disease may compromise cardiac function to point of decompensation. Reduced perfusion of the brain can produce observable changes in sensorium. Peripheral circulation is reduced when cardiac output falls, giving the skin a pale or gray color (depending on level of hypoxia) and diminishing the strength of peripheral pulses.

Prepare for surgical interventions (e.g., angioplasty with/without intracoronary stent placement, valve replacement, CABG) if indicated. Prepare for transfer to critical care unit if condition warrants.

Angioplasty (also called percutaneous transluminal coronary angioplasty [PTCA]) increases coronary blood flow by compression of atheromatous lesions and dilation of the vessel lumen in an occluded coronary artery. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency. This procedure is preferred over the more invasive CABG surgery. Drug-eluting (drug-coated) stents my be considered for clients at high risk for thrombosis, acute closure, and for diabetics. Several different drugs are available to help decrease restenosis after stenting or angioplasty. Stent placement may also be effective for the variant form of angina where periodic vasospasms impair arterial flow. Note: A recent innovation in thrombolytic therapy associated with angioplasty and stenting is the Anjiojet (a device approved for removing blood clots from coronary arteries), which can reduce risk of heart attack or death. CABG is the recommended treatment when testing confirms myocardial ischemia as a result of left main coronary artery disease or symptomatic three-vessel disease, especially in those with left ventricular dysfunction. Profound/prolonged chest pain with decreased cardiac output reflects development of complications requiring more intense/emergency interventions.

NURSING DIAGNOSIS: Anxiety [specify level]

May be related to

Situational crises

Threat to self-concept (altered image/abilities)

Underlying pathophysiologic response

Threat to or change in health status (disease course that can lead to further compromise, debility, even death)

Negative self-talk

Possibly evidenced by

Expressed concern regarding changes in life events

Increased tension/helplessness

Apprehension, uncertainty, restlessness

Association of diagnosis with loss of healthy body image, loss of place/influence

View of self as noncontributing member of family/society

Fear of death as an imminent reality

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Anxiety Self-Control (NOC)

Verbalize awareness of feelings of anxiety and healthy ways to deal with them.

Report anxiety is reduced to a manageable level.

Express concerns about effect of disease on lifestyle, position within family and society.

Demonstrate effective coping strategies/problem-solving skills.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Explain purpose of tests and procedures; e.g., stress testing. Promote expression of feelings and fears; e.g., denial, depression, and anger. Let client/SO know these are normal reactions. Note statements of concern, such as, “Heart attack is inevitable.” Encourage family and friends to treat client as before. Tell client the medical regimen has been designed to reduce/limit future attacks and increase cardiac stability. Collaborative Administer sedatives, tranquilizers, as indicated.

RATIONALE Reduces anxiety attributable to fear of unknown diagnosis and prognosis. Unexpressed feelings may create internal turmoil and affect self-image. Verbalization of concerns reduces tension, verifies level of coping, and facilitates dealing with feelings. Presence of negative self-talk can increase level of anxiety and may contribute to exacerbation of anginal attacks. Reassures client that role in the family and business has not been altered. Encourages client to test symptom control (e.g., no angina with certain levels of activity), to increase confidence in medical program, and to integrate abilities into perceptions of self. (Refer to CP: Psychosocial Aspects of Care, ND: Anxiety [specify level]/Fear, p. 000, for additional considerations.)     May be desired to help client relax until physically able to reestablish adequate coping strategies.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, treatment needs, self-care, and discharge needs

May be related to

Lack of exposure

Inaccurate/misinterpretation of information

Unfamiliarity with information resources

Possibly evidenced by

Questions; statement of concerns

Request for information

Inaccurate follow-through of instructions

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Participate in learning process.

Assume responsibility for own learning, looking for information and asking questions.

Knowledge: Cardiac Disease Management (NOC)

Verbalize understanding of condition/disease process and potential complications.

Verbalize understanding of /participate in therapeutic regimen.

Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) Independent Discuss pathophysiology of condition. Stress need for preventing and managing anginal attacks. Review significance of cholesterol levels and differentiate between LDL and HDL factors. Emphasize importance of periodic laboratory measurements, and use of cholesterol-lowering drugs.. Encourage avoidance of factors/situations that may precipitate anginal episode; e.g., emotional stress, extensive or intense physical exertion, ingestion of large/heavy meal, especially at bedtime, exposure to extremes in environmental temperature. Assist client/SO to identify sources of physical and emotional stress and discuss ways that they can be avoided. Review importance of cessation of smoking, weight control, dietary changes, and exercise. Encourage client to follow prescribed reconditioning program; caution to avoid exhaustion. Discuss impact of condition on desired lifestyle and activities, including work, driving, sexual activity, and hobbies. Provide information, privacy, or consultation, as indicated. Demonstrate how/encourage client to monitor own pulse and BP during/after activities, when appropriate, and to schedule/simplify activities, avoid strain, and take rest periods. Discuss steps to take when anginal attacks occur; e.g., cessation of activity, keeping “rescue” NTG on hand, administration of prn medication, use of relaxation techniques.

RATIONALE Clients with angina need to learn why it occurs and what they can do to control it. This is the focus of therapeutic management to reduce likelihood of MI and promote healthy heart lifestyle. Although the American Heart Association recommended LDL is ±130mg/dL, clients with two or more risk factors (e.g., smoking, hypertension, diabetes mellitus, positive family history) should keep LDL ±100 mg/dL, and those with diagnosis of CAD need to keep LDL below 100 mg/dL. HDL below 35–45 is considered a risk factor; a level above 60 mg/dL is considered an advantage. Note: The National Choleterol Education Program Guidelines now state that all adult high-risk clients with LDL 100mg/dL should be treated with drug therapy. May reduce incidence/severity of ischemic episodes. Helps client manage symptoms. This is a crucial step in limiting/preventing anginal attacks. Knowledge of the significance of risk factors provides client with opportunity to make needed changes. Clients with high cholesterol who do not respond to 6-month program of low-fat diet and regular exercise will require medication. Fear of triggering attacks may cause client to avoid participation in activity that has been prescribed to enhance recovery (increase myocardial strength and form collateral circulation). Cardiac rehab programs provide a phased approach to increaasing client’s activity and exercise tolerance. Client may be reluctant to resume/continue usual activities because of fear of anginal attack or death. Client should take nitroglycerin prophylactically before any activity that is known to precipitate angina. Allows client to identify those activities that can be modified to avoid cardiac stress and stay below the anginal threshold. Being prepared for an event takes away the fear that client will not know what to do if attack occurs.

Review prescribed medications for control/prevention of anginal attacks as previously presented: ASA and other antiplatelet agents; Lipid-lowering agents: bile acid sequestrants; e.g., cholestyramine (Questran), colestipol (Colestid); nicotinic acid (Niacin); fibrates; e.g. fenofibrate (Tricor), gemfibrozil (Lopid); and HMG-CoA reductase inhibitors; e.g., lovastatin (Lipitor), fluvastatin (Lescol) pravastatin (Pravachol), simvastatin (Zocor). Stress importance of checking with physician before taking OTC drugs. Discuss use of herbals (e.g., gensing, garlic, ginkgo, hawthorn, bromelain) as indicated. Review symptoms to be reported to physician; e.g., increase in frequency/duration of attacks, changes in response to medications. Discuss importance of follow-up appointments.

Angina is a complicated condition that often requires the use of many drugs given to decrease myocardial workload, improve coronary circulation, and control the occurrence of attacks. May be given prophylactically on a daily basis to decrease platelet aggregation and improve coronary circulation. May prolong survival rate of clients with unstable angina. These drugs are considered first-line agents for lowering serum cholesterol levels. Note: Questran/Colestid may inhibit absorption of fat-soluble vitamins and some drugs such as Coumadin, Lanoxin, and Inderal. The HMG-CoA reductase inhibitors may cause photosensitivity. Most lipid-lowering agents are inhibited by grapefruit juice. OTC drugs may potentiate or negate effects of prescribed medications. Some herbals (e.g., ginkgo, gensing, bromelain) can impact bleeding/clotting, especially when added to medications such as Plavix or Coumadin (increases bleeding). Others (e.g., hawthorn) can increase the effects of certain heart medications. Knowledge of expectations can avoid undue concern for insignificant reasons or delay in treatment of important symptoms. Angina is a symptom of progressive coronary artery disease that should be monitored and may require occasional adjustment of treatment regimen.

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on client’s age, physical condition/presence of complications, personal resources, and life responsibilities)

acute Pain—episodes of decreased myocardial blood flow/ischemia

Activity Intolerance—imbalance between oxygen supply/demand, sedentary/stressful lifestyle

ineffective Denial—learned response patterns (e.g., avoidance), cultural factors, personal and family value systems

interrupted Family Processes—situational transition and crisis

impaired Home Maintenance—altered ability to perform tasks, inadequate support systems, reluctance to request assistance