ANGINA PECTORIS

Question 1

It is a medical condition characterized by chest pain or discomfort due to reduced blood flow to the heart muscle. It is typically caused by the narrowing or obstruction of the coronary arteries, often due to the buildup of fatty deposits called plaque

Answer 1

ANGINA

Question 2

Lack of oxygen causes the production

Answer 2

lactic acid by the injured tissue, and that lactic acid will irritate the nerve endings in the heart causing angina.

Question 3

 The chest pain may radiate because of the presence of

Answer 3

nerve endings

Question 4

Myocardial _____ happens when there is less blood supply to the heart due to an _____.

If left untreated, it can damage tissues and may result to myocardial ____.

It may further lead to Myocardial ____ if not treated immediately, the arteries are completely blocked.

Answer 4

Ischemia

obstruction

injury

infarction

Question 5

o Less blood going to the heart
 Blood have nutrients and oxygen
 Hwo do you expect heart to contract
 Contract in less manner
 Less cardiac output causing diff sys tem of the body
* there is less blood going to brain (dizziness), body (fatigue)
o Heart is the pumping organ of the body

Answer 5

 MYOCARDIAL Ischemia

Question 6

 Heart is the pumping organ of the body. If there’s not enough blood going to the heart,

Answer 6

the heart will not contract 60-100 times per minute; therefore, there will be less cardiac output, resulting in less blood flow going to the different organs of the body.

Question 7

Less blood going to the Brain can cause .

Answer 7

dizziness

Question 8

Less blood going to the Body can cause

Answer 8

fatigue

Question 9

 4 E’s:

Answer 9

Exertion, Exposure to Cold, Eating Heavy, and Emotional Stress

Question 10

Exertion

Answer 10

 Moving a lot can increase the demand for oxygen and nutrients because there is an increase in metabolism of the cells in the muscles; however, the coronary artery is obstructed; therefore, less blood is received by the heart causing a less cardiac output.
 Less cardiac output can cause you to not be able to finish your task.

▪ Doing activities causes the heart to demand more blood. However, the arteries are already obstructed causing sluggish circulation. Therefore, less blood goes to different systems of the body resulting to exhaustion and angina.

Question 11

Exposure to Cold

Answer 11

 Because when exposed to cold, the blood vessels are constricted, which causes the heart to push blood against a high pressure.
 The more the coronary artery will constrict, the more you will have angina.
————————
▪ When a person is exposed to cold, the body compensates by vasoconstricting the vessels to retain the heat. It can contribute to angina because vasoconstriction lessens the blood flow to the heart.

Question 12

Eating Heavy

Answer 12

 The heart will give the stomach more blood for digestion, causing less blood going to the brain.
 The heart has to work harder to supply stomach with blood for food digestion; however, when the coronary artery is partially obstructed, it is impossible for the heart to pump enough blood which leads to angina.
 Advised patient to eat small amount of food because there will be less blood supply needed by the stomach; therefore, the heart is able to supply it because it is only in a minimal amount
———————
▪ The heart is already partially obstructed and eating a heavy meal increases the workload of the heart. The heart will work harder to pump more blood to the stomach to digest the food, and this can reduce the blood to other systems of the body, including the heart, contributing to angina and may lead to heart attack.
▪ Advise patient to frequently eat small amounts of food.

Question 13

Emotional Stress

Answer 13

▪ Stress triggers the release of catecholamines. Norepinephrine causes vasoconstriction and increases blood pressure while Epinephrine increases heart rate; However, the heart is partially obstructed and these catecholamines increases the workload of the heart therefore the heart is demanding more oxygen, inducing chest pain.

Question 14

peripheral neuropathy

Answer 14

 Patient with diabetes will not have severe pain because in diabetes there is less insulin —> the glucose needs insulin to enter the cell however if there’s not enough insulin the glucose will go to the blood; the blood will become viscous causing less blood flow —> can lead to increased pressure; the nerve endings will be destroyed; if destroyed there will be no pain. (peripheral neuropathy)

Question 15

 Prolonged ischemia —> can cause tissue damage —>

Answer 15

myocardial injury

Question 16

—> the coronary artery died.

Answer 16

Myocardial Infarction

Question 17

3 steps to kill the heart

Answer 17

 Myocardial ischemia
 Myocardial Injury
 Myocardial Infarction

Question 18

Types of Angina

Answer 18

1. Variant / Prinzmetal
2. Unstable
3. Stable
4. Silent
5. Refractory

Question 19

no lipids, only spasm
 Rare case
 Bc of spasms coronary artery narrowed resulting less blood
 Spasm only temporary

▪ The obstruction is not caused by lipids, it is due to spasms which causes the narrowing of arteries.
▪ It occurs when a person is at rest, usually between midnight and early morning.
▪ These attacks can be very painful.

Answer 19

Variant

Question 20

▪ The coronary arteries are obstructed by 70%
to 90%.
▪ Characterized by attacks that increase in
frequency and severity; may not be
relieved by rest or nitroglycerin.

 Common
 50% obstruction
 Stop activity you are doing
 Rest

Answer 20

unstable angina

Question 21

▪ The coronary arteries are obstructed by 50%
▪ It may be relieved by rest and/or
nitroglycerin

Answer 21

stable

Question 22

If the obstruction is 100%, complete obstruction

Answer 22

Myocardial Infarction

Question 23

severe incapacitating chest pain

Answer 23

refractory agina

Question 24

objective evidenced of ischemia but patient reports no pain

Answer 24

silent ischemia

Question 25

 Elevated cardiac biomarkers

Answer 25

 Enzymes released if the heart is injured —> troponin I, T, creatinine kinase (CK-MB)

Question 26

 ST elevated; t-wave inverted

Answer 26

myocardial injury

Question 27

 Q deep and wide, ST elevation, inverted T-Wave –

Answer 27

myocardial infarction

Question 28

o Elevation of ST: Myocardial injury

Answer 28

 St elevated
 T wave inverted
 Q Normal

Question 29

o Elevation of ST: Myo infarction

Answer 29

 ST elevated
 T wave inverted
 Q deep and wide

Question 30

MEDICAL MANAGEMENT FOR ANGINA:

Oxygen why?

Answer 30

because if you don’t give oxygen it will further damage the heart
 To lessen the damage area in the heart
 To relieve patient from chest pain
 The injured tissue will not produce lactic acid

Question 31

MEDICAL MANAGEMENT FOR ANGINA:

Nitroglycerin why?

Answer 31

▪ It will dilate the coronary arteries to increase blood flow; there will be no lactic acid produced and chest pain is relieved.
➢ Vasodilation causes headache.
➢ This drug should be tapered over
several weeks to prevent rebound
effect of severe pain.

▪ Common side effect if given sublingual or oral is headache. Patch has slow absorption so less headache.
➢ If there is headache, place the patch on the arm and abdomen to lessen the effect of the arteries in the brain.

Question 32

MEDICAL MANAGEMENT FOR ANGINA:

 Beta-adrenergic blocking agents why?

Answer 32

o It will reduce the heart rate (slow down)
o Not given to patient with atrioventricular block
 AV block: there is a blockage in right and left bundle of his; the impulse cannot be received therefore the ventricles will not contract —> decreased output.
 It will worsen the situation.
————————–
▪ It decreases the heart’s workload by blocking signals from the sympathetic nervous system. This reduces the heart’s demand for oxygen.
➢ Decreased heart rate, blood pressure, contractility.

▪ Contraindicated for patients with hypotension, bradycardia, acute HF, and AV Block.
➢ AV block is a blockage of right and left bundle of his, its function is to send impulse to ventricles for contraction. However, due to blockage of bundle of his, the ventricles are not contracting resulting to less cardiac output.

▪ Patients should not stop taking them abruptly because it can worsen the chest pain and may result to MI.
➢ It should be tapered for several days.

▪ Beta-blockers can mask signs of hypoglycemia so diabetic patients are advised to monitor their blood glucose levels.

Question 33

MEDICAL MANAGEMENT FOR ANGINA:

Aspirin why?

Answer 33

 If the patient is taking aspirin it can cause bleeding and GI irritation,
 H2 Blockers and PPI will decrease gastric juices so that you will not experience stomach pain, and bleeding
 Take it will full stomach —> if there’s still GI irritation report to the doctor.
—————————-
▪ It prevents platelet aggregation which impedes blood flow through the coronary arteries

Question 34

Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous coronary intervention (PCI)

Answer 34

 If the obstruction is 70%
 There is a catheter (cardiac catheterization to know what artery is obstructed)
 Diagnostic test
 Femoral artery
 They will inject a dye but this dye can accumulate in the kidneys which can destroy the kidneys
 They will insert the stent, then inflate to push the fats on the side of the lumen —> this it to improve the flow of blood however the fats will stay there forever.
 Reason why the stent has many butas; so that the tissue will grow to hold the stent there forever.
 The reason why doctors are giving aspirin is that because there is a foreign body which is a stent; this is used to prevent further clotted blood

Question 35

 Coronary Bypass Surgery

Answer 35

If the number of coronary arteries obstructed is more than 4

Question 36

PATIENT TEACHINGS – NO SURGERY

Answer 36

1.  Avoid activity after eating
   o The heart is busy giving blood to the stomach; however, if you do any activities it will just add workload to the heart because the muscles you used in that activity also needs blood to work. —> heart attack
2. After eating is already obstructed, its having hard time digesting food
   o There are indulged in sexual intercourse
    Good blood supply
   o Increase workload of heart
3. DIET
   o Maintain a diet low in fat and sodium
   o If obese, weight reduction
4. Participate in Resuglar Exercise
   o When performing, you are increasing good cholesterol, it decreases bad cholesterol
   o Increase nitric oxide food
   (Arugula, Spinach, Red Beets, Garlic, Cilantro-Coriander, Lettuce, Basil)
5.  Cold weather
   o Avoid exposure to cold and windy weather
   o When outdoors, dress in watm clothing
6.  Advise the patient to stop all the activities
   o This will just add workload to the heart leading to heart attack
   o Immediately take nitroglycerin

Question 37

 Combination medication of omeprazole/aspirin
 For patients who required aspirin for secondary prevention of cardiovascular and cerebrovascular events
 For patients who are at risk of developing aspirin associated gastric ulcers

Answer 37

YOSPRALA

Question 38

NURSING INTERVENTION BEFORE CARDIAC CATHETERIZATION:

Answer 38

1. instruct to fast for 8-12 hours before procedure
2. reassure that iv meds are given to maintai comfort
3. encourage px to express fear and anxiety

4.

Question 39

NURSING INTERVENTION AFTER CARDIAC CATHETERIZATION:

Answer 39

Observe catheter access site for bleeding formation

assess for pain, numbness, or tingling sensation that may indicate arterial inssufiency

Question 40

❖ CLINICAL MANIFESTATIONS

Answer 40

→ Body Weakness, Pain Radiation, Shortness of Breath, Pallor, Diaphoresis, Lightheadedness

Question 41

→ Diabetic people may not have severe pain. With less insulin, glucose can’t enter resulting to
hyperglycemia and making the blood viscous. With less blood supply to the nerves, the nerves are destroyed, this condition is called

Answer 41

Autonomic Neuropathy

Question 42

❖ DIAGNOSTIC FINDINGS
→ STEMI: ST Elevation MI

Answer 42

▪ Myocardial Injury – Q is still normal, ST Elevated, T-Wave Inversion
▪ Myocardial Infarction – Q is deep and wide, ST Elevation, and T-Wave Inversion
▪ Results from a fully occluded coronary artery.
➢ has significant damage to the myocardium
➢ has ECG evidence of acute MI

Question 43

❖ DIAGNOSTIC FINDINGS
→ STEMI: ST Elevation MI
Treatments

Answer 43

➢ Same with NSTEMI: Percutaneous Coronary Intervention
➢ Fibrinolytic Therapy within 30 minutes of medical evaluation

Question 44

❖ DIAGNOSTIC FINDINGS
→ NSTEMI: Non-ST Elevation MI

Answer 44

▪ Myocardial Ischemia – ST Depression
▪ Cardiac biomarkers are elevated.
➢ Cardiac Biomarkers are the enzymes released if heart is injured. Troponin I, Troponin T, Creatinine Kinase (CKMB).
➢ Cardiac Troponins are more reliable because these are primarily found in cardiac muscle tissue. They are not typically found in significant amounts in other tissues, which makes them highly specific to the heart.
▪ There is less damage to the myocardium.
▪ No definite ECG evidence of acute MI.

Question 45

Nitroglycerine Routes

Answer 45

➢ Sublingual – fast absorption; it acts within 1-3 minutes and lasts 30 to 60 minutes.
➢ Topical – slow absorption and acts within 30 to 60 minutes and lasts for 14 hours.

Question 46

MEDICAL MANAGEMENT FOR ANGINA:

Nitroglycerin
▪ Nursing Interventions: Sublingual

Answer 46

➢ Keep the drugs in the original container and place it in a cool-dark place to prevent decomposition when exposed to heat and light.
➢ Advise the patient to take the medication three times at 5-minute intervals if they experience chest pain. If the pain is not relieved, instruct them to go to the hospital.
➢ Do not place in the pockets because the body is warm and can affect the potency of the drug, place it in bags.
➢ Advise patient to discard if there is discoloration of the tablet.
➢ If she/he anticipates a heavy workload even without chest pain, advise to take one table and wait for 5 minutes before doing the work.

Question 47

MEDICAL MANAGEMENT FOR ANGINA:

Nitroglycerin
▪ Nursing Interventions: Transdermal

Answer 47

➢ Change the placement of the medication because applying it on the same area causes dermatitis.
➢ Assess the area first if there is lesion, sweat, hair, body lotion, skin should be dry before applying the patch.
➢ Advise patient to do not shave the area because it can result to fast absorption.
➢ Use clean gloves to remove the patch because that medicine can be in contact with the skin and can cause headache.
➢ Advise patient to remove the patch before they sleep to allow for a 6-to12-hour nitrate free interval, and to avoid tolerance.
* Apply a new one the next morning.

Question 48

MEDICAL MANAGEMENT FOR ANGINA:

 Calcium Channel Blocker why?

Answer 48

▪ It decreases SA node automaticity and AV node conduction, resulting to a decrease in heart rate and contractility.
➢ It increases myocardial oxygen supply by dilating the smooth muscles of coronary arteries.

▪ Amlodipine and Diltiazem are commonly used.

▪ Hypotension may occur after administration, particularly IV.

▪ Side effects may include AV block, bradycardia, and constipation.

Question 49

MEDICAL MANAGEMENT FOR ANGINA:

Aspirin
NURSING INTERVENTION

Answer 49

➢ Advise patient to use a soft bristle toothbrush to prevent gums from bleeding.
➢ Advise patient to avoid shaving because bleeding from shaving cuts may be difficult to control.
➢ Educate patient to control external hemorrhage from accidents or injuries by applying firm-direct pressure for at least 5 to 10 minutes with a clean, dry, and absorbent material.
➢ Advise patient to avoid alcohol because it can increase gastric juice which may result to gastric bleeding.
➢ Advise patient to avoid blowing nose vigorously because it can cause epistaxis.
➢ Advise patient to increase iron-rich foods such as red meat (beef & pork), tuna, salmon, beans, lentils, tofu, almonds, cashews, spinach, raisins, prunes, bread, and pasta.
➢ Advise the patient to take the drug with meals to avoid gastrointestinal (GI) bleeding

Question 50

❖ NURSING INTERVENTIONS IN TREATING ANGINA

Answer 50

→ A patient experiencing angina is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce oxygen demands of the heart.
→ Monitor vital signs and signs of respiratory distress.
→ If the patient is in the hospital, a 12-lead ECG is usually obtained and assessed for ST-segment and T-wave changes.
→ Nitroglycerin is given sublingually at three doses with 5 minutes interval.
→ Administer oxygen if respiratory rate increased and oxygen saturation decreased. Usually given at 2L/min by nasal cannula

Question 51

❖ HEALTH TEACHINGS FOR ANGINA

Answer 51

→ Advise patient to alternate activity with periods of rest.
▪ moderate activity level as needed
→ Advise patient to avoid smoke-filled environments because it causes vasoconstriction which delays wound healing and increases blood pressure; it also inactivates the cilia –therefore patient can’t remove the pathogens that entered the lungs; it also creates carbon monoxide and hemoglobin is more attracted to this type of gas therefore there is less carrier for oxygen.
→ Advise patient to maintain a diet low in fat and sodium.
→ Advise obese patient to reduce weight.
→ Advise patient to avoid activity immediately after meals.
▪ The heart is already working hard to pump more blood to the stomach to digest the food, so if you do activity after meals, it can increase the workload of the heart and
may result to heart attack.
→ Advise patient to restrict intake of caffeine
because it increases the heart rate and can further decrease the cardiac output.
→ Advise patient to eat smaller portions.
→ Advise patient to avoid exposure to cold and windy weather. When outdoors, dress in warm clothing.
→ Advise patient to avoid strong emotions.
→ Advise patient to participate in regular exercise program.
→ If there is anginal attack, stop all activity and
remain sitting upright, and take nitroglycerin.

Question 52

REVASCULARIZATION PROCEDURE:

Answer 52

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

Question 53

→ Its purpose is to improve blood flow within a coronary artery

Answer 53

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)

Question 54

During PTCA, a sheath is inserted into the femoral artery and advanced into the coronary artery.

_____ is then performed by injecting a
contrast dye to visualize which artery is
obstructed. Afterwards, a balloon-tipped dilation catheter is carefully guided through the sheath and positioned over the narrowed or damaged artery using fluoroscopy. The balloon is inflated with high pressure for several seconds to compress the plaque and widen the artery, restoring blood flow. After deflating the balloon, a stent may be placed at the site of the
previously narrowed artery to help keep it open.

▪ The stent is a foreign body and can cause
infection or blood clotting formation.

➢ Meds: Aspilet 80mg & Clopidogrel

▪ If more than 4 arteries are obstructed, open heart surgery is performed.

Answer 54

Angiography

Question 55

PTCA POST-OP CARE

Answer 55

▪ Nonpharmacologic: Heat application and repositioning the patient
▪ Patient may go home after 2nd post op day.
▪ Monitor the patient closely for signs and symptoms of Myocardial Ischemia.
➢ If present, notify the physician immediately. Administer oxygen by mask or cannula and monitor VS.

▪ If condition is uncomplicated, patient is advised to bed rest for 4 to 6 hours.
▪ Instruct patient to keep the involved leg ina straight position and not to elevate the head of the bed more than 30 degrees to maintain hemostasis.

▪ Advise patient to do not bend the legs, because after removing the catheter, there may be formation of thrombus so by keeping the legs still helps prevent embolism.

▪ Observe for bleeding at the puncture site every 15 minutes for 1 to 2 hours.
➢ Apply pressure dressing, 5-lb sandbag.
➢ Back pain – retroperitoneal bleeding
▪ Patients are allowed to resume ambulation 6 to 8 hours later.
➢ At the end of the day after the procedure, he may sit on the edge of the bed or in a bedside chair.
➢ The 2nd day after, he may walk around his room.
➢ 3rd day – discharge.

▪ Advise patient to avoid vigorous use of abdominal muscles such as coughing, sneezing, moving the bowels, and lifting items heavier than 10lbs (4.5kg).

▪ Increase fluid intake to flush out the dye injected during the procedure because it may accumulate at the kidneys causing acute kidney injury.
➢ IV: 0.45% Normal Saline 50 to 150mL/hr.

Question 56

→ Medical Management FOR ANGINA

Answer 56

▪ Antiplatelet Medications
➢ Aspirin
➢ Clopidogrel (Plavix)

▪ Statins
➢ Rosuvastatin (Crestor)

▪ Beta-blocker or Ace Inhibitor

▪ Yosprala