• Is characterized by the accumulation of plaque within coronary arteries, which

progressively enlarge, thicken and calcify. This causes critical narrowing of the coronary
artery lumen (75% occlusion), resulting in a decrease in coronary blood flow and an
inadequate supply of oxygen to the heart muscle.
• Ischemia may be silent (asymptomatic but evidenced by ST depression of 1 mm or more
on electrocardiogram (ECG) or may be manifested by angina pectoris (chest pain).
• Risk factor for Coronary Artery Disease include dyslipidemia, smoking, hypertension,
male gender (women are protected until menopause), aging, non-white race, family
history, obesity, sedimentary lifestyle, diabetes mellitus, metabolic syndrome, elevated
homocysteine, and stress.
• Acute coronary syndrome is a complication of CAD due to lack of oxygen to the
myocardium. Mnaifestations include unstable angina, non ST-segment elevation
infarction, and ST-segment elevation infarction.
• Other causes of angina include coronary artery spasm, aortic stenosis, cardiomyopathy,
severe anemia, and thyrotoxicosis.

Assessment:

Chest pain is provoked by exertion or stress and is

relieved by nitroglycerin and rest.

1. Character. Substernal chest pain, pressure,

heaviness, or discomfort. Other sensations
include a squeezing, aching, burning,
choking, strangling, or cramping pain.
 2. Severity. Pain maybe mild or severe and typically present with a gradual buildup of
discomfort and subsequent gradual fading away.
3. Location. Behind middle or upper third of sternum; the patient will generally will make a
fist over the site of pain (positive Levine sign; indicates diffuse deep visceral pain), rather
than point to it with fingers.
4. Radiation. Usually radiates to neck, jaw, shoulders, arms, hands, and posterior
intrascapular area. Pain occurs more commonly on the left side than the right; may
produce numbness or weakness in arms, wrist, or hands.
5. Duration. Usually last 2 to 10 minutes after stopping activity; nitroglycerin relieves pain
within 1 minute.
6. Precipitating factors. Physical activity, exposure to hot or cold weather, eating a heavy
meal, and sexual intercourse increase the workload of the heart and, therefore, increase
oxygen demand.
7. Associated manifestation. Diaphoresis, nausea, indigestion, dyspnea, tachycardia, and
increase in blood pressure.
8. Signs of unstable angina:

• A change in frequency, duration, and intensity of stable angina symptoms.

• Angina pain last longer than 10 minutes, is unrelieved by rest or
sublingual nitroglycerin, and mimics signs and symptoms of impending
myocardial infarction.

Diagnostic Evaluation:

1. Resting ECG may show left ventricular hypertrophy, ST-T changes, arrhythmias, and
possible Q waves.
2. Exercise stress testing with or without perfusion studies shows ischemia.
3. Cardiac catheterization shows blocked vessels.
4. Position emission tomography may show small perfusion defects.
5. Radionuclide ventriculography shows wall motion abnormalities and ejection fraction.
6. Fasting blood levels of cholesterol, low density lipoprotein, high density lipoprotein,
lipoprotein A, homocysteine, and triglycerides may be abnormal.
7. Coagulation studies, hemoglobin level, fasting blood sugar as baseline studies.

Pharmacologic Interventions:

1. Antianginal medications (nitrates, beta-adrenergic blockers, calcium channel blockers,

and angiotensin converting enzyme inhibitors) to promote a favorable balance of oxygen
supply and demand.
2. Antilipid medications to decrease blood cholesterol and tricglyceride levels in patients
with elevated levels.
3. Antiplatelet agents to inhibit thrombus formation.
4. Folic acid and B complex vitamins to reduce homocysteine levels.

Surgical Interventions:
 1. Percutaneous transluminal coronary angioplasty or intracoronary atherectomy, or
placement of intracoronarystent.
2. Coronary artery bypass grafting.
3. Transmyocardial revascularization.

Nursing Interventions:

1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes during an
anginal attack.
2. Maintain continuous ECG monitoring or obtain a 12-lead ECG, as directed, monitor for
arrhythmias and ST elevation.
3. Place patient in comfortable position and administer oxygen, if prescribed, to enhance
myocardial oxygen supply.
4. Identify specific activities patient may engage in that are below the level at which anginal
pain occurs.
5. Reinforce the importance of notifying nursing staff whenever angina pain is experienced.
6. Encourage supine position for dizziness caused by antianginals.
7. Be alert to adverse reaction related to abrupt discontinuation of beta-adrenergic blocker
and calcium channel blocker therapy. These drug must be tapered to prevent a “rebound
phenomenon”; tachycardia, increase in chest pain, and hypertension.
8. Explain to the patient the importance of anxiety reduction to assist to control angina.
9. Teach the patient relaxation techniques.
10. Review specific factors that affect CAD development and progression; highlight those
risk factors that can be modified and controlled to reduce the risk.
11. Nursing care plan for angina pectoris with a primary nursing diagnosis of Altered
tissue perfusion (myocardial) related to narrowing of the coronary artery(ies) and
associated with atherosclerosis, spasm, or thrombosis.

Angina pectoris is a symptom of ischemic heart disease that is characterized by

paroxysmal and usually recurring substernal or precordial chest pain or discomfort. More
than 6 million Americans experience angina, and approximately 350,000 new cases of
angina occur every year. Angina pectoris is caused by varying combinations of
increased myocardial demand and decreased myocardial perfusion. The imbalance
between supply and demand is caused either by a primary decrease in coronary blood
flow or by a disproportionate increase in myocardial oxygen requirements. Blood flow
through the coronary arteries is partially or completely obstructed because of coronary
artery spasm, fixed stenosing plaques, disrupted plaques, thrombosis, platelet
aggregation, and embolization.
 12.
13. Angina pectoris can be classified as chronic exertional (stable, typical) angina, variant
angina (Prinzmetal’s), unstable or crescendo angina, or silent ischemia. Chronic
exertional angina is usually caused by obstructive coronary artery disease that causes the
heart to be vulnerable to further ischemia whenever there is increased demand or
workload. Variant angina may occur in people with normal coronary arteries who have
cyclically recurring angina at rest, unrelated to effort. Unstable angina is diagnosed in
patients who report a changing character, duration, and intensity of their pain. Experts are
also recognizing that not all ischemic events are
perceived by patients, even though such events, called silent ischemia, may have adverse
implications for the patient.

Causes of Angina Pectoris

Most recurrent angina pectoris is caused by atherosclerosis, which is the most common
cause of coronary artery disease (CAD) and continues to be the leading cause of death for
both women and men in the United States. However, it may occur in patients with normal
coronary arteries as well. Approximately 90% of patients with recurrent Angina pectoris
have hemodynamically significant stenosis or occlusion of a major coronary artery.

Nursing care plan Physical Assessment and Examination: Ask the patient to describe
past chest discomfort in terms of quality (aching, sharp, tingling, knifelike, choking,
squeezing), location and radiation, precipitating factors (activity), duration, alleviating
factors (relieved by rest), and associated signs and symptoms during the attack (dyspnea,
anxiety, diaphoresis, nausea). Obtain information regarding the medications, family
history, and modifiable risk factors such as eating habits, lifestyle, and physical activity.
If chest discomfort is present at the time of the interview, delay collection of historical
data until you implement appropriate interventions for ischemic chest pain and the patient
is pain-free.

The Canadian Cardiovascular Society grading scale is used to classify the severity of
angina: Class I: angina only during strenuous or prolonged physical activity; Class II:
slight limitation, with angina only during vigorous physical activity; Class III: symptoms
with everyday living activities; Class IV: inability to perform any activity without angina
or angina at rest.
During anginal attacks, chest discomfort is often described as an ache, rather than an
actual pain, and may be characterized as a heaviness, pressure, tightness, squeezing
sensation, or indigestion. The discomfort is typically located in the substernal region or
across the anterior upper chest. Often, the area of pain is the size of a clenched fist and
the patient may place his or her fist over the area of discomfort (Levine’s sign). The
sensation may radiate to the neck, jaw, or tongue; to either arm, elbow, wrist, or hand; or
to the upper abdomen.

Anginal discomfort is typically of short duration, usually 3 to 5 minutes, but can last up
to 30 minutes or longer. The discomfort may have been brought on by physical or
emotional stress, exposure to extreme temperatures, or eating a heavy meal. Termination
of the precipitating factor may bring about alleviation of the discomfort. Frequently, the
patient is anxious, pale,
diaphoretic, lightheaded, dyspneic, tachycardiac, and nauseated. Upon auscultation, the
patient
may have atrial or ventricular gallops (S3, S4).

Patients often rationalize that their symptoms are the result of indigestion or overexertion.
Denial can interfere with identification of a symptom and be harmful to the patient. Chest
pain and all the surrounding implications can be extremely stressful and
anxietyproducing to the patient and family.

Nursing care plan intervention and treatment: For any patient who is experiencing an
acute anginal episode, pain management is the priority, not only for patient comfort but
also to decrease myocardial oxygen consumption. The physician orders selected therapies
that either decrease myocardial oxygen demand or increase coronary blood and oxygen
supply. These therapies may include short-term bedrest; oxygen therapy; cardiac
monitoring to prevent potential complications; and small, frequent, easily digested meals.
Surgical and other invasive options are discussed under Coronary Artery Disease.

A collaborative effort among the patient, dietitian, physician, and nurse plans for a diet
low in cholesterol, fat, calories, and sodium. Drinks in the coronary care unit or step-
down unit are usually decaffeinated and not too hot or cold.

During unstable periods, the nurse and physician closely monitor the patient’s vital signs
and her or his response to pain-relieving therapies (narcotics, nitrates). Often the patient
is placed on a cardiac monitor to determine if life-threatening dysrhythmias occur during
an anginal episode, particularly if the angina may be a symptom that the patient is having
an MI.

To decrease oxygen demand, encourage the patient to maintain bedrest until the pain
subsides; even though bedrest is usually short term, a sheepskin, air mattress, foam pad,
foot cradle, or heel pads can reduce the risk of skin breakdown and increase patient
comfort. Encourage rest throughout the entire hospitalization.

Because anxiety and fear are common among both patients and families, attempt to have
them discuss concerns and express their feelings. With the patient and family, discuss the
diagnosis, the activity and diet restrictions, and the medical treatment. Refer the patient to
a smoking cessation program if appropriate. Numerous lifestyle changes may be needed.
Cardiac rehabilitation is helpful in limiting risk factors and providing additional
guidance, social support, and encouragement. Adequate education and support are
essential if the patient is to adhere to the prescribed therapy and treatment plan.

Nursing care plan discharge instruction and evaluation: PREVENTION. Teach the
patient factors that may precipitate anginal episodes and the appropriate measures to
control episodes. Teach the patient the modifiable cardiovascular risk factors and ways to
reduce them. Manage risk factors, including hypertension, diabetes mellitus, obesity, and
hyperlipidemia.

Each person has a different level of activity that will aggravate anginal symptoms. Most
patients with stable angina can avoid symptoms during daily activities by reducing the
speed of any activity.

Be sure the patient understands all medications, including the dose, route, action, and
adverse effects. If the patient’s physician prescribes sublingual nitroglycerin (NTG),
instruct the patient to lie in semi-Fowler position and take up to three tablets 5 minutes
apart to relieve chest discomfort. Instruct the patient that if relief is not obtained after
ingestion of the three tablets, he or she should seek medical attention immediately.
Remind the patient to check the expiration date on the NTG tablets and to replace the
bottle, once it is opened, every 3 to 5 months.