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Angina | 마이메르시 MyMerci
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Angina

NCLEX Review Guide: Angina

Pathophysiology of Angina

Definition and Mechanism

  • Angina pectoris is chest pain that occurs when myocardial oxygen demand exceeds oxygen supply, typically due to coronary artery disease (CAD) resulting in myocardial ischemia. The pain is temporary and reversible, without permanent damage to the myocardium.
  • The underlying cause is usually atherosclerotic narrowing of coronary arteries, reducing blood flow to the myocardium during increased demand (exercise, stress, etc.).

Key Points

  • Angina is a symptom, not a disease itself
  • Reversible myocardial ischemia without infarction
  • Usually caused by atherosclerotic CAD

Types of Angina

Type Characteristics Management
Stable Angina Predictable, occurs with exertion, relieved by rest or nitroglycerin Lifestyle modification, antianginals, nitrates
Unstable Angina Occurs at rest, increasing frequency/severity, poor response to nitroglycerin Emergency care, anticoagulants, possible revascularization
Prinzmetal's (Variant) Angina Occurs at rest due to coronary artery spasm, often at night Calcium channel blockers, nitrates
Microvascular Angina Chest pain with normal coronary arteries, affects small vessels Beta-blockers, calcium channel blockers

Key Points

  • Unstable angina is a medical emergency and part of acute coronary syndrome
  • Stable angina follows a predictable pattern with specific triggers
  • Prinzmetal's angina shows ST elevation on ECG during episodes

Clinical Presentation

Classic Symptoms

  • Chest pain typically described as pressure, squeezing, heaviness, burning, or tightness in the substernal or left precordial region. The pain may radiate to the left arm, jaw, neck, back, or epigastrium.
  • Associated symptoms include dyspnea, diaphoresis, nausea, fatigue, dizziness, and anxiety. Duration is usually 2-10 minutes for stable angina; longer for unstable angina.

Clinical Scenario

Mr. Johnson, a 62-year-old male with history of hypertension and hyperlipidemia, reports substernal chest pressure that occurs when walking up stairs or in cold weather. The pain subsides after 3-5 minutes of rest or after taking sublingual nitroglycerin. He denies pain at rest. This presentation is consistent with stable angina.

Key Points

  • Classic angina is substernal chest pressure/pain that may radiate
  • Stable angina is triggered by predictable factors (exertion, stress, cold)
  • Women, elderly, and diabetic patients may present with atypical symptoms

Atypical Presentations

  • Women, elderly patients, and those with diabetes often present with atypical symptoms including isolated dyspnea, fatigue, nausea, epigastric discomfort, or jaw/arm pain without chest discomfort.
  • Anginal equivalents refer to symptoms other than chest pain that indicate myocardial ischemia, such as unexplained dyspnea, fatigue, or diaphoresis during exertion.

Key Points

  • Diabetic patients may have "silent ischemia" due to neuropathy
  • Elderly patients often report fatigue or dyspnea rather than chest pain
  • Women more commonly experience atypical symptoms than men

Diagnostic Evaluation

Initial Assessment

  • History and physical examination are crucial, focusing on risk factors (hypertension, diabetes, smoking, family history, hyperlipidemia), chest pain characteristics, and cardiac examination.
  • ECG may show ST-segment depression or T-wave inversion during episodes of pain but may be normal between episodes. In Prinzmetal's angina, ST-segment elevation may be seen during episodes.

Key Points

  • Detailed history of pain characteristics helps differentiate angina from other causes
  • ECG changes are often transient and present only during symptoms
  • Risk factor assessment is essential for diagnosis and management planning

Diagnostic Tests

  • Cardiac biomarkers (troponin, CK-MB) are typically normal in stable angina but may be elevated in unstable angina. These tests help differentiate angina from myocardial infarction.
  • Stress testing (exercise or pharmacological) with or without imaging (echocardiography, nuclear imaging) can identify inducible ischemia. Coronary angiography remains the gold standard for visualizing coronary artery stenosis.

Memory Aid: CARDIAC

Cardiac tests for angina evaluation:

  • Cardiac biomarkers (troponin, CK-MB)
  • Angiography (gold standard)
  • Rest and stress ECG
  • Doppler echocardiography
  • Imaging (nuclear, CT, MRI)
  • Assessment of risk factors
  • Coronary calcium scoring

Key Points

  • Normal cardiac biomarkers help differentiate angina from MI
  • Stress testing evaluates functional significance of coronary disease
  • Coronary angiography visualizes anatomy and guides intervention decisions

Management

Pharmacological Management

  • Nitrates (nitroglycerin) dilate coronary arteries and reduce preload, decreasing myocardial oxygen demand and increasing oxygen supply. Available in sublingual, oral, transdermal, and IV forms.
  • Beta-blockers decrease heart rate and contractility, reducing myocardial oxygen demand. They are first-line therapy for stable angina along with aspirin.
  • Calcium channel blockers cause coronary and peripheral vasodilation and may decrease heart rate (non-dihydropyridines), particularly useful for Prinzmetal's angina.
  • Antiplatelet therapy (aspirin, P2Y12 inhibitors) reduces thrombotic risk, especially important in unstable angina.
  • Statins stabilize atherosclerotic plaques and improve endothelial function beyond lipid-lowering effects.

Important Alert

Nitroglycerin is contraindicated in patients taking phosphodiesterase-5 inhibitors (sildenafil, tadalafil) as the combination can cause severe hypotension. These medications should be separated by at least 24-48 hours.

Key Points

  • Nitrates provide rapid symptom relief but may cause headache and hypotension
  • Beta-blockers reduce mortality in post-MI patients
  • Ranolazine may help patients with refractory angina

Acute Management of Angina

  1. Stop activity and place patient in a sitting position
  2. Administer sublingual nitroglycerin 0.4 mg; may repeat every 5 minutes for a total of 3 doses
  3. If pain persists after 3 doses, consider unstable angina and activate emergency response
  4. Administer oxygen if hypoxemia is present (SpO₂ <94%)
  5. Obtain 12-lead ECG to evaluate for acute ischemic changes
  6. Administer aspirin 162-325 mg (chewable) if not contraindicated
  7. Monitor vital signs and cardiac rhythm continuously
  8. Prepare for possible cardiac catheterization if unstable angina is suspected

Key Points

  • Persistent angina despite nitroglycerin requires emergency evaluation
  • Oxygen therapy is only indicated for hypoxemic patients
  • Early aspirin administration reduces mortality in ACS

Revascularization

  • Percutaneous Coronary Intervention (PCI) involves balloon angioplasty and stent placement to restore coronary blood flow. Indicated for significant coronary stenosis causing refractory symptoms or high-risk anatomy.
  • Coronary Artery Bypass Grafting (CABG) is preferred for patients with left main coronary disease, three-vessel disease (especially with diabetes or reduced ejection fraction), or complex coronary anatomy unsuitable for PCI.

Key Points

  • PCI provides more rapid symptom relief but may require repeat procedures
  • CABG offers more durable results for complex disease
  • Diabetes is an important factor favoring CABG over PCI

Nursing Care

Assessment and Monitoring

  • Perform thorough pain assessment using PQRST method: Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Document response to interventions.
  • Monitor vital signs, oxygen saturation, cardiac rhythm, and for signs of heart failure (dyspnea, crackles, edema). Assess for medication side effects, particularly hypotension with nitrates.

Key Points

  • Detailed pain assessment helps differentiate cardiac from non-cardiac pain
  • Monitor for complications of angina including arrhythmias and heart failure
  • Assess orthostatic blood pressure before and after nitrate administration

Patient Education

  • Teach patients to recognize angina symptoms, use nitroglycerin properly, and when to seek emergency care. Instruct on medication administration, side effects, and importance of adherence.
  • Provide education on modifiable risk factors: smoking cessation, diet modification, weight management, regular exercise, stress reduction, and management of comorbidities (diabetes, hypertension, hyperlipidemia).

Memory Aid: HEART SMART

Patient education for angina management:

  • Health diet (low sodium, low saturated fat)
  • Exercise regularly (as prescribed)
  • Adhere to medication regimen
  • Recognize symptoms and respond appropriately
  • Tobacco cessation
  • Stress management
  • Manage comorbidities (diabetes, hypertension)
  • Alcohol limitation
  • Regular medical follow-up
  • Track symptoms in a diary

Key Points

  • Proper nitroglycerin storage and administration is critical (keep in original container, replace every 6 months)
  • Patients should seek emergency care if pain persists after 3 nitroglycerin doses
  • Cardiac rehabilitation improves outcomes for patients with CAD

Commonly Confused Points

Angina vs. Myocardial Infarction

Feature Angina Myocardial Infarction
Duration Usually 2-10 minutes Usually >30 minutes
Response to nitroglycerin Usually relieved within minutes May not be relieved or only partially relieved
Pain intensity Mild to moderate Usually severe
Associated symptoms May have mild diaphoresis, dyspnea Often has marked diaphoresis, nausea, vomiting
Cardiac biomarkers Normal Elevated
ECG changes May have transient ST depression or T-wave inversion ST elevation (STEMI) or new LBBB, or ST depression/T-wave inversion (NSTEMI)
Myocardial damage No permanent damage Irreversible myocardial necrosis

Key Points

  • Timing is crucial: angina typically resolves within minutes, MI pain persists
  • Response to nitroglycerin helps differentiate but is not definitive
  • Only MI shows elevated cardiac biomarkers indicating myocardial damage

Stable vs. Unstable Angina

Feature Stable Angina Unstable Angina
Pattern Predictable, consistent pattern New onset, increasing frequency/intensity, or at rest
Precipitating factors Exertion, stress, cold weather May occur at rest or with minimal exertion
Duration Usually 2-10 minutes Often >10 minutes
Response to nitroglycerin Prompt relief May have delayed or incomplete relief
Risk of MI Lower risk Higher risk (part of acute coronary syndrome)
Management Outpatient medical therapy Emergency hospitalization, possible intervention

Key Points

  • Unstable angina is a medical emergency requiring immediate evaluation
  • New onset angina should be considered unstable until proven otherwise
  • Unstable angina may progress to myocardial infarction if untreated

Nitroglycerin Administration Routes

Route Onset Duration Nursing Considerations
Sublingual tablet 1-3 minutes 30-60 minutes Place under tongue; may cause burning sensation; don't swallow
Sublingual spray 1-3 minutes 30-60 minutes Spray under tongue or onto oral mucosa; no need to shake canister
Oral (long-acting) 30-60 minutes 4-8 hours Used for prophylaxis; take on empty stomach; don't crush
Transdermal patch 30-60 minutes 12-24 hours Rotate sites; remove for 10-12 hours daily to prevent tolerance
IV infusion 1-2 minutes During infusion Requires continuous monitoring; use glass bottles and special tubing

Key Points

  • Sublingual forms are for acute symptom relief, while oral/transdermal are for prevention
  • Nitrate-free interval prevents tolerance development
  • Monitor for hypotension with all nitrate formulations

Study Tips and Memory Aids

Angina Assessment

Memory Aid: "PAIN CHEST"

Key assessment points for angina:

  • Provocation: What triggers the pain?
  • Associated symptoms: Diaphoresis, nausea, dyspnea?
  • Intensity: Severity on scale of 0-10
  • Nature: Quality of pain (pressure, squeezing)
  • Chronology: When did it start? Duration?
  • History: Previous episodes? Risk factors?
  • Exacerbation: What makes it worse?
  • Site: Location and radiation
  • Treatment response: Relief with rest or nitrates?

Key Points

  • Thorough assessment helps differentiate angina from other causes of chest pain
  • Response to nitrates provides valuable diagnostic information
  • Pattern recognition is crucial for identifying unstable vs. stable angina

Pharmacology

Memory Aid: "ABCN" for Angina Medications

Main drug classes for angina management:

  • Antiplatelet drugs (aspirin, P2Y12 inhibitors) - prevent thrombosis
  • Beta-blockers (metoprolol, carvedilol) - reduce oxygen demand
  • Calcium channel blockers (diltiazem, amlodipine) - vasodilate, reduce workload
  • Nitrates (nitroglycerin, isosorbide) - increase oxygen supply, reduce preload

Common Pitfalls

  • Confusing contraindications: Remember that nitrates are contraindicated with PDE-5 inhibitors, not with beta-blockers
  • Forgetting nitrate tolerance: Patients need a nitrate-free interval to prevent tolerance
  • Overlooking beta-blocker contraindications: Asthma, severe bradycardia, heart block

Key Points

  • Each medication class works through different mechanisms
  • Combination therapy often provides better symptom control
  • Medication selection should be individualized based on comorbidities

Quick Review of Angina Types

Memory Aid: "PUMP" for Angina Types

  • Prinzmetal's: Caused by coronary spasm, occurs at rest, shows ST elevation
  • Unstable: New onset, increasing severity/frequency, occurs at rest, medical emergency
  • Microvascular: Small vessel disease, normal coronaries on angiography
  • Predictable (Stable): Consistent pattern, triggered by exertion, relieved by rest/NTG

Quick Check

Which type of angina is considered part of acute coronary syndrome?

  • A. Stable angina
  • B. Prinzmetal's angina
  • C. Unstable angina ✓
  • D. Microvascular angina

Answer: C. Unstable angina, along with NSTEMI and STEMI, comprises acute coronary syndrome.

Key Points

  • Recognizing angina type guides appropriate management
  • Unstable angina requires emergency intervention
  • Prinzmetal's angina responds best to calcium channel blockers

Summary of Key Points

Essential Concepts

  • Angina is chest pain resulting from myocardial ischemia without infarction, typically caused by coronary artery disease that creates an imbalance between oxygen supply and demand.
  • Stable angina follows a predictable pattern triggered by exertion or stress, while unstable angina is a medical emergency characterized by new onset, increasing severity/frequency, or occurrence at rest.
  • Diagnostic evaluation includes history, ECG, cardiac biomarkers, stress testing, and possibly coronary angiography. Normal cardiac biomarkers help differentiate angina from myocardial infarction.
  • Management involves antiplatelet therapy, nitrates, beta-blockers, calcium channel blockers, and statins. Revascularization (PCI or CABG) may be necessary for refractory symptoms or high-risk anatomy.
  • Patient education on medication adherence, lifestyle modifications, symptom recognition, and when to seek emergency care is essential for effective management.

Key Points

  • Angina represents reversible myocardial ischemia without permanent damage
  • Unstable angina requires immediate medical attention
  • Treatment aims to reduce myocardial oxygen demand and increase supply

Self-Assessment Checklist

  • I can differentiate between the types of angina and their clinical presentations
  • I understand the pathophysiology of angina and the oxygen supply-demand mismatch
  • I can describe the appropriate diagnostic tests for evaluating angina
  • I know the pharmacological management of angina including medication classes and their mechanisms
  • I understand the acute management protocol for angina episodes
  • I can explain the indications for revascularization and differences between PCI and CABG
  • I know the key patient education points for angina management
  • I can differentiate between angina and myocardial infarction
  • I understand the nursing assessment and monitoring requirements for patients with angina
  • I know the contraindications and precautions for nitrate therapy

Remember that understanding angina is crucial for providing effective care to cardiac patients. Your ability to recognize different types of angina, implement appropriate interventions, and educate patients can significantly improve outcomes and potentially save lives. Keep reviewing these concepts as they appear frequently on the NCLEX and are essential for clinical practice!

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