angina pectoris, a paroxysmal thoracic pain caused most often by myocardial anoxia as a result of atherosclerosis or spasm of the coronary arteries. The pain usually radiates along the neck, jaw, and shoulder and down the inner aspect of the left arm. It is frequently accompanied by a feeling of suffocation and impending death. Attacks of angina pectoris are often related to exertion, emotional stress, eating, and exposure to intense cold, but unstable angina can occur in the absence of a stimulus or exertion. The pain may be relieved by rest and vasodilation of the coronary arteries by medication, such as nitroglycerin. Also called cardiac pain. ▪ OBSERVATIONS: The chief symptom of stable angina is a highly variable, transient, substernal pain that typically starts with physical or emotional exertion and subsides with rest. It may range from a vague ache to an intense crushing sensation. Radiation to the left shoulder, arm, or jaw or to the back is common but does not occur in all cases. Attacks are exacerbated by cold. The most severe class of angina is a constant pain even at rest. Symptom patterns tend to be consistent and stable for a given individual. Any change in symptom patterns, such as an increase in attack frequency or intensity, should be viewed as serious. Such changes are known as unstable angina and are associated with the deterioration of atherosclerotic plaque. The pain in unstable angina is frequently not fully relieved by rest. Unstable angina is often a precursor to myocardial infarction. Tests include a stress test to deliberately induce an angina attack and check for electrocardiographic (ECG) changes. A test dose of nitroglycerin is administered to evaluate the degree of pain relief. Serum lipid and cardiac enzyme levels are evaluated to screen for cardiac risk factors. Nuclear scanning, angiography, and PET may be indicated to check myocardial perfusion and determine the presence of underlying coronary artery disease (CAD). ▪ INTERVENTIONS: The first line of treatment is aggressive modification of risk factors, such as smoking, obesity, physical inactivity, elevated lipid levels, and elevated blood pressure. Drug therapy focuses on the prevention of myocardial insufficiency and pain relief and includes nitrates, beta-blockers, and calcium channel blockers. Prophylactic aspirin and statins are given for individuals with known CAD, and aspirin and heparin are used to treat intracoronary blood clotting in unstable angina and to prevent progression to myocardial infarction. Coronary artery bypass is used for selected individuals with severe angina, localized CAD, no history of MI, and good ventricular function. Percutaneous coronary intervention may be emergently performed to compress plaque, and a stent may be placed to keep the coronary artery open. Angioplasty may be used to remove obstructive atherosclerotic lesions. Unstable angina necessitates immediate hospitalization, bed rest, and ECG monitoring for possible MI. ▪ PATIENT CARE CONSIDERATIONS: The individual should be able to recognize and report symptoms of unstable angina. Nursing intervention during an acute attack is aimed at maintaining adequate tissue perfusion and relieving pain, including assessment and monitoring of vital signs and ECG patterns, auscultation of heart and lung sounds, administration of oxygen, and prompt administration of nitrates and narcotic analgesics as needed. Rest and cessation of all activity should occur until pain subsides. The nurse should provide comfortable positioning, and supportive calm reassurance to reduce anxiety. Patient education is tailored to the individual’s symptom set and includes identification of precipitating factors and education to prevent or control those factors. The health care team plays a large role in reducing risk behaviors through smoking-cessation protocols, dietary modification (low-fat, low-sodium diet with complex carbohydrates and fruits), consistent aerobic exercise routines (three to four times weekly for at least 30 minutes), and stress-reduction activities. Education about medication effects and side effects is essential.
