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Ep11: Angina | Treatment, nursing consideration, physiology

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What exactly is angina? What causes the pain that patients are feeling? What are the various nursing considerations when caring for a patient experiencing angina? These questions are answered in this podcast.  This is an important cardiac disorder to understand.  I do briefly cover stents and angio.

I am also excited today because we have a few very kind reviews on iTunes! That is awesome! Thank you so much.  I read each review and really appreciate it. Also, I am working with my team in developing the first EVER NCLEX® simulation testing software to help students prepare.  This is not out yet but we are working hard at it.  If you want to know more or want to be part of the Beta testing please check it out at Simclex.com

Podcast Transcription

Welcome to the NRSNG.com podcast, the podcast created by nurses, for nurses. Are you ready to take your learning to the next level? Sit back and crank up the volume. Here’s your host, Jon Haws.

 

This is Jon with NRSNG.com podcast. I’m pretty excited today because we have a couple really nice reviews up there on iTunes. I really appreciate that, appreciate you guys listening and giving us the feedback that you’re giving. If you have a chance, we’d really appreciate you heading over there and leaving us a nice review and letting us know what you think of the podcast. You can leave any questions there. You can also email any questions directly to me at [email protected]

 

Also excited because we’re in the process of working on and finalizing steps to creating a simulation NCLEX test. This is going to be computer adaptive, just like the NCLEX. It will be very unique in the way that it’s developed, so we’re really excited about that. If you’re interested in learning more about that, I invite you to go over to simclex.com. That’s S-I-M-C-L-E-X.com, simclex.com. That’ll give you a chance to sign up for a special off of there to get either reduced pricing or be part of the beta testing of that to get it for free and give us your feedback with that.

 

All right, so let’s move on with today’s podcast. Today, we’re going to talk about angina. Angina’s important to understand, but it’s also actually really simple to understand. It’s really just a pretty basic cardiac abnormality, but it’s important to understand because a lot of patients can suffer from this and it can be new and scary for patients to experience. Really, what angina is, basically, is just chest pain resulting from decreased blood flow to the heart, the coronary arteries. This results from a deficit in the myocardial oxygen supply and demand.

 

What can actually cause that deficit? Okay, so there’s just an imbalance, and this imbalance between the O2 supply and demand is termed ischemia. Ischemia is temporary and it is reversible. There’s three things that can cause this ischemia. It’s an obstruction, it’s vasal spasming, and it’s a thrombus. You may have an obstruction in the arteries, or those arteries might be spasming. Those things can actually cause this disruption in oxygen supply, distal to that obstruction or to that spasm.

 

What’s going to happen is because there’s that lack of oxygen supply distal to that obstruction or that spasm, that area of the heart is not receiving oxygen. Since it’s not receiving oxygen, it can’t carry out ATP, right? Oxygen is vital to cells being able to carry out ATP. If oxygen isn’t being delivered beyond a specific point of if there’s a decrease in the amount of oxygen required to carry out ATP beyond a certain point, the cells distal to that point aren’t going to be able to carry out ATP.

 

What happens is these cells require to switch to an anaerobic metabolism, since they’re not able to use oxygen, and this causes a buildup of lactic acid. This buildup of lactic acid causes this pain, okay? They start to feel this pain due to this buildup of lactic acid. Then there may be spasming and these cells start to become more permeable and they release histamines and things like that into outside of their cells. This starts to cause more pain. These pain impulses are sent to the CNS, central nervous system, and they begin to radiate to the upper body as well as the chest, the area of the heart that’s actually being affected. Since the upper body kind of shares the same dermatomes, the same pain sensors as the heart, as that area, you’re going to feel that pain in the upper body, the left arm, et cetera.

 

Okay, now there’s three types of angina. Those three types are stable, variant, and unstable. Okay, so the three types of angina are stable, variant, and unstable. Now we’ve determined that angina’s really just chest pain, and we know that the reason for that chest pain is a lack of oxygen supply and we know that that lack of oxygen supply causes cells to be unable to carry out normal metabolic processes and you get a buildup of lactic acid and pain sensation. The three types of angina that you can have are stable, variant, and unstable.

 

These make sense. These terms are actually really good, abnormally for how things are termed at the body and stuff. The three types of angina are stable, which is the most common, and the pain, this angina that you feel, this pain, begins at predictable moments, predictable amount of exertion, and it’s relieved by rest and/or nitrates. What will happen is this person will mow the yard, and every time they mow the yard they get this chest pain and they know that it happens every time and they sit down for five minutes and the pain goes away. That’s stable angina. It’s very stable, very predictable, and it is the most common.

 

Now, what will happen with these patients, though, since they might just think it’s heartburn … It happens every time I walk around the block or every time I walk the dog, every time I mow the yard, so it’s important to kind of dig a little deeper with these patients and find out if it’s always happening after a certain amount of exertion or what is causing this pain. Then, to help them determine whether that is heartburn or whether it really is possibly angina, and that’s something they would need to bring up with their physician to investigate a little further.

 

Then, you have variant angina. Variant is unrelated to any sort of physical activity, and it generally happens in the evening time. It’s actually caused by coronary artery spasms. These spasms, not really sure why they’re happening, they don’t happen at any predictable time, they just happen.

 

Then you have unstable angina. The pain is very unpredictable. It occurs with increasing frequency. It may occur even at rest. These people are at high risk for MI, for having a heart attack. With unstable, what you’re seeing is you’re seeing this patient, the pain is very unpredictable, and it begins to happen more frequently. They maybe were having it started a month ago, it would happen once a day, and now it’s starting to happen a couple times a day and it’s becoming stronger and stronger pain. This is the unstable angina. That differs from the stable that’s very predictable. Unstable is unpredictable and it gets worse and worse and worse.

 

Okay, so what are we going to see in our patients that are experiencing angina? Obviously, chest pain. I mean, with the stable type of angina, it’s going to be they have an activity, they have pain, they rest, then they get relief. They may also experience dyspnea, little shortness of breath, anxiety, fear, of course.

 

They go into the doctor. What are the things the doctor’s actually going to do to attempt to diagnose angina? Well, the first thing they’re going to do is they’re just going to run a basic EKG. The reason they do this is because angina typically demonstrates predictable changes with the EKG. What you’ll usually see with the EKG is you’ll see ST depression or possibly an inverted T wave. When you’re thinking … Remember, angina is lack of oxygen supply. What you’re going to see on your EKG is this ST depression or inverted T wave. These cells have not infarcted, they’re not dead, they’re just not getting enough oxygen. What’s going to happen is you’re going to see this depressed ST, ST depression, that’s just sunk below your isoelectric line, or you may also see the inverted T wave. Rather than it being pointed up, it’s going to be actually just pointed down. When you think lack of oxygen supply, think ST depression, inverted T wave.

 

The next thing the doctor may do, they bring the patient in, the patient’s complaining of this chest pain. They’ll do the EKG. They see this ST depression. They’ll say, “Okay, well let’s do a stress test.” What a stress test is, it kind of hooks them up to a continuous EKG and what they’ll do is they’ll have the patient start running on a treadmill and they’ll increase the amount of work that they’re required to do. It’ll get harder and harder and harder and they’ll monitor the EKG. They’ll see what changes occur and when they occur. Now, if that’s positive, they may do an echocardiogram. What that does is it gives them a very clean, clear picture of the heart. They may also do a transesophageal echocardiogram, or TEE. What that is is that actually goes into the esophagus and that cleans up the picture even more where they’re not getting the rib cage or the chest involved in the picture.

 

Okay, now if all that is saying, “Okay, yes we think there is still definitely some sort of angina going on, there could be some sort of obstruction or thrombus,” what they’re going to do next is most likely a coronary angio. What that is is they insert a catheter into the femoral or brachial artery, and they actually inject a little dye. What this dye does is it goes into those coronary arteries and it allows them to assess blood flow to the various parts of the heart. What that can actually assess is how occluded the vessels are, where they’re occluded at, and what percentage of vessel is occluded. If it’s about 50%, that’s something to be worried about. 70%, that’s something to really be worried about.

 

What they can actually do, I mean, your cardiologist is actually going to be very skilled in determining exactly how much blood flow has been cut off and exactly where the blood should be going. Based on what they’re seeing with this dye that’s injected, because the dye is taken up into the blood and that is then circulated throughout these coronary arteries, they can actually determine how much blood flow is being cut off and exactly to what areas.

 

They determine that. What they’ll most likely do is if there’s this occlusion, there is this obstruction or spasming or whatever going on, what they will mostly likely do, some of the meds they can put them on are going to be nitrates. Now, what nitrates do, nitroglycerin, it’s a really scary term for your patients. They’ll probably be terrified, freaked out that they’ve been prescribed nitroglycerin, right? What nitroglycerin actually does is it dilates the vessels and it reduces the stenosis. It’s a very potent vasal dilator. What that’s going to do is it’s going to allow blood to get to where it needs to go in these occluded vessels.

 

They may also get on beta blockers. What beta blockers do, we’ve talked about this a few times in the past, but what beta blockers do, obviously, is they prevent the beta receptors in the heart from being stimulated. When the beta receptors are stimulated, what they do is they create that fight or flight syndrome. They’re going to cause faster heart pumping, they’re going to increase oxygen demand of the heart. When you get the beta blockers, you’re decreasing the oxygen demand of the heart, okay?

 

Calcium channel blockers might also be given, and they’re going to do a similar thing as far as reducing oxygen demand and increasing blood supply. These patients will also oftentimes be started on aspirin. Aspirin, obviously, is just to thin the blood out a little bit and reduce platelet aggregation, so if they do h ave some sort of occlusion in their heart, their vessel is 50% occluded or whatever, a physician will want to thin that blood out a little bit to prevent further occlusion until something further can be done or further assessment is completed.

 

Okay, so one of the things that they can do is called angio stent. What they’ll actually do is they’ll go into the vessel that’s occluded and they’ll actually go right to where it’s occluded and they’ll blow a little balloon up in there, and what that’ll do is it’ll push the occlusion against the walls, open up that vessel a little bit more, and then they’ll put a stent in there. The stent is just a wire mesh. It’s just a little, tiny wire mesh cylinder that’s hollow in the middle. They’ll blow that balloon up, push that occlusion away, and compress it, and then they’ll put this stent in there. What this stent does is it holds that vessel open once it’s been opened by that balloon. What’ll happen is it will become kind of part of the vessel there and it keeps that artery open so that blood can then flow like normal to the heart, where it was previously occluded.

 

Okay, so that’s what is the preferred … That is a treatment that physicians may choose with angina, if it becomes to the point that it’s warranted to go and open up that vessel a bit more. All right, so that is angina. It’s really not too complicated, but it’s important to understand, important to be able to answer some of these questions on tests and be able to answer questions for your patients.

 

This is Jon with the NRSNG podcast. We really appreciate you if you could leave a nice review here for us on iTunes or Stitcher. Also be sure to check out simclex.com, S-I-M-C-L-E-X. That’s where you’re going to find information about our very soon to come computer adaptive NCLEX prep program. It’s very exciting. It’ll be the first of its kind on the market and we’re very excited about that. If you have any questions, contact me directly. This is Jon. You can contact me at [email protected] You can also find us on YouTube, iTunes, Stitcher, and Facebook. All right, appreciate it. Have a good day.

 

Thank you for listening to the NRSNG.com podcast. Visit us at nrsng.com for disclaimer information, and to keep the learning going.

 

Date Published - Nov 3, 2014
Date Modified - Apr 18, 2019

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.