Angina pectoris, commonly referred to as “angina”, is chest pain or discomfort that occurs when the heart muscle does not receive enough blood flow and oxygen. It is often described as tightness, pressure, squeezing, or crushing pain in the chest. Angina is a symptom of coronary artery disease (CAD), which is caused by plaque buildup and narrowing of the coronary arteries.There are three main types of angina:

Stable angina: Occurs during increased activity, emotional stress, exposure to cold temperatures, or after eating heavy meals. Pain is relieved by rest or nitroglycerin medication. This is the most common type.
Unstable angina: Chest pain that changes in frequency, duration, intensity, or triggers. It can occur at rest.
Variant/Prinzmetal angina: Caused by coronary artery spasm. Pain can occur at rest or while sleeping.

For nurses and nursing students preparing for the NCLEX exam, having a strong understanding of the pathophysiology, signs and symptoms, diagnosis, and treatments for angina is essential. This article provides a comprehensive nursing guide to caring for patients with different types of angina.

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Angina Pathophysiology

Angina occurs when there is an imbalance between the heart’s oxygen demand and the oxygen supplied by the coronary arteries. When the demand exceeds supply, ischemia (lack of blood flow) occurs, causing chest pain.

The most common cause is atherosclerotic plaque accumulation over time. Plaque narrows the coronary arteries (the vessels that supply oxygenated blood to the heart muscle), limiting blood flow. Any increased oxygen demand, like during exercise, emotions, or cold exposure cannot be met, resulting in angina pain.With unstable angina, plaques become unstable and rupture, causing platelets to form blood clots at the rupture site.

This can further block the artery.Variant angina is caused by coronary artery spasm, which abruptly reduces blood flow despite no plaque rupture or clotting. The exact mechanism is unclear but it may relate to endothelial dysfunction.

Signs and Symptoms

Typical angina symptoms include:

Chest pain described as tightness, pressure, squeezing, crushing, burning or aching sensation
Pain that moves to the shoulders, arms, neck, back, or jaw
Shortness of breath
Nausea
Sweating
Lightheadedness

The chest pain often lasts between 1-15 minutes.With stable angina, symptoms occur during physical exertion or stress and resolve with rest.Unstable angina is considered an emergency as symptoms can occur suddenly at rest, indicating high risk for myocardial infarction.

Additional symptoms may include palpitations, fatigue, and weakness.Variant angina pain also comes on at rest but symptoms may happen in clusters at night.

Diagnosis

To diagnose angina, physicians take a full history looking closely at the chest pain characteristics, triggers, relieving factors, and associated symptoms. Diagnostic tests aid in confirming angina and evaluating the extent of CAD.

Medical History

Doctors assess:

Chest pain onset, location, quality, severity, duration
Triggers – activity, cold, emotions
Relieving factors – rest, nitroglycerin
Risk factors – family history, smoking, obesity, hypertension
Existing diagnoses – previous heart attack, heart failure, arrhythmias

Physical Exam

The physical exam evaluates for:

Irregular heart sounds, murmurs, rhythm
Signs of heart failure – edema, jugular vein distension
Diminished peripheral pulses

Diagnostic Tests

Electrocardiogram (ECG): Looks for signs of ischemia (inverted T waves) or prior infarction (Q waves). Can show changes during an angina episode.
Exercise stress test: Monitors ECG while patient exercises on treadmill. Ischemic ECG changes confirm angina diagnosis.
Echocardiogram: Evaluates heart structure and function. Can identify prior infarction.
Cardiac catheterization: Injects contrast dye to visualize coronary arteries for blockages using angiograms. Can also measure blood flow.
Blood tests: Evaluate cardiac enzyme levels to rule out heart attack. Also assess cholesterol levels.

Angina Treatments

The main goals of angina treatment are to:

Improve blood flow to the heart
Decrease oxygen demand
Prevent future cardiac events

This involves medications and lifestyle changes. Procedures or surgery may be done for refractory cases.

Medications

Several medication classes are used:

Nitrates

Most common is nitroglycerin, available as short-acting tablets, sprays, or patches. Nitrates relax blood vessels to improve flow. Used to treat acute angina attacks and prevent episodes.

Beta blockers

Help decrease heart rate and blood pressure to reduce oxygen demand. Examples: metoprolol, carvedilol.

Calcium channel blockers

Relax coronary arteries to increase blood flow. Also used to lower blood pressure. Examples: amlodipine, diltiazem.

Antiplatelets

Like aspirin. Help prevent blood clot formation. Important for reducing risk of heart attack and stroke.

Statins

Decrease LDL cholesterol levels in blood to prevent further plaque buildup. Examples: atorvastatin, rosuvastatin.

Ranolazine

Used in combination therapy for refractory chronic angina unresponsive to other medications. Exact mechanism uncertain but likely improves blood flow.

Lifestyle Changes

Lifestyle changes that reduce cardiac workload are key:

Smoking cessation
Weight loss if overweight
Healthy diet low in saturated fats
Regular aerobic activity
Stress management
Avoiding triggers like cold temperatures

Procedures and Surgery

For severe refractory angina, procedures to improve blood flow include:

Angioplasty and stenting
Coronary artery bypass grafting (CABG)

These aim to bypass or physically open critically narrowed arteries.

Nursing Care and Considerations

Nurses play a pivotal role in caring for patients with angina. Priorities include patient education, administering medications, monitoring symptoms, and ensuring patient safety.

Patient Education

Education should cover:

Disease process
Medication purpose and administration
Warning signs to promptly report
Risk factor modification
Individualized trigger avoidance

Reinforce calling 911 for unrelieved chest pain lasting >15 minutes.

Review nitroglycerin administration for acute attacks.

Instruct patients to sit or lie down before taking nitroglycerin to prevent falls from sudden blood pressure drops.

Medication Administration

Nurses should:

Administer medications on time
Teach patients proper administration
Monitor for side effects
Assess medication efficacy and tolerance

With nitrates, monitor for headaches, dizziness, or hypotension.

Symptom Monitoring

Track frequency, duration, and severity of chest pain episodes. Notify physician of any worsening or sudden changes.Check oxygen saturation and lung sounds, as shortness of breath may occur.

Safety and Risk Reduction

Ensure bed rails raised for patients at fall risk from nitrate use.Educate on cardiac risk factor modification for secondary prevention. Encourage smoking cessation, diet changes, activity goals tailored to tolerance, and tips to manage stress.

NCLEX Angina Questions

Let’s review some angina questions commonly seen on the NCLEX:

A 68-year-old female with a 30-pack-year smoking history comes to the ED reporting chest tightness, rating it 8/10. Symptoms started while gardening and were relieved with rest in 10 minutes. She has a history of type 2 diabetes and hypertension. What type of angina does she most likely have?

A. Unstable angina

B. Variant angina

C. Stable angina

D. Non-cardiac chest pain

Rationale: Her long smoking history and comorbidities indicate high risk for CAD. The pain was triggered by activity and resolved fully with rest in a short period, indicative of stable angina.

A nurse is caring for a patient who had a stent placed for a 90% LAD artery stenosis. The patient has new-onset angina occurring at rest. Which finding should the nurse recognize as the priority to report?

A. Jugular vein distension

B. Crackles on lung auscultation

C. New T wave inversions on ECG

D. Chest pain unrelieved by nitroglycerin

Rationale: Unrelieved chest pain with rest angina indicates unstable angina or possible infarction. This should be reported urgently as it signifies myocardial ischemia despite revascularization.

A patient asks the nurse why he has to take multiple medications for his angina. Which response by the nurse is most appropriate?

A. “Each medication works by a different mechanism to prevent chest pain.”

B. “The synergistic effects of the drugs enhance efficacy.”

C. “It’s important we try to identify which one helps you the most.”

D. “Using different drug classes reduces your risk of future cardiac events.”

Rationale: The nurse should educate that multiple drugs targeting different pathways, like nitrates, beta blockers, and statins, help improve blood flow while reducing risk factors and preventing recurrent ischemia or infarction.

Conclusion

Angina requires prompt evaluation and tailored management to relieve symptoms and minimize adverse cardiac outcomes.

As patients’ primary caregivers, nurses need an excellent grasp of assessment findings, diagnostic evaluation, optimal medical therapy, patient education priorities, and safety considerations for optimal outcomes across the angina spectrum. Appropriate nursing interventions can significantly improve function, quality of life, and prognosis.

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Comprehensive Nursing Guide to Angina: Symptoms, Diagnosis, Treatments, and NCLEX Review for Stable, Unstable and Variant Angina