DR. HANA OMER

 ANGINA PECTORIS :is a clinical syndrome characterized by paroxysmal chest pain due to transient myocardial ischemia.  It may be occur whenever there is imbalance between myocardial oxygen supply and demand.  The most common cause is atherosclerosis, aortic stenosis, and hypertrophic cardiomyopathy.

 Stable angina.  Unstable angina.

 is the angina that occurs when coronary perfusion is impaired by fixed or stable atheroma of coronary arteries i-e patient has fixed capacity of exertion after that he starts feeling chest pain.

 is the angina that is characterized by rapidly worsening chest pain, pain on minimal exertion or pain at rest.  It is carachterized by :-  More serious, higher level of obstruction  Changes in frequency, severity, duration  May begin during sleep or at rest  Warning of impending MI

 Prinzmetal angina  Caused by coronary artery vasospasm  Causes chest pain at rest  Increased risk of: ▪ Ventricular dysrhythmias ▪ Myocardial infarction ▪ Heart block ▪ Sudden death

 Usually diagnosis is clinically, by present of these symptoms :- 1. Chest pain increase with exertion. 2. Typical chest pain. 3. Releaved by Nitroglycerin.  all 3 ₌ stable angina, 2 ₌ unstable angina  1 ₌ no angina.

 Acute ischemic necrosis of an area of myocardium is known as myocardial infarction, OR myocardial necrosis occurring as a result of critical imbalance between coronary blood supply and myocardial demand is called myocardial infarction.  It has the the same symptoms and signs, etiology, as angina pectoris.

 Any group of clinical symptoms consistent with acute MI  Patients should receive a 12-lead ECG. ▪ ST-segment elevation: “Q-wave AMI” ▪ No ST-segment elevation: unstable angina or a non-ST- segment elevation (UA/NSTEMI) we find inverted T.

 Symptoms  Chest pain is the most common symptom. ▪ Patient often clenches fist when describing ▪ May radiate to arms, fingers, neck, jaw, upper back, or epigastrium. ▪ Sometimes mistaken for indigestion ▪ Not influenced by body movements

 Other symptoms include:  Diaphoresis  Dyspnea  Anorexia, nausea, vomiting, belching, hiccups  Profound weakness, dizziness, palpitations  Feeling of impending doom

 Symptoms (cont’d)  Patients with silent MI may present with: ▪ Sudden dyspnea ▪ Rapid progress to pulmonary edema ▪ Sudden loss of consciousness ▪ Unexplained drop in blood pressure ▪ Apparent stroke or simply confusion

 Symptoms (cont’d)  Women more likely to present with: ▪ Nausea ▪ Lightheadedness ▪ Epigastric burning ▪ Sudden onset of weakness or tiredness ▪ Pain radiating down right side

 Assessment  For history, ask usual questions, but also if any pain medication has helped.

 Take note of:  Patient’s general appearance  Patient’s state of consciousness  Pale, cold, and clammy skin  Vital signs  Left-sided heart failure signs  Right-sided heart failure signs

 Typical signs include:  Ashen-gray pallor  Cold, wet skin  Rapid pulse rate  Decreased blood pressure from decreased CO  Increased blood pressure from pain and anxiety

 Treatment goals:  Limit size of infarct.  Decrease fear and pain.  Prevent serious cardiac dysrhythmias.

 Place patient at physical and emotional rest.  Stress response can make damaged heart race  Can place peripheral circulation in a state severe vasoconstriction

 To begin treatment, place patient in a semi- Fowler position.  Do not allow patient to get on stretcher alone.

 Treat (MONA) in following order:  Oxygen  Aspirin  Nitroglycerine  Morphine

 Give nitroglycerin if BP is adequate.  Do not mix with PDE-5 inhibitors.  Place 0.4-mg under tongue.  Do not give with hypotension or bradycardia.  Repeat every 3 to 5 minutes, up to three doses.

 Morphine sulfate may be given by IV.  2- to 4-mg doses as needed  Do not give if patient has/is: ▪ Low blood pressure ▪ Dehydrated ▪ AMI involving the heart’s inferior wall  Some protocols prefer fentanyl.

 Perform cardiac monitoring.  Document the initial rhythm.  Place anterior chest leads.  Keep cardiac drugs close at hand.

 Record vital signs.  Measure blood pressure at least every 5 minutes.  Measure pulse rate.

 History and secondary assessment  Find out if patient: ▪ Has history of cardiac disease ▪ Takes any heart medications ▪ Has had a previous heart attack or heart surgery  Obtain more details about current symptoms and any relevant past medical history.

 Transport the patient.  Once stable, transport in semi-Fowler position  Use safe and appropriate transport.  If serious dysrhythmia develops, consider stopping and treating immediately.