Understanding Angina

Angina is a general term that refers to chest pain related to the heart not getting enough oxygen. There are several types of angina, multiple causes and varying treatments. Understanding angina is key for those nursing school exams as they will likely require you to be able to apply knowledge, differentiate between the types of angina, create care plans, and identify patients at risk of serious complications.

Understanding angina: the four types

Understanding angina starts with learning that there are essentially four types of angina, categorized by their key features. The thing they all have in common is that they involve ischemia of the heart muscle. There are, however, a few key differences:

• Angina Pectoris (also known as “stable angina”): usually related to exertion, but can also be caused by smoking, emotional distress, eating a large meal or exposure to extreme temperatures…think of things that can cause stress. It occurs relatively predictably in that it has consistent triggers, and is typically relieved by rest or nitroglycerin. Angina Pectoris typically occurs in patients with atherosclerosis, causing narrowed coronary arteries (when the arteries are blocked completely, we have much bigger problems!)
• Prinzmetal or Variant Angina: Occurs at rest, often in the middle of the night or early  morning. It is caused by coronary artery spasm and is relieved by nitroglycerin and calcium channel blockers (CCBs). The pain associated with variant angina can be severe.
• Microvascular Angina: Spasm of the microvascular arteries surrounding the heart as a result of ischemic heart disease. Pain typically lasts longer than 30 minutes and is severe. This type of angina may or may not respond to medications, so it can be classified as unstable at times.
• Unstable Angina: This is a medical emergency! Unlike stable angina, unstable angina doesn’t follow any predictable pattern. It can occur at rest or with physical activity and may not be relieved by medication. It is very serious and, if left untreated, can lead to a myocardial infarction. To see how unstable angina is treated, check out this post or podcast on acute coronary syndrome. 

What causes angina? 

Angina is a result of the heart not getting enough blood flow and, as a result, not enough oxygen. Blood flow can be decreased due to different reasons. Either the vessel is narrowed due to the buildup of plaque (a condition called atherosclerosis), or it’s narrowed due to spasm of the vessels. It can even have reduced blood flow due to abnormal blood flow, as is the case with polycythemia vera, a disease that results in overproduction of blood cells (often to dangerously high levels).

For those of you who have followed me for awhile, you may have read my post Nursing School Almost Killed Me…if you haven’t, I highly recommend it…it’s a doozy! The point of this detour is that I swear I had angina in a yoga class. I had not yet been diagnosed and my hematocrit was crazy high. I was getting frequent migraines due to the thick blood not being able to flow effectively through the cerebral micorvasculature…my guess is that my coronary microvasculature was also having the same problems.

I went to yoga and pushed myself harder than usual until severe chest pain literally took my breath away. I was stunned…and thought, “it can’t possibly be angina…I’m too young! I work out! I rock climb and do yoga!” I took a break for a few minutes, and to my immense relief the pain slowly started to subside. Like a complete idiot, I continued with the yoga class, only with much, much less gusto. I didn’t put the pieces together until a few weeks later when I learned that I had a dangerously high hematocrit level and a new diagnosis of polycythemia vera. And, in case you’re getting worried…I am doing much better now…thanks for asking! 

Back to our regularly scheduled program

You may be thinking, “why don’t patients with atherosclerosis have pain ALL the time?” Well, here’s the deal. Patients with atherosclerosis may feel fine at rest, and this is because when you’re resting, your heart isn’t working so hard…so therefore it has low oxygen demands. But, let’s say you turn up the demand (exercise does a great job of this) and now the heart notices that reduced oxygen…cue the angina, folks! 

Vasospasm can also cause angina, and this is typically what occurs with variant angina and microvascular angina. When the artery spasms, it narrows. And you can guess what happens next, right? Narrow, spasming arteries lead to reduced blood flow, reduced oxygen and BAM! Angina!

How do we know what kind of angina a patient has?

This is where your mad assessment skills come in. Note that you’re not diagnosing the angina, but as the physician’s eyes and ears when he/she is away from the bedside, it’s important to know what you’re assessing and why. 

• Determine the location of the pain. The patient may name a specific body part or indicate the pain is generalized.
• Perform a full pain assessment, which can be done using an acronym such as PQRST. Note that there are other pain assessment modalities, this is just one of several!
  • P: Provacative and palliative – what makes the pain worse or what causes the pain; what makes the pain better?
  • Q: Quality – have the patient describe the quality of the pain (crushing, sharp, dull, tearing, throbbing, etc…). 
  • R: Radiate – determine if the pain radiates anywhere. For example, angina pain can radiate to the left arm or jaw.
  • S: Severity – have the patient describe the severity of the pain, typically done on a 0-10 scale, but there are loads of other pain scales out there (hmmm…this is a great idea for a post!).
  • T: Time – does the pain get better or worse over time?
• The pain may follow a specific  pattern, depending on the type of angina the patient has. 
  • Stable angina (Angina Pectoris)
    • Provacation – exercise or stress, improves with rest or medication
    • Quality – tightness, pressure, sqeezing
    • Radiation – can radiate to arm, jaw, shoulders or back
    • Severity – predictable in severity, typically less severe than other types of angina
    • Time – improves over time (as long as patient resting)
  • Variant angina (Prinzmetal Angian)
    • Provacation – occurs at rest, often in middle of night or early morning
    • Quality – tightness, pressure, squeezing
    • Radiation – can radiate to arm, jaw, shoulders or back
    • Severity – can be severe
  • Microvascular angina
    • Provacation – often occurs at rest, typically lasts longer than 30 minutes
    • Quality – tightness, pressure, squeezing
    • Radiation – can radiate to arm, jaw, shoulders or back
    • Severity – can be severe
  • Unstable angina
    • Provacation – can occur with activity or rest, is unpredictable and usually lasts up to 30 minutes or longer; pain may not be relieved by medication
    • Quality – tightness, pressure, squeezing
    • Radiation – can radiate to arm, jaw, shoulders or back
    • Severity – very severe

Do men and women experience angina differently? 

Soooooo glad you asked! Why yes, they certainly can! The American Heart Association tells us that women could be more likely to experience microvascular angina while men may experience angina due to blockages. The Mayo Clinic points out that women may also experience nausea, shortness of breath, a pain described as “stabbing” instead of pressure, pain in neck/back/jaw and even abdominal pain. Women can also experience myocardial infarction differently than men, which you can read about here.

What are you going to DO about it?

As always, nurses solve problems. When we see a problem, we fix it…when we see a potential problem, we try like heck to avoid it. THAT’S NURSING IN A NUTSHELL, FOLKS! 

For patients with angina, the key therapies are aimed at increasing the blood flow to the heart. For stable angina, that’s typically rest and/or nitroglycerin. For variant angina, the patient may take a calcium channel blocker (for the vasospasm) and nitroglycerin. Microvascular angina patients may also take CCBs and nitro, but may also be on a beta blocker and a sodium blocker called Ranazaline. Treatment for this form of angina can be complex, but those are the highlights! For unstable angina, this deserves a post all its own. which you can listen to here!

Next week we’ll dive into one of the most fascinating medications you’ll ever give…nitroglycerin. See you soon!

Get this on audio in podcast episode 62

____________________________________________________________

The information, including but not limited to, audio, video, text, and graphics contained on this website are for educational purposes only. No content on this website is intended to guide nursing practice and does not supersede any individual healthcare provider’s scope of practice or any nursing school curriculum. Additionally, no content on this website is intended to be a substitute for professional medical advice, diagnosis or treatment.

 

---

References

American Heart Association. (2019). Angina in Women Can Be Different Than Men. Retrieved July 31, 2019, from Www.heart.org website: https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/angina-in-women-can-be-different-than-men

Crea, F., & Lanza, G. A. (2016). Treatment of microvascular angina: The need for precision medicine. European Heart Journal, 37(19), 1514–1516. https://doi.org/10.1093/eurheartj/ehw021

Mayo Clinic. (n.d.). Angina—Symptoms and causes. Retrieved July 31, 2019, from Mayo Clinic website: https://www.mayoclinic.org/diseases-conditions/angina/symptoms-causes/syc-20369373

Merck. (n.d.). Angina—Heart and Blood Vessel Disorders. Retrieved March 8, 2019, from Merck Manuals Consumer Version website: https://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/coronary-artery-disease/angina

Samim, A., Nugent, L., Mehta, P. K., Shufelt, C., & Merz, C. N. B. (2010). Treatment of Angina and Microvascular Coronary Dysfunction. Current Treatment Options in Cardiovascular Medicine, 12(4), 355–364. https://doi.org/10.1007/s11936-010-0083-8