Case Study: Comprehensive Analysis of Angina Pectoris Management

This case study examines the pathophysiology, assessment, and treatment of angina pectoris, focusing on an 84-year-old male patient named John with a history of hypertension, angina, and hypercholesterolemia. The study details the risk factors associated with angina, including smoking and age, and explores various treatment options, with a focus on nitroglycerin, beta-blockers, and statins. It emphasizes the importance of thorough chest pain assessment using techniques like 'OLD CARTS' and electrocardiography (ECG), along with nursing interventions to manage patient anxiety and enhance awareness. The study also discusses the administration of sublingual glyceryl trinitrate, its benefits and risks, and the interpretation of ECG findings, particularly the significance of ST segment elevation in indicating myocardial ischemia. The case study concludes with relevant references, providing a comprehensive overview of angina management and patient care.

Running head: CASE STUDY ON ANGINA
Case study on Angina
Name of the Student
Name of the University
Author Note

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1.1
Pathophysiology of Angina
The term angina is also referred to as angina pectoris that is another form of chest
pain due to inadequate blood flow to the cardiac muscle of the body. It is generally found
that, any obstruction in the coronary arteries and arterioles can cause the problem of angina
among the patients. The oxygen deprivation in the cardiac muscle is due to mainly the
formation of atherosclerosis plaques in the coronary arteries. The early stage of the plaques
formation is resulted in for the deposition of fatty acid streak. The fatty acid streak is
deposited on the intimal surface of the blood vessels and from this early stages of fatty acid
streak, advanced atherosclerosis plaques are formed (Hall, 2015; Da Costa et al., 2016). This
formation of plaques in the blood vessels restricts the blood flows towards the heart and as a
result, adequate amount of oxygen cannot be supplied to the cardiac muscles and angina
pectoris takes place. In this case study it is observed that John is 84 year old man who is
admitted to the hospital with the problem of cellulitis in his left leg. Along with this, he has
past history of hypertension, angina and hypercholesterolemia. From the case study it is
noted that, John is a regular smoker and he smoked 20 cigarettes daily. In various studies it is
reported that, the practice of smoking is associated with the formation of atherosclerosis
plaque in the blood vessels. During the assessment a few vital signs such as blood pressure,
pulse rate are recorded (Ford et al., 2018).
Risk factors
There are a few risk factors that can promote the onset of angina among patients. For
example it can be said that diabetes mellitus, smoking, age of the person (More than 45 in
case of male), hypertension, family history of cardiovascular disease, lack of physical activity
can be counted as major risk factors of angina (Bohm, Reil, Deedwania, Kim & Borer,2015).
Therefore, in this case ,it is noted that, John has history of hypertension, practice of serious

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smoking and more over John is 64 year old which is one of the risk factor of the disease
(Madias, 2018).
Treatment of Angina
In the treatment of angina, most specifically nitro-glycerine can be uses as it is a
vasodilator and will enhance the blood flow by increasing the diameter of the vessels. In
addition, calcium channel blocker and beta-blocker are also prescribed to reduce the work
load of the heart (Ferrari et al., 2018; Maughan et al., 2018). In case of John, it is reported
that, doctor has prescribed metoprolol which is a beta blocker, glyceryl trinitrate that is the
medication of angina and pravastatin and the last one is used for treating
hypercholesterolemia which is one of the major reason of plaques formation (Ferrari et al.,
2018).
1.2 Assessment of Chest Pain
The chest pain is one of the most common problems in the emergency department of
the hospitals in a worldwide manner. It is very crucial to assess the severe chest pain in the
early stage of the pain in order to start the treatment as soon as possible. As an untreated
chest pain can create severe consequences regarding heart disease. The nursing assessment
for the chest pain are as follows-
 The nurse can use the ‘OLD CARTS’ during the assessment of the pain. In this
technique, the nurse at first will assess if there is any history of injury related pain or not as it
is sometimes observed that, although the pain is characterized as chest pain, but the actual is
pain is due to any previous injury. In this case, no such previous pain is reported. After that,
the exact location of pain will be assessed in order to identify the pain, whether it is an
ischemic chest pain or not. Then the duration and character of the pain will be assessed. In
this case, according to John, the pain is severe in nature. Along with this, the nurse can use
the pain scores to know the severity of the pain (Cullen et al., 2014; Widmer et al., 2017).

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 Another important assessment technique for the chest pain is the use of
electrocardiography (ECG) as it is the primary assessment procedure for the patients with the
chest pain. ECG is a very effective techniques for patients who are facing severe chest pain.
The technique can provide high-yield information about the condition of the patients’
cardiovascular system and a result, the initial management and prognosis will be a little easy
for the nurse practitioners (Abid et al., 2015; Abawi et al., 2016). In case of John, the ECG
will be effective as it is important to know about the condition of the cardiovascular system
of John. Any severe changes in the ECG can be a serious signs of severe condition of the
cardiovascular system of the body (Gentry, Mentz, Hurdle & Wang, 2016).
 The American college of Cardiology also recommends echocardiography for the
assessment of chest pain patients. In case of John, the nurse can use this techniques as John
has previous history of hypertension and this technique is generally used for those who have
previous history of cardiovascular problems. Hypertension is counted as a major symptoms
of cardiovascular disease (Abid et al., 2015; Brinkert et al., 2017; Werdan et al., 2016).
Nursing Interventions
After assessing the condition of the patients, the nurses should take steps for
managing the condition of the patients. As a part of this, the nurses can start medication in
order to give relief to the patients. In case of John, the interventions other than the
pharmacological interventions will be discussed. The nursing interventions are as follows-
 In case of John, the nurses should immediately initiate the ‘OLD CART’ technique.
The nurse should ask John about the location of the pain so that the nurse can be sure about
the type of pain whether it is ischemic pain or not. After that, she should use the chest pain
scale so that the nurse can assess the severity of the pain. Along with this, the facial
expression of the patients should also be assessed in order to judge the severity of the pain.

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The nurse should tell the patient to stop all the activities. In addition to this, it should be
recommended that, the patient will take rest in the bed in a semi-flower position (Mastue et
al., 2017). The nurse should also look after patients pain in an hourly manner so that any
improvement or deteriorate condition can be observed among in the patient.
 The nurses should also take care about the anxiety of the patient. It may happen that,
due to the during the ECG, the patient may have anxiety due to the technique. As a part of the
nursing intervention, the nurse should take initiatives for reducing the anxiety of the patients.
In case of John, it may possible that, the John may feel anxiety (Cohen et al., 2015). So it is
very crucial to reduce the anxiety of John. Along with this, echocardiography will also be
performed as a part of the assessment plan. So, during this assessment process, again John
may feel anxiety and it is the duty of the nurses to reduce it (Nezamzadeh et al., 2012).
 Another nursing intervention for after the assessment of the chest pain is the raising
of awareness among the patients and among their family. The enhanced awareness among the
patients and their family will help to manage the stress and anxiety among the patients
(Tummala & Farshid, 2015). This technique can be applied in case of John as he has no
adequate knowledge related to the assessment technique. So a proper knowledge about the
chest pain assessment will allow the patient to assess the problem in a proper way.
1.4
Administration of Sublingual Glyceryl Trinitrate
As a part of the John’s treatment, it is observed that, he is prescribed to take glyceryl
trinitrate as a spray for his angina. The sublingual administration of the drug through
sublingual method will cause direct vasodilation and causes reduction in systemic vascular
resistance that is the after load. This administration of drugs will cause dilation of venous and
arterial beds. The dilation of the post capillary beds will cause peripheral pooling of bloods.

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As a result, the venous returns are lowered and the end diastolic pressure is reduced.
Arteriolar relaxation in the cardiovascular system lowers the systematic vascular resistance
and the consumption of myocardial oxygen is decreased by the effect of the glyceryl trinitrate
( Hope et al., 2014).
Benefits
In the human body, the liver is associated with the detoxification of various
exogenous agents that are present in the blood. In the liver, those exogenous agents go
through the process of breakdown as a part of the first pass effect. However, if the glyceryl
trinitrate is administered orally most of the drugs molecule will be metabolized due to the
first pass effect of the liver. As the drug is administered sublingually, the drug is absorbed in
the blood directly and the there is no first pass effect of the liver. So the drug can exert its
function maximally. Along with this, there is no harm is associated with this as it is not an
invasive technique (Bind, Gnanarajan & Kothiyal, 2017).
Risks
During the administration the person may swallow the medicine and it will reduce the
effect of the medicine (Valensise, Presti & Spaanderman, 2018).
Contradiction
During administration, it should be carefully noted that, the patient has no
hypersensitivity issue regarding this drugs. The drugs that may cause hypersensitivity are
ethanol, peppermint oil. In case of severe hypotensive condition, this drug should not be
prescribed at all. In addition, patients with hypotensive shock, brain trauma, cerebral
haemorrhage, anaemia, cardiogenic shock and toxic pulmonary oedema should not be given
at all (Valensise, Presti & Spaanderman, 2018).

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1.5
Finding in the ECG
In the ECG of the John it can be found that, the nature of the ECG is not normal at all.
In a normal ECG, the prominent presence of the QRS segment and a small P and T wave can
be reported. A normal ECG curve can indicate a well condition of the heart of the patients. In
this ECG of John, it can be noted that, there is prominent P wave in the ECG. After that it is
observed that a ST segment of the ECG is elevated. Due to the deprived oxygen supply to
the cardiac cells, ischemic necrosis may happen in the myocardial tissues of the heart. As a
result, the infracted cells become less negative due to increased potassium efflux. During the
ventricular repolarization, the current flows more to the unaffected areas of the tissues. Hence
the reduction of the TQ segment and elevation of ST segments occur. In case of John, it is
very crucial to report immediately as it is the indication of STEMI that is ST elevated
myocardial ischemia (Hall, 2015).

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