Recognizing And Treating Angina Attacks With Your Patients
It used to freak me out all the time.
He’d come into my first aid room, complaining of chest pain, explaining that he just overdid it a little, then immediately the hair on the back of my neck would stand up.
Was this going to be the time? Should I start calling for more help? Should I just call 911 to be safe?
Inevitably I would ask the same questions every time, do the same thing, and it would usually work out just fine.
Sit him down, he’d take his meds and within twenty minutes or so, he’d be back on the job and carry on like it was any other day.
But I always worried about when one of his angina attacks was going to turn into a full on heart attack and be a major emergency.
Angina Types And Recognition
Angina Pectoralis is a coronary artery disease where people experience chest pain that comes and goes but the pain isn’t caused by a heart attack. One of the big differences is that a heart attack actually causes damage to the heart muscle, whereas angina does not.
If someone is having an angina attack it’s a sign that the heart isn’t getting enough oxygen-rich blood and usually happens during physical activities or during emotional stress. Typically this will only last for three to five minutes, but usually for under 10 minutes. When this happens, the symptoms can look a lot like someone having a heart attack; constricting chest pain, jaw pain, neck pain, pain in the arms (mostly on the left), and sometimes difficulty breathing.
There are four different types of angina:
- Stable Angina
- pain is the same each time
- brought on by physical exercise, extreme weather, heavy meals
- relieved with rest/nitroglycerin
- Unstable Angina
- pain is worse than usual and lasts longer
- brought on even when resting
- no relief
- Variant (Prizmental) Angina
- caused by spasm of coronary arteries
- brought on by medicine, cold weather, smoking, cocaine use
- extreme pain
- usually, happens during early morning hours
- Microvascular Angina
- affects the heart’s smallest coronary arteries and causes them to spasm
- may be part of a coronary microvascular disease
- severe unpredictable pain that lasts for an extended period
- medication may not relieve the pain
Angina is one of those things that you may or may not have seen on one of your patient intake forms.
There are those patients who would recognize it as something you should know about and others figure that because they’re on prescribed medication and it’s being managed successfully it’s not that important to tell you. However, as healthcare professionals, it’s important for us to know and understand all these types of angina in case a patient ever comes in complaining of chest pain.
Even more important is knowing how treating an angina attack is different from treating a heart attack, even though the risk factors, pain, and symptoms are quite similar.
By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons
Emergency Care For Angina Attack
The difference between angina attack and a heart attack can be a little confusing.
Both can look the same because of the visible signs and symptoms the patient presents with.
One big difference is that someone with angina, typically knows they have it and have been through this before, so making sure to ask the person if they’ve ever experienced this kind of pain before is critically important. If they haven’t, assume it’s a heart attack and call 911.
If there is no record on their intake form, and you’re not sure what’s going on, asking the SAMPLE questions can help you get to the bottom of the situation.
S – Signs and symptoms?
A- Any allergies?
M- Medications? Are they taking any?
P- Past medical history?
L- Last meal?
E- Events leading up to this emergency.
The critical ones, in this case, are signs and symptoms, past medical history, and medications. All of those should give you a clue if this is an angina attack (if the patient is being honest with you).
We reviewed the signs and symptoms (chest pain, jaw pain etc), and hopefully, they would tell you angina when asking about past medical history. But it is also important to know the medication prescribed in this case, Nitroglycerin. Nitroglycerin is a vasodilator that relaxes the smooth muscle and blood vessels, increasing blood return to the heart and making it work less hard. It comes in a few different forms; a sublingual tablet, a spray, patch, aerosol solution, ointment, and an extended release caplet. The most common I’ve seen is the sublingual tablet. In this case, the patient puts it under their tongue and lets it dissolve.
If you’re assisting a patient with their medication (remember assisting means getting it for them, not administering it), make sure it’s their medication and it’s the right dose.
HOWEVER, before they can take the nitroglycerin you have to ask them if they have taken any erectile dysfunction drugs (probably the only time it’s appropriate for you to ask a patient this), and yes even for women as some women take it as well. If they have taken any, they CANNOT take the prescribed medication as the combination of the two can lower their blood pressure to a fatal level. If they have taken Viagra or Levitra in the past 24 hours or Cialis in the last 48, they cannot take nitroglycerin.
Sit them down and have them rest in a comfortable position (sitting leaning forward usually makes it easier to breathe) and then they can take their medication. If after five minutes the chest pain doesn’t go away, give another dose. This can be done to a maximum of three doses, always five minutes apart. If after that 3rd dose, the pain hasn’t gone away it’s time to call 911 as this could be turning into a heart attack.
If they don’t have nitroglycerin but there is Aspirin (ASA) available (make sure it’s Aspirin, not Ibuprofen or Tylenol), they can chew two 80mg or one 325mg dose but only one dose of either, do not repeat it. If after taking the proper medication, the pain subsides and everything goes back to normal, this isn’t necessarily a 911 call. This is a condition the patient deals with on a regular basis and their medication is doing what it was intended for.
The biggest thing we can do to help is remain calm and recognize what is happening with our patient. It can be pretty scary having to deal with any kind of emergency that happens in our clinic, or anywhere else for that matter. The differences between an angina attack and heart attack can be hard to decipher, but with a good medical history and asking the right questions you can be successful in figuring it out. More importantly, as healthcare professionals, it’s important that we know what to do in these cases in order to give our patients the best care possible.
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