Variant or Prinzmetal angina is also distinguished by attacks that occur when the patient is at rest.  This type of angina is not caused by fatty deposits in the coronary arteries, but by spasm of the arteries.  Variant angina is often accompanied by abnormal heart rhythms, such as ventricular fibrillation or ventricular tachycardia, which may increase the risk of sudden death in patients. ³’⁴ 

     Atherogenesis (i.e., gruel-like, soft and pasty materials),  begins early in life, progresses slowly over several decades, and ultimately results in the development of mature atherosclerotic plaques at lesion-prone sites, as bifurcation points and areas of increased wall stress.  In the hypertensive patient, this may indeed accelerate the atherosclerotic process, through increased transmural (i.e., through any given wall, as of the body), pressure. ⁵ Also, the augmentation of mechanical stress, and the greater wall tension in the coronary vessel. 

     For the registered nurse, she or he clinically knows that unstable angina (e.g., burning, heaviness, aching, strangling, or compression), represents the last opportunity to restore adequate blood flow to the at-risk region of the myocardium (MV₀₂).  Assessing the breathing at rest with chest pain may be cause by Tietze’s syndrome (i.e., swelling near the rib cage, 3^rd rib area), also, visual redness may be identified.

 As seen on the ECG strip or the monitoring system, the ST-segment elevation will be makeable.  Also, an echocardiographic (diminished or an absent regional wall motion), and a nuclear imaging will also show abnormalities and offer guides to therapeutic intervention. 

     In the serial ECG/EKG study, there may be an acute ST-T wave changes and also, an increase in blood levels of cardiac muscle enzymes (e.g., creatine kinase MB fraction or troponin).  In many clinical case studies, the “non-Q-wave” infarction may occur.  Therefore, a loss of subendocardial muscle mass with some preservation of the outer layers of myocytes will be noted.  The presence of the Q-wave (e.g., in lateral leads V⁵ and V⁶), may indicate a wider transmural area of injury; with patchy or incomplete loss of myofibrils (e.g., atrophy of the muscular tissue). 

Note:  Usually the development of the Q-wave generally indicates an irreversible loss of myofibrils as part of a “complete infarction”.        

Heart Sounds –

     For the registered nurse and for that matter all nurses including specialist and practitioners, one of the most valuable and useful tools must be your stethoscope (cardiac preferred).  In your assessment practice you need to know how to listen to heart sounds.  For example:  Aloud first heart sound (S₁) and brisk carotid upstroke in a hypertensive patient suggest a hyperdynamic circulatory state.  The second heard sound (S₂) is usually narrowly split, and the aortic component may be accentuated.  Although paradoxical splitting (i.e., inconsistent) of (S₂) may occur, it is uncommon and in the absence of a left bundle-branch block (i.e., LBBB), suggests left ventricular (i.e., LV), systolic dysfunction.  A third heard sound (S₃) unusual except when LV systolic failure occurs.  In almost all patients, a fourth heart sound (S₄) will develop before the (S₃) is heard, and when the (S₃) is heard, the (S₄) is almost always present. ⁶  

     In hypertensive patients the incidence of an (S₄) has been estimated to be between 50% and 70% especially in the presence of LVH and in older patients.  An (S₄) is the auscultatory counterpart of a vigorous atrial contraction into a relatively non-compliant left ventricle. ⁷  An (S₄) sound may be associated with a palpable presystolic impulse or an A (α)-wave; the (S₄) best appreciated when the patient is in the left lateral decubitus position and with the bell of your stethoscope, gently place directly on the point of maximal apical impulse for optimal sounds.  Also, you may hear an aortic systolic ejection sound (or click or clicking sound) which is occasionally heard in HTN patients and may appear to be related in a forceful expansion of the dilated aortic root. ⁸  In this matter, if you do hear a clicking sound, call for a cardiac clinician to confirm and possibly order a 2-D, and/or 3-D Echocardiography with color flow Doppler reading.

Electrocardiography -

     For many hospitals systems and health care facilities in the U.S. today RN’s and LVN’s/LPN’s even some NP’s are augmenting their technical skills as an ECG/EKG assessment nurse.  This means they are trained and capable to run the technical mechanism and in many instances give the treating physician a preliminary report. 

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